John M. O’Donnell
Flávio E. Nácul
Editors

Surgical
Intensive Care
Medicine
Third Edition

13


Surgical Intensive Care Medicine



John M. O’Donnell • Flávio E. Nácul
Editors

Surgical Intensive Care
Medicine
Third Edition


Editors
John M. O’Donnell, MD
Division of Surgery
Department of Surgical Critical Care
Lahey Hospital and Medical Center
Burlington, MA, USA

Flávio E. Nácul, MD, PhD
Critical Care Medicine
University Hospital
Federal University of Rio de Janeiro
Surgical Critical Care Medicine
Pró-Cardíaco Hospital
Rio de Janeiro, RJ, Brazil

ISBN 978-3-319-19667-1
ISBN 978-3-319-19668-8
DOI 10.1007/978-3-319-19668-8

(eBook)

Library of Congress Control Number: 2016943138
Springer Cham Heidelberg New York Dordrecht London
© Springer Science+Business Media New York 2001
© Springer Science+Business Media, LLC 2010
© Springer International Publishing Switzerland 2016
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Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www.springer.com)


This book is dedicated to my wife, Rocky, and daughter, Jacquelyn, who give
me purpose; to my beloved parents, Kay and Frank “Shorty” O’Donnell,
who never lost faith; to my mentors, medical students, and residents,
whose patience was tested every day; and to all of the nurses who have ever
cared for patients in the surgical intensive care unit at the Lahey Hospital
and Medical Center.
John M. O’Donnell, MD
To my parents Lilian and Jacob, for showing me that possibilities are infinite;
To my wife Alessandra, for her unconditional love;
To my children Mariana and Rafael, for enriching my life and making
everything worthwhile;
And to my brother Luis and my uncle Sabino, for showing me that medical
practice should be guided by kindness, knowledge, ethics, and common sense;
with admiration.
Flávio E. Nácul, MD, PhD



Preface

We are honored to present the third edition of Surgical Intensive Care Medicine and we are
very grateful for the enthusiastic reception with which the academic community received the
first two editions. Most considered them to be important contributions to the critical care literature. Although the basic organization of our new book remains unchanged, being composed of
63 carefully selected chapters divided into 11 parts, the chapters have been largely rewritten to
include the many important advances that have been made and the controversies that have
arisen over the past few years. While the chapters discuss definitions, pathophysiology, clinical
course, complications, and prognosis, the primary emphasis is devoted to patient management.

We have been extremely fortunate to attract a truly exceptional group of contributors, many of
whom are nationally and internationally recognized researchers, speakers, and practitioners in
the field of critical care medicine. An important feature of this edition is the geographical
diversity of authors. Most are based in the USA but colleagues from Australia, Belgium,
Brazil, Canada, Denmark, France, Germany, Italy, The Netherlands, Norway, Portugal,
Sweden, and the UK have also made notable contributions. The book is written for medical
students, residents, fellows, practitioners, and for all health care professionals involved in the
care of the critically ill surgical patient. We are fortunate to have Springer as our publisher and
we are especially thankful to our chapter authors and their families. We anticipate that our
book will be both educational and enjoyable and it is our hope that both our readers and their
patients will benefit.
John M. O’Donnell, MD
Burlington, MA, USA

Flávio E. Nácul, MD, PhD
Rio de Janeiro, RJ, Brazil

vii



Acknowledgements

We would first like to thank Springer Publishing Company for giving us the opportunity and
providing the support necessary to develop the third edition of Surgical Intensive Care
Medicine. We are forever grateful to Barbara Murphy, Melissa Ramondetta, and Paula
Callaghan for helping us with the publications of our first two editions. It is difficult to adequately express our appreciation and thanks to Lorraine Coffey, to whom we are indebted for
her assistance, advice, and friendship during the preparation of this present text. Without her
dedicated help, completion of this project would not have been possible. Lastly, we are especially grateful to the many colleagues who helped us by offering recommendations for improving the content and format of our textbook.
John. M. O’Donnell, MD

Flávio E. Nácul, MD, PhD

ix



Contents

Part I

Resuscitation and General Topics

1

Supplemental Oxygen Therapy ..............................................................................
Andrew G. Villanueva, Sohail K. Mahboobi, and Sana Ata

3

2

Airway Management in the Intensive Care Unit ..................................................
Catherine Kuza, Elifçe O. Cosar, and Stephen O. Heard

15

3

Vascular Cannulation ..............................................................................................
Monique Espinosa, Shawn E. Banks, and Albert J. Varon


37

4

Fluid Resuscitation...................................................................................................
N.E. Hammond, M.K. Saxena, and J.A. Myburgh

47

5

Vasopressors and Inotropes ....................................................................................
Flávio E. Nácul

55

6

Shock .........................................................................................................................
Joshua M. Glazer, Emanuel P. Rivers, and Kyle J. Gunnerson

61

7

Oxygen Transport ....................................................................................................
Michael B. Maron

81


8

Evaluation of Tissue Oxygenation ..........................................................................
Daniel de Backer and Katia Donadello

91

9

Hemodynamic Monitoring ......................................................................................
Flávio E. Nácul and John M. O’Donnell

