Oxford Handbook of Critical Care - part 10 potx

Publ ished in the United States by Oxford Universi tyPress Inc > Table of Co ntents > Pain and Po st-operative In ten sive C are Pain and Post-operative Intensive Care Pain Pai n results

P.527

P.528

See also:

Venti latory support—indicati ons, p4; Endotracheal i ntubation, p36; Defibril lation, p52; Cardiac function tests, p150;

Basic resuscitation, p270; Cardiac arrest, p272; Fluid challenge, p274; Tachyarrhythmias, p316; Acute coronary

syndrome (1), p320; Acute coronary syndrome (2), p322; Burns—fluid management, p510; Burns—general

management, p512; Rhabdomyol ysi s, p528

Near-drowning

Fol lowing near-drowni ng the major compli cations are lung injury, hypothermi a and the effects of prol onged hypoxi a

Al though hypothermia bestows protective effects against organ damage, rewarming carries parti cular hazards

Pathophysiology

Prolonged immersi on usuall y results in i nhal ation of fluid; however, 10–20% of patients devel op intense

laryngospasm leadi ng to so-cal led ‘dry drowni ng’ Traditionall y, fresh water drowni ng was consi dered to lead to rapi d

absorpti on of water i nto the circul ati on with haemolysis, hypo-osmolali ty and possi ble el ectrol yte di sturbance

whereas i nhalation of hypertonic fluid from sea water drowni ng produced a marked flux of fl uid into the al veol i In

practice, there seems to be li ttle disti nction between fresh and sea water as both cause l oss of surfactant and severe

inflammatory di sruption of the al veolar-capil lary membrane l eading to an ARDS-type picture Ini tiall y, haemodynami c

instabil ity is often mi nor A si mi lar pi cture often develops after ‘dry drowning’ and subsequent endotracheal

Rewarmi ng fol lows conventional practi ce; cardi opulmonary bypass may be consi dered if core temperature i s

<30°C Cardiopul monary resusci tation includi ng cardiac massage shoul d be continued until normothermia isachi eved

Venti latory support—indicati ons, p4; Endotracheal i ntubation, p36; Positi ve end expiratory pressure (1), p22; Positive

end expiratory pressure (2), p24; Conti nuous posi ti ve airway pressure, p26; Bronchodi lators, p186; Antiarrhythmi cs,

p204; Antimi crobi als, p260; Acute respi ratory di stress syndrome (1), p292; Acute respiratory distress syndrome (2),

p294; Metabol ic acidosis, p434; Hypothermi a, p516

Rhabdomyolysis

Breakdown of striated muscl e which may result in compartment syndrome, acute renal fail ure and electrolyte

abnormali ti es (hyperkalaemi a, hypocalcaemi a, hyperphosphataemia)

Causes

Trauma, especial ly crush injuryProl onged immobi li sation, e.g after fal l, drug overdose

Suggested by di sproporti onatel y high serum creatinine compared to urea (usual ratio is approximatel y10µmol :1mmol)

Raised creati ne ki nase (usuall y >2000IU/l)

Myoglobinuri a—this produces a positi ve urine di pstick to bl ood; l aboratory analysis is requi red to confi rmmyoglobin rather than bl ood or haemoglobin The urine i s usuall y red or black but may appear clear despitesignificant rhabdomyolysis

General management

Prompt fluid resuscitati on

Hypocal caemia shoul d not be treated unless the patient is symptomatic; administered cal cium may form crystal swith the high circulati ng phosphate

Hyperkalaemia may be resi stant to medical management and requi re urgent haemodialysis orhaemo(dia)fil trati on

Compartment syndrome

Suspect i f l imb is tender or painful and peri pheri es are cool Loss of peripheral pulses and tense muscl es are latesigns

Manometry in muscle compartments reveal pressures >20–25mmHg

Arm, l egs and buttock compartments may be affected

Management invol ves ei ther prophyl actic fasci otomies i f at high ri sk or close monitori ng (including regularmanometry) wi th decompression i f pressures exceed 20–25mmHg

Fasciotomi es may resul t i n major blood l oss

If renal fail ure i s establi shed, di alysis or fi ltration techniques wil l be required, usual ly for a peri od of 6–8 weeks

Key paper

Better OS, Stein JH Early management of shock and prophyl axi s of acute renal fail ure i n traumatic rhabdomyolysis N

