Surgical Intensive Care Medicine (eBook)

Preface to the Second Edition 6
Acknowledgements 7
Contents 8
Contributors 12
Part I: Resuscitation and General Topics 21
Chapter 1 22
Supplemental Oxygen Therapy 22
Pathophysiology of Hypoxemia 22
Goals of Supplemental Oxygen Therapy 23
Oxygen Delivery Systems 23
Low-Flow Systems 24
Nasal Cannula 24
Simple Face Mask 24
Partial-Rebreathing Mask 24
Nonrebreathing Mask 25
Tracheostomy Collars 25
High-Flow Systems 26
Air-entrainment (Venturi) Mask 26
Aerosol Mask 27
Helium-Oxygen Therapy 27
Noninvasive Ventilation 27
Continuous Positive Airway Pressure (CPAP) 27
Noninvasive Ventilation (NIV) 28
Bedside Monitoring of Oxygenation 28
Arterial Blood Gas Analysis 28
Pulse Oximetry 28
Complications of Oxygen Therapy 29
Worsening Acute on Chronic Respiratory Acidosis 29
Absorption Atelectasis 29
Oxygen Toxicity 30
References 30
Chapter 2 32
Airway Management in the Intensive Care Unit 32
Review of Airway Anatomy 32
Patient History and Physical Exam 33
Airway History 33
Physical Exam 33
Clinical Management of the Airway 34
Preoxygenation 34
Intravenous Sedatives and Muscle Relaxants 34
Propofol 35
Etomidate 35
Ketamine 35
Succinylcholine (SCh) 35
Rocuronium 35
Opioid Agents 35
Local Anesthetics and the Airway 35
Tracheal Intubation 36
Rapid Sequence Intubation 37
Awake Intubation Techniques 39
The Difficult Extubation 39
Rescue Airway Devices: The Supraglottic Airways 40
The Face Mask 40
The Laryngeal Mask Airway (LMA) 40
The Combitube 42
Transtracheal Procedures 42
Transtracheal Ventilation (TTV or TTJV) 42
Percutaneous Cricothyroidotomy 42
Conclusion 43
References 43
Chapter 3 44
Vascular Cannulation 44
Preparation 44
Arterial Catheterization 44
Indications 44
Contraindications 44
Clinical Utility 45
Technique and Sites of Catheterization 45
Radial Artery 45
Axillary Artery 46
Femoral Artery 46
Dorsalis Pedis Artery 46
Superficial Temporal Artery 46
Brachial Artery 46
Complications 46
Central Venous Catheterization 46
Indications 46
Contraindications 46
Clinical Utility 46
Technique and Sites of Catheterization 47
Subclavian Vein 47
Internal Jugular Vein 47
External Jugular Vein 47
Femoral Vein 48
Ultrasound Guided Techniques 48
Complications 49
Pulmonary Artery Catheterization 49
Indications 49
Contraindications 49
Clinical Utility 49
Technique 49
Complications 50
References 51
Chapter 4 53
Fluid Resuscitstion 53
Pathophysiology of Fluid/Volume Deficits 53
Armamentarium to Correct Fluid/Volume Deficits 54
Crystalloids 54
Hypertonic Crystalloids 54
Colloids 55
Albumin 55
“Synthetic” Colloids 55
Dextrans 55
Gelatins 55
Hydroxyethylstarch (HES) 55
Risks of Fluid Resuscitation 56
Coagulation Problems 56
Kidney Function 56
Fluid Resuscitation and Additional Effects 57
A New Debate: “Dry or Wet” 57
How Is Fluid Therapy Guided? 58
Fluid Resuscitation in the Mirror of Meta-Analyses 58
Conclusions 59
References 60
Chapter 5 62
Vasoactive Amines and Inotropic Agents 62
Autonomic Innervation of the Heart 62
Autonomic Innervation of the Peripheral Circulation 62
Neurotransmitters 62
Adrenergic Receptors 63
Vasoactive Amines and Inotropes 63
Endogenous Catecholamines 63
Epinephrine 63
Cardiovascular Effects 63
Effects on the Airway 64
Metabolic Effects 64
Effects on Electrolytes 64
Miscellaneous Effects 64
Adverse Effects and Contraindications 65
Norepinephrine 65
Dopamine 65
Synthetic Catecholamines 66
Dobutamine 66
Isoproterenol 66
Synthetic Non-Catecholamines 66
Ephedrine 66
Phenylephrine 66
Phosphodiesterase Inhibitors 67
Vasopressin 67
Conclusions 67
References 68
Chapter 6 70
Shock 70
Introduction 70
Determinants of Oxygen Delivery 70
Compensatory Responses to Shock 72
Stages of Shock 72
Oxygen Debt 72
Autonomic Nervous System 72
Renin-Angiotensin System 73
Arginine Vasopressin 73
Transcapillary Refill 74
Decompensatory Mechanisms in Shock 74
Vasomotor Decompensation 74
Microvascular Alterations 75
Endothelial Activation and Leukosequestration 75
Decreased Erythrocyte Deformability 75
Cellular Depolarization 76
Mitochondrial Dysfunction 76
Classifications of Shock 76
Hypovolemic Shock 76
Cardiogenic Shock 77
Obstructive Shock 77
Distributive, Hormonal, and Dissociative Shock 78
Diagnosing Shock 78
Treatment of Shock 79
Assuring Adequate Oxygen Delivery 79
Achieving End Points of Resuscitation 81
References 81
Chapter 7 84
Hemodynamic Monitoring 84
Pulmonary Artery Catheter 84
Hemodynamic Parameters 84
Pulmonary Artery Pressure 85
Cardiac Output 85
Derived Hemodynamic Parameters 85
Oxygenation Parameters 85
Calculated Oxygenation Parameters 86
Complications 86
Controversy 86
Echocardiography 87
Pulse Contour Analysis 87
Esophageal Doppler 88
Microcirculation Monitoring 88
Tissue Oxygenation Monitoring 88
Venous Oxygen Saturation 88
Lactate 89
Other Techniques 89
Conclusions 89
References 90
Chapter 8 92
Acid–Base Disorders 92
Henderson–Hasselbalch Equation 92
