Ebook Principles of critical care (4th edition): Part 2

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(BQ) Part 2 book Principles of critical care presents the following contents: Neurologic disorders, hematologic and oncologic disorders, renal and metabolic disorders, gastrointestinal disorders, the surgical patient, special problems in critical care. PART / ri Neurologic Disorders h /: / a k s tt p e s /r u t c a t r/ h section06.indd 755 1/23/2015 12:55:24 PM Onset Acute (hours to days) Insidious (months to years) Course Fluctuating Progressive Diagnostic Features • Impaired ability to focus, shift • Memory impairment plus one or sustain attention of the following: • Change in cognition (eg, memory • Aphasia impairment, disorientation • Apraxia or language) or development in • Agnosia perceptual disturbances • Impaired executive functioning • Fluctuating course • Impairments must be severe enough to cause impairments in social or occupational functioning and represent a decline from baseline • Sleep/wake disturbances • Extremes in psychomotor activity • Emotional disturbances (fear, anxiety, depression, irritability, euphoria, apathy) Common Causes • Acute medical illness • Medication/substance/toxin ingestion or withdrawal • Multifactorial t c s tt p /: / a k Disturbance of consciousness, with reduced awareness of the environment and impaired ability to focus, sustain or shift attention Altered cognition (eg, memory impairment, disorientation, or language disturbance) or the development of a perceptual disturbance (eg, delusion, hallucination, or illusion) that is not better accounted for by preexisting or evolving dementia Disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day Evidence of an etiological cause, which the DSM-IV uses to classify delirium as Delirium Due to a General Medical Condition, SubstanceInduced Delirium, Delirium Due to Multiple Etiologies, or Delirium Not Otherwise Specified h Historically, two words were used to describe acutely confused patients The Roman word delirium referred to an agitated and confused person (ie, hyperactive delirium) The Greek word lethargus was used to describe a quietly confused person (ie, hypoactive delirium) ICU patients commonly demonstrate both subtypes of delirium as they progress through different stages of their illness and therapy In both subtypes, the patient’s brain is not functioning normally It therefore makes sense that the original derivation of delirium comes from the Latin word deliria, which literally means to “be out of your furrow.” For greater clarity and to avoid misuse of terms such as dementia and delirium, Table  82-1 lists basic definitions and clinical characteristics of each syndrome Delirium in the ICU has been referred to in the medical literature using a multitude of terms, including ICU psychosis, ICU syndrome, brain failure, encephalopathy, postoperative psychosis, acute organic syndrome, section06.indd 756 ­ a t r/ ­ e s /r u The American Psychological Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV describes delirium as a disturbance in consciousness and cognition that develops over a short period of time (eg, hours to days) and tends to fluctuate during the course of the day.1 Specifically, there are four criteria required to diagnose delirium1: / 9 r i h Associated Features ­ DEFINITION AND TERMINOLOGY     Dementia ­ Patients in the intensive care unit (ICU) who experience delirium are exhibiting an under-recognized form of organ dysfunction Delirium is extremely common in ICU patients as factors such as comorbidity, the acute critical illness itself, and iatrogenesis intersect to create a high-risk setting for delirium This neurologic complication is often hazardous, being associated with death, prolonged hospital stays, and long-term cognitive impairment and institutionalization Neurologic dysfunction compromises patients’ ability to be removed from mechanical ventilation or to fully recover and regain independence Unfortunately, health care providers in the ICU are unaware of delirium in many circumstances, especially those in which the patient’s delirium is manifesting predominantly as the hypoactive (quiet) subtype rather than the hyperactive (agitated) subtype Despite being often overlooked clinically, ICU delirium has increasingly been the subject of research during the past decade, which has brought to light the scope of the problem in critically ill patients and provided clinicians with tools for routinely monitoring delirium at the bedside This chapter reviews the definition and salient features of delirium, its primary risk factors, including drugs associated with the development of delirium, proposed pathophysiologic mechanisms, validated methods for bedside delirium assessment, and nonpharmacologic