99

10

Acid–Base.................................................................................................................. 109
Paul Elbers, Victor van Bochove, Pieter Roel Tuinman, and Rainer Gatz

11

Analgesia and Sedation............................................................................................ 119
Shaan Alli and Ruben J. Azocar

12

Neuromuscular Blocking Agents ............................................................................ 131
Gerardo Rodríguez, Ruben J. Azocar, and Rafael A. Ortega


13

Optimisation of the High-Risk Surgical Patient.................................................... 143
Hollmann D. Aya and Andrew Rhodes

14

Cardiopulmonary Resuscitation ............................................................................. 153
Andreas Schneider, Erik Popp, and Bernd W. Böttiger

Part II
15

Neurocritical Care

Management of Closed Head Injury ...................................................................... 169
Jason P. Rahal, Steven W. Hwang, and Peter K. Dempsey

xi


xii

Contents

16

Spinal Cord Injuries ................................................................................................ 181
Zarina S. Ali and Robert G. Whitmore


17

Malignant Ischemic Infarction ............................................................................... 195
Katja E. Wartenberg

18

Hemorrhagic Stroke ................................................................................................ 211
Katja E. Wartenberg

19

Status Epilepticus ..................................................................................................... 243
Andreas H. Kramer and Thomas P. Bleck

20

Delirium .................................................................................................................... 259
Bjoern Weiss, Alawi Lütz, and Claudia Spies

Part III

Cardiology

21

Management of Perioperative Hypertension ......................................................... 271
Daniela M. Darrah and Robert N. Sladen

22


Postoperative Myocardial Infarction ..................................................................... 283
Glynne D. Stanley and Sundara K. Rengasamy

23

Postoperative Arrhythmias: Diagnosis and Management.................................... 295
Eugene H. Chung and David T. Martin

Part IV

Pulmonary Medicine

24

Acute Respiratory Failure ....................................................................................... 319
Luca M. Bigatello and Rae M. Allain

25

Mechanical Ventilation ............................................................................................ 335
Virginia Radcliff and Neil MacIntyre

26

Fat Embolism Syndrome ......................................................................................... 349
John M. O’Donnell

27


Gas Embolism........................................................................................................... 357
Carl J. Borromeo

Part V

Sepsis and Infectious Diseases

28

Sepsis ......................................................................................................................... 373
Patricia Mello, Dimitri Gusmao-Flores, and R. Phillip Dellinger

29

Vascular Catheter-Related Bloodstream Infections.............................................. 389
Donald E. Craven and Kathleen A. Craven

30

Pneumonia ................................................................................................................ 407
Jana Hudcova, Kathleen A. Craven, and Donald E. Craven

31

Intra-abdominal Sepsis............................................................................................ 427
Reuben D. Shin and Peter W. Marcello

32

Evaluation of the Febrile Patient in the Intensive Care Unit ............................... 437

François Philippart, Alexis Tabah, and Jean Carlet

33

Antimicrobial Use in Surgical Intensive Care ....................................................... 449
Robert A. Duncan


Contents

xiii

Part VI

Hematology

34

Coagulation Abnormalities in Critically Ill Patients ............................................ 463
Marcel Levi and Steven M. Opal

35

Blood Products ......................................................................................................... 473
Leanne Clifford and Daryl J. Kor

Part VII

Metabolism and Nutrition


36

Hyperglycemia in the Surgical Intensive Care Unit ............................................. 497
Steven Thiessen, Ilse Vanhorebeek, and Greet Van den Berghe

37

Adrenal Insufficiency ............................................................................................... 507
Bala Venkatesh and Jeremy Cohen

38

Nutrition Support in Intensive Care ...................................................................... 517
Jan Wernerman

Part VIII

Nephrology

39

Acute Kidney Injury ................................................................................................ 529
Rashid Alobaidi and Sean M. Bagshaw

40

Disorders of Electrolytes ......................................................................................... 539
Flávio E. Nácul and José Mauro Vieira Jr.

Part IX


Gastroenterology

41

Gastrointestinal Bleeding ........................................................................................ 555
Frank M. Phillips, Sam Thomson, and Tony M. Rahman

42

Acute Pancreatitis .................................................................................................... 571
Jan J. De Waele

43

Postoperative Gastrointestinal Dysfunction .......................................................... 589
Martijn Poeze

Part X

Trauma, Surgery, Transplantation

44

Trauma ...................................................................................................................... 599
Michael S. Rosenblatt and Theodore Delmonico

45

Burns ......................................................................................................................... 611

Sara A. Mansfield and Larry M. Jones

46

Intra-Abdominal Hypertension and the Abdominal
Compartment Syndrome ......................................................................................... 621
Derek J. Roberts, Jan J. De Waele, Andrew W. Kirkpatrick,
and Manu L.N.G. Malbrain

47

Rhabdomyolysis ....................................................................................................... 645
Genevra L. Stone, Flávio E. Nácul, and John M. O’Donnell

48

Postoperative Care of the Cardiac Surgical Patient ............................................. 653
Joshua C. Grimm and Glenn J.R. Whitman


xiv

Contents

49

Postoperative Care Following Major Vascular Surgery ....................................... 669
Elrasheed S. Osman and Thomas F. Lindsay