Henderson Equation 92
Acid–Base Disturbances 93
Metabolic Acidosis 94
Expected Compensatory Response 94
Anion Gap 94
Elevated AG Acidosis 94
Delta Gap 95
Osmolar Gap 95
Normal AG Metabolic Acidosis 95
Urinary Anion Gap 96
Decreased AG 96
Clinical Presentation 96
Management 96
Buffers 96
Metabolic Alkalosis 97
Expected Compensatory Response 97
Effects of Metabolic Alkalosis 97
Managemen 97
Respiratory Acidosis 97
Expected Compensatory Response 97
Effects of Respiratory Acidosis 98
Management 98
Respiratory Alkalosis 98
Expected Compensatory Response 98
Effects of Respiratory Alkalosis 98
Management 98
Clinical Approach 98
Case Examples 99
Case 8-1 99
Case 8-2 99
Case 8-3 99
The Fencl–Stewart Approach to Acid–Base Disorders 100
The Acid–Base Physiology of Crystalloid Solutions 100
References 100
Chapter 9 102
Analgesia and Sedation 102
Analgesia 102
Assessment of Pain 103
Agents for Analgesia 103
Opioids 103
Morphine 104
Fentanyl 104
Hydromorphone 104
Remifentanil 104
Meperidine 104
Nonopioid Analgesics 105
Epidural Analgesia 105
Sedation 106
Agents Used for Sedation 107
Benzodiazepines 108
Propofol 108
Alpha-Agonists 108
Delirium 108
Conclusions 111
References 111
Chapter 10 114
Neuromuscular Blocking Agents 114
Indications 114
Neuromuscular Transmission Physiology 115
Pharmacology 115
Depolarizing Drugs 116
Nondepolarizing Muscle Relaxants 116
Atracurium 116
Cisatracurium 116
d-Tubocurarine 117
Doxacurium 117
Metocurine 117
Mivacurium 117
Pancuronium 117
Pipecuronium 117
Rapacuronium 117
Rocuronium 117
Vecuronium 117
Monitoring Neuromuscular Block 118
The Nerve Stimulator 118
Single Twitch 118
Sustained Tetanus 118
Train-of-Four 118
Double-Burst Suppression 119
Posttetanic Count 119
Electrode Placement 119
Interpretation Errors 119
Complications of Neuromuscular Blockade 119
Reversal of Neuromuscular Blockade 120
Sugammadex 121
Conclusions 121
References 121
Chapter 11 124
Optimization of the High-Risk Surgical Patient 124
Identifying the High-Risk Patient 124
The Process of Optimization 124
Intravenous Fluid Therapy and Blood 125
Cardiac Output Monitoring 126
Inotropic Support 126
The Timing of Optimization 127
Conclusion 127
References 127
Chapter 12 129
Cardiopulmonary Resuscitation 129
Pathophysiology of Cardiac Arrest 129
Signs and Diagnosis of Cardiac Arrest 130
Clinical Assessment 130
Technical Assessment 130
Cardiopulmonary Resuscitation 130
Mechanical CPR 130
Chest Compressions 130
Ventilation 131
Compression-to-Ventilation Ratio 131
Electrical Defibrillation 132
Drugs 132
Epinephrine 132
Amiodarone 132
Magnesium 133
Atropine 133
Bicarbonate 133
Thrombolytics 133
Algorithms for CPR 133
Basic Cardiac Life Support 133
Advanced Cardiac Life Support: Nonshockable Rhythms 135
Postresuscitation Care 135
Prerequisites 135
Goal-Directed Therapies 135
Blood Pressure 135
Blood Glucose 135
Blood CO 2 Tension 135
Mild Therapeutic Hypothermia 135
Prognostication 136
Clinical Tests 136
Supplementary Diagnostics 136
References 136
Part II: Neurocritical Care 142
Chapter 13 143
Management of Closed Head Injury 143
Introduction 143
Closed Head Injury 143
Physiology 143
Diagnosis 144
Radiographic Diagnosis 145
Surgical Management 145
Medical Management 146
Monitoring Tools 146
Treatment of Intracranial Hypertension 147
To Increase Venous Outflow 147
CSF Removal 148
Osmotic Diuretics 148
Alteration in pCO 2 148
Sedation 149
Pharmacologic Methods 149
Temperature 149
Neuroprotective Agents 149
Conclusion 149
References 150
Chapter 14 151
Spinal Cord Injuries 151
Cause and Nature of Injury 151
Experimental Treatments 151
Treatments with more Consensus and Evidence 152
Acute Care Phases 153
The First Care Phase Begins in the Field 153
The Second Care Phase Is Medical Support 154
The Third Phase: Reestablishing Bony Alignment of the Spinal Column 155
The Fourth Care Phase: Radiology 155
The Fifth Phase: Surgical Decompression 155
The Sixth or Final Care Phase: Mechanical Stabilization 156
Detailed Spinal Cord Injury Neurologic Assessment 156
Discussion 158
References 159
Chapter 15 162
Ischemic Stroke 162
Signs and Symptoms 162
Stroke Mimics 164
Etiology 165
Diagnosis 166
Computed Tomography 167
Magnetic Resonance Imaging 167
Diagnostic Ultrasound 167
Treatment 168
General Treatment 168
Thrombolysis 168
Revascularization 169
Pathophysiology-Based Therapy 169
Malignant Ischemic Brain Edema 170
Postoperative Stroke in Specific Settings 170
CEA 170
Coronary Artery Bypass Grafting 171
Spinal Cord Stroke After Aortic Surgery 171
Type A Aortic Dissection 171
References 171
Chapter 16 175
Hemorrhagic Stroke 175
Intracerebral Hemorrhage 175
Etiology 175
Symptoms and Signs 175
Diagnosis 176
Management 176
Subarachnoid Hemorrhage 177
Etiology 177
Signs and Symptoms 178
Diagnosis 178
Preoperative Management 179
Surgical and Endovascular Treatment 179
Postoperative Management 180
References 181
