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Abstract
Here’s the most clinically oriented critical care text focusing on the adult patient. In full-color and superbly illustrated with clinical photographs, imaging studies, and management algorithms, and with a broad multidisciplinary focus, this text will help you enhance your skills at any level of training.
- Stands alone as a clinically oriented comprehensive reference.
- Completely updated and authorship expanded to reflect the evolution in critical care practice.
- In color for the first time, with new color schematics and treatment algorithms for greater ease of reference.
- Utilizes key points lists at the end of chapter, to help you make decisions rapidly and easily.
- Delivers key references that list other useful resources for information.
- Learn from the best ICU specialists worldwide with contributions from an increased number of international authorities.
- Effectively manage common complications in the ICU with updated coverage of severe sepsis, septic shock, surgical infections, neurogenic and anaphylactic shock, severe heart failure, acute coronary syndromes, and Acute Respiratory Distress Syndrome.
- Access the complete contents online at Expert Consult, along with an image bank and instructional videos!
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Expert Consult ad | IFC1 | ||
| Critical Care Medicine, 4/e | i | ||
| Copyright Page | iv | ||
| Dedication | v | ||
| Contributors | vii | ||
| Preface | xiii | ||
| Table Of Contents | xv | ||
| Video Contents | xix | ||
| Second Half title page | xxi | ||
| 1 Critical Care Procedures, Monitoring, and Pharmacology | 1 | ||
| 1 Cardiac Arrest and Cardiopulmonary Resuscitation | 3 | ||
| Chapter Outline | 3 | ||
| Epidemiology and General Principles | 3 | ||
| Cardiopulmonary Resuscitation and Advanced Cardiac Life Support | 3 | ||
| Chest Compressions | 4 | ||
| Defibrillation | 4 | ||
| Rescue Breathing | 4 | ||
| Advanced Cardiac Life Support | 5 | ||
| Postresuscitation Care | 5 | ||
| General Approach | 5 | ||
| Critical Care Support | 7 | ||
| Cardiac Catheterization | 7 | ||
| Therapeutic Hypothermia | 7 | ||
| Neurologic Prognostication | 9 | ||
| Selected References | 10 | ||
| References | 10.e1 | ||
| 2 Airway Management in the Critically Ill Adult | 11 | ||
| Chapter Outline | 11 | ||
| Structure and Function of the Normal Airway | 11 | ||
| The Nose | 11 | ||
| The Oral Cavity | 12 | ||
| The Pharynx | 12 | ||
| The Larynx | 12 | ||
| The Tracheobronchial Tree | 12 | ||
| Overview of Airway Function | 13 | ||
| Assessing Adequacy of the Airway | 13 | ||
| Patency | 13 | ||
| Protective Reflexes | 13 | ||
| Inspired Oxygen Concentration | 13 | ||
| Respiratory Drive | 14 | ||
| Management of the Airway | 14 | ||
| Providing an Adequate Inspired Oxygen Concentration | 14 | ||
| Establishing a Patent and Secure Airway | 14 | ||
| Airway Maneuvers | 14 | ||
| Positioning for Airway Management | 14 | ||
| Clearing the Airway | 14 | ||
| Triple Airway Maneuver | 15 | ||
| Artificial Airways | 15 | ||
| Advanced Airway Adjuncts | 15 | ||
| Tracheal Intubation | 16 | ||
| Providing Ventilatory Support | 17 | ||
| Bag-Valve-Mask Ventilation | 17 | ||
| Prolonged Ventilation Using a Sealed Tube in the Trachea | 17 | ||
| Apneic Oxygenation | 18 | ||
| Physiologic Sequelae and Complications of Tracheal Intubation | 18 | ||
| The Difficult Airway | 19 | ||
| Recognizing the Potentially Difficult Airway | 19 | ||
| The Obstructed Airway | 20 | ||
| Trauma and the Airway | 20 | ||
| The Airway Practitioner and the Clinical Setting | 20 | ||
| Managing the Difficult Airway | 21 | ||
| The Anticipated Difficult Airway | 21 | ||
| Awake Intubation | 21 | ||
| Fiberoptic Intubation. | 21 | ||
| Retrograde Intubation. | 21 | ||
| Intubation Under Anesthesia | 21 | ||
| Unanticipated Airway Difficulty | 21 | ||
| Bimanual Laryngoscopy | 22 | ||
| Stylet (“Introducer”) and Gum Elastic Bougie | 23 | ||
| Different Laryngoscope or Blade | 23 | ||
| Lighted Stylet | 24 | ||
| Video Laryngoscopy | 24 | ||
| Fiberoptic Intubation | 24 | ||
| Cannot Intubate–Cannot Ventilate | 24 | ||
| Confirming Tube Position in the Trachea | 25 | ||
| Surgical Airway | 25 | ||
| Cricothyrotomy | 25 | ||
| Tracheostomy | 25 | ||
| Extubation in the Difficult Airway Patient (Decannulation) | 26 | ||
| Tube Displacement in the Critical Care Unit | 27 | ||
| Endotracheal Tube | 27 | ||
| Tracheostomy Tube | 27 | ||
| The NAP4 Project | 27 | ||
| Common Problems in Airway Management | 28 | ||
| Selected References | 30 | ||
| References | 30.e1 | ||
| 3 Assessment of Cardiac Filling and Blood Flow | 31 | ||
| Chapter Outline | 31 | ||
| Cardiac Filling | 31 | ||
| Preload | 31 | ||
| Indicators of Preload | 33 | ||
| Static Indicators of Preload | 33 | ||
| Volumetric Indicators of Preload | 34 | ||
| Dynamic Indicators of Preload (or Preload Responsiveness) | 34 | ||
| Stroke Volume Variation | 34 | ||
| Pulse Pressure Variation | 34 | ||
| Plethysmographic Variability Index | 34 | ||
| Indices Derived by Echocardiography | 34 | ||
| Contractility | 34 | ||
| Afterload | 35 | ||
| Indicators of Afterload | 35 | ||
| Clinical Limitations of Systemic Vascular Resistance and Pulmonary Vascular Resistance | 36 | ||
| Clinical Interpretation of Indicators of Preload | 36 | ||
| Static Indicators of Preload | 36 | ||
| Volumetric Indicators of Preload | 36 | ||
| Dynamic Indicators of Preload | 36 | ||
| The Passive Leg-Raising Test | 36 | ||
| The Diagnostic Fluid Challenge | 37 | ||
| Hemodynamic Status and Blood Flow | 37 | ||
| Measurement of Cardiac Output | 37 | ||
| The Fick Principle | 37 | ||
| Thermodilution | 38 | ||
| Dye/Indicator Dilution | 38 | ||
| Arterial Pulse Pressure Analysis | 38 | ||
| Proprietary Systems Requiring Calibration | 40 | ||
| PiCCO System | 40 | ||
| LiDCOplus System | 40 | ||
| EV1000 System | 40 | ||
| Uncalibrated Systems | 40 | ||
| PulsioFlex System. | 40 | ||
| LiDCOrapid System. | 40 | ||
| Flotrac. | 40 | ||
| Nexfin. | 40 | ||
| Masimo System. | 40 | ||
| Transesophageal Doppler | 41 | ||
| Echocardiography | 41 | ||
| Bioimpedance and Bioreactance | 42 | ||
| Bioreactance | 42 | ||
| Application of the Fick Principle | 42 | ||
| Assessment of Adequacy of the Circulation | 42 | ||
| Clinical Assessment | 42 | ||
| Mixed Venous Oxygenation | 42 | ||
| Central Venous Oxygen Saturation | 43 | ||
| Blood Lactate | 43 | ||
| Venous-to-Arterial CO2 Difference (Pco2 Gap) | 43 | ||
| Goal-Directed Therapy | 43 | ||
| Hemodynamic Optimization of the High-Risk Surgical Patient | 43 | ||
| Early Goal-Directed Therapy of Severe Sepsis | 44 | ||
| Conclusions | 44 | ||
| Selected References | 46 | ||
| References | 46.e1 | ||
| 4 Arterial, Central Venous, and Pulmonary Artery Catheters | 47 | ||
| Chapter Outline | 47 | ||
| Arterial Catheters | 47 | ||
| What Do They Offer? | 47 | ||
| Arterial Pressure Measurement | 47 | ||
| Fluid Responsiveness | 48 | ||
| Cardiac Output Assessment | 48 | ||
| Blood Sampling | 48 | ||
| Access | 48 | ||
| Complications | 48 | ||
| Central Venous Catheters | 48 | ||
| What Do They Offer? | 48 | ||
| Fluid Administration | 48 | ||
| Measurement of Central Venous Pressure | 49 | ||
| Access to Blood in Superior Vena Cava | 49 | ||
| Trace Analysis | 49 | ||
| Access | 49 | ||
| Complications | 49 | ||
| Pulmonary Artery Catheters | 49 | ||
| What Do They Offer? | 49 | ||
| Pressures | 49 | ||
| Right Atrial Pressure | 49 | ||
| Pulmonary Artery Occlusion Pressure | 49 | ||
| Pulmonary Artery Pressures | 51 | ||
| Cardiac Output | 51 | ||
| Right Ventricular Volumes | 51 | ||
| Mixed Venous Oxygen Saturation | 52 | ||
| Derived Variables | 52 | ||
| Resistance. | 52 | ||
| Ventricular Stroke Work. | 52 | ||
| Oxygen-Derived Variables. | 52 | ||
| Venous Admixture. | 53 | ||
| Complications | 53 | ||
| Technical Limitations | 53 | ||
| Applications: Diagnosis Versus Monitoring | 54 | ||
| Assessing Effects of Interventions | 56 | ||
| Clinical Indications for Pulmonary Artery Catheter Insertion | 56 | ||
| Pulmonary Artery Occlusion Pressure and Partial Occlusion | 56 | ||
| Does the Use of a Pulmonary Artery Catheter Improve Outcome? | 56 | ||
| Selected References | 58 | ||
| References | 58.e1 | ||
| 5 Cardiac Pacing | 59 | ||
| Chapter Outline | 59 | ||
| Indications for Permanent Pacemaker Implantation | 60 | ||
| Pacing Indications for Sinus Node Dysfunction | 60 | ||
| Pacing Indications for Acquired Atrioventricular Block | 60 | ||
| Other Permanent Pacing Indications | 61 | ||
| Indications for Temporary Pacing | 63 | ||
| Atrioventricular Nodal Dysfunction | 64 | ||
| High-Grade and Paroxysmal Atrioventricular Block | 64 | ||
| Electrolyte and Metabolic Derangement | 64 | ||
| Drug Side Effects | 65 | ||
| Infectious Disease | 66 | ||
| After Myocardial Infarction | 66 | ||
| Torsades de Pointes | 66 | ||
| Conditions That Do Not Normally Require Pacing | 69 | ||
| Hypothermia | 69 | ||
| Hypothyroidism | 69 | ||
| Obstructive Sleep Apnea | 69 | ||
| Preoperative Anesthesia | 69 | ||
| Seizure | 69 | ||
| Spinal Cord Injury and Tracheal Suctioning | 69 | ||
| Esophageal and Transthoracic Pacing | 70 | ||
| Transcutaneous Pacing | 70 | ||
| Background | 70 | ||
| 2 Critical Care Cardiovascular Disease | 297 | ||
| 21 Circulatory Shock | 299 | ||
| Chapter Outline | 299 | ||
| Introduction | 299 | ||
| History | 299 | ||
| Definitions and Categorization of Shock | 300 | ||
| Classification | 301 | ||
| Hypovolemic Shock | 302 | ||
| Cardiogenic Shock | 303 | ||
| Obstructive Shock | 305 | ||
| Distributive Shock | 306 | ||
| Pathogenesis and Pathophysiology of Shock | 310.e1 | ||
| Hemodynamic Basis of Shock | 310.e1 | ||
| Arterial Pressure | 310.e1 | ||
| Cardiac Output | 310.e1 | ||
| Venous Function in Shock | 310.e2 | ||
| Graphic Analysis of Venous-Cardiac Interactions during Shock | 310.e3 | ||
| Microvascular Function in Shock | 310.e5 | ||
| Mechanisms of Cellular Injury in Shock | 310.e7 | ||
| Compensatory Responses to Shock | 310 | ||
| Organ System Dysfunction Due to Shock (Table 21.3) | 312 | ||
| Central Nervous System | 312 | ||
| Heart | 312 | ||
| Respiratory System | 313 | ||
| Kidney | 313 | ||
| Gastrointestinal System | 313 | ||
| Liver | 313 | ||
| Hematologic System | 313 | ||
| Metabolic Alterations | 314 | ||
| Immune System | 314 | ||
| Diagnostic Approach and Evaluation | 314 | ||
| Clinical Evaluation | 314 | ||
| Laboratory Studies | 315 | ||
| Imaging | 315 | ||
| Invasive Hemodynamic Monitoring | 316 | ||
| Ancillary Monitoring Techniques | 317 | ||
| Oximetry | 317 | ||
| Management and Therapy | 318 | ||
| Aims | 318 | ||
| Resuscitation | 319 | ||
| Conclusion | 323 | ||
| Selected References | 324 | ||
| References | 324.e1 | ||
| 22 Cardiogenic Shock | 325 | ||
| Chapter Outline | 325 | ||
| Definition | 325 | ||
| Epidemiology | 325 | ||
| Incidence | 326 | ||
| Etiology | 326 | ||
| Pathogenesis | 327 | ||
| Systemic Effects | 327 | ||
| Myocardial Pathology | 328 | ||
| Cellular Pathology | 329 | ||
| Reversible Myocardial Dysfunction | 329 | ||
| Clinical Assessment | 330 | ||
| Evaluation | 330 | ||
| Initial Management | 331 | ||
| Therapy | 331 | ||
| Thrombolytic Therapy | 332 | ||
| Intra-aortic Balloon Pumping | 332 | ||
| Revascularization | 333 | ||
| Direct Coronary Angioplasty | 333 | ||
| Randomized Studies | 333 | ||
| Coronary Artery Bypass Surgery | 334 | ||
| Other Causes of Cardiogenic Shock | 334 | ||
| Right Ventricular Infarction | 334 | ||
| Acute Mitral Regurgitation | 334 | ||
| Ventricular Septal Rupture | 335 | ||
| Free Wall Rupture | 335 | ||
| Myocardial Dysfunction After Cardiopulmonary Bypass | 335 | ||
| Myocarditis | 335 | ||
| Left Ventricular Assist Devices | 336 | ||
| Conclusion | 336 | ||
| Selected References | 337 | ||
| References | 337.e1 | ||
| 23 Septic Shock | 338 | ||
| Chapter Outline | 338 | ||
| Overview | 338 | ||
| Historical Perspective | 338 | ||
| Contemporary Definitions | 338 | ||
| Epidemiology | 339 | ||
| Pathogenesis | 340 | ||
| Clinical Presentation | 341 | ||
| Hemodynamic Profile of Septic Shock | 341 | ||
| Hypovolemia | 341 | ||
| Myocardial Dysfunction | 341 | ||
| Distributive Shock | 342 | ||
| Microcirculatory and Mitochondrial Dysfunction | 342 | ||
| Microcirculatory Dysfunction | 343 | ||
| Mitochondrial Dysfunction | 344 | ||
| Management of Septic Shock | 345 | ||
| Overview and Management Guidelines | 345 | ||
| General Principles | 345 | ||
| Antibiotic Therapy and Source Control | 345 | ||
| Early Resuscitation | 346 | ||
| Cardiovascular Support | 347 | ||
| Volume Resuscitation | 347 | ||
| Vasopressor Therapy | 348 | ||
| Individual Vasoactive Agents | 348 | ||
| Inotropic Support | 349 | ||
| Corticosteroids | 349 | ||
| Summary | 350 | ||
| Selected References | 350 | ||
| References | 350.e1 | ||
| 24 Cardiac Tamponade | 351 | ||
| Chapter Outline | 351 | ||
| Fundamentals of Tamponade | 351 | ||
| Pericardial Anatomy | 351 | ||
| Physiology | 351 | ||