and pharmacologic strategies for delirium management Delirium ­ INTRODUCTION Differentiating Delirium From Dementia • Visuospatial impairment • Little/no awareness of memory impairment • Gait disturbances (falls) • Anxiety/mood/sleep disturbances ­ Nathan E Brummel Timothy D Girard TABLE 82-1 ­ 82 Delirium in the Intensive Care Unit ­ CHAPTER PART 6: Neurologic Disorders   756 • Dementia of Alzheimer type • Vascular dementia • Chronic medical conditions (eg, Pick disease, HIV, stroke, head injury) Data from American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 4th ed Text Revision Washington, D.C.: American Psychiatric Association; 2000 subacute befuddlement, and toxic confusional state.2-5 Neurologists often use “encephalopathy” to refer to hypoactive delirium and “delirium” to describe only hyperactive delirium.6 Among ICU practitioners, “delirium” is used inconsistently, as evidenced by a recent survey of Canadian intensivists that found respondents were more likely to use the term “delirium” when no specific underlying etiology could be identified for a patient with fluctuating mental status with inattention, perceptual changes, and disorganized thinking, whereas alternative terms (eg, hepatic encephalopathy) were used when the etiology of delirium was obvious.5,7 Increasingly, however, the ICU community is seeking to standardize delirium terminology to conform to the APA definition, with the hope that use of “delirium” to describe this syndrome of acute brain dysfunction, regardless of etiology, will improve cross-talk between specialists with different medical backgrounds, collaborative research efforts, and ultimately management of this widely prevalent syndrome.4 Therefore, the unifying term “delirium” should be applied whenever patients meet DSM-IV diagnostic criteria for delirium, and the underlying etiology, when known, can be used as an associated term (eg, “delirium secondary to sepsis” is preferred over “septic encephalopathy”) PREVALENCE AND SUBTYPES Delirium during critical illness occurs in 20% to 80% of ICU patients depending on the severity of illness of the population studied and methods used to detect delirium.8-16 The prevalence is highest, for example, in mechanically ventilated ICU patients, with 60% to 80% developing delirium during their ICU stay,8,10,12,14,17 whereas lower prevalence rates are reported in nonventilated patients and in mixed ICU populations.9,11,18 In general, ICU patients have a higher prevalence of delirium compared with noncritically ill hospitalized patients.19,20 The prevalence of ICU delirium will likely increase as the U.S population ages Delirium can be subtyped based on observed changes in motor activity, resulting in hypoactive, hyperactive, and mixed subtypes.21 Peterson et al reported these delirium subtypes in a cohort of 613 ventilated and nonventilated ICU patients in whom delirium was monitored for more 1/23/2015 12:55:25 PM CHAPTER 82: Delirium in the Intensive Care Unit RISK FACTORS t c       Nearly every ICU patient is exposed to one or more risk factors for delirium; the average patient in one study, in fact, had 11 identifiable risk factors for delirium.32 These risk factors may be divided into predisposing (baseline) factors and precipitating (hospitalization-related) TABLE 82-2 s tt p Risk Factors for Delirium Not modifiable or preventable h ­ h a t r/ e s Host Factors Factors Relating to Critical Illness Environmental and Iatrogenic Age Hypertension APOE-4 Preexisting cognitive impairment Alcohol use Tobacco use Depression High severity of illness Respiratory disease Medical illness Need for mechanical ventilation Number of infusing medications Lack of daylight Isolation Hearing or vision impairment Anemia Acidosis Hypotension Infection/sepsis Metabolic disturbances (eg, hypocalcemia, hyponatremia, azotemia, transaminitis, hyperamylasemia, hyperbilirubinemia) Fever Lack of visitors Sedatives/analgesics (eg, benzodiazepines and opiates) Immobility Bladder catheters Vascular catheters Gastric tubes Sleep deprivation ­ ­ Potentially modifiable/preventable / ri /r u a k /: / factors.33 Patients who are highly vulnerable to developing delirium (ie, who have multiple predisposing risk factors) may become delirious with only minor insults, whereas those with low baseline vulnerability may require a greater insult to become delirious.33 Predisposing risk factors, those related to patient characteristics or underlying chronic pathology, are difficult to alter, whereas precipitating factors, such as those related to the acute illness or the ICU environment, represent areas of risk that are modifiable or preventable (Table 82-2) Baseline risk factors that have been identified in both ICU and non-ICU populations include older age, depression, vision