a L A N G E medical book

CURRENT

Diagnosis & Treatment
Critical Care
THIRD EDITION
Edited by
Frederic S. Bongard, MD
Professor of Surgery
David Geffen School of Medicine
University of California, Los Angeles
Chief, Division of Trauma and Critical Care
Director of Surgical Education
Harbor-UCLA Medical Center
Torrance, California

Darryl Y. Sue, MD
Professor of Clinical Medicine
David Geffen School of Medicine
University of California, Los Angeles
Director, Medical-Respiratory Intensive Care Unit
Division of Respiratory and Critical Care Physiology and Medicine
Associate Chair and Program Director
Department of Medicine
Harbor-UCLA Medical Center
Torrance, California

Janine R. E. Vintch, MD
Associate Clinical Professor of Medicine

David Geffen School of Medicine
University of California, Los Angeles
Divisions of General Internal Medicine and Respiratory and Critical Care Physiology and Medicine
Harbor-UCLA Medical Center
Torrance, California

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Sydney

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Toronto


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DOI: 10.1036/007143657X


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Contents
Authors
Preface
1. Philosophy & Principles of Critical Care
Darryl Y. Sue, MD, & Frederic S. Bongard, MD
General Principles of Critical Care
Role of the Medical Director of the Intensive
Care Unit
Critical Care Scoring
Current Controversies &
Unresolved Issues

2. Fluids, Electrolytes, & Acid-Base
Darryl Y. Sue, MD, & Frederic S. Bongard, MD
Disorders of Fluid Volume
Disorders of Water Balance
Disorders of Potassium Balance
Disorders of Phosphorus Balance
Disorders of Magnesium Balance
Disorders of Calcium Balance
Acid-Base Homeostasis & Disorders

3. Transfusion Therapy
Elizabeth D. Simmons, MD
Blood Components
Blood Component Administration
Complications of Transfusion
Current Controversies &

Unresolved Issues

4. Pharmacotherapy
Darryl Y. Sue, MD
Pharmacokinetic Parameters
Pharmacokinetic Considerations
Medication Errors & Prevention in
the ICU

vii
xi

6. Nutrition
John A. Tayek, MD
Nutrition & Malnutrition in the Critically Ill
Patient
Nutritional Therapy
Nutritional Support in Specific Diseases
New Treatment Strategies for the Malnourished
Critically Ill Patient

1
1
8
10

7. Imaging Procedures
12

Kathleen Brown, MD, Steven S. Raman, MD,

& Nam C. Yu, MD
Imaging Techniques
Iodinated Contrast Agents
Use of Central Venous Catheters for Contrast
Injection
Imaging of Support & Monitoring Devices
in the ICU
Imaging in Pulmonary Diseases
Imaging in Pleural Disorders
Imaging of the Abdomen & Pelvis
Imaging of Acute Gallbladder & Biliary
Tract Disorders
Imaging in Emergent & Urgent Genitourinary
Conditions

14
14
22
34
42
47
51
56

71
71
79
79

8. Intensive Care Monitoring


88
88
88
95

97

Tai-Shion Lee, MD, & Biing-Jaw Chen, MD
Physiologic Effects of Anesthesia in
the Critically Ill
Airway Management
Pain Management in the ICU
Muscle Relaxants in Intensive Care
Sedative-Hypnotics for the
Critically Ill
Malignant Hyperthermia

97
101
103
106

117
126
130
134

137


137
138
139
139
144
161
167
181
184

187

Kenneth Waxman, MD, Frederic S. Bongard, MD,
& Darryl Y. Sue, MD
Electrocardiography
187
Blood Pressure Monitoring
188
Central Venous Catheters
193
Pulmonary Artery Catheterization
196
Cardiac Output
199
Pulse Oximetry
201
203
Airway CO2 Monitoring
Transcutaneous Blood Gases
204

Respiratory Mechanics
204
Respired Gas Analysis
206
Clinical Applications
206

82

5. Intensive Care Anesthesia & Analgesia

117

9. Transport
Samuel J. Stratton, MD, MPH
Interhospital Transport
Equipment & Monitoring
Education & Training
Reimbursement Standards & Costs
Current Controversies & Unresolved Issues

110
115

iii

208
208
211
212

213
214


iv

ᮡ

CONTENTS

10. Ethical, Legal, & Palliative/End-of-Life
Care Considerations
215
Paul A. Selecky, MD
Ethical Principles
Conflicts Between Ethical Principles
Ethical Decision Making
Advance Care Planning
Medicolegal Aspects of Decision Making
Withholding & Withdrawing Life Support
Organ Donation
Role of the Health Care Professional
Web Sites for Health Care Ethics Information
& Policies

11. Shock & Resuscitation
Frederic S. Bongard, MD
Hypovolemic Shock
Distributive Shock
Cardiac Shock


12. Respiratory Failure
Darryl Y. Sue, MD, & Janine R. E. Vintch, MD
Pathophysiology of Respiratory Failure
Treatment of Acute Respiratory Failure
Acute Respiratory Failure
from Specific Disorders

13. Renal Failure
Andre A. Kaplan, MD
Nondialytic Therapy for Acute Renal Failure
Dialytic Therapy for the Critically Ill Patient
Critical Illness in Patients with Chronic
Renal Failure

14. Gastrointestinal Failure in the ICU
Gideon P. Naudé, MD
Pancreatitis
Bowel Obstruction
Obstruction of the Large Bowel
Adynamic (Paralytic) Ileus
Diarrhea & Malabsorption
Pancreatic Insufficiency
Lactase Deficiency
Diarrhea

15. Infections in the Critically Ill
Laurie Anne Chu, MD, & Mallory D. Witt, MD
Sepsis
Community-Acquired Pneumonia

Urosepsis
Infective Endocarditis

215
216
216
217
217
218
219
219

Necrotizing Soft Tissue Infections
Intraabdominal Infections
Infections in Special Hosts
Principles of Antibiotic Use in the ICU
Evaluation of the ICU Patient with New Fever
Nosocomial Pneumonia
Urinary Catheter–Associated Infections
Intravenous Catheter–Associated Infections
Clostridium Difficile–Associated Diarrhea
Hematogenously Disseminated Candidiasis
Antimicrobial Resistance in the ICU
Botulism
Tetanus

370
372
373
376

379
379
382
384
386
388
389
392
394

221

222
222
230
242

247
247
253
280

314
330
334
342

345
345
351

354
355
356
357
357
357

359
359
362
365
367

16. Surgical Infections
Timothy L. Van Natta, MD
Evaluation and Management of Infection by
Body Site

17. Bleeding & Hemostasis
Elizabeth D. Simmons, MD
Approach to the Bleeding Patient
Current Controversies & Unresolved Issues

18. Psychiatric Problems

397

400

409

427
427

431

Stuart J. Eisendrath, MD,
& John R. Chamberlain, MD
Delirium
Depression
Anxiety & Fear
Staff Issues

431
436
438
440

19. Care of the Elderly Patient

443

Shawkat Dhanani, MD, MPH,
& Dean C. Norman, MD
Physiologic Changes with Age
Management of the Elderly Patient in the ICU
Special Considerations

443
445
447


20. Critical Care of the Oncology Patient

451

Darrell W. Harrington, MD, & Darryl Y. Sue, MD
Central Nervous System Disorders
451
Metabolic Disorders
457
Superior Vena Cava Syndrome
465

21. Cardiac Problems in Critical Care

467

Shelley Shapiro, MD, PhD,
& Malcolm M. Bersohn, MD, PhD
Atrial Arrhythmias
Ventricular Arrhythmias

486
488


CONTENTS
Heart Block
Cardiac Problems During Pregnancy
Toxic Effects of Cardiac Drugs


22. Coronary Heart Disease
Kenneth A. Narahara, MD
Physiologic Considerations
Myocardial Ischemia (Angina Pectoris)
Acute Coronary Syndromes: Unstable Angina
and Non-ST-Segment-Elevation
Myocardial Infarction
Acute Myocardial Infarction with
ST-Segment Elevation

23. Cardiothoracic Surgery

491
493
494

498
498
499

502
505

514

Edward D. Verrier, MD, & Craig R. Hampton, MD
Aneurysms, Dissections, & Transections
of the Great Vessels
514

Postoperative Arrhythmias
518
Bleeding, Coagulopathy, & Blood Product
Utilization
520
Cardiopulmonary Bypass, Hypothermia,
Circulatory Arrest, & Ventricular
Assistance
525
Postoperative Low-Output States
529

24. Pulmonary Disease
Darryl Y. Sue, MD, & Janine R. E. Vintch, MD
Status Asthmaticus
Life-Threatening Hemoptysis
Deep Venous Thrombosis & Pulmonary
Thromboembolism
Anaphylaxis
Angioedema

25. Endocrine Problems in the
Critically Ill Patient

534
534
540
545
562
563


566

Shalender Bhasin, MD, Piya Ballani, MD,
& Ricky Phong Mac, MD
Thyroid Storm
Myxedema Coma
Acute Adrenal Insufficiency
Sick Euthyroid Syndrome

