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Intensive Medicine
Intensive Medicine
Intensive care
medicine
Intensive care medicine (or critical care medicine) is concerned mainly with the management of patients with acute
life-threatening conditions (the critically ill) in a specialized unit. It also encompasses the resuscitation and transport of those who become acutely ill, or are injured, either
elsewhere in the hospital or in the community. An intensive
care unit (ICU) has the facilities and expertise to provide
cardiorespiratory support to these sick patients, some of
whom also have kidney or liver failure, and management
of this is described in the relevant chapters.
All patients admitted to the ICU require skilled nursing
care (patient to nurse ratio of 1:1) and physiotherapy. Many
require nutritional support. General medical management
includes the prevention of venous thrombosis (p. 217), pressure sores and constipation. A number of scoring systems,
such as the APACHE score, are in use to evaluate the severity of the patients illness.
Pathophysiology
Sympathoadrenal In response to hypotension there is a
reex increase in sympathetic nervous activity and catecholamine release from the adrenal medulla. The resulting
vasoconstriction, increased myocardial contractility and
heart rate help restore blood pressure and cardiac output.
Activation of the reninangiotensin system leads to
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Clinical features
Clinical features
The history will often indicate the cause of shock, e.g. a
patient with major injuries (often internal and thus concealed) will often develop hypovolaemic shock. A patient
with a history of peptic ulceration may now be bleeding
into the gastrointestinal tract, and rectal examination will
show melaena. Anaphylactic shock may develop in susceptible individuals after insect stings and eating certain
foods, e.g. peanuts.
Hypovolaemic shock Inadequate tissue perfusion causes
blue cold skin with slow capillary rell. The blood pressure
(particularly when supine) may be maintained initially, but
later hypotension supervenes (systolic BP < 100 mmHg)
with oliguria (< 30 mL of urine/h), confusion and restlessness. Increased sympathetic tone causes tachycardia (pulse
> 100/min) and sweating.
Cardiogenic shock Additional clinical features are those
of myocardial failure, e.g. raised jugular venous pressure
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Management
Management of shock
Ensure adequate oxygenation and ventilation
Maintain patent airway: use oropharyngeal airway or
endotracheal tube if necessary.
Administer 100% oxygen via tight-fitting face mask.
Monitor respiratory rate, blood gases and chest X-ray.
Restore cardiac output and BP
Lay patient flat or head-down.
Expand circulating volume with appropriate fluids given
quickly via large-bore cannulae.
Monitor skin colour, pulse and blood pressure, peripheral
temperature, urine output, ECG.
CVP monitoring is required in most cases, SwanGanz catheter
in selected cases.
Investigations
FBC, U+E, glucose, liver biochemistry, and blood gases in
all cases.
Infection screen, lactate levels, fibrinogen degradation
products and crossmatch blood in selected cases.
Echocardiogram in post-MI patients to identify patients with
intra- or extramyocardial rupture.
Treat underlying cause
Haemorrhage
Sepsis
Anaphylaxis.
Treat complications
e.g. Coagulopathy, renal failure.
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Myocardial contractility and inotropic agents Myocardial contractility is impaired in cardiogenic shock and at
a later stage in other forms of shock as a result of hypoxaemia, acidosis and the release of mediators. It is recommended that the treatment of acidosis should concentrate
on correcting the cause; intravenous bicarbonate should
only be administered to correct extreme (pH < 7.0) persistent metabolic acidosis. Drugs that impair cardiac
performance, e.g. -blockers, should be stopped. When a
patient remains hypotensive despite adequate volume
replacement inotropic agents are administered. This must
be via a large central vein and the effects carefully monitored. The inotropic agents used and their clinical effects
are shown in Table 11.2. Many consider dopamine to be the
inotrope of choice in critically ill patients, but dobutamine
is a better choice when vasconstriction caused by dopamine
could be dangerous. Norepinephrine (noradrenaline) in
combination with dobutamine (depending on the cardiac
output) is used for shocked patients with a low peripheral
resistance, e.g. septic patients.