impairment, hearing impairment, hypertension, history of smoking, history of alcohol use, living single at home, underlying cognitive impairment or dementia, and APOE4 polymorphism.9,10,13,34-37 Numerous features of the acute critical illness have been identified as delirium risk factors in studies specifically examining ICU patients; these include admission to an ICU for a medical illness, high severity of illness (indicated by high APACHE II and SAPS II scores), need for mechanical ventilation, receipt of sedative and/or analgesic medications (particularly when used to induce coma), respiratory disease, anemia, hypotension, hypocalcemia, hyponatremia, azotemia, transaminitis, hyperamylasemia, hyperbilirubinemia, acidosis, fever, infection, sepsis, gastric tubes, bladder catheters, arterial lines, and more than three infusing medications.9,13,17,35-39 Risk factors related to the ICU environment include lack of daylight in the ICU, isolation, lack of visitors, and sleep disturbances.37,40 Though difficult to accurately measure in ICU patients, sleep deprivation is believed to be nearly universal in the ICU and has long been proposed as a risk factor for delirium The relationship, however, between sleep disturbance and delirium in the ICU remains controversial, and there is significant overlap in the symptoms of both syndromes such that either may present with inattention, fluctuating mental status and cognitive dysfunction, making it difficult to ascertain whether sleep deprivation causes delirium or vice versa.40,41 On average, ICU patients sleep between and hours in a 24-hour period, often with severe and frequent disruptions and only a small fraction of “restorative,” rapid eye movement (REM) sleep.42 In repeated studies, between one-third and one-half of patients’ sleep in the ICU occurs during daytime hours.42,43 Reasons for poor sleep in this setting are multifactorial The ICU environment, with its continuous cycle of alarms, lights, and care-related interruptions interferes with a patient’s sleep cycle and may disrupt their circadian rhythm.41,43 Acute illness, with symptoms such as nausea, pain, and fever, may also disrupt sleep Mechanically ventilated patients may additionally suffer sleep disruptions due to anxiety, ventilator dyssynchrony, central apneas, and mode of mechanical ventilation.44 ­ ­ than 20,000 observations Among patients who developed delirium, pure hyperactive delirium was rare (20 mg of lorazepam per day universally developed delirium (A) Reproduced with permission from Girard TD, Pandharipande PP, Ely EW Delirium in the intensive care unit Crit Care 2008;(12 suppl 3):S3 Similarly, daily midazolam use is associated with an increase in the proportion of days with delirium in surgical and trauma ICU patients (B) Reproduced with permission from Pandharipande P, Cotton BA, Shintani A Prevalence and risk factors for development of delirium in surgical and trauma intensive care unit patients J Trauma July 2008;65(1):34-41 and inactivation of neurotransmitters—especially acetylcholine and dopamine—that control arousal and the sleep-wake cycle are the underlying mechanism leading to delirium.49,50 Studies measuring the amount of anticholinergic activity in hospitalized patients found higher levels of serum anticholinergic activity (SAA) were associated with an increased risk of delirium, even in patients not exposed to medications with anticholinergic properties.51,52 Central cholinergic deficiency can theoretically result from derangements occurring anywhere along the continuum from acetylcholine production and release to its action on postsynaptic receptors In addition to cholinergic deficiency, dopamine excess is thought to be associated with delirium, likely via its action on central dopamine receptors that regulate acetylcholine production.50-54 Finally, imbalances in the production, release, and degradation of numerous other neurotransmitters, such as serotonin, norepinephrine, glutamate, melatonin, and gammaaminobutyric acid (GABA), have also been suspected to play a role in the development of delirium.49-54 Large neutral amino acids (LNAAs), including leucine, valine, tryptophan, tyrosine, and phenylalanine, are the precursors of several neurotransmitters that are involved in arousal, attention, and cognition and are therefore hypothesized to be involved in the pathogenesis of delirium.52 The synthesis of serotonin and melatonin depend on the availability of tryptophan, whereas the production of norepinephrine and dopamine require both tyrosine and phenylalanine The LNAAs compete for transfer across the blood-brain barrier, such that an increase in ­ ­ s tt p t c / 9 ir h a t r/ e s 4+ Log scale 55+ Original scale Midazolam ­ 80 /r u h section06.indd 758 0-1 1-2 2-3 3-4 0-2.7 2.7-7.4 