Chapter 17 184
Status Epilepticus 184
Classification 184
Epidemiology 184
Etiology 185
Pathophysiology 185
Manifestations 186
Diagnosis 187
Treatment 188
Continuous EEG Monitoring 190
References 191
Chapter 18 196
Critical Illness Polyneuropathy and Myopathy 196
Epidemiology 196
Pathophysiology 196
Critical Illness Polyneuropathy 196
Critical Illness Myopathy 196
Risk Factors 197
Diagnosis 197
Electromyographic Studies 197
Differential Diagnosis 198
Management 198
Prognosis 198
References 198
Part III: Cardiology 200
Chapter 19 201
Management of Hypertension in the Perioperative Period 201
Definition of Postoperative Hypertension 201
Blood Pressure Targets in Various Postoperative States 202
Prevalence of Postoperative Hypertension 202
Pathophysiology 202
Etiology 203
Patients with Preexisting Hypertension 204
Hyperadrenergic States Associated with Acute Postoperative Hypertension and Hypertensive Crisis 204
Assessment of Patients with Acute Postoperative Hypertension 204
Future Trends in the Management of Postoperative Hypertension 205
Conclusion 205
References 207
Chapter 20 208
Postoperative Myocardial Infarction 208
Incidence 208
Pathogenesis 208
Risk Factors 210
Presentation 211
Management 212
Prevention 212
Conclusion 214
References 214
Chapter 21 218
Management of Postoperative Arrhythmias 218
General Approach 218
ECG Diagnosis of Arrhythmias 219
Classification of Tachyarrhythmias 219
Tachyarrhythmias: Supraventricular 219
Epidemiology 219
Diagnosis 219
Predisposing Factors 222
Prophylaxis 222
Treatment 223
Tachyarrhythmias: Ventricular 224
Epidemiology 224
Diagnosis 224
Predisposing Factors 224
Prophylaxis 225
Treatment 225
Classification of Bradyarrhythmias and Conduction Disturbances 226
Epidemiology 227
Diagnosis 227
Conduction Disturbances 228
Predisposing Factors and Prophylaxis 230
Treatment 230
Perioperative Care of Patients with Pacemakers and Implantable Cardioverter Defibrillators 231
Antiarrhythmic Agents 233
Conclusion 233
References 234
Part IV: Pulmonary Medicine 237
Chapter 22 238
Acute Respiratory Failure 238
Pathophysiology 238
Oxygenation Failure 238
Alveolar Hypoxia 238
Hypoxemia Due to Shunt 239
Ventilatory Failure 239
Approach to the Patient with Respiratory Failure 240
Clinical Symptoms 240
Instrumentation 240
Gas Analysis 240
Chest X-Rays 241
CT-Scanning 241
Hemodynamics 241
Etiology and Diagnosis of Hypoxemia 241
Pulmonary Edema 242
High Hydrostatic Pressure Edema 242
Inflammatory Lung Edema 242
Myocardial Infarction 242
Thromboembolism 242
Aspiration Pneumonia 242
Hypoventilation 243
Etiology and Diagnosis of Hypercapnia (Hypoventilation) 243
Comorbid States 243
Central Depression and Residual Curarization 243
Increased Work of Breathing and Muscle Fatigue 243
Oxygen Administration to Patients with Chronic Respiratory Failure 243
Treatment of Respiratory Failure 243
Treatment of Hypoxemia 243
Lung Recruitability 244
Positive Pressure Ventilation 244
Ventilatory Treatment 245
References 245
Chapter 23 248
Mechanical Ventilation 248
Components of a Mechanical Breath 248
Triggering 248
Cycling Mechanisms 248
Volume-Cycled Breaths 248
Time-Cycled Breaths 249
Flow-Cycled Breaths 249
Modes of Ventilation 249
Assist-Control Ventilation 249
Synchronized Intermittent Mandatory Ventilation 249
Pressure Support Ventilation 250
Airway Pressure-Release Ventilation 250
High Frequency Oscillatory Ventilation 252
Continuous Positive Airway Pressure and Positive End-Expiratory Pressure 252
Noninvasive Positive Pressure Ventilation 252
Mechanical Ventilation for Specific Diseases 253
Acute Respiratory Distress Syndrome 253
Chronic Obstructive Airway Disease 254
Airway Obstruction: Bronchial Asthma 255
Complications of Mechanical Ventilation 255
Barotrauma 255
Ventilator-Associated Lung Injury 255
Ventilator-Associated Pneumonia 255
Weaning from Mechanical Ventilation 256
Indices to Predict Outcome 256
Respiratory Failure After Extubation 256
Weaning by Protocols 257
Tracheostomy 257
Conclusion 257
References 258
Chapter 24 261
Venous Thromboembolism 261
Fundamental Concepts 261
Risk Factors for VTE 262
Acquired Causes of Venous Thrombosis 262
Inherited Causes of Venous Thrombosis 262
Diagnosis of Acute VTE 263
Imaging Studies for the Diagnosis of DVT 263
Contrast Venography 263
Impedance Plethysmography 263
Compression Ultrasound with Venous Imaging (Duplex Ultrasound) 263
Computed Tomography Venography 264
Magnetic Resonance Imaging 264
Imaging Studies for the Diagnosis of Acute PE 264
Chest Radiography 265
Contrast-Enhanced Computed Tomography Arteriography 265
Ventilation–Perfusion Scan 265
Magnetic Resonance Imaging 266
Echocardiography 266
Pulmonary Angiography 266
Other Diagnostic Tools 266
Electrocardiography 266
Arterial Blood Gas Analysis 267
D-Dimer 267
Troponin 267
Brain Natriuretic Peptide 267
Determination of Pretest Probability 267
