This is a review of the use of colloid and crystalloid in shock. The article discusses the pathophysiological consequences of ischaemia and shock; reviews the underlying physiology of fluid compartments and how they may be affected by disease; examines the physiological determinants of intravenous (IV) fluid use; and finally reviews the literature on colloid and crystalloid use for the management of shock.

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Organophosphate compound (OPC) poisoning with suicidal intent is common in Indian ICUs. The effect of OPCs is to produce a persistent depolarization of the neuromuscular junction leading to muscle weakness. After initial recovery from cholinergic crisis, some patients have resurgence of respiratory muscle paralysis requiring continued ventilatory support. This is termed intermediate syndrome (IMS). This could be due to a change in the type of neuromuscular block to a non depolarisation block characterized by a fade on tetanic stimulation. However peripheral nerve stimulation using train-of-four ratio (TOF) and/tetanus have failed to consistently show such a change. We elected to study whether electro physiological monitoring using repetitive nerve stimulation might show a decremental response during IMS. Material & Methods: This was a prospective blinded study done from April 2002 to March 2003 in our ICU. 45 consecutive patients of OPC poisoning admitted during this period were included in this study. Repetitive nerve stimulation (RNS) using a train of ten at 3Hz 10Hz and 30Hz (slow , intermediate and fast speeds respectively) at the median nerve was done on all patients on day 1, 4, 7 and every 4th day thereafter until discharge. Patients were ventilated until ready to wean as per our usual protocol. The results of the RNS study were not revealed to the intensivist. Results: 9 out of 45 patients required ventilation for more than 6 days and showed overt signs of intermediate syndrome - proximal muscle weakness, twitching and respiratory weakness. Only 2 patients out of the 9 had a decremental response on RNS at 3Hz indicating a post-junctional dysfunction at the motor end-plate, Both patients had consumed a very large quantity of OPC and were deeply comatose for >4 days and required ventilation for >12 days. All other patients with IMS showed no changes on RNS. The exact type of poison consumed varied with each individual patient. Conclusion: RNS is a poorly sensitive marker in diagnosing intermediate syndrome after OPC poisoning. We need to develop more sensitive markers to diagnose IMS.

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In recent years, increasingly, intensivists have focused attention on the ethical aspects of end-of- life care. This has led to shifts in the approach from aggressive interventions to one of mitigating pain and taking into account the wishes and sensibilities of the patients' families with regard to continuing futile care. While the legal implications of this change in practice has led to the evolution of precise guidelines in the US and in Europe, in India this vital area of critical care remains largely unexplored. This review outlines the recent changes in clinical practice based on ethical principles and the legality of limiting life support in the context of futile or end-of-life care. An appraisal of the ethical issues in critical care urges us to apply intensive care with humanity and compassion. We need to respect the choices and the emotional needs of the patient and his family. Our duties must include providing information, balanced interpretation of results & counseling of the family to enable them to take rational decisions. Our strategy in end-of-life care should be unambiguous and we should ensure that there is consensus among all the physicians involved in the patient’s care. The medical community must work towards evolving legislation appropriate to Indian conditions.

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Postoperative fever is one of the most common problems seen in the postoperative ward. Most cases of fever immediately following surgery are self-limiting. The appearance of postoperative fever is not limited to specific types of surgery. Fever can occur immediately after surgery and seen to be related directly to the operation or may occur sometime after the surgery as a result of an infection at the surgical site or infections that involve organs distant from the surgery. Therefore, during evaluating postoperative fever, it is important to recognize when a wait - and - see approach is appropriate, when further work-up is needed and when immediate action is indicated.

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The neuromuscular syndrome of acute limb and respiratory weakness that commonly accompanies patients with multi-organ failure and sepsis constitutes critical illness polyneuropathy. It is a major cause of difficulty in weaning off the patient from the ventilator after respiratory and cardiac causes have been excluded. It is usually an axonal motor-sensory polyneuropathy, and is usually associated with or accompanied with a coma producing septic encephalopathy. The neuropathy is usually not apparent until the patient's encephalopathy has peaked, and may be noted only when the brain dysfunction is resolving. Patients usually have a protracted hospital course complicated by multi-organ failure and the systemic inflammatory response syndrome. Elevated serum glucose levels and reduced albumin are risk factors for nerve dysfunction, as is prolonged intensive care unit stay. Polyneuropathy may develop after only one week of the systemic inflammatory response syndrome, but the frequency tends to correlate with the duration of the severe illness.

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Septic shock in children is the prototype combination of hypovolemia,cardiogenic and distributive shock. Recently published American college of critical care medinie(ACCM )recommendations for hemodynamic support of neonatal and pediatric patients with sepsis,Surviving sepsis campaign and its pediatric considerations and subsequent revision of definitions for pediatric sepsis has led to compilation of this review article. Practical application of this information in Indian set up in a child with septic shock will be discussed based on available evidence.Though guidelines mainly apply to pediatric age group,however a reference has been made to neonatal age group wherever applicable.