566
570
572
576

26. Diabetes Mellitus, Hyperglycemia,
& the Critically Ill Patient

581

Eli Ipp, MD, & Chuck Huang, MD
Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar
Nonketotic Coma
Management of the Acutely Ill Patient
with Hyperglycemia or Diabetes Mellitus

581
593
594


ᮡ

Hyperglycemia
Hypoglycemia
Other Complications of
Diabetes Mellitus

27. HIV Infection in the Critically Ill
Patient
Mallory D. Witt, MD, & Darryl Y. Sue, MD
Complications of HIV Disease:
An Overview
Other Infectious Causes of Pneumonia and
Respiratory Failure

28. Dermatologic Problems
in the Intensive Care Unit

v
594
595
597

598

598
604

609


Kory J. Zipperstein, MD
Common Skin Disorders
Drug Reactions
Purpura
Life-Threatening Dermatoses
Cutaneous Manifestations of Infection

609
612
619
623
626

29. Critical Care of Vascular Disease
& Emergencies

632

James T. Lee, MD, & Frederic S. Bongard, MD
Vascular Emergencies in the ICU
Critical Care of the Vascular
Surgery Patient

30. Critical Care of Neurologic Disease

632
651

658


Hugh B. McIntyre, MD, PhD, Linda Chang, MD,
& Bruce L. Miller, MD
Encephalopathy & Coma
658
Seizures
662
Neuromuscular Disorders
666
Cerebrovascular Diseases
673

31. Neurosurgical Critical Care
Duncan Q. McBride, MD
Head Injuries
Aneurysmal Subarachnoid Hemorrhage
Tumors of the Central Nervous System
Cervical Spinal Cord Injuries

32. Acute Abdomen
Allen P. Kong, MD, & Michael J. Stamos, MD
Specific Pathologic Entities
Current Controversies & Unresolved Issues

680
680
686
688
690


696
700
701


vi

ᮡ

CONTENTS

33. Gastrointestinal Bleeding
Sofiya Reicher, MD, & Viktor Eysselein, MD
Upper Gastrointestinal Bleeding
Lower Gastrointestinal Bleeding

34. Hepatobiliary Disease
Hernan I. Vargas, MD
Acute Hepatic Failure
Acute Gastrointestinal Bleeding from
Portal Hypertension
Ascites
Hepatorenal Syndrome
Preoperative Assessment & Perioperative
Management of Patients with Cirrhosis
Liver Resection in Patients with Cirrhosis

35. Burns

703

703
710

714
714
716
717
719
720
720

723

David W. Mozingo, MD, William G. Cioffi, Jr., MD,
& Basil A. Pruitt, Jr., MD
I. Thermal Burn Injury
723
Initial Care of the Burn Patient
727
Principles of Burn Treatment
730
Care of the Burn Wound
735
Postresuscitation Period
741
Nutrition
743
II. Chemical Burn Injury
749
III. Electrical Burn Injury

750

36. Poisonings & Ingestions
Diane Birnbaumer, MD
Evaluation of Poisoning in the Acute Care
Setting or ICU
Treatment of Poisoning in the ICU
Management of Specific Poisonings

752

752
754
757

37. Care of Patients with
Environmental Injuries

786

James R. Macho, MD, & William P. Schecter, MD
Heat Stroke
786
Hypothermia
788
Frostbite
791
Near-Drowning
793
Envenomation

795
Electric Shock & Lightning Injury
798
Radiation Injury
800

38. Critical Care Issues in Pregnancy
Marie H. Beall, MD, & Andrea T. Jelks, MD
Physiologic Adaptation to Pregnancy
General Considerations in the Care of the
Pregnant Patient in the ICU
Management of Critical Complications
of Pregnancy

39. Antithrombotic Therapy
Elizabeth D. Simmons, MD
Physical Measures
Antiplatelet Agents
Anticoagulants
New Anticoagulants
Defibrinating Agents
Oral Anticoagulants
Thrombolytic Therapy
Antithrombotic Therapy in Pregnancy
Antiphospholipid Antibody Syndrome
Thrombosis in Cancer Patients
Future Directions

Index


802
802
804
807

821
821
821
825
831
832
832
836
838
839
840
840

843


Authors
Piya Ballani, MD

Kathleen Brown, MD

Southern California Endocrine Medical Group, Anaheim,
California

Endocrine Problems in the Critically Ill Patient


Professor of Clinical Radiology, David Geffen School
of Medicine, University of California,
Los Angeles, California

Imaging Procedures

Marie H. Beall, MD
Clinical Professor of Obstetrics and Gynecology, David
Geffen School of Medicine, University of California,
Los Angeles; Vice Chair, Department of Obstetrics and
Gynecology, Harbor-UCLA Medical Center, Torrance,
California

Critical Care Issues in Pregnancy

John R. Chamberlain, MD

Malcolm M. Bersohn, MD, PhD

Linda Chang, MD

Professor of Medicine, David Geffen School of Medicine,
University of California, Los Angeles; Director,
Arrhythmia Service, Veterans Administration Greater
Los Angeles Health Care System, Los Angeles, California

Cardiac Problems in Critical Care

Professor of Medicine, John A. Burns School of Medicine,

University of Hawaii; Queens Medical Center, Honolulu,
Hawaii

Critical Care of Neurologic Disease

Assistant Clinical Professor, Department of Psychiatry,
University of California, San Francisco; Assistant
Director, Psychiatry and the Law Program, University
of California, San Francisco, San Francisco, California

Psychiatric Problems

Biing-Jaw Chen, MD
Shalender Bhasin, MD

Clinical Associate Professor, David Geffen School of
Medicine, University of California, Los Angeles,
Harbor-UCLA Medical Center, Torrance, California

Intensive Care Anesthesia & Analgesia

Professor of Medicine, Boston University School of
Medicine; Chief, Section of Endocrinology, Diabetes, and
Nutrion, Boston Medical Center, Boston, Massachusetts

Endocrine Problems in the Critically Ill Patient

Laurie Anne Chu, MD
Diane Birnbaumer, MD, FACEP


Southern California Permanente Medical Group, Kaiser
Bellflower Medical Center, Bellflower, California

Infections in the Critically Ill

Professor of Clinical Medicine, David Geffen School of
Medicine, University of California, Los Angeles; Associate
Residency Program Director, Harbor-UCLA Medical
Center, Torrance, California

Poisonings & Ingestions

William G. Cioffi, Jr., MD
J. Murray Beardsley Professor & Chairman, Department
of Surgery, Brown Medical School; Surgeon-in-Chief,
Department of Surgery, Rhode Island Hospital,
Providence, Rhode Island

Burns

Frederic S. Bongard, MD
Professor of Surgery, David Geffen School of Medicine,
University of California, Los Angeles; Chief, Division of
Trauma and Critical Care, Director of Surgical
Education, Harbor-UCLA Medical Center, Torrance,
California

Philosophy & Principles of Critical Care; Fluids, Electrolytes,
& Acid-Base; Intensive Care Monitoring; Shock &
Resuscitation; Critical Care of Vascular Disease &

Emergencies

Shawkat Dhanani, MD, MPH
Associate Clinical Professor, David Geffen School of
Medicine, University of California, Los Angeles; Director,
Geriatric Evaluation and Management Unit, Veterans
Administration Greater Los Angeles Healthcare System,
Los Angeles, California

Care of the Elderly Patient

vii
Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.


viii

ᮡ

AUTHORS

Stuart J. Eisendrath, MD

Allen P. Kong, MD

Professor of Clinical Psychiatry, Department of Psychiatry,
University of California, San Francisco; Director of
Clinical Services, Langley Porter Psychiatric Hospital
and Clinics, San Francisco, California


Psychiatric Problems

Resident Physician, Department of Surgery,
University of California, Irvine, Orange, California

Acute Abdomen

Viktor Eysselein, MD
Professor of Medicine, David Geffen School of Medicine,
University of California, Los Angeles; Clinical Professor
of Medicine, Harbor-UCLA Medical Center, Torrance,
California

Gastrointestinal Bleeding

Craig R. Hampton, MD
Staff Surgeon, St. Luke’s Cardiothoracic Surgical Associates,
St. Luke's Hospital, Duluth, Minnesota

Cardiothoracic Surgery

Darrell W. Harrington, MD
Chief, Division of General Internal Medicine,
Harbor-UCLA Medical Center, Torrance, California

Critical Care of the Oncology Patient

James T. Lee, MD
Fellow, Peripheral Vascular and Endovascular Surgery,
Division of Vascular Surgery, Harbor-UCLA Medical

Center, Torrance, California

Critical Care of Vascular Disease & Emergencies

Tai-Shion Lee, MD
Clinical Professor, David Geffen School of Medicine,
University of California, Los Angeles, Harbor-UCLA
Medical Center, Torrance, California

Intensive Care Anesthesia & Analgesia

Ricky Phong Mac, MD
Clinical Endcrinology Fellow, Division of Endocrinology,
Metabolism and Molecular Medicine, Charles R. Drew
University of Medicine and Science, Los Angeles,
California
Endocrine Problems in the Critically Ill Patient

James R. Macho, MD, FACS
Chuck Huang, MD
Private Practice, Internal Medicine and Endocrinology,
Grants Pass, Oregon
Diabetes Mellitus, Hyperglycemia, & the Critically Ill Patient