| Pericardial Pressure | 352 | ||
| Etiology | 353 | ||
| History and Physical Examination | 354 | ||
| Pulsus Paradoxus | 354 | ||
| Venous Pressure | 356 | ||
| Cardiac and Chest Examination | 357 | ||
| Diagnostic Tests | 357 | ||
| Echocardiography | 357 | ||
| X-Ray Studies | 358 | ||
| Electrocardiography | 358 | ||
| Overall Assessment | 359 | ||
| Special Syndromes in Tamponade | 360 | ||
| Effusive Constrictive Disease | 360 | ||
| Low- and High-Pressure Tamponade | 360 | ||
| Settings in Which Tamponade is Seen | 360 | ||
| The Emergency Room | 360 | ||
| The Cardiac Catheterization and Electrophysiology Laboratories | 361 | ||
| Critical Care Units and Medical Wards | 362 | ||
| Management | 363 | ||
| Acknowledgment | 364 | ||
| Selected References | 364 | ||
| References | 364.e1 | ||
| 25 Severe Sepsis and Multiple Organ Dysfunction | 365 | ||
| Chapter Outline | 365 | ||
| Introduction | 365 | ||
| Definitions | 365 | ||
| Epidemiology | 366 | ||
| Pathophysiology | 366 | ||
| Role of the Immune System in the Early Phases of Sepsis | 367 | ||
| Role of Inflammation | 367 | ||
| Alterations of Hemostasis | 368 | ||
| Management | 369 | ||
| Infection Management | 370 | ||
| Hemodynamic Optimization | 371 | ||
| Modulation of the Host Response | 373 | ||
| Supportive Therapies | 374 | ||
| Multiple Organ Dysfunction | 376 | ||
| Pathophysiology of Multiple Organ Dysfunction Syndrome in Sepsis | 376 | ||
| Organ Dysfunction Scoring Systems | 377 | ||
| Selected References | 378 | ||
| References | 378.e1 | ||
| 26 Hypovolemic Shock | 379 | ||
| Chapter Outline | 379 | ||
| Pathogenesis and Pathophysiology | 379 | ||
| Circulatory Changes | 379 | ||
| General Changes | 379 | ||
| Oxygen Balance | 381 | ||
| Macrocirculation | 382 | ||
| Microcirculation | 383 | ||
| Cells | 384 | ||
| Organ Perfusion and Function in Shock | 384 | ||
| Heart | 384 | ||
| Lung | 385 | ||
| Brain | 386 | ||
| Kidney | 386 | ||
| Gut | 386 | ||
| Liver | 387 | ||
| Spleen | 388 | ||
| Pancreas | 388 | ||
| Hormones and Metabolism | 388 | ||
| Inflammatory and Immunologic Changes | 388 | ||
| Reperfusion and Irreversible Shock | 390 | ||
| Clinical Features | 391 | ||
| Causes | 391 | ||
| Signs and Symptoms | 392 | ||
| Diagnostic Approach | 393 | ||
| General | 393 | ||
| Laboratory Investigations | 393 | ||
| Monitoring | 394 | ||
| Approach to Management | 395 | ||
| General | 395 | ||
| Resuscitation Strategies | 396 | ||
| Fluids | 397 | ||
| Fluid Controversies | 400 | ||
| Blood Products and Substitutes | 402 | ||
| Acidosis and Optimal Hematocrit | 403 | ||
| Vasoactive Drugs | 404 | ||
| Brain Injury and Resuscitation | 404 | ||
| In Practice | 404 | ||
| Supportive Care | 405 | ||
| Miscellaneous Therapies | 406 | ||
| Complications and Prognosis | 406 | ||
| Conclusion | 407 | ||
| Selected References | 407 | ||
| References | 408.e1 | ||
| 27 Traumatic Shock and Tissue Hypoperfusion: | 409 | ||
| Chapter Outline | 409 | ||
| Classic Neuroendocrine Response | 410 | ||
| Inflammation in Shock after Injury | 411 | ||
| Cellular Energetics | 411 | ||
| Immune Mediator Cascades | 411 | ||
| Neuroimmune Response to Trauma | 411 | ||
| Acute Coagulopathy after Trauma | 412 | ||
| Historical Perspective | 412 | ||
| Recent Studies | 414 | ||
| Fluid Therapy | 414 | ||
| Isotonic Crystalloids | 416 | ||
| Colloids | 416 | ||
| Hypertonic Saline | 417 | ||
| Hypertonic-Hyperoncotic Fluids | 417 | ||
| Crystalloids Versus Colloids | 417 | ||
| Blood Component Therapy | 418 | ||
| End Points | 419 | ||
| The Problem | 419 | ||
| Oxygen Delivery Parameters | 419 | ||
| Lactate | 420 | ||
| Base Deficit | 420 | ||
| Gastric Mucosal pH | 421 | ||
| Near-Infrared Spectroscopy | 421 | ||
| Adrenal Insufficiency | 422 | ||
| Clinical Strategies | 422 | ||
| Early Limited Resuscitation | 422 | ||
| Animal Studies | 422 | ||
| Clinical Studies | 423 | ||
| Clinical Pathway—Early Resuscitation | 424 | ||
| Management of Traumatic Shock in the Intensive Care Unit | 425 | ||
| Massive Transfusion | 427 | ||
| Tranexamic Acid | 428 | ||
| Risks of Early Red Blood Cell Transfusion | 428 | ||
| Special Problems | 428 | ||
| Abdominal Compartment Syndrome | 428 | ||
| Extremity Compartment Syndrome | 430 | ||
| Pelvic Fractures | 431 | ||
| Selected References | 431 | ||
| References | 431.e1 | ||
| 28 Anaphylaxis and Anaphylactic Shock | 432 | ||
| Chapter Outline | 432 | ||
| History and Incidence | 433 | ||
| Pathogenesis and Pathophysiology | 434 | ||
| Immunologic Mechanisms Leading to Mast Cell and Basophil Activation and Mediator Release | 434 | ||
| Nonimmunologic Events Leading to Mediator Release | 435 | ||
| Cellular Characteristics of Anaphylaxis | 435 | ||
| Biochemical Mediators of Anaphylaxis | 435 | ||
| Biochemical and Pharmacologic Regulation of Mediator Release | 437 | ||
| Pathophysiologic Effects of Mediators | 437 | ||
| Late-Phase or Biphasic Reactions | 437 | ||
| Clinical and Hemodynamic Features | 437 | ||
| Management | 438 | ||
| Initial Management | 438 | ||
| Additional Therapeutic Options | 440 | ||
| Prophylaxis and Immunotherapy | 440 | ||
| Acknowledgment | 441 | ||
| Selected References | 441 | ||
| References | 441.e1 | ||
| 29 Severe Heart Failure | 442 | ||
| Chapter Outline | 442 | ||
| Definition, Epidemiology, and Staging of Heart Failure | 442 | ||
| Pathophysiology | 444 | ||
| Diagnosis | 445 | ||
| Prognosis in Acute Heart Failure | 446 | ||
| Acute Heart Failure Syndromes | 447 | ||
| Initial Evaluation and Therapy | 447 | ||
| Indications for Invasive Hemodynamic Monitoring | 449 | ||
| Pharmacologic Management of Acute Heart Failure | 450 | ||
| Intravenous Diuretics | 450 | ||
| Vasopressin Inhibitors | 451 | ||
| Parenteral Vasodilators (Table 29.5) | 452 | ||
| Nitroglycerin | 452 | ||
| Nitroprusside | 452 | ||
| Nesiritide (B-natriuretic Peptide) | 452 | ||
| Angiotensin-Converting Enzyme Inhibitors | 453 | ||
| Inotropic Drugs (see Table 29.5) | 453 | ||
| Dobutamine | 453 | ||
| Milrinone | 453 | ||
| Considerations Regarding the Use of Inotropes | 453 | ||
| Vasopressors | 454 | ||
| Dopamine | 454 | ||
| Norepinephrine | 454 | ||
| Ultrafiltration | 454 | ||
| Transition to Chronic Pharmacologic Therapy for Severe Heart Failure | 456 | ||
| Diuretics | 456 | ||
| Beta Blockers (Table 29.7) | 457 | ||
| Angiotensin-Converting Enzyme Inhibitors (see Table 29.7) | 458 | ||
| Angiotensin Receptor Blockers (see Table 29.7) | 458 | ||
| Aldosterone Antagonists (see Table 29.7) | 458 | ||
| Combination Hydralazine/ Isosorbide Dinitrate | 459 | ||
| Digoxin | 459 | ||
| Coronary Heart Disease and Heart Failure: Special Considerations | 460 | ||
| Acute Heart Failure Following Myocardial Infarction | 460 | ||
| Heart Failure with Preserved Left Ventricular Ejection Fraction (Diastolic Heart Failure) | 461 | ||
| Acute Myocarditis and Heart Failure | 462 | ||
| Device Therapy: Implanted Cardioverter-Defibrillators and Cardiac Resynchronization Therapy | 463 | ||
| Implanted Cardioverter-Defibrillator Therapy | 464 | ||
| Cardiac Resynchronization Therapy | 464 | ||
| Mechanically Assisted Circulatory Support: Ventricular Assist Devices | 466 | ||
| Selected References | 469 | ||
| References | 469.e1 | ||
| 30 Acute Coronary Syndromes and Acute Myocardial Infarction | 470 | ||
| Chapter Outline | 470 | ||
| Definitions | 470 | ||
| ST Segment Elevation Myocardial Infarction | 471 | ||
| Clinical Manifestations | 471 | ||
| Clinical History | 471 | ||
| Physical Examination | 473 | ||
| Diagnostic Approach | 473 | ||
| Electrocardiogram | 473 | ||
| Cardiac Enzymes | 475 | ||
| Echocardiography | 475 | ||
| Hemodynamic Monitoring | 476 | ||
| Diagnostic Cardiac Catheterization and Coronary Angiography | 476 | ||
| Approach to Management | 477 | ||
| General Considerations | 477 | ||
| Oxygen | 477 | ||
| Analgesia and Sedation | 478 | ||
| Nitrates | 479 | ||
| Aspirin | 479 | ||
| Inhibitors of the Platelet P2Y12 Receptor | 480 | ||
| Anticoagulant Therapy | 480 | ||
| Fibrinolytic Therapy | 482 | ||
| Effect of Fibrinolysis on Survival | 482 | ||
| Coronary Artery Patency after Fibrinolytic Therapy | 484 | ||
| Complications of Fibrinolytic Therapy | 485 | ||
| Patient Selection | 485 | ||
| Percutaneous Coronary Intervention | 486 | ||
| Primary Percutaneous Intervention | 487 | ||
| Rescue Percutaneous Coronary Intervention | 489 | ||
| Selection of Reperfusion Strategy | 490 | ||
| Platelet Glycoprotein Ilb/IIIa Receptor Antagonists | 490 | ||
| β-Blockers | 492 | ||
| Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers | 493 | ||
| Antiarrhythmic Drugs | 494 | ||
| Calcium Antagonists | 495 | ||
| Lipid-Lowering Agents | 495 | ||
| Intra-aortic Balloon Counterpulsation | 496 | ||
| Coronary Artery Bypass Graft Surgery | 496 | ||
| Management of Complications | 497 | ||
| Pericarditis and Pericardial Tamponade | 497 | ||
| Recurrent Ischemia or Infarction | 497 | ||
| Congestive Heart Failure | 499 | ||
| Right Ventricular Dysfunction and Infarction | 500 | ||
| Mechanical Causes of Congestive Heart Failure or Low Cardiac Output | 502 | ||
| Mitral Regurgitation | 502 | ||
| Ventricular Septal Rupture | 503 | ||
| Left Ventricular Free Wall Rupture | 503 | ||
| Cardiac Arrhythmias and Heart Block | 503 | ||
| Unstable And Non–ST Segment Elevation Myocardial Infarction | 504 | ||
| Clinical Manifestations | 504 | ||
| Definition | 504 | ||
| Clinical History | 504 | ||
| Physical Examination | 504 | ||
| Diagnostic Approach | 504 | ||
| Electrocardiogram | 504 | ||
| Biochemical Markers | 505 | ||
| Coronary CT Angiography | 505 | ||
| Approach to Management | 505 | ||
| Anti-ischemic Therapy | 505 | ||
| Nitrates | 505 | ||
| β-Blockers | 506 | ||
| Calcium Antagonists | 507 | ||
| Intra-aortic Balloon Counterpulsation | 507 | ||
| Antiplatelet Therapy | 507 | ||
| Aspirin | 507 | ||
| Inhibitors of the Platelet P2Y12 Receptor | 507 | ||
| Platelet Glycoprotein IIb/IIIa Receptor Antagonists | 508 | ||
| Antithrombin Therapy | 509 | ||
| Unfractionated Heparin | 509 | ||
| Low-Molecular-Weight Heparin | 510 | ||
| Direct Thrombin Inhibitors | 510 | ||
| Factor Xa Inhibitors | 510 | ||
| Angiotensin-Converting Enzyme Inhibitors | 510 | ||
| Lipid-Lowering Therapy | 510 | ||
| Invasive versus Conservative Management | 511 | ||
| Long-Term Medical Therapy | 512 | ||
| References | 514.e1 | ||
| Selected References | 514 | ||
| 31 Cardiac Arrhythmias | 515 | ||
| Chapter Outline | 515 | ||
| Bradycardias | 516 | ||
| Sinus Bradycardia and Sinus Node Dysfunction | 516 | ||
| Atrioventricular Block | 516 | ||
| Junctional Rhythm | 518 | ||
| Vagally Mediated Sinus Arrest, Bradycardia, and Heart Block | 518 | ||
| Supraventricular Tachycardia | 519 | ||
| Overview | 519 | ||
| Premature Atrial Contractions | 519 | ||
| Paroxysmal Supraventricular Tachycardia | 519 | ||
| Approach to Paroxysmal Supraventricular Tachycardia Therapy | 520 | ||
| Wolff-Parkinson-White Syndrome and Its Variants | 520 | ||
| Acute Management of Tachycardia Associated with Wolff-Parkinson-White Syndrome | 521 | ||
| Nonparoxysmal Atrioventricular Junctional Tachycardia, Paroxysmal Atrial Tachycardia with Block, and Automatic Atrioventricular Junctional Tachycardia | 522 | ||
| Multifocal Atrial Tachycardia | 522 | ||
| Sinus Tachycardia | 523 | ||
| Atrial Flutter | 523 | ||
| Atrial Fibrillation | 524 | ||
| Acute Management of Atrial Fibrillation | 524 | ||
| Special Considerations for the Intensivist | 526 | ||
| Anticoagulants for Stroke Prevention in Atrial Fibrillation. | 526 | ||
| Anticoagulation in the ICU. | 526 | ||
| Direct Current Cardioversion | 527 | ||
| Deep Sedation for Cardioversion | 527 | ||
| Technical Aspects | 528 | ||
| Determinants of Short- and Long-Term Success of Cardioversion | 528 | ||
| A Brief Review of Antiarrhythmic Drugs | 529 | ||
| Ventricular Arrhythmias | 530 | ||
| Arrhythmogenesis | 531 | ||
| Metabolic Disturbances and Ischemia | 531 | ||
| Differential Diagnosis of Wide QRS Tachycardia | 531 | ||
| Approach to Ventricular Arrhythmias in the Critically Ill | 532 | ||
| Specific Ventricular Arrhythmias | 532 | ||
| Less Common Substrates | 533 | ||
| Idiopathic Ventricular Tachycardia | 533 | ||
| Cardiac Arrest and Electrical Storm | 537 | ||
| Catheter Ablation of Cardiac Arrhythmias | 538 | ||
| Pacemakers and Implantable Defibrillators | 539 | ||
| Electrocardiographic Patterns Intensivists Should Recognize | 540 | ||
| Electrolyte, Endocrine, and Metabolic Abnormalities | 540 | ||
| Brugada Pattern | 542 | ||
| Long QT Syndromes | 543 | ||
| Torsades de Pointes | 544 | ||
| Wolff-Parkinson-White Pattern | 544 | ||
| Arrhythmogenic Right Ventricular Dysplasia | 546 | ||
| Conclusions | 546 | ||
| Selected Readings | 546 | ||
| References | 547.e1 | ||
| 32 Valvular Heart Disease in Critical Care | 548 | ||
| Chapter Outline | 548 | ||
| Aortic Stenosis | 550 | ||
| Pathophysiology | 550 | ||
| Aortic Valve Sclerosis | 550 | ||
| Diagnosis | 552 | ||
| Physical Examination | 552 | ||