Diagnostic Approach 268
Treatment of VTE 269
Anticoagulation 269
Unfractionated Heparin 269
Low-Molecular-Weight Heparin 270
Fondaparinux 270
Warfarin 270
Thrombolytic Therapy 271
Procedural and Surgical Treatments 271
Inferior Vena Caval Interruption 271
Embolectomy 272
Risk Stratification and Treatment Options 273
Special Considerations in the ICU 273
Heparin-Induced Thrombocytopenia 273
Catheter-Related DVT 274
Pregnancy 275
Prevention of VTE 275
References 275
Chapter 25 282
Fat Embolism Syndrome 282
Epidemiology 282
Pathogenesis 282
Pathophysiology 283
Clinical Presentation 283
Investigations 284
Diagnosis 285
Management 285
Prognosis 287
References 287
Chapter 26 290
Venous Air Embolism 290
Definitions 290
Systemic Gas Embolism 290
Venous Gas Embolism 291
Historical Perspective and Etiology 291
Surgery Above the Heart 291
Procedures Utilizing Pressurized Gases 292
Intravenous Catheterization 292
Clinical Presentation 292
Symptoms 293
Signs 293
Laboratory Studies and Hemodynamic Monitoring 293
Pathophysiology 293
Circulation 293
Pulmonary Changes 294
Neurological Changes 294
Treatment 295
Durant’s Position 295
Closed-Chest Cardiac Massage 295
Aspiration of Air 295
Supportive Measures and Oxygen Therapy 295
Experimental Therapies 296
References 296
Part V: Infectious Diseases, Sepsis, MODS 299
Chapter 27 300
Sepsis 300
Epidemiology 300
Definitions in Sepsis 301
PIRO 302
Pathogenesis 303
Inflammation, Coagulation, and Immune Dysfunction 303
Macrocirculation and Microcirculation 303
Diagnosis and Treatment 305
Source Control and Antibiotics 305
Hemodynamic Support and Optimization of Oxygen Delivery 306
Other Supportive Therapy 308
Activated Protein C 308
Steroids 308
Surviving Sepsis Campaign 308
Novel, Controversial, and Future Therapies 308
Conclusion 309
References 309
Chapter 28 313
Vascular Catheter-Related Bloodstream Infections 313
Introduction 313
Terminology and Epidemiology 313
Etiologic Agents Causing CR-BSIs 315
Pathogenesis 315
Diagnosis 316
Paired Blood and Intravenous Catheter Blood Cultures 317
Quantitative Blood Cultures: Peripheral Blood and CVC 317
Differential Time to Positivity for CVC vs. Peripheral Blood Cultures 317
Therapy 318
Non-tunneled Catheters 318
Coagulase-Negative Staphylococci 319
S. aureus 319
Gram-Negative Bacilli 320
Candida Species 321
Tunneled Catheters 321
Complications 321
Prevention 321
Skin Preparation 322
Site of Insertion 322
Dressing 322
Catheter Handling 322
Catheter Replacement 322
Antibiotic and Antiseptic-Coated Catheters 322
Chlorhexidine Patches 322
Antibiotic Lock Therapy for Prevention 323
Anticoagulants 323
Silver-Impregnated Collagen Cuff 323
Summary 323
Future Directions 323
References 323
Chapter 29 327
Pneumonia 327
Epidemiology 327
Pathogenesis 328
Immune Defenses in the Lung 330
Etiologic Agents 330
Diagnosis 331
Clinical Diagnosis 331
Microbiologic Diagnosis 332
Antimicrobial Management 332
Early, Appropriate, and Adequate Initial Empiric Antibiotic Therapy 332
Assessing Clinical Response, Cultures, and Antibiotic De-escalation 333
Limiting Duration of Therapy 333
Management of Selected MDR Pathogens 333
Pseudomonas Aeruginosa 333
Acinetobacter Species 334
Extended-Spectrum beta -Lactamase Producers 334
MRSA 334
Lack of Response to Initial Therapy 334
Prevention 335
General Prevention Strategies 336
Modifiable Risk Factors 336
Modulation of Bacterial Colonization 337
Oral Care 337
Antiseptics 337
Antibiotic Prophylaxis Strategies 337
Endotracheal Tube and Mechanical Ventilation 337
Subglottic Secretion Drainage 337
Silver 338
Non-invasive Positive Pressure Ventilation 338
Sedation and Weaning 338
Miscellaneous Strategies 338
Enteral Feeding 338
Intensive Insulin Therapy 338
Stress Bleeding Prophylaxis 339
Transfusion Risk 339
Prevention Strategies at Discharge 339
Conclusion 339
References 339
Chapter 30 344
Intra-abdominal Sepsis 344
Systemic Inflammatory Response Syndrome 344
Classification of Peritonitis 344
Diagnosis 345
Management 346
Special Considerations 347
Acalculous Cholecystitis 347
Role of Laparoscopy in Intra-abdominal Sepsis 347
Modulation of Immune Response 347
Conclusions 348
References 348
Chapter 31 350
Evaluation of the Febrile Patient in the ICU 350
Introduction 350
Pathophysiology of Fever 351
The Pyrogenic Signaling 351
The Antipyretic Process 351
Thermal Measurements 352
Evaluating the Febrile Patient for Infection 352
Patients Admitted for a Febrile Process 353
Fever in ICU Patients 353
ICU-Related Sources of Infection 353
Catheters 353
Ventilator-Associated Pneumonia 353
Urinary Tract Infection 353
Clostridium Difficile Colitis 354
Sinusitis 354
Intra-Abdominal Infections 354
Systemic Fungal Infections 355
Noninfectious Causes of Fever 355
Postoperative Fever 355
Myocardial Infarction 356
Venous Thromboembolism 356
Acute Acalculous Cholecystitis 356
Mesenteric Ischemia 356
Blood Products 356