Eli Ipp, MD
Professor, David Geffen School of Medicine, University
of California, Los Angeles; Head, Section of Diabetes
and Metabolism, Harbor-UCLA Medical Center,
Torrance, California


Diabetes Mellitus & the Critically Ill Patient

Andrea T. Jelks, MD
Associate Clinical Professor, Stanford University Medical
Center; Maternal Fetal Medicine Specialist, Santa Clara
Valley Medical Center, San Jose, California

Critical Care Issues in Pregnancy

Andre A. Kaplan, MD
Professor of Medicine, University of Connecticut Health
Center; Chief, Blood Purification, John Dempsey
Hospital, Farmington, Connecticut

Renal Failure

Emeritus Professor of Surgery, University of California, San
Francisco; Director, Bothin Burn Center and Chief of
Critical Care Medicine, Saint Francis Memorial Hospital,
San Francisco, California

Care of Patients with Environmental Injuries

Duncan Q. McBride, MD
Associate Professor of Clinical Neurosurgery, Department
of Neurosurgery, David Geffen School of Medicine,
University of California, Los Angeles; Chief, Division of
Neurosurgery, Harbor-UCLA Medical Center, Torrance,
California


Neurosurgical Critical Care

Hugh B. McIntyre, MD
Professor of Neurology, David Geffen School of Medicine,
University of California, Los Angeles, Harbor-UCLA
Medical Center, Torrance, California

Critical Care of Neurologic Disease


AUTHORS

ᮡ

ix

Bruce L. Miller, MD

Sofiya Reicher, MD

Clausen Distinguished Professor of Neurology, University
of California, San Francisco; Memory and Aging Center,
San Francisco, California

Critical Care of Neurologic Disease

Assistant Clinical Professor of Medicine, David Geffen
School of Medicine, University of California, Los Angeles,
California


Gastrointestinal Bleeding

David W. Mozingo, MD

William P. Schecter, MD

Professor of Surgery and Anesthesiology, University of
Florida; Chief, Division of Acute Care Surgery, Director,
Shands Burn Center, Gainesville, Florida

Burns

Professor of Clinical Surgery and Vice Chair, University
of California, San Francisco, San Francisco, California;
Chief of Surgery, San Francisco General Hospital, San
Francisco, California

Care of Patients with Environmental Injuries

Kenneth A. Narahara, MD
Professor of Medicine, David Geffen School of Medicine,
University of California, Los Angeles, School of
Medicine; Assistant Chair for Clinical Affairs,
Department of Medicine, Director, Coronary Care,
Division of Cardiology, Harbor-UCLA Medical Center,
Torrance, California

Coronary Heart Disease

Paul A. Selecky, MD

Clinical Professor of Medicine, David Geffen School of
Medicine, University of California, Los Angeles,
California; Medical Director, Pulmonary Department,
Hoag Hospital, Newport Beach, California

Ethical, Legal, & Palliative/End-of-Life Care Considerations

Shelley Shapiro, MD, PhD
Gideon P. Naudé, MD
Chairman, Department of Surgery, Tuolumne General
Hospital, Sonora, California

Gastrointestinal Failure in the ICU

Clinical Professor of Medicine, David Geffen School of
Medicine, University of California, Los Angeles,
California

Cardiac Problems in Critical Care

Dean C. Norman, MD

Elizabeth D. Simmons, MD

Chief of Staff, Veterans Administration Greater Los Angeles
Healthcare System; Professor of Medicine, University of
Southern California, Los Angeles, California

Care of the Elderly Patient


Partner, Southern California Permanente Medical Group,
Los Angeles, California

Transfusion Therapy; Bleeding & Hemostasis; Antithrombotic
Therapy

Basil A. Pruitt, Jr., MD, FACS, FCCM

Michael J. Stamos, MD

Clinical Professor, Department of Surgery, University of
Texas Health Science Center at San Antonio; Consultant,
U.S. Army Institute of Surgical Research, San Antonio,
Texas

Burns

Professor of Surgery and Chief, Division of Colon and Rectal
Surgery, University of California, Irvine, Orange, California

Acute Abdomen

Steven S. Raman, MD
Associate Professor, Department of Radiology, David Geffen
School of Medicine, University of California,
Los Angeles, California

Imaging Procedures

Samuel J. Stratton, MD, MPH

Professor of Emergency Medicine, University of California
Irvine, Orange, California

Transport


x

ᮡ

AUTHORS

Darryl Y. Sue, MD

Janine R. E. Vintch, MD

Professor of Clinical Medicine, David Geffen School
of Medicine, University of California, Los Angeles,
California; Director, Medical-Respiratory Intensive Care
Unit, Division of Respiratory and Critical Care
Physiology and Medicine, Associate Chair
and Program Director, Department of Medicine,
Harbor-UCLA Medical Center, Torrance, California

Philosophy & Principles of Critical Care; Fluids, Electrolytes,
& Acid-Base; Pharmacotherapy; Intensive Care
Monitoring; Respiratory Failure; Critical Care
of the Oncology Patient; Pulmonary Disease; HIV
Infection in the Critically Ill Patient


Associate Clinical Professor of Medicine, David Geffen
School of Medicine, University of California, Los
Angeles, Divisions of General Internal Medicine and
Respiratory and Critical Care Physiology and Medicine,
Harbor-UCLA Medical Center, Torrance, California

Respiratory Failure; Pulmonary Disease

John A. Tayek, MD

Mallory D. Witt, MD

Associate Professor of Medicine-in-Residence, David Geffen
School of Medicine, University of California, Los Angeles,
Harbor-UCLA Medical Center, Torrance, California

Nutrition

Professor of Medicine, David Geffen School of Medicine,
University of California, Los Angeles, California;
Associate Chief, Division of HIV Medicine, HarborUCLA Medical Center, Torrance, California

Infections in the Critically Ill; HIV Infection in the
Critically Ill Patient

Timothy L. Van Natta, MD
Associate Professor of Surgery, David Geffen School of
Medicine, University of California, Los Angeles,
Harbor-UCLA Medical Center, Torrance, California


Surgical Infections

Hernan I. Vargas, MD
Associate Professor of Surgery, David Geffen School
of Medicine, University of California, Los Angeles,
California; Chief, Division of Surgical Oncology, HarborUCLA Medical Center, Torrance, California

Hepatobiliary Disease

Edward D. Verrier, MD
William K. Edmark Professor of Cardiovascular Surgery,
Vice Chairman, Department of Surgery, University
of Washington, Seattle, Washington; Chief, Division
of Cardiothoracic Surgery, University of Washington,
Seattle, Washington

Cardiothoracic Surgery

Kenneth Waxman, MD
Director of Surgical Education, Santa Barbara Cottage
Hospital, Santa Barbara, California

Intensive Care Monitoring

Nam C. Yu, MD
Resident Physician, Department of Radiology, David Geffen
School of Medicine, University of California,
Los Angeles, California

Imaging Procedures


Kory J. Zipperstein, MD
Chief, Department of Dermatology, Kaiser-Permanente
Medical Center, San Francisco, California

Dermatologic Problems in the Intensive Care Unit


Preface
The third edition of Current Diagnosis & Treatment: Critical Care is designed to serve as a single-source reference for the adult
critical care practitioner. The diversity of illnesses encountered in the critical care population necessitates a well-rounded and
thorough knowledge of the manifestations and mechanisms of disease. In addition, unique to the discipline of critical care is
the integration of an extensive body of medical knowledge that crosses traditional specialty boundaries. This approach is
readily apparent to intensivists, whose primary background may be in internal medicine or one of its subspecialties, surgery,
or anesthesiology. Thus a central feature of this book is a unified and integrated approach to the problems encountered in
critical care practice. Like other books with the Lange imprint, this book emphasizes recall of major diagnostic features,
concise descriptions of disease processes, and practical management strategies based on often recently acquired evidence.

INTENDED AUDIENCE
Planned by two internists and a surgeon to meet the need for a concise but thorough source of information, Current Diagnosis
& Treatment: Critical Care is intended to facilitate both teaching and practice of critical care. Students will find its consideration of basic science and clinical application useful during clerkships on medicine, surgery, and intensive care unit electives.
House officers will appreciate its descriptions of disease processes and organized approach to diagnosis and treatment. Fellows
and those preparing for critical care specialty examinations will find those sections outside their primary disciplines particularly useful. Clinicians will recognize this succinct reference on critical care as a valuable asset in their daily practice.
Because this book is intended as a reference on various aspects of adult critical care, it does not contain chapters on
pediatric or neonatal critical care. These areas are highly specialized and require entire monographs of their own. Further, we
have not included detailed information on performing bedside procedures such as central venous catheterization or arterial line
insertion. Well-illustrated pocket manuals are available for readers who require basic technical information. Finally, we have
chosen not to include a chapter on nursing or administrative topics, details of which can be found in other works.

ORGANIZATION

Current Diagnosis & Treatment: Critical Care is conceptually organized into three major sections: (1) fundamentals of critical care applicable to all patients, (2) topics related primarily to critical care of patients with medical diseases, and (3) essentials of
care for patients requiring care for surgical problems. Early chapters provide information about the general physiology and
pathophysiology of critical illness. The later chapters discuss pathophysiology using an organ system– or disease-specific
approach. Where appropriate, we have placed the medical and surgical chapters in succession to facilitate access to information.

