Therapeutic strategies in managing cardiac arrest

Therapeutic strategies in managing cardiac arrest

  • Updated resuscitation guidelines emphasize the need for minimally interrupted high quality chest compressions as a prerequisite for successful resuscitation outcome.
  • Resuscitation involves the integration of complex systems and the interdisciplinary coordination of multispecialty emergency and critical care providers.
  • The immediate period following return of spontaneous circulation (ROSC) is crucial and is dominated by the presence of two critical goals- identification of pathophysiological cause, and the assessment and initiation of time- dependent interventions, directed at preventing recurrent arrest, and improving immediate and long- term outcome.
  • There is no vasopressor or anti-arrhythmic agent whose use is associated with improved outcome at discharge. In-hospital resuscitation should focus on the provision of high quality chest compressions and the search for immediate treatable precipitants of the arrest in those patients who achieve ROSC.
  • A systematic checklist may aid in the systematic evaluation of patients following ROSC.

Management after resuscitation from cardiac arrest

  • Following return of spontaneous circulation, the quality of the treatment provided in the post-arrest period influences outcome.
  • Most patients resuscitated after a prolonged period of cardiac arrest will develop the post-cardiac arrest syndrome.
  • All survivors of out-of-hospital cardiac arrest should be considered for urgent coronary angiography unless the cause of cardiac arrest was clearly non-cardiac or continued treatment is considered futile.
  • Several interventions may impact on neurological out-come, the most significant of these is targeted temperature management.
  • In patients remaining comatose after resuscitation from cardiac arrest, prediction of the final outcome in the first few days may be unreliable. Prognostication should normally be delayed until at least 3 days after return to normothermia and should involve more than one than one mode (e.g. clinical examination combined with another investigation).

Key components of the post-cardiac arrest syndrome.

  • Post- cardiac arrest brain injury- this manifests as coma and seizures.
  • Post- cardiac-arrest myocardial dysfunction –this can be severe and usually recovers after 48 hours.
  • Systemic ischemia/reperfusion response –tissue reperfusion can cause programmed cell death (apoptosis) effecting all organ systems.
  • Persisting precipitating pathology-coronary artery disease is the commonest precipitating cause after OHCA

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Management of Benzodiazepine Poisoning

Key points in Critical Care Medicine

                       “Adapted from Oxford Textbook of Critical Care”

Management of Benzodiazepine Poisoning

  • Benzodiazepines are the drugs most frequently involved in acute self-poisoning.
  • Benzodiazepine overdose usually has a good prognosis. Most patients do well with careful observation and prevention of complications. Supportive care including oxygen, intubation, respiratory support, and fluid administration may be required in some cases.
  • Care should be taken with elderly patients, or those with chronic obstructive pulmonary disease or liver disease. Fast- acting agents and ingestion of other central nervous system depressants, including alcohol, may present an additional risk.
  • Early administration of activated charcoal in fully conscious patients who are able to protect their airway is only needed if there are co-ingestants.
  • Flumazenil may help confirm the diagnosis, improve alertness, and prevent the need for respiratory support in some patients, especially after accidental poisoning in children. Contraindications include patients on long-term treatment and/or dependent on benzodiazepines, or those who have simultaneously ingested proconvulsant or prodysrhythmic substances, or at risk of increase intracranial pressure.

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Extracorporeal liver support devices in the ICU.

Key points in Critical Care Medicine

Extracorporeal liver support devices in the ICU.

 “Adapted from Oxford Textbook of Critical Care”

  • There is an unmet need for a liver support system because of the increasing shortage of organs for transplantation and the complications associated with the procedure.
  • In theory, acute liver failure and acute decompensation of chronic liver disease secondary to a precipitating event are potentially reversible. In this context, an extracorporeal liver support can temporarily substitute liver functionality to allow natural recovery through regeneration of hepatocytes and elimination of the precipitating event.
  • Goals of liver support system are to provide all functions of the liver, including synthetic and metabolic functions, and to remove as well as reduce the production of pro-inflammatory mediators to attenuate the inflammatory process.
  • Currently existing devices are either purely mechanical and/or cell-based. Detoxification is provided by both systems, but biological activities are limited only to the cell- based systems. Albumin dialysis is the major component of mechanical devices because albumin is irreversibly destroyed in liver failure.
  • Cell-based or bio-artificial systems are essentially ‘mini-livers’, but their success is limited by the lack of a continuous and abundant supply of high-quality hepatocytes.

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Pathophysiology, causes, and management of acute hepatic failure

Key points in Critical Care Medicine

Pathophysiology, causes, and management of acute hepatic failure

“Adapted from Oxford Textbook of Critical Care”

  • Acute liver failure (ALF) is a rare, life-threatening clinical syndrome occurring in a person with no prior history of liver disease.
  • Acute liver failure (ALF) occurs in patients with acute hepatic necrosis resulting in hepatic encephalopathy, jaundice, and coagulopathy.
  • Acute liver failure is a multisystem disorder.
  • Viral hepatitis is the most common cause of ALF worldwide, with drug-induced liver failure the most common in the developed world.
  • ALF is a multi-system disorder resulting in encephalopathy, coagulopathy, systemic inflammatory response syndrome, and multi-organ failure.
  • Patients can be prothrombotic or have balanced coagulation disorders.
  • Several classifications exist incorporating time to encephalopathy from the onset of jaundice. O’Grady’s classification is the most widely used.
  • The management is initially supportive. Intravenous N-acetylcysteine is recommended for all patients.
  • Elective intubation is recommended for all patients who develop Grade III hepatic encephalopathy.
  • Liver transplantation is an appropriate and viable treatment for ALF. Early and safe transfer to a transplant centre for transplant assessment is advised.