7.4-20 20-55 Lorazepam dose (mg) B 100   ­ ­ ­ Finally, medications commonly given to ICU patients, such as sedatives, analgesics, vasopressors, β-agonists, and corticosteroids, disrupt slow-wave and REM sleep.45 Further study of sleep in the ICU is necessary to understand the underlying mechanisms for sleep disruption and the relationship between sleep and delirium Meanwhile, clinicians should attend to modifiable risk factors by reducing noise and light at night, minimizing other disruptions in the ICU environment, treating symptoms, and judiciously using sleep-disrupting medications The deliriogenic effects of medications given for sedation and/or analgesia—drugs used to treat nearly all ICU patients at some time during their ICU stay—have received specific attention in many studies, as they represent a potent yet potentially modifiable risk factor for delirium Though sedative and analgesic medications are prescribed to relieve pain and anxiety and to improve patient tolerance of treatments during critical illness, these medications have important side effects Continuous infusion of sedatives, for example, is associated with prolonged mechanical ventilation,31 whereas interruption of sedative infusions expedites weaning from mechanical ventilation, speeds discharge from the ICU and hospital, and improves long-term survival.12,46 Multiple studies have now clearly demonstrated a link between benzodiazepines and development of delirium Lorazepam dose was found to be an independent risk factor for the delirium in medical ICU patients, such that each day a patient was treated with the drug, the odds of being delirious the next day increased by 20% In fact, patients treated with greater than 20 mg of lorazepam in a day were nearly all delirious or comatose the following day.13 Numerous other studies have consistently found similar links between benzodiazepine administration (whether lorazepam or midazolam) and delirium in patients in surgical, trauma, burn, and mixed ICUs (Fig 82-1).14,15,17,36,38,39,47 Narcotic pain medications present a more complex picture in terms of their relationship with delirium in the ICU, in that they have been associated with development of delirium in some studies but not in others This is likely due to the differing indications for (or dual effects of) analgesics in the ICU Narcotic pain medications are associated with the development of delirium in populations frequently sedated with these drugs, such as medical and surgical ICU patients.9,17,37 In these settings, narcotics are often co-administered with benzodiazepines; in one study, elderly ICU patients treated with benzodiazepines and opioids had a longer duration of delirium.39 When narcotic medications are used to induce coma, the odds of developing delirium triple.36 Thus, clinicians should seek to minimize the use of heavily sedating medications, whether benzodiazepines or narcotics, by using evidenced based protocols to interrupt continuous sedative infusions12,46 and seek to use nonbenzodiazepine sedative medications where possible.14,15,48 Patients more often treated with narcotics because of pain, such as trauma ICU patients, are found to have a lower risk of the development of delirium when treated with fentanyl or morphine compared to patients who were not exposed to these drugs.17 Intravenous opiates and exposure to methadone was protective against development of delirium in burn ICU patients.47 1/23/2015 12:55:26 PM CHAPTER 82: Delirium in the Intensive Care Unit Medications Medical illness Surgical illness Medications Alcohol withdrawal Medications Stroke Cholinergic activation Benzodiazepine and alcohol withdrawal Cholinergic inhibition Reduced GABA activity Dopamine activation Cytokine excess GABA activation Serotonin activation / ri Benzodiazepines Hepatic failure Delirium Glutamate activation Serotonin deficiency Medications substance withdrawal 759 Cortisol excess h a t r/ Hepatic failure Alcohol withdrawal Tryptophan depletion Phenyalanine elevation Glucocorticoids Cushings syndrome Surgery Stroke Surgical illness Medical illness e s   FIGURE 82-2 Delirium pathophysiology represents a complex series of interrelated events Multiple pathways to delirium may be present in a single patient (Reproduced with permission from Flacker JM, Lipsitz LA, et al Neural mechanisms of delirium: current hypotheses and evolving concepts J Gerontol A Biol Sci Med Sci June 1999;54(6):B239-B246.) /r u a k /: / s tt p ­ ­ section06.indd 759 ­ ­ ­ h ­ ­ t c neuronal cell death, resulting in a functional disconnection between anatomical structures leading to the acute neurobehavioral changes observed in delirium.59 Indeed, recent data indicate that inflammatory biomarkers, such as procalcitonin, are associated with increased days of