OUTSTANDING FEATURES
Concise, readable format, providing efficient use in a variety of clinical and academic settings
Edited by both surgical and medical intensivists, with contributors from multiple subspecialties
ᮣ Illustrations chosen to clarify basic and clinical concepts
ᮣ Careful evaluation of new diagnostic procedures and their usefulness in specific diagnostic problems
ᮣ Updated information on the management of severe sepsis and septic shock, including hydrocortisone therapy
ᮣ New information on the serotonin syndrome
ᮣ Carefully selected key references in Index Medicus format, providing all information necessary to allow electronic retrieval
ᮣ
ᮣ

ACKNOWLEDGMENTS
The editors wish to thank Robert Pancotti and Ruth W. Weinberg at McGraw-Hill for unceasing efforts to motivate us and keep
us on track. We are also very grateful to our families for their support.
Frederic S. Bongard, MD
Darryl Y. Sue, MD
Janine R. E. Vintch, MD
July 2008

xi
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ᮡ

Philosophy & Principles
of Critical Care
Darryl Y. Sue, MD
Frederic S. Bongard, MD

Critical care is unique among the specialties of medicine.
While other specialties narrow the focus of interest to a single body system or a particular therapy, critical care is
directed toward patients with a wide spectrum of illnesses.
These have the common denominators of marked exacerbation of an existing disease, severe acute new problems, or
severe complications from disease or treatment. The range
of illnesses seen in a critically ill population necessitates
well-rounded and thorough knowledge of the manifestations and mechanisms of disease. Assessing the severity of
the patient’s problem demands a simultaneously global and
focused approach, depends on accumulation of accurate
data, and requires integration of these data. Although practitioners of critical care medicine—sometimes called
intensivists—are often specialists in pulmonary medicine,
cardiology, nephrology, anesthesiology, surgery, or critical
care, the ability to provide critical care depends on the basic
principles of internal medicine and surgery. Critical care
might be considered not so much a specialty as a “philosophy” of patient care.
The most important development in recent years has
been an explosion of evidence-based critical care medicine
studies. For the first time, we have evidence for many of the
things that we do for patients in the ICU. Examples include
low tidal volume strategies for acute respiratory distress
syndrome, tight glycemic control, prevention of ventilatorassociated pneumonia, and use of corticosteroids in septic
shock (Table 1–1). The resulting improvement in outcome

is gratifying, but even more surprising is how often evidence contradicts long-held beliefs and assumptions.
Probably the best example is recent studies that conclude
that the routine use of pulmonary artery catheters in ICU
patients adds little or nothing to management. Much more
needs to be studied, of course, to address other unresolved
issues and controversies.
Do intensivists make a difference in patient outcome?
Several studies have shown that management of patients by
full-time intensivists does improve patient survival. In fact,

1

1

several national organizations recommend strongly that fulltime intensivists provide patient care in all ICUs. It can be
argued, however, that local physician staffing practices;
interactions among primary care clinicians, subspecialists, and intensivists; patient factors; and nursing and
ancillary support play large roles in determining outcomes. In addition, recent studies show that patients do
better if an ICU uses protocols and guidelines for routine
care, controls nosocomial infections, and provides feedback to practitioners.
The general principles of critical care are presented in this
chapter, as well as some guidelines for those who are responsible for leadership of ICUs.

GENERAL PRINCIPLES OF CRITICAL CARE
ᮣ Early Identification of Problems
Because critically ill patients are at high risk for developing
complications, the ICU practitioner must remain alert to
early manifestations of organ system dysfunction, complications of therapy, potential drug interactions, and other premonitory data (Table 1–2). Patients with life-threatening
illness in the ICU commonly develop failure of other
organs because of hemodynamic compromise, side effects

of therapy, and decreased organ function reserve, especially those who are elderly or chronically debilitated. For
example, positive-pressure mechanical ventilation is associated with decreased perfusion of organs. Many valuable
drugs are nephro- or hepatotoxic, especially in the face of
preexisting renal or hepatic insufficiency. Older patients
are more prone to drug toxicity, and polypharmacy presents a higher likelihood of adverse drug interactions. Just as
patients with acute coronary syndrome and stroke benefit
from early intervention, an exciting finding is the evidence
that the first 6 hours of management of septic shock are very
important.

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2

ᮡ

CHAPTER 1

Table 1–1. Recent developments in evidence-based
critical care medicine.

Table 1–2. Recommendations for routine patient care in
the ICU.

• Corticosteroids improve outcome in exacerbations of chronic obstructive respiratory disease (COPD).

• Assess current status, interval history, and examination.

• A low tidal volume strategy decreases mortality in acute respiratory

distress syndrome (ARDS).

• Review medication record, including continuous infusions:
Duration and dose
Changes in dose or frequency based on changes in renal, hepatic,
or other pharmacokinetic function
Changes in route of administration
Potential drug interactions

• A lower hemoglobin decision point for transfusion of red blood cells
in many ICU patients results in similar outcome and greatly reduced
use of blood products.
• Tight glycemic control in postoperative surgical patients, most of
whom did not have diabetes, resulted in less mortality and fewer
complications.
• Elevating the head of the bed to 30–45 degrees in ICU patients
reduces the incidence of nosocomial pneumonia.
• Daily withholding of sedation in the ICU decreases the number of
ICU days and results in fewer evaluations for altered level of
consciousness.
• Daily spontaneous breathing trials lead to faster weaning from
mechanical ventilation and shorter duration of ICU stay.
• Low-dose (physiologic) vasopressin may reduce the need for pressors in septic shock.
• Fluid resuscitation using colloid-containing solutions is not more beneficial than crystalloid fluids.
• Low-dose dopamine does not improve renal function or diuresis and
does not protect against renal dysfunction.

• Review vital signs for interval period (since last review).

• Correlate changes in vital signs with medication administration and

other changes by use of chronologic charting.
• Integrate nursing, respiratory therapists, patient, family, and other
observations.
• Review, if indicated:
Respiratory therapy flow chart
Hemodynamics records
Laboratory flowsheets
Other continuous monitoring
• Review all problems, including adding, updating, consolidating, or
removing problems as indicated.
• Periodically, review supportive care:
Intravenous fluids
Nutritional status and support
Prophylactic treatment and support
Duration of catheters and other invasive devices
• Review and contrast risks and benefits of intensive care.

• Acetylcysteine or sodium bicarbonate protect against radiocontrast
material–induced acute renal failure.
• Patients with bleeding esophageal varices have a higher rebleeding
risk if they have infection, especially spontaneous bacterial peritonitis.
• Noninvasive positive-pressure ventilation decreases the need for
intubation in patients with COPD exacerbation.
• Noninvasive positive-pressure ventilation is associated with fewer
respiratory infections than conventional ventilation.
• Early goal-directed therapy for sepsis (specific targets for central
venous pressure, hemoglobin, and central venous oxygen content
during the first 6 hours of care) decreases mortality.

Identifying and acting on new problems and complications in the ICU demands frequent and regular review of all

information available, including changes in symptoms, physical findings, and laboratory data and information from monitors. In some facilities, early identification and treatment are
provided by rapid-response teams. Once notified that a patient
outside the ICU may be deteriorating, the team is mobilized

to provide a mini-ICU environment in which critical care can
be delivered early, even before the patient is actually
transferred.

ᮣ Effective Use of the Problem-Oriented
Medical Record
The special importance of finding, tracking, and being aware
of ICU issues demands an effective problem-oriented medical record. In order to define and follow problems effectively, each problem should be reviewed regularly and
characterized at its current state of understanding. For example, if the general problem of “renal failure” subsequently has
been determined to be due to aminoglycoside toxicity, it
should be described in that way in an updated problem list.
However, even the satisfaction of identifying a cause of the
renal failure may be short-lived. The same patient subsequently may develop other related or unrelated renal problems, thereby forcing reassessment.
In our opinion, ICU problems must not be restricted to
“diagnoses.” We list intravascular catheters and the date they


PHILOSOPHY & PRINCIPLES OF CRITICAL CARE
were inserted on the problem list. This helps us to remember
to consider the catheter as a site of infection if the patient
has a fever. Other “nondiagnoses” on our problem list
include nutritional support, prevention of deep vein
thrombosis and decubitus ulcers, drug allergies, patient
positioning, and prevention of stress ulcers. It may be useful to include nonmedical issues as well so that they can be
discussed routinely. Examples are psychosocial difficulties, unresolved end-of-life decisions, and other questions
about patient comfort. Finally, we share the patient’s

problem-oriented record with nonphysicians caring for the
patient, a process that enhances communication, simplifies
interactions between staff members, and furthers the goals
of patient care.