Engl J Med 1990; 322:825–9

See also:

Haemo(dia)fil trati on (1), p62; Haemo(dia)fi ltration (2), p64; Peritoneal di alysis, p66; Uri nal ysi s, p166; Sodium

bicarbonate, p178; Di ureti cs, p212; Oli guria, p330; Acute renal fai lure—diagnosis, p332; Acute renal

fai lure—management, p334; Poisoni ng—general princi ples, p452; Amphetami nes i ncl udi ng Ecstasy, p462; Cocaine,

p464; Mul tiple trauma (1), p500; Multiple trauma (2), p502; Burns—flui d management, p510; Burns—general

management, p512; Hyperthermia, p522; El ectrocution, p524

Ovid: Oxford Handbook of Critical Care

Editors: Singer, Mervyn; Webb, Andrew R.

Title: Oxford Handbook of Critical Care, 2nd Edition

Copyri ght ©1997,2005 M Si nger and A R Webb, 1997, 2005 Publ ished in the United States by Oxford Universi tyPress Inc

> Table of Co ntents > Pain and Po st-operative In ten sive C are

Pain and Post-operative Intensive Care

Pain

Pai n results from many i nsults, e.g trauma, invasi ve procedures, speci fic organ di sease and inflammatory processes

Pai n reli ef is necessary for physiological and psychological reasons:

Anxiety and l ack of sl eep

Increased sympathetic activity contributi ng to an increased metaboli c demand

The capaci ty of the ci rculation and respiratory system to meet the demands of metabol isi ng tissues may not beadequate

Myocardial i schaemia is a signifi cant risk

The endocrine response to injury i s exaggerated with consequent sal t and water retention

Physiol ogical attempts to l imi t pai n may i ncl ude i mmobil ity and muscle spl inting and consequent reducti ons inventil atory functi on and cough

Pain perception

The degree of ti ssue damage is rel ated to the magnitude of the pain stimulus The site of i njury is also i mportant;

thoracic and upper abdominal i njury is more pai nful than injury el sewhere However, the percepti on of pai n i s

dependent on other factors, e.g simultaneous sensory input, personal ity, cul tural background and previous

experi ences of pai n

Management of pain

Systemic analgesia

Opi oid analgesi cs form the mai nstay of anal gesic drug treatment in intensive care

Smal l, frequent IV doses or a continuous i nfusion provide the most stabl e blood l evels Si nce the degree ofanal gesia is dependent on bl ood level s i t i s important that they are maintai ned

Higher doses are required to treat rather than prevent pain

The dose of drug requi red for a parti cul ar individual depends on thei r perception of pain and whether tol erancehas bui lt up to previ ous analgesi c use

The use of non-opioi d drugs may avoid the need for or reduce the dose requi red of opioi d drugs Thi s includesparacetamol and non-steroidals, ketamine and α2-agoni sts such as cloni dine and dexmedetomidi ne

Regional analgesia

Regi onal techni ques reduce respiratory depressi on but requi re experi ence to ensure procedures are performedsafely

Epi dural analgesia may be achieved wi th local anaesthetic agents or opioi ds

Opi oids avoi d the vasodi latati on and hypotensi on associated with l ocal anaestheti c agents but do not produce asprofound anal gesia

The combinati on of opi oid and l ocal anaestheti c i s synergistic

Intravenous opi oids should be avoi ded or cl ose monitoring shoul d continue for 24h after cessation of epiduralopi oids due to the potential for l ate respiratory fail ure Sample regimens are shown opposite

Local anaesthetic agents may be used to block superfici al nerves, e.g intercostal nerve block wi th 3–5ml 0.5%

bupi vacai ne plus adrenal ine

Non-pharmacological techniques

Adequate explanati on, positioning and physical techni ques may all reduce drug requi rements

Regimens for epidural analgesia

Opi oi d anal gesics, p234; Non-opioi d anal gesics, p236; Multipl e trauma (1), p500; Multi pl e trauma (2), p502; Head

injury (1), p504; Head i njury (2), p506; Burns—general management, p512; Post-operati ve i ntensive care, p534

