Anaesthesia
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Liver injury or failure is observed in up to 20% of patients admitted to the intensive care unit and is associated with poor prognosis. Timely recognition and initiation of appropriate management are the most important steps in minimising adverse outcome for patients. Distinguishing between primary or secondary liver failure, and between acute or chronic liver disease aids appropriate management. ⋯ We focus on interpretation of patterns of deranged liver biochemistry and the necessary investigations required to identify the related aetiologies. We also propose an evidence-based approach to the management of liver failure and its extrahepatic manifestations. This review, in addition, clarifies when to seek expert advice or refer patients to a tertiary centre.
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Close liaison with ICU-trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients- this should be done while monitoring closely for refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient-centred outcomes including complications and mortality. ⋯ It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post-pyloric feeding and a multidisciplinary framework to support the importance of nutritional education.
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Maternal critical care is a developing area of clinical practice. Looking after a critically ill woman requires a multidisciplinary team that must endeavour to maintain the relative normality of pregnancy. ⋯ The management of a critically ill obstetric patient must reflect, as closely as possible, the management of critical illness outside pregnancy. We will discuss some of the current evidence and concepts around this emerging area in obstetrics, including enhanced maternity care, maternal medicine networks and clinical care.
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Viral infections form a substantial part of the intensive care workload, even before the recent and ongoing COVID-19 pandemic. The growing availability of molecular diagnostics for viral infections has led to increased recognition of these pathogens. This additional information, however, provides new challenges for interpretation and management. ⋯ We will also discuss herpesviridae complications, commonly seen due to reactivation of latent infections. Further, we explore some rarer and emerging viruses, including recognition of viral haemorrhagic fevers, and briefly discuss post-viral syndromes which may present to the intensive care unit. Finally, we will discuss infection control and its importance in preventing nosocomial viral transmission.
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Propfol-remifentanil-based total intravenous anaesthesia has dominated recent clinical practice due to its favourable pharmacokinetic profile. Interruption in remifentanil supply has presented an opportunity to diversify or even avoid the use of opioids and consider adjuncts to propofol-based total intravenous anaesthesia. Propofol, while a potent hypnotic, is not an effective analgesic. ⋯ We provide an overview of both target-control and manual infusion regimes for the alternative opioids: alfentanil, sufentanil and fentanyl. The optimal combination of hypnotic-opioid dose, titration sequence and anticipated additional postoperative analgesia required depend on the chosen combination. In addition, we include a brief discussion on the role of non-opioid adjuncts in total intravenous anaesthesia, suggested doses and expected reduction in propofol dose.