1 the beginner s guide to intensive care 2nd edition 2018

SECOND EDITION

THE
BEGINNER’S
GUIDE TO
INTENSIVE CARE

A HANDBOOK FOR JUNIOR DOCTORS
AND ALLIED PROFESSIONALS

Edited by

Nitin Arora
Shondipon K. Laha


The Beginner’s Guide
to Intensive Care
A Handbook for Junior Doctors
and Allied Professionals



The Beginner’s Guide
to Intensive Care
A Handbook for Junior Doctors
and Allied Professionals
Second Edition

Edited by

Nitin Arora
Shondipon K. Laha


CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742
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Contents

Foreword

ix

Acknowledgements

xi

Editors

xiii

Contributors

xv

Introduction

xxi

PART 1

BASICS

1

1 Your first day and what to expect
James Turner and Joyce Yeung

3

2 The daily review of a patient
Shondipon K. Laha

7

3 Communication
Mark Pugh and Robert Fallon

13

4 Capacity and consent
Angela Day and Michael Elliot

21

5 FOAMed and social media as an aid to education in

intensive care
Jonathan Downham
6 Research in intensive care
Catriona Frankling and Gavin Perkins
7 Stress and burnout in intensive care medicine: Looking
after yourself
Olusegun Olusanya and Adrian Wong
PART 2

STAFFING ON THE INTENSIVE CARE UNIT: THE
MULTIDISCIPLINARY TEAM

8 The intensive care nurse
Gavin Denton

27
33

39

47
49
v


vi Contents

9 Speech and language therapists
Asfa Bashir, Nicola Pargeter and Lucy Wood

51

10 The critical care physiotherapist
Sarah Bunting

55

11 Advanced critical care practitioners (ACCP)
Gavin Denton

59

12 The critical care pharmacist
Adeyemi Oyedele

63

PART 3

67

INITIAL ASSESSMENT: THE FIRST HOUR

13 Assessing ICU referrals on the ward
Catriona Frankling and Joyce Yeung

69

14 Assessment and management of major trauma patients
Ian Tyrell-Marsh and Edward Denison-Davies

75

15 Management of the head-injured patient
Kunal Lund and Thomas Owen

85

16 Initial management of the patient with burns
Karen Meacher and Nitin Arora

95

PART 4

DRUGS

105

17 Analgesia, sedation and muscle relaxation
Hozefa Ebrahim

107

18 Drugs that work on the heart
Rachel Howarth and Andrew Haughton

117

19 Nutrition and fluids in intensive care

Ben Slater

125

PART 5

133

EQUIPMENT AND INVESTIGATIONS

20 Face masks, continuous positive airway pressure (CPAP)
and airways
Anna Herbert and Shondipon K. Laha
21 The ventilator
Irfan Chaudry