50


Postoperative Care After Bariatric Surgery.......................................................... 679
Fredric M. Pieracci, Alfons Pomp, and Philip S. Barie

51

Care of the Organ Donor......................................................................................... 693
Marie R. Baldisseri and Younghoon Kwon

52

Postoperative Care of the Heart Transplant Patient ............................................ 701
Aida Suarez Barrientos, Georgios Karagiannis, and Nicholas R. Banner

53

Postoperative Care of the Lung-Transplant Patient ............................................. 731
Wickii T. Vigneswaran and Sangeeta M. Bhorade

Part XI

Additional Topics

54

Management of the Critically Ill Geriatric Patient .............................................. 743
Paul E. Marik

55


Critical Care Issues in Oncologic Surgery Patients .............................................. 759
Kunal P. Patel, Kaye Hale, and Stephen M. Pastores

56

Echocardiography in the Critically Ill ................................................................... 771
Viviane G. Nasr, Anam Pal, Mario Montealegre-Gallegos,
and Robina Matyal

57

Point-of-Care Ultrasound ........................................................................................ 787
Peter E. Croft and Vicki E. Noble

58

Scoring Systems and Outcome Prediction ............................................................. 817
Rui P. Moreno, Susana Afonso, and Bruno Maia

59

Long-Term Outcomes After Intensive Care .......................................................... 825
Hans Flaatten

60

Ethics in the Intensive Care Unit ............................................................................ 837
Dan R. Thompson

61


Triage of Surgical Patients for Intensive Care ...................................................... 851
Julia Sobol and Hannah Wunsch

62

Improving the Quality of Care in the ICU............................................................. 861
Asad Latif, Bradford Winters, Sean M. Berenholtz, and Christine Holzmueller

63

Continuing Education in Critical Care Medicine ................................................. 873
Todd Dorman and Michael C. Banks

Index .................................................................................................................................. 883


Contributors

Susana Afonso, MD Neurointensive Care Unit, Hospital de São José, Centro Hospitalar de
Lisboa Central, E.P.E., Lisbon, Portugal
Zarina S. Ali, MD Department of Neurosurgery, Hospital of the University of Pennsylvania,
Philadelphia, PA, USA
Rae M. Allain, MD Department of Anesthesiology, Critical Care, and Pain Medicine, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA, USA
Shaan Alli, MD Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
Rashid Alobaidi, MD Department of Pediatrics and Critical Care Medicine, Faculty of
Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
Sana Ata, MD Department of Anesthesiology and Interventional Pain Management, Lahey
Hospital and Medical Center, Burlington, MA, USA

Hollmann D. Aya, MD, EDIC. Adult Intensive Care Directorate, St George’s University
Hospital, NHS Foundation Trust and University of London, London, UK
Ruben J. Azocar, MD, FCCM Department of Anesthesiology, Tufts Medical Center, Boston,
MA, USA
Daniel de Backer, MD, PhD. Department of Intensive Care, CHIREC Hospitals, Univerisité
Libre de Bruxelles (ULB)35 rue Wayez1420, Braine L’Alleud, Belgium
Sean M. Bagshaw, MD, MSc Department of Critical Care Medicine, Faculty of Medicine
and Dentistry, University of Alberta, Edmonton, AB, Canada
Marie R. Baldisseri, MD, MPH, FCCM University of Pittsburgh Medical Center, Pittsburgh,
PA, USA
Michael C. Banks, MD Department of Anesthesiology & Critical Care Medicine, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
Shawn E. Banks, MD Department of Anesthesiology, University of Miami Miller School of
Medicine, Miami, FL, USA
Nicholas R. Banner, MD, FRCP Harefield Hospital, Royal Brompton and Harefield Hospital
NHS Foundation, Middlesex, UK
Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS New York-Presbyterian Hospital/
Weill Cornell Medical Center, New York, NY, USA
Aida Suarez Barrientos, MD Royal Brompton and Harefield Hospital NHS Foundation,
Harefield Hospital, Middlesex, UK

xv


xvi

Sean M. Berenholtz, MD MHS FCCM Department of Anesthesiology and Critical Care
Medicine, Johns Hopkins University School of Medicine, Armstrong Institute for Patient
Safety and Quality, Baltimore, MD, USA
Greet Van den Berghe, MD, PhD. Clinical Division and Laboratory of Intensive Care

