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Current theories on the concept of a post-resuscitation syndrome describe the development of a systemic inflammatory response/sepsis following resuscitation from cardiac arrest. Critical care treatments during the post-resuscitation phase should focus on correcting hypoxia and hypercarbia, optimizing organ perfusion, identifying and treating the underlying cause of the cardiac arrest and optimizing neurological outcomes. Several randomized controlled trials and a meta-analysis have shown that therapeutic hypothermia is associated with improved survival and neurological outcome in initially comatose survivors of cardiac arrest. Observational studies in cardiac arrest survivors have shown that hyperglycaemia after return of spontaneous circulation is associated with an adverse outcome. Myocardial dysfunction is common after cardiac arrest and usually starts to improve within 72 hours after return of spontaneous circulation. Acidosis and control of seizures are explained in this chapter. The ability to predict the likely neurological outcome of a patient following admission to critical care is important.
An immunosuppressed patient is unable to mount the normal, co-ordinated immune response to trauma and infection. Respiratory failure or sepsis are the commonest reasons for immunosuppressed patients to require ICU admission. Respiratory failure can result from multiple simultaneous pulmonary processes, both infectious and noninfectious. As a consequence of both the primary illness and its treatment, patients with malignancies are prone to episodes of neutropenia. Despite rigorous screening, transmission of infection from the donor organ can occur. With the advent of highly active antiretroviral therapy (HAART), the prognosis of patients with HIV and AIDS has improved enormously. Splenic macrophages have an important filtering and phagocytic role in removing bacteria and parasitized red cells from the circulation. Life-threatening infection is a major long-term risk post splenectomy. Most serious infections are due to encapsulated bacteria. Lifelong antibiotics should be offered to all patients; however, the first 2 years post splenectomy appear especially important.
Oxygenation is one of the primary gas exchange functions of the lung. This chapter reviews how to assess the adequacy of oxygen uptake and, in the context of the mechanisms of arterial hypoxaemia, examines how this can be improved in the mechanically ventilated patient. The oxygenation assessment has two facets, one pulmonary, and one extra-pulmonary. Oxygen moves from the alveolar gas to the pulmonary capillary blood by diffusion. Currently in the UK, as with high-frequency oscillatory ventilation (HFOV), airway pressure release ventilation (APRV) is typically used as a rescue technique for those failing to achieve adequate oxygenation with conventional ventilation. The diffusion coefficient for a gas is proportional to the gas's solubility in the medium through which the gas has to diffuse, and is inversely proportional to the square root of the gas's relative molecular mass. Imbalance between pulmonary ventilation and pulmonary perfusion is the most common cause of hypoxaemia.
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