Classification      Time of onset jaundice to encephalopathy

Hyper acute            0-1 weeks

Acute                     1-4 weeks

Subacute                4-26 weeks

Causes

  • Paracetamol, ischemia, recreational drugs, toxins (amanita)
  • Hepatitis B,A, and E
  • Non-paracetamol drug-induced liver injury, seronegative
  • Hepatitis.

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Immunomodulation strategies in the critically ill

Immunomodulation strategies in the critically ill

  • Severe sepsis is the result of an infectious stimulus that triggers a hyper-inflammatory response and results in multiple organ failure. This hyper immune response triggers a phase of immunoparalysis that results in the patient’s inability to resist and clear infections, causing the delayed mortality observed is some septic patients.
  • The inflammatory and coagulation cascades are closely linked such that a significant aspect of the disease process is attributed to the activation of the coagulation cascade by circulating inflammatory mediators.
  • Therapeutic approaches to sepsis have targeted the hyper-inflammatory response, inhibition of the subsequent coagulation cascade, and immunostimulation during the immunoparalysis phase.
  • Proven beneficial therapies for sepsis are limited to the mechanical eradication of the source of infection, antibiotics to clear the organism, the judicious use of fluids to support organ perfusion, and oxygen supplementation. Studies evaluating immunotherapeutics for the treatment of severe sepsis have failed to show efficacy in clinical trials.
  • Further research may demonstrate effectiveness using a strategy of targeting therapies based on an improved identification of the patient’s phase of sepsis, use of combination therapies, a better understanding and strategy aimed at specific host-organism interactions, and /or better specified therapies in relation to identified biomarkers.

Conclusion:

  • Studies evaluating the use of immunotherapeutics for severe sepsis are plagued with multiple confounding factors including the pre-dominant phase of sepsis (hyperimmune versus hypoimmune), differing offending organisms, differing host-organism interactions, heterogeneity in the patient populations, and underpowered study designs.
  • Perhaps the correct immunotherapy will need to be tailored in order to decrease the immune response in the hyperimmune phase and increase it during the hypoimmune phase. In order to do so, better markers of these phases of sepsis are needed. Further studies may also find more efficacy in using multiple therapies simultaneously to obtain best results.
  • Finally, there exists a close interaction between in the immune and coagulation system. Further study of this link and therapies to temper the coagulation cascade many prove to be a successful modality of therapy in order to halt the body’s progression to multiple organ failure.

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Antidepressants in Critical Illness

Key points in Critical Care Medicine:

Antidepressants in critical illness

“Adapted from Oxford Textbook of Critical Care-Oxford University Press 2016”

  • Selective serotonin reuptake inhibitors (SSRIs), Serotonin Norepinephrine reuptake inhibitors (SNRIs), Bupropion and Mirtazapine are typically the first-line agents for the treatment of depression in the intensive care unit (ICU) setting given their safety and tolerability.
  • Serotonin syndrome is a significant risk in overdose of most antidepressants and can also be seen in the setting of combining more than one antidepressant.
  • Stimulants can be used safely and effectively to treat apathy, loss of appetite, and low energy in ICU patients.
  • Antidepressants should typically be continued during ICU stays (except in the presence of delirium), as abrupt cessation may produce withdrawal phenomenon.
  • Current evidence does not recommend prophylactic initiation of antidepressants following trauma.

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Managing ICU Staff Welfare, Morale, and Burnout

Key points in Critical Care Medicine:

Managing ICU staff Welfare, Morale, and Burnout

 “Adapted from Oxford Textbook of Critical Care-Oxford University Press 2016”

  • The intensive care unit (ICU) environment exposes staff to stressful and emotionally-demanding situations, which places them at high risk for burnout.
  • Risk factors for Burnout can be found at both individual and organization levels.
  • Consequences of low morale and burnout include personal distress for clinicians, poor quality of care for patients, and highly health care costs for organizations and society.
  • Staff engagement is emerging as the antithesis of burnout.
  • We need to promote a wider recognition among ICU staff regrading risks of burnout and the consequences for both them and the patients in their care.

Potential phases of Burnout

  • The need to prove oneself: often occurring in highly motivated and ambitious individuals.
  • Working harder: high personal expectations emerge as further work commitments are undertaken.
  • Neglecting personal needs: no time or energy is reserved for activities or relationships outside the workplace.
  • Displacement of conflict: The individual is unable to identify the cause for their difficulties.
  • Revision of values: isolation from family and friends with a solely job- related value system.
  • Denial: cynicism, aggression, and intolerance of others emerge, leading to isolation.
  • Behavioral changes become more apparent to others: e.g conflict.
  • Depersonalization: loss of appreciation for self and self- worth. Cannot appreciate further success.
  • Inner emptiness: may seek an activity to full the void such as eating, drugs, etc.
  • Depression: typical affective, cognitive and somatic features are present.

Burnout ensues: complete physical and emotional collapse.

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