delirium or coma.63 Elevation of these inflammatory markers was not consistently associated with other organ failures, suggesting that systemic inflammation may modulate CNS inflammation and may be an important contributor to brain dysfunction in critically ill patients ­ one LNAA causes a decrease in the entry of other LNAAs into the brain.52 Thus, changes in serum levels of individual LNAAs may directly effect CNS neurotransmitter concentrations With this in mind, Flacker and collegues55 examined LNAA levels in acutely ill elderly medical patients and found an association between delirium and an elevated plasma phenylalanine/LNAA ratio Tryptophan/LNAA ratios are decreased and phenylalanine/LNAA ratios increased in cardiac surgery patients who developed delirium.56 Low plasma levels of tryptophan were also observed in delirious postoperative patients.57 Finally, Pandharipande and collaborators described both high and low tryptophan/LNAA ratios and high and low tyrosine/LNAA ratios as independent risk factors for delirium (with mid-range ratios being low-risk for delirium) in a cohort of mechanically ventilated ICU patients.58 These studies suggest that changes in LNAA concentrations with subsequent alterations in CNS neurotransmitter levels are important in the pathogenesis of delirium Delirium is also hypothesized to result from systemic inflammation, which occurs frequently in critical illness as a result of infection, tissue destruction, or surgery Proinflammatory cytokines, such as interleukin-1 beta, tumor necrosis factor-alpha, and interleukin-6, as  well as prostaglandins and bloodborne molecules, such as lipopolysaccharide, communicate with the brain via either direct autonomic neural pathways, active transport of cytokines across the blood-brain barrier, second messenger systems in the blood-brain barrier, or via disruption of the blood-brain barrier.59-61 Recognition of these peripheral inflammatory stimuli initiates a cascade resulting in astrocyte, microglial, and endothelial activation, leading to production of additional inflammatory cytokines, reactive oxygen species, and expansion of the microglia population, culminating in neuroinflammation and ultimately neuronal damage.59,61 Advanced age, underlying dementia, and states of chronic inflammation may “prime” microglial cells, resulting in an exaggerated inflammatory response.59-61 In addition, systemic inflammation results in endothelial damage leading to thrombin formation and vasoconstriction with resultant microvascular compromise.62 The combination of neuroinflammation and disruption of normal CNS perfusion may then impair neurotransmitter synthesis and release (particularly acetylcholine),50 impair oxidative metabolism, and deplete neuronal energy stores.52 These processes then may lead to MONITORING FOR DELIRIUM Current Society of Critical Care Medicine (SCCM) guidelines recommend that all critically ill patients be monitored for delirium as well as changes in level of consciousness.64 Bedside critical care nurses and the rest of the ICU team should use data obtained from well-validated, reliable but brief assessment tools to monitor both level (which can change frequently during critical illness) and content of consciousness, with changes in both components required before delirium is diagnosed Such neurologic monitoring can be streamlined in the ICU by using a two-step approach The first step in the neurologic assessment of an ICU patient is to assess that patient’s level of consciousness using an objective tool Though the available tools are typically referred to as sedation scales, they should be used to assess all critically ill patients—whether receiving sedation or not—and should be viewed as assessments of level of consciousness rather than solely level of sedation In addition to helping practitioners avoid oversedation, objective sedation scales provide a common language for the multidisciplinary team to use when discussing goals and treatments for patients For decades, the Ramsay Scale was the instrument most widely used in clinical practice and the published literature.65,66 The Riker Sedation-Agitation Scale67 and Richmond Agitation-Sedation Scale,68 however, have been better validated67,69 and are also being widely used.16,66,70 Chapter 22 includes a thorough discussion of how to manage sedation in the ICU The second step in the neurological assessment of an ICU patient—a step that can only be completed when a patient is not comatose—is to evaluate that patient for delirium using an objective tool Over the last 1/23/2015 12:55:27 PM 760 PART 6: Neurologic Disorders Checklist Item Altered level of consciousnessa a k A No response B Response to intense and repeated stimulation C Response to mild or moderate stimulation D Normal wakefulness