| Noninvasive Evaluation | 552 | ||
| Cardiac Catheterization | 553 | ||
| Low-Gradient, Low-Output Aortic Stenosis | 554 | ||
| Therapy | 554 | ||
| Medical Management | 554 | ||
| Percutaneous Interventions | 555 | ||
| Balloon Valvuloplasty | 555 | ||
| Transcatheter Aortic Valve Replacement | 556 | ||
| Aortic Valve Replacement | 557 | ||
| Aortic Insufficiency | 558 | ||
| Pathophysiology | 558 | ||
| Diagnosis | 559 | ||
| Physical Examination | 559 | ||
| Noninvasive Evaluation | 560 | ||
| Cardiac Catheterization | 560 | ||
| Therapy | 560 | ||
| Medical Management | 560 | ||
| Aortic Valve Replacement | 561 | ||
| Mitral Regurgitation | 561 | ||
| Pathophysiology | 562 | ||
| Diagnosis | 564 | ||
| Physical Examination | 564 | ||
| Noninvasive Evaluation | 565 | ||
| Cardiac Catheterization | 565 | ||
| Therapy | 566 | ||
| Medical Management | 566 | ||
| Mitral Valve Surgery | 566 | ||
| Future Directions | 567 | ||
| Hypertrophic Obstructive Cardiomyopathy | 567 | ||
| Pathophysiology | 567 | ||
| Diagnosis | 568 | ||
| Physical Examination | 568 | ||
| Noninvasive Evaluation | 569 | ||
| Cardiac Catheterization | 569 | ||
| Therapy | 569 | ||
| Medical Management | 569 | ||
| Percutaneous Intervention or Surgery | 570 | ||
| Mitral Valve Stenosis | 570 | ||
| Pathophysiology | 571 | ||
| Diagnosis | 571 | ||
| Physical Examination | 571 | ||
| Noninvasive Evaluation | 572 | ||
| Therapy | 572 | ||
| Medical Therapy | 572 | ||
| Percutaneous Intervention or Surgery | 572 | ||
| Acknowledgment | 575 | ||
| Selected References | 575 | ||
| References | 575.e1 | ||
| 33 Acute Aortic Dissection | 576 | ||
| Chapter Outline | 576 | ||
| Introduction | 576 | ||
| History | 576 | ||
| Types of TAD | 576 | ||
| Risk Factors for Thoracic Aortic Dissection | 577 | ||
| Pathophysiology | 577 | ||
| Diagnosis | 578 | ||
| Symptoms | 578 | ||
| Physical Exam | 578 | ||
| Imaging | 578 | ||
| Chest Radiograph | 578 | ||
| Computed Tomography | 578 | ||
| Echocardiography | 578 | ||
| Aortography | 579 | ||
| Magnetic Response Imaging (MRI) | 580 | ||
| Summary | 580 | ||
| Perioperative Management | 580 | ||
| General Principles | 580 | ||
| Specific Medications | 582 | ||
| Operative Approach | 582 | ||
| Ascending Aortic Dissections | 582 | ||
| Descending Aortic Dissection and Endovascular Therapy | 583 | ||
| Treatment of Aortic Intramural Hematoma and Atherosclerotic Aortic Ulcer | 583 | ||
| Outcomes and Prognosis | 583 | ||
| Summary | 584 | ||
| Selected References | 584 | ||
| References | 584.e1 | ||
| 34 Hypertensive Crises | 585 | ||
| Chapter Outline | 585 | ||
| Introduction | 585 | ||
| Definitions | 585 | ||
| Pathophysiology | 586 | ||
| Approach to Management | 586 | ||
| Should the Blood Pressure Be Lowered Acutely? | 587 | ||
| How Much Should the Blood Pressure Be Lowered? | 587 | ||
| Which Medication Should Be Used to Lower the Blood Pressure? | 588 | ||
| Clevidipine | 588 | ||
| Esmolol | 588 | ||
| Fenoldopam | 589 | ||
| Labetalol | 589 | ||
| Nicardipine | 590 | ||
| Nitroprusside | 590 | ||
| Other Agents | 590 | ||
| Specific Clinical Considerations | 590 | ||
| Hypertensive Encephalopathy | 590 | ||
| Hypertensive Crisis in Cerebrovascular Accidents | 591 | ||
| Acute Aortic Dissection | 591 | ||
| Hypertensive Crises in Pregnancy | 592 | ||
| Postoperative Hypertension | 592 | ||
| Catecholamine-Associated Hypertensive Crisis | 592 | ||
| Hypertensive Urgency | 593 | ||
| Selected References | 593 | ||
| References | 593.e1 | ||
| 35 General Principles of Postoperative Intensive Care Unit Care | 594 | ||
| Chapter Outline | 594 | ||
| Postoperative Evaluation | 594 | ||
| Recovery From Anesthesia | 597 | ||
| Postoperative Resuscitation | 597 | ||
| Assessment | 597 | ||
| Management Theory | 597 | ||
| Temperature Control | 598 | ||
| Awakening from Anesthesia | 599 | ||
| Postoperative Extubation | 599 | ||
| Best Practices | 600 | ||
| Prevention of Venous Thromboembolism and Deep Venous Thrombosis | 600 | ||
| Stress Ulcer Prophylaxis | 600 | ||
| Preventing Nosocomial Pneumonia | 601 | ||
| Management of Agitation and Delirium | 601 | ||
| Management of Blood Glucose Level | 601 | ||
| Postoperative Nutrition | 602 | ||
| Timing and Route | 603 | ||
| Feeding Considerations in General Surgery Patients | 603 | ||
| Esophagus | 603 | ||
| Stomach | 603 | ||
| Small and Large Intestine | 603 | ||
| Fistulas | 604 | ||
| Pancreatitis | 604 | ||
| Nutrition in Wound Healing | 604 | ||
| Wound Healing and Care | 604 | ||
| Physiology and Biology of Wound Healing | 604 | ||
| Epithelialization and Wound Care | 605 | ||
| Optimizing Wound Healing | 605 | ||
| Antibiotics | 605 | ||
| Surgical Site Infections | 605 | ||
| Drains | 606 | ||
| Acknowledgments | 608 | ||
| Selected References | 609 | ||
| References | 609.e1 | ||
| 36 Postoperative Management of the Cardiac Surgery Patient | 610 | ||
| Chapter Outline | 610 | ||
| Neurologic Care | 610 | ||
| Cardiovascular Care | 612 | ||
| Hemodynamic Changes | 612 | ||
| Mean Arterial Pressure | 613 | ||
| Hypertension | 613 | ||
| Hypotension | 613 | ||
| Tamponade | 614 | ||
| Arrhythmias | 614 | ||
| Bleeding | 614 | ||
| Pulmonary Care | 615 | ||
| Renal Care | 617 | ||
| Applications of Echocardiography after Cardiac Surgery | 618 | ||
| The FATE Examination | 619 | ||
| Acquisition of Images | 619 | ||
| Role of Ultrasonography in Postcardiotomy Tamponade | 619 | ||
| Rescue Applications of Echocardiography | 623 | ||
| Miscellaneous Considerations | 623 | ||
| Intra-aortic Balloon Pump Weaning | 623 | ||
| Routine Order Sets | 624 | ||
| Intensive Care Unit Length of Stay | 624 | ||
| Selected References | 625 | ||
| References | 625.e1 | ||
| 3 Critical Care Pulmonary Disease | 627 | ||
| 37 Acute Respiratory Failure | 629 | ||
| Chapter Outline | 629 | ||
| Acute Respiratory Failure—Types 1 and 2 | 629 | ||
| Hypoxemic Respiratory Failure | 629 | ||
| Basic Mechanisms | 629 | ||
| Assessment of Oxygenation | 631 | ||
| Hypercapnic Respiratory Failure | 631 | ||
| Assessment of Ventilation | 632 | ||
| Clinical Manifestations | 632 | ||
| Acute Respiratory Distress Syndrome | 632 | ||
| Risk Factors | 633 | ||
| Incidence and Prevalence | 634 | ||
| Clinical Manifestations | 635 | ||
| Pathologic Manifestations | 635 | ||
| Pathophysiology | 635 | ||
| Management Strategies | 635 | ||
| Mechanical Ventilation | 636 | ||
| Fluid Management and Vasoactive Support | 638 | ||
| Prevention of Complications of Critical Illness | 638 | ||
| Strategies to Improve Oxygenation | 639 | ||
| Inhaled Nitric Oxide | 639 | ||
| Surfactant Replacement Therapy | 640 | ||
| Enhanced Edema Clearance | 640 | ||
| Experimental/Innovative Therapies | 640 | ||
| Prevention | 641 | ||
| Fibroproliferative Phase | 641 | ||
| Multiple Organ Dysfunction/Failure | 642 | ||
| Prognosis | 642 | ||
| Future Considerations | 643 | ||
| Summary | 643 | ||
| Selected References | 644 | ||
| References | 644.e1 | ||
| 38 Life-Threatening Asthma | 645 | ||
| Chapter Outline | 645 | ||
| Epidemiology of Life-Threatening Asthma | 645 | ||
| Triggers of Acute Asthma | 645 | ||
| Mortality Rates for Asthma | 645 | ||
| Classification | 646 | ||
| Pathophysiology and Immunology | 646 | ||
| Asthma Genetics | 647 | ||
| Symptoms and Signs | 647 | ||
| Objective Measurement of Obstruction | 648 | ||
| Laboratory and Radiographic Data | 648 | ||
| Inpatient Admission Decisions | 649 | ||
| Drug Therapy (Table 38.1) | 649 | ||
| Oxygen | 649 | ||
| β-Adrenergic Therapy | 649 | ||
| Inhaled β2-Selective Agonists (Albuterol or Salbutamol) and Short-Acting β-Agonists | 649 | ||
| Subcutaneous β-Agonist Therapy (Epinephrine or Terbutaline) | 651 | ||
| Corticosteroids | 651 | ||
| Inhaled Anticholinergic Therapy with Ipratropium | 652 | ||
| Methyxanthines: Theophylline or Aminophylline | 652 | ||
| Magnesium Sulfate | 652 | ||
| Heliox | 652 | ||
| Other Agents | 653 | ||
| Antibiotics | 653 | ||
| Fluids | 653 | ||
| Ketamine | 653 | ||
| Leukotriene Antagonists | 653 | ||
| Omalizumab (Anti-IgE Antibody) | 653 | ||
| Nontraditional Therapy of Severe Bronchospasm (Table 38.2) | 653 | ||
| Acute Severe Asthma in Pregnancy | 654 | ||
| Mechanical Ventilation in Asthma Patients | 655 | ||
| Indications | 655 | ||
| Aerosol Delivery | 655 | ||
| Sedation and Analgesia | 655 | ||
| Neuromuscular Blockade | 655 | ||
| Initiating Mechanical Ventilation | 655 | ||
| Auto–Positive End-Expiratory Pressure | 656 | ||
| Definition and Predisposing Factors | 656 | ||
| Diagnosis and Treatment | 656 | ||
| Increased Work of Breathing with Auto–Positive End-Expiratory Pressure | 657 | ||
| Barotrauma | 657 | ||
| Non-invasive Positive-Pressure Ventilation | 657 | ||
| Complications of Asthma | 659 | ||
| Approach to Acute Life-Threatening Asthma | 659 | ||
| Selected References | 660 | ||
| References | 661.e1 | ||
| 39 Chronic Obstructive Pulmonary Disease | 662 | ||
| Chapter Outline | 662 | ||
| Definitions | 662 | ||
| Background | 662 | ||
| Pathophysiology | 663 | ||
| Clinical Manifestations | 664 | ||
| Precipitating Factors | 664 | ||
| Infections | 664 | ||
| Environmental Factors | 664 | ||
| Pulmonary Thromboembolism | 664 | ||
| Medication Failure or Noncompliance | 665 | ||
| Other Causes | 665 | ||
| Initial Management | 665 | ||
| Oxygen | 665 | ||
| Drug Treatment | 666 | ||
| Bronchodilators | 666 | ||
| Corticosteroids | 666 | ||
| Antibiotics | 667 | ||
| Hemodynamic Support | 667 | ||
| Fluid Management | 667 | ||
| Inotropes and Vasodilators | 667 | ||
| Nutritional Support | 667 | ||
| Noninvasive Mechanical Ventilation | 668 | ||
| Indications | 668 | ||
| Implementation of Noninvasive Positive-Pressure Ventilation | 668 | ||
| Weaning | 669 | ||
| Invasive Mechanical Ventilation | 669 | ||
| Initial Approach and Maintenance | 669 | ||
| Ventilation Modes | 669 | ||
| Inspired Oxygen | 669 | ||
| Intrinsic Positive End-Expiratory Pressure | 669 | ||
| Inspiratory Triggering Sensitivity Settings | 670 | ||
| Inspiratory Flow Rate | 670 | ||
| Tidal Volume | 670 | ||
| Respiratory Rate | 670 | ||
| Positive End-Expiratory Pressure | 670 | ||
| Weaning | 670 | ||
| Extubation to Noninvasive Ventilation | 670 | ||
| Prognosis | 671 | ||
| Terminal Care for the End-Stage Patient | 672 | ||
| Selected References | 672 | ||
| References | 673.e1 | ||
| 40 Hypoventilation and Respiratory Muscle Dysfunction | 674 | ||
| Chapter Outline | 674 | ||
| Decreased Neuromuscular Capacity | 674 | ||
| Decreased Respiratory Center Output | 675 | ||
| Respiratory Muscle Weakness | 675 | ||
| Detection of Respiratory Muscle Weakness in Critically Ill Patients | 675 | ||
| Weakness Due to Preexisting Conditions | 676 | ||
| Neuromuscular Disorders | 676 | ||
| Hyperinflation | 677 | ||
| Malnutrition | 677 | ||
| Endocrine Disturbances | 677 | ||
| Weakness Due to New-Onset Conditions | 678 | ||
| Ventilator-Associated Respiratory Muscle Dysfunction | 678 | ||
| Sepsis-Associated Myopathy | 680 | ||
| Intensive Care Unit–Acquired Paresis | 681 | ||
| Acid-Base Disorders | 684 | ||
| Metabolic Acidosis. | 684 | ||
| Acute Respiratory Acidosis. | 684 | ||
| Electrolyte Disturbances | 685 | ||
| Decreased Oxygen Delivery | 685 | ||
| Medications | 686 | ||
| Limitations in the Current Classification of Respiratory Muscle Weakness | 687 | ||
| Respiratory Muscle Fatigue | 687 | ||
| Increased Load | 689 | ||
| Increased Mechanical Load | 689 | ||
| Increased Ventilatory Requirements | 689 | ||
| Hypercapnia-Induced Hypoventilation | 690 | ||
| Summary | 690 | ||
| Selected References | 691 | ||
| References | 691.e1 | ||
| 41 Nonpulmonary Causes of Respiratory Failure | 692 | ||
| Chapter Outline | 692 | ||
| Introduction | 692 | ||
| Hypoventilation | 692 | ||
| Pathophysiology (Fig. 41.1) | 692 | ||
| Mechanisms Underlying Chronic Alveolar Hypoventilation (see Fig. 41.1) | 693 | ||
| Etiologic Classification | 694 | ||
| Respiratory Failure from Neuromuscular Disease | 694 | ||
| Tests of Respiratory Muscle Strength | 694 | ||
| Tests of Respiratory Control and Drive | 694 | ||
| Clinical Recognition and Manifestations | 694 | ||
| Patient Management | 696 | ||
| Respiratory Failure | 696 | ||
| Acute Respiratory Failure Caused by Neuromuscular Disease | 697 | ||
| Noninvasive Positive Pressure Ventilation | 697 | ||
| When to Use Noninvasive Ventilation in Nonpulmonary Causes of Respiratory Failure | 697 | ||
| Patients | 697 | ||
| Blood Gases | 697 | ||
| Clinical State | 697 | ||
| Contraindications Excluded | 697 | ||
| Premorbid State | 697 | ||
| Contraindications to Noninvasive Ventilation | 697 | ||
| Chronic Respiratory Failure | 698 | ||
| Chronic Ventilatory-Assist Devices | 698 | ||
| Management of Airway Secretion Clearance | 702 | ||
| Selected References | 703 | ||
| References | 703.e1 | ||
| 42 Pneumonia: | 704 | ||
| Chapter Outline | 704 | ||
| Definitions and Risk Factors | 705 | ||
| Severe Community-Acquired Pneumonia | 705 | ||
| Risk Factors for Severe Forms of Community-Acquired Pneumonia | 706 | ||
