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Acknowledgements
xii
Fiona J Lamb MBBS FRCA FFICM Consultant in Anaesthesia and
Intensive Care Medicine
Nick Lees FRCA EDIC FFICM Consultant in Anaesthesia and
Intensive Care Medicine
Donald Leith MRCP MBBS
iBSc (Hons)
Clinical Research Fellow in
Acute Medicine
Finnian D Lesser MBChB MRCP Acute Medicine and Intensive
Care Registrar
Robert Loveless MBChB
FRCA FFICM
ST6 Anaesthetics and Intensive
Care Medicine
Jennifer Macallan
BSc MBBS FRCA
ST5 Anaesthetics
Claire Mearns MBChB
FRCA FFICM
Consultant in Anaesthesia and
Intensive Care Medicine
Patrick Morgan MBChB
FRCA FFICM
Consultant in Anaesthesia and
Intensive Care Medicine
Aikaterini Papadopoulou
MBBS FRCA FCAI PGDip Cert
Maths (Open)
ST7 Anaesthetics
Elizabeth Potter BSc (Hons)
MRCP FRCA FFICM
Consultant in Anaesthesia and
Intensive Care Medicine
Nicola Raeside MBBS
BSc(Hons) DipABRSM
CT1 Anaesthetics
Sameer Ranjan MBBS
FCARCSI EDIC
Consultant in Anaesthesia and
Intensive Care Medicine
Alana Rochester
MBChB BSc MRCP
IMT3 Registrar in General Medicine
Mark Salmon MBBS
FRCA DipIMC
Consultant Anaesthetist
Thomas Sanderson
MBBS MmedEd
Clinical Fellow in Intensive Care
Medicine and Critical Care
Echocardiography
Eleanor de Sausmarez
BMBS BmedSci (Hons) MSc
MRCEM FRCA
ST4 Anaesthetics and Intensive
Care Medicine
Matthew Sinnott MB ChB (Hons)
BSc (Hons) FRCA
ST6 Anaesthetics
Amybel Belladonna
Taylor BSc MBChB
IMT3 in General Medicine
Patrick Thorburn MBChB
BSc(Hons) PGDip FRCA FFICM
Consultant in Anaesthesia and
Intensive Care Medicine
Andrew Williams
BMBS MRCP MRCA
ST3 Anaesthetic Trainee
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List of Abbreviations
ABG Arterial blood gas
ACT Activated clotting time
AF Atrial fibrillation
AKI Acute kidney injury
APACHE Acute physiology and chronic health evaluation
ARDS Acute respiratory distress syndrome
ATLS® Advanced trauma life support
ATP Adenosine triphosphate
BP/SBP/
NBP/IBP
Blood pressure/systolic blood pressure/non-
invasive blood
pressure/invasive blood pressure
bpm Beats per minute (heart rate)
BSA Body surface area
CABG Coronary artery bypass graft
CAP Community acquired pneumonia
CD4 Cluster of differentiation 4
CMV Cytomegalovirus
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPB Cardiopulmonary bypass
CPR Cardiopulmonary resuscitation
CRP C-
reactive protein
CSA Cross-
sectional area
CSF Cerebrospinal fluid
CT Computed tomography
CTA Computed tomography angiography
CTPA Computed tomography pulmonary angiography
CVC Central venous catheter
DC Direct current
DIC Disseminated intravascular coagulation
DKA Diabetic ketoacidosis
DNACPR Do not attempt cardiopulmonary resuscitation
EBV Epstein–Barr virus
ECMO Extracorporeal membrane oxygenation
ED Emergency department
ERCP/MRCP Endoscopic retrograde cholangiopancreatography/magnetic
retrograde cholangiopancreatography
ETT Endotracheal tube
FBC Full blood count
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List of Abbreviations
xiv
FEV1 Forced expiratory volume in 1 second
FRC Functional residual capacity
FVC Forced vital capacity
GABA Gamma-
aminobutyric acid
GBS Guillain–Barré syndrome
GCS Glasgow Coma Scale
HFNC/HFNO High-
flow nasal cannulae/oxygen
HIV Human immunodeficiency virus
HR Heart rate
IABP Intra-
aortic balloon pump
IBW Ideal body weight
ICP Intracranial pressure
INR International normalised ratio
IV Intravenous
LOS Length of stay
LV Left ventricle
LVOT Left ventricular outflow tract
MDT Multidisciplinary team
MRA Magnetic resonance angiography
MRI Magnetic resonance imaging
NG Nasogastric
NIV Non-
invasive ventilation
PEEP Positive end-
expiratory pressure
PLAPS Posterolateral alveolar and/or pleural syndrome
Plat Platelets
RCUK Resuscitation Council UK
ReSPECT Recommended summary plan for emergency care
and treatment
ROSC Return of spontaneous circulation
RR Respiratory rate
RV Right ventricle
SBT Spontaneous breathing trial
SOFA Sequential organ failure assessment
SVV Stroke volume variation
TEG Thromboelastography
TOE Transoesophageal echocardiography
TTE Transthoracic echocardiography
U&E Urea and electrolytes
US Ultrasound
VTI Velocity time integral
WBC White blood count
WHO World Health Organization
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I
Introduction
Part
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Clinical Cases in Critical Care, First Edition. Alice Myers and Theophilus Samuels.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
A Brief
Introduction
to Critical Care
1
Setting the scene
Critical care is a specialised form of healthcare, usually a department within a
hospital (often called the intensive care unit or ICU), which can provide organ
support and invasive monitoring for a patient while treating a reversible illness.