ᮣ Monitoring & Data Display
A tremendous amount of patient data is acquired in the
ICU. Although ICU monitoring is often thought of as
electrocardiography, blood pressure measurements, and
pulse oximetry, ICU data include serial plasma glucose
and electrolyte determinations, arterial blood gas determinations, documentation of ventilator settings and
parameters, and body temperature determinations. Taking
a daily weight is invaluable in determining the net fluid
balance of a patient.
Flowcharts of laboratory data and mechanical ventilator
activity, 24-hour vital signs, graphs of hemodynamic data, and
lists of medications are indispensable tools for good patient
care, and efforts should be made to find the most effective and
efficient ways of displaying such information in the ICU.
Methods that integrate the records of physicians, nurses, respiratory therapists, and others are particularly useful.
Computer-assisted data collection and display systems
are found increasingly in ICUs. Some of these systems
import data directly from bedside monitors, mechanical
ventilators, intravenous infusion pumps, fluid collection
devices, clinical laboratory instruments, and other devices.
ICU practitioners may enter progress notes, medications
administered, and patient observations. Advantages of these
systems include decreased time for data collection and the
ability to display data in a variety of formats, including flowcharts, graphs, and problem-oriented records. Such data can
be sent to remote sites for consultation, if necessary.

Computerized access to data facilitates research and quality
assurance studies, including the use of a variety of prognostic indicators, severity scores, and ICU decision-making
tools. Computerized information systems have the potential
for improving patient care in the ICU, and their benefit to
patient outcome continues to be studied.
The next step is to integrate ICU data with treatment,
directly and indirectly. One excellent example is glycemic
control so that up-to-date blood glucose measurements
will be linked closely to insulin protocols—at first with
the nurse and physician “in the loop” but potentially with

ᮡ

3

real-time feedback and automated adjustment of insulin
infusions.

ᮣ Supportive & Preventive Care
Many studies have pointed out the high prevalence of gastrointestinal hemorrhage, deep venous thrombosis, decubitus ulcers, inadequate nutritional support, nosocomial
and ventilator-associated pneumonias, urinary tract infections, psychological problems, sleep disorders, and other
untoward effects of critical care. Efforts have been made to
prevent, treat, or otherwise identify the risks for these
complications. As outlined in subsequent chapters, effective prevention is available for some of these risks (Table 1–3);
for other complications, early identification and aggressive intervention may be of value. For example, aggressive
nutritional support for critically ill patients is often indicated both because of the presence of chronic illness and
malnutrition and because of the rapid depletion of
nutritional reserves in the presence of severe illness.
Nutritional support, prevention of upper gastrointestinal
bleeding and deep venous thrombosis, skin care, and other

supportive therapy should be included on the ICU
patient’s problem list. To these, we have added glycemic
control because of recent data indicating reduced morbidity and mortality in medical and surgical patients whose
plasma glucose concentration is maintained in a relatively
narrow range.
Because of expense and questions of effectiveness and
safety, studies of preventive treatment of ICU patients continue. For example, a multicenter study reported that clinically important gastrointestinal bleeding in critically ill
patients was seen most often only in those with respiratory
failure or coagulopathy (3.7% for one or both factors).
Otherwise, the risk for significant bleeding was only 0.1%.
The authors suggested that prophylaxis against stress ulcer
could be withheld safely from critically ill patients unless
they had one of these two risk factors. On the other hand,
about half the patients in this study were post–cardiac surgery patients, and the majority of patients in many ICUs have
one of the identified risk factors. Thus there may not be sufficient compelling evidence to discontinue the practice of
providing routine prophylaxis for gastrointestinal bleeding
in all ICU patients.
Other routine practices have been challenged. For example, several studies show that routine transfusion of red
blood cells in ICU patients who reached an arbitrary hemoglobin level did not change outcome when compared with
allowing hemoglobin to fall to a lower value. Further studies
are needed to define the role of other preventive strategies.
Important questions include differences in the need for
glycemic control, critical differences in the intensity and type
of therapy needed to prevent thrombosis, the optimal hemoglobin for patients with myocardial infarction, and the benefit of tailored nutritional support.


4

ᮡ


CHAPTER 1

Table 1–3. Things to think about and reminders for ICU patient care.
Things To Think About

Reminders

General ICU Care
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Nosocomial infections, especially line- and catheter-related.
Stress gastritis.
Deep venous thrombosis and pulmonary embolism.
Exacerbation of malnourished state.
Decubitus ulcers.
Psychosocial needs and adjustments.
Toxicity of drugs (renal, pulmonary, hepatic, CNS).
Development of antibiotic-resistant organisms.
Complications of diagnostic tests.

Correct placement of catheters and tubes.
Need for vitamins (thiamine, C, K).
Tuberculosis, pericardial disease, adrenal insufficiency, fungal sepsis,
rule out myocardial infarction, pneumothorax, volume overload or
volume depletion, decreased renal function with normal serum creatinine, errors in drug administration or charting, pulmonary vascular
disease, HIV-related disease.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

Discontinue infected or possibly infected lines.
Need for H2 blockers, antacids, or sucralfate.
Provide enteral or parenteral nutrition.
Change antibiotics?
Chest x-ray for line placement.
Review known drug allergies (including contrast agents).
Check for drug dosage adjustments (new liver failure or renal failure).
Need for deep venous thrombosis prophylaxis?
Pain medication and sedation.

Weigh patient.
Give medications orally, if possible.
Does patient really need an arterial catheter?
Give thiamine early.

Nurition
1.
2.
3.
4.
5.
6.
7.
8.
9.

Set goals for appropriate nutrition support.
Avoid or minimize catabolic state.
Acquired vitamin K deficiency while in ICU.
Avoidance of excessive fluid intake.
Diarrhea (lactose intolerance, low serum protein, hyperosmolarity,
drug-induced, infectious).
Minimize and anticipate hyperglycemia during parenteral nutritional
support.
Adjustment of rate or formula in patients with renal failure or liver
failure.
Early complications of refeeding.
Acute vitamin insufficiency.

1. Calculate estimated basic caloric and protein needs. Use 30 kcal/kg

and 1.5 g protein/kg for starting amount.
2. Regular food preferred over enteral feeding; enteral feeding preferred
over parenteral in most patients.
3. Increased caloric and protein requirements if febrile, infected, agitated,
any inflammatory process ongoing, some drugs.
4. Adjust protein if renal or liver failure is present. Adjust again if dialysis
is used.
5. Measure serum albumin as primary marker of nutritional status.
6. Give vitamin K, especially if malnourished and receiving antibiotics.
7. Consider volume restriction formulas (both enteral and parenteral).
8. Give phosphate early during refeeding.
9. Control hyperglycemia (glucose <110–120 mg/dL).

Acute Renal Failure
1.
2.
3.
4.
5.
6.

Volume depletion, hypoperfusion, low cardiac output, shock.
Nephrotoxic drugs.
Obstruction of urine outflow.
Interstitial nephritis.
Manifestation of systemic disease, multiorgan system failure.
Degree of preexisting chronic renal failure.

1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
11.

Measure urine Na+, Cl–, creatinine, and osmolality.
Volume challenge, if indicated.
Discontinue nephrotoxic drugs if possible.
Adjust all renally excreted drugs.
Renal medicine consultation for dialysis, other management.
Renal ultrasound if indicated for obstruction.
Check catheter and replace if indicated.
Stop potassium supplementation if necessary.
Adjust diet (Na+, protein, etc.).
If dialytic therapy is begun, adjust drugs if necessary.
Weigh patient daily.
(continued )


PHILOSOPHY & PRINCIPLES OF CRITICAL CARE

ᮡ

5


Table 1–3. Things to think about and reminders for ICU patient care. (continued)
Things To Think About

Reminders

Acute Respiratory Failure, COPD
1.
2.
3.
4.
5.
6.
7.
8.
9.

Adequacy of oxygenation.
Exacerbation due to infection, malnutrition, congestive heart failure.
Airway secretions.
Other medical problems (coexisting heart failure).
Hypotension and low cardiac output response to positive-pressure
ventilation.
Hyponatremia, SIADH.
Severe pulmonary hypertension.
Sleep deprivation.
Coexisting metabolic alkalosis.

1. Should patient be intubated or mechanically ventilated?
Noninvasive mechanical ventilation?
2. Bronchodilators.

3. Consider corticosteroids, ipratropium.
4. Sufficient supplemental oxygen.
5. Antibiotic coverage for common bacterial causes of exacerbations.
Evaluate for pneumonia as well as acute bronchitis.
6. Early nutrition support.
7. Check theophylline level, if indicated.
8. Ventilator management: low tidal volume, long expiratory time, high
inspiratory flow, watch for auto-PEEP.
9. Think about weaning early.

Acute Respiratory Failure, ARDS
1. Sepsis as cause, from pulmonary or nonpulmonary site (abdominal,
urinary).
2. Possible aspiration of gastric contents.
3. Fluid overload or contribution form congestive heart failure.
4. Anticipate potential multiorgan system failure.
5. Assess the risks of oxygen toxicity versus complications of PEEP.
6. Consider the complications of high airway pressure or large tidal volume in selection of type of mechanical ventilatory support.
7. Low serum albumin (contribution from hypo-oncotic pulmonary
edema).

