Diabetic ketoacidosis (DKA) is one of the most common hyperglycemic complications of diabetes mellitus (DM) that is encountered in clinical practice as anesthesiologists and intensivists. Various stressors can lead to DKA in a diabetic patient, but it also remains a common manifestation at the outset of the disease among young diabetics. Thorough knowledge of the disease pathophysiology and treatment modalities help to reduce both duration of ICU stay and the morbidity and mortality associated with DKA.
With increasing incidence of diabetes mellitus, complications associated with it are also increasing. The hyperglycemic hyperosmolar state (HHS) is one of the common complications seen in old diabetics where patients have markedly increased serum glucose concentrations and hyperosmolality in absence of significant ketosis. Most common precipitating factor is infection. In HHS, levels of insulin in circulation reduce significantly while counterregulatory or stress hormones such as cortisol, catecholamines, glucagon, and growth hormone increase along with greater degree of dehydration. Hence, these patients, in addition to typical features of diabetes, generally present with dehydration and progressive mental deterioration. Basic hematological, biochemical, and radiological investigations are important to find and rule out precipitating factors and complications. Aggressive correction of the fluid and electrolyte imbalance along with the maintaining levels of insulin are very important components of the treatment. Simultaneously, identification and treatment of any underlying precipitating events should be done. Awareness, early diagnosis, and aggressive proper treatment play very crucial role in preventing the morbidity and mortality associated with HHS, which is 10 times more than diabetic ketoacidosis.
Myasthenia gravis (MG) is an autoimmune disorder affecting nicotinic acetylcholine receptors at the post-synaptic site in the neuromuscular junction (NMJ). Myasthenia gravis presents with muscle weakness and fatigability of varying degrees affecting many muscle groups, mainly proximal skeletal muscles, ocular, respiratory, and bulbar. Myasthenia gravis has many implications for safe management of anesthesia. They are due to the disease process, association with other autoimmune diseases [diabetes mellitus (DM), thyroid disorders, systemic lupus erythematosis (SLE), rheumatoid arthritis (RA)], the medications used for treatment, potential for respiratory compromise, interaction of many anesthetic drugs in particular being resistance to suxamethonium, and high sensitivity to nondepolarizing muscle relaxants [neuromuscular blockers (NMB)]. Hence, detailed knowledge of the disease is necessary to the anesthesiologist for successful perioperative management and outcome.
Critically ill patients need appropriate nutritional supplementation for their energy requirements during their intensive care unit (ICU) stay and even after ICU stay.1 Any critical illness is a catabolic state and all critically ill patients have an ongoing low-grade inflammation and protein catabolism referred to as persistent inflammatory catabolism syndrome (PICS).2 Adequate supplementation of nutrition attenuates the stress response and modulates immune responses. The aim of nutritional supplementation is to supplement both macro- and micronutrient requirements. Careful supplementation of protein and caloric intake can avoid under- and overfeeding and will decrease the hospital stay and morbidity. Route of supplementation, that is, oral, enteral, or parenteral depends on the patient's hemodynamic status and gastrointestinal functioning. Initiation of feeding within 24–48 hours of critical illness has been recommended. Also, early start of physical exercise has favorable effect on muscle preservation and reduces protein catabolism. The patient's outcome in intensive care depends upon the timing of nutrition, amount, and type of nutrition.
The number of organ transplantation has risen exponentially in the last few decades. The concept of brain death and the ability to harvest vital organs in a limited time have contributed to the recent success. In this review, we attempt to delineate the criteria for brain death as well as the testing methodology. The challenges and the legal aspects related to organ donation have also been discussed.
The arterial blood gas analysis provides extensive and crucial information to the intensivist. It indicates the state of alveolar ventilation, the oxygenation, as well as the acid–base balance. It is an invaluable tool in expert hands. This review attempts to clarify the concepts related to respiratory and metabolic acid–base disturbances with several examples.
Ventilator-associated pneumonia (VAP) is the most frequent intensivecare unit (ICU)-acquired infection for patients on mechanical ventilators. There are no goal standards for VAP diagnosis and this makes it the leading cause of death in critically ill patients. The prediction of its outcome is important in the decision-making process and management. This article reviews the various aspects of VAP such as definition, risk factors, etiological agents, diagnosis, treatment, and prevention with emphasis on the recent advances.