Working in ICU can be rewarding and challenging. The aim of this introduc-
tion is to give you a brief overview of critical care with an idea of what it can
and cannot oer, and its context within the hospital.
Although the life-
saving possibilities are often remarkable, many of the
techniques used for providing critical care support can be aggressive, with the
potential to cause discomfort and psychological distress for both the patient
and their family. In addition, critical care is resource heavy, has limited avail-
ability and is expensive to deliver. For these reasons, the ‘reversibility’ of a
patient’s condition is an important consideration when deciding whether or
not to admit. A risk versus benet assessment is always appropriate– risk
being the degree of harm you may cause the patient through applying your
organ support interventions, and benet being the likelihood that you will
be able to reverse the acute illness and return the patient to an acceptable
quality of life.
Throughout the book, we will often use the terms ‘critical care’, ‘intensive
care’ and ‘ICU’ interchangeably. Although dierent hospitals may draw prac-
tical distinction between areas, for the purposes of this book, HDU (high-
dependency unit) or level 2 care can be assumed to be included as part of
critical care unless otherwise specied.
It is worth noting that medical knowledge inevitably advances over time.
Conditions which were terminal 20 years ago may well be considered revers-
ible now. So, one must be cautious when discussing patient selection. It is not
usually acceptable to refuse admission based on advanced age alone or the
presence of cancer. Sometimes you may wish to admit a patient for a lower
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Clinical Cases in Critical Care
4
level of critical care with an ‘escalation plan’ in place, ensuring that, should the
patient’s condition deteriorate, there would be no progression to more invasive
and ultimately futile treatments. For instance, a physically frail 85 year old with
urosepsis and hypotension might be an excellent candidate for vasopressors and
antibiotics but may not benet from intubation and ventilation in the context
of multiorgan failure secondary to severe pneumococcal sepsis.
Approximately 15–20% of patients in critical care in the UK will die
before leaving hospital. ICU mortality is usually higher for patients with
acute medical pathologies compared with high-
risk elective postoperative
patients. Recognising when a patient is dying is an important skill but
identifying when efforts are futile is not always easy or possible. Timely
acknowledgment that the patient is in the terminal phase of life, combined
with sensitive and frank communication, allows carers to consider chang-
ing the focus of care from aggressive resuscitation to prioritising comfort,
dignity and time with family.
The COVID-
19 pandemic (which occurred during the writing of this
book!) thrust critical care into the public eye. The pandemic was a dicult
period for everyone working in ICUs throughout the world. The challenges
were many:
Academic
Rapidly learning as much as possible about an unfamiliar disease
and its management.
Physical
Caring for an overwhelming number of patients while wearing
restrictive personal protective equipment.
Increased need for manual handling due to frequent implementation
of prone positioning.
Increased working hours for many healthcare professionals.
Psychological
The emotional challenge of seeing so many patients succumb to this
terrible disease while their relatives were unable to spend time with
them due to quarantine.
Moral injury sustained through the impact of allocating limited
resources in the face of overwhelming demands.
Many ICU staff suffered burnout or post- traumatic stress dis-
order (PTSD).
However, the pandemic also allowed us to learn a great deal about such things
as the importance of teamwork, psychological support, mutual aid within critical
care networks, video- conferencing and the use of technology to share information.
Perhaps the period which follows the pandemic will be a time for post- traumatic
growth with new positive developments in light of the lessons learned.
The ICU and its role within the hospital
Levels of care
The UK National Health System (NHS) uses the following denitions:
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A Brief Introduction to Critical Care
5
Level Denition
0 Needs can be met through normal ward care in an acute hospital
1 Patients are at risk of deteriorating
– care needs can be met on an acute ward
with additional support from ICU or critical care
outreach services
2 More detailed observation or support is needed, e.g. where there is single
organ failure or where the patient has undergone major surgery, or where
patients are ‘stepping down’ from level 3
3 Either advanced ventilation alone is required, or two or more organ systems
are failing
Some hospitals have ‘Level 1+’ or ‘Enhanced Care’ units. These are able to
oer specialised postanaesthetic care to surgical patients who do not require
management in a level 2 or HDU area but who need more than can be deliv-
ered in a level 1 unit.