Post-operative intensive care

Patients may be admitted to the ICU after surgery, either electively (see opposite) or after unexpected peri-operati ve

compli cations

General care

Ensure surgi cal and anaestheti c plan has been agreed, e.g overnight ventil ati on, speci al precauti ons (e.g wirecutters i f mandibl e wired), movement all owed, haemodynamic targets, etc

Provide adequate analgesi a

Ensure adequate rewarming

Maintai n eugl ycaemi a

Provide appropriate thrombosis prophylaxis

Blood gas, el ectrolyte and haemogl obi n moni toring

Post-operative respiratory problems

Common in those with pre-exi sti ng respi ratory di sease, especial ly wi th a reduced vital capacity or peak flow rate

Problems include:

Exacerbati on of chroni c chest diseaseRetained secreti ons

Basal atelectasisPneumonia

Upper airway problems, e.g laryngeal oedema

Anaesthesia and surgery (especial ly upper abdomi nal surgery) reduce functi onal resi dual capacity, thoracic

compli ance and cough There is reduced macrophage function and systemic inflammatory activati on with i nfecti on and

acute lung i njury as possi ble consequences

Therapeutic aims

Pre-operative preparation may hel p avoid some of the probl ems:

Cessati on of smoking for >1 weekBronchodi latati on

Respiratory muscle trainingChest physiotherapy

Avoi dance of hypovolaemia in the ni l-by-mouth peri od

Post-operati ve clearance of secretions and maintenance of basal lung expansi on are very important These require

effective analgesi a and chest physiotherapy Consider early use of non-invasive venti lation if spontaneously breathing

but requi ri ng high FIO2 Mechanical venti lation assists basal expansion and secreti on cl earance where anaesthetic

recovery is expected to be prolonged or where surgery ± pre-existing disease i ncrease the risk of secreti on retention

and atelectasis Ensure a patent airway prior to extubati on where intubation was difficult or after upper ai rway

surgery

Post-operative circulatory problems

Prevention of hypovolaemi a i s crucial i n avoiding i nfl ammatory acti vation and, therefore, many post-operativecompli cations

Haemorrhage i s usuall y obvi ous and managed by resuscitation, correcti on of coagul ati on disturbance andsurgery

Subcli ni cal hypovolaemia is common postoperatively Hypothermia and high catechol ami ne levels help tomaintai n CVP and BP despi te conti nui ng hypovol aemia Avoiding reduced stroke volume or metabol ic aci dosis arethe best i ndicators of adequate resusci tation

Post-operative flui d management requi res a high degree of suspicion of hypovolaemia; flui d chal lenges wi thcol loi d should be used to confi rm and treat hypovolaemi a where there i s any circul atory di sturbance, metabol icaci dosis or oli guria

Reasons for elective ICU admission

Airway monitori ng: e.g major oral , head and neck surgeryRespiratory moni toring: e.g cardiothoraci c surgery, upper abdominal surgery, prolonged anaesthesi a, previousrespiratory disease

Cardiovascul ar moni toring: e.g cardiac surgery, vascular surgery, major abdominal surgery, prolongedanaesthesi a, previ ous cardi ovascular di sease

Neurol ogi cal monitori ng: e.g neurosurgery, cardiac surgery wi th circul atory arrestElecti ve ventil ati on: e.g cardiac surgery, major abdominal surgery, prolonged anaesthesia, previous respiratorydisease

See also:

Venti latory support—indicati ons, p4; Endotracheal i ntubation, p36; Non-invasive respi ratory support, p32; Chest

physiotherapy, p48; Pulse oximetry, p90; Blood gas anal ysi s, p100; ECG monitori ng, p108; Blood pressure

monitori ng, p110; Central venous catheter—use, p114; Central venous catheter—inserti on, p116; Cardiac

output—thermodi lution, p122; Cardiac output—other i nvasive, p124; Cardiac output—non-invasive (1), p126; Cardiac

output—non-i nvasive (2), p128; El ectrol ytes

, p146; Full bl ood count, p154; Coagulation monitori ng, p156; Col loi ds, p180; Bl ood transfusion, p182;

Bronchodilators, p186; Respi ratory stimulants, p188; Opioid anal gesics, p234; Non-opioid analgesics, p236;

Sedati ves, p238; Muscle rel axants, p240; Anti coagul ants, p248; Coagulants and anti fibri nol yti cs, p254; Fluid

chall enge, p274; Respiratory fail ure, p282; Atel ectasi s and pul monary collapse, p284; Chroni c airflow li mi tation,

p286; Hypotensi on, p312; Ol iguria, p330; Metaboli c acidosi s, p434; Hypothermi a, p516; Pai n, p532

Ovid: Oxford Handbook of Critical Care

Editors: Singer, Mervyn; Webb, Andrew R.