| Mortality Risk from Community-Acquired Pneumonia | 707 | ||
| Pneumonia Acquired in the Hospital | 708 | ||
| Risk Factors Associated with Nosocomial Pneumonia | 708 | ||
| Mortality Risk from Ventilator-Associated Pneumonia | 709 | ||
| Health Care–Associated Pneumonia | 710 | ||
| Pathogenesis | 710 | ||
| General Overview | 710 | ||
| Route of Entry | 711 | ||
| Colonization of the Upper Respiratory System and Digestive Tract | 711 | ||
| The Role of Respiratory Therapy Equipment and Endotracheal Tubes | 711 | ||
| Clinical Features | 712 | ||
| Historical Information | 712 | ||
| Physical Examination | 713 | ||
| Etiologic Pathogens | 713 | ||
| Community-Acquired Pneumonia | 713 | ||
| Nosocomial Pneumonia | 714 | ||
| Isolation of Patients with Pneumonia | 715 | ||
| Diagnostic Issues | 715 | ||
| General Considerations | 715 | ||
| Radiographic Evaluation | 715 | ||
| Routine Laboratory Tests | 715 | ||
| Blood Culture | 715 | ||
| Sputum Examination | 716 | ||
| Invasive Cultures | 716 | ||
| Urinary Antigen, Serologic, and Polymerase Chain Reaction Testing | 716 | ||
| Role of Biomarkers | 716 | ||
| Serum Biomarkers | 716 | ||
| Open Lung Biopsy | 717 | ||
| Recommended Testing for Community-Acquired Pneumonia | 717 | ||
| Recommended Testing for Nosocomial Pneumonia | 717 | ||
| Therapy | 719 | ||
| General Considerations | 719 | ||
| Microbial Resistance | 720 | ||
| Antibiotic Considerations | 720 | ||
| Role of Corticosteroids | 721 | ||
| Nonpharmacologic Measures | 721 | ||
| Community-Acquired Pneumonia Therapy Algorithm (see Fig. 42.4) | 722 | ||
| Monotherapy Versus Combination Therapy | 722 | ||
| ATS/IDSA 2007 Guidelines | 722 | ||
| Timing of Antibiotics | 722 | ||
| Duration of Treatment | 722 | ||
| Nosocomial Pneumonia Therapy Algorithm (see Fig. 42.5) | 722 | ||
| Choosing the Appropriate Regimen | 723 | ||
| Duration of Treatment | 723 | ||
| De-escalation of Treatment | 724 | ||
| Localized Treatment | 724 | ||
| Evaluation of Nonresponding Patients | 724 | ||
| Prevention | 725 | ||
| Community-Acquired Pneumonia | 725 | ||
| Pneumococcal Vaccination | 725 | ||
| Influenza Vaccination | 725 | ||
| Nosocomial Pneumonia | 725 | ||
| Selected References | 727 | ||
| References | 727.e1 | ||
| 43 Weaning from Mechanical Ventilation | 728 | ||
| Chapter Outline | 728 | ||
| Pathophysiology of Weaning Failure | 728 | ||
| Control of Breathing | 728 | ||
| Respiratory Mechanics | 728 | ||
| Patient Effort | 729 | ||
| Respiratory Muscles | 729 | ||
| Cardiovascular Performance | 730 | ||
| Gas Exchange | 730 | ||
| Weaning-Predictor Testing | 730 | ||
| Pitfalls in Use of Weaning-Predictor Tests | 731 | ||
| Respiratory Frequency/Tidal Volume Ratio | 731 | ||
| Weaning Trials | 732 | ||
| Multiple T-Tube Trials | 733 | ||
| Intermittent Mandatory Ventilation | 733 | ||
| Pressure Support | 733 | ||
| Once-Daily T-Tube Trials | 733 | ||
| Comparison of Weaning Methods | 733 | ||
| Weaning by Protocol Versus Usual Care | 733 | ||
| Extubation | 734 | ||
| Conclusion | 734 | ||
| References | 735.e1 | ||
| Selected References | 735 | ||
| 44 Acute Pulmonary Embolism | 736 | ||
| Chapter Outline | 736 | ||
| Prevalence of Venous Thromboembolism in Intensive Care Unit Patients | 737 | ||
| Risk Factors | 737 | ||
| Deep Venous Thrombosis | 738 | ||
| Pathophysiology | 738 | ||
| Hemodynamic Consequences | 738 | ||
| Respiratory Consequences | 740 | ||
| Clinical Presentation | 740 | ||
| Clinical Presentation on Admission to the Intensive Care Unit | 740 | ||
| Recognition of Pulmonary Embolism During Intensive Care Unit Admission | 741 | ||
| Diagnostic Testing for Pulmonary Embolism | 741 | ||
| Arterial Blood Gas Measurement | 741 | ||
| Chest Radiography | 741 | ||
| Electrocardiography | 741 | ||
| D-Dimer Assay | 741 | ||
| Duplex Compression Ultrasonography | 742 | ||
| Ventilation-Perfusion Nuclear Scans | 742 | ||
| Multidetector Computed Tomography Scan of the Chest | 742 | ||
| Magnetic Resonance Imaging | 743 | ||
| Risk Stratification | 743 | ||
| Clinical and Hemodynamic Parameters | 744 | ||
| Electrocardiogram | 745 | ||
| Cardiac Biomarkers | 745 | ||
| Brain Natriurectic Peptide | 745.e1 | ||
| Cardiac Troponin | 745.e1 | ||
| Echocardiography | 745 | ||
| Computed Tomography Pulmonary Angiography | 746 | ||
| The Management of Acute Pulmonary Embolism | 746 | ||
| Pharmacologic Management | 746 | ||
| Unfractionated and Low-Molecular-Weight Heparin | 747 | ||
| Fondaparinux | 748 | ||
| Warfarin Therapy | 748 | ||
| New Oral Anticoagulants | 748 | ||
| Duration of Anticoagulation Therapy | 748 | ||
| Heparin-Induced Thrombocytopenia | 748 | ||
| Thrombolytic Therapy | 749 | ||
| Submassive Pulmonary Embolism with Hemodynamic Stability and Right Ventricular Dysfunction | 749 | ||
| Role of Thrombolytic Therapy in Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction | 750 | ||
| Role of Catheter-Directed Therapy in Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction | 750 | ||
| Role of Inferior Vena Cava Filters in Patients with Submassive Pulmonary Embolism with Right Ventricular Dysfunction | 750 | ||
| Massive Pulmonary Embolism | 751 | ||
| Respiratory Support | 751 | ||
| Hemodynamic Support in Massive Pulmonary Embolism | 751 | ||
| Volume Resuscitation | 751 | ||
| Vasoactive Drugs | 751 | ||
| Inotropic Agents | 751 | ||
| Systemic Thrombolysis in Massive Pulmonary Embolism | 752 | ||
| Inferior Vena Cava Filters in Massive Pulmonary Embolism | 752 | ||
| Pulmonary Embolectomy in Massive Pulmonary Embolism | 752 | ||
| Endovascular Therapy in Massive Pulmonary Embolism | 752 | ||
| Special Populations | 753 | ||
| Pregnancy | 753 | ||
| Diagnosis of Pulmonary Embolism in Pregnancy | 754 | ||
| Treatment of Pulmonary Embolism in Pregnancy | 754 | ||
| Right-Sided Heart Thrombi | 754 | ||
| Chronic Thromboembolic Pulmonary Hypertension | 754 | ||
| Prophylaxis | 754 | ||
| Long-Term Prognosis | 755 | ||
| Selected References | 756 | ||
| References | 756.e1 | ||
| Supplemental References | 756.e5 | ||
| 45 Pulmonary Hypertension | 757 | ||
| Chapter Outline | 757 | ||
| Pathophysiology of Pulmonary Hypertension and Right Ventricular Failure | 757 | ||
| Development of Pulmonary Hypertension | 757 | ||
| Right Ventricular Failure | 758 | ||
| Clinical Classification of Pulmonary Hypertension | 759 | ||
| Acute on Chronic Pulmonary Hypertension | 759 | ||
| Acute Pulmonary Hypertension | 760 | ||
| Acute Respiratory Distress Syndrome and Sepsis | 760 | ||
| Postsurgical Pulmonary Hypertension | 760 | ||
| Integrated Approach to the Diagnosis of Pulmonary Hypertension | 760 | ||
| Echocardiography | 762 | ||
| Right-Sided Heart Catheterization | 762 | ||
| Management of Arterial Pulmonary Hypertension and Right Ventricular Failure in the Intensive Care Unit | 763 | ||
| General Management Principles | 763 | ||
| Monitoring | 763 | ||
| Fluid Management | 764 | ||
| Oxygenation and Ventilatory Support | 764 | ||
| Vasopressors and Inotropic Agents | 765 | ||
| Pulmonary Vasodilators | 766 | ||
| Inhaled Nitric Oxide | 766 | ||
| Prostanoids | 766 | ||
| Phosphodiesterase-5 Inhibitors | 766 | ||
| Other Therapies and Mechanical Cardiovascular Support | 767 | ||
| Prognosis | 768 | ||
| Selected References | 769 | ||
| References | 769.e1 | ||
| 46 Massive Hemoptysis | 770 | ||
| Chapter Outline | 770 | ||
| Anatomic Considerations | 770 | ||
| Pulmonary Circulation | 770 | ||
| Bronchial Circulation | 770 | ||
| Nonbronchial Systemic Collateral Circulation | 771 | ||
| Pulmonary Venous Abnormalities | 771 | ||
| Causes of Hemoptysis | 771 | ||
| Bronchiectasis | 771 | ||
| Tuberculosis | 772 | ||
| Lung Malignancy | 773 | ||
| Lung Abscess | 773 | ||
| Chronic Bronchitis | 773 | ||
| Other Pulmonary Infections | 773 | ||
| Pulmonary Embolism | 773 | ||
| Aspergillus Fungus Balls | 773 | ||
| Cardiovascular Causes | 774 | ||
| Interstitial Lung Disease | 774 | ||
| Broncholithiasis | 774 | ||
| Diffuse Alveolar Hemorrhage | 774 | ||
| Immunologic Lung Disease | 775 | ||
| Idiopathic Pulmonary Hemosiderosis | 776 | ||
| Immunocompromised Host | 776 | ||
| Bleeding Diathesis | 776 | ||
| Drug-Induced Alveolar Hemorrhage | 776 | ||
| Vascular Abnormalities | 776 | ||
| Aortobronchial Fistulas | 777 | ||
| Pulmonary Artery Aneurysms | 777 | ||
| Arteriovenous Malformations | 777 | ||
| Trauma | 777 | ||
| Vascular Monitoring Catheters | 777 | ||
| Management | 778 | ||
| Airway and Lung Protection | 779 | ||
| Patient Positioning | 779 | ||
| Endotracheal Intubation | 779 | ||
| Double-Lumen Endotracheal Tubes | 779 | ||
| Localization of Bleeding | 779 | ||
| Chest Radiograph | 780 | ||
| Chest Computed Tomography | 780 | ||
| Bronchoscopy | 780 | ||
| Hemorrhage Control | 780 | ||
| Expectant Therapy | 780 | ||
| Endobronchial Tamponade | 780 | ||
| Endobronchial Infusions | 781 | ||
| Laser Photocoagulation | 781 | ||
| Bronchial Artery Embolization | 781 | ||
| Surgery | 782 | ||
| Other Therapies | 782 | ||
| References | 783.e1 | ||
| Selected References | 783 | ||
| 47 Pneumothorax and Barotrauma | 784 | ||
| Chapter Outline | 784 | ||
| Definition and History | 784 | ||
| Incidence | 784 | ||
| Pathophysiology | 785 | ||
| Emphysema-like Changes | 785 | ||
| Pleural Porosity | 785 | ||
| Distal Airway Inflammation | 786 | ||
| Smoking | 786 | ||
| Genetics | 786 | ||
| Classification | 786 | ||
| Spontaneous Pneumothorax | 786 | ||
| Primary Spontaneous Pneumothorax | 786 | ||
| Secondary Spontaneous Pneumothorax | 786 | ||
| Chronic Obstructive Pulmonary Disease | 787 | ||
| Pneumothorax in Drug Abusers | 787 | ||
| Pneumothorax in HIV-Infected Patients | 787 | ||
| Catamenial Pneumothorax | 788 | ||
| Cystic Fibrosis | 788 | ||
| Nonspontaneous Pneumothorax | 788 | ||
| Traumatic Pneumothorax | 788 | ||
| Traumatic Iatrogenic Pneumothorax | 788 | ||
| Pulmonary Barotrauma During Mechanical Ventilation | 788 | ||
| Clinical Presentation | 789 | ||
| Diagnosis | 789 | ||
| Prevention | 789 | ||
| Management | 790 | ||
| Prognosis | 790 | ||
| Pneumothorax After Fiberoptic Bronchoscopy and Needle Biopsy of the Lung | 790 | ||
| Pneumothorax After Thoracentesis | 791 | ||
| Pneumothorax Resulting from Nasogastric Feeding Tubes | 791 | ||
| Pneumothorax After Percutaneous Dilational Tracheostomy | 791 | ||
| Special Situations | 791 | ||
| Pneumothorax ex Vacuo | 791 | ||
| Sport-Related Pneumothorax | 791 | ||
| Barotrauma Unrelated to Mechanical Ventilation | 792 | ||
| Tension Pneumothorax | 792 | ||
| Clinical Features | 792 | ||
| Electrocardiographic Features | 793 | ||
| Diagnostic Imaging Modalities | 793 | ||
| Radiographic Signs | 793 | ||
| Upright Chest Radiograph | 793 | ||
| Supine Chest Radiograph | 793 | ||
| Lateral Decubitus Chest Radiograph | 794 | ||
| Computed Tomography | 794 | ||
| Pulmonary Ultrasonography | 794 | ||
| Differential Diagnosis: Conditions Mimicking Pneumothorax | 794 | ||
| Management | 795 | ||
| Management of the First Episode of Pneumothorax | 795 | ||
| Estimating the Size of a Pneumothorax | 795 | ||
| Treatment Options | 795 | ||
| Supplemental Oxygen | 795 | ||
| Removal of Air from Pleural Space | 795 | ||
| Aspiration | 795 | ||
| Tube Thoracostomy | 796 | ||
| Percutaneous Pneumothorax Catheters and Thoracic Vents | 796 | ||
| Thoracoscopy | 796 | ||
| Persistent Air Leak and Bronchopleural Fistula | 796 | ||
| Recurrence Prevention | 796 | ||
| Chemical Pleurodesis | 797 | ||
| Video-Assisted Thoracoscopic Surgery Pleurodesis | 797 | ||
| Surgical Thoracotomy | 797 | ||
| Management Under Special Circumstances | 797 | ||
| Secondary Spontaneous Pneumothorax | 797 | ||
| Pneumothorax in HIV-Infected Patients | 797 | ||
| Pneumothorax in Cystic Fibrosis | 797 | ||
| Catamenial Pneumothorax and Pneumothorax Complicating Pregnancy | 798 | ||
| Pneumothorax in Air Travelers | 798 | ||
| Pneumothorax in Lymphangioleiomyomatosis | 799 | ||
| Complications Related to Management | 799 | ||
| Selected References | 800 | ||
| References | 800.e1 | ||
| 48 Toxic Gas, Fume, and Smoke Inhalation | 801 | ||
| Chapter Outline | 801 | ||
| Introduction | 801 | ||
| Epidemiology | 801 | ||
| History | 801 | ||
| Pathogenesis of Inhalation Injury | 803 | ||
| Toxic Smoke Compounds | 803 | ||
| Heat | 803 | ||
| Systemic Toxins | 803 | ||
| Airway Injury | 803 | ||
| Pulmonary Parenchymal Injury | 804 | ||
| Diagnostics and Treatment | 804 | ||
| Initial Prehospital Rescue | 804 | ||
| Airway Management | 805 | ||
| Monitoring and Investigations | 806 | ||
| Fluid Resuscitation | 807 | ||
| Treatment of Carbon Monoxide Intoxication | 808 | ||
| Treatment of Cyanide Intoxication | 808 | ||
| Bronchoscopy | 809 | ||
| Mechanical Ventilation | 810 | ||
| Nebulization Treatments | 810 | ||
| Nonventilatory Pulmonary Treatments | 810 | ||
| Experimental Treatments | 811 | ||
| Selected References | 811 | ||
| References | 811.e1 | ||
| 49 Immunologic Lung Disease in the Critically Ill | 812 | ||
| Chapter Outline | 812 | ||