Bed capacity
In 2016–17, the NHS reported it had 5912 critical care beds (levels 1 and 2)–
68% adult, 32% children or infants. Wong etal. (SNAP-
2 and EPICCS collab-
orators) found in 2019 that the UK had a median of 2.7 critical care beds per
100 hospital beds (compared with, for instance, 3.7in Australia and 3.5in
New Zealand).
It is dicult to directly compare the number of critical care beds in dier-
ent countries around Europe since the denitions are heterogenous. However,
one study published in 2012 (Rhodes etal., Crit. Care Med.) found that, per
100
000 of the population, the number of critical care beds diered widely
across Europe– 6.6in the UK, 11in Switzerland, 21.4in Romania, 21.8in
Austria, 11.6in France, 29.2in Germany.
Bed capacity (i.e. the number of staed beds available) aects a hospital’s
ability to deliver elective services since emergencies will take priority. Insuf-
cient critical care bed capacity can lead to cancellation of high- risk surgical
procedures, delays in delivering life-
saving treatment and an increase in non-
clinical interhospital transfers.
‘Surge capacity’ is a term used to describe the additional critical care beds
which can be rapidly created during times of increased demand– for instance
during a pandemic. The total number of critical care beds in the UK at the peak
of the COVID-
19 pandemic was not available at the time of writing. However,
many units doubled, tripled or quadrupled their ICU capacity in response to
the overwhelming number of patients. Some centres created de novo tempo-
rary ICUs in dierent wards within their hospitals. It should be remembered
that these units will often not have had the infrastructure of a purpose- built
ICU (e.g. wall- piped oxygen, store cupboards appropriately stocked, ICU reg-
ulation ventilation levels, etc.). These temporary ICUs were sometimes in
distant isolated sites, staed by non- intensivists, had a lower sta- to- patient
ratio, and used non- standard equipment (e.g. anaesthetic machine ventila-
tors). ‘Surge capacity’ beds are temporary and not included in the numbers
otherwise quoted here.
Levels of care
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Clinical Cases in Critical Care
6
What can be offered in critical care?
Many hospitals have a ‘general’ adult ICU which cares for a mixed population
of medical and surgical patients aged over 16
years. These units vary in size
from a handful of beds to some with more than 100 beds. In 2015, NHS Digital
reported that patients aged over 50
years accounted for 77% of the 271 079
critical care episodes in its analysis. Demographics vary between units but
nationally, males accounted for 56% of admissions.
Subspecialty critical care such as neurology and neurosurgery, cardiothoracic
and liver can be integrated into a larger general unit or managed in a dened,
ring- fenced specialist unit. Children and neonates are usually cared for in sep-
arate paediatric and neonatal critical care units.
Although some of the following techniques can be oered in other specialised
areas of the hospital (e.g. operating theatres, coronary care units, acute medical
units), the equipment and training required usually necessitates admission to
ICU. This list is not exhaustive:
Advanced monitoring
Techniques requiring invasive catheterisation
Intra- arterial blood pressure monitoring.
Central venous pressure monitoring.
Cardiac output monitoring, e.g. pulse contour analysis.
Techniques requiring specialist interpretation that may be more easily
undertaken in a higher level of care area
Continuous electroencephalogram.
Frequent thromboelastography.
Intracranial pressure monitoring.
Serial echocardiography.
Respiratory
Invasive and non- invasive ventilation.
Extracorporeal carbon dioxide extraction.
Extracorporeal membrane oxygenation (primarily venovenous).
High- frequency oscillatory ventilation.
Cardiovascular
Vasopressor drugs.
Inotropic drugs.
Intra- arterial balloon pumps.
Extracorporeal membrane oxygenation (primarily venoarterial).
Mechanical assist devices, e.g. left or right ventricular assist devices.
Renal
Continuous venovenous haemoltration and haemodialtration.
Other
Molecular adsorbent recirculating system (MARS
®
) for liver failure.
Extracorporeal cytokine adsorption devices for sepsis.
Interface with the hospital
Critical care interacts with the whole hospital, in particular supporting the
work of the emergency department, operating theatres and acute medical
teams. The nuances of individual departmental relationships are unique to
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A Brief Introduction to Critical Care
7
each organisation but there are usually rules or agreements which act as a
framework for these interactions. Examples include the following:
Referral systems– the specic logistics may vary (e.g. verbal versus digital
referrals and whether a consultant or registrar receives referrals) but the
Guidelines for the Provision of Intensive Care Services (GPICS V2.1)
makes the following recommendations:
Decisions to admit to ICU must be discussed with the ICU consultant.
There should be a process to review referrals and associated
decision making.
