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The science and art of risk stratification appeared in early 1953, when Virginia Apgar [] published a simple physiological scoring tool to evaluate the newborn child. This system, still commonly used worldwide, evaluates only two physiologic systems: Cardiopulmonary and central nervous system (CNS) function. Several years later, in the early 1980s, several researchers applied the same concept to critically ill patients, through the introduction of the acute physiology and chronic health evaluation (APACHE) and the simplified acute physiological score (SAPS), both physiologically based classification systems [, ]. These instruments, named general severity scores, are tools that aim at stratifying patients based on their severity, assigning to each patient an increasing score as their severity of illness increases. Initially designed to be applicable to individual patients, it became apparent very early after their introduction that both systems could in fact be used only in large heterogeneous groups of critically ill patients.

Increasing use of intensive care unit (ICU) resources by an aging population has resulted in a large and growing group of adults who are ‘chronically critically ill’ [], Although these patients have survived acute illness, they are profoundly debilitated and have ongoing serious complications with continued dependence on life-sustaining therapies. Chronic critical illness is not simply a prolongation of acute critical illness, but a distinct syndrome consisting of persistent respiratory failure and significant derangements of metabolic, neuroendocrine, neuropsychiatric and immunologic function [], The number of patients in the USA with chronic critical illness is estimated to approach 100,000 []. As the population ages and ICU treatments are increasingly offered to older, sicker patients, these numbers will increase. In this chapter, we will discuss the definition of chronic critical illness, the scope of this serious health problem, venues of care, outcomes and symptoms, and issues with communication between the health care team and patients and their families. We will end by reviewing an interdisciplinary approach to managing this challenging patient population.

The vegetative state is a clinical diagnosis first defined by Jennett and Plum in 1972 []. It is a diagnosis based on the absence of clinical signs of awareness of self or environment despite preserved arousal. That is, if a patient repeatedly fails to answer to commands and if all observed behavior is considered reflexive, the patient is considered to be unconscious.

Unlike the situation in North America, respiratory physicians in most European countries have not been involved in critical care medicine until recently [], since both specialties have developed separately over time. This separate development has been particularly clear in Spain, due to the following circumstances []: 1) When intensive care medicine began in Spain, Spanish pulmonary physicians did not have a strategic vision of the future, unlike cardiologists, who demanded and assumed responsibility for the coronary units; 2) historically, pulmonary physicians have shown little interest in the care of critically ill respiratory patients; and 3) specialists in intensive care medicine have defended their specialty and have avoided others entering it.

Noise may be defined simply as “unwanted sound” []. The World Health Organization (WHO) recommends that the average background noise in hospitals should not exceed 30 A weighted decibels (dB [A]), and that peaks during the night-time should be less than 40 dB(A) []. Noise in hospitals and particularly in intensive care units (ICUs), frequently exceeds these values []–[]. The United States Environmental Protection Agency in fact defines noise as “any sound that may produce an undesired physiological or psychological effect in an individual or group”. Noise affects both staff and patients. It may impede concentration and cognitive function [, ]. It interferes with effective communication and may thus increase the risk of accidents [, ]. The critically ill are particularly sensitive to the disruption of sleep by noise []. In addition, and especially for the elderly and hard of hearing, noise may hinder communication and impair understanding of their environment. It may also potentially contribute to the abnormal thought processes and behavior associated with ICU delirium [].

Up to 77% of admissions to medical intensive care units (ICUs) take place, at least in part, for monitoring purposes, even though only 10% of the patients monitored will subsequently have indications for major interventions []. Modern ICU equipment takes advantage of a wide range of technologies to track physiological variables in order to detect changes that could be life-threatening. As response time is a key issue, most of these devices are equipped with a more or less sophisticated set of alarms that alert intensivists, nurses or respiratory therapists about changes that could represent a risk to patients.

There is a growing need for critical care services, with increasing demands due to demographic trends, technological advances, growing costs of standard care, unexpected surges in demand, and public expectations. With the practice of critical care medicine evolving so rapidly due to the ability to sustain lives indefinitely, patients are living longer in the intensive care unit (ICU). As a result, patients and caregivers are faced with difficult decisions, often based on differing opinions on the appropriate use of newly emerging, potentially life-sustaining, yet expensive interventions. When conflicting views are held, their resolution can place undue strain on families and caregivers. To help deal with these situations, some institutions have developed guidelines and policies to reflect best standards to help guide difficult decisions about limits to treatment. However, there is no consensus on the use of such guidelines and their application in practice.

On March 30, 1981, a 70-year-old Caucasian male walked into George Washington Hospital emergency room in Washington, DC, complaining of dyspnea after sustaining a gunshot wound. The patient collapsed upon his arrival and was immediately brought to the trauma room where the emergency room team resuscitated him. Once the patient was stable, he was transferred to the intensive care unit (ICU).

Critical care physicians often certify brain death and may continue the care of those patients who become organ donors. This chapter will review recent publications and current practices in these topic areas with the intent of encouraging compliance with established policies for brain death determination and promoting investigations needed to establish evidence-based treatment guidelines for donor care.

Human influenza pandemics over the last 100 years have been caused by H1, H2, and H3 subtypes of influenza A viruses. More recently, avian influenza viruses have been found to directly infect humans from their avian hosts. The recent emergence, host expansion, and spread of a highly pathogenic avian influenza (HPAI) H5N1 subtype in Asia has heightened concerns globally, both in regards to mortality of HPAI H5N1 in humans and the potential of a new pandemic. In response, many agencies and organizations have been working collaboratively to develop early detection systems, preparedness plans, and objectives for further research. As a result, there has been a large influx of published information regarding potential risk, surveillance, prevention and control of highly pathogenic avian influenza, particularly in regards to animal to human and subsequent human to human transmission. This chapter will review the current human infections with avian influenza and its public health and medical implications.