Title: Oxford Handbook of Critical Care, 2nd Edition

Copyri ght ©1997,2005 M Si nger and A R Webb, 1997, 2005 Publ ished in the United States by Oxford Universi tyPress Inc

> Table of Co ntents > Obs tetr ic Emergencies

Obstetric Emergencies

Pre-eclampsia and eclampsia

The hallmark of pre-eclampsia is hypertension wi th protei nuria It i s considered mi ld if proteinuria is 0.25–2g/l and

severe if >2g/l Eclampsia is the same condition associated with seizures They are associ ated with cerebral oedema

and, i n some cases, haemorrhage A reduced pl asma volume, rai sed peri pheral resistance and di sseminated

intravascul ar coagul ati on all i mpai r tissue perfusion, with possible renal and hepati c fai lure Pul monary oedema may

occur secondary to increased peripheral resi stance and l ow col loi d osmoti c pressure

Management

Hypertensive crises and convul si ons may continue for 48h post-partum, duri ng whi ch time close moni toring in a high

dependency or i ntensi ve care area is essential

Circulatory management

High blood pressure i s due to arteri olar vasospasm so controll ed plasma vol ume expansion i s essenti al as thefirst line treatment

P.540

A standard flui d chal lenge regimen may be used in the i ntensive care area wi th li ttl e risk of fl uid overl oad

Oli guria may coexi st with reduced pl asma volume; controll ed vol ume expansion is usual ly more appropriate thandiuretic therapy

If plasma vol ume expansion fail s to control hypertension, anti-hypertensi ves such as labetalol , nifedi pine orhydral azi ne may be used

Convulsions

Convulsions are best avoi ded by good blood pressure control

Ini tial seizure control may be achieved wi th small doses of benzodiazepi nes

Magnesi um sul phate is the treatment of choi ce for eclampti c convul sions Magnesium l evel s should be monitoredand kept between 2.5–3.75mmol /l Above 3.75mmol /l toxi ci ty with possibl e cardiorespiratory arrest may beseen

Prophyl actic anticonvulsant therapy with magnesi um may al so be considered i n pre-ecl ampsia

Excess sedati on shoul d be avoided due to the risk of aspirati on although continued seizures may require el ectiveintubation, mechanical hyperventi lation and further anti convul sant therapy

Early fetal delivery

The definiti ve treatment for eclampsia is fetal del ivery but the needs of the fetus must be balanced against those of

the mother If fetal maturi ty has been reached i mmediate deli very after control of seizures and hyper-tension i s

necessary

Drug dosages

Labetalol Start at 2mg/min IV or quicker if a rapid response is required Labetalol is usually

effective once 200mg has been given after which a maintenance infusion of 5–50mg/h may be continued.

Nifedipine 10mg SL is an often effective alternative, given every 20min if necessary.

Hydralazine 5–10mg by slow IV bolus, repeat after 20–30min Alternatively, by infusion starting

at 200–300µg/min and reducing to 50–150µg/min.

Magnesium 4g over 20min followed by 1–1.5g/h by intravenous infusion until seizures have

stopped for 24h.

Key papers

Magpie Trial Coll aboration Group Do women wi th pre-eclampsi a, and their babies, benefi t from magnesium sulphate?

The Magpi e Trial: a randomi sed pl acebo-controlled tri al Lancet 2002; 359:1877–90

Whi ch anticonvulsant for women wi th ecl ampsia? Evidence from the Coll aborative Eclampsi a Tri al Lancet 1995;

345:1455–63

See also:

Venti latory support—indicati ons, p4; Bl ood pressure monitori ng, p110; Central venous catheter—use, p114; Central

venous catheter—inserti on, p116; EEG/CFM monitori ng, p138; Coagul ati on monitoring, p156; Coll oi d osmotic

pressure, p172; Col loids, p180; Hypotensive agents, p202; Anti convulsants, p242; Fluid chall enge, p274;