135
145


Contents vii

22 Monitoring the critical care patient
Rochelle Velho and Robert O’Brien

151

23 Ultrasound in intensive care
Adrian Wong and Olusegun Olusanya

159

24 Renal replacement therapy in intensive care
Aoife Abbey and Nitin Arora

171

25 Interpreting arterial blood gases (ABGs)
Nafeesa Akhtar and Julian Hull

179

PART 6

189

AIRWAY AND RESPIRATORY EMERGENCIES

26 Maintaining an airway
Vijay Venkatesh and Nitin Arora

191

27 Rapid sequence induction
Sudhindra Kulkarni and Shondipon K. Laha

195

28 Endotracheal tube and tracheostomy problems
Brendan McGrath

207

29 ‘Fighting the ventilator’
Mohammed Hatab and Peter Frank

219

30 Pneumothorax
Gareth P. Jones and Amanda Shaw

225

PART 7

231

OTHER EMERGENCIES

31 Cardiac arrhythmias
Katherine Turner, Peter Bunting and Mike Dickinson

233

32 ICU delirium and the agitated patient
Nicholas R. Plummer and Shondipon K. Laha

241

33 Status epilepticus

Bryony Patrick and Andrew Gosling

251

34 The critically ill or injured child in a non-paediatric hospital
Eldilla Rizal and Nitin Arora

259

35 Management of hyperglycaemic emergencies
Ben Wooldridge and Paul Johnston

269

36 Poisoning
Nagendra Pinnampeni and Arumugam Jagadeeswaran

279


viii Contents

PART 8

MANAGEMENT

37 Pneumonia
Joseph Herold and Shondipon K. Laha
38 Acute severe asthma
Carl Groves and Govindan Raghuraman

39 The COPD patient in intensive care
Daniel Park
40 Acute respiratory distress syndrome
Richard Benson and Craig Spencer
41 Sepsis
Daniel Shuttleworth and Ron Daniels
42 Acute renal failure in intensive care (Acute kidney injury)
Nitin Arora and Shondipon K. Laha

287
289
297
305
313
321
331

43 Management of severe acute pancreatitis
Laura Dyal and Fang Gao
44 Hepatic failure
Fayaz Baba and Mark Pugh
45 Non-traumatic brain injuries
Richard Yardley and Shashikumar Chandrashekaraiah
46 Ongoing management of the patient with burns
Karen Meacher and Thomas Owen
47 Ageing and frailty
Vanisha Patel and Joyce Yeung
48 Transfer of the critically ill patient
Emma Foster and Neil Crooks

339

49 The critically ill obstetric patient
Jennifer Hares and Naresh Sandur
50 The bariatric patient in intensive care
Helga Fichter

397

51 Post-ICU syndrome
Jonathan Paige and Anna Dennis
52 End of life care in ICU
Sarah Milton-White and Lucie Linhartova
53 Brain stem death and organ donation
Huw Twamley

421

Index

349
359
371
377
387

413

427
435

443


Foreword

In this introduction to intensive care medicine (ICM), Arora and Laha have
provided a very useful overview of what it means to be an intensive care clinician, whether physician, nurse, or allied health professional. We are the
acute general practitioners of hospital medicine. We care for patients with
life-threatening acute illnesses, for patients with severe chronic disease, and
for their families at what is often the most difficult time of their lives. To do
this we have to work collaboratively, across disciplines, at pace, often multitasking, synthesising large volumes of data into information, and transforming information into action. This demands high-level technical and
non-technical skills. For the beginner, it is usually the technical elements
which are the most obvious challenge at first, but with acquisition of expertise these become part of the background, and it is the non-technical skills
which come to the fore – learning to listen, to work as a team, to minimise
error, to relieve suffering.
These elements are all components of the competency-based training
programme in ICM ( />-assessment-training), which was approved by the General Medical Council
in 2011 thereby making ICM a primary speciality. The review board was
impressed by the multidisciplinary nature of the programme, the firm emphasis on research and evidence-based practice, and co-design with patients and
relatives through CoBaTrICE ( These
features are reflected in this book, which provides an excellent introduction
to the management of acute illness for all clinical staff, and a solid foundation
for those who choose to make ICM a fulfilling lifelong career.
Julian Bion, FRCP, FRCA, FFICM, MD
Professor of Intensive Care Medicine
University of Birmingham
Founding Dean
Faculty of Intensive Care Medicine

ix

Acknowledgements

We would like to thank all the medical and nursing staff working in critical
care at University Hospitals Birmingham NHS Foundation Trust, and
Lancashire Teaching Hospitals NHS Foundation Trust. Thanks to my wife
Ira for her support, encouragement and patience over the years.
Nitin
I would like to thank my wife Alex and my parents with their unswerving
support over many decades. I hope my kids, Jonny, Ned and Meg benefit from
the ever rapidly developing technology that means the medicine in this book
will be out of date by the time they come of age.
Shond

xi



Editors

Dr Nitin Arora, FRCA, FRCPE, DICM, FFICM, is a Consultant in Intensive
Care Medicine and Anaesthesia at University Hospitals Birmingham NHS
Foundation Trust, Birmingham. He has previously worked in medicine,
intensive care and anaesthesia in India and the United Kingdom.
Dr Shondipon K. Laha, BM, BCh, MA, FRCA, FFICM, is a Consultant in
Intensive Care Medicine and Anaesthesia at Lancashire Teaching Hospitals
NHS Foundation Trust. He read medicine at Oxford University and completed dual specialty training in anaesthesia and intensive care medicine in
the North West of England.