Drug Allergy 357
Conclusions 357
References 357
Chapter 32 362
Antimicrobial Use in Surgical Intensive Care 362
General Principles 362
Infection and Diagnosis 362
Antibiotics and Resistance 363
Impact of Hospital-Acquired Infections and Antimicrobial Resistance 364
Antimicrobial Therapy 364
Pharmacodynamics 364
Monitoring Drug Levels 364
Dosing Considerations 364
Parenteral to Oral Conversion 364
Allergy and Other Adverse Effects 365
Therapeutic Interactions 365
Special Patient Populations 365
Improving the Quality of Critical Care 365
Prevention 365
Surgical Prophylaxis 365
Prophylaxis for Infective Endocarditis 366
Therapy 366
Empiric Therapy 366
Antifungal Therapy 367
Multidrug-Resistant Organisms 367
De-Escalation 367
Conclusions 368
References 368
Part VI: Hematology 370
Chapter 33 371
Coagulation Abnormalities in the Critically Ill 371
Incidence and Relevance 371
Causes of Prolonged Global Coagulation Times 372
Causes of Thrombocytopenia 373
Disseminated Intravascular Coagulation 375
Coagulation Defects with Normal Routine Coagulation Tests 375
Management of Coagulation Abnormalities in Critically Ill Patients 376
Conclusions 377
References 377
Chapter 34 379
Blood Products 379
Red Blood Cells 379
Platelets 380
Plasma 380
Cryoprecipitated Antihemophilic Factor (Cryoprecipitate) 380
Albumin 380
Factor Concentrates 380
Additional Processing 380
Blood Product Administration 381
Urgent Transfusion 381
Massive Transfusion 382
Risks of Transfusion 383
Transfusion Reactions 383
Transfusion-Transmitted Diseases 385
Utilization Review 385
References 386
Part VII: Metabolism and Nutrition 388
Chapter 35 389
Hyperglycemia in the Surgical Intensive Care Unit 389
Introduction 389
Hyperglycemia and Adverse Clinical Outcomes 389
Diabetes Mellitus 390
Prevalence and Nomenclature 390
Complications 390
Medical Therapy 391
Glycemic Control 392
Evidence for Benefit 392
Intraoperative Glycemic Control 392
Insulin Therapy 393
Infusion Protocols 393
Hypoglycemia Correction 393
Transitioning to Subcutaneous Regimens 394
Basal Insulin 394
Pre-prandial Insulin 394
Special Circumstances 394
Diabetic Ketoacidosis 394
Non-ketotic Hyperosmolar State 395
References 395
Chapter 36 397
Adrenal Insufficiency 397
Adrenal Physiology 397
Control of Secretion 398
HPA Axis Changes in Critical Illness 398
Tissue Activity of Glucocorticoids in Critical Illness 398
Adrenal Insufficiency 399
Presentation 399
Secondary Adrenal Insufficiency 399
Diagnosis 399
Dynamic Testing 400
Low Dose Short Synacthen Test 400
Additional Testing 400
Adrenal Insufficency in Critical Illness 400
Total Plasma Cortisol 401
The Corticotropin Test in Critical Illness 401
Conclusions 402
References 402
Chapter 37 405
Nutrition Support in Intensive Care 405
Metabolic Response to Stress 405
Indications for Nutritional Support 406
Nutritional Assessment 406
Route of Feeding 406
Assessment of Needs 407
Vitamins and Minerals 408
Fluid Requirements 409
Enteral Feeding 409
Formula Selection 410
Immune Enhancing Diets 410
Parenteral Feeding 410
Indication 410
Metabolic Complications of Parenteral Nutrition 411
Hypophosphatemia 411
Hypomagnesemia 412
Hyperglycemia 412
Evaluating Nutrition Support Efficacy 412
Conclusion 413
References 413
Part VIII: Nephrology and Electrolytes 416
Chapter 38 417
Acute Kidney Injury 417
Classification and Pathophysiology of AKI 417
Pre-renal AKI 418
Renal (Parenchymal) AKI 419
Glomerular Disease 419
Interstitial Disease 419
Vascular Disease 419
Tubular Disease or ATN 420
Post-renal AKI 420
Radiocontrast Nephropathy 420
AKI Associated with Hepato-Renal Syndrome 421
Rhabdomyolysis-Associated AKI 421
Diagnostic Tools 421
Treatment Options 421
Conclusions 423
References 424
Chapter 39 427
Renal Replacement Therapy 427
Introduction 427
General Principles 427
Dialysis 428
Continuous Renal Replacement Therapy (CRRT) 428
Peritoneal Dialysis 429
Slow Extended Daily Dialysis 429
Indications for Renal Replacement Therapy 430
Mode of Renal Replacement Therapy 430
Continuous Renal Replacement Therapy 430
Dose of CRRT and Circuit Anticoagulation 430
CRRT Technology 431
Intermittent Hemodialysis 431
Peritoneal Dialysis 431
Other Blood Purification Techniques 431
Hemoperfusion 431
Plasmapheresis or Plasma Exchange 432
Blood Purification Technology Outside of ARF 432
Drug Prescription During Dialytic Therapy 432
Conclusion 432
References 433
Chapter 40 434
Disorders of Electrolytes 434
Introduction 434
Disorders of Sodium 434
Hyponatremia 434
Etiology 434
Clinical Manifestations 434
Diagnostic Approach 434
Hypotonic Hyponatremia (Serum Osmolality < 275 mOsm/L)
Hypovolemic 435
Euvolemic 436
Hypervolemic (Edematous Patients) 436
Isotonic Hyponatremia (Serum Osmolality 275–295 mOsm/L) 436
Hypertonic Hyponatremia (Serum Osmolality > 295 mOsm/L)
Treatment 436
Hypernatremia 437
Etiology 437
Clinical Manifestations 437
Diagnostic Approach 437