Hypertension, p314; General ised sei zures, p372

HELLP syndrome

HELLP syndrome is a pregnancy rel ated disorder associ ated with haemol ysis, el evated li ver function tests and l ow

platel ets Cri teria used for the di agnosi s of HELLP are shown bel ow

Microangi opathi c haemolysis resul ts from destructi on of red cells as they pass through damaged smal l vessel s

Hepati c dysfunction i s characteri sed by peri portal necrosis and hyal ine deposits i n the sinusoids In some caseshepati c necrosi s may proceed to hepatic haemorrhage or rupture

Thrombocytopenia resul ts from increased pl atelet consumption, although prothrombi n time and acti vated parti althrombopl astin time are normal , unli ke in DIC

Clinical features

P.542

P.543

P.544

Epi gastri c or right upper quadrant pai n with malai se

Nausea and vomiting

General ised oedema is usual but hypertensi on is less common Presentation may occur post-partum

Criteria for diagnosis of HELLP syndrome

HaemolysisAbnormal blood filmHyperbi lirubinaemi aLDH >600U/l

Elevated l iver enzymesAST >70U/l

ThrombocytopeniaPlatelets <100 × 109/l

Plasma exchange, p68; Li ver function tests, p152; Full blood count, p154; Coagul ati on monitori ng, p156; Blood

products, p252; Basic resusci tation, p270; Vomiti ng/gastri c stasis, p338; Haemol ysi s, p404; Platel et disorders, p406

Post-partum haemorrhage

Usuall y due to incomplete uterine contraction after deli very, but may be due to retained products The magni tude of

haemorrhage may be severe and l ife threatening

Resuscitation

The principles of resuscitati on are the same as those applying to any haemorrhagi c condition Blood transfusion

requi rements may be massive and there may therefore be a need to replace coagulation factors There may be

si gni ficant retropl acental bleeding which may l ead to underestimati on of blood volume l oss It is safer to manage

fluid and bl ood replacement wi th haemodynamic monitori ng

Aortic compression

Temporary reducti on of haemorrhage may be achi eved by compressing the aorta with a fist pushed firml y above the

umbil icus, usi ng the pressure between the fi st and vertebral column to achieve compression Thi s manoeuvre may

buy ti me whi le defini ti ve surgical repair i s organised

Stimulated uterine contraction

Prostagl andi n F2α injected locall y i nto the uterus or IM is an effective method of stimulating uterine contraction and

may avoid the need for surgery

Arterial occlusion

Angiographi c embolisati on or internal il iac artery l igati on may avoid the need for hysterectomy i n some cases The

disadvantages of these procedures include a signifi cant del ay i n organi sation and, in the latter case, the high fail ure

rate

See also:

Bl ood pressure monitori ng, p110; Central venous catheter—use, p114; Central venous catheter— i nserti on, p116; Ful l

blood count, p154; Coagul ati on monitori ng, p156; Blood transfusi on, p182

Amniotic fluid embolus

An uncommon but dangerous compl icati on of chil dbirth

There i s a hi gh early mortal ity associated wi th acute pul monary hypertension

The ini ti al response of the pulmonary vasculature to the presence of amni oti c flui d is intense vasospasmresulting in severe pulmonary hypertension and hypoxaemia

Right heart functi on is ini ti all y compromised severel y but returns to normal with a secondary phase duri ng whi chthere i s severe left heart fail ure and pul monary oedema

Amniotic fluid contai ns li pid-ri ch parti cul ate material which stimulates a systemic inflammatory reaction In thisrespect the progress of the condi tion i s simi lar to other causes of multiple organ fai lure with associated capil laryleak and dissemi nated intravascul ar coagul ati on

Diagnosis is supported by amni oti c flui d and fetal cel ls in pulmonary artery blood and urine, though thi s finding

is not speci fic for embolus

Management

Management i s enti rel y supportive If amni oti c fluid emboli sm occurs prior to deli very urgent Caesarean secti on must

be performed to prevent further embol isati on

Management of the coagulopathy requires blood product therapy guided by l aboratory assessment of coagul ati on

ti mes In addition, some cases improve after treatment wi th cryopreci pi tate, possible due to the effects of fibronectin

replacement

See also:

Venti latory support—indicati ons, p4; Conti nuous positi ve airway pressure, p26; Pulmonary artery catheter—use,

p118; Pul monary artery catheter—i nsertion, p120; Fluid chall enge, p274; Pulmonary embolus, p308; Heart

fai lure—assessment, p324; Heart fail ure—management, p326; Systemic inflammation/multi organ fai lure, p484

Ovid: Oxford Handbook of Critical Care

Editors: Singer, Mervyn; Webb, Andrew R.