xiii



Contributors

Aoife Abbey
Specialty Registrar Intensive
Care Medicine
West Midlands
Nafeesa Akhtar
Specialty Registrar Anaesthesia
West Midlands
Fayaz Baba
Specialty Registrar Anaesthesia
West Midlands
Asfa Bashir
Highly Specialist Speech and
Language Therapist
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Richard Benson
Specialty Registrar Intensive Care
Medicine and Anaesthesia
North West Deanery
Peter Bunting
Consultant Intensive Care
Medicine and Anaesthesia

Lancashire Teaching Hospitals
NHS Foundation Trust
Preston

Sarah Bunting
Intensive Care Medicine
Physiotherapist
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Shashikumar Chandrashekaraiah
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Irfan Chaudry
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Neil Crooks
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham

xv

xvi Contributors

Ron Daniels
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Chief Executive UK Sepsis Trust
Birmingham
Angela Day
Specialty Doctor Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Edward Denison-Davies
Consultant Intensive Care
Medicine and
Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Anna Dennis
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Gavin Denton

Advanced Critical Care
Practitioner
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Mike Dickinson
Human Patient Simulator
Training Coordinator
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston

Jonathan Downham
Advanced Critical Care Practitioner
South Warwickshire NHS
Foundation Trust
Warwick
Laura Dyal
Specialty Registrar Anaesthesia
West Midlands
Hozefa Ebrahim
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Michael Elliot
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham

NHS Foundation Trust
Birmingham
Robert Fallon
Senior Clinical Fellow
Intensive Care Medicine and
Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Helga Fichter
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Emma Foster
Clinical Fellow
University Hospitals Birmingham
NHS Foundation Trust
Birmingham


Contributors xvii

Peter Frank
Consultant Intensive Care
Medicine and
Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust

Preston
Catriona Frankling
Specialty Registrar Anaesthesia
West Midlands
Fang Gao
Professor of Anaesthesia
Critical Care and Pain
University of Birmingham
Honorary Consultant Intensive
Care Medicine
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Andrew Gosling
Consultant Anaesthetics and
Critical Care
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Carl Groves
Core Trainee ACCS
Anaesthesia
West Midlands
Jennifer Hares
Specialty Registrar
Anaesthesia
West Midlands
Mohammed Hatab
Specialty Registrar Intensive
Care Medicine and

Anaesthesia
North West Deanery

Andrew Haughton
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Anna Herbert
Core Trainee Medicine
North West Deanery
Joseph Herold
Core Trainee Anaesthesia
North West Deanery
Rachel Howarth
Core Trainee Anaesthesia
North West Deanery
Julian Hull
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Arumugam Jagadeeswaran
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham

Gareth P. Jones
Foundation Doctor
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Paul Johnston
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham


xviii Contributors

Sudhindra Kulkarni
Specialty Registrar Intensive Care
Medicine and Anaesthesia
North West Deanery
Lucie Linhartova
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Kunal Lund
Specialty Registrar Intensive
Care Medicine and
Anaesthesia
North West Deanery

Brendan McGrath
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals of South
Manchester
National Tracheostomy Lead
Clinician
Manchester
Karen Meacher
Specialty Registrar Anaesthesia
West Midlands
Sarah Milton-White
Specialty Registrar Intensive
Care Medicine and
Anaesthesia
West Midlands
Robert O’Brien
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham

Olusegun Olusanya
Clinical Fellow
Intensive Care Medicine
North Hampshire Hospital
Basingstoke
Thomas Owen
Consultant Intensive Care

Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Adeyemi Oyedele
Critical Care Pharmacist
University Hospitals of Coventry
and Warwickshire
Coventry
Jonathan Paige
Specialty Registrar Intensive
Care Medicine and
Anaesthesia
West Midlands
Nicola Pargeter
Highly Specialist Speech and
Language Therapist
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Daniel Park
Consultant Intensive Care
Medicine and Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Vanisha Patel
Research Fellow Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust

Birmingham


Contributors xix

Bryony Patrick
Senior Clinical Fellow
Intensive Care Medicine and
Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Gavin Perkins
Professor of Critical Care
Warwick University
Honorary Consultant Intensive
Care Medicine
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Nagendra Pinnampeni
Specialty Registrar Anaesthesia
East Midlands
Nicholas R. Plummer
Core Trainee ACCS
North West Deanery
Mark Pugh
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals

NHS Foundation Trust
Preston
Govindan Raghuraman
Consultant Intensive Care
Medicine and
Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Eldilla Rizal
Specialty Registrar Paediatric
Intensive Care Medicine
West Midlands

Naresh Sandur
Consultant Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Amanda Shaw
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
Daniel Shuttleworth
Specialty Registrar Intensive
Care Medicine and
Anaesthesia
West Midlands

Ben Slater
Consultant Intensive Care
Medicine and Anaesthesia
Victoria Hospitals
Kirkcaldy
Craig Spencer
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston
James Turner
Research Fellow Anaesthesia
University Hospitals Birmingham
NHS Foundation Trust
Birmingham
Katherine Turner
Foundation Doctor
Lancashire Teaching Hospitals
NHS Foundation Trust
Preston


xx Contributors

Huw Twamley
Consultant Intensive Care
Medicine and Anaesthesia
Lancashire Teaching Hospitals
NHS Foundation Trust

Preston

Lucy Wood
Highly Specialist Speech and
Language Therapist
University Hospitals Birmingham
NHS Foundation Trust
Birmingham

Ian Tyrell-Marsh
Specialty Registrar Intensive
Care Medicine and
Anaesthesia
North West Deanery

Ben Wooldridge
Specialty Registrar Anaesthesia
West Midlands

Rochelle Velho
Academic Clinical Fellow in
Critical Care Medicine
CT2 Anaesthesia
West Midlands
Vijay Venkatesh
Specialty Registrar Anaesthesia
West Midlands
Adrian Wong
Consultant Intensive Care
Medicine and Anaesthesia

Oxford University Hospitals NHS
Foundation Trust
Oxford

Richard Yardley
Core Trainee ACCS
North West Deanery
Joyce Yeung
Associate Professor in Critical
Care and Anaesthesia
Warwick University
Honorary Consultant Intensive
Care Medicine
University Hospitals Birmingham
NHS Foundation Trust
Birmingham


Introduction

The first edition of this book was published in 2010. As it was a book that was
designed to be basic and introductory, we hoped that we would never have to
revisit it. However, as time went on, we have been inundated with requests.
These were initially minor but it became clear that we needed to give the book
an overhaul to keep it relevant.
In the last seven years, we have seen a number of new therapies in intensive care, as well as the rising popularity of imaging modalities like point of
care ultrasound.
Intensive care medicine (ICM) has become a stand-alone specialty in the
United Kingdom, and we are beginning to understand the psychological burden of intensive care, not just on survivors and families but also on healthcare
professionals.

The new edition has been almost completely re-written and greatly
expanded. There are new chapters on ultrasound, social media, stress and
burnout, research, the ICU team and many others. All chapters have been
written by established intensive care consultants or experts in their respective fields. Some skills are best learned at the bedside, so we have limited the
length for some chapters while others have more detail.
The previous edition proved to be surprisingly popular with non-medical
professionals, and so whilst we have attempted to follow the ICM curriculum
for stage-1 training we want this book to also be accessible to the foundation
doctor, advanced critical care practitioner or critical care nurse.
This book is not a replacement for the traditional textbooks, but adopts a
pragmatic approach to common problems on the unit for both doctors and
allied healthcare professionals.
Nitin Arora
Shondipon K. Laha

xxi



PART

1

BASICS

1 Your first day and what to expect
James Turner and Joyce Yeung
2 The daily review of a patient
Shondipon K. Laha
3 Communication

Mark Pugh and Robert Fallon
4 Capacity and consent
Angela Day and Michael Elliot
5 FOAMed and social media as an aid to education in
intensive care
Jonathan Downham
6 Research in intensive care
Catriona Frankling and Gavin Perkins
7 Stress and burnout in intensive care medicine: Looking
after yourself
Olusegun Olusanya and Adrian Wong

3
7
13
21

27
33

39