| Clinicopathologic Considerations during Mechanical Ventilation | 812 | ||
| Idiopathic Pulmonary Fibrosis | 813 | ||
| Hamman-Rich Syndrome | 814 | ||
| Alveolar Hemorrhage Syndromes | 814 | ||
| Goodpasture’s Syndrome | 815 | ||
| Wegener’s Granulomatosis | 816 | ||
| Microscopic Polyangiitis | 817 | ||
| Catastrophic Antiphospholipid Syndrome | 817 | ||
| Systemic Lupus Erythematosus | 818 | ||
| Idiopathic Pulmonary Hemosiderosis | 818 | ||
| Cryptogenic Organizing Pneumonia | 818 | ||
| Connective Tissue Diseases | 819 | ||
| Lupus Pneumonitis | 819 | ||
| Rheumatoid Arthritis | 819 | ||
| Progressive Systemic Sclerosis | 820 | ||
| Hypersensitivity Pneumonitis | 821 | ||
| Drug-Induced Respiratory Failure | 821 | ||
| Summary | 822 | ||
| References | 822.e1 | ||
| Selected References | 822 | ||
| 4 Critical Care Infectious Disease | 823 | ||
| 50 Nosocomial Infection in the Intensive Care Unit | 825 | ||
| Chapter Outline | 825 | ||
| Incidence and Profile | 825 | ||
| Definitions | 825 | ||
| Incidence | 826 | ||
| Profile and Secular Trends | 826 | ||
| Morbidity and Economic IMPACT | 829 | ||
| Pathogenesis and Epidemiology | 829.e1 | ||
| Pathogenesis | 829.e1 | ||
| Reservoirs and Transmission | 829.e1 | ||
| Risk Factors | 829.e1 | ||
| General Infection Control Measures | 829 | ||
| Hospital Infection Control Programs | 829 | ||
| Role of the Microbiology Laboratory | 831 | ||
| Architectural and Environmental Issues | 832 | ||
| Reliable Sterilization Procedures, Chemical Disinfectants, and Antiseptics | 834 | ||
| Hand Hygiene | 835 | ||
| Isolation Precautions for Communicable Infections | 837 | ||
| Isolation Systems | 837 | ||
| Special Issues in the ICU | 839 | ||
| Tuberculosis | 839 | ||
| Standard Precautions | 840 | ||
| Antibiotic Stewardship | 840 | ||
| Nosocomial Infections and Specific Infection Control Measures | 842 | ||
| Intravascular Device–Related Bloodstream Infection | 842 | ||
| Impact | 842 | ||
| Definitions | 842 | ||
| Recognition and Diagnosis | 843 | ||
| Clinical Features | 843 | ||
| Blood Cultures | 844 | ||
| Cultures of Removed Intravascular Devices | 844 | ||
| Diagnosis of Infection with Implanted Long-Term Intravascular Devices | 844 | ||
| Detection of Contaminated Infusate | 845 | ||
| Incidence | 845 | ||
| Pathogenesis and Risk Factors | 845 | ||
| Microbiology | 846 | ||
| Treatment | 847 | ||
| Strategies for Prevention | 847 | ||
| At-Device Insertion | 847 | ||
| Insertion Site Care and IVD Maintenance | 850 | ||
| Novel Technology | 851 | ||
| Ventilator-Associated Pneumonia | 853 | ||
| Incidence and Impact | 853 | ||
| Pathogenesis | 853 | ||
| Microbiology | 854 | ||
| Diagnosis | 854 | ||
| Risk Factors | 856 | ||
| Treatment | 856 | ||
| Prevention | 856 | ||
| Nonpharmacologic Preventive Measures | 856 | ||
| Pharmacologic Preventive Measures | 858 | ||
| Catheter-Associated Urinary Tract Infection | 859 | ||
| Incidence and Impact | 859 | ||
| Pathogenesis | 859 | ||
| Prevention | 859 | ||
| Control of Antibiotic Resistance | 860 | ||
| Evolution of Antibiotic Resistance in Intensive Care Units | 860 | ||
| Forces Driving Resistance | 860 | ||
| Controlling Antimicrobial Resistance in the Intensive Care Unit | 860 | ||
| Avant Garde Infection Control Measures | 864 | ||
| Selective Digestive Decontamination | 864 | ||
| Preemptive Barrier Isolation | 864 | ||
| Approach to a Nosocomial Epidemic | 866.e1 | ||
| Protection of Health Care Workers in the Intensive Care Unit | 866.e3 | ||
| General Precautions Against Biohazardous Exposure | 866.e3 | ||
| Vaccine-Preventable Diseases | 866.e5 | ||
| Hepatitis B | 866.e5 | ||
| Measles, Mumps, and Rubella | 866.e5 | ||
| Varicella | 866.e5 | ||
| Influenza | 866.e5 | ||
| Pertussis | 866.e5 | ||
| Non–Vaccine-Preventable Diseases of Major Interest | 866.e6 | ||
| Herpetic Whitlow | 866.e6 | ||
| Tuberculosis | 866.e6 | ||
| Hepatitis C | 866.e6 | ||
| Human Immunodeficiency Virus | 866.e6 | ||
| Goals for the Future | 866 | ||
| Selected References | 869 | ||
| References | 869.e1 | ||
| 51 Principles Governing Antimicrobial Therapy in the Intensive Care Unit | 870 | ||
| Chapter Outline | 870 | ||
| Adequacy of Initial Empiric Antibiotic Therapy | 870 | ||
| Optimal Dose | 872 | ||
| Penetration at the Site of Infection: Tissue-Targeted Therapy | 873 | ||
| Role of Combination Therapy | 874 | ||
| Synergy | 874 | ||
| Enhanced Efficacy Against a Pathogen | 875 | ||
| Prevention of the Emergence of Resistance | 875 | ||
| Increased Opportunity for Achieving Appropriate Therapy | 875 | ||
| Immunomodulating Effect of Antibiotics | 875 | ||
| Timing | 876 | ||
| Special Pharmacologic Properties | 877 | ||
| Unintended Consequences of Antibiotic Therapy | 877 | ||
| Clinician Responses to Multidrug Resistance | 878 | ||
| Mechanisms of Action and of Resistance | 878 | ||
| Binding to a Target Site | 878 | ||
| Penetration Through the Bacterial Cell Wall | 878 | ||
| Enzymatic Degradation | 879 | ||
| Type 1 β-lactamase | 879 | ||
| Extended-Spectrum β-Lactamases | 880 | ||
| Carbapenemases | 881 | ||
| Efflux Pumps | 882 | ||
| The Clinical Relevance for Understanding Antibiotic Resistance | 883 | ||
| De-Escalation | 883 | ||
| Decreasing Broadness or Number of Agents | 883 | ||
| Duration of Therapy | 884 | ||
| Minimizing Clinical Resistance | 884 | ||
| Conclusions | 885 | ||
| Selected References | 885 | ||
| References | 885.e1 | ||
| 52 Antifungal and Antiviral Therapy | 886 | ||
| Chapter Outline | 886 | ||
| Systemic Antifungal Agents | 886 | ||
| Polyenes | 886 | ||
| Amphotericin B and Its Lipid Formulations | 886 | ||
| Flucytosine | 888 | ||
| The Azole Antifungal Agents | 888 | ||
| Fluconazole | 889 | ||
| Itraconazole | 889 | ||
| Voriconazole | 890 | ||
| Posaconazole | 890 | ||
| Echinocandins | 890 | ||
| Caspofungin | 890 | ||
| Micafungin | 891 | ||
| Anidulafungin | 891 | ||
| Specific Indications and Uses for Antifungal Therapy | 891 | ||
| Candida Infections | 893 | ||
| Candidemia and Disseminated Candidiasis | 893 | ||
| The Intravenous Catheter in Candidemic Patients | 893 | ||
| Mucosal Infections and Colonization | 893 | ||
| Candiduria | 893 | ||
| Other Forms of Invasive Candidiasis | 893 | ||
| Cryptococcosis | 894 | ||
| Aspergillosis | 894 | ||
| Histoplasmosis | 894 | ||
| Mucormycosis | 894 | ||
| Other Fungal Infections | 894 | ||
| Areas of Controversy in Antifungal Therapy | 895 | ||
| Empirical Antifungal Therapy for the Febrile ICU Patient | 895 | ||
| Antifungal Prophylaxis in the ICU | 895 | ||
| Duration of Therapy and Accumulated Dosing | 895 | ||
| Measurement of Drug Levels | 895 | ||
| Susceptibility Testing | 895 | ||
| Antiviral Agents | 896 | ||
| Acyclovir, Famciclovir, and Valacyclovir | 896 | ||
| Ganciclovir and Valganciclovir | 896 | ||
| Cidofovir | 897 | ||
| Foscarnet | 897 | ||
| Amantadine and Rimantadine | 897 | ||
| Ribavirin | 897 | ||
| Oseltamivir | 898 | ||
| Zanamivir | 898 | ||
| Specific Indications and Uses for Antiviral Therapy | 898 | ||
| Herpes Simplex and Varicella-Zoster | 898 | ||
| Cytomegalovirus Infection | 899 | ||
| Influenza | 899 | ||
| Other Viral Infections | 899 | ||
| Selected References | 900 | ||
| References | 900.e1 | ||
| 53 Critically Ill Immunosuppressed Host | 901 | ||
| Chapter Outline | 901 | ||
| Definition | 901 | ||
| Host Defense Mechanisms | 901 | ||
| General Approach to Management | 903 | ||
| Management of Specific Patient Populations | 908 | ||
| Cancer Patients with Neutropenia | 908 | ||
| General Principles | 908 | ||
| Diagnostic Approach | 912 | ||
| Empiric and Specific Antimicrobial Therapy | 912 | ||
| Prevention of Infection | 913 | ||
| Patients with HIV/AIDS | 913 | ||
| Spectrum of Clinical Manifestations | 913 | ||
| Management of Antiretroviral Drugs | 913 | ||
| Diagnosis of Opportunistic Infections | 914 | ||
| Clinical Syndromes | 915 | ||
| Respiratory Insufficiency | 915 | ||
| Central Nervous System Dysfunction | 929 | ||
| Meningitis | 929 | ||
| Focal Central Nervous System Lesions | 930 | ||
| Focal White Matter Lesions | 930 | ||
| Diffuse Encephalopathy | 930 | ||
| Diarrhea | 930 | ||
| Hypotension | 930 | ||
| Prevention of Opportunistic Infection | 931 | ||
| HIV Transmission in the Intensive Care Unit | 931 | ||
| Human Stem Cell, Bone Marrow, and Solid Organ Transplant Recipients | 932 | ||
| Diagnostic Approach | 932 | ||
| Infectious Complications of Transplantation | 932 | ||
| Cytomegalovirus | 932 | ||
| Pneumocystis Pneumonia | 933 | ||
| Fungal Infections | 933 | ||
| Respiratory Viruses Including Respiratory Syncytial Virus | 934 | ||
| Noninfectious Complications in Human Stem Cell Transplant Recipients | 934 | ||
| Graft-Versus-Host Disease | 934 | ||
| Immune Reconstitution Syndrome | 934 | ||
| Toxicities of Immunosuppressive Drugs | 934 | ||
| Selected References | 935 | ||
| References | 935.e1 | ||
| 54 Specific Infections with Critical Care Implications | 936 | ||
| Chapter Outline | 936 | ||
| Overwhelming Infections of the Central Nervous System | 936 | ||
| Acute Bacterial Meningitis | 937 | ||
| Epidemiology, Pathogenesis, Risk Factors, and Clinical Presentation | 937 | ||
| Diagnostic Strategies and Early Management of Suspected Bacterial Meningitis | 937 | ||
| Complications, ICU Monitoring, and Prognosis | 940 | ||
| Encephalitis | 941 | ||
| West Nile Virus Encephalitis | 942 | ||
| Brain Abscess | 942 | ||
| Spinal Epidural Abscess | 942 | ||
| Fulminant Endovascular Infections | 943 | ||
| Acute Infective Endocarditis | 943 | ||
| Device-Related Endovascular Infections | 946 | ||
| Primary Bacteremias | 946 | ||
| Meningococcemia and Meningococcal Sepsis | 946 | ||
| Primary Pneumococcal Bacteremia | 948 | ||
| Staphylococcus aureus Bacteremia | 948 | ||
| Toxin-Mediated Infections | 948 | ||
| Staphylococcal Toxic Shock Syndrome | 948 | ||
| Streptococcal Toxic Shock Syndrome | 949 | ||
| Clostridial Toxic Shock Syndrome | 949 | ||
| Tetanus | 949 | ||
| Botulism | 950 | ||
| Diphtheria | 950 | ||
| Serious Skin and Skin Structure Infections | 950 | ||
| Necrotizing Fasciitis | 950 | ||
| Clostridial Myonecrosis (Gas Gangrene) | 951 | ||
| Vibrio Infections | 951 | ||
| Community-Acquired MRSA | 952 | ||
| Serious Gastrointestinal and Intra-Abdominal Infections | 952 | ||
| Bacteremia Associated with Diarrheal Illness | 952 | ||
| Peritonitis | 952 | ||
| Intra-abdominal Abscess | 953 | ||
| Biliary Tract Infections | 953 | ||
| Pancreatic Infections | 954 | ||
| Clostridium difficile Colitis | 955 | ||
| Life-Threatening Infections of the Head and Neck | 955 | ||
| Ludwig’s Angina, Lateral Pharyngeal Space Infections, and Peritonsillar Abscess | 955 | ||
| Lemierre Syndrome | 956 | ||
| Epiglottitis | 957 | ||
| Mediastinitis | 957 | ||
| Serious Vector-Borne Infections | 957 | ||
| Rocky Mountain Spotted Fever | 957 | ||
| Ehrlichioses and Anaplasmosis | 958 | ||
| Malaria | 958 | ||
| Dengue | 958 | ||
| Severe Viral Infections | 959 | ||
| Hantavirus Pulmonary Syndrome | 959 | ||
| Influenza | 959 | ||
| Potential Agents of Bioterrorism | 959 | ||
| Anthrax | 960 | ||
| Smallpox | 960 | ||
| Plague | 960 | ||
| Tularemia | 960 | ||
| Viral Hemorrhagic Fevers | 960 | ||
| Selected References | 961 | ||
| References | 961.e1 | ||
| 5 Renal Disease and Metabolic Disorders in the Critically Ill | 963 | ||
| 55 Acute Kidney Injury | 965 | ||
| Chapter Outline | 965 | ||
| Definition | 965 | ||
| Epidemiology | 967 | ||
| Pathogenesis | 968 | ||
| Prerenal Acute Kidney Injury | 969 | ||
| Postrenal Acute Kidney Injury | 971 | ||
| Intrinsic Acute Kidney Injury | 971 | ||
| Acute Tubular Necrosis | 971 | ||
| Acute Interstitial Nephritis | 971 | ||
| Acute Glomerulonephritis | 972 | ||
| Acute Vascular Syndromes | 972 | ||
| Intratubular Obstruction | 972 | ||
| Clinical Manifestations | 972 | ||
| Retention of Filtration Markers | 972 | ||
| Urea | 972 | ||
| Creatinine | 973 | ||
| Cystatin C | 973 | ||
| Markers of Tubular Injury | 973 | ||
| Oligoanuria | 973 | ||
| Detection of Biochemical or Clinical Complications | 974 | ||
| Diagnostic Approach | 974 | ||
| General Aspects | 974 | ||
| History, Physical Examination, and Record Review | 974 | ||
| Urinalysis and Urine Indices | 975 | ||
| Radiologic Imaging | 976 | ||
| Other Laboratory Testing | 976 | ||
| Novel Biomarkers | 976 | ||
| Renal Biopsy | 976 | ||
| Prevention | 976 | ||
| Maintenance of Renal Perfusion | 976 | ||
| Avoidance of Nephrotoxicity | 977 | ||
| Prevention of Contrast-Induced Acute Kidney Injury | 978 | ||
| Management of Established Acute Kidney Injury | 978 | ||
| Management of Volume Status | 979 | ||
| Preventing, Monitoring, and Treating Complications | 979 | ||
| Hyperkalemia | 979.e1 | ||
| Hyponatremia | 979.e1 | ||
| Calcium, Phosphorus, and Magnesium Disorders | 979.e1 | ||
| Hyperuricemia | 979.e2 | ||
| Metabolic Acidosis | 979.e2 | ||
| Anemia | 979.e2 | ||
| Bleeding | 979.e2 | ||
| Infections | 979.e3 | ||
| Cardiovascular Complications | 979.e3 | ||
