A.Gullo(Editor) Anaesthesia, Pain, Intensive Care and Emergency – A.P.I.C.E. Proceedingsofthe 19thPostgraduateCourseinCriticalCareMedicine Trieste,Italy- November12- 15,2004 A. Gullo (Editor) Anaesthesia, Pain, Intensive Care and Emergency A.P.I.C.E. Proceedings of the th 19 Postgraduate Course in Critical Care Medicine Trieste, Italy – November 12-15, 2004 Springer ANTONINOGULLO,M.D. Head,DepartmentofPerioperativeMedicine, IntensiveCareandEmergency TriesteUniversitySchoolofMedicine Trieste,Italy LibraryofCongressControlNumber:2004115099 ISBN88-470-0288-5 SpringerMilanBerlinHeidelbergNewYork Thisworkissubjecttocopyright.Allrightsarereserved,whetherthewholeorpartofthematerial isconcerned,specificallytherightsoftranslation,reprinting,reuseofillustrations,recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. 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Coverdesign:SimonaColombo,Milan,Italy Typesettingandprinting:ArtiGraficheStella,Trieste,Italy V Table of Contents ADVANCESINCRITICALCARE Chapter1–Effectsofbodypositiononventilation/perfusionmatching G.HEDENSTIERNA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter2–ChestPain F.SCHIRALDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Chapter3–Theelectrocardiogramintheemergencydepartment F.SCHIRALDI,F.PALADINO,E.G.RUGGIERO . . . . . . . . . . . . . . . . . . . . . . 27 Chapter4–Theuseofimagingtoresolvedifficultdiagnoses V.CIOFFI,L.CALDERAN,M.COVA . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Chapter5–AssessmentofPain D.CARISTI,A.GALZERANO,M.PIVA . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Chapter6–Titrationofopioidsforacutepainmanagement Y.LEYKIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Chapter7–Neonatalmechanicalventilation A.BOUGATEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Chapter8–Extracorporealcirculationintheintensivecareunit V.GA[PAROVI],M.MERKLER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Chapter9–Clinicaldecision-makinginthemanagementofsepsisandsepticshock F.BARATTO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Chapter10–Intracranialhaemorrhage:thesolutionofferedbyrecombinantfactorVIIa G.MICIELI,A.CAVALLINI,S.MARCHESELLI . . . . . . . . . . . . . . . . . . . . . . 101 VI Chapter11–AnintroductiontoOpenSourcesoftwarelicensing anduseinanaesthesiadepartment V.LANZA,M.SAJEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 MICRODIALYSIS Chapter12–Lessonswehavelearntfrommicrodialysisinanimalsandhumans NORDSTRÖM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Chapter13–Secondarybraininjury-doesmicrodialysishavearole? M.SMITH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Chapter14–Livergraftmonitoringwithintrahepaticmicrodialysis G.NOWAK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Chapter15–Myocardialmetabolismduringopenheartsurgery,assessed withmicrodialysis L.BAHLMANN,J.PÖLING,S.KLAUS . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 CLINICALPHARMACOLOGY Chapter16–Thejourneyofadrugtothetargetsite:whatisitdecisive? C.THALLINGER,C.JOUKHADAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Chapter17–Thepharmacokineticsandpharmacodynamicsofantimicrobialagents inintensivecareunitpatientsasassessedbymicrodialysis V.KULEMANN,C.JOUKHADAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 PERIOPERATIVEMEDICINE Chapter18–Anaestheticeffectsonregionalcerebralbloodflowandmetabolism: threecontemporaryreasonstocare M.ALKIRE,J.MILLER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Chapter19–Whyandwhenisinhalationanaesthesiabetter I.SALVO,P.SILVANI,A.CAMPORESI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Chapter20–Analysisandinstrumentationsforestimatingcerebralactivity E.FACCO,S.BARBIERI,M.MUNARI . . . . . . . . . . . . . . . . . . . . . . . . . . 205 VII Chapter21–Neuroimagingpharmacologyofattentionandmemory U.FREO,C.ORI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Chapter22–Intracranialpressuremonitoring M.MUNARI,S.M.VOLPIN,E.FACCO . . . . . . . . . . . . . . . . . . . . . . . . . 227 Chapter23–Improvingqualityofrecovery M.KLIMEK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 LUNGANDARTIFICIALVENTILATION Chapter24–Molecularbiologyandlungdisease.Whatistheimpact? A.C.ANDRADE,M.M.MORALES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Chapter25–Surfactantmetabolism:factorsaffectinglipiduptakeinvivoandinvitro D.L.H.POELNA,J.F.VANIWAARDEN,B.LACHMANN . . . . . . . . . . . . . . . . . 259 Chapter26–Respiratorymechanicsatthebedside T.LUECKE,F.FIEDLER,P.PELOSI. . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Chapter27–PEEPandcardiacoutput T.LUECKE,R.GIESER,P.PELOSI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 Chapter28–ExpiratoryflowlimitationandintrinsicPEEP J.MILIC-EMILI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Chapter29–Mechanicalventilationstrategiesforlungprotection N.R.MACINTYRE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Chapter30–Recruitmentandoxygenation T.MUDERS,H.WRIGGE,C.PUTENSEN . . . . . . . . . . . . . . . . . . . . . . . . . 