Treatment 438
Disorders of Potassium 438
Hypokalemia 439
Etiology 439
Clinical Manifestations 439
Diagnostic Approach 439
Treatment 439
Hyperkalemia 439
Etiology 439
Clinical Manifestations 439
Diagnostic Approach 440
Treatment 440
Disorders of Magnesium 440
Hypomagnesemia 440
Etiology 441
Clinical Manifestations 441
Diagnostic Approach 441
Treatment 441
Hypermagnesemia 441
Etiology 441
Clinical Manifestations 441
Treatment 441
Disorders of Calcium 441
Hypocalcemia 442
Etiology 442
Clinical Manifestations 442
Treatment 442
Hypercalcemia 442
Etiology 442
Clinical Manifestations 442
Treatment 442
Disorders of Phosphorus 443
Hypophosphatemia 443
Etiology 443
Clinical Manifestations 443
Treatment 443
Hyperphosphatemia 444
Etiology 444
Clinical Manifestations 444
Treatment 444
References 444
Part IX: Gastroenterology 447
Chapter 41 448
Gastrointestinal Bleeding 448
Etiology 448
Upper Gastrointestinal Bleeding 448
Stress-Related Mucosal Disease 448
Pathogenesis of Stress-Related Mucosal Disease 449
Variceal Hemorrhage 450
Other 450
Lower Gastrointestinal Bleeding 451
General Management 451
Assessment and Scoring Systems 451
Airway 452
Resuscitation 452
Coagulopathy 452
Specific Management of Stress-Related Mucosal Disease 453
Pharmacological Management 453
Endoscopic Management 454
Radiological Management 455
Angiography 455
Radionuclide Imaging 455
CT Angiography 455
Specific Management of Variceal Bleeding 456
Pharmacological Management 456
Endoscopic Management 457
Non-endoscopic Management 457
Radiological Management 457
Specific Management of Lower Gastrointestinal Bleeding 458
Endoscopic Management 458
Radiological Management 458
Surgical Management 458
Conclusion 458
References 458
Chapter 42 463
Acute Pancreatitis 463
Natural History of Acute Pancreatitis 463
Epidemiology and Etiology 464
Pathophysiology 464
Phase 1: Cellular Damage 465
Phase 2: Local Inflammation in the Pancreatic Tissue 465
Phase 3: Systemic Inflammation 465
Clinical Presentation 466
Diagnosis 466
Biochemistry 466
Imaging 466
CT Scan 467
MRI 467
Ultrasound 467
Risk Stratification 467
Intra-abdominal Hypertension 468
Complications in Severe Pancreatitis 468
Necrosis 468
Infected Necrosis 469
ICU Management of Patients with Severe Acute Pancreatitis 469
ICU Admission 469
Monitoring 469
Support of Organ Dysfunction 470
Limiting Disease Progress 470
Prevention of Infection 471
Prophylactic Antibiotics 471
Selective Digestive Decontamination 471
Enteral Nutrition 472
Treatment of Complications 472
Sterile Pancreatic Necrosis 472
Infected Pancreatic Necrosis 472
Microbiology of Infected Pancreatic Necrosis 472
Diagnosis of Infection in Acute Pancreatitis 473
Source Control 473
Antibiotics 474
Fungal Infections and Infected Pancreatitis 474
Abdominal Compartment Syndrome 474
Conclusion 475
References 475
Part X: Surgery, Trauma, and Transplantation 478
Chapter 43 479
Trauma 479
Principles of Prioritization 479
Airway 479
Breathing 480
Circulation 480
Head Injury 481
Aortic Injury 481
Pelvic Fracture 482
Extremity Injury 482
Soft Tissue and Non-life or Non-limb-Threatening Injuries 482
Stages of Resuscitation 482
Phase I: Damage Control 482
Phase II: SICU Resuscitation 482
Phase III: Completion Workup/Re-exploration 482
Specific Organ System Injuries: ICU Implications 482
Central Nervous System Injuries 482
Maxillofacial Trauma 482
Spinal Column Injuries 483
Chest Injuries 483
Abdominal Injuries 483
Pelvic Injuries 483
Extremity Injuries 484
Miscellaneous Considerations 484
Hypothermia/Acid-Base Disorders/Coagulation Disorders 484
Deep Venous Thrombosis/Pulmonary Embolism 484
Nutrition 484
Rehabilitation 484
Geriatric Trauma 485
References 485
Chapter 44 487
Burns 487
Initial Evaluation and Resuscitation 487
Wound Management 488
Pain Management 491
Metabolic Response and Nutrition 491
Complications 492
Chemical Burns 493
Electrical Injury 493
References 493
Chapter 45 496
The Abdominal Compartment Syndrome 496
Historical Background 496
Definitions 497
Intra-abdominal Pressure (IAP) 497
Abdominal Perfusion Pressure (APP) 497
Filtration Gradient 497
IAP Measurement 497
Normal and Pathologic IAP Values 497
Intra-Abdominal Hypertension (IAH) 498
Abdominal Compartment Syndrome (ACS) 498
Classification of IAH/ACS 498
Recognition of ACS 498
Clinical Awareness 498
Etiology 499
Diagnosis 499
Clinical and Radiologic Examination 499
Measurement of Intra-Abdominal Pressure 500
Pathophysiologic Implications 500
Neurologic Function 500
Cardiovascular Function 502
Respiratory Function 503
Renal Function 504
Liver Function 504
Splanchnic Perfusion 505
Abdominal Wall Abnormalities 505
Multiple Organ Failure 505
Importance of Iap in Other Clinical Conditions 505
IAH and Lymphatic Drainage 505
ACS in Burn Patients 505
ACS in Hematologic Patients 506
IAP During Pregnancy 506
ACS in Morbidly Obese Patients 506
