Management of the airway in intensive care Publication date: Available online 25 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Miles Beeny, Arno Crous Abstract Airway management in the intensive care unit (ICU) is largely uneventful; there is a higher incidence of airway difficulties, however, than those encountered in the operating suite. Management of the airway in the ICU presents challenges unique to this environment that must be coped with by a multidisciplinary team that may be less experienced in airway management than clinicians in the operating theatre. The risks associated with this situation, we believe, may be ameliorated by planning and forethought. This article outlines some of the specific difficulties faced by clinicians in ICU and attempts to provide some guidance as to how these may be overcome, or at least abated. Drug and equipment choices are discussed. A suggestion for a difficult airway algorithm for use in the ICU is put forward. The timing of tracheostomy is discussed. Finally, the importance of the team and the human factors that are at play are touched upon.

Ventilatory support in the intensive care unit Publication date: Available online 21 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Eumorfia Kondili, Athanasia Proklou, Aikaterini Vaporidi Abstract This article focuses on the functional features of positive-pressure ventilators, the modes of invasive and non-invasive mechanical ventilation, and the main ventilator settings. It also highlights the potential complications of mechanical ventilation, the basic principles of weaning, and the pathophysiological basis of patient-ventilator dyssynchrony.

Self-assessment Publication date: Available online 19 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Vijayanand Nadella

Field anaesthesia and critical care equipment used by the British Military Publication date: Available online 19 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Emma L. Watson, Jonathan A. Round Abstract This article provides a description and discussion of the key equipment used by the British Defence Medical Services (DMS) to provide anaesthesia and critical care in the field. There is a need to balance equipment clinical capability against its suitability for use in the field. By necessity, military anaesthesia and critical care equipment should be robust, portable, compact, easy to use, easy to maintain and clean, and require minimal consumables.

Strong ion analysis at the bedside Publication date: Available online 18 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Nithin Abraham Raju, Ryan Hughes, Matthew J. Brain Abstract Quantitative physicochemical models of human acid–base physiology filled a void between clinical acid–base analysis and general fluid physiology. Established approaches centred on the Henderson–Hasselbalch (HH) equation allow satisfactory bedside exploration of respiratory perturbations, but do not fully elucidate mechanisms of common non-respiratory ‘metabolic’ components. Though useful at the bedside, commonly used ‘rules of thumb’ that classify disturbances based on quantification of bicarbonate relative to CO2 have also fostered a language that often misrepresents bicarbonate physiology. The physicochemical model is frequently perceived as too complex for bedside use, however a set of simplified screening questions based on Stewart's model can be utilized to aid acid-base interpretation. Examples using this approach are included in an online appendix. Emphasis is placed on understanding the consequences of hypoalbuminaemia, volume status, tonicity and chloride derangements as these are common in ICU patients.

Disinfection, sterilization and disposables Publication date: Available online 18 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Anthony J. Wilson, Sandeep Nayak Abstract Medical devices are one way by which healthcare-associated infections can be transmitted. Medical equipment can be categorized based on its risk of spreading infection and these categories aid decisions about whether to decontaminate or dispose of a used medical device. Decontamination is the process by which a reusable device is rendered safe for further use through cleaning and either disinfection or sterilization. It is frequently an automated process which usually involves thermal or chemical techniques and is subject to extensive quality control. Most microorganisms are inactivated or destroyed by disinfection but sterilization is required to eliminate resistant organisms and bacterial spores. Single-use medical devices are now commonplace and avoid the need for decontamination altogether.

Initial assessment and management of trauma encountered in the field Publication date: Available online 17 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Emma Coley, Sarah Fadden Abstract This article covers the principles of trauma care relating to specific competencies within the military higher training module. The majority of these principles relate to the pre-hospital assessment and management of patients, introducing some of the nuances of military medicine in comparison to civilian practice.

Surgical diathermy and electrical hazards: causes and prevention Publication date: Available online 16 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): James H. MacG Palmer Abstract The hospital environment is both unique and unusual in that electrical equipment is directly applied to the human body. From this application either capacitive or resistive coupling may lead to current flow and harm. Surgical diathermy, patient monitoring and imaging, although universal, are often misunderstood, and many clinicians are ignorant of their principles and hazards. Electrical equipment in hospital therefore has the potential to lead to serious injury or death. This article outlines the basic physics of electricity, in particular the principles behind diathermy, the hazards posed by it and by other devices and the various measures available to reduce the risk of these.

Asthma and chronic obstructive pulmonary disease in the intensive care unit Publication date: Available online 16 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): David Tuxen, Mark Hew Abstract There are many pitfalls in the management of patients with asthma or COPD especially when their condition becomes severe enough to warrant intensive care. Mortality in both groups remains significant. Standard principles of oxygen and drug administration and mechanical ventilation technique used for other critically ill patients can all cause problems in this patient group. Recognition of the presence of airflow obstruction, the potential for dynamic hyperinflation and careful adherence to the principles of therapy specific to this group are required to avoid complications. This article addresses the physiological derangements in airflow obstruction, their treatment consequences and how to avoid the management pitfalls that are important contributors to the morbidity and mortality of both conditions.

The poisoned patient Publication date: Available online 16 October 2019 Source: Anaesthesia & Intensive Care Medicine Author(s): Nora Gonzalez, Fin O'Sullivan Abstract Poisoning is a common reason for admission to the intensive care unit. The majority of patients are due to deliberate self-harm with common poisons; however, there are occasional unusual poisons which require more detailed assessment. Patients are often obtunded or unwilling to co-operate so a knowledge of toxidromes to recognize symptoms that are related to groups of drugs that act on receptors is essential. Management of poisoned patients is generally supportive, including measures to reduce absorption and increase elimination, as well as the use of specific antidotes and techniques to remove poisons.