Open and closed units– the traditional ‘open’ model of ICU allowed phy-
sicians and surgeons to admit to ICU and invite review by intensivists
at their own discretion. The ‘closed’ model has been shown to result in
improved morbidity and mortality. In this model, only intensivists have
admitting rights to the ICU and the critical care team is responsible for
the patient’s care while they remain an inpatient on the unit. Some spe-
cialist units have a modied closed system whereby, for instance, neuro-
surgeons may share admitting rights to a neurocritical care alongside the
neurointensivists.
Critical care without walls– this concept was developed to improve rec-
ognition and response to deteriorating patients in the rest of the hospital
by expanding the role and inuence of intensivists beyond the four walls
of the ICU. Critical care outreach teams play a key role here.
The critical care team
This list is a general overview for the UK and similar countries.
Doctors–by training, doctors in critical care are usually a mixture of inten-
sivists, physicians and anaesthetists although some other specialist doctors,
e.g. microbiologists, also work routinely in critical care units. The Intensive
Care Society (ICS) recommends that ICU should be led by a consultant
intensivist with a consultant to patient ratio of up to 1:8 to 1:15. During
the COVID- 19 pandemic, this was temporarily reduced to 1:30 due to the
increased volume of patients. The ICU resident to patient ratio should be
up to 1:8. Residents include trainees, specialty doctors and advanced criti-
cal care practitioners (ACCPs). GPICS V2.1 recommends that consultant-
led ward rounds should occur twice per day and all critical care admissions
should be reviewed by a consultant within 12 hours of admission.
Nurses–nursing ratios dier according to the level of care. It is recom-
mended that the nurse to patient ratio is 1:1in level 3 and 1:2in level 2.
The nursing team should be led by a senior, experienced nurse. There
should also be additional supernumerary nurses available and a clinical
co- ordinator. ICU nurses are also often heavily involved in teaching and
training around the hospital. Some ICU follow- up clinics are nurse led.
The value and range of work done by critical care nurses is immense.
Critical care outreach–GPICS V2.1 standards state that there should
be a clear hospital- wide mechanism for recognising the deteriorating
patient and a clearly documented escalation process. An early warning
system must be in place, e.g. NEWS (National Early Warning System). An
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Clinical Cases in Critical Care
8
outreach or rapid response team is recommended to be available 24 hours
per day, 7days per week. There is NICE guidance for outreach services
(NG 94, chapter27, 2018). The National Outreach Forum dened seven
core elements of outreach in 2018 (PREPARE).
Patient track and trigger
Rapid response
Education, training and support
Patient safety and clinical governance
Audit, evaluation and monitoring of patient outcome and continuing
quality care
Rehabilitation after critical illness
Enhancing service delivery
Pharmacists–GPICS V2.1 recommends that each ICU should have a
dedicated pharmacist and should have access to an Advanced Stage II
(excellence-
level) pharmacist. Pharmacy services should be available for
advice 24
hours per day, 7 days per week.
Physiotherapists–physiotherapists should be involved in rehabilitation of
critical care patients (NG 83). They play a vital role in helping to reduce
the muscle weakness and reduced mobilisation which often accompany
critical illness. Chest physiotherapy, involving positioning, percussive
techniques, suctioning and breathing exercises, can be extremely useful
in preventing ventilator-
associated pneumonias and improving weaning
from mechanical ventilatory support.
Psychologists–GPICS V2.1 and NG 83 are both clear in stating the value of
regular psychological assessment throughout a patient’s ICU admission.
Psychologists are essential in the detection, assessment and management of
psychological trauma and play an integral role in successful post- ICU reha-
bilitation. In addition, the importance of providing psychological support for
critical care sta and preventing burnout is increasingly being recognised.
Dietitians–provision of nutrition for critically unwell patients is often
complex, with patients at high risk of malnutrition. GPICS V2.1 recom-
mends that ICUs should have access to a dietitian during working hours
and that they should form an integral part of the multidisciplinary team
(MDT), being involved in critical care meetings and training.
Speech and language therapists–SALT input is hugely important in the
management of patients with impaired communication, e.g. due to tra-
cheostomy, and those with swallowing diculties. The SALT team can
help with diagnosis (performing procedures such as ne endoscopic eval-
uation of swallowing and videouoroscopy), rehabilitation and teaching
techniques for long- term management of irreversible problems.
Healthcare assistants–HCAs carry out a large range of vital clinical and
non- clinical tasks within critical care. These include recording obser-
vations, undertaking personal care, ordering medical consumables and
restocking clinical areas.
Allied support staff –these include ward clerks, managers, porters,
orderlies and domestics. Without support sta, critical care would be
unable to function eciently.
Advanced critical care practitioners and physician’s associates–increas-
ingly, critical care units are encouraging development of the ACCP and
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