Medicine, Department of Cellular and Molecular Medicine, University Hospital KU Leuven,
Leuven, Belgium
Sangeeta M. Bhorade, MD Section of Pulmonary and Critical Care Medicine, Division of
Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
Luca M. Bigatello, MD Department of Anesthesiology, Critical Care, and Pain Medicine, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA, USA
Thomas P. Bleck, MD, MCCM, FNSC Rush Medical College, Chicago, IL, USA
Victor A. van Bochove, MSc Department of Anesthesiology, Erasmus University Medical
Center, Rotterdam, The Netherlands
Carl J. Borromeo, MD Department of Anesthesiology, Lahey Hospital and Medical Center,
Burlington, MA, USA
Bernd W. Böttiger, MD Department of Anesthesiology and Intensive Care Medicine,
University Hospital of Cologne, Köln, Germany
Jean Carlet, MD Department of Medical-Surgical Intensive Care Medicine, Groupe
Hospitalier Paris Saint Joseph, Paris, France
Eugene H. Chung, MD, MSc Division of Cardiology, Cardiac Electrophysiology, Department
of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Leanne Clifford, BM, MSc Department of Anesthesiology, Mayo Clinic, Rochester, MN,
USA
Jeremy Cohen, MBBS, MD(Int.Med), FRCA, FFARCSI Burns, Trauma and Critical Care
Research Centre, University of Queensland, St Lucia, QLD, Australia
Royal Brisbane Hospital, Brisbane, QLD, Australia
Elifçe O. Cosar, MD Department of Anesthesiology, UMass Memorial Medical Center,
Worcester, MA, USA
Donald E. Craven, MD, FACP, FIDSA, FRCP(C) Infectious Diseases Research &
Prevention, Lahey Health Medical Center & Hospital, Burlington, MA, USA
Tufts University School of Medicine, Boston, MA, USA
Visiting Scientist, Harvard T. H. Chen School of Public Health, Boston, MA, USA
Kathleen A. Craven, RN, BS, MPH Preventionist and Public Health Consultant, Wellesley,
MA, USA

Peter E. Croft, BA, MD Department of Emergency Medicine, Massachusetts General
Hospital, Boston, MA, USA
Daniela M. Darrah, MD Division of Critical Care Medicine, Department of Anesthesiology,
Columbia University Medical Center, New York, NY, USA
R. Phillip Dellinger, MD Department of Medicine, Cooper Medical School of Rowan
University, Cooper University Hospital, Camden, NJ, USA
Theodore R. Delmonico, MD Department of General Surgery, Lahey Hospital and Medical
Center, Burlington, MA, USA

Contributors


Contributors

xvii

Peter K. Dempsey, MD Department of Neurosurgery, Lahey Hospital & Medical Center,
Burlington, MA, USA
Katia Donadello, MD Department of Intensive Care, Azienda Ospedaliera Universitaria
Integrata (AOUI) di Verona, Verona, Italy
Dipartimento ad Attività Integrata (DAI) di Emergenza e Terapie Intensive, U.O.C. Anestesia
e Rianimazione B, Verona, Italy
Todd Dorman, MD Department of Anesthesiology and Critical Care Medicine, Surgery and
the School of Nursing, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Robert A. Duncan, MD, MPH Tufts University School of Medicine, Boston, MA, USA
Center for Infectious Diseases & Prevention, Lahey Hospital & Medical Center, Burlington,
MA, USA
Paul W.G. Elbers, MD, PhD Department of Intensive Care Medicine, VU University Medical
Center, Amsterdam, The Netherlands
Monique Espinosa, MD Department of Anesthesiology, University of Miami Miller School

of Medicine, Miami, FL, USA
Hans Flaatten, MD, PhD General Intensive Care Unit, Haukeland University Hospital,
Bergen, Norway
Rainer Gatz, MD Department of Anesthesia and Intensive Care, Herlev Hospital, Herlev,
Denmark
Joshua M. Glazer, MD Department of Emergency Medicine, University of Michigan, Ann
Arbor, MI, USA
Joshua C. Grimm, MD Division of Cardiac Surgery, Department of Surgery, The Johns
Hopkins Hospital, Baltimore, MD, USA
Kyle J. Gunnerson, MD Department of Emergency Medicine, Division of Emergency
Critical Care, University of Michigan Health System, Ann Arbor, MI, USA
Dimitri Gusmao-Flores, MD Hospital Universitário Prof. Edgar Santos, Universidade
Federal da Bahia, Salvador, Bahia, Brazil
Kaye Hale, MD Department of Anesthesiology and Critical Care Medicine, Memorial SloanKettering Cancer Center, New York, NY, USA
Naomi E. Hammond, BN, MN (Crit. Care), MPH Malcolm Fisher Department of Intensive
Care, Royal North Shore Hospital, St. Leonards, NSW, Australia
Stephen O. Heard, MD Department of Anesthesiology, UMass Memorial Medical Center,
Worcester, MA, USA
Christine Holzmueller, BLA Department of Anesthesiology and Critical Care Medicine,
Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
Jana Hudcova, MD Department of Surgical Critical Care, Lahey Hospital and Medical
Center, Burlington, MA, USA
Steven W. Hwang, MD Department of Neurosurgery, Tufts Medical Center, Boston, MA, USA
Larry M. Jones, MD Department of Surgery, The Ohio State University Wexner Medical
Center, Columbus, OH, USA
Georgios Karagiannis, MD Royal Brompton and Harefield Hospital NHS Foundation,
Harefield Hospital, Middlesex, UK