Additional treatment Vasodilators, e.g. sodium nitroprusside and isosorbide dinitrate, may be useful in selected
1
++
++
++(+)
++
+++
(Dose, g/kg/min)
Epinephrine (adrenaline)
Low dose (0.060.1)
Moderate dose (0.10.18)
High dose (>0.18)
Norepinephrine (noradrenaline)
Isoprenaline
1
+
++
+++
+++
2
+
+
+
+++
+++
+
+
+++
2
0
0
0
DA1
0
0
0
DA2
Rarely used
Comments
Table 11.2
Inotropic agents used in the management of shock: the effect of each inotrope on the adrenergic and dopaminergic receptors is shown
Acute disturbances of haemodynamic function (shock)
Management
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++
Dobutamine
Enoximone
++
++
++(+)
++(+)
DA1
+
+
+
DA2
+
+
+
2
Comments
0, no agonism; + mild agonism; ++, moderate agonism; +++, profound agonism; , -adrenergic receptors; , -adrenergic receptors; DA, dopamine receptors
+++
0
++
+++
Dopexamine
0
+
++
+
++
+++
1
Dopamine
Low dose (13)
Moderate (310)
High dose (> 10)
2
1
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(Dose, g/kg/min)
Table 11.2
(continued)
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Monitoring
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Respiratory failure
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Monitoring
Hypervolaemic
CVP (cmH2O)
10
Normovolaemic
Hypovolaemic
Time (min)
Respiratory failure
(K&C p. 944)
Monitoring
Clinical Assessment should be made on the following criteria: tachypnoea, tachycardia, sweating, pulsus paradoxus,
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Type 2
Pulmonary oedema
Pneumonia
Asthma
COPD
Pulmonary embolism
Acute respiratory distress
syndrome
Fibrosing alveolitis
Right-to-left cardiac shunts
COPD
Severe asthma
Muscle weakness, e.g.
GuillainBarr syndrome
Respiratory centre depression, e.g.
with sedatives
Chest wall deformities
Respiratory failure
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Management
Management
This includes the administration of supplemental oxygen,
control of secretions, treatment of pulmonary infection,
control of airway obstruction and limiting pulmonary
oedema. In most patients oxygen is given by a face mask or
nasal cannulae. With these devices, inspired oxygen concentration varies from 35% to 55%, with ow rates between
6 and 10 litres. However, in patients with chronically
elevated carbon dioxide (e.g. COPD), hypoxia rather than
hypercapnia maintains the respiratory drive and thus xedperformance masks (e.g. Venturi masks) should be used, in
which the concentration of oxygen can be accurately
controlled. Respiratory stimulants such as doxapram have
a very limited role in treatment.
Respiratory support Respiratory support should be considered when the above measures are not sufcient. The
type depends on the underlying disorder and its clinical
severity. Careful consideration should be given to ventilating patients with severe chronic lung disease, as those who
are severely incapacitated may be difcult to wean from the
ventilator.
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Trauma
Head injury
In poor-risk patients
Comment
Indication
Table 11.4
Indications for IPPV
Respiratory failure
Management
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Aetiology
The commonest precipitating factor is sepsis. Other causes
include trauma, burns, pancreatitis, fat or amniotic uid
embolism, aspiration pneumonia or cardiopulmonary
bypass.
Pathophysiology
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Clinical features
Tachypnoea, increasing hypoxia and laboured breathing are
the initial features. The chest X-ray shows diffuse bilateral
shadowing, which may progress to a complete white-out.
Management
This is based on the treatment of the underlying condition.
Pulmonary oedema should be limited with uid restriction,
diuretics, and haemoltration if these measures fail.
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Prognosis
Prognosis
Although the mortality has fallen over the last decade, it
remains at 3040%, most patients dying from sepsis. The
prognosis is very dependent on the underlying cause, and
rises steeply with age and with the development of multiorgan failure.
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