E Exaggerated response to normal stimulation s tt p Inattentiveness /: / Difficulty following instructions or easily distracted Disorientation To time, place or person Hallucination-delusion-psychosis h Clinical manifestation or suggestive behavior Psychomotor agitation or retardation Agitation required use of drugs or restraints or slowing Inappropriate speech or mood Related to events or situation or incoherent speech Sleeping 2 Errors h a t r/ RASS other than zero Altered level of consciousness Current RASS level (think back to sedation assessment in step 1) RASS = zero Disorganized thinking: CAM-ICU positive Delirium present >1 error Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two? Can you use a hammer to pound a nail? e s Command: “Hold up this many fingers” (Hold up fingers) “Now the same thing with the other hand” (Do not demonstrate) Or “Add one more finger” (If patient unable to move both arms) /r u 0-1 error CAM-ICU negative No delirium FIGURE 82-3 The CAM-ICU assesses for the four features of delirium Feature is an acute change in mental status or a fluctuating mental status (first box), feature 2, is inattention, (second box), feature 3, is altered level of consciousness (third box) and feature 4, is disorganized thinking (fourth box) A patient screens positive for delirium if features and and either feature or feature are present (Used with permission of E Wesley Ely, MD and Vanderbilt University Copyright © 2002.) a k /: / s tt p 1.0 0.9 Survival probability 0.8 0.7 h 0.6 0.5 0.4 0.3 1-2 Days 3-4 Days 5-9 Days 10 + Days 0.1 0.0 75 150 225 300 375 450 Time to death (Days)   FIGURE 82-4 Survival probability and duration of delirium The hazard ratio for death at year is 1.10 (95% CI 1.02-1.18, p 450 to 500 ms or a prolongation of 25% or greater from baseline The role of novel agents, such as dexmedetomidine and rivastigmine, in delirium treatment has recently been investigated As described in the delirium prevention section above, use of the α2-agonist dexmedetomidine as a sedative for mechanically ventilated ICU patients is associated with lower rates of ICU delirium when compared with benzodiazepines Dexmedetomidine has also been compared with haloperidol as a treatment for agitated delirium in a small pilot study of mechanically ventilated patients.110 Patients treated with dexmedetomidine were more quickly extubated than those patients whose agitation was treated with haloperidol Though delirium prevalence at baseline was similar between the two groups, patients treated with dexmedetomidine may have had more rapid resolution of delirium though these results were not significantly different between groups Although further study is required, this pilot study suggests dexmedetomidine may have a role not only in preventing delirium among mechanically ventilated patients but also treating delirium in this population van Eijk explored the use of a cholinesterase inhibitor, rivastigmine, as an adjuvant treatment for ICU delirium in a population of ICU patients.111 The trial was stopped prematurely after differences in the mortality rate between the rivastigmine group (22%) and placebo (8%) met the predefined stopping criteria Further, the rivastigmine group also demonstrated a trend toward longer duration of delirium compared with placebo These results not support the use of cholinesterase inhibitors for the treatment of delirium in the ICU 763 KEY POINTS • • • Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y Intensive Care Delirium Screening Checklist: evaluation of a new screening tool Intensive Care Med May 2001;27(5):859-864 • Ely EW, Shintani A, Truman B, et al Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit JAMA April 14, 2004;291(14):1753-1762 section06.indd 763 • • ICU-acquired weakness designates clinically detected weakness in critically ill patients in whom there is no plausible etiology other than critical illness Patients can be labeled with this diagnosis with a suggestive history and when they can participate in a comprehensive bedside neuromuscular examination • Electrophysiology testing, direct muscle stimulation, and biopsy may be necessary to characterize neuromuscular injury in the patient who • KEY REFERENCES 1/23/2015 12:55:29 PM 764 PART 6: Neurologic Disorders • ­ • ­ • is unable to participate in a comprehensive neuromuscular examination, is failing to improve function despite weeks of therapy, or for the patient with asymmetric weakness • When conducted, advanced testing, particularly electrophysiology tests, can characterize the specific phenotype of ICU-AW including critical illness polyneuropathy, critical illness myopathy, a combination of the two (polyneuromyopathy), or prolonged neuromuscular blockade • The exact epidemiology of ICUAW is unknown