xviii

Andrew W. Kirkpatrick, MD, MHSc Department of Surgery and the Regional Trauma
Program, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
Daryl J. Kor, MD Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
Andreas H. Kramer, MD, MSc, FRCPC Department of Critical Care Medicine & Clinical
Neurosciences, University of Calgary, Foothills Medical Center, Calgary, AB, Canada
Catherine Kuza, MD Department of Anesthesiology, UMass Memorial Medical Center,
Worcester, MA, USA
Younghoon Kwon, MD Division of Cardiology, Department of Medicine, University of
Minnesota, Minneapolis, MN, USA
Asad Latif, MD, MPH Department of Anesthesiology and Critical Care Medicine, Johns
Hopkins University School of Medicine, Armstrong Institute for Patient Safety and Quality,
Baltimore, MD, USA
Marcel Levi, MD, PhD Department of Medicine, Academic Medical Center, Amsterdam,
The Netherlands
Thomas F. Lindsay, MDCM, MSc, FRCS, FACS Division of Vascular Surgery, Department
of Surgery, University of Toronto, Toronto, ON, Canada
R. Fraser Elliot Chair in Vascular Surgery, Peter Munk Cardiac Centre, Toronto General
Hospital, University Health Network, Toronto, ON, Canada
Alawi Lüetz, MD Department of Anesthesiology and Intensive Care Medicine, CharitéUniversitaetsmedizin Berlin, Berlin, Germany
Neil MacIntyre, MD Duke University Medical Center, Durham, NC, USA
Sohail K. Mahboobi, MD Department of Anesthesiology, Lahey Hospital and Medical
Center, Burlington, MA, USA
Tufts University School of Medicine, Boston, MA, USA
Bruno Maia, MD Neurointensive Care Unit, Hospital de São José, Centro Hospitalar de
Lisboa Central, E.P.E., Lisbon, Portugal
Manu L.N.G. Malbrain, MD, PhD Department of Intensive Care, Ziekenhuis Netwerk
Antwerpen, Antwerpen, Belgium
Sara A. Mansfield, MD Department of General Surgery, The Ohio State University,

Columbus, OH, USA
Peter W. Marcello, MD Department of Colon and Rectal Surgery, Lahey Hospital & Medical
Center, Burlington, MA, USA
Paul E. Marik, MD, FCCM Department of Medicine, Eastern Virginia Medical School,
Norfolk, VA, USA
Michael B. Maron, PhD Department of Integrative Medical Sciences, Northeast Ohio
Medical University, Rootstown, OH, USA
David T. Martin, MD, FRCP, FACP, FACC, FHRS Lahey Hospital and Medical Center,
Tufts University School of Medicine, Burlington, MA, USA
Robina Matyal, MD Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel
Deaconess Medical Center, Boston, MA, USA
Mario Montealegre-Gallegos, MD Department of Anesthesia, Critical Care and Pain
Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

Contributors


Contributors

xix

Rui P. Moreno, MD, PhD Neurointensive Care Unit, Hospital de São José, Centro Hospitalar
de Lisboa Central, E.P.E., Lisbon, Portugal
John A. Myburgh, AO, MBBCh, PhD, FCICM Department of Intensive Care Medicine, St
George Hospital, Sydney, New South Wales, Australia
Flávio E. Nácul, MD, PhD Critical Care Medicine, University Hospital, Federal University
of Rio de Janeiro; Surgical Critical Care Medicine, Pró-Cardíaco Hospital, Rio de Janeiro, RJ,
Brazil
Viviane G. Nasr, MD Department of Anesthesiology and Critical Care, Boston Children’s
Hospital, Boston, MA, USA

Vicki E. Noble, MD Department of Emergency Medicine, Massachusetts General Hospital,
Boston, MA, USA
John M. O’Donnell, MD Division of Surgery, Department of Surgical Critical Care, Lahey
Hospital and Medical Center, Burlington, MA, USA
Steven M. Opal, MD Division of Infectious Diseases, The Memorial Hospital of Rhode
Island-Brown University, Pawtucket, RI, USA
Rafael A. Ortega, MD Department of Anesthesiology, Boston Medical Center, Boston, MA,
USA
Elrasheed S. Osman, MBBS, FRCSI Division of Vascular Surgery, Department of Surgery,
Toronto General Hospital, Toronto, ON, Canada
Anam Pal, MD Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess
Medical Center, Harvard Medical School, Boston, MA, USA
Stephen M. Pastores, MD Department of Anesthesiology and Critical Care Medicine,
Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Kunal P. Patel, MD Department of Critical Care Medicine, Memorial Sloan Kettering
Medical Center, New York, NY, USA
François Philippart, MD, PhD Department of Medical-Surgical Intensive Care Medicine,
Groupe Hospitalier Paris Saint Joseph, Paris, France
Frank M. Phillips, BSc, MBBS, MRCP Department of Gastroenterology, Royal Derby
Hospital, Derby, UK
Fredric M. Pieracci, MD, MPH University of Colorado School of Medicine, Denver, CO,
USA
Martijn Poeze, MD, PhD Department of Surgery and Intensive Care Medicine, Maastricht
University Medical Center, Maastricht, The Netherlands
Alfons Pomp, MD Weill Cornell Medical Center, New York Presbyterian Hospital, New
York, NY, USA
Erik Popp, MD Department of Anesthesiology, University of Heidelberg, Heidelberg,
Germany
Virginia Radcliff, MD Duke University Medical Center, Durham, NC, USA
Jason Pierce Rahal, MD Department of Neurosurgery, Lahey Hospital and Medical Center,