| Pulmonary Complications | 979.e3 | ||
| Gastrointestinal Complications | 979.e3 | ||
| Neurologic Complications | 979.e4 | ||
| Medication Dosing Considerations | 979 | ||
| Nutritional Considerations | 979 | ||
| Renal Replacement Therapy | 980 | ||
| Modalities of Renal Replacement Therapy | 980 | ||
| Timing of Initiation of Renal Replacement Therapy | 981 | ||
| Intensity of Renal Support in Acute Kidney Injury | 982 | ||
| Prognosis and Outcomes | 982 | ||
| Suggested References | 984 | ||
| References | 984.e1 | ||
| 56 Chronic Kidney Disease | 985 | ||
| Chapter Outline | 985 | ||
| Introduction | 985 | ||
| Definition and Etiology | 985 | ||
| Diagnosis | 985 | ||
| Physiology | 987 | ||
| Hypertension | 987 | ||
| Electrolyte Disorders | 987 | ||
| Sodium | 987 | ||
| Water | 987 | ||
| Potassium | 988 | ||
| Metabolic Acidosis | 988 | ||
| Mineral Bone Disorder | 989 | ||
| Anemia and Hematologic Disease | 989 | ||
| End-Stage Renal Disease | 990 | ||
| Kidney Transplant Patients | 990 | ||
| Drug Dosing | 990 | ||
| Summary | 991 | ||
| Selected References | 991 | ||
| References | 992.e1 | ||
| 57 Acid-Base, Electrolyte, and Metabolic Abnormalities | 993 | ||
| Chapter Outline | 993 | ||
| Acid-Base Homeostasis | 993 | ||
| Normal Acid-Base Physiology | 993 | ||
| Metabolic Acidosis | 994 | ||
| Definition and Classification | 994 | ||
| Consequences of Acidemia | 996 | ||
| Diagnosis of Acid-Base Disorders | 996 | ||
| Treatment of Metabolic Acidosis | 997 | ||
| Metabolic Alkalosis | 998 | ||
| Definition and Classification | 998 | ||
| Clinical Consequences | 998 | ||
| Treatment | 999 | ||
| Potassium Homeostasis | 999 | ||
| Normal Potassium Physiology | 999 | ||
| Regulation of Internal Potassium Balance | 999 | ||
| Regulation of External Potassium Balance | 1000 | ||
| Disorders of Potassium Homeostasis | 1000 | ||
| Acute Hyperkalemia (Box 57.6) | 1001 | ||
| Excessive Potassium Intake | 1001 | ||
| Abnormal Potassium Distribution | 1001 | ||
| Pharmacologic Agents | 1001 | ||
| Hyperkalemic Periodic Paralysis | 1001 | ||
| Acute Renal Failure | 1001 | ||
| Pseudohyperkalemia | 1002 | ||
| Acute Hypokalemia | 1002 | ||
| Treatment of Diabetic Ketoacidosis | 1002 | ||
| Refeeding | 1002 | ||
| Pharmacologic Agents | 1002 | ||
| Hypokalemic Periodic Paralysis | 1002 | ||
| Pseudohypokalemia | 1002 | ||
| Chronic Hyperkalemia | 1003 | ||
| Renal Failure | 1003 | ||
| Mineralocorticoid Deficiency | 1003 | ||
| Renal Potassium Secretory Defect | 1003 | ||
| Chronic Hypokalemia | 1003 | ||
| Inadequate Potassium Intake | 1003 | ||
| Excessive Potassium Losses | 1003 | ||
| Clinical Manifestations of Potassium Imbalance | 1004 | ||
| Clinical Manifestations of Hyperkalemia | 1004 | ||
| 6 Neurologic Disease in the Critically Ill | 1079 | ||
| 61 Coma | 1081 | ||
| Chapter Outline | 1081 | ||
| Concept and Terminology of Impaired Consciousness | 1081 | ||
| Neuroanatomy, Neurotransmitter, and Pathology | 1084 | ||
| Pathology Seen in Patients with Impaired Consciousness | 1085 | ||
| Approach to Coma | 1085 | ||
| Emergency Management | 1085 | ||
| Oxygenation and Intubation | 1085 | ||
| Respiration/PEEP | 1085 | ||
| Circulation | 1086 | ||
| Glucose and Thiamine | 1086 | ||
| Seizures | 1086 | ||
| Sedation and Paralysis | 1086 | ||
| Reversal of Drug Overdose | 1086 | ||
| Body Temperature | 1087 | ||
| History | 1087 | ||
| Physical Examination | 1087 | ||
| Assessment of Coma: General Aspects | 1089 | ||
| Standardized Neurobehavioral Assessment | 1089 | ||
| Neuroimaging | 1090 | ||
| Conventional Magnetic Resonance Imaging (MRI) | 1090 | ||
| Proton Magnetic Resonance Spectroscopy (MRS) | 1090 | ||
| Positron Emission Tomography (PET) | 1090 | ||
| Functional MRI (fMRI) | 1090 | ||
| Electrophysiology | 1091 | ||
| EEG | 1091 | ||
| Event-Related Potentials (ERPs) | 1092 | ||
| Evoked Potentials | 1092 | ||
| Cerebral Blood Flow Monitoring | 1092 | ||
| Xenon-Enhanced CT Scanning | 1092 | ||
| General Treatment Approach | 1092 | ||
| Traumatic and Nontraumatic Coma | 1093 | ||
| Coma after Severe Traumatic Brain Injury | 1093 | ||
| Coma after Cardiac Arrest | 1095 | ||
| Ethical Considerations | 1096 | ||
| Selected References | 1097 | ||
| References | 1097.e1 | ||
| 62 Neurologic Criteria for Death in Adults | 1098 | ||
| Chapter Outline | 1098 | ||
| Historical Perspective and Definitions | 1098 | ||
| Determination of Brain Death | 1099 | ||
| Clinical Evaluation of Coma and Prerequisites | 1099 | ||
| Absence of Brainstem Reflexes | 1100 | ||
| Apnea | 1100 | ||
| Confirmatory Testing | 1101 | ||
| Origins of Confirmatory Testing in Brain Death | 1102 | ||
| Accuracy of Confirmatory Tests | 1102 | ||
| Recommendations for Confirmatory Testing | 1103 | ||
| Special Circumstances | 1104 | ||
| Determination of Brain Death After Cardiac Arrest in the Era of Therapeutic Hypothermia | 1104 | ||
| Extracorporeal Membrane Oxygenation | 1104 | ||
| Conclusions | 1104 | ||
| References | 1105.e1 | ||
| Selected References | 1105 | ||
| 63 Stroke | 1106 | ||
| Chapter Outline | 1106 | ||
| Historical Background | 1106 | ||
| Overview | 1106 | ||
| Advances in Radiology | 1108 | ||
| Thrombolysis in Stroke | 1109 | ||
| Symptomatic Carotid Disease/Stenting | 1113 | ||
| Anticoagulation in Stroke | 1115 | ||
| Antiplatelet Agents in Stroke | 1117 | ||
| Patent Foramen Ovale | 1118 | ||
| Massive Hemispheric Cerebral Infarct | 1118 | ||
| Critical Care Consultation | 1119 | ||
| Summary | 1119 | ||
| Selected References | 1119 | ||
| References | 1120.e1 | ||
| 64 Muscular Paralysis: | 1121 | ||
| Chapter Outline | 1121 | ||
| Clinical Presentation | 1121 | ||
| Myasthenia Gravis | 1121 | ||
| Guillain-Barré Syndrome | 1122 | ||
| Acute Neuromuscular Respiratory Failure | 1122 | ||
| Pathophysiology | 1122 | ||
| Clinical Evaluation | 1123 | ||
| Noninvasive Ventilation: Bilevel Positive Airway Pressure | 1124 | ||
| Mechanical Ventilation: Endotracheal Intubation | 1125 | ||
| Myasthenia Gravis | 1125 | ||
| Guillain-Barré Syndrome | 1125 | ||
| Extubation Trials | 1126 | ||
| Management | 1126 | ||
| Myasthenia Gravis | 1126 | ||
| Guillain-Barré Syndrome | 1128 | ||
| Selected References | 1129 | ||
| References | 1129.e1 | ||
| 65 Seizures in the Critically Ill | 1130 | ||
| Chapter Outline | 1130 | ||
| History | 1130 | ||
| Epidemiology | 1130 | ||
| Nosology and Semiology | 1131 | ||
| Pathogenesis | 1132 | ||
| Pathophysiology | 1133 | ||
| Clinical Manifestations | 1137 | ||
| Recognition of Seizures | 1137 | ||
| Manifestations of Status Epilepticus | 1137 | ||
| Diagnostic Approach | 1138 | ||
| The Intensive Care Unit Patient with New-Onset Seizures | 1138 | ||
| The Patient Presenting with or Developing Status Epilepticus | 1139 | ||
| Management Approach | 1139 | ||
| The Intensive Care Unit Patient with New-Onset Seizures | 1139 | ||
| Status Epilepticus | 1140 | ||
| Specific Agents | 1140 | ||
| Benzodiazepines | 1140 | ||
| Hydantoins | 1141 | ||
| Barbiturates | 1142 | ||
| Valproate | 1142 | ||
| Isoflurane and Desflurane | 1142 | ||
| Propofol | 1142 | ||
| Ketamine | 1142 | ||
| Levetiracetam | 1142 | ||
| Lacosamide | 1142 | ||
| Controversial Management Issues | 1143 | ||
| Prognosis | 1143 | ||
| Selected References | 1144 | ||
| References | 1144.e1 | ||
| 66 Head Injury | 1145 | ||
| Chapter Outline | 1145 | ||
| Introduction | 1145 | ||
| Incidence | 1145 | ||
| Diagnostic Approach | 1146 | ||
| Glasgow Coma Scale | 1146 | ||
| Computed Tomography Classification: Marshall Classification | 1146 | ||
| Prediction of Outcomes | 1147 | ||
| Primary Head Injury | 1147 | ||
| Skull Fractures | 1148 | ||
| Epidural Hematoma | 1150 | ||
| Subdural Hematoma | 1152 | ||
| Traumatic Subarachnoid Hemorrhage | 1154 | ||
| Intraparenchymal Contusions and Hematomas | 1154 | ||
| Hypothalamic-Pituitary Injury | 1157 | ||
| Diffuse Axonal Injury | 1157 | ||
| Penetrating Brain Injury | 1159 | ||
| Classification | 1159 | ||
| Ballistics | 1160 | ||
| Initial Resuscitation | 1161 | ||
| Surgical Management | 1161 | ||
| Predictive Factors | 1161 | ||
| Special Problems | 1162 | ||
| Course in the Intensive Care Unit | 1162 | ||
| Secondary Head Injury | 1162 | ||
| Basic Concepts | 1162 | ||
| Cerebral Blood Volume | 1163 | ||
| Arterial Blood Compartment | 1164 | ||
| Blood Pressure | 1164 | ||
| Cerebral Perfusion Pressure | 1165 | ||
| Carbon Dioxide | 1166 | ||
| Oxygen | 1167 | ||
| Metabolism | 1167 | ||
| Viscosity | 1167 | ||
| Venous Blood Compartment | 1168 | ||
| Brain Compartment | 1168 | ||
| Cerebral Edema | 1168 | ||
| Hyperosmolar Therapy | 1169 | ||
| Mannitol | 1169 | ||
| Hypertonic Saline | 1169 | ||
| Cerebrospinal Fluid Compartment | 1170 | ||
| Specific Treatment Considerations | 1170 | ||
| Craniectomy | 1170 | ||
| Management of Intracranial Hypertension | 1170 | ||
| Anticoagulation | 1171 | ||
| Nutritional Support | 1173 | ||
| Role of Steroid Therapy | 1173 | ||
| Conclusions | 1173 | ||
| Selected References | 1173 | ||
| References | 1173.e1 | ||
| 7 Physical and Toxic Injury in the Critically Ill | 1175 | ||
| 67 Critical Care Management of the Severely Burned Patient | 1177 | ||
| Chapter Outline | 1177 | ||
| Introduction | 1177 | ||
| Incidence and Survival from Burn Injury | 1177 | ||
| Pathophysiology of Burns | 1178 | ||
| Acute Care of the Burned Patient | 1179 | ||
| Initial Assessment | 1180 | ||
| Scene Safety: Stop the Burning Process | 1180 | ||
| The Primary Survey and Inhalation Injury | 1180 | ||
| Carbon Monoxide Poisoning | 1180 | ||
| Upper Airway Injury | 1180 | ||
| Indications for Intubation | 1180 | ||
| Pulmonary (“True”) Inhalation Injury | 1181 | ||
| Begin Resuscitation | 1181 | ||
| The Secondary Survey | 1181 | ||
| Burns and Multiple Trauma | 1181 | ||
| The Resuscitation Phase | 1183 | ||
| Burn Shock | 1183 | ||
| Fluid Resuscitation of Burn Patients | 1184 | ||
| The Phenomenon of “Fluid Creep” | 1185 | ||
| Hypertonic Resuscitation | 1186 | ||
| Crystalloid Versus Colloid | 1186 | ||
| Pharmacologic Manipulation of Resuscitation | 1187 | ||
| Practicing Effective Resuscitation | 1187 | ||
| Complications of Edema | 1187 | ||
| Facial Swelling | 1187 | ||
| Ocular Swelling | 1187 | ||
| Extremity Compartment Syndromes | 1187 | ||
| Torso Compartment Syndromes | 1189 | ||
| Acute Renal Failure | 1190 | ||
| Electrolyte Abnormalities | 1190 | ||
| The Wound Coverage Phase | 1190 | ||
| Surgical Treatment of Burn Patients | 1190 | ||
| Indications and Timing of Surgery | 1190 | ||
| Hemodynamic Support | 1191 | ||
| Temperature Control | 1191 | ||
| Burn Pharmacology and Anesthesia | 1191 | ||
| Pain Control | 1191 | ||
| Pulmonary Management | 1191 | ||
| Cardiovascular Complications and Care | 1192 | ||
| Adrenal Insufficiency | 1192 | ||
| Infection Control | 1192 | ||
| Burn Wound Infections | 1192 | ||
| Other Infections | 1193 | ||
| Metabolic Support and Gastrointestinal Management | 1193 | ||
| The Hypermetabolism of Burn Injury | 1193 | ||
| Route and Timing of Nutritional Support | 1194 | ||
| Energy Requirements | 1194 | ||
| Enteral Formulas | 1194 | ||
| Carbohydrates and Glucose Control | 1194 | ||
| Fat | 1194 | ||
| Protein | 1194 | ||
| Specific Amino Acids | 1194 | ||
| Other Nutrients | 1195 | ||
| Monitoring Nutritional Support | 1195 | ||
| Modulation of Hypermetabolism | 1195 | ||
| Gastrointestinal Complications in Burn Patients | 1195 | ||
| Acute Cholecystitis | 1195 | ||
| Hepatic Enzyme Elevation | 1195 | ||
| Pancreatitis | 1195 | ||
| Gastrointestinal Bleeding | 1196 | ||
| Ileus and Intestinal Necrosis | 1196 | ||
| Diarrhea | 1196 | ||
| Hematologic Considerations | 1196 | ||
| Red Blood Cells | 1196 | ||
| White Blood Cells | 1196 | ||
| Platelets | 1196 | ||
| Thromboembolism | 1196 | ||
| The Rehabilitation Phase | 1197 | ||
| Selected References | 1198 | ||
| References | 1198.e1 | ||
| 68 Poisonings | 1199 | ||
| Chapter Outline | 1199 | ||
| Resuscitation and Stabilization | 1199 | ||
| Diagnosis | 1199 | ||
| History | 1199 | ||
| Physical Examination | 1200 | ||
| Toxidromes | 1200 | ||
| Laboratory Tests | 1201 | ||
| Gastrointestinal Decontamination | 1201 | ||
| Enhanced Elimination | 1202 | ||
| Specific Poisonings | 1203 | ||
| Alcohols | 1203 | ||
| Ethylene Glycol and Methanol | 1203 | ||
| Isopropyl Alcohol | 1205 | ||
| Propylene Glycol | 1205 | ||
| Analgesics | 1205 | ||
| Acetaminophen | 1205 | ||
| Opioids | 1206 | ||
| Salicylates | 1207 | ||
| Carbon Monoxide | 1207 | ||
| Cardiovascular Drugs | 1208 | ||
| Beta Blockers | 1208 | ||
| Calcium Channel Blockers | 1209 | ||
| Digoxin | 1209 | ||
| Cyanide | 1210 | ||
| Dietary and Nutritional Agents | 1211 | ||
| Methemoglobin Inducers | 1211 | ||
| Organophosphate and Carbamate Agents | 1212 | ||
| Psychotropic Drugs | 1213 | ||
| Cyclic Antidepressants | 1213 | ||
| Lithium | 1214 | ||
| Selective Serotonin Reuptake Inhibitors | 1214 | ||
| Sedatives | 1215 | ||
| Benzodiazepines | 1215 | ||
| Gamma Hydroxybutyrate | 1215 | ||
| Propofol | 1216 | ||