Clinical Management and Medical Treatment 506
Improvement of Abdominal Wall Compliance 508
Evacuation of Intra-Luminal Contents 508
Evacuation of Abdominal Fluid Collections 508
Correction of Capillary Leak and Positive Fluid Balance 508
Specific Treatments 508
Surgical Treatment 509
Abdominal Decompression 509
Planned Re-laparotomy vs. On-Demand Laparotomy 510
Planned Re-laparotomy 510
On-Demand Laparotomy 510
Conclusions 510
References 511
Chapter 46 517
Rhabdomyolysis 517
Etiology 517
Selected Causes 517
Cocaine 517
Exercise 517
Injuries 517
Operative-Positioning Injury 518
Statins 518
Propofol 518
Malignant Hyperthermia 518
Pathophysiology 518
Diagnosis 519
History and Physical Examination 519
Laboratory Data 519
Electrocardiogram 520
Magnetic Resonance Imaging 520
Complications 520
Management 520
Volume Resuscitation 520
Alkalinization of the Urine 520
Diuresis 520
Management of Metabolic Abnormalities 521
Treatment of AKI 521
Treatment of Compartment Syndrome 521
The Role of Free-Radical Scavengers and Antioxidants 521
Treatment of the Local Injury 521
Prognosis 521
References 521
Chapter 47 523
Postoperative Care of the Cardiac Surgical Patient 523
Pathophysiologic Consequences 523
Management of the Postoperative Open-Heart Patient 524
Initial Management 524
Basics of Cardiovascular Hemodynamic Management 524
Low Cardiac Output in the Postoperative Period 525
Clinical Manifestations of Low Cardiac Output 525
Etiology of Low Cardiac Output 526
Diagnosis of Low Cardiac Output 526
Management of Low Cardiac Output 527
Pharmacologic Management of Low Cardiac Output 527
Mechanical Support for Low Cardiac Output 531
Circulatory Assist Devices 532
Common Postoperative Hemodynamic Problems 533
Hypotension with Normal Cardiac Output 534
Hypertension and a Normal Cardiac Output 534
Low Cardiac Output and Normal Left Ventricular Function 536
Arrhythmias 537
Ventricular Ectopy 537
Atrial Fibrillation 538
Bradycardia 539
Hemorrhagic Complications of Open-Heart Surgery 540
Etiology of Coagulopathy 540
Diagnosis of Coagulopathy 540
Treatment of Coagulopathy 541
Blood Component Therapy 542
Blood Conservation 542
Mediastinal Bleeding 542
Noncardiac Complications of Open-Heart Surgery 543
Pulmonary Complications 543
Renal Complications 544
Gastrointestinal Complications 544
Metabolic Complications 545
Hematologic Complications 546
Infectious Complications 546
Neurologic Complications 547
References 548
Chapter 48 555
Postoperative Care Following Major Vascular Surgery 555
Postoperative Triage 555
General Postoperative Considerations 556
Postoperative Hemodynamics and Bleeding 556
Myocardial Ischemia 556
Renal Failure 557
Respiratory Complications 557
Gastrointestinal Complications 557
Pain Management 558
Multisystem Organ Failure 558
Surgery-Specific Considerations 558
Carotid Endarterectomy 558
Open AAA Repair 559
Ruptured AAA Repair 559
Endovascular Aortic Repair 559
Thoracoabdominal Aortic Repair 560
Revascularization for Peripheral Artery Disease 561
Conclusion 561
References 561
Chapter 49 564
Postoperative Care After Bariatric Surgery 564
Pathophysiology of Obesity 564
Pulmonary 564
Cardiovascular 567
Nutrition 567
Pharmacology 568
Propofol 568
Benzodiazepines 568
Fentanyl 568
Antimicrobials 568
Drotrecogin Alfa 569
Hematologic 569
Specific Complications Following Bariatric Surgery 569
Anastomotic Leak 569
Early Small Bowel Obstruction 570
Pressure-Induced Rhabdomyolysis 571
Outcomes 571
Conclusion 572
References 572
Chapter 50 577
Care of the Organ Donor 577
Evaluation and Selection of Donors 578
Pathophysiology of Brain Death 579
Monitoring 580
Medical Management 580
Cardiovascular Management 580
Respiratory Management 581
Endocrine and Metabolic Management 581
Hematologic Management 582
Immunologic Management 582
Conclusion 582
References 582
Chapter 51 584
Postoperative Care of the Heart Transplant Patient 584
Medical Evaluation 584
Mechanical Circulatory Support: A Bridge to Transplantation 585
Donor Selection and Management 587
Donor–Recipient Matching 588
Organ Retrieval 588
Recipient Assessment Prior to Surgery 588
Anesthesia 588
Surgery 589
Postoperative Care 591
Assessment of Cardiac Function 591
Immunosuppression and Allograft Rejection 592
Induction Therapy 592
Maintenance Immunosuppression 593
Rejection 594
Specific Postoperative Problems 595
Hypotension and Low Cardiac Output 595
Acute Renal Failure 597
Bradycardia and Arrhythmia 598
Infection 599
Long-Term Results 599
References 600
Chapter 52 605
Postoperative Care of the Lung-Transplant Patient 605
Patient Characteristics and Preoperative Preparation 605
Lung-Transplant Patient Care Team 605
Respiratory Management 605
Ventilation 607
Noninvasive Ventilation 607
Bronchial Hygiene 607
Hypercapnia 607
Hemodynamic Management 607
Pulmonary Hypertension 608
Systemic Hypotension 608
Supraventricular Arrhythmias 608