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Ventricular tachyarrhythmias – Ventricular fibrillation (VF) and Ventricular tachycardia (VT) account for most of out-of-hospital sudden cardiac arrests. Defibrillation is the specific therapy for VF/pulseless VT. Time to defibrillation is the most important determinant of survival from these cardiac arrests. Automated external defibrillator (AED) has largely replaced the conventional defibrillator in Basic life support (BLS) programmes for out-of-hospital cardiac arrests. AED use by trained laypersons in the community as part of Public Access Defibrillation (PAD) programmes has significantly reduced time to defibrillation and increased survival. AED is now being stipulated for home use in people at high risk of sudden cardiac death. AED placement is also recommended in all areas of hospital. Physicians and Intesivists should strive to familiarize the medical fraternity in our country with AED use so that PAD programmes can be launched in the near future.

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Ingestion of copper sulphate is an uncommon mode of poisoning in the Indian subcontinent. Cases are mainly suicidal in nature. The clinical course of the copper sulphate intoxicated patient is often complex involving intravascular hemolysis, jaundice and renal failure. The treatment is mainly supportive. In severe cases methemoglobinemia needs treatment. Mortality is quite high in severe cases. A comprehensive review of the clinical presentation and management of copper sulphate poisoning is done.

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Much progress has been made in the therapy of pediatric HIV infection, which has been transformed from a usually fatal disease into that of a chronic disease model. Early, aggressive therapy with the goal of complete suppression of viral replication (undetectable plasma virus) should be the therapeutic goal, but this new, more hopeful environment has been created at the cost of complexity and compromises in quality of life. The rapid pace of new developments and therapeutic complexities argue strongly for care in specialized centers or, at least, frequent consultation. Principles of therapy in the pediatric intensive care unit remain unchanged. Efforts are ongoing to develop simpler, more effective therapeutic regimens that suppress and ultimately eradicate infection and that stimulate immune reconstitution and reduces need for frequent hospitalization.

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Appropriate fluid replacement is an essential component of trauma fluid resuscitation. Once hemorrhage is controlled, restoration of normovolemia is a priority. In the presence of uncontrolled haemorrhage, aggressive fluid management may be harmful. The crystalloid-colloid debate continues but existing clinical practice is more likely to reflect local biases rather than evidence based medicine. Colloids vary substantially in their pharmacology and pharmacokinetics,and the experimental finding based on one colloid cannot be extrapolated reliably to another. In the initial stages of trauma resuscitation the precise fluid used is probably not important as long as an appropriate volume is given. Later, when the microcirculation is 'leaky', there may be some advantages to high or medium weight colloids such as hydroxyethyl starch. Hypertonic saline solutions may have some benefit in patients with head injuries. A number of hemoglobin solutions are under development, but one of the most promising of these has been withdrawn recently. It is highly likely that at least one of these solutions will eventually become routine therapy for trauma patient resuscitation. In the meantime, contrary to traditional teaching, recent data suggest that restrictive strategy of red cell transfusion may improve outcome in some critically ill patients.

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Postoperative delirium (POD) is frequently under diagnosed and more often than not, under treated. It is the final common manifestation of multiple neurotransmitter abnormalities; with features of impaired cognition, fluctuating consciousness and a disturbed sleep-awake cycle. At least 15% of elderly patients undergoing major procedures have POD, with an associated increase in mortality. Various risk factors and batteries of clinical examination have been devised to diagnose delirium, followed by a multifaceted approach to treatment, using biopsychological along with pharmacological intervention.

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Traumatic brain injury is a devastating problem with both high mortality and high subsequent morbidity. Injury to the brain occurs both at the time of the initial trauma (the primary injury) and subsequently due to ongoing cerebral ischaemia (the secondary injury). Hypotension and hypoxaemia are well recognized causes of this secondary injury. In the intensive care unit raised intracranial pressure (intracranial hypertension) is seen frequently after a severe diffuse brain injury and leads to cerebral ischaemia by compromising cerebral perfusion. This paper reviews the pathophysiology of intracranial hypertension and summarises current and experimental approaches to its management in the intensive care unit.

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Disorders of acid-base balance can lead to severe complications in many disease states, and occasionally the abnormality may be so severe as to become a life-threatening risk factor. The process of analysis and monitoring of arterial blood gas (ABG) is an essential part of diagnosing and managing the oxygenation status and acid-base balance of the high-risk patients, as well as in the care of critically ill patients in the Intensive Care Unit. Since both areas manifest sudden and life-threatening changes in all the systems concerned, a thorough understanding of acid-base balance is mandatory for any physician, and the anesthesiologist is no exception. However, the understanding of ABGs and their interpretation can sometimes be very confusing and also an arduous task. Many methods do exist in literature to guide the interpretation of the ABGs. The discussion in this article does not include all those methods, such as analysis of base excess or Stewart's strong ion difference, but a logical and systematic approach is presented to enable us to make a much easier interpretation through them. The proper application of the concepts of acid-base balance will help the healthcare provider not only to follow the progress of a patient, but also to evaluate the effectiveness of care being provided.