1. Early therapeutic goal of Fi02 <0.50 and lowest PEEP (<5–10 cm H2O),
resulting in acceptable O2 delivery.
2. Directed (if possible) or broad-spectrum antibiotics.
3. Evaluate for soft tissue or intra-abdominal infection source.
4. Diuretics, if necessary. Assess need for fluid intake to support O2 delivery.
5. Evaluate intake and output daily; weigh patient daily.
6. Use low tidal volume, ≤6 ml/kg to keep plateau pressure <30 cm H2O.
7. Follow renal function, electrolytes, liver function, mental status to
assess organ system function.


Asthma
1. Airway inflammation is the primary cause of status asthmaticus.
2. Auto-PEEP or hyperinflation dominates gas exchange when using
mechanical ventilation.
3. Potentially increased complication rate of mechanical ventilation.

1 High-dose corticosteroids are primary treatment.
2. Aggressive inhaled aerosolized β2 agonists (hourly, if needed).
3. Early intubation if necessary.
4. Adequate oxygen to inhibit respiratory drive.
5. Use low tidal volume, high inspiratory flow, low respiratory frequency
with mechanical ventilation to avoid barotrauma and auto-PEEP.
6. May need to sedate or paralyze to reduce hyperinflation.
7. Measure peak flow or FEV, as a guide to therapeutic response.

Diabetic Ketoacidosis
1. Evaluate degree of volume depletion and relationship of water to
solute balance (hyperosmolar component).
2. Avoid excessive volume replacement.
3. Look for a trigger for diabetic ketoacidosis (infection, poor compliance,
mucormycosis, other).
4. Avoid hypoglycemia during correction phase.
5. Identify features of hyperosmolar complications.
6. Calculate water and volume deficits.
7. Evaluate presence of coexisting acid-base disturbances (lactic acidosis,
metabolic alkalosis).
8. Avoid hypokalemia and hypophosphatemia during correction phase.

1. Give adequate insulin to lower glucose at appropriate rate (increase

aggressively if no response). Use continuous insulin infusion.
2. Give adequate volume replacement (normal saline) and water replacement, if needed (half normal saline, glucose in water).
3. Follow glucose and electrolytes frequently.
4. Consider stopping insulin infusion when glucose is about 250 mg/dL
and HCO3– is >18 meq/L.
5. Avoid hypoglycemia; if you continue insulin drip with glucose <250mg/dL,
then give D5W. If glucose continues to fall, lower insulin drip rate.
6. Monitor serum potassium, phosphorus.
7. Calculate water deficit, if any.
8. Urine osmolality, glucose, etc.
9. Check sinuses, nose, mouth, soft tissue, urine, chest x-ray, abdomen for
infection.
(continued )


6

ᮡ

CHAPTER 1

Table 1–3. Things to think about and reminders for ICU patient care. (continued)
Things To Think About

Reminders

Hyponatremia
1. Consider volume depletion (nonosmolar stimulus for ADH secretion).
2. Consider edematous state with hyponatremia (cirrhosis, nephrotic
syndrome, congestive heart failure).

3. SIADH with nonsuppressed ADH.
4. Drugs (thiazide diuretics).
5. Adrenal insuffieiency, hypothyroidism.

Measure urine Na+, Cl–, creatinine, and osmolality.
Calculate or measure serum osmolality.
Volume depletion? Give volume challenge?
Ask if patient is thirsty (may be volume-depleted).
Review medication list.
Primary treatment may be water restriction.
Consider need for hypertonic saline (carefully calculate amount)
and furosemide.
8. Other treatment (demeclocycline).
1.
2.
3.
4.
5.
6.
7.

Hypernatremia
1.
2.
3.
4.
5.

Diabetes insipidus (CNS or renal disease, lithium?)
Diabetes mellitus.

Has patient been water-depleted for a long-time?
Concomitant volume depletion?
Is the urine continuing to be poorly concentrated?

1.
2.
3.
4.
5.

Calculate water deficit and ongoing water loss.
Replace with hypotonic fluids (0.45% NaCl, D5W) at calculated rate.
Replace volume deficit, if any, with normal saline.
Measure urine osmolality, Na+, Cl–, creatinine.
Does patient need desmopressin acetate (central diabetes insipidus)?

Hypotension
1.
2.
3.
4.
5.
6.

Volume depletion.
Sepsis. (Consider potential sources; may need to treat empirically.)
Cardiogenic. (Any reason to suspect?)
Drugs or medications (prescribed or not).
Adrenal insufficiency.
Pneumothorax, pericardial effusion or tamponade, fungal sepsis,

tricyclic overdose, amyloidosis.

1. Volume challenge; decide how and what to give and how to monitor.
2. If volume-depleted, correct cause.
3. Gram-positive or gram-negative sepsis (or candidemia) may also cause
hypotension and shock.
4. Give naloxone if clinically indicated.
5. Echocardiogram (left ventricular and right ventricular function, pericardial
disease, acute valvular disease) may be helpful.
6. Does the patient need a Swan-Ganz catheter?
7. Cosyntropin stimulation test or empiric corticosteroids.

Swan-Ganz Catheters
1. Site of placement (safety, risk, experience of operator).
2. Coagulation times, platelet count, bleeding time, other
bleeding risks.
3. Document in medical record.
4. Estimate need for monitoring therapy.
5. Predict whether interpretation of data may be difficult (mechanical
ventilation, valvular insufficiency, pulmonary hypertension).

1.
2.
3.
4.
5.

Check for contraindications.
Write a procedure note.
Make measurements and document immediately after placement.

Obtain chest x-ray afterward.
Level transducer with patient before making measurement; eliminate
bubbles in lines or transducer.
6. Discontinue as soon as possible.
7. Use Fick calculated cardiac output to confirm thermodilution
measurements.
8. Send mixed venous blood for O2 saturation.

Upper Gastrointestinal Bleeding
1.
2.
3.
4.
5.
6.
7.
8.

Rapid stabilization of patient (hemoglobin and hemodynamics).
Identification of bleeding site.
Does patient have a nonupper GI bleeding site?
Consider need for early operation.
Review for bleeding, coagulation problems.
Determine when “excessive” amounts of blood products given.
Do antacids, H2 blockers, PPIs play a role?
Reversible causes or contributing causes.

1.
2.
3.

4.
5.
6.

Monitor vital signs at frequent intervals.
Monitor hematocrit at frequent intervals.
Choose hematocrit to maintain.
Consider need and timing of endoscopy.
Consult surgery.
Patients with abnormally long coagulation time may benefit from freshfrozen plasma (calculate volume of replacement needed).
7. Platelet transfusions needed?
8. Desmopressin acetate (renal failure).
(continued )


PHILOSOPHY & PRINCIPLES OF CRITICAL CARE

ᮡ

7

Table 1–3. Things to think about and reminders for ICU patient care. (continued)
Things To Think About

Reminders

Fever, Recurrent or Persistent
1. New, unidentified source of infection.
2. Lack of response of identified or presumed source of infection.
3. Opportunistic organism (drug-resistant, fungus, virus, parasite,

acid-fast bacillus).
4. Drug fever.
5. Systemic noninfectious disease.
6. Incorrect empiric antibiotics.
7. Slow resolution of fever (deep-seated infection: endocarditis,
osteomyelitis).
8. Infected catheter site or foreign body (medical appliance).
9. Consider infections of sinuses, CNS, decubitus ulcers; septic arthritis.

1. Examine catheter sites (old and new), surgical wounds, sinuses, back
and buttocks, large joints, pelvic organs, catheters and tubes, skin
rashes, hands and feet.
2. Consider pleural, pericardial, subphrenic spaces; perinephric infection;
spleen, prostate, intra-abdominal abscess; bowel infarction or necrosis.
3. Abscess in area of previous known infection.
4. Review prior culture results and antibiotic use.
5. Consider change in empiric antibiotics.
6. Culture usual locations plus any specific areas.
7. Discontinue or change catheters.
8. Consider candidemia or disseminated candidiasis.
9. Discontinue antibiotics?
10. Abdominal ultrasound, CT scan, gallium, leukocyte scans.

Pancytopenia (After Chemotherapy)
1.
2.
3.
4.
5.
6.


Fever, presumed infection, response to antimicrobials.
Thrombocytopenia and spontaneous bleeding.
Drug fever.
Transfusion reactions.
Staphylococcus, candida, other opportunistic infections.
Infection sites in patient without granulocytes may have induration,
erythema, without fluctuance.
7. Pulmonary infiltrates and opportunistic infection.

ᮣ Attention to Psychosocial
& Other Needs of the Patient
Psychosocial needs of the patient must be a major consideration in the ICU. The psychological consequences of critical
illness and its treatment have a profound impact on patient
outcome. Leading factors include the patient’s lack of control
over the local environment, severe disruption of the sleepwake cycle, inability to communicate easily and quickly with
critical care providers, and pain and other types of physical
discomfort. Inability to communicate with family members,
as well as concern about employment status, activities of daily
living, finances, and other matters, further inflates the emotional costs of being seriously ill. The intensivist and other
staff members must pay close attention to these problems
and issues and consider psychological problems in the differential diagnosis of any patient’s altered mental status.
Adequate yet appropriate sedation and analgesia are mandatory to preserve the balance of comfort with patient assessment and interaction needs.
There is increased awareness of the potential harm to
patients and caregivers from the ICU environment. The

1. Fever workup; see above.
2. Special sites: soft tissues, perirectal abscess, urine fungal cultures,
lungs.
3. Bronchoscopy with bronchoalveolar lavage.

