Shock is an emergency, and if it is not treated, it will mostly be fatal. Early intervention and admission to the ICU is essential. Our cover story considers several aspects of shock, including pathophysiology and multi-organ dysfunction syndrome, as well as source control, fluids, differentiation using point-of-care ultrasound and vasoactive medication. Francesco Forfori, Greta Giuliano and Gabriella L

Cover Story

Mechanisms of endotoxin-induced multi-organ damage. Endotoxin-induced sepsis remains a leading cause of mortality in intensive care units (ICUs) worldwide. Lipopolysaccharide (LPS) identification by the immune system triggers a cascade of signalling pathways, leading to the release of several cytokines and chemokines, which orchestrate the antimicrobial and inflammatory response, though causing multiorga

Fluid management during shock from physiology to bedside. Shock is a common life-threatening, generalised form of acute circulatory failure in critically ill patients, which is usually managed by infusing fluids to increase cardiac output and supply the systemic oxygen request. International guidelines recommend use of an aggressive fluid resuscitation in the early phases of shock. In this context, cryst

A conceptual framework for developing institutional programmes and guidelines to enhance fluid stewardship (especially in the intensive care unit [ICU] environment), an activity that includes appropriate selection, dosing, duration, de-escalation, and monitoring of fluid therapy. The primary goal of fluid stewardship is to optimise clinical outcomes while minimising unintended consequences of intravenous

A review and introduction of the concept “enough.” We provide a brief overview of important physiology and the pharmacology of vasoactive drugs that are currently used in the ICU as well as newer agents, along with a concise review of recent publications comparing these agents. We attempt to answer the question what drug dose should be administered as well as what haemodynamic values to pursue, and h

In the past decades there have been significant advances in the diagnosis and management of patients with sepsis and septic shock, and overall awareness has increased significantly (Angus and van der Poll 2013). Emphasis is currently on the early detection of sepsis and rapid initiation of fluid administration and antibiotic therapy, all of which have improved outcomes (Rhodes et al. 2017). Nevertheless,

Organ cross-talk is a popular mechanism invoked to explain the progression of multi-organ dysfunction syndrome; however this term is often ill-defined and may encompass many differing mechanisms of organ interaction. In this article the concept of cross-talk is reviewed and its real meaning to the clinical is critically appraised. Multi-organ failure, better termed multi-organ dysfunction syndrome (MODS

Point-of-care ultrasound (POCUS) is an invaluable tool to differentiate the various types of shock which may co-exist in the critically unwell patient. It is beyond the remit of this article to teach the skill of POCUS. Rather, it provides an overview of how the various POCUS modules could be integrated and utilised in the shocked patient. "A fool with a tool is still a fool" What is point-of-care ultr


An individualised goal-directed approach to managing coagulopathy is recommended to treat bleeding trauma patients. Severe trauma is a great burden to society, with millions of victims worldwide. If trauma patients are hazardly bleeding, surgical bleeding requires the surgeon to fix the problem, while coagulopathy requires management with an algorithm that includes monitoring and specific treatment.

Fibrinogen limits coagulopathy and massive bleeding, has less transfusion requirements and thereby decreases the risk of multi-organ failure in trauma patients. What stops the bleeding? Haemostatic therapy aims to stop the bleeding, but is it a concentration of coagulation factors, mainly assessed by international normalised ratio (INR) readings that works, or is it fibrinogen/fibrin, which are the prec

Goal-directed therapy of coagulopathy is recommended for trauma patients. Can guidelines direct our strategy? When presented with bleeding trauma patients, our management strategy may be directed by guidelines, e.g. the European trauma guideline (Rossaint et al. 2016). This recommends treatment with fibrinogen concentrate or cryoprecipitate if significant bleeding is accompanied by viscoelastic signs

Series: Gases

Xenon and brain injury. Xenon, a chemically inert but biologically active monatomic gas, has been applied in patients for anaesthesia/sedation, and most recently in the critical care of patients with acute ongoing neurological damage. Following preclinical evidence that xenon has ameliorative activity in several pathobiologic pathways that are involved in central nervous system injury, xenon was shown


The latest in diagnosis and treatment. Sepsis is a life-threatening condition in children. Current paediatric definitions are based on systemic inflammatory response syndrome. Since the publication of the third international consensus definitions for sepsis and septic shock for adults, efforts in paediatrics are focused on finding a definition that involves a premature diagnosis with prognostic implicati

Disordered sleep is common in ICU patients. While many of the reasons for this are impossible to modify, and others rely on improvement in the underlying condition, many directly depend on the actions of the treating team: for example, exposure to noise, timing of therapeutic procedures, tapering of sedating drug doses, and daytime mobilisation. Some patients might benefit from nocturnal sedation, but the

Recent advances and new challenges.It has been thought for years that cancer patients have not benefitted from intensive care unit (ICU) admission when they suffer from severe and potentially reversible acute illnesses. Fortunately, numerous studies have shown that this is not the case. Today, the number of cancer patients in ICUs around the world is increasing every year, and both survival and quality of

In this article, I highlight that the most important thing intensive care physicians should stop doing is ignoring that they are prone to several cognitive biases. I will first support my statement by looking for conceptual caveats and cognitive bias in routine intensive care unit (ICU) care, and then move to specific patient and structural problems. Intensive care is an interesting specialty. From all

Describes the epidemiology and outcomes for very old patients as known in 2018, along with a short introduction to the most relevant “geriatric syndromes” important also for intensivists, and discusses where we should increase our body of knowledge to make a more precise triage in this patient group. The very old ICU patient is a term often used for those patients aged ≥ 80 years. This group of pa

Evaluation of aids to the delivery of sepsis treatment. In NHS Wales the Sepsis 6 bundle, delivered within one hour of sepsis recognition, has been standard treatment in acute hospital settings since 2013. We describe various methods for increasing the speed and effectiveness of Sepsis 6 bundle delivery that have been trialled with positive outcomes. Sepsis is defined as a “life-threatening organ dys

Management Matters

Avicenne ICU’s initiative. Decisions to limit therapy (DTLT) are routine for ICU physicians. Although breaking bad news is one of the most difficult tasks clinicians face, ongoing communication is even more crucial as families (not necessary following a legal or genetic definition) of critically ill patients have heightened communication needs. Supporting families during the process of shared decision-m

Shares experiences of implementing extracorporeal life support in a non-academic hospital. Acute respiratory distress syndrome (ARDS) is a life-threatening disorder characterised by severe impairment of gas exchange. The most common causes are pneumonia, sepsis and acute pancreatitis. It is accurately defined in the Berlin definitions (ARDS Definition Task Force 2012). Progression to ARDS is associated

I-I-I Blog

(I expert, I question, I answer) Have you got something to say?Visit https://healthmanagement.org/c/icu/list/blog or contact [email protected] Jean Baptiste LascarrouMedical Intensive Care Unit, Nantes University Hospital, France @jblascarrou Epinephrine for out-of-hospital cardiac arrest “Epinephrine (or adrenaline for EU physicians) has alpha-adrenergic action which leads to increase


Interview with Jannicke Mellin-Olsen, President, World Federation of Societies of Anaesthesiologists. Jannicke Mellin-Olsen, MD, DPH is Consultant Anaesthesiologist at the Department of Anaesthesia, Intensive Care and Emergency Medicine, Bærum Hospital, Norway. She is President of the World Federation of Societies of Anaesthesiologists, and serves as a member of the Patient Safety and Quality Committee

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