Title: Oxford Handbook of Critical Care, 2nd Edition

Copyri ght ©1997,2005 M Si nger and A R Webb, 1997, 2005 Publ ished in the United States by Oxford Universi tyPress Inc

> Table of Co ntents > Death and th e Dying Patien t

Death and the Dying Patient

Brain stem death

The correct di agnosi s of brai n stem death all ows di scontinuati on of futile venti lation and enables potential retrieval of

organs for donation Diagnosis of brain stem death is usuall y foll owed by asystol e within a few days Before brain

stem function testing can be performed to confirm the diagnosis the pati ent must have an underlying di agnosi s

compatibl e with brai n stem death They must be comatose and non-responsive for at l east 6h and there should be a

minimum of 2h foll owi ng a cardiac arrest There must be no hypothermi a (temperature >35°C), evi dence or suspi cion

of depressant drugs, si gni ficant metaboli c abnormality or muscle rel axant effect The performance of brai n stem

death tests should not proceed until relatives and al l medi cal and nursing staff invol ved wi th the patient have had a

chance to take part i n discussions, al though the test itsel f does not require consent Cessation of mechani cal

ventil ation is seen by many lay peopl e as the final poi nt of death Cl early, this final step i s easi er if al l are aware

that i t i s to happen If organ donation is consi dered, the transplant coordinator should be involved at an earl y stage

Brain stem death testing

Procedures vary international ly In the UK cl inical assessment of brain stem reflexes must be performed by 2 doctors

who have been registered for >5 years An EEG is required in other countries

Pupillary light reflex

Pupil s should appear fi xed in si ze and fai l to respond to a light stimulus

Corneal reflexes

These should be absent bilaterall y

After confi rmi ng that the tympani c membranes are cl ear and unobstructed 20ml iced water i s syri nged i nto the ear.

The eyes woul d normall y devi ate toward the opposi te direction Absence of movement to bi lateral cold stimulation

confirms an absent reflex

Oculo-cephalic reflexes

Al so cal led ‘doll 's eye’ refl exes With the eyelids held open, brisk lateral rotation of the head normal ly produces

opposi te rotati on of the eyebal l as if to fix the gaze on an object This rotation is lost in brain stem death

Gag reflex

The gag refl ex is absent in brain stem death However, the gag refl ex is often l ost i n pati ents who are intubated

Apnoea test

Whi le the refl ex assessments are bei ng performed the pati ent shoul d be pre-oxygenated wi th 100% oxygen The

ventil ator is disconnected and 6l/min oxygen is passed i nto the trachea via a catheter Apnoeic oxygenati on can

sustai n SaO2 for prol onged periods but there is an inevitabl e rise i n PaCO2 whi ch should stimulate respiratory effort

After 3-15mi n of disconnection bl ood gas anal yses are performed until PaCO2 >6.7 kPa Any respi ratory effort negates

the di agnosi s of brai n stem death

See also:

Bl ood gas analysis, p100; EEG/CFM moni toring, p138; Urea and creati nine, p144; Electrolytes

, p146; Toxi col ogy, p162; Opioi d anal gesics, p234; Non-opioid analgesics, p236; Sedati ves, p238; Muscl e rel axants,

p240; Cardiac arrest, p272; Hypogl ycaemi a, p438; Hypothermi a, p516; Care of the potenti al organ donor, p552

Withdrawal and withholding treatment

Thi s i s arguably the most difficult and stressful decision that has to be made for the criti cally il l pati ent Withdrawal

involves reduction or cessati on of vasoactive drugs and/or respiratory support In some ICUs the patient is heavil y

sedated and disconnected from the venti lator Wi thholding i nvolves non-commencement or non-escalati on of

treatment, e.g applying an upper threshol d dose for an i notrope and/or not starting renal replacement therapy

Before approaching the pati ent/famil y, there should ideal ly be a consensus among medi cal and nursing staff that

quanti ty and/or quali ty of life are significantly compromised and unl ikely to recover Often, the pati ent's vi ewpoint i s

very well -defined and the carers may rue the fact that the di scussi on was not i nitiated earli er