Burlington, MA, USA


xx

Tony M. Rahman, MA, DIC, PhD, FFICM, FRCP, FRACP Department of Gastroenterology
& Hepatology, The Prince Charles Hospital, Brisbane, QLD, Australia
Sundara K. Rengasamy, MD Department of Anesthesiology, Boston University Medical
Center, Boston, MA, USA
Andrew Rhodes, MD, FRCA, FRCP, FFICM Adult Critical Care, St George’s University
Hospital, NHS Foundation Trust and University of London, London, UK
Emanuel P. Rivers, MD, MPH Department of Emergency Medicine and Surgical Critical
Care, Henry Ford Hospital, Wayne State University, Detroit, Michigan, USA
Derek J. Roberts, BSc(Pharm), MD, PhD(Cand) Departments of Surgery and Community
Health Sciences (Division of Epidemiology), Intensive Care Unit Administration, Foothills
Medical Centre, University of Calgary, Calgary, Alberta, Canada
Gerardo Rodriguez, MD Department of Anesthesiology, Boston Medical Center, Boston,
MA, USA
Michael S. Rosenblatt, MD, MPH, MBA Department of General Surgery, Lahey Hospital
and Medical Center, Burlington, MA, USA
Manoj Saxena, MBBChir, BSc Department of Intensive Care Medicine, St. George Hospital,
Kogarah, NSW, Australia
Andreas Schneider, MD Department of Anesthesiology and Intensive Care Medicine,
University Hospital of Cologne, Köln, Germany
Reuben D. Shin, MD Department of General Surgery, Lahey Hospital and Medical Center,
Burlington, MA, USA
Robert N. Sladen, MBChB, MRCP(UK), FRCP[C] Department of Anesthesiology,
Columbia University Medical Center, New York, NY, USA
Julia Sobol, MD, MPH Department of Anesthesiology, Columbia University Medical Center,
New York, NY, USA

Claudia Spies, MD Department of Anesthesiology and Intensive Care Medicine, Charité
Campus Mitte and Charité Virchow Klinikum, Charité-Universitätsmedizin, Berlin, Germany
Glynne D. Stanley, MBChB, FRCA Plexus Anesthesia Services Management, Westwood,
MA, USA
Genevra L. Stone, MD Graduate of Tufts University School of Medicine Class of 2014,
Boston, MA, USA
Alexis Tabah, MD Burns Trauma and Critical Care Research Centre, The University of
Queensland, St Lucia, QLD, Australia
Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
Steven Thiessen, MD Clinical Division and Laboratory of Intensive Care Medicine,
Department of Cellular and Molecular Medicine, University Hospital KU Leuven, Leuven,
Belgium
Dan R. Thompson, MD, MA, MCCM Department of Surgery, Albany Medical College,
Albany, NY, USA
Sam Thomson, MD, MBBS, MRCP Department of Gastroenterology & Hepatology,
Western Sussex Hospitals NHS Foundation Trust, Worthing Hospital, West Sussex, UK
Pieter Roel Tuinman, MD, PhD Department of Intensive Care Medicine, VU University
Medical Center, The Netherlands

Contributors


Contributors

xxi

Ilse Vanhorebeek, MEng, PhD Clinical Division and Laboratory of Intensive Care Medicine,
Department of Cellular and Molecular Medicine, University Hospital KU Leuven, Leuven,
Belgium
Albert J. Varon, MD, MHPE, FCCM Department of Anesthesiology, University of Miami

Miller School of Medicine, Miami, FL, USA
Patricia Mello, MD Hospital Getulio Vargas, Universidade Federal do Piauí, Teresina, Brazil
Bala Venkatesh, MBBS, MD(Int.Med), FRCA, FFARCSI Wesley Hospital, Auchenflower,
QLD, Australia
Princess Alexandra Hospital, Harlow, UK
University of Quensland, Brisbane, QLD, Australia
University of Sydney, Sydney, Australia
José Mauro Vieira Jr. , MD, PhD Critical Care Medicine, Hospital Sírio Libanês, São Paulo,
SP, Brazil
Wickii T. Vigneswaran, MD Department of Surgery, University of Chicago Medicine,
Chicago, IL, USA
Andrew G. Villanueva, MD Department of Pulmonary and Critical Care Medicine, Lahey
Hospital and Medical Center, Burlington, MA, USA
Jan J. De Waele, MD, PhD Department of Critical Care Medicine, Ghent University Hospital,
Ghent, Belgium
Katja E. Wartenberg, MD, PhD Neurointensive Care Unit, Department of Neurology,
Martin-Luther-University, Halle, Germany
Bjoern Weiss, MD Department of Anesthesiology and Intensive Care Medicine, Charité
Campus Mitte and Charité Virchow Klinikum, Charité-Universitätsmedizin, Berlin, Germany
Jan Wernerman, MD, PhD Department of Anesthesia and Intensive Care Medicine,
Karolinska University Hospital Huddinge, Stockholm, Sweden
Glenn J.R. Whitman, MD Division of Cardiac Surgery, Department of Surgery, Johns
Hopkins Hospital, Baltimore, MD, USA
Robert G. Whitmore, MD Department of Neurosurgery, Lahey Hospital and Health System,
Tufts University School of Medicine, Burlington, MA, USA
Bradford Winters, MD, PhD Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins University School of Medicine, Armstrong Institute for Patient Safety and
Quality, Baltimore, MD, USA
Hannah Wunsch, MD, MSc Department of Critical Care Medicine, Sunnybrook Health
Sciences Centre and Department of Anesthesia, University of Toronto, Toronto, ON, Canada



