Contributors xix
Preface xxv
Acknowledgements xxvii
How to use your textbook xxix
About the companion website xxxi
Chapter 1 The critical care unit 1
Vikki Park
Introduction 2
Levels of care 2
The critical care environment 2
Critical care patients 3
Level 1 care 4
Level 2 care 4
Level 3 care 4
Critical care competence 5
The interprofessional team 6
Communication 7
Ways of working 7
Understanding philosophies of care 8
Humanising critical care 8
Surviving critical care 9
Death in critical care 9
Resilience 9
Nursing considerations and recommendations for practice 11
Future challenges 11
Conclusion 11
References 12
Chapter 2 Organisational influences 14
Vikki Park
Introduction 15
The four UK nations 15
Legislation 15
Professional Statutory Regulatory Bodies (PSRBs) 15
Shared decision making 16
Capacity for shared decision making 16
Confidentiality 17
Decisions relating to end-of-life care 17
Risk management 18
International influences 18
National influences 18
UK government organisations 18
Networks 19
National guidelines 20
Quality assurance 20
Local policies 21
Nursing considerations and recommendations for practice 21
Conclusion 21
References 22
Chapter 3 Legal and ethical issues 24
Leonie Armstrong, Tracey Carrott, and Jacqueline Newby
Introduction 25
Confidentiality 25
End-of-life care and best interest decisions 26
Ethical themes 27
Mental Capacity Act 27
Organ donation 29
Consent (authorisation in Scotland) for organ donation 30
First person consent 31
First person opt-in 31
First person opt-out 31
Appointed/nominated representative (not Scotland) 31
Deemed consent 31
The ethics of deemed consent 32
Consent from a person in the highest-ranking relationship 32
Cadaveric organ donation 33
The organ donation process 33
Post organ retrieval 34
Organ allocation 34
Conclusion 35
References 35
Chapter 4 Professional issues in critical care 37
Aurora Medonica
Introduction 38
Opportunities for learning 38
NMC Code in critical care units: journey to independent, safe practice 38
The core principles 39
UK National Competency Framework: critical care 41
Development of critical thinking in healthcare 42
The prioritising process 42
Support systems: the student 44
Conclusion 44
References 45
Chapter 5 Using an evidence-based approach 46
Sadie Diamond-Fox and Alexandra Gatehouse Introduction 47
What is evidence-based practice (EBP)? 47
Step 1: formulating a clinical question – the PICO method 48
Step 2: locating the evidence/research: performing a systematic literature review 48
Step 3: critical appraisal and the hierarchy of evidence 49
Step 4: extracting the most relevant and useful results 51
Step 5: implementing research into practice 52
Quality healthcare in critical care 53
Clinical audit and quality improvement 53
Research and development in critical care 55
Conclusion 56
References 56
Chapter 6 Nursing care 58
Sarah Crowe and Fiona McLeod
Introduction 59
Standards of care 59
Physical care 63
Mobility 66
Critical care bundles 67
Conclusion 67
References 68
Chapter 7 Skin integrity 70
Victoria Clemett
Introduction 71
Anatomy and physiology of the skin 71
Impact of ageing on skin and tissue integrity 71
Pressure ulcers 71
Nursing assessment 75
Prevention of pressure ulcers 76
Management of pressure ulcers 79
Wound healing 79
Patient factors that affect wound healing 79
Nursing assessment 79
Recognising wound infection 81
Management of non-healing wounds 83
Conclusion 83
References 84
Chapter 8 Shock 86
Barry Hill
Introduction 87
Shock 87
Hypovolaemic shock 87
Blood analysis 88
Multiple organ dysfunction syndrome 89
Staging of hypovolaemic shock 89
Principles of managing hypovolaemic shock 90
Fluid resuscitation 91
Training and education for Registered Nurses 91
Cardiogenic shock 91
Obstructive shock 93
Altered pathophysiology 93
Tension pneumothorax 94
Cardiac tamponade 94
Pulmonary embolism (PE) 94
Distributive shock 95
Conclusion 96
References 97
Chapter 9 Communication 98
Paul Jebb
Introduction 99
Communicating effectively with patients 100
Communicating during a pandemic 100
Communication with families 102
Conclusion 103
References 103
Chapter 10 Electronic health records 105
Timothy Kuhn