331 Chapter31–Lungoedemainacutelunginjury(ALI) S.NUNES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Chapter32–Gradingseverityofrespiratorydysfunction,clinicalcorrelates andindicationsformechanicalventilation N.THEUERKAUF,H.WRIGGE,C.PUTENSEN . . . . . . . . . . . . . . . . . . . . . . 357 Chapter33–Weaningasacardiacstresstest B.LAMIA,J.-L.TEBOUL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 VIII Chapter34–Respiratorymanagementinobesepatients P.PELOSI,T.LUECKE,P.CAIRONI . . . . . . . . . . . . . . . . . . . . . . . . . . . 379 Chapter35–Istheacuterespiratorydistresssyndromeasystemicdisease? L.BRANDER,A.S.SLUTSKY,H.ZHANG . . . . . . . . . . . . . . . . . . . . . . . . . 395 CARDIOVASCULARCRITICALCARE Chapter36–Invasiveversusnon-invasivehaemodinamicmonitoring inmajorvascularsurgery B.ALLARIA,M.RESTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 Chapter37–Analysisofarterialpulse–clinicalimplications GIOMARELLI,S.SCOLLETTA,S.M.ROMANO . . . . . . . . . . . . . . . . . . . . . . . 417 Chapter38–Beat–by–beatmonitoringofcardiacoutput withpressurerecordinganalyticalmethod S.SCOLLETTA,P.GIOMARELLI,B.BIAGIOLI . . . . . . . . . . . . . . . . . . . . . 425 Chapter39–Haemodynamicstandardisationproceduresinhigh-risksurgery T.YAMAGUTI,S.MINHYEKIM,J.O.C.AULER . . . . . . . . . . . . . . . . . . . . . 437 Chapter40–FromFrank–Starlingrelationshipstoventriculo–arterialcoupling R.NAEIJE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 Chapter41–Pharmacologyandselectionofinotropictherapy J.O.C.AULER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461 Chapter42–Decision–makingincriticalcare:cardiacarrhythmias andrelatedtopics J.L.ATLEE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473 Chapter43–Managementforthepatientwithanimplantedcardiacrhythm managementdevice(CRMD) J.L.ATLEE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483 Chapter44–Hypothemiaincardiacsurgery J.O.C.AULER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495 IX CARDIOPULMONARYRESUSCITATION Chapter45–Pharmacologicalmanagementofcardiopulmonaryresuscitation T.PELLIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509 Chapter46–Myocardialpreservation,reperfusioninjury, andpostresuscitationmyocardialdysfunction R.J.GAZMURI,J.RADHAKRISHNAN,J.KORALOVA. . . . . . . . . . . . . . . . . . . . 517 MICROCIRCULATIONANDSHOCK Chapter47–Regionalbloodflowdistributioninseptic,cardiogenic andhaemorrhagicshock D.DEBACKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529 Chapter48–Orthogonalpolarisationspectralimaging:principles,techniques, humanstudies D.DEBACKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 Chapter49–Carbondioxidemonitoringtoevaluatecelloxygenation J.CRETEUR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543 Chapter50–Themicrocirculationindistress;monitoringandrecruitment P.GOEDHART,C.INCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557 Chapter51–Tissuemetabolismindifferenttypesofshock S.KLAUS,J.PÖLING,L.BAHLMANN . . . . . . . . . . . . . . . . . . . . . . . . . . . 565 Chapter52–Organdysfunctionincirculatoryshock–alteredperfusion,metabolism ortightjunctions?Doweneedashiftofparadigm? J.TENHUNEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 Chapter53–Haemodynamicsupportofpaediatricpatientsinsepticshock G.ZOBEL,S.RÖDL,H.-M.GRUBBAUER . . . . . . . . . . . . . . . . . . . . . . . . 587 PAEDIATRICCRITICALCARE Chapter54–Recentadvancesinartificialventilationinpaediatricage G.A.MARRARO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599 X Chapter55–Complicationsinpaediatricregionalanaesthesia G.IVANI,V.MOSSETTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 Chapter56–Homeventilationinpaediatricpatientswithchronicrespiratoryfailure B.FAUROUX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619 Chapter57–Decision–makinginpaediatricextracranialtrauma E.CALDERINI,R.SCARANI,D.NIRO . . . . . . . . . . . . . . . . . . . . . . . . . . 633 Chapter58–Developmentinthetreatmentofpostoperativepaininpaediatrics P.BUSONI,A.MESSERI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653 TRAUMAANDEMERGENCYSYSTEM Chapter59–Prehospitalcare:triageandprimarysurvey O.PREDESCU,A.BAKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663 Chapter60–Spineandspinalcordtrauma O.PREDESCU,A.BAKER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673 Chapter61–Treatmentoftheacutepneumothoraxinthefield G.BERLOT,D.MASSARUTTI,E.CARCHIETTI . . . . . . . . . . . . . . . . . . . . . . 683 CLINICALSTUDYDESIGN Chapter62–Criticalappraisalskills S.MARTINS, A.ZIN,W.ZIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 695 Chapter63–Literaturesearch S.MARTINS,A.ZIN,W.ZIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 707 Chapter64–Studydesign S.MARTINS,A.ZIN,W.ZIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749