Studies show that 46% of patients with sepsis, multiorgan failure, or prolonged mechanical ventilation are diagnosed with ICUAW In patients undergoing mechanical ventilation for days or more, 25% develop ICUAW • Factors associated with the diagnosis of ICUAW include the presence of multisystem organ dysfunction, sepsis, SIRS, and hyperglycemia and the duration of mechanical ventilation The only known therapy to prevent ICUAW has been strict glycemic control with insulin; however, adverse events with this therapy have prevented its utilization INTRODUCTION Many patients admitted to the intensive care unit (ICU) develop a syndrome of neuromuscular dysfunction characterized by generalized muscle weakness and an inability to be liberated from mechanical ventilation Since this syndrome occurs in the absence of preexisting neuromuscular disease, it is believed to reflect illnesses or treatments occurring in the ICU Early reports described two categories of acute, acquired neuromuscular dysfunction: polyneuropathy (during sepsis and multisystem organ failure)1,2 and myopathy (particularly in patients with acute respiratory failure who received glucocorticoids and/or neuromuscular blocking agents).3,4 Decades of research on this acquired nerve and muscle injury has characterized specific phenotypes via comprehensive physical examination, electrophysiologic testing, and histopathology Overall, the spectrum of neuromuscular disorders acquired in the ICU is now collectively referred to as “ICU-acquired weakness” (ICUAW) (Fig 83-1).5 The rising incidence and societal burden of critical illness—such as sepsis and the acute respiratory distress syndrome6-8—coupled with declining case fatality rates and an aging population,9,10 suggests that the number of patients with ICUAW and its sequelae may be substantial and likely to grow Accordingly, intensivists must have familiarity with the presentation of ICUAW, recognize when to conduct advanced testing, and understand the diagnostic tests involved Although currently limited in scope, measures designed to prevent or attenuate ICUAW must be considered and implemented ­ s tt p /: / CRITICAL CARE SURVIVORSHIP AND ICUAW h Critical care outcomes research has demonstrated substantial morbidity in survivors Injuries include general deconditioning, muscle weakness, dyspnea, depression, anxiety, and reduced health-related quality of life.11 CIM ICU-acquired weakness CIPNM CIP Prolonged NMJ blockade   FIGURE 83-1 Classification of intensive care unit-acquired weakness CIM, critical illness myopathy; CINM, critical illness polyneuromyopathy; CIP, critical illness polyneuropathy; NMJ, neuromuscular junction section06.indd 764 a t r/ / 9 r i h e s /r u t c a k One widely cited catalyst for attention to the burden of neuromuscular weakness was the comprehensive observations of a cohort of survivors of acute respiratory distress syndrome (ARDS) published in 2003.12 These 109 survivors were young (median age, 45 years), had few preexisting comorbidities, and were severely ill (median APACHE II score, 23) Their critical illness was marked by prolonged mechanical ventilation (median duration, 21 days) and ICU and hospital lengths of stay (median duration, 25 and 48 days, respectively) Despite severe acute lung injury, serial follow-up examination during the first year after ICU discharge demonstrated restoration of lung function Lung volumes and spirometry normalized by months and carbon monoxide diffusion capacity improved to 72% predicted at 12 months In contrast, all 109 patients reported poor function attributed to the loss of muscle bulk, proximal weakness, and fatigue One year after ICU discharge, the median distance walked in minutes was 66% of predicted and only 49% of patients had returned to work More recently, the same cohort was characterized at years after ICU discharge.13 All patients reported subjective weakness and decreased exercise capacity when compared to function before ICU admission Although there was no evidence of clinical weakness on examination, the median distance walked in minutes remained lower than expected based on age and sex (76% predicted) By the fifth year, 77% of patients had returned to work; however, patients often required a modified work schedule, gradual transition back to work, or job retraining In addition, patients were plagued with the psychological ramifications of their severe illness; more than half of survivors experienced at least one episode of physician-confirmed depression or anxiety Others have reported similar findings of post-ARDS debilitation Specifically, an observational trial of 112 ARDS survivors without baseline impaired physical function noted a 66% cumulative incidence of physical impairment during year follow-up.14 This impairment, defined