Introduction 106
Digitisation within healthcare 106
Understand your responsibilities and the law in relation to record keeping 107
Intensive Care Society Guidelines 107
Understanding the different types of EHRs in critical care and how they are used 108
Understanding what patient data is available within the critical care unit and how this is recorded in an electronic health record 109
Understanding how EHRs are used in critical care audit and research 110
Understanding the benefits and barriers to EHRs 112
Conclusion 113
References 113
Chapter 11 Pharmacology 115
Sadie Diamond-Fox and Alexandra Gatehouse
Introduction 116
Principles of pharmacology and pharmacotherapy 116
The processes of drug therapy 116
Medication safety in critical care 119
Drugs and dialysis 120
Core drugs utilised within critical care 120
Respiratory drugs 120
Cardiovascular drugs 122
Haematological drugs 126
Renal drugs 126
Fluids and electrolytes 127
Gastrointestinal drugs 128
Insulin 129
H2-histamine antagonists and proton pump inhibitors (PPIs) 129
Anti-emetics 129
Laxatives and anti-diarrhoeal drugs 130
Neurological drugs 130
Analgesics 130
Opioids 130
Non-opioid analgesics 130
Epidural and regional anaesthesia 130
Sedatives and anxiolytics 131
Muscle relaxants 131
Anticonvulsants 132
Antideliriogenics 132
Immunomodulatory drugs 132
Antibacterial agents 132
Antifungals 133
Antiviral drugs 134
Corticosteroids 134
Immunoglobulins 134
Toxicology 134
Conclusion 135
References 135
Chapter 12 Anaesthesia and sedation 138
Lorraine Mutrie and Iain Carstairs
Introduction 139
Indications for sedation and anaesthesia 139
Anaesthetic and sedative medications 142
Sedative drugs 142
Neuromuscular blocking agents and reversal agents 143
Sedation management 145
Conclusion 147
References 148
Chapter 13 Medicines management and drug calculations 150
Jan Guerin
Introduction 151
Purpose of pharmacological interventions in the critically ill adult patient 152
Legal and professional issues 152
Collaborative multidisciplinary team working 154
Medication errors 154
Overview of routes and methods of administering medications in CCU 155
Rights of medication administration 158
Managing and reporting a medication error 159
Anaphylaxis 160
Pathophysiology and clinical manifestations of DIA 160
Management for DIA 160
Medication calculation formulae 160
Displacement 165
Conclusion 165
References 166
Chapter 14 Neurological critical care 167
Samantha O’Driscoll
Introduction 168
Neurological anatomy and physiology 168
Central nervous system 169
Neurological assessment 174
Signs and symptoms of increasing ICP 179
Primary and secondary brain injury 180
Management of raised ICP 180
Nursing care 181
Transfer 182
Conclusion 184
References 184
Chapter 15 Cognition 186
Barry Hill and Sadie Diamond-Fox
Introduction 187
Cognitive impairment 187
Causes of cognitive impairment 187
Signs of cognitive impairment 188
Delirium 188
Risk factors 190
Management of delirium 191
Sleep 193
Assessment of sleep in ICU 193
Conclusion 195
References 195
Chapter 16 Respiratory care: intubation and mechanical ventilation 197
Barry Hill and Lorraine Mutrie
Introduction 198
Respiratory failure 198
Hypoventilation 198
Ventilation/perfusion (V/Q) mismatch 199
Work of breathing 199
Arterial blood gases (ABGs) 200
Non-invasive
ventilation (NIV) 201
Continuous positive airway pressure (CPAP) 204
High flow nasal oxygen 204
Intubation 204
Mechanical ventilation 206
Artificial ventilation 207
Minute ventilation (Vm) 207
Fraction of inspired oxygen 207
Positive end-expiratory
pressure (PEEP) 207
Volume control 207
Pressure control 207
Inspiratory:Expiratory (I:E) ratio 208
Inverse ratio 208
Synchronisation 208
Humidification 208
Benefits of mechanical ventilation 208
Risks of mechanical ventilation 208
Ventilator care bundles 209
Prone positioning 209
Prone positioning in COVID-19 209
Weaning from mechanical ventilation 210
Conclusion 210
References 211
Chapter 17 Lung function in critical care 213
Rana Din and Joyce Smith
Introduction 214
Anatomy and physiology 214
Composition of air 215
Alveolar gas 215
Expired air 216
Lung volumes 216
Pulmonary ventilation 216
