Non-pulmonary Critical Care: Managing Multisystem Critical Illness

Care of the critically ill patient is truly multisystem management of highly complex patients who typically have numerous acute physiological derangements superimposed upon underlying medical ailments. Historically, the majority of patients admitted to intensive care units (particularly medical ICUs) have respiratory failure requiring mechanical ventilation, often along with other acute and chronic pulmonary problems. Much ICU-related research and education has similarly focused on pulmonary issues such as the acute respiratory distress syndrome (ARDS), pneumonia, and mechanical ventilation. Additionally, a great majority of intensivists have received training in pulmonary and critical care medicine. Thus it is not surprising that the phrase “non-pulmonary critical care” has arisen to address many general critical care issues. However, this vast body of knowledge might more appropriately be considered “multisystem critical care” as an inclusive term that encompasses the many important organ system derangements that plague our ICU patients.

This issue of Seminars provides scholarly and clinically relevant reviews of major non-pulmonary organ dysfunction in the ICU setting. Clearly, a comprehensive review of the numerous organ system-based medical conditions seen in our ICUs is well beyond the scope of a single issue of Seminars, more appropriately filling several thousand pages and hundreds of chapters typical of current major textbooks on critical care medicine. Nevertheless, we have identified a cross-section of key topics and have solicited state-of-the-art reviews by highly qualified experts.

Starting at the top, so to speak, Dr. Bleck presents a discussion of neurological complications of critical illness, with particular emphasis on metabolic encephalopathies, seizures, and neuromuscular conditions. Drs. Miller and Ely share their current understanding of the rapidly evolving areas of delirium and cognitive dysfunction in the ICU. Drs. Tarditi and Hollenberg present a structured approach to the ICU patient who has cardiac arrhythmias, emphasizing the challenges of managing tachyarrhythmias, whereas Dr. Axler discusses the evaluation and management of shock. Drs. Rinella and Sanyal provide a comprehensive review of acute hepatic failure as well as acute complications of chronic advanced liver disease. Drs. Weisbord and Palevsky examine acute renal failure, including sections on epidemiology, causes, prevention, and management.

Drs. Raghavan and Marik present an in-depth review of adrenal insufficiency and the many issues related to hyperglycemia and glycemic control in the ICU. Drs. Mercer, Macik, and Williams expertly address hematological disorders in the ICU, with particular emphasis on thrombocytopenia and bleeding disorders. Drs. Afessa and Peters provide a practical framework for evaluating and managing the many serious infectious and non-infectious complications related to hematopoietic stem cell transplantation. Drs. Bearman, Munro, Sessler, and Wenzel conclude with a comprehensive overview of infection control and prevention of nosocomial infections in the ICU, with emphasis on ventilator-associated pneumonia and catheter-related bloodstream infection.

I would like to acknowledge the amazing expertise, attention to detail, and hard work of the authors of these articles, and convey my thanks for the steady hand of the Seminars Editor-in-Chief, Joseph P. Lynch, III, M.D., and the understanding and support of my wife and children, in creating this issue of Seminars.