Diagnosis and Management of Early Surgical Complications 608
Bleeding 608
Bronchial Anastomotic Complications 608
Vascular Anastomotic Complications 608
Axial Torsion 609
Pain Management 609
Immunosuppression 609
Infection Prophylaxis 609
Early Medical Complications and Management 610
Pulmonary Complications 610
Gastrointestinal Complications 610
Renal Complications 611
Neurological and Psychological Complications 611
Patient and Family Education 611
References 611
Chapter 53 613
Postoperative Care of the Liver-Transplant Patient 613
Introduction 613
Preoperative Physiological Profiles and Approaches to Optimization 613
Chronic Liver Disease 613
Acute Liver Failure 613
Overview of Surgical Techniques 614
Physiological Challenges During Surgery 615
Immediate Postoperative Care 615
Cardiovascular 615
Respiratory 616
Renal 616
Gastrointestinal 616
Neurological 617
Hematological 617
Antimicrobial Prophylaxis 617
Graft Failure and Dysfumction 617
Clinical Picture 618
Management of PGD 618
Immunosuppression 618
Rejection 619
Other Early Graft-Related Considerations 619
Further Monitoring of the Graft 619
Laboratory Tests 619
Imaging 619
Postoperative Bleeding 620
Days 1–7 620
Ventilatory Weaning and Decision to Perform Tracheostomy 620
Sepsis 620
The First Month 621
Early Opportunistic Infection 621
Bone Marrow Dysfunction 621
Outcomes 621
References 621
Chapter 54 623
Postoperative Care of the Pancreas- Transplant 623
Indications 623
Evaluation and Recipient Selection 624
Operative Technique 624
Immunosuppression 626
Perioperative Care and Potential Complications 626
Conclusion 628
References 628
Part XI: Additional Topics 630
Chapter 55 631
Management of the Critically III Geriatric Patient 631
The Physiology of Aging 631
The Outcome of Elderly Patients Admitted to the ICU 633
Trauma and the Elderly Patient 634
Surgery and the Elderly 635
Delirium in the Elderly 635
Postoperative Cognitive Dysfunction 636
Drug Dosing in the Elderly 636
Conclusion 637
References 637
Chapter 56 641
Alcohol Withdrawal in the Surgical Patient: Prevention and Treatment 641
Epidemiology and Clinical Relevance of Alcohol-Use Disorders 641
Clinical Presentation 641
Differential Diagnosis 642
The Pathophysiology of AWS 642
Perioperative Assessment 642
Diagnosis and Monitoring of Delirium 643
Prevention of AWS 643
Treatment of AWS and DT 644
Benzodiazepines 644
Adjuvant Therapy 646
Conclusion 647
References 647
Chapter 57 649
Ethics and the End-of-Life Care 649
Ethical Theory and Principles 649
Autonomy 649
Beneficence 650
Justice 650
Nonmaleficence 650
Decision Making 650
The Four Boxes Concept 650
Medical Indications 651
Patient Preferences 651
Quality of Life 651
Contextual Features 651
Resolution 651
Foregoing Life-Sustaining Therapies 652
Definitions 652
Extraordinary or Ordinary 652
Autonomy 652
Capacity and Competency 652
Surrogate Decision Makers 652
Appointed 653
Family 653
Friends 653
Court-appointed 653
Bioethics Consultation 653
Differences between Services 654
Effective Use of the Ethics Consult 654
Special Problems 654
Artificial Nutrition and Hydration 654
Transfusion 654
End-of-Life Care 655
Ethics in Critical Care Research 655
Basic Requirements 656
Conducting Critical Care Research 656
Patients with Decision-making Cap 656
Incapacitated Patients 656
Proxy Consent 656
Prospective Consent 657
Risk 657
Benefit 657
Informed Consent 657
Medical Emergency Consent 657
Waiver of Consent 657
Defining Death and Organ Transplantation 657
History 657
Brain Death 657
Whole Brain Theory 657
Adult 657
Children 658
Philosophical and Religious Concepts 658
Alternative Views to Whole Brain Death 658
Organ Transplantation 658
Non-heart-beating Donor 658
Time of Death 658
Conclusion 659
References 659
Chapter 58 660
Scoring Systems and Outcome Prediction 660
Update on Terminology 660
General Severity of Illness Scoring Systems and General Outcome Prediction Models 661
The SAPS 3 Admission Model 662
The APACHE IV Model 662
The MPM III 0 Model 663
Organ Dysfunction/Failure Scores 663
Making a Decision 663
References 664
Chapter 59 666
Improving the Intensive Care Unit 666
Defining ICU Performance 667
Measuring and Interpreting ICU Performance 669
Framework for Improving ICU Performance 670
Specific Strategies to Improve Performance 673
Changes to ICU Structures and Processes Not Directly Related to Specific Technical Aspects of Care 673
Strategies to Increase Use of EBBP 674
Information Technologies in ICU Performance Improvement 675
Summary and Conclusions 677
References 678
Chapter 60 689
Continuing Education in Critical Care Medicine 685
Historical Overview and New Approaches 685
Improving Traditional Methods of Continuing Medical Education 686
Lectures and Presentations 686
Immersive Education: Simulation and Virtual Reality 687
New Procedural Skills and Credentialing 688
Future Directions 689
Summary 689
References 689
Index 691