| Stimulants | 1216 | ||
| Amphetamines/Methamphetamines | 1216 | ||
| Cocaine | 1216 | ||
| Mephedrone/Methylenedioxypyrovalerone (Bath Salts) | 1217 | ||
| Valproic Acid | 1218 | ||
| Selected References | 1218 | ||
| References | 1219.e1 | ||
| 69 Hypothermia, Hyperthermia, and Rhabdomyolysis | 1220 | ||
| Chapter Outline | 1220 | ||
| Hypothermia | 1220 | ||
| Epidemiology | 1220 | ||
| Definition | 1221 | ||
| Heat Regulation | 1221 | ||
| Clinical Presentation | 1221 | ||
| Etiologic Factors (Fig. 69.1) | 1221 | ||
| Diagnosis | 1221 | ||
| End-Organ Manifestations (Fig. 69.2) | 1222 | ||
| Cerebral Effects | 1222 | ||
| Cardiovascular Effects | 1222 | ||
| Respiratory Changes | 1223 | ||
| Renal Changes | 1223 | ||
| Gastrointestinal Changes | 1223 | ||
| Laboratory Evaluation | 1223 | ||
| Arterial Blood Gases | 1224 | ||
| Complete Blood Count | 1224 | ||
| Coagulation Factors | 1224 | ||
| Blood Urea Nitrogen/Creatinine/Electrolytes | 1224 | ||
| Blood Glucose | 1224 | ||
| Other Laboratory Abnormalities | 1224 | ||
| Electrocardiography Changes | 1224 | ||
| Management | 1224 | ||
| Initial Stabilization | 1224 | ||
| Airway/Breathing Support | 1224 | ||
| Cardiocirculatory Support | 1224 | ||
| Volume Resuscitation | 1224 | ||
| Cardiac Resuscitation | 1225 | ||
| Defibrillation. | 1225 | ||
| Cardioactive Drugs. | 1225 | ||
| Additional Support | 1225 | ||
| Rewarming Methods | 1225 | ||
| Passive External Rewarming | 1225 | ||
| Active Rewarming | 1225 | ||
| Active External Rewarming. | 1225 | ||
| Active Internal Rewarming. | 1225 | ||
| Peritoneal and Pleural Lavage | 1225 | ||
| Extracorporeal Methods of Rewarming | 1226 | ||
| Hemodialysis. | 1226 | ||
| Continuous Arteriovenous Rewarming. | 1226 | ||
| Continuous Venovenous Hemofiltration. | 1226 | ||
| Cardiopulmonary Bypass. | 1226 | ||
| Extracorporeal Membrane Oxygenation. | 1226 | ||
| Endovascular Temperature Control Device. | 1226 | ||
| Prognosis | 1226 | ||
| Hyperthermia | 1226 | ||
| History and Incidence | 1226 | ||
| Pathogenesis | 1227 | ||
| Thermoregulation | 1227 | ||
| Acclimatization | 1227 | ||
| Acute-Phase Response | 1227 | ||
| Heat Shock Response | 1227 | ||
| Predisposing Factors | 1227 | ||
| Presentation and Clinical Manifestations | 1228 | ||
| Diagnostic Approach | 1228 | ||
| Approach to Management | 1228 | ||
| Supportive Measures | 1229 | ||
| Cooling Measures | 1229 | ||
| Specific Hyperthermic Syndromes | 1230 | ||
| Malignant Hyperthermia | 1230 | ||
| Pathogenesis | 1230 | ||
| Presentation | 1230 | ||
| Diagnosis | 1231 | ||
| Treatment | 1231 | ||
| Neuroleptic Malignant Syndrome | 1231 | ||
| Pathophysiology | 1231 | ||
| Presentation | 1231 | ||
| Treatment | 1232 | ||
| Rhabdomyolysis | 1232 | ||
| Epidemiology | 1232 | ||
| Pathophysiology | 1233 | ||
| Clinical Presentation | 1233 | ||
| Specific Treatment Requirements | 1234 | ||
| Selected References | 1235 | ||
| References | 1235.e1 | ||
| 8 Administrative, Ethical, and Psychological Issues in the Care of the Critically Ill | 1237 | ||
| 70 Intensive Care Unit Administration and Performance Improvement | 1239 | ||
| Chapter Outline | 1239 | ||
| The Present-Day Critical Care Landscape | 1240 | ||
| Idealized Design for Critical Care Practice | 1241 | ||
| Rational Model for Critical Care Delivery | 1241 | ||
| Financial Modeling of Critical Care | 1243 | ||
| State of Critical Care Reimbursement | 1243 | ||
| Focus on Expenditures and Revenues | 1244 | ||
| Critical Care as a Product Line | 1244 | ||
| Critical Care Quality Improvement | 1244 | ||
| Background | 1244 | ||
| Donabedian Framework | 1245 | ||
| Quality Improvement Landscape | 1245 | ||
| Agency for Healthcare Research and Quality | 1245 | ||
| National Quality Forum | 1245 | ||
| The Joint Commission | 1245 | ||
| Alignment of Efforts | 1246 | ||
| The Leapfrog Group: Purchasers and Payers | 1246 | ||
| The Institute for Healthcare Improvement | 1246 | ||
| Sponsored Statewide and Integrated Health System Collaboratives | 1246 | ||
| Pay for Performance and Quality Reporting | 1246 | ||
| Specific Quality Improvement Interventions in Critical Care | 1247 | ||
| Shewart Model for Process Improvement | 1247 | ||
| Decreasing Ventilator-Associated Pneumonia Rates | 1247 | ||
| Decreasing Central Line–Associated Bloodstream Infection Rates | 1248 | ||
| Deploying Rapid Response Teams | 1248 | ||
| Resuscitation and Treatment for Severe Sepsis or Septic Shock | 1248 | ||
| Establishing Multidisciplinary Rounds | 1248 | ||
| Assessing Daily Patient Goals | 1248 | ||
| Practice Management-Clinician-Family Communication | 1249 | ||
| Open Versus Closed Intensive Care Units: Intensivist-Led Model | 1249 | ||
| Culture Transformation and Organizational Learning | 1249 | ||
| Selected References | 1250 | ||
| References | 1250.e1 | ||
| 71 Ethical Considerations in Managing Critically Ill Patients | 1251 | ||
| Chapter Outline | 1251 | ||
| The Doctor-Patient Relationship | 1251 | ||
| Communication with Patients | 1252 | ||
| Decision Making for Cognitively Impaired Patients | 1252 | ||
| Collaborative Care | 1253 | ||
| Avoiding Conflicts in the Intensive Care Unit | 1253 | ||
| Justice-Related Issues | 1253 | ||
| Admission Criteria | 1255 | ||
| Discharge Criteria | 1255 | ||
| Triage | 1255 | ||
| Disparity in Use and Outcome of Intensive Care | 1256 | ||
| Ethics Consultation in the Intensive Care Unit | 1256 | ||
| The Ethics of End-of-Life Care | 1256 | ||
| Defining Death | 1256 | ||
| Withholding and Withdrawing Life-Sustaining Treatment | 1257 | ||
| Advance Care Directives and Durable Powers of Attorney | 1257 | ||
| Futile Treatments | 1260 | ||
| Ordinary/Extraordinary Care | 1261 | ||
| Substituted Judgment | 1261 | ||
| Best Interests | 1261 | ||
| Ethical Issues in Transitioning Patients to Palliative Care | 1261 | ||
| Palliative Sedation | 1262 | ||
| Euthanasia and Physician-Assisted Suicide | 1263 | ||
| Research in Critically Ill Patients | 1264 | ||
| History and Fundamentals of Human Research Ethics | 1264 | ||
| Putting Principles into Practice: Applications | 1265 | ||
| Scientific Validity | 1265 | ||
| Placebo Controls | 1266 | ||
| Choice of Control in Clinical Trials Comparing a New Intervention with the Current Standard of Care | 1266 | ||
| Informed Consent | 1266 | ||
| Disclosure of Information | 1266 | ||
| Decision-Making Capacity | 1266 | ||
| Voluntariness | 1267 | ||
| Proxy Consent | 1267 | ||
| Waiver of Informed Consent | 1268 | ||
| Analysis of Risks and Benefits | 1268 | ||
| Core Safeguards for Vulnerable Subjects | 1269 | ||
| Monitoring for Safety of Research Participants | 1269 | ||
| Research in the International Context | 1269 | ||
| Collection and Storage of Tissue Samples for Future Unspecified Research, Particularly Genetic Research | 1269 | ||
| Response to Disaster | 1270 | ||
| Selected References | 1270 | ||
| References | 1270.e1 | ||
| 72 Delirium, Sleep, and Mental Health Disturbances in Critical Illness | 1271 | ||
| Chapter Outline | 1271 | ||
| Overview | 1271 | ||
| Acute Brain Dysfunction or Delirium | 1272 | ||
| Definition | 1272 | ||
| Prevalence and Subtypes | 1272 | ||
| Prognostic Significance | 1272 | ||
| Pathophysiology | 1272 | ||
| Neurotransmitters | 1273 | ||
| Inflammatory Mediators | 1273 | ||
| Impaired Oxidative Metabolism | 1273 | ||
| Cholinergic Deficiency | 1273 | ||
| Large Neutral Amino Acid in Delirium | 1273 | ||
| Inflammation | 1273 | ||
| Risk Factors for Delirium | 1273 | ||
| Sedatives and Analgesic Agents Contributing to Delirium | 1274 | ||
| Diagnosis | 1275 | ||
| Prevention and Management | 1276 | ||
| Primary Prevention and Nonpharmacologic Approaches | 1276 | ||
| Pharmacologic Therapy | 1277 | ||
| Sleep Disruption in the Critically Ill | 1280 | ||
| Neurotransmission in Sleep | 1280 | ||
| Posttraumatic Stress Disorder | 1281 | ||
| Definition and Diagnostic Criteria | 1281 | ||
| Prevalence of ICU-Related Posttraumatic Stress Disorder | 1282 | ||
| Risk Factors for Posttraumatic Stress Disorder | 1282 | ||
| Conceptual Explanations for Posttraumatic Stress Disorder After Critical Illness | 1282 | ||
| Long-Term Cognitive Impairment after Critical Illness | 1283 | ||
| Depression | 1283 | ||
| Concluding Thoughts | 1284 | ||
| Selected References | 1285 | ||
| References | 1285.e1 | ||
| 73 Severity of Illness Scoring Systems | 1286 | ||
| Chapter Outline | 1286 | ||
| Historical Perspective | 1287 | ||
| Severity of Illness Assessment and Outcome Prediction | 1287 | ||
| Recalibrating and Expanding Existing Models | 1289 | ||
| Building New Models | 1289 | ||
| The SAPS 3 Admission Model | 1289 | ||
| The APACHE IV Model | 1290 | ||
| The MPM0 III Model | 1290 | ||
| Developing Predictive Models | 1290 | ||
| Selecting the Target Population | 1290 | ||
| Outcome Selection | 1290 | ||
| Data Collection | 1291 | ||
| Selection of Variables | 1291 | ||
| Validation of the Model | 1292 | ||
| Goodness of Fit | 1292 | ||
| Uniformity of Fit | 1293 | ||
| Updating Severity Scores | 1293 | ||
| Using a Severity of Illness Score | 1293 | ||
| Calculating a Severity of Illness Score | 1293 | ||
| Transforming the Score into a Probability of Death | 1294 | ||
| Application of a Severity of Illness Score: Evaluation of Patients | 1294 | ||
| Evaluating Individual Patients | 1294 | ||
| Evaluating Groups of Patients | 1294 | ||
| Organ Dysfunction/Failure Scoring Systems | 1295 | ||
| Multiple Organ Dysfunction Score | 1295 | ||
| Sequential Organ Failure Assessment Score | 1296 | ||
| Logistic Organ Dysfunction System Score | 1296 | ||
| Comparison of the Described Systems | 1296 | ||
| Scoring Systems for Specific Clinical Conditions | 1296 | ||
| Directions for Further Research | 1297 | ||
| Selected References | 1297 | ||
| References | 1298.e1 | ||
| 74 Education and Training in Intensive Care Medicine | 1299 | ||
| Chapter Outline | 1299 | ||
| Training Aspirations for Intensive Care Medicine | 1299 | ||
| The Training Environment | 1299 | ||
| Current Training in Intensive Care Medicine | 1300 | ||
| Competency-Based Training | 1301 | ||
| Defining Core Competencies | 1301 | ||
| Evolving Professional Roles: Implications for Training | 1301 | ||
| Practical Implications of Competency-Based Training | 1301 | ||
| Assessment | 1302 | ||
| Delivering Training and Assessment in the Workplace: Role of Simulation | 1303 | ||
| Summary | 1305 | ||
| Selected References | 1305 | ||
| References | 1305.e1 | ||
| 9 Other Critical Care Disorders and Issues in the Critically Ill | 1307 | ||
| 75 Diagnosis and Management of Liver Failure in the Adult | 1309 | ||
| Chapter Outline | 1309 | ||
| Decompensation of Chronic Liver Disease | 1309 | ||
| Precipitating Factors of Acute on Chronic Liver Failure | 1310 | ||
| Alcoholic Hepatitis | 1310 | ||
| Portal Hypertensive Bleeding | 1310 | ||
| Bacterial Peritonitis | 1310 | ||
| Supportive Management in Critical Care | 1310 | ||
| Outcome and Data on ICU Use in Decompensated Cirrhosis | 1312 | ||
| Acute (Fulminant) Liver Failure | 1312 | ||
| Etiology | 1313 | ||
| Acetaminophen (Paracetamol) | 1314 | ||
| Viral Hepatitis | 1315 | ||
| Acute Presentation of Autoimmune Hepatitis | 1317 | ||
| Drug-Induced Liver Disease | 1317 | ||
| Pregnancy-Induced Liver Disease | 1318 | ||
| Wilson’s Disease | 1319 | ||
| Neoplastic Infiltration | 1319 | ||
| Budd-Chiari Syndrome | 1319 | ||
| Veno-occLusive Disease of the Liver | 1320 | ||
| Hypoxic (Ischemic) Hepatitis | 1320 | ||
| Heat Stroke | 1321 | ||
| Mushroom Poisoning | 1321 | ||
| Clinical Course | 1321 | ||
| History and Physical Examination | 1321 | ||
| Initial Resuscitation and Emergency Care | 1321 | ||
| Investigation in a Patient with Suspected Acute Liver Failure | 1323 | ||
| Transfer Criteria Guide | 1323 | ||
| Management | 1324 | ||
| Supportive Care | 1324 | ||
| Airway and Ventilation | 1324 | ||
| Circulation | 1324 | ||
| Renal Support | 1325 | ||
| Intracranial Hypertension | 1325 | ||
| Etiology | 1325 | ||
| Management | 1326 | ||
| Predicting Intracranial Hypertension | 1326 | ||
| Monitoring the Brain | 1326 | ||
| Prophylactic Measures | 1328 | ||
| Cerebral Perfusion Pressure | 1328 | ||
| General Management of Patients with Raised Intracranial Pressure | 1328 | ||
| Seizures | 1329 | ||
| Infection and Immunosuppression | 1329 | ||
| Nutrition | 1330 | ||
| Artificial Liver Support | 1330 | ||
| Biologic Systems | 1330 | ||
| Nonbiologic Systems | 1330 | ||
| Liver Transplantation | 1330 | ||
| When and Whom to Transplant | 1330 | ||
| Outcome from Transplantation | 1331 | ||
| Auxiliary Transplantation | 1332 | ||
| Living Related Lobe Donation | 1332 | ||
| Selected References | 1333 | ||
| References | 1333.e1 | ||
| 76 Gastrointestinal Bleeding | 1334 | ||
| Chapter Outline | 1334 | ||
| Clinical Presentation | 1334 | ||
| Initial Evaluation and Resuscitation | 1334 | ||
| History and Clinical Findings | 1335 | ||
| Diagnostic Tests | 1337 | ||
| Therapeutic Options | 1337 | ||