Ethni c, cul tural and reli gious factors will i nfl uence both doctor and patient/fami ly in the ti mi ng and frequency of such

decisions In some soci eti es doctors have a more paternal istic approach wi th littl e i nvolvement of patient and/or

family in the deci si on-maki ng process Others are overly inclusive, someti mes to the point of excessi vel y acqui escing

to the famil y's demands despite obvi ous futil ity i n continuing care Cl early, a bal ance needs to be struck that serves

the best interests of the pati ent Although potential ly awkward, the mental ly competent patient should be invol ved in

the most important decision affecti ng thei r life Thi s should be done as considerately as possi ble, avoi ding

unnecessary distress A seri es of discussions over several days may be needed, al lowing ti me to contemplate

Consensus is reached with >95% of patients/famili es by the third discussion

It shoul d be stressed to the pati ent and fami ly that care is not being wi thdrawn/wi thhel d but that pain relief,

comfort, hydration and general nursi ng care are to be continued Likewise, no decisi on is bi ndi ng but can be amended

depending on the pati ent's progress, e.g moving from withholdi ng to withdrawal, or re-insti tution of ful l treatment A

‘negotiated settl ement’ is often a useful interim compromise for fami li es unable to accept a withdrawal deci si on,

whereby l imi tation of treatment i s i nstituted and subsequently reviewed

Rel ati ves can sometimes be very di straught and, occasi onally, i rrati onal on discussing wi thdrawal /withholding For

many, thi s will be their fi rst experience of the dying process in a loved fami ly member A number of other factors

including guil t, anger and wi thi n-fami ly disagreements may also surface It should be stressed that the

withdraw/withhold decisi on shoul d not be l eft to the fami ly alone as thi s i s an unfair burden for them to carry

Rather, i t i s thei r passive agreement with a medical recommendation that is being sought The emphasis of the

discussi on is to inform them of the li kel y outcome and to seek thei r view of what the patient woul d want They need

to be dealt with both sensi tively and honestl y, and they should not feel pressured to gi ve instant decisi ons

Di scussi ons shoul d i nvolve the pati ent's nurse and other i nvol ved carers as appropriate It shoul d be accurately

documented i n the case notes to ensure good communicati on between caregivers and act as source data should

subsequent complai nts surface

See also:

Communication, p564

Care of the potential organ donor

Patients with suspected brain stem death should be consi dered candidates for organ donation unless there is evi dence

The transpl ant co-ordinator should be contacted early (before the fami ly are approached) to confi rm likely suitabi lity

If the famil y are amenabl e, the transpl ant co-ordinator wi ll then ini ti ate organ donati on procedures Do not reject

those brain dead potenti al donors who, for exampl e, have full y treated infections or acute renal fai lure without

consul tation wi th the transpl ant co-ordinator

The transpl ant co-ordinator wi ll advise on other organ and tissue suitabil ity, e.g pancreas, trachea, bowel, ski n

See also:

Bl ood gas analysis, p100; Urea and creatini ne, p144; El ectrol ytes

, p146; Coll oids, p180; Inotropes, p196; Vasopressors, p200; Flui d chal lenge, p274; Hypotension, p312

Ovid: Oxford Handbook of Critical Care

Editors: Singer, Mervyn; Webb, Andrew R.

Title: Oxford Handbook of Critical Care, 2nd Edition

Copyri ght ©1997,2005 M Si nger and A R Webb, 1997, 2005 Publ ished in the United States by Oxford Universi tyPress Inc

> Table of Co ntents > ICU Or gan isatio n and Management

ICU Organisation and Management

ICU layout

The intensi ve care unit shoul d be easil y accessibl e by departments from whi ch patients are admi tted and close to

departments whi ch share engineeri ng servi ces It i s desi rable that cri ti cal ly ill pati ents are separated from those

requi ring coronary care or hi gh dependency care where a quieter environment is often needed It is possible to

provide i ntensive care and high dependency care in the same uni t so l ong as patients can be separated within the

uni t However, the di ffering requirements of these patients may li mit such flexibil ity The floor sizes given bel ow

represent a minimum guide

Size

Intensive care bed requi rements depend on the activity of the hospital with additional beds required for regional