External respiration 217
Ventilation/Perfusion 217
Transport of gases 217
Internal respiration 218
Assessment of lung function 220
Normal breath sounds (vesicular) 221
Absent Sounds 221
Wheeze 222
Crackles 222
The work of breathing 222
Compliance 222
Resistance 222
Emphysema 222
Asthma 223
Obstructive sleep apnoea 224
Prone positioning 224
Conclusion 225
References 226
Chapter 18 Cardiac physiology 227
Paul Sinnott
Introduction 228
Functions of the cardiovascular system 228
Anatomy of the heart and great vessels 228
Pericardium 229
Layers of the heart 229
Chambers of the heart 230
Valves of the heart 230
Coronary circulation 232
Cardiac conduction system 235
The cardiac cycle 236
Cardiac output and blood pressure 237
Regulation of heart rate 238
Stroke volume 239
The regulation of blood pressure 240
The microcirculation 242
Capillary exchange 243
Effects of ventilation on the cardiovascular system 245
Conclusion 245
References 246
Chapter 19 Cardiovascular critical care 247
Alice Shaw and Paul Sinnott
Introduction 248
Cardiovascular assessment 248
Heart rate and rhythm 248
Atrial ectopic beats 249
Ventricular ectopic beats 253
Blood pressure 254
Invasive blood pressure monitoring 255
Central venous catheters (CVCs) and central venous pressure (CVP) 256
Markers of organ and tissue perfusion 258
Neurological status 258
Urine output 258
Blood results 259
Advanced haemodynamic monitoring 260
Cardiac pacing 262
Nursing considerations and recommendations for practice 263
Conclusion 263
References 263
Chapter 20 Fluids and electrolytes in critically ill patients 265
Barry Hill
Introduction 266
The role of the critical care nurse 266
Intravenous fluids 266
Crystalloids versus colloids critical care 267
Fluid management 268
Third spacing 269
Assessment and monitoring 269
Training and education 271
Electrolyte replacement therapy 271
Management of hyperkalaemia 272
Oral sodium and water 272
Oral rehydration therapy (ORT) 272
Oral bicarbonate 273
Parenteral preparations for fluid and electrolyte imbalance 273
Plasma and plasma substitutes 276
Plasma substitutes 276
Fluid overload 276
The four Ds of fluid management 276
Hyponatraemia 277
Hypernatraemia 277
Hypokalaemia 277
Hyperkalaemia 277
Hypophosphataemia 278
Hypocalcaemia 278
Hypomagnesaemia 278
Conclusion 279
References 279
Chapter 21 Critical care emergencies 280
Alexandra Gatehouse and Sadie Diamond-Fox
Introduction 281
A – Airway 282
B – Breathing 290
C – Circulation/Cardiovascular 291
D – Disability 298
E – Everything else (exposure, endocrine, electrolytes and environmental) 301
Care of the patient post return of spontaneous circulation (ROSC) 307
Critical care emergencies and human factors 307
Debriefing 309
Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) and Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) 309
Conclusion 310
References 310
Chapter 22 Gastrointestinal critical care 313
Anna Riley, Joe Box, and Aileen Aherne
Introduction 314
Anatomy and physiology 314
GI monitoring and investigation in the critically ill 317
Imaging and endoscopy 318
Bowel charts and abnormal GI motility 320
The acute abdomen in critical care 322
Common surgical procedures cared for in critical care 325
Post-operative monitoring 325
Abdominal surgical drains 326
Anaesthetics 326
Post-operative complications 326
Wound dehiscence 327
GI pharmacology 327
Conclusion 328
References 328
Chapter 23 Nutrition in critical care 330
Barry Hill and Lorraine Mutrie
Introduction 331
Pathophysiology 331
Fight or flight 332
Resistance 332
Exhaustion 332
Nutritional screening and assessment 333
Indirect calorimetry (IC) 333
Routes of administration 334
Nursing considerations and recommendations for practice 336
Care of people with feeding tubes 336
Glycaemic control 337
Refeeding syndrome 338
Discontinuing feed 339
Nutritional guidance 339
Conclusion 340
References 341
Chapter 24 Renal critical care 343
Alexandra Gatehouse and Sadie Diamond-Fox
Introduction 344
Anatomy and physiology of the renal tract 344
Vascular supply 344
Renin-angiotensin-aldosterone system (RASS) 344
The nephrons 345
Control of plasma osmolality 346
Electrolyte balance 346
Acid-base balance 352