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Mechanical ventilation is routinely delivered to patients admitted in intensive care units to reduce work of breathing, improve oxygenation, or correct respiratory acidosis. Although traditional modes of mechanical ventilation achieve many of these goals, they have important limitations. Alternative modes are supposed to handle some of these limitations and are now available on modern ventilators. This article reviews general aspects of functioning and limitations of traditional modes of mechanical ventilation, and the potential interest of some new promising modes.

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Hyponatremia is the commonest electrolyte disturbance encountered in the neurological and neurosurgical intensive care units. It can present with signs and symptoms mimicking a neurological disease and can worsen the existing neurological deficits. Hyponatremia in neurological disorders is usually of the hypo-osmolar type caused either due to the Syndrome of Inappropriate Secretion of Anti Diuretic Hormone (SIADH) or Cerebral Salt Wasting Syndrome (CSWS). It is important to distinguish between these two disorders, as the treatment of the two differ to a large extent. In SIADH, the fluid intake is restricted, whereas in CSWS the treatment involves fluid and salt replacement.

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Acute Colonic pseudo-obstruction (Ogilvie's syndrome) is common occurrence in both the ICU and long-term acute care units. If not treated in time, it may lead to Colonic perforation or ischemia. Recent report showed that intravenous neostigmine, an acetylcholienastrase inhibitor, produces rapid colonic decompression in patients with acute colonic pseudo-obstruction (ACPO). We report four cases of acute colonic pseudo-obstruction in critical care unit and the response of neostigmine therapy.

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The Law Commission of India has recently taken up the study of legal issues relating to 'limiting life support' in patients in Intensive care units. Physicians, particularly, those dealing with critical care, feel that a debate on these issues is necessary towards the creation of appropriate legal provisions. This article summarises the existing international legal position.

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Airway Management for the victims of major trauma is the first priority in the care of the trauma victim and is a core skill in emergency medicine and critical care. Endotracheal intubation remains the gold standard for trauma airway management. Airway management in trauma patients is not just the capability to insert an oral/nasal airway or endotracheal tube beyond the vocal cords. The five components integral to modern, sophisticated airway management in trauma patients include equipment, pharmacologic adjuncts, manual techniques, physical circumstances, and patient profile. A trauma patient may require airway management in a variety of physical circumstances. Whereas, the commonly used airway management algorithms may not suffice in all these situations, the construction of a truly complete decision tree is also virtually impossible. There is consensus that it is not the intervention per se but rather the conditions, skills, and performance that might be the possible variables that affect outcome. Paramedics have only limited experience and on-the-job skills for invasive airway management. Difficult airway management is best left for the experienced physicians to handle.

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The mortality of critically ill patients who develop ARF in an ICU setting is extremely high (50-80%). Any mode of renal replacement therapy chosen should be able to achieve solute and water clearance while maintaining hemodynamic stability, have a positive effect on nutrition, and have low complication rates. AIM: To determine the efficacy and feasibility of Continuous Venovenous hemofiltration (CVVH) in critically ill patients with ARF. Inclusion criteria: Patients with ARF requiring 2 or more inotropes to maintain systolic blood pressure >100 mm of Hg. Failed or technically impossible hemodialysis or peritoneal dialysis. Time Period: July 2002 - June 2003. MATERIALS AND METHODS: Polysulfone hemofilter 0.7m2, [Aquamax (Edwards) or Multimat BL680 (Bellco).] Blood flow of 150-200 ml/minute (Travenol). Volumetrically controlled Ultrafiltration of > 2000 ml per hour (Watson Marlowe) and replacement fluid infusion [(Infusomat-P) post filter]. Anticoagulation: Heparin infusion or regional heparinisation. RESULTS: 22 patients included, 6 with recent abdominal surgery. 11 underwent hemodiafiltration and hemofiltration each. Severe sepsis was present in 21, and DIC in18. 5 patients were on immunosuppressive therapy. The time from ICU admission to the start of CVVH was 114 + 88.08 hours. The duration of CVVH was 35.93 + 20.91 hours, (range 11 to 84 hours). The mean hourly ultrafiltration of 93.72 + 65.57 ml and total ultrafiltration of 3955.55 + 4132 ml was tolerated by all patients without limiting hypotension. The APACHE II scores had significantly worsened between admission (22.5 + 6.71) to starting CVVH (36.05 + 4.08), [P<0.001]. The daily costs of CVVH were Rs. 5000 compared to Rs. 2150 for PD and Rs. 1500 for extended daily dialysis CONCLUSIONS: CVVH was effective in providing metabolic correction in ARF, in the setting of multi-organ failure. It is technically feasible even when conventional hemodialysis or peritoneal dialysis cannot be performed.

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