as the acquisition of two or more dependencies in instrumental activities of daily living, had greatest incidence by months after discharge and was associated with longer ICU stay and prior depressive symptoms More recently, a comprehensive year follow-up of patients enrolled in a randomized controlled trial of nutritional strategies in patient with ARDS demonstrated that survivors, regardless of nutritional strategy, experienced substantial impairments in endurance (as defined by six minute walk test) and cognitive function.15 Acquired neuromuscular weakness and loss of function have been measured in other contexts of critical illness, including severe sepsis and mechanical ventilation in the elderly To determine the impact of a hospitalization for severe sepsis, Iwashyna and colleagues utilized The Health and Retirement Study, a cohort of Americans over age 50 undergoing biennial surveys of physical and cognitive function.16 Participants were stratified into those surviving a hospitalization for severe sepsis (n = 516) versus controls (survivors of a nonsepsis hospitalization, n = 4517) Among patients with no functional limitations at baseline, severe sepsis was associated with the development of 1.57 new limitations (95% CI: 0.99-2.15), as well as a more rapid rate of development of functional limitations after hospitalization (0.51 new limitations per year, p = 0.007 compared with baseline) The study also found that the incidence of severe sepsis was highly associated with progression to moderate to severe cognitive impairment In a similar design, Barnato et al used a longitudinal cohort study of Medicare recipients to investigate the association of mechanical ventilation and disability.17 Community dwelling patients over age 65 completed quarterly interviews of physical function for four years Survivors of hospitalization with or without mechanical ventilation had similar levels of disability from each other, but significantly more than those who were never hospitalized There was a substantial increase in disability in both groups after hospitalization, greater among survivors of mechanical ventilation than in those hospitalized without mechanical ventilation In adjusted analyses, mechanical ventilation was associated with a 30% greater disability in activities of daily living (ADLs) and a 14% greater disability in mobility 1/23/2015 12:55:29 PM Index novel modes of, 434–439 addressing improved patient ventilator interactions, 437–438, 438f clinical challenges facing clinicians, 434–435, 434f strategies addressing challenge of balancing gas exchange versus vili, 435–437 in pregnancy, 1267–1268, 1267t sleep and, 159–160 Meckel diverticulum, 1021 Medical anthropologists, use of narrative by, 116 Medical dermatoses, 1290–1296 bullous pemphigoid, 1292, 1292f edema bullae, 1295–1296, 1296f erythroderma, 1293, 1293ft graft-versus-host disease, 1294–1295 pemphigus vulgaris, 1290–1292, 1291f psoriasis, 1292–1293, 1292f purpura, 1294 Medical informatics, 49–50 Medical schools and residency programs, teaching critical care in curricula of, Medical surge intensive-care unit exercises related to needs for, 58 modeling for patients and resources, 58–59 Medication-induced thrombocytopenia, 850–851, 850t, 851t MELD score, 223 Meleney gangrene, 690, 691 Meleney ulcers, 691 Meningitis, 638, 837 bacterial, 652 clinical presentation, 652–658, 653–654 diagnosis of, 654 due to aerobic gram negative bacilli, 653 epidemiology and etiology, 652–653, 652t pneumococcal, 652–653 prevention, 657–658 sickle cell disease and, 911 treatment of, 654–657, 654f, 655t, 656t Meningococcemia, 1298–1299, 1299f, 1300ft Meningococcus, infection control and, 31 Meperidine, 151 Mephedrone (4-MMC), 560 Meropenem, 546 MERS-CoV, 720 Mesenteric ischemia, 1036–1044, 1037t anatomy and dynamics of mesenteric circulation, 1036–1037, 1037f clinical presentation of, 1039–1040 control of circulation, 1037–1038, 1038t diagnosis of acute, 1040–1042, 1040f, 1041f intestinal risk factors, 1039 management of, 1042–1043 nonocclusive, 1039 pathophysiology of intestinal ischemia, 1038 prognosis, thyroid function, 1037 systemic response to revascularization, 1039 Mesenteric venous thrombosis, 1039 Meta-analysis of ECMO trials and ARDS, 478–479 Metabolic acidosis, 932 in acute kidney injury, 932 bicarbonate therapy of, 261 Metabolic alkalosis, 932, 951 acid-base balance and, 973 in acute kidney injury, 932 Metabolic disorders, specific, 969–970 Metabolic disturbances, acid-base balance and, 969 Metabolic emergencies, 877–878, 878f Metabolic management in head injury, 1136–1137 glycemic control in, 1136–1137 thyroid function in, 1137 Metabolism, sepsis and, 574 Methanol, 1208 Methemoglobinemia, 1218–1219 Methicillin-resistant Staphylococcus aureus (MRSA), 559 Methodologic