Renal failure 352
Acute kidney injury 353
Classification of AKI 353
Pathophysiology 353
Organ cross-talk 354
Risk factors for AKI 355
Clinical features and examination 355
Investigations 355
Specific disorders associated with AKI 357
Drug-induced renal damage 357
Management of AKI 359
Clinical features and examination 361
Management 361
Chronic kidney disease 362
Management 362
Diabetic nephropathy 362
Continuous renal replacement therapy (CRRT) 364
Dosing of CRRT 364
Anticoagulation 364
Drug dosing and RRT 367
Kidney transplantation – critical care considerations 367
Conclusion 368
References 368
Chapter 25 Endocrine critical care 370
Geraldine Fitzgerald O’Connor and Emma Long
Introduction 371
Thyroid and parathyroid glands 371
Disorders of the thyroid gland 371
Thyroid crisis 372
Parathyroid glands 372
Disorders of the parathyroid glands 372
Hypocalcaemia 373
Pituitary gland 373
Disorders of the pituitary gland 373
Diabetes insipidus 374
Pathophysiology 375
Hyperglycaemia in the critically ill 376
Diabetic emergencies 376
Pathophysiology 380
Conclusion 383
References 384
Chapter 26 Haematological and immunological critical care 385
Barry Hill, Gerri Mortimore, and Pamela Arasen
Introduction 386
Normal physiology 386
Blood components 386
Haematopoiesis 387
Disorders of erythrocytes 387
B12 vitamin deficiency 387
Sickle cell anaemia 388
Genetic haemochromatosis 389
Haemostasis 390
Lymphoma 390
Disseminated intravascular coagulation 393
Thrombocytopenia 394
Neutropenia and sepsis 394
Vasculitis 396
Blood transfusions in adults 397
Blood sample collections 398
Blood groups 398
Compatibility 399
Indications for blood transfusions 399
Platelets 400
Fresh frozen plasma (FFP) 400
Cryoprecipitate 400
Granulocytes 400
Procedural safety 400
Pre-procedure and sampling 400
Administration of the blood product 400
Post-procedural care 401
Traceability 401
Patient information 402
Alternatives to blood transfusions 403
Summary of SaBTO recommendations on consent 403
Conclusion 408
References 408
Chapter 27 Musculoskeletal considerations in critical care 411
Clare L. Wade and Helen Sanger
Introduction 412
Trauma 412
Management of traumatic injury 413
Intensive care unit-acquired weakness 415
Assessment of musculoskeletal impairment or injury 418
Management of musculoskeletal injury and impairment 419
Conclusion 424
References 424
Chapter 28 Burn care within a critical care setting 426
Nicole Lee
Introduction 427
Classification of burn wound depths 427
Pathological considerations 429
Burn size estimation 430
An ABCDE approach to burn care 432
Breathing 433
Cardiovascular 433
Disability (neurological assessment) 434
Exposure (and everything else) 434
Psychological support 434
Acknowledgement 436
References 436
Chapter 29 Maternal critical care 438
Wendy Pollock
Introduction 439
Epidemiology 439
Adapted physiology 439
Recognising clinical deterioration 441
Nursing considerations and recommendations for practice 442
Conclusion 448
References 449
Chapter 30 Critical care transfers 451
Kirstin Geer, Mark Cannan, and Stuart Cox
Inter-hospital and intra-hospital patient transfers 452
Transfer of the critically ill adult 452
Critical care bed and repatriation 456
The risks of critical care transfer 457
Preparation for transfer 458
ABCDE process during critical care transfer 458
Conclusion 469
References 469
Chapter 31 Rehabilitation after critical illness 470
Helen Sanger and Clare L. Wade
Introduction 471
The impact of critical illness – what do we mean by morbidity? 471
Describing physical functioning and morbidity 472
Models of post-critical care morbidity 473
Assessment 473
Goals 475
Key timepoints in RaCI 477
Treatment 478
National guidelines and standards 480
Conclusion 481
References 481
Chapter 32 Dying and death 484
Helen Merlane and Leonie Armstrong
Introduction 485
End-of-life care 485
Palliative care 486
Dying 486
Recognising Dying 486
Advance care planning 488
Involve and support 489
Nursing the dying patient 489
The critical care environment 489
Symptom management 490
End-of-life care discharges from a critical care setting 491
Care after death 494
Conclusion 495
References 495
Index 497