4. Empiric antibiotics, continue until afebrile, doing well, granulocytes
>1000/μL.
5. Empiric or directed vancomycin, antifungal drugs, antiviral drugs, antituberculous drugs.
6. Check intravascular catheters, bladder, catheter.
7. Platelet transfusions, prophylaxis for spontaneous bleeding (or if
already bleeding).

noise level is high (reported to exceed 60–84 dB, where a
busy office might have 70 dB and a pneumatic drill at 50 feet
might be as loud as 80 dB), notably from mechanical ventilators, conversations, and telephones but especially from
audio alarms on ICU equipment. One study found that caregivers were unable to discern and identify alarms accurately,
including alarms that indicated critical patient or equipment
conditions.
Sleep disruption deserves much more attention. Very disruptive sleep architecture has been identified in patients in
the ICU. Frequent checking of vital signs and phlebotomy
were most disruptive to patients, and environmental factors
were less of a problem to patients surveyed. Most recently, in
addition, the impact of duty hours, sleep, and time off on the
cognitive and patient care ability of house officers is being
studied and reported.

ᮣ Understand the Limits of Critical Care
All physicians involved with critical care must be familiar
with the limitations of such care. Interestingly, physicians
and other care providers may have to be reminded that


8

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CHAPTER 1

critical illness is and always will be associated with high
morbidity and mortality rates. The outcome of some disease processes simply cannot be altered despite the availability of modern comprehensive treatment. On the basis
of medical evidence and after consultation with the
patient and family, some patients will continue to receive
aggressive treatment; for others, withdrawal or withholding of ICU care may be the most appropriate and correct
decision.
It is not surprising that critical care physicians, together
with medical ethicists, have played a major role in developing a body of ethical constructs concerned with such
issues as forgoing of care, determination of brain death,
and withholding feeding and hydration. The critical care
physician must be familiar with ethical and legal concepts
of patient autonomy, informed consent and refusal, application of advanced directives for health care, surrogate
decision makers, and the legal consequences of decisions
made in this context. The cost of care in the ICU will be
scrutinized increasingly because of economic constraints
on health care.
There is evidence that care in the ICU improves outcome
in only a small subgroup of patients admitted. Some patients
may be so critically ill with a combination of chronic and
acute disorders that no intervention will reverse or even ameliorate the course of disease. Others may be admitted with
very mild illness, and admission to the ICU rather than a
non-ICU area does not improve the outcome. On the other
hand, two other subgroups emerge from this analysis of ICU
patients. First, a small subgroup with a predictably poor outcome may have an unexpectedly successful result from ICU
care. A patient with cardiogenic shock with a predicted mortality rate of over 90% who survives because of aggressive
management and reversal of myocardial dysfunction would
fall into this group. The other small group consists of

patients admitted for monitoring purposes only or for minor
therapeutic interventions who develop severe complications
of treatment. In these patients with predicted favorable outcomes, unanticipated adverse effects of care may result in
severe morbidity or death.
Areas of critical care outcome research have, for example,
focused on the elderly, those with hematologic and other
malignancies, patients with complications of AIDS, and
those with very poor lung function from chronic obstructive
pulmonary disease, interstitial lung disease, acute respiratory
distress syndrome, multiorgan failure, or pancreatitis. Much
more needs to be learned about prognosis and factors that
determine outcome, but it is essential that data be used
appropriately and not applied indiscriminately for individual
patient decisions.
Alternatives to current care should be reviewed periodically and considered in every patient in the ICU. Some
patients may no longer require the type of care available in
the ICU; transfer to a lower level of care may benefit the
patient medically and emotionally and may decrease the

risk of complications and the costs of treatment. Admission
criteria should be reviewed regularly by the medical staff.
Similarly, ongoing resource utilization efforts should be
directed at determining which types of patients are best
served by continued ICU care.

ROLE OF THE MEDICAL DIRECTOR
OF THE INTENSIVE CARE UNIT
The medical director of the ICU has administrative and
regulatory responsibilities for this patient care area. As
medical director, leadership is vital in establishing policies

and procedures for patient care, maintaining communication across health care disciplines, developing and ensuring
quality care, and helping to provide education in a rapidly
and constantly changing medical field. The medical director and the ICU staff may choose to coordinate care in a
number of areas.

ᮣ Protocols, Practice Guidelines,
& Order Sets
A survey of outcomes from ICUs concluded that established
protocols for management of specific critical illnesses contribute to improved results. The medical director and medical
staff, nursing staff, and other health care practitioners may
choose to develop protocols that define uniformity of care or
ensure that complete orders are written. Some protocols may
be highly detailed, complete, and focused on a single clinical
condition. An example might be a protocol for treatment of
patients with suspected acute myocardial infarction—the
protocol could specify the frequency, timing, and types of cardiac enzyme or troponin determination and the timing for
ECGs and other diagnostic tests. Certain standardized medications, such as aspirin, heparin, angiotensin-converting
enzyme inhibitors, and beta-adrenergic blockers, might be
included in such a protocol, and the physician could choose
to give these or not depending on the particular clinical situation. Protocols are used by many ICUs for communityacquired pneumonia, ventilator-associated pneumonia,
sepsis, ventilator weaning, and other clinical situations.
Another type of protocol can be “driven” by critical care
nurses or respiratory therapists. In these protocols, nurses or
therapists are given orders to assess the effectiveness and side
effects of therapy and are given freedom to adjust therapy
based on these results. A protocol for aerosolized bronchodilator treatment might specify administration of albuterol by
metered-dose inhaler, but the respiratory therapist would
determine the optimal frequency and dose on the basis of how
much improvement in peak flow or FEV1 was obtained and
how much excessive tachycardia was encountered.

The ICU medical director may consider limiting the use
of certain medications based on established protocols. For
example, some antibiotics may be restricted because of cost,
toxicity, or potential for development of microbial resistance.


PHILOSOPHY & PRINCIPLES OF CRITICAL CARE
Neuromuscular blocking agents may be restricted to use only
by certain qualified personnel because of need for special
expertise in dosing or patient support. Protocols can take
several different forms, and patient care in the ICU may benefit from their development.
Physician practice guidelines are being developed for
many aspects of medical practice. Although some critics of
guidelines argue that these are unnecessarily restrictive and
that elements of medical practice cannot be rigidly defined,
practice guidelines may be useful for diagnosing and treating
patients in the ICU. Guidelines may vary from recommendations for dose and adjustment of heparin infusion for anticoagulation to specific minimum standards of care for status
asthmaticus, unstable angina, heart failure, or malignant
hypertension. Practice guidelines will be found commonly in
the ICU of the near future, and ICU directors will be called
on to develop, review, accept, or modify guidelines for individual ICUs.
The next step beyond practice guidelines is ICU order
sets. Order sets, either paper or paperless, can streamline
practice guidelines accepted by the ICU staff. Highly recommended orders can be preselected, whereas guidance may be
given for other choices. A major feature of order sets will be
reduction of errors because the order sets include preprinted
medication names, recommended dosages, and potential
drug interactions. Computerized order entry goes beyond
the ICU order set, permitting immediate dosage calculations,
for example, or other real-time recommendations. Although

some have questioned the “one size fits all” nature of order
sets, evidence suggests that there is an increase in the correct
application of evidence-based treatment with implementation of ICU order sets.

ᮣ Quality Assurance
The ICU medical director participates in quality-of-care
evaluation. Quality of care may be assessed by measurement of patient satisfaction, analyzing frequency of delivery of care, monitoring of complications, duration of
hospitalization, analysis of mortality data, and other ways.
Patient outcome eventually may emerge as the most effective global determination of the quality of care, but such
measures suffer from the difficulty in stratifying severity in
very complex patients with multiple medical problems. The
development of protocols and programs to measure and
enhance the quality of care is beyond the scope of this presentation. However, the medical and nursing leadership of the
ICU must play key roles in any such projects.
The medical director also plays an important role in
granting privileges to practice in the ICU. Competence in
and experience with medical procedures must be investigated, documented, and maintained for all physicians who
use the service. While this is especially important for invasive
procedures such as placement of pulmonary artery catheters
and endotracheal intubation, consideration also should be

ᮡ

9

given to developing and granting privileges for mechanical
ventilator management, management of shock, and other
nonprocedural care. Similarly, the skills and knowledge of
nurses, respiratory therapists, and other professionals in the
ICU should be determined, documented, and matched to

their duties. The ICU medical director has the responsibility
to develop standards for those who care for the patients in
that unit.
Effective quality improvement activities go far beyond
simple data collection and reporting. A dedicated group of
health care providers should meet regularly to review the
data, establish trends, and suggest methods for improvement. The importance of “closing the loop” in the quality
improvement process cannot be overstated. Monitoring of
outcomes after instituting change is an important part of this
activity and is mandatory if patient care is to be effectively
and expeditiously improved.