| Upper Gastrointestinal Bleeding | 1337 | ||
| Differential Diagnosis | 1337 | ||
| Nonvariceal Bleeding | 1337 | ||
| Peptic Ulcer Disease | 1337 | ||
| Other Sources of Nonvariceal Upper Gastrointestinal Bleeding | 1338 | ||
| Bleeding Secondary to Portal Hypertension | 1339 | ||
| Esophageal Varices | 1339 | ||
| Gastric Varices | 1339 | ||
| Diagnostic Evaluation | 1339 | ||
| Endoscopic Examination | 1339 | ||
| Nonendoscopic Assessment | 1340 | ||
| Therapeutic Alternatives | 1341 | ||
| Nonvariceal Bleeding | 1341 | ||
| Pharmacotherapy | 1341 | ||
| Endoscopic Therapy | 1341 | ||
| Angiographic Therapy | 1342 | ||
| Surgical Therapy | 1342 | ||
| Variceal Bleeding | 1342 | ||
| Pharmacotherapy | 1342 | ||
| Endoscopic Therapy | 1343 | ||
| Balloon Tamponade | 1343 | ||
| Transjugular Intrahepatic Portosystemic Shunt | 1343 | ||
| Surgical Therapy | 1344 | ||
| Stress-Related Mucosal Disease | 1344 | ||
| Prophylaxis | 1345 | ||
| Treatment | 1346 | ||
| Lower Gastrointestinal Bleeding | 1346 | ||
| Differential Diagnosis | 1346 | ||
| Diverticular Bleeding | 1346 | ||
| Ischemic Colitis and Other Forms of Colitis | 1346 | ||
| Angiodysplasia | 1346 | ||
| Other Sources of Lower Gastrointestinal Bleeding | 1347 | ||
| Diagnostic Evaluation | 1348 | ||
| Colonoscopy | 1348 | ||
| Radionuclide Scanning | 1348 | ||
| Angiography | 1348 | ||
| Computed Tomography | 1348 | ||
| Therapeutic Alternatives | 1349 | ||
| Endoscopic Therapy | 1349 | ||
| Angiographic Therapy | 1349 | ||
| Surgical Therapy | 1349 | ||
| Obscure Gastrointestinal Bleeding | 1349 | ||
| Differential Diagnosis | 1349 | ||
| Diagnostic Evaluation | 1349 | ||
| Conclusion | 1350 | ||
| Selected References | 1352 | ||
| References | 1352.e1 | ||
| 77 Acute Pancreatitis | 1353 | ||
| Chapter Outline | 1353 | ||
| Introduction | 1353 | ||
| Definitions and Terminology | 1353 | ||
| Pathogenesis | 1354 | ||
| Etiology and Risk Factors | 1355 | ||
| Clinical Presentation and Diagnosis | 1356 | ||
| Early Management of the Critically Ill Patient with Acute Pancreatitis | 1357 | ||
| Initial Resuscitation | 1357 | ||
| Infection Prophylaxis | 1357 | ||
| Nutritional Support | 1358 | ||
| Adjuvant Therapy | 1358 | ||
| Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Gallstone Pancreatitis | 1358 | ||
| Management of the Late Complications of Severe Acute Pancreatitis | 1359 | ||
| Pancreatic Pseudocysts | 1359 | ||
| Infected Necrosis and Pancreatic Abscess | 1359 | ||
| Vascular Complications of Necrotizing Pancreatitis | 1360 | ||
| Long-Term Outcome and Quality of Life | 1361 | ||
| Conclusions | 1361 | ||
| Selected References | 1361 | ||
| References | 1362.e1 | ||
| 78 Hemorrhagic and Thrombotic Disorders | 1363 | ||
| Chapter Outline | 1363 | ||
| Approach to a Critically Ill Patient with Hemorrhage or Thrombosis | 1363 | ||
| Laboratory Tests of Coagulation | 1363 | ||
| Disorders of Platelets | 1364 | ||
| Thrombocytopenia | 1364 | ||
| Mechanisms and General Management | 1364 | ||
| Pseudothrombocytopenia | 1364 | ||
| Drug-Induced Thrombocytopenia | 1364 | ||
| Glycoprotein IIb/IIIa Inhibitors | 1365 | ||
| Immune Thrombocytopenic Purpura | 1365 | ||
| Post-transfusion Purpura | 1365 | ||
| Acquired Platelet Dysfunction | 1365 | ||
| Medication-Induced Abnormalities | 1365 | ||
| Renal Failure | 1365 | ||
| Thrombocytosis | 1366 | ||
| Complex Thrombohemorrhagic Disorders | 1366 | ||
| Heparin-Induced Thrombocytopenia | 1366 | ||
| Thrombotic Thrombocytopenic Purpura | 1368 | ||
| Hemolytic-Uremic Syndrome | 1368 | ||
| Disseminated Intravascular Coagulation | 1368 | ||
| Disorders of Hemostasis | 1370 | ||
| Artifacts | 1370 | ||
| Coagulation Factor Abnormalities | 1370 | ||
| Acquired Deficiencies of Procoagulants | 1370 | ||
| Vitamin K Deficiency | 1370 | ||
| Liver Disease | 1370 | ||
| Massive Transfusion | 1370 | ||
| Acquired Circulating Inhibitors | 1371 | ||
| Factor VIII Inhibitors | 1371 | ||
| Factor V Inhibitor | 1371 | ||
| Inherited Deficiencies of Procoagulants | 1371 | ||
| von Willebrand Disease | 1371 | ||
| Factor VIII Deficiency | 1371 | ||
| Factor IX Deficiency | 1371 | ||
| Factor XI Deficiency | 1372 | ||
| Venous Thromboembolism | 1372 | ||
| Deep Venous Thrombosis Prophylaxis | 1372 | ||
| Therapy for Venous Thromboembolism | 1372 | ||
| Inferior Vena Cava Filter | 1372 | ||
| Catastrophic Antiphospholipid Syndrome | 1372 | ||
| Anticoagulants | 1372 | ||
| Heparin, Heparin Derivatives, and Heparinoid | 1372 | ||
| Heparin | 1372 | ||
| Unfractionated Heparin | 1373 | ||
| Low-Molecular-Weight Heparin | 1373 | ||
| Pentasaccharide | 1373 | ||
| Heparinoid | 1373 | ||
| Direct Thrombin Inhibitors | 1373 | ||
| Oral Factor Xa Inhibitors | 1374 | ||
| Apixiban | 1374 | ||
| Rivaroxaban | 1374 | ||
| Warfarin | 1375 | ||
| Selected References | 1375 | ||
| References | 1375.e1 | ||
| 79 Use of Blood Components in the Intensive Care Unit | 1376 | ||
| Chapter Outline | 1376 | ||
| Blood Components and Indications for Transfusion | 1376 | ||
| Whole Blood and Red Blood Cells | 1377 | ||
| Indications for Red Blood Cell Transfusion | 1378 | ||
| Platelets | 1380 | ||
| Indications for Platelet Transfusion | 1381 | ||
| Plasma-Derived Components | 1382 | ||
| Plasma | 1382 | ||
| Indications for Fresh Frozen Plasma | 1382 | ||
| Cryoprecipitate | 1383 | ||
| Indications for Cryoprecipitate Transfusion | 1383 | ||
| Adverse Effects of Blood Component Transfusion | 1384 | ||
| Acute Transfusion Reactions | 1384 | ||
| Acute Hemolytic Transfusion Reaction | 1384 | ||
| Febrile Nonhemolytic Transfusion Reactions | 1384 | ||
| Anaphylaxis | 1385 | ||
| Allergic and Urticarial Reactions | 1385 | ||
| Delayed Hemolytic Transfusion Reactions | 1385 | ||
| Transfusion-Associated Circulatory Overload | 1385 | ||
| Transfusion-Related Acute Lung Injury | 1386 | ||
| Transfusion-Associated Graft-Versus-Host Disease | 1386 | ||
| Transfusion-Related Immunomodulation | 1386 | ||
| Transfusion-Transmitted Infectious Diseases | 1387 | ||
| Microbial and Endotoxin Contamination | 1387 | ||
| Hepatitis | 1387 | ||
| Retroviruses | 1387 | ||
| Cytomegalovirus | 1388 | ||
| Parasites | 1388 | ||
| Emerging Infections in Transfusion Medicine | 1388 | ||
| Special Transfusion Situations in the Critical Care Setting | 1388 | ||
| Massive Transfusion | 1388 | ||
| Autoimmune Hemolytic Anemia | 1390 | ||
| Necessary Transfusion of Incompatible Blood | 1390 | ||
| Transfusion in Patients with Disseminated Intravascular Coagulation | 1390 | ||
| Hepatic Failure | 1390 | ||
| Alternatives to Transfusion of Blood Components | 1390 | ||
| Blood Substitutes | 1391 | ||
| Desmopressin | 1391 | ||
| Antifibrinolytic Agents | 1391 | ||
| Vitamin K | 1391 | ||
| Hematopoietic Growth Factors | 1391 | ||
| Cell Salvage Technology | 1391 | ||
| Legal Issues in Transfusion Medicine | 1392 | ||
| Selected References | 1392 | ||
| References | 1393.e1 | ||
| 80 Intensive Care of the Cancer Patient | 1394 | ||
| Chapter Outline | 1394 | ||
| Metabolic and Endocrine Complications | 1395 | ||
| Tumor Lysis Syndrome | 1395 | ||
| Hypercalcemia | 1396 | ||
| Oncogenic Osteomalacia | 1396 | ||
| Syndrome of Inappropriate Secretion of Antidiuretic Hormone | 1396 | ||
| Adrenal Failure | 1397 | ||
| Pheochromocytoma | 1397 | ||
| Tumor-Induced Hypoglycemia | 1397 | ||
| Chemotherapy-Induced Metabolic Disturbances | 1398 | ||
| Cardiac Complications in Cancer Patients | 1398 | ||
| Superior Vena Cava Syndrome | 1398 | ||
| Cardiac Tamponade | 1398 | ||
| Treatment-Induced Cardiac Dysfunction | 1399 | ||
| Pulmonary Complications in Cancer Patients | 1399 | ||
| Lymphangitic Tumor Involvement | 1399 | ||
| Treatment-Induced Pulmonary Dysfunction | 1399 | ||
| Diffuse Interstitial Pneumonitis | 1400 | ||
| Hemoptysis | 1400 | ||
| Infectious Complications in Cancer Patients | 1401 | ||
| Febrile Neutropenia and Septic Shock | 1401 | ||
| Neurologic Complications in Cancer Patients | 1401 | ||
| Spinal Cord Compression | 1401 | ||
| Brain Metastases and Hemorrhage | 1401 | ||
| Uncontrolled Seizures | 1402 | ||
| Gastrointestinal Complications in Cancer Patients | 1402 | ||
| Tumor-Induced Emergencies | 1402 | ||
| Chemotherapy-Induced Gastrointestinal Dysfunction | 1402 | ||
| Gastrointestinal Lymphomas | 1404 | ||
| Genitourinary Complications in Cancer Patients | 1404 | ||
| Tumor-Induced Genitourinary Dysfunction | 1404 | ||
| Chemotherapy-Induced Genitourinary Complications | 1404 | ||
| Hematologic Complications in Cancer Patients | 1404 | ||
| Hyperleukocytosis | 1405 | ||
| Disseminated Intravascular Coagulation | 1405 | ||
| Biologic Therapy | 1405 | ||
| Interleukin 2 | 1405 | ||
| Interleukin 2 Pulmonary Capillary Leak | 1405 | ||
| Interleukin 2 Renal Dysfunction | 1406 | ||
| Cardiac Rhythm Disturbances and Myocardial Infarction | 1406 | ||
| Allergic and Anaphylactic Reactions to Monoclonal Antibodies | 1406 | ||
| Immune-Mediated Toxicities from T-Cell–Directed Therapy | 1407 | ||
| Special Considerations in Bone Marrow Transplantation | 1407 | ||
| Acute and Chronic Graft-Versus-Host Disease | 1407 | ||
| Veno-occlusive Disease | 1407 | ||
| Infectious Complications of Stem Cell Transplantation | 1407 | ||
| Code Status and Intensive Care in Cancer Patients | 1408 | ||
| Summary | 1408 | ||
| Selected References | 1409 | ||
| References | 1409.e1 | ||
| 81 Critical Care Medicine in Pregnancy | 1410 | ||
| Chapter Outline | 1410 | ||
| Physiologic Changes in Pregnancy | 1410 | ||
| Critical Care Management | 1412 | ||
| General Care | 1412 | ||
| Positioning | 1412 | ||
| Nutrition | 1412 | ||
| Thrombosis Prophylaxis | 1412 | ||
| Radiologic Procedures and Fetal Risk | 1412 | ||
| Drug Therapy in Pregnancy | 1413 | ||
| Catecholamines | 1413 | ||
| Sedation, Analgesia, and Neuromuscular Blockade | 1413 | ||
| Antibiotics | 1413 | ||
| Fetal Oxygenation and Monitoring | 1413 | ||
| Hemodynamic Monitoring | 1414 | ||
| Ventilatory Support | 1414 | ||
| Noninvasive Ventilation | 1414 | ||
| Airway Management | 1414 | ||
| Mechanical Ventilation | 1414 | ||
| Cardiopulmonary Resuscitation | 1414 | ||
| Pregnancy-Specific Conditions Requiring Intensive Care Unit Care | 1414 | ||
| Preeclampsia | 1414 | ||
| HELLP Syndrome | 1415 | ||
| Acute Fatty Liver of Pregnancy | 1416 | ||
| Amniotic Fluid Embolism | 1416 | ||
| Obstetric Hemorrhage | 1417 | ||
| Peripartum Cardiomyopathy | 1417 | ||
| Tocolytic Pulmonary Edema | 1417 | ||
| Gestational Trophoblastic Disease | 1417 | ||
| Conditions Not Specific to Pregnancy | 1417 | ||
| Septic Shock | 1417 | ||
| Acute Respiratory Distress Syndrome in Pregnancy | 1418 | ||
| Pulmonary Thromboembolic Disease | 1418 | ||
| Asthma | 1419 | ||
| Cardiac Disease | 1419 | ||
| Trauma | 1419 | ||
| Selected References | 1420 | ||
| References | 1420.e1 | ||
| 82 Nutrition Support | 1421 | ||
| Chapter Outline | 1421 | ||
| Malnutrition | 1421 | ||
| Starvation Versus Stress Metabolism | 1421 | ||
| Carbohydrate Metabolism in Critical Illness | 1422 | ||
| Fat Metabolism in Critical Illness | 1423 | ||
| Protein Metabolism in Critical Illness | 1423 | ||
| Indications for Nutrition Support | 1423 | ||
| Goals of Nutrition Support | 1423 | ||
| Nutrition Support in Critical Illness | 1424 | ||
| Calories | 1424 | ||
| Carbohydrate | 1424 | ||
| Fat | 1425 | ||
| Protein | 1425 | ||
| Electrolytes, Vitamins, and Trace Elements | 1425 | ||
| Route and Timing of Administration | 1427 | ||
| Types of Nutritional Formulas | 1428 | ||
| Organ-Specific Enteral Formulas | 1428 | ||
| Immunomodulating Enteral Formulas | 1429 | ||
| Nutritional Assessment and Monitoring | 1429 | ||
| Complications of Nutrition Support | 1432 | ||
| Complications of Enteral Nutrition Support | 1433 | ||
| Complications of Parenteral Nutrition Support | 1434 | ||
| Metabolic Complications of Nutrition Support | 1434 | ||
| Selected References | 1435 | ||
| References | 1435.e1 | ||
| 83 Bedside Ultrasonography in the Critical Care Patient | 1436 | ||
| Chapter Outline | 1436 | ||
| Lung Ultrasonography | 1436 | ||
| Technique and Equipment | 1436 | ||
| Pneumothorax | 1437 | ||
| Lung Consolidation | 1438 | ||
| Alveolar-Interstitial Syndrome | 1439 | ||
| Pleural Effusion | 1439 | ||
| Thoracentesis | 1439 | ||
| Abdominal Ultrasonography | 1440 | ||
| Paracentesis | 1440 | ||
| The “FAST” Examination | 1441 | ||
| Abdominal Aorta | 1442 | ||
| Renal Ultrasonography | 1443 | ||
| Deep Venous Thrombosis Ultrasonography | 1444 | ||
| Vascular Access | 1445 | ||
| Selected References | 1447 | ||
| References | 1447.e1 | ||
| Index | 1449 | ||
| A | 1449 | ||
| B | 1454 | ||
| C | 1456 | ||
| D | 1461 | ||
| E | 1462 | ||
| F | 1464 | ||
| G | 1465 | ||
| H | 1466 | ||
| I | 1469 | ||
| J | 1471 | ||
| K | 1471 | ||
| L | 1472 | ||
| M | 1473 | ||
| N | 1475 | ||
| O | 1476 | ||
| P | 1477 | ||
| Q | 1481 | ||
| R | 1481 | ||
| S | 1483 | ||
| T | 1485 | ||
| U | 1488 | ||
| V | 1488 | ||
| W | 1489 | ||
| X | 1490 | ||
| Y | 1490 | ||
| Z | 1490 | ||
| Clinical Key ad | IBC1 |