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The inflammatory response is a central component of sepsis as it drives the physiological alterations that are recognized as systemic inflammatory response syndrome (SIRS). In contrast to the hypothesis of exuberant inflammatory response in sepsis is the finding that septic patients may have a relative anti-inflammatory environment. Cellular death may be a key factor in sepsis and its related mortality. Cells that are destined to die can do so by two mechanisms: apoptosis and necrosis. In sepsis, cytokine-induced coagulopathy triggers increased activity of tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1) and decreased levels of the natural anticoagulant protein C on mononuclear and endothelial cells. Critical illness related corticosteroid insufficiency (CIRCI) occurs as a result of either a decrease in adrenal steroid production. In patients with severe sepsis, a strategy of glycaemic control using intravenous insulin should include a nutritional protocol with preferential use of the enteral route.
This chapter discusses the cell-based model of coagulation, regulation of coagulation, and bleeding disorders. The disorders include congenital disorders and acquired disorders such as thrombocytopenia, disseminated intravascular coagulation (DIC) and microangiopathic haemolytic anaemia. Thrombocytopenia may occur because of impaired production, sequestration, increased consumption, and enhanced degradation. Activated protein C has been shown to reduce mortality in sepsis especially in patients with DIC and multi-organ failure. During the resuscitation of patients who have suffered a major haemorrhage, factors that can contribute to associated coagulopathy are: hypothermia, metabolic acidosis, and consumption of clotting products. Heparin-induced thrombocytopenia (HIT) usually occurs 5-10 days following exposure to heparin. It is a pro-thrombotic disorder and can lead to significant venous and arterial thrombosis. HIT usually resolves following the discontinuation of heparin over a few days. Management includes the prompt removal of all heparin containing medication and the substitution of a direct thrombin inhibitor to control clotting.
The initial assessment of the critically ill patient should begin with a brief, targeted history and an appraisal of the patient's vital signs to identify life threatening abnormalities that merit immediate attention. The goals of resuscitation are usually achieved by the use of supplemental oxygen, fluid or red blood cell transfusion, inotropic support or antibiotics as needed. Physiological Scoring Systems (PSS) developed from the recognition that critically ill patients, and in particular patients who suffered cardiac arrests, often had long periods of deterioration before the crisis or medical emergency occurred. Medical emergency teams (METs) and critical care outreach (CCO) teams aim to provide critical care skills rapidly to critically ill patients. Referrals to the critical care services may happen from any level, but the final decision to admit a patient to a critical care bed should be made by an experienced critical care physician.
The critical care unit manages patients with a vast range of disease and injuries affecting every organ system. The unit can initially be a daunting environment, with complex monitoring equipment producing large volumes of clinical data. Core Topics in Critical Care Medicine is a practical, comprehensive, introductory-level text for any clinician in their first few months in the critical care unit. It guides clinicians in both the initial assessment and the clinical management of all CCU patients, demystifying the critical care unit and providing key knowledge in a concise and accessible manner. The full spectrum of disorders likely to be encountered in critical care are discussed, with additional chapters on transfer and admission, imaging in the CCU, structure and organisation of the unit, and ethical and legal issues. Written by Critical Care experts, Core Topics in Critical Care Medicine provides comprehensive, concise and easily accessible information for all trainees.
The passing of a postgraduate examination in intensive care medicine (ICM) identifies the successful individual to all as someone who has been trained to a high standard in ICM. The knowledge required to thrive in clinical practice as well as examinations in ICM is broad based involving most hospital speciality areas. This chapter focuses on two examinations, namely, the Intercollegiate Diploma in Intensive Care Medicine (DICM), and European Diploma in Intensive Care Medicine (EDIC). Success in professional examinations requires a substantial investment of time. Candidates preparing for examinations must avail themselves of all the educational opportunities at local, regional and national levels in ICM. In the UK, there are many specialist society ICM meetings such as the Intensive Care Society. The internet offers a wealth of useful websites relating to ICM and all can be used to prepare for diploma examinations. Preparation for diploma examinations extends ICM knowledge.