ᮣ Infection Control
Nosocomial infections are important problems in the ICU,
and their prevention and management can provide insight
into the effectiveness of protocols and quality assurance
functions. Infection control is particularly important
because of increased antimicrobial resistance of organisms
such as methicillin-resistance Staphylococcus aureus (MRSA),
multidrug-resistant Acinetobacter, vancomycin-resistant
enterococci (VRE), and Clostridium difficile. As described
elsewhere, nosocomial infections are often preventable by
adherence to procedures and policies designed to limit
spread of infection between patients and between ICU staff
and patients. The ICU medical director must take the lead in
establishing infection control protocols, including procedures for aseptic technique for invasive procedures, standards for universal precautions, duration of invasive catheter
placement, suctioning of endotracheal tubes, appropriate use
of antibiotics, procedures in the event of finding antibioticresistant microorganisms, and the need for isolation of
patients with communicable diseases. Consequently, an
important measure of the quality of care being provided is

the nosocomial infection rate in the ICU, especially intravascular infections secondary to indwelling catheters. The ICU
medical director should work closely with the nursing staff
and hospital epidemiologist in the event of excessive nosocomial infections. Often a breach in procedures can be identified and corrected. Importantly, it has been demonstrated
that simple measures to prevent infection at the time of
placement of intravenous catheters is highly effective.

ᮣ Education & Errors
The ICU medical director is required to provide educational
resources for the staff of the ICU, including critical care
nurses, respiratory therapists, occupational therapists, and
other physicians. This may be in the form of lectures, small


10

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CHAPTER 1

group discussions, audiovisual presentations, or prepared
handouts or directed readings. An effective strategy is to
focus presentations on problems recently or commonly
encountered; recent experience may help to clarify and
amplify the more didactic portion. Very often in critical care
areas there is a need for personnel to develop skills for using
new equipment such as monitors, catheters, and ventilators.
Appropriate time and feedback should be planned with the
introduction of such equipment before it can be assumed
that it can be used for patient care.
In the teaching hospital, the faculty and attending staff not

only must convey the principles of critical care practice but
also must foster an attitude of rigorous critical review of data,
cooperation between medical and other personnel, and attention to detail. The new focus on reduction of medical errors
has greatly changed the way critical care medicine is practiced. The potential for errors is enormous in the ICU. Data
show that changing error reporting from a potentially punitive system to one in which future errors are prevented is key.

ᮣ Communication
The ICU medical director serves as a communication link
between physician staff, including primary care and consulting physicians, and the nursing and other health care professional staff in the ICU. Most of this communication will
occur naturally as a result of interaction during patient care,
quality assurance activities, and other administrative meetings. On occasion, further communication is needed to
address specific complaints, procedures, or policies.
Depending on the organization of the hospital, the ICU also
may be served by a multidisciplinary committee that can
participate in development of protocols and policies. This
committee may function with respect to a single ICU in a
hospital or may have responsibility for standardization of
activities in several ICUs in the area.

studies have confirmed that a good proportion of patients
admitted to ICUs receive diagnostic studies and monitoring of physiologic variables only—ie, no therapy that could
not be given outside the ICU. On the other hand, other
patients admitted to the ICU do receive such “intensive”
therapy, and some of these have better outcomes. Because
ICU beds are a limited resource in all hospitals, ICU medical directors must develop familiarity with the overall outcomes and results of patients admitted to their ICU beds.
They will be called on not infrequently to make decisions
about admissions, discharge, and transfer from the ICU,
and these decisions at times may be arrived at painfully. As
with all decisions affecting patient care, the medical director must weigh the body of medical knowledge available;
the wishes of patients, families, and physicians; and the

likelihood or not that intensive care will benefit the patient.
At times, these decisions will involve only “medical judgment”; at other times, the choice will reflect an ethical,
legal, or philosophical perspective.
Specific practice guidelines for individual diseases have
been developed for the purpose of identifying particular
patients. Recognition that many patients previously admitted
to ICUs did not require or receive major diagnostic or therapeutic interventions led to the design of progressive care,
“step-down,” or noninvasive monitoring units in some hospitals. Equipped and staffed generally for electrocardiography, pulse oximetry, and sometimes for noninvasive
respiratory impedance plethysmography—but not for
intravascular instrumentation—these units have potential as
highly effective, less costly alternatives to ICUs. A number of
studies have provided justification for intermediate care
units either as an area for patients leaving the ICU or as an
area devoted to care of certain kinds of medical problems—
primarily mild respiratory failure, cardiac arrhythmias, or
moderately severe electrolyte disorders.

ᮣ Burnout

CRITICAL CARE SCORING

A different topic is burnout among ICU physicians, nurses,
and other health care workers. Valuable data are now available about the risks of burnout and its effects on patient
care, productivity, and career planning. Burnout is one
effect of psychosocial stress and is related to duration of
work hours, the impact of taking care of patients with critical illness, the effects of poor patient outcome despite maximal effort, and organizational issues. Intensivists, ICU
nurses, and respiratory therapists may experience occupational burnout.

The combination of an increasing patient population and
diminished funding for hospital services is creating a need

for optimized distribution of medical resources. This challenge is being met in a number of ways, including regionalization of care, specialization of critical care facilities (both
between and within hospitals), and better allocation of available personnel and equipment. To this end, the intensivist
must be prepared to make both administrative and medical
decisions about which patients will benefit most from admission to a critical care unit. Data in 1987 indicated that up to
40% of patients in ICUs were inappropriately admitted
either because they probably would have died regardless of
the care provided or because their illnesses were not lifethreatening enough to require ICU care. Indeed, a substantial
number of patients treated in critical care units at teaching
hospitals are admitted for “observation and monitoring”
only.

ᮣ Outcomes & Alternatives
In many facilities, ICU beds are limited in number, and
incoming patients with varying degrees of morbidity
often must be evaluated and compared to determine who
might best be treated in the ICU. A number of published


ᮡ

PHILOSOPHY & PRINCIPLES OF CRITICAL CARE
Illness scoring has become a popular method for triage
within and between hospitals. Many such scores have been
introduced over the past two decades in an attempt to prioritize illness and injury for ICU admission purposes. Such
scores must be used with full appreciation of their limitations. While they are useful for comparing institutional performances and outcomes in studies of certain groups of
patients, great caution must be exercised when applying
these protocols to individual patients.
The most commonly used trauma and critical care scores
are discussed below and are illustrated in the accompanying
tables.


11

Table 1–4. The Glasgow Coma Scale.
Eye

Motor

Verbal

4 = Spontaneous

6 = Obedient

5 = Oriented

3 = To Voice

5 = Purposeful

4 = Confused

2 = To pain

4 = Withdrawal

3 = Inappropriate

1 = None


3 = Flexion

2 = Incomprehensible

2 = Extension

1 = None

1 = None

Glasgow Coma Scale
The Glasgow Coma Scale assesses the extent of coma in patients
with head injuries (Table 1–4). The scale is based on eye opening, verbal response, and motor response. The total is the sum
of each of the individual responses and varies between 3 points
and 15 points. Mortality risk is correlated with the total score
and with a similar Glasgow Outcome Scale. Examination of the
patient and calculation of the score can be accomplished in less
than 1 minute. The scale is easy to use and highly reproducible
between observers. It has been incorporated into several other
scoring systems. The Glasgow Coma Scale is useful for prehospital trauma triage as well as for assessment of patient progress
after arrival and during critical care admission.

Trauma Score and Revised Trauma Score
Because of the increasing number of trauma patients admitted
to critical care facilities, familiarity with trauma scales is important. The Trauma Score is based on the Glasgow Coma Scale
and on the status of the cardiovascular and respiratory systems.

Weighted values are assigned to each parameter and summed
to obtain the total Trauma Score, which ranges from 1 to 16
(Table 1–5). Mortality risk varies inversely with this score.

After extensive use and evaluation of the Trauma Score, it
was found to underestimate the importance of head injuries.
In response to this, the Revised Trauma Score (RTS) was introduced and is now the most widely used physiologic trauma
scoring tool. It is based on the Glasgow Coma Scale, systolic
blood pressure, and respiratory rate. For evaluation of inhospital outcome, coded values of the Glasgow Coma Scale,
blood pressure, and respiratory rate are weighted and summed
(Table 1–6). Better prognosis is associated with higher values.

CRAMS Scale
The Circulation, Respiration, Abdomen, Motor, Speech
(CRAMS) Scale is another trauma triage scale that has found

Table 1–5. Trauma Score.
A. Systolic blood pressure

B. Respiratory rate

>90
70–90
59–69
<50
0

10–24
25–35
>35
10
0

4

3
2
1
0

2. Motor response
Obedient
Purposeful
Withdrawal
Flexion
Extension
None

6
5
4
3
2
1

4
3
2
1
0

C. Respiratory effort

D. Capillary refill


Normal
Shallow or retractions

1
0

3. Verbal response
Oriented
Confused
Inappropriate
Incomprehensible
None

5
4
3
2
1

Normal
Delay
None

2
1
0

(1 + 2 + 3)
14–15
11–13

8–10
5–7
3–4

5
4
3
2
1

E. 4 GCS points
1. Eye opening
Spontaneous
To voice
To pain
None

4
3
2
1

TRAUMA SCORE (A + B + C + D + E) ______