Part I
Resuscitation and General Topics


1

Supplemental Oxygen Therapy
Andrew G. Villanueva, Sohail K. Mahboobi, and Sana Ata

Oxygen is the most commonly used medication in intensive
care units. Intensivists caring for critically ill patients in a
surgical intensive care unit continually face multiple diverse
and challenging problems regarding adequacy of oxygen
therapy. A fundamental goal is to provide adequate cellular
respiration and thereby maintain sufficient tissue oxygenation and normal organ function. Routinely supplemental
oxygen is being used in settings of normal oxygen saturation
believing it will increase oxygen delivery to the tissues.
Hyperoxia in the setting of decrease perfusion can result in
hyperoxia-induced tissue injury, and this narrow margin of
safety makes it important for intensivists to understand all
aspects of oxygen therapy. Successful cellular oxygenation
depends on the maintenance of several factors, including
adequate alveolar ventilation, a functioning gas-exchange
surface, the capacity to transport oxygen to the tissue, and
intact tissue respiration (the mitochondrial cytochrome oxidase system). Subsequent chapters in this textbook describe
problems with each of these factors and how intensivists
should approach and manage them. This chapter focuses on
alveolar ventilation and how to use supplemental oxygen

therapy to improve arterial oxygenation in patients who are
hypoxemic but do not require mechanical ventilation.

A.G. Villanueva, MD
Department of Pulmonary and Critical Care Medicine,
Lahey Hospital and Medical Center, Burlington, MA, USA
S.K. Mahboobi, MD (*)
Department of Anesthesiology, Lahey Hospital and Medical
Center, 41 Mall Road, Burlington, MA 01805, USA
Tufts University School of Medicine, Boston, MA, USA
e-mail:
S. Ata, MD
Department of Anesthesiology and Interventional Pain
Management, Lahey Hospital and Medical Center,
Burlington, MA, USA
e-mail:

Indications of Oxygen Therapy
The most common and important indication of oxygenation
therapy is the prevention and correction of hypoxemia aiming
to avoidance or treatment of tissue hypoxia. Other indications
for oxygen therapy include suspected hypoxemia, acute myocardial infarction, severe trauma, and postoperative recovery
from anesthesia. Early clinical findings associated with
hypoxemia include tachycardia, tachypnea, increased blood
pressure, restlessness, disorientation, headache, impaired
judgment, and confusion. Some patients may become euphoric
and lack the classic signs and symptoms of hypoxemia. Severe
hypoxemia is associated with slow and irregular respirations,
bradycardia, hypotension, convulsions, and coma.


Pathophysiology of Hypoxemia
Hypoxemia and hypoxia are not synonymous. Hypoxemia is
defined as a relative deficiency of oxygen in the arterial
blood as measured by arterial oxygen tension (PaO2).
Hypoxia is defined as inadequate oxygen tension at the cellular level. Currently, there is no way for clinicians to directly
measure hypoxia, and the diagnosis must be made indirectly
based on the assessment of organ function, oxygen delivery,
and mixed venous oxygen tension. Patients may have
hypoxia without hypoxemia, but patients cannot have sustained severe hypoxemia without developing hypoxia. It is
thus imperative to promptly treat patients who have significant hypoxemia with supplemental oxygen.
The PaO2 is determined by the inspired oxygen tension,
the alveolar ventilation, and the distribution of ventilation
and perfusion (V/Q) in the lungs. The five major mechanisms of hypoxemia are (1) decreased ambient fraction of
inspired oxygen (FiO2), (2) alveolar hypoventilation, (3) diffusion limitation across the alveolar–capillary membrane,
(4) shunt, and (5) V/Q mismatch [1]. Decreased ambient
FiO2 is generally not a cause, unless the altitude is very high.

© Springer International Publishing Switzerland 2016
J.M. O’Donnell, F.E. Nácul (eds.), Surgical Intensive Care Medicine, DOI 10.1007/978-3-319-19668-8_1

3


4

A.G. Villanueva et al.

Pure alveolar hypoventilation is often related to drug
overdose, the excess use of medications that suppress the
respiratory drive such as opiates or benzodiazepines, or catastrophic events of the central nervous system such as head

trauma, stroke, subarachnoid hemorrhage, subdural hematoma, or cerebral edema. The hypoxemia is caused by a
decrease in the alveolar oxygen tension (PAO2), which can be
measured using the alveolar gas equation:
PA O2 = FiO2 ( PB - 47 ) - PaCO2 / R
where FiO2 is the fraction of inspired oxygen (expressed as a
decimal), (PB − 47) is the barometric pressure minus water
vapor pressure, PaCO2 is the arterial carbon dioxide tension,
and R is the respiratory quotient (usually 0.8). Clinically,
hypoventilation results in a decreased PaO2 and an elevated
PaCO2. With hypoventilation, however, the alveolar–arterial
oxygen gradient ([A − a]O2) and the arterial–alveolar ratio
(PaO2/PAO2) are normal (2.5 + [0.21 × age] mmHg, and 0.77–
0.82, respectively). Diffusion limitation across the alveolar–
capillary membrane, shunt, and V/Q mismatch all causes an
abnormal [A − a]O2 and PaO2/PAO2.
Diffusion limitation across the alveolar–capillary membrane can be caused by pulmonary edema fluid or interstitial
fibrotic tissue between the alveolar epithelium and the capillary endothelium. This impaired oxygen exchange is worsened as blood transit time through the pulmonary capillaries
decreases, such as during exercise. Arterial hypoxemia secondary to diffusion defects is not common but is responsive
to an increase in PAO2 using supplemental oxygen therapy.
True shunt occurs when right-heart blood enters the left
heart without an increase in oxygen content because the
blood does not interact with alveolar gas (zero V/Q). The
shunt can be intracardiac (e.g., atrial septal defect, patent
foramen ovale) or intrapulmonary. Causes of intrapulmonary
shunting include alveolar collapse, which occurs with acute
lung injury or acute respiratory distress syndrome (ARDS),
complete lobar collapse due to retained respiratory secretions, pulmonary arterial-venous malformations, and pulmonary capillary dilatation, as is sometimes seen in liver disease
(the so-called hepatopulmonary syndrome) [2]. Oxygen therapy is of limited benefit with significantly increased shunt
because, regardless of the FiO2, oxygen transfer cannot occur
when blood does not come into contact with functional alveolar units. Therefore, true shunt pathology is refractory to

oxygen therapy. The shunt, however, can be improved if the
cause is lobar or alveolar collapse. Lobar lung collapse can
often be reversed with appropriate bronchial hygiene or
removal of the source of obstruction. Alveolar collapse
resulting from destabilization of the alveolar architecture due
to disruption of the surfactant layer, such as with acute lung
injury (ALI) or acute respiratory distress syndrome (ARDS),
can improve with the use of positive end-expiratory pressure
(PEEP), but this requires mechanical ventilation.

V/Q mismatch is defined as an imbalance between
alveolar ventilation and pulmonary capillary blood flow.
A detailed explanation of why V/Q mismatch results in
hypoxemia is beyond the scope of this chapter (see Chap.
7), but this mechanism is believed to be the most common
cause of hypoxemia [3, 4]. V/Q mismatching can result
from an array of disorders such as bronchospasm, chronic
obstructive pulmonary disease (COPD), bronchial secretions, mild pulmonary edema, interstitial lung disease,
venous thromboembolism, pleural effusion, pulmonary
contusion, aspiration of gastric contents, and pneumonia, to
name just a few. The hallmark of hypoxemia due to V/Q
mismatch is that it improves with oxygen therapy. In contrast to shunt, an increase in the FiO2 causes a substantial
increase in PaO2.

Goals of Supplemental Oxygen Therapy
A constant supply of oxygen is required for proper tissue
function as it is not stored. An adequately functioning cardiovascular system is required for adequate delivery of oxygen to the tissues. Oxygen supply must match the metabolic
demand by tissues; otherwise organ dysfunction may occur.
Oxygen delivery is the total amount of oxygen delivered to
tissues and is described by the equation:

DO2 = CaO2 ´ CO
where DO2 is oxygen delivery in ml/m, CaO2 is arterial oxygen content, and CO is cardiac output. Arterial oxygen content can be calculated by following equation:
CaO2 = SaO2 ´ Hg ´ 1.39 + PaO2 ´ 0.003
where SaO2 is arterial oxygen saturation, Hg is hemoglobin,
1.39 is oxygen carrying capacity of hemoglobin, PaO2 is
arterial partial pressure of oxygen, and 0.003 is solubility
coefficient of oxygen in plasma. In healthy persons DO2 is
more than oxygen consumption, but in critical illness, the
ability of tissues to extract oxygen is not efficient. The purpose of oxygen therapy is to correct hypoxemia by achieving
a PaO2 ≥ 60 mmHg or an arterial oxygen saturation of ≥90 %
[5]. Little additional benefit is gained from further increases
because of the functional characteristics of hemoglobin
(Fig. 1.1). Different criteria are used for patients with COPD
and chronic carbon dioxide retention. In these patients, values that define hypoxemia are PaO2 of 50–55 mmHg, corresponding to arterial oxygen saturation 88–90 % [6]. These
target values for PaO2 or arterial oxygen saturation assume
the presence of normally functioning hemoglobin. In situations with abnormal hemoglobins that cannot effectively
bind oxygen, such as methemoglobinemia or carbon monoxide poisoning, even supranormal PaO2 values may be