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oxford desk reference - critical care

OXFORD MEDICAL PUBLICATIONS
Oxford Desk Reference
Critical Care
Oxford University Press makes no representation, express
or implied, that the drug dosages in this book are correct.
Readers must therefore always check the product informa-
tion and clinical procedures with the most up-to-date pub-
lished product information and data sheets provided by
the manufacturers and the most recent codes of conduct
and safety regulations. The authors and the publishers do
not accept responsibility or legal liability for any errors in
the text or for the misuse or misapplication of material in
this work.
2 Except where otherwise stated, drug doses and recom-
mendations are for the non-pregnant adult who is not
breast-feeding.
Oxford Desk Reference
Critical Care
Carl Waldmann
Consultant in Anaesthesia and Intensive Care

Royal Berkshire Hospital
Reading
Neil Soni
Honorary Clinical Senior Lecturer
Division of Surgery, Oncology,
Reproductive Biology and Anaesthetics
Imperial College
London
and
Andrew Rhodes
Consultant in Intensive Care
St George's Hospital
London
1
1
Great Clarendon Street, Oxford OX2 6DP
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© Oxford University Press 2008
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First published 2008
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Typeset by Cepha Imaging Private Ltd., Bangalore, India
Printed in Great Britain
on acid-free paper by
CPI Antony Rowe,
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ISBN 978–0–19–922958–1
10 9 8 7 6 5 4 3 2 1
v
Intensive care medicine is an evolving speciality in which the amount of available informa-
tion is growing daily and increasingly, textbooks refl ect this in terms of their size. Size and
immediate clinical utility are often inversely related and ‘bottom line’ practicality is drowned
in comprehensive discussion. The natural habitat of this new textbook of critical care and
emergency medicine is on the desktops of Intensive Care units, High Dependency units,
acute medical or surgical wards, Accident & Emergency departments and maybe even
operating theatres where it is easily accessible with useful and relevant information.
While aimed primarily at a specialist readership including clinicians, nurses, and other
allied health professionals in Critical Care, Anaesthesia and the acute specialities, we hope
it will fi nd a niche with anyone involved in care of the critically ill, whether in specialist areas
or in the wards.
It is intended that the key feature of this book is ease of access to up-to-date relevant
evidenced-based information regarding the management of commonly encountered condi-
tions, techniques, and problems in those who are critically ill. Most importantly that it is
practical and useful. The content of the book is based, wherever possible and useful, upon
the latest sets of guidelines from national or international bodies (e.g. Society of Critical
Care Medicine, European Society of Intensive Care Medicine). We hope the book will be
useful not only in the United Kingdom, but to anyone using international guidelines. Indeed,
the range of invited authors incorporates a large number of countries but for all, the com-
mon theme is management of the critically ill.
To facilitate the key aim of rapid and easy access to information, the book is designed
such that each subject will form a self-contained topic in its own right, laid out across two
(or, for larger subjects, up to four) pages. This format facilitates the use of the book as a
desk reference and we envisage that it will be consulted in the clinic or ward setting for
information on the optimum management of a particular condition.
It is the fervent wish of the editors that this book, one in a series of desk top books from
Oxford University Press, becomes a valuable tool in the management of critically ill pa-
tients.
CW, NS, and AR
Preface
This page intentionally left blank
viivii
Brief contents
Detailed Contents ix
Abbreviations xiii
Contributors xix
1 Respiratory therapy techniques
1
2 Cardiovascular therapy techniques
51
3 Renal therapy techniques
63
4 Gastrointestinal therapy techniques
73
5 Nutrition
81
6 Respiratory monitoring
89
7 Cardiovascular monitoring
97
8 Neurological monitoring
129
9 Fluids
141
10 Respiratory drugs
153
11 Cardiovascular drugs
165
12 Gastrointestinal drugs
193
13 Neurological drugs
205
14 Haematological drugs
219
15 Miscellaneous drugs
227
16 Resuscitation
239
viii
PRELIM RUNNING HEAD
17 Respiratory disorders
247
18 Cardiovascular disorders
283
19 Renal disorders
311
20 Gastrointestinal disorders
317
21 Hepatic disorders
347
22 Neurological disorders
359
23 Haematological disorders
387
24 Metabolic disorders
409
25 Poisoning
439
26 Shock
445
27 Infection and infl ammation
461
28 Trauma and burns
481
29 Physical disorders
497
30 Pain and post-operative intensive care
507
31 Obstetric emergencies
517
32 Death and dying
529
33 ICU organization and management
541
Appendix
591
Index 593
BRIEF CONTENTS
Abbreviations xiii
Contributors xix
1 Respiratory therapy
techniques
1
Oxygen therapy 2
Ventilatory support: indications 6
IPPV—description of ventilators 8
IPPV—modes of ventilation 10
IPPV—adjusting the ventilator 12
IPPV—barotrauma 14
IPPV—weaning techniques 16
High-frequency ventilation 18
Positive end-respiratory pressure 22
Continuous positive airway pressure
ventilation (CPAP)
24
Recruitment manoeuvres 26
Prone position ventilation 28
Non-invasive positive pressure
ventilation (NIPPV)
30
Extracorporeal membrane
oxygenation (ECMO) for adults in respiratory
failure
32
Tracheostomy 34
Aftercare of the patient with a tracheostomy 36
Chest drain insertion 38
Pleural aspiration 40
Flexible bronchoscopy 42
Chest physiotherapy 44
Humidifi cation 46
Heart–lung interactions 48
2 Cardiovascular therapy
techniques
51
Defi brillation 52
Temporary cardiac pacing 54
Intra-aortic balloon counterpulsation pump 56
Cardiac assist devices 58
Therapeutic cooling 60
3 Renal therapy techniques 63
Haemodialysis 64
Haemo(dia)fi ltration 68
Peritoneal dialysis (PD) 70
4 Gastrointestinal therapy
techniques
73
Insertion of a Sengstaken–Blakemore
tube in critical care
74
Upper gastrointestinal endoscopy 76
Nasojejunal feeding in critical
care patients
78
5 Nutrition 81
Enteral nutrition 82
Parenteral nutrition 84
Immune-enhancing nutrition 86
6 Respiratory monitoring 89
Pulmonary function tests in
critical illness
90
End-tidal CO
2
monitoring 92
Pulse oximetry 94
7 Cardiovascular monitoring 97
ECG monitoring 98
Arterial pressure monitoring 102
Insertion of central venous
catheters
104
Common problems with central
venous access
106
Pulmonary artery catheter:
indications and use
108
Pulmonary artery catheter:
insertion
110
Echocardiography 112
Clinical application of echocardiography
in the ICU
116
Doppler 118
Pulse pressure algorithms 120
Non-invasive methods 122
Measurement of preload status 124
Detection of fl uid responsiveness 126
8 Neurological monitoring 129
Intracranial pressure monitoring 130
Intracranial perfusion 132
EEG and CFAM monitoring 134
Other forms of neurological
monitoring
138
Detailed contents
ix
9 Fluids 141
Crystalloids 142
Colloids 144
Sodium bicarbonate 146
Blood 150
10 Respiratory drugs 153
Bronchodilators 154
Nitric oxide 156
Mucolytics 158
Surfactant 160
Helium–oxygen gas mixtures 162
11 Cardiovascular drugs 165
B-Adrenergic agonists 166
Phosphodiesterase inhibitors 168
Vasodilators 170
Vasopressors 174
Antiarrhythmic agents 176
Chronotropes 178
Antianginal agents 182
Antiplatelet agents 184
Diuretics and the critically ill 186
Levosimendan 190
12 Gastrointestinal drugs 193
H2 blockers and proton pump inhibitors 194
Antiemetics 196
Gut motility agents 198
Antidiarrhoeals 200
Constipation in critical care 202
13 Neurological drugs 205
Opioid and non-opioid analgesics
in the ICU
206
Sedation management in ICU 208
Muscle relaxants 210
Anticonvulsant drugs 212
Cerebroprotective agents 214
Mannitol and hypertonic saline 216
14 Haematological drugs 219
Anticoagulants and heparin-induced
thrombocytopenia
220
Thrombolysis 224
Antifi brinolytics 226
15 Miscellaneous drugs 227
Antibiotics 228
Antifungals 230
Antiviral agents 232
N-Acetylcysteine 234
Activated protein C 236
16 Resuscitation 239
Basic and advanced resuscitation 240
Post-cardiac arrest management 242
Fluid challenge 244
17 Respiratory disorders 247
Upper airway obstruction 248
Respiratory failure 250
Pulmonary collapse and atelectasis 252
Chronic obstructive pulmonary
disease (COPD)
254
ARDS: diagnosis 256
ARDS: general management 258
ARDS: ventilatory management 260
Asthma 262
Asthma: ventilatory management 264
Pneumothorax 266
Empyema 268
Haemoptysis 270
Inhalation injury 272
Pulmonary embolism 274
Community-acquired pneumonia 276
Hospital-acquired pneumonia 278
Pulmonary hypertension 280
18 Cardiovascular disorders 283
Hypertension 284
Tachyarrhythmias 288
Bradyarrhythmias 290
Myocardial infarction: diagnosis 292
NSTEMI 294
STEMI 296
Acute heart failure: assessment 300
Acute heart failure: management 304
Bacterial endocarditis 308
19 Renal disorders 311
Prevention of acute renal failure 312
Diagnosis of acute renal failure 314
20 Gastrointestinal disorders 317
Vomiting and gastric stasis/gastroparesis 318
Gastric erosions 320
Diarrhoea 322
Upper gastrointestinal haemorrhage
(non-variceal)
324
x
DETAILED CONTENTS
Bleeding varices 326
Intestinal perforation 328
Intestinal obstruction 330
Lower gastrointestinal bleeding 332
Colitis 334
Intra-abdominal sepsis 336
Pancreatitis 338
Acute acalculous cholecystitis 340
Splanchnic ischaemia 342
Abdominal hypertension (IAH) and
abdominal compartment syndrome
344
21 Hepatic disorders 347
Jaundice 348
Acute liver failure 350
Hepatic encephalopathy 352
Chronic liver failure 354
Abnormal liver function tests 356
22 Neurological disorders 359
Agitation and confusion 360
Status epilepticus 362
Meningitis 364
Intracerebral haemorrhage 366
Subarachnoid haemorrhage 368
Ischaemic stroke 370
Guillain–Barre syndrome 372
Myasthenia gravis 374
ICU neuromuscular disorders 376
Tetanus 378
Botulism 380
Neurorehabilitation 382
Hyperthermias 384
23 Haematological disorders 387
Bleeding disorders 388
Anaemia in critical care 392
Sickle cell anaemia 394
Haemolysis 396
Disseminated intravascular coagulation 398
Neutropenic sepsis 400
Haematological malignancies in the ICU 404
Coagulation monitoring 406
24 Metabolic disorders 409
Electrolyte disorders 410
Hyponatraemia 414
Hypernatraemia 416
Categorizing metabolic acidoses 418
Metabolic acidosis aetiology 420
Metabolic alkalosis 422
Glycaemic control in the critically ill 426
Diabetic ketoacidosis 428
Hyperosmolar diabetic emergencies 430
Thyroid emergencies: thyroid
crisis/thyrotoxic storm
432
Thyroid emergencies:
myxoedema coma
434
Hypoadrenal crisis 436
25 Poisoning 439
Management of acute poisoning 440
26 Shock 445
Shock: defi nition and diagnosis 446
Hypovolaemic shock 450
Cardiogenic shock 452
Anaphylactic shock 456
Septic shock: pathogenesis 458
27 Infection and infl ammation 461
Pathophysiology of sepsis and multi-organ
failure
462
Infection control—general principles 464
HIV 466
Severe falciparum malaria 468
Vasculitides in the ICU 470
Source control 472
Selective decontamination of the
digestive tract (SDD)
474
Markers of infection 476
Adrenal insuffi ciency and sepsis 478
28 Trauma and burns 481
Initial management of major trauma 482
Head injury 484
Spinal trauma 486
Chest trauma 488
Pelvic trauma 490
Burns—fl uid management 492
Burns—general management 494
29 Physical disorders 497
Hypothermia 498
Drowning and near-drowning 500
Rhabdomyolysis 502
Pressure sores 504
30 Pain and post-operative
intensive care
507
Pain management in ICU 508
xi
DETAILED CONTENTS
xii
Intensive care for the high risk surgical
patient
510
The acute surgical abdomen in the ITU 512
The medical patient with surgical
problems
514
31 Obstetric emergencies 517
Pre-eclampsia 518
Eclampsia 520
HELLP syndrome 522
Postpartum haemorrhage 524
Amniotic fl uid embolism 526
32 Death and dying 529
Confi rming death using neurological
criteria (brainstem death)
530
Withdrawing and withholding
treatment
532
The potential heart-beating
organ donor
534
Non-heart-beating organ donation 538
33 ICU organization and
management
541
Consent on the ICU 542
Rationing in critical care 544
ICU layout 546
Medical staffi ng in critical care 548
ICU staffi ng: nursing 550
ICU staffi ng: supporting professions 554
Fire safety 556
Legal issues and the Coroner 560
Patient safety 564
Severity of illness scoring systems 568
Comparison of ICUs 570
Critical care disaster planning 572
Health technology assessment 574
Transfer of the critically ill patient 576
Aeromedical evacuation 580
Outreach 582
Medical emergency teams 584
Critical care follow-up 586
Managing antibiotic resistance 588
Appendix 591
Respiratory physiology 592
Index 593
DETAILED CONTENTS
xiii
± plus or minus
≤ less than or equal to
≥ more than or equal to
∼ approximatley
° degrees
↑ increase
↓ decrease
–ve negative
+ve positive
AAC acute acalculous cholecystitis
AAFB acid- and alcohol-fast bacilli
ABG arterial blood gas
ABPA allergic bronchopulmonary aspergillosis
AC activated charcoal
ACS acute coronary syndrome
ACTH adrenocorticotrophic hormone
ACE angiotension-converting enzyme
AChR acetylcholine receptor
ACTH adrenocorticotrophic hormone
ADH antidiuretic hormone
AECOPD acute exacerbations of chronic obstructive
airways disease
AED automated external defi brillator/
antiepileptic drug
AF atrial fi brillation
AFE amniotic fl uid embolism
AG anion gap
AHF acute heart failure
AI acoustic impedance
AIDP acute infl ammatory demyelinating
polyneuropathy
AIDS autoimmune defi ciency syndrome
AKI acute kidney injury
ALI acute lung injury
ALS advanced life support
AMAN acute motor axonal neuropathy
AMI acute myocardial infarction
AMSAN acute motor sensory axonal neuropathy
ANC absolute neutrophil count
ANCA antineutrophil cytoplasmic antibody
ANP atrial natriuretic peptide
APACHE Acute Physiology and Chronic Health
Evaluation
APC activated protein C
APH antepartum haemorrhage
APP abdominal perfusion pressure
aPPT activated partial prothrombin time
AR aortic regurgitation
ARB angiotensin II receptor blocker
ARDS acute respiratory distress syndrome
ARF acute respiratory failure
ARV antiretroviral
AS aortic stenosis
ASA acetylsalicylic acid (aspirin)
aSAH aneurysmal subarachnoid haemorrhage
AST aspartate aminotransferase
ATLS Advanced Trauma Life Support
ATP adenosine triphosphate
AV atrioventricular
AVP arginine vasopressin
AXR abdominal X-ray
BAE bronchial artery embolization
BAL bronchoalveolar lavage
BAEP brainstem auditory evoked potential
BBB blood–brain barrier
bd twice a day
BiPAP bilevel positive airway pressure
BLS basic life support
BMI body mass index
BMP bone morphogenetic protein
BMPR2 bone morphogenetic protein receptor II
BMS bone marrow suppression
BP blood pressure
BPF bronchopleural fi stula
bpm beats per minute
BNP brain natriuretic peptide
BTF Brain Trauma Foundation
CABG coronary artery bypass graft
CAD coronary artery disease
cAMB conventional amphotericin B
CAP community-acquired pneumonia
CAPD continuous ambulatory peritoneal dialysis
CBF cerebral blood fl ow
CCB calcium channel blocker
CCC Comprehensive Critical Care
CCCP Critical Care Contingency Planning
CCN critical care nurse
CDAD Clostridium diffi cile-associated disease
CDT Clostridium diffi cile toxin
CEA cost-effective analysis
CEMCH Confi dential Enquiry into Maternal and
Child Health
CFAM cerebral function analysing monitor
CFM colour fl ow mapping
CHF chronic heart failure
CI confi dence interval
CIM critical illness myopathy
CIN contrast-induced nephropathy
Abbreviations
xiv
CINM critical illness neuromyopathy
CIP critical illness polyneuropathy
CK creatine kinase
CMAP compound muscle action potential
CMR cerebral metabolic rate
CMV conventional mechanical ventilation/
cytomegalovirus
cNOS constitutive nitric oxide synthase
CNS central nervous system
COMT catechol-o-methyltransferase
COPD chronic obstructive pulmonary disease
COX cyclo-oxygenase
CPAP continuous positive airway pressure
CPIS Clinical Pulmonary Infection Score
CPP cerebral perfusion pressure
CPR cardiopulmonary resuscitation
CPT chest physiotherapy
CrAg cryptococcal antigen
CR-BSI catheter-related bloodstream infection
CRP C-reactive protein
Crs respiratory compliance
CSF cerebrospinal fl uid
CSS Churg–Strauss syndrome
CT computed tomography
CTA CT angiogram
CTV CT venogram
CTZ chemoreceptor trigger zone
CVA cerebrovascular accident
CVC central venous catheter
CVP central venous pressure
CV ratio compression:ventilation ratio
CVVH continuous venovenous haemofi ltration
CVVHD continuous venovenous haemodialysis
CVVHDF continuous venovenous haemodiafi ltration
CXR chest X-ray
DBP diastolic blood pressure
DCCV direct current cardioversion
DAH diffuse alveolar haemorrhage
DAI diffuse axonal injury
DD deep dermal
DDAVP 1-deamino-D-arginine vasopressin
DGLA di-homo-γ-linolenic acid
DHA docosohexanoic acid
DIC disseminated intravascular coagulation
DIND delayed ischaemic neurological defi cit
DKA diabetic ketoacidosis
DMS direct muscle stimulation
DNAR do not attempt resuscitation
2,3-DPG 2,3-diphosphoglycerate
DPPC dipalmitoylphosphatidylcholine
DrotAA drotrecogin alfa (activated)
DSA digital subtraction angiogram
DVT deep vein thrombosis
EACA ε-aminocaproic acid
EBV Epstein–Barr virus
ECG electrocardiograph
ECMO extracorporeal membrane oxygenation
EDA end-diastolic area
EDV end-diastolic volume
EEG electroencephalograph
EF ejection fraction
ELISA enzyme-linked immunosorbent assay
EMG electromyograph
EN enteral nutrition
ENT ear, nose and throat
EPA eicosopentanoic acid
EPCR endothelial protein C receptor
EPO erythropoietin
EPUAP European Pressure Ulcer Advisory Panel
ERCP endoscopic retrograde
cholangiopancreatography
ESBL extended-spectrum β-lactamase
ESD end-systolic volume
ESRD end-stage renal disease
ESR erythrocyte sedimentation rate
ETCO
2
end-tidal CO
2

ETT endotracheal tube
EVLW extravascular lung water
FBC full blood count
FDA Food and Drug Administration
FDP fi brinogen degradation product
FEV forced expiratory volume
FFP fresh frozen plasma
FiO
2
fractional inspired oxygen concentration
FNA fi ne needle aspiration
FRC functional residual capacity
FT full thickness
FTc corrected fl ow time
FVC forced vital capacity
GABA γ-aminobutyric acid
GAVE gastric antral vascular ectasia
GBS Guillain–Barre syndrome
GCS Glasgow Coma Score (Scale)
G-CSF granulocyte colony-stimulating factor
GDP Gross Domestic Product
GEDVI global end-diastolic volume index
GFR glomerular fi ltration rate
GI gastrointestinal
GIST gastrointrestinal stromal tumour
GLA γ-linolenic acid
GNC General Medical Council
GM-CSF granulocyte–macrophage
colony-stimulating factor
GOJ gastro-oesophageal junction
G-6-PD glucose-6-phospate dehydrogenase
γGT γ-glutamyltransferase
ABBREVIATIONS
xv
GTN glyceryl trinitrate
GvHD graft vs host disease
HAART highly active antiretroviral therapy
HAP hospital-acquired pneumonia
HAS human albumin solution
HAV hepatitis A virus
Hb haemoglobin
H2B histamine receptor 2 blocker
HBO hyperbaric oxygen
HBV hepatitis B virus
HCA healthcare assistant
HCT haematopoetic cell transplantation
HCV hepatitis C virus
HDU High Dependency Unit
HELLP haemolysis, elevated liver enzymes, low
platelets
HEPA high effi ciency particulate air
HF haemofi ltration/heart failure
HFJV high-frequency jet ventilation
HFOV high-frequency oscillatory ventilation
HFV high-frequency ventilation
HIT heparin-induced thrombocytopenia
HIV human immunodefi ciency virus
HLA human leucocyte antigen
HME heated membrane exchange
HNS hyperosmolar non-ketotic state
HO heterotopic ossifi cation
HOCM hypertrophic obstructive cardiomyopathy
HPA hypothalamo-pituitary–adrenal
HRCT high resolution CT
HRS hepatorenal syndrome
HSCT haematopoietic stem cell transplantation
HSV herpes simplex virus
5-HT 5-hydroxytryptamine
HT health technology assessment
HTS hypertonic saline
HU hydroxyurea
HUS haemolytic–uraemic syndrome
HVAC heating, ventilation and air conditioning
HVHF high volume haemofi ltration
IABP intra-aortic balloon pump
IAH intra-abdominal hypertension
IAP intra-abdominal pressure
IBD irritable bowel disease
IBTICM Intercollegiate Board for Training in
Intensive Care Medicine
IBW ideal body weight
ICG indocyanine green
ICH intracranial (intracerebral) haemorrhage
ICNSS Intensive Care Nursing Scoring System
ICP intracranial pressure
ICS inhaled corticosteroid/Intensive Care
Society
ICU Intensive Care Unit
IE infective endocarditis
IEN immune-enhancing nutrition
I:E ratio inspiratory:expiratory ratio
IGF-1 insulin-like growth factor-1
IL interleukin
ILMA intubating laryngeal mask airway
IM intramuscular
iNO inhaled nitric oxide
iNOS inducible nitric oxide synthase
INR international normalized ratio
IPPV intermittent positive pressure ventilation
IPV intrapulmonary percussive ventilator
IRDS infant respiratory distress syndrome
IRIS immune reconstitution infl ammatory
syndrome
IS incentive spyrometry
ITBVI intrathoracic blood volume index
ITP intrathoracic pressure
ITT intention-to-treat
ITU Intensive Therapy Unit
IV intravenous
IVC inferior vena cava
IVIG intravenous immunoglobulin
JVP jugular venous pressure
LA left atrium
LABA long-acting β
2
agonist
LBBB left bundle branch block
LDH lactate dehydrogenase
LEMS Lambert–Eaton myasthenia syndrome
LFT liver function test
LIP lower infl ection point
LMA laryngeal mask airway
LMWH low molecular weight heparin
LOLA L-ornithine l-aspartate
LOS length of stay
LP lumbar puncture
LPA Lasting Power of Attorney
LPS lipopolysaccharide
LTB leukotriene B
LTOT long-term oxygen therapy
LV left ventricle
LVAD left ventricular assist device
LVH left ventricular hypertrophy
LVOT left ventricular outfl ow tract
MAO monoamine oxidase
MAOI monoamine oxidase inhibitor
MAP mean arterial pressure
MCA middle cerebral artery
MDI metered-dose inhalation
MDR multiple drug-resistant
MEG-X monoethylglycinxylidide
MET medical emergency team
ABBREVIATIONS
xvi
MetHb methaemoglobin
MG myasthenia gravis
MH malignant hyperthermia
MHI manual hyperinfl ation
MI myocardial infarction
MOD multi-organ dysfunction
MODS multi-organ dysfunction syndrome
MOF multi-organ failure
MPA microscopic polyangitis
MPM Mortality Probability Model
MPO myeloperoxidase
MR mitral regurgitation
MRCP magnetic resonance
cholangiopancreatography
MRI magnetic resonance imaging
MRSA methicillin-resistant Staphylococcus aureus
MS mitral stenosis
MuSK muscle-specifi c receptor kinase
NAC N-acetylcysteine
nAChR nicotinic acetylcholine receptor
NAECC North American–European Consensus
Conference
NAG N-acetylglucosaminidase
NAPQI N-acetyl-p-benzoquinone imine
NCEPOD National Confi dential Enquiry into Patient
Outcome and Death
NCSE non-convulsive status epilepticus
NF-κB nuclear factor-κB
NG nasogastric
NHBD non-heart-beating donor
NICE National Institute for Health and Clinical
Excellence
NIPPV non-invasive positive pressure ventilation
NIRS near-infrared spectroscopy
NIV non-invasive ventilation
NJ nasojejunal
NK neurokinin
NMDA N-methyl-D-aspartate
NO nitric oxide
NOS nitric oxide synthase
NRT nicotine replacement therapy
NSAID non-steroidal anti-infl ammatory drug
NSTEMI non-ST-segment elevation myocardial
infarction
nv-CJD new variant Creutzfeld–Jacob disease
NYHA New York Heart Association
od once daily
OHCA out-of-hospital cardiac arrest
OJEU Offi cial Journal of the European Union
OP opening pressure
OR odds ratio
OSAHS obstructive sleep apnoea hypopnoea
syndrome
PaCO
2
arterial partial pressure of carbon dioxide
PAH pulmonary arterial hypertension
PAMP pathogen-associated molecular pattern
PAN polyarteritis nodosa
Pao pressure at airway opening
PaO
2
arterial partial pressure of oxygen
PAoP pulmonary artery occlusion pressure
PAR1 protease-activated receptor 1
PAWP pulmonary artery wedge pressure
PBV pulmonary blood volume
PBW predicted body weight
PCA patient-controlled anaesthesia
PCC prothrombin complex concentrate
PCI percutaneous coronary intervention
PCP Pneumocystis carinii pneumonia
PCR polymerase chain reaction
PCT procalcitonin
PD peritoneal dialysis
PDE phosphodiesterase
PDH pyruvate dehydrogenase
PE pulmonary embolism
PEA pulseless electrical activity
PECO
2
partial pressure of expired CO
2
PEEP positive end-expiratory pressure
PEFR peak expiratory fl ow rate
PEG percutaneous endoscopic gastrostomy
PEJ percutaneous endoscopic jejunostomy
PEP positive expiratory pressure
PET positron emission tomography
PetCO
2
end-tidal CO
2
partial pressure
PG prostaglandin
PIE pulmonary interstitial emphysema
PIP positive inspiratory pressure
PLR passive leg raising
PN parenteral nutrition
PO per os
PONV post-operative nausea and vomiting
PP partial pressure
PPA plexogenic pulmonary arteriopathy
PPH postpartum haemorrhage
PPHN persistent pulmonary hypertension of the
newborn
PPI proton pump inhibitor
PPM potentially pathogenic microorganism
PPV pulse pressure variation
PR3 proteinase 3
PRA plasma renin activity
PRF pulse repetition frequency
PSV pressure support ventilation
PT prothrombin time
PTC percutaneous transhepatic
cholecystotomy
PTCA percutaneous transluminal coronary
angioplasty
ABBREVIATIONS
xvii
PTSD post-traumatic stress disorder
PUFA polyunsaturated fatty acid
P/V pressure–volume
PVR pulmonary vascular resistance
QALY quality-adjusted life year
qds four times a day
RA right atrium
RAAS renin–angiotensin–aldosterone system
Raw airway resistance
RBBB right bundle branch block
RCT randomized controlled trial
RDS respiratory distress syndrome
REM rapid eye movement
RH relative humidity
ROSC return (restoration) of spontaneous
circulation
RPGN rapidly progressive glomerulonephritis
RR relative risk
Rrs respiratory resistance
RRT renal replacement therapy
RV right ventricle
RVAD right ventricular assist device
RV EDVI right ventricular end-diastolic volume
index
RWMA regional wall motion abnormality
SA sinoatrial
SABA short-acting β agonist
SAH subarachnoid haemorrhage
SAP severe acute pancreatitis
SAPS Simplifi ed Acute Physiology Score
SB spontaneous breathing
SBE standard base excess
SBP systolic blood pressure
SBT spontaneous breathing trial
SBT-CO
2
single breath test for CO
2
SC subcutaneous/seiving coeffi cient
SCD sickle cell disease
SCI spinal cord injury
SCUF slow continuous ultrafi ltration
SD superfi cial dermal
SDB sleep-disoderded breathing
SDD selective decontamination of the digestive
tract
SE status elipticus
SEP sensory evoked potential
SIADH syndrome of inappropriate ADH secretion
SID strong ion difference
SIG strong ion gap
SIMV synchronized intermittent mandatory
ventilation
SIRS systemic infl ammatory response
syndrome
SLE systemic lupus erythematosus
SLED sustained low effi ciency dialysis
SNP sodium nitroprusside
SOFA Sequential Organ Failure Assessment
SP surfactant protein
SRH stigmata of recent haemorrhage
SSEP somatosensory evoked potential
STEMI ST-segment elevation myocardial infarction
SV stroke volume
SVC superior vena cava
SVR systemic vascular resistance
SVT supraventricular tachycardia
SVV stroke volume variation
T
3
triiodothyronine
T
4
thyroxine
TB tuberculosis
TBI traumatic brain injury
TBSA total body surface area
TCA tricyclic antidepressant
TCD transcranial Doppler
Tds three times a day
TED thromboembolism deterrent
TEG thromboelastogram
TENS transcutaneous electrical nerve
stimulation
TGF transforming growth factor
TIA transient ischaemic attack
TIPS transjugular intrahepatic portosystemic
shunt
TK thymidine kinase
TLC total lung capacity
TLR Toll-like receptor
TLS tumour lysis syndrome
TMP transmembrane pressure
TNF tumour necrosis factor
TOD target organ damage
TOE transoesophageal echocardiography
tPA tissue plasminogen activator
TPN total parenteral nutrition
TR tricuspid regurgitation
TSH thyroid-stimulating hormone
TT thrombin time
TTE transthoracic echocardiography
TTP thrombotic thrombocytopenic purpura
TURP transurethral resection of prostate
UA unstable angina
UAO upper airway obstruction
UC ulcerative colitis
U&E urea and electrolyte
UF ultrafi ltration
UFH unfractionated heparin
UIP upper infl ection point
UKOSS UK Obstetric Surveillance System
URR urea reduction ratio
ABBREVIATIONS
xviii
UTI urinary tract infection
VA ECMO venoarterial extracorporeal membrane
oxygenation
VV ECMO venovenous extracorporeal membrane
oxygenation
VAD ventricular assist device
VAP ventilator-associated pneumonia
VATS video-assisted thoracoscopy
VC vital capacity
VEP visual evoked potential
VF ventricular fi brillation
VHI ventilator hyperinfl ation
VIE vacuum-insulated evaporator
VILI ventilator-induced lung injury
V/Q ventilation/perfusion
VRE vancomycin-resistant enterococci
VSD ventricular septal defect
VT ventricular tachycardia
VTEC verocytotoxin-producing Escherichia coli
vWF von Willebrand factor
VZV varicella-zoster virus
WA Welfare Attorney
WBC white blood cell
WCC white cell count
WG Wagner’s granulomatosis
WOB work of breathing
WPW Wolff–Parkinson-White
ABBREVIATIONS
xix
Dr. Jane Adcock
Consultant Neurologist
John Radcliffe Hospital, Oxford
Royal Berkshire Hospital, Reading
Dr Imran Ahmad
Specialist Registrar in Anaesthesia
John Radcliffe Hospital
Oxford
Dr Peter Anderson
Specialist Registrar in Critical Care
St. Georges Hospital
London
Professor Peter JD Andrews
Anaesthetics, Intensive Care & Pain
Medicine
University of Edinburgh & Lothian
University Hospitals Division
Professor Djillali Annane
General Intensive Care Unit,
Department of Acute Medicine
Raymond Poincaré hospital (AP-HP)
University of Versailles SQY
(UniverSud Paris)
104 boulevard Raymond Poincaré,
92380 Garches, France
Dr Tarek F Antonios
Senior Lecturer & Consultant Physician
Blood Pressure Unit,
St. George’s, University of London
London
Dr Elizabeth Ashley
The Intensive Care Unit
The Heart hospital,
Westmoreland Street,
London
Dr Jonathan Ball
Consultant in Intensive Care
General Intensive Care Unit
St George’s Hospital
London
Dr Nicholas Barrett
Consultant in Intensive Care Medicine
Guy’s and St Thomas’ Hospital
Westminster Bridge Road
London
Dr Anthony Bastin
Specialist Registrar in Intensive
Care Medicine
Royal Brompton Hospital
London
Dr Anna Batchelor
Consultant in Anaesthesia and
Intensive Care Medicine
Royal Victoria Infi rmary Newcastle
Newcastle
Dr Rafi k Bedair
Department of Critical Care
Manchester Royal Infi rmary
Manchester
Dr Geoff Bellingan
Director of Intensive Care
University College Hospital
London
Dr Dennis CJJ Bergmans
Intensive Care Center Maastricht
Maastricht University Medical Center+
The Netherlands
Professor Julian Bion
Professor of Intensive Care Medicine
University Department of
Anaesthesia & Intensive Care Medicine,
N5 Queen Elizabeth Hospital,
Edgbaston,
Birmingham
Dr Andrew Bodenham
Anaesthetic Department
Leeds General Infi rmary
Leeds
Dr Jonathan Booth
Consultant Gastroenterologist
Royal Berkshire Hospital
Reading
Mr Michael Booth FRCS
Consultant Upper GI Surgeon,
Royal Berkshire Hospital
Reading
Mr Mark Borthwick,
Consultant Pharmacist, Critical Care
John Radcliffe Hospital
Oxford
Mr Richard Bourne,
Lead Critical Care Pharmacist
Sheffi eld Teaching Hospital
Sheffi eld
Ms Gillian Bradbury
Matron, Intensive Care Unit
The Royal London Hospital
Whitechapel Road
London
Contributors
xx
Dr Aimee Brame
Specialist Registrar in Intensive Care Medicine
Adult Intensive Care Unit,
Royal Brompton Hospital
London
Dr Stephen Brett
Consultant in Intensive Care Medicine
Imperial College London
Hammersmith Hospital
Du Cane Road, London
Dr Kate Brignall,
Specialist Registrar in critical care
Guy’s and St Thomas’ Hospital Trust
London
Dr Matthew A Butkus
The CRISMA (Clinical Research, Investigation, and
Systems Modeling of Acute Illness) Laboratory,
Department of Critical Care Medicine,
University of Pittsburgh,
Pittsburgh, PA, USA
Dr Luigi Camporota
Specialist Registrar in Intensive Care Medicine
Department of Adult Intensive Care
Guy’s and St Thomas’ NHS Foundation Trust
London, UK
Dr Jean Carlet
Directeur médical,
Direction de l’Amélioration et de la Qualité
et de la Sécurité des Soins (DAQSS)
HAS, 2 avenue du Stade de France
93218 Saint-Denis La Plaine Cedex
France
Dr Susana Afonso de Carvalho
Unidade de Cuidados Intensivos Polivalente
Hospital de St. António dos Capuchos
Centro Hospitalar de Lisboa Central, E.P.E.
Lisboa Portugal
Dr Maurizio Cecconi
Consultant in Anaesthesia and Intensive Care Medicine
Dept. of Anaesthesia and Intensive Care,
University of Udine Italy
Dr. Felix Chua
Consultant in Respiratory Medicine
St. George’s Healthcare NHS Trust
Blackshaw Road
London
Dr Jerome Cockings
Consultant in Intensive Care Medicine and Anaesthesia
Royal Berkshire Hospital
Reading
Dr Andrew Cohen
Consultant, Anaesthesia and Intensive Care Medicine
St James’s University Hospital
Leeds
Professor Christine Collin
Neurorehabilitation
Royal Berkshire Hospital
Reading
Ms Catherine Collins
Dept of Nutrition and Dietetics
St Georges Hospital
London
Mr P Conaghan
Specialist Registrar
John Radcliffe Hospital
Oxford
Dr Daniel Conway
Dept of Anaesthesia
Manchester Royal Infi rmary
Manchester
Dr Jeremy Cordingley
Consultant in Intensive Care Medicine
Royal Brompton Hospital
London
Dr Matthew Cowan,
Specialist Registrar & NIH Research Fellow
St. George’s,
University of London,
London
Dr Agnieszka Crerar-Gilbert
Consultant in Cardiothoracic Intensive Care &
Anaesthesia
St George’s Cardiothoracic Intensive Care Unit
London
Dr Chris Danbury
Consultant Intensivist
Royal Berkshire Hospital
Reading
Dr Craig Davidson
Director Lane Fox Respiratory Unit
Guys & St Thomas’ Foundation Trust
London
Dr Rebecca Davis
Microbiology department
Chelsea and Westminster Hospital
Fulham Road
London
Dr Jamil Darrouj
Pulmonary/Critical Care Division
Cooper University Hospital
Robert Wood Johnson Medical School
393 Dorrance
Camden
USA
Dr Daniel De Backer
Dpt of Intensive Care
Erasme University Hospital
Université Libre de Bruxelles
808 Route de Lennik
B-1070 Brussels (Belgium)
CONTRIBUTORS
xxi
Dr Kayann Dell
John Radcliffe Hospitals
Oxford
Prof. Giorgio Della Rocca
Professor of Anesthesia and Intensive Care
Chair of the Dept of Anesthesia and Intensive Care
University of Udine.
Udine, Italy
Dr Phil Dellinger
Critical Care Division
Cooper University Hospital
Robert Wood Johnson Medical School
393 Dorrance
Camden USA
Dr James Down
Consultant in Intensive care and Anaesthesia
University College Hospital
London
Dr Martin Dresner
Consultant Obstetrics
Leeds Royal Infi rmary
Leeds
Dr Robert T Duncan
Senior Trainee in Burns
Wythenshawe Hospital
Manchester
Miss N Dunne
Specialist Registrar
John Radcliffe Hospital,
Oxford
Dr Andy Eynon
Director of Neurosciences Intensive Care
Wessex Neurological Centre
Southampton General Hospital
Southampton
Dr Paul Ferris
Advanced Trainee in Intensive Care
Wythenshawe Hospital
Manchester
Dr Simon Finney
Consultant in Intensive Care Medicine
The Royal Brompton Hospital
London
Dr Robert Galland
Royal Berkshire Hospital
Reading
Dr Magnus Garrioch
Dept of Anaesthesia and Critical Care,
Manchester Royal Infi rmary,
Manchester
Anis el Ghorch
Département d’Anesthésie et Réanimation
Hôpital Lariboisière
Paris France
Dr Phil Gillen
Specialist Registrar in Anaesthesia and Intensive Care
Royal Berkshire Hospital
Reading
Dr David Goldhill
Consultant, Department of Anaesthesia and Critical Care
The Royal National Orthopaedic Hospital
Stanmore
Middlesex
Dr Andrew Gratrix
Consultant in Intensive Care and Anaesthesia
Hull Royal Infi rmary
Hull
Dr Mark Griffi ths
Consultant in Intensive Care Medicine
The Royal Brompton Hospital
London
Prof Richard D Griffi ths
Professor of Medicine (Intensive Care),
Unit of Pathophysiology
School of Clinical Science
University of Liverpool
Liverpool
Dr Mark Hamilton
Consultant in Anaesthesia &
Intensive Care Medicine
St. George’s Hospital,
London,
Dr Olfa Hamzaoui
Réanimation médicale
CHU Bicêtre
Université Paris-Sud, 11
France
Dr Jonathan M Handy
Consultant in Intensive Care Medicine
Chelsea & Westminster Hospital
Honorary Senior Lecturer
Imperial College
London
Dr Derek Hausenloy
Clinical Lecturer,
The Hatter Cardiovascular Institute,
University College London Hospital,
London
Professor Ken Hillman
Professor of Intensive Care,
University of New South Wales
Sydney
Australia
Dr Steven Hollenberg
Professor of Medicine
Robert Wood Johnson Medical School/UMDNJ
Director, Coronary Care Unit
Cooper University Hospital
Camden, NJ
CONTRIBUTORS
xxii
Dr Simon Hughes
RAF Consultant in Intensive Care Medicine and
Anaesthesia
John Radcliffe Hospital,
Oxford
Professor Beverley J Hunt
Consultant, Depts of Haematology,
Pathology & Rheumatology Lead in Blood Sciences,
Guy’s & St Thomas’ Trust
London
Dr Shabnam Iyer
Dept Microbiology
Royal Berkshire Hospital
Dr Ana Luisa Jardim
Unidade de Cuidados Intensivos Polivalente
Hospital de St. António dos Capuchos
Centro Hospitalar de Lisboa Central, E.P.E.
Lisboa
Portugal
Dr. Michael Joannidis,
Professor
Director, Medical Intensive Care Unit
Department of Internal Medicine
Medical University of Innsbruck
Innsbruck,
Austria
Dr Max Jonas
Consultant in Intensive Care
Intensive Care Unit
Southampton General Hospital
Southampton
Dr Andrew Jones
Consultant Critical Care and Respiratory Medicine
Guy’s and St Thomas’s NHS Foundation Trust
Department of Intensive Care
St Thomas’s Hospital
London
Dr Christina Jones
Nurse Consultant Critical Care Follow-up
Whiston Hospital
Warrington Road
Prescot
Liverpool
Dr Rachael Jones
Department of HIV/GU Medicine,
St Stephens Centre,
Chelsea & Westminster Healthcare NHS Trust,
London
Dr Atul Kapila
Consultant Anaesthetist
Royal Berkshire Hospital
Reading
Dr Juliane Kause
Department of Critical Care
Queen Alexandra Hospital
Portsmouth
Dr Richard Keays
Consultant in Intensive Care Medicine
Chelsea & Westminster Hospital
London
Dr John A Kellum
The CRISMA (Clinical Research, Investigation, and
Systems Modeling of Acute Illness) Laboratory,
Department of Critical Care Medicine,
University of Pittsburgh,
Pittsburgh, PA, USA
Dr Chris Kirwan
Clinical Research Fellow,
Intensive Care Medicine
St George’s NHS Trust
Dr Roop Kishen,
Consultant in Intensive Care Medicine & Anaesthesia,
Hon Lecturer,
Salford Royal NHS Foundation Trust,
Salford, Manchester
Dr John Knighton
Consultant in Critical Care & Anaesthesia
Portsmouth Hospitals NHS Trust
Portsmouth
Dr Martin Kuper
Consultant in Anaesthesia and Intensive Care.
The Whittington Hospital NHS Trust,
London
Professor Richard Langford
Professor of Infl ammation Science
William Harvey Research Institute
Barts and The London,
Queen Mary’s School of Medicine and Dentistry
London
Dr Smaoui Lassäad
Département d’Anesthésie et Réanimation
Hôpital Lariboisière
Paris France
Dawn Lau
Specialist Registrar in Respiratory Medicine
Osler Chest Unit
Churchill Hospital
Oxford
Dr Jonathan Lightfoot
Anaesthetic Trainee Bristol Rotation
Department of Anaesthetics
Weston-Super-Mare General Hospital
Dr Thiago Lisboa,
CIBER Respiratory Diseases.
Tarragona,
Spain
Professor Richard Langford
Director, Anaesthetic Laboratory
Barts and the London NHS Trust
London
CONTRIBUTORS
xxiii
Dr. Lies Langouche
Department of Intensive Care Medicine
University Hospital
Katholieke Universiteit Leuven
Belgium
Dr Andrew Lawson
Consultant in Pain Medicine & Anaesthesia
Royal Berkshire Hospital
Reading
Dr Peter MacNaughten
Clinical Director Critical Care
Intensive Care Unit
Derriford Hospital
Plymouth
Professor Brendan Madden
Professor of Cardiothoracic Medicine
St George’s Hospital, Cardiothoracic Unit
Blackshaw Road
London
Dr Hilary Madder
Clinical Director, Neurosciences Intensive Care Unit
John Radcliffe Hospital
Oxford
Dr Nicholas Madden
The CRISMA (Clinical Research, Investigation, and
Systems Modeling of Acute Illness) Laboratory,
Department of Critical Care Medicine,
University of Pittsburgh,
Pittsburgh, PA,
USA
Dr. Michael MacMahon
Anaesthetic Trainee South East Scotland Rotation
Intensive Care Unit
Western General Hospital
Edinburgh
Alexander R. Manara
Consultant in Anaesthesia and Intensive Care.
The Intensive Care Unit,
Frenchay Hospital,
Frenchay Park Road,
Bristol
Dr Luciana Mascia
Department of Anesthesia and Intensive Care Medicine
University of Turin,
Italy
Alexandre Mebazaa
Université Paris 7 Denis Diderot
Département d’Anesthésie et Réanimation
Hôpital Lariboisière
Paris
France
Mr S Middleton
Royal Berkshire Hospital
Reading
Dr Rui Moreno
Unidade de Cuidados Intensivos Polivalente
Hospital de St. António dos Capuchos
Centro Hospitalar de Lisboa Central, E.P.E.
Lisboa Portugal
Dr Giles Morgan
Queen Alexandra Hospital
Portsmouth
Mr Satvinder Mudan
Consultant Surgeon
Royal Marsden Hospital
Fulham Road London
Raghavan Murugan,
The CRISMA (Clinical Research, Investigation,
and Systems Modelling of Acute Illness)
Laboratory Department of Critical Care Medicine
University of Pittsburgh
Pittsburgh PA, USA
Dr Mark Nelson
Director of HIV Services
Chelsea and Westminster Hospital
London
Dr Peter Nightingale
Consultant in Anaesthesia
Wythenshawe Hospital
Manchester
Dr Jerry Nolan
Consultant in Anaesthesia and
Intensive Care Medicine
Royal United Hospital
Bath
Mrs Michelle Norrenberg
Head of ICU physiotherapist
Dept of Intensive Care
Erasme University Hospital
Brussels
Dr Pauline O’Neil
Aberdeen Royal Infi rmary
Foresterhill
Aberdeen
Dr Mark Palazzo
Consultant Critical Care Medicine
Imperial College Healthcare NHS Trust
Charing Cross Hospital
London
Dr Tim Palfreman
Specialist Registrar in Intensive Care Medicine
Adult Intensive Care Unit,
Royal Brompton Hospital
London
Dr John Park
Specialist Registrar in Intensive Care Medicine
The Royal Brompton Hospital
London
CONTRIBUTORS
xxiv
Dr Tim Parke
Consultant in Intensive Care Medicine and Anaesthesia
Royal Berkshire Hospital
Reading
Dr Hina Pattani
Specialist Registrar in Critical Care
Queens Medical Centre
Nottingham
Dr Rupert Pearse
Senior Lecturer and Honorary Consultant in
Intensive Care Medicine
Barts and The London School of
Medicine and Dentistry
Queen Mary’s, University of London
Dr Barbara Philips
Senior Lecturer, Intensive Care Medicine
Department of Cardiac and Vascular Sciences
St Georges Hospital Medical School
London
Mr Giles Peek
Consultant in Cardiothoracic Surgery & ECMO
Glenfi eld Hospital
Groby Road
Leicester
Dr Amanda Pinder
Consultant Obstetric Anaesthetist,
Leeds Teaching Hospitals
Dr Alison Pittard
Consultant in Anaesthesia and Intensive Care
Leeds General Infi rmary
Leeds
Professor Michael R Pinsky
Professor of Critical Care Medicine,
Bioengineering and Anesthesiology
University of Pittburgh
Pittsburgh USA
Dr Kees Polderman
Associate Professor in Intensive Care Medicine,
Department of Intensive Care
University medical center Utrecht
Heidelberglaan 100
Utrecht 3584 CX
The Netherlands
Dr Susanna Price
Consultant Cardiologist and Intensivist,
Royal Brompton Hospital,
London
Dr Caroline Pritchard
Clinical Research Fellow
Department of Neuroanesthesia and
Neurocritical Care
The National Hospital for Neurology and
Neurosurgery
Queen Square London
Dr Paul Quinton
Consultant in Cardiothoracic
Intensive Care & Anaesthesia
St George’s Cardiothoracic Intensive Care Unit
London
Dr Tony Rahman
Consultant Gastroenterologist & ICU Physician
Honorary Senior Lecturer,
St. George’s,
University of London,
London
Professor Marco Ranieri
President of ESICM
Professor of Anesthesia and Intensive Care
University of Turin, Italy
Dr Ravishankar Rao Baikady
Consultant in Anaesthesia
The Royal Marsden NHS Foundation Trust
London
Dr Charlotte FJ Rayner
Consultant Physician
Parkside Hospital, London
Dr Ian Rechner
Consultant in Intensive Care Medicine and Anaesthesia
Royal Berkshire Hospital
Reading
Dr Jennie Rechner
Specialist Registrar is Anaesthesia
John Radcliffe Hospital
Oxford
Dr A Reece-Smith
Clinical Fellow in Surgery
Addenbrookes Hospital
Cambridge
Mr Howard Reece-Smith
Consultant Surgeon
Royal Berkshire Hospital
Reading
Prof. Dr. Konrad Reinhart
Director of Clinic for Anaesthesiology and Intensive Care
University of Jena
Erlanger Allee 101
07747 Jena
Germany
Jordi Rello,
Critical Care Department.
Joan XXIII University Hospital
University Rovira & Virgili.
Tarragona, Spain
Dr Andrew Retter
Specialist Registrar in Intensive Care and Haematology
Department of Haematology
Guy’s & St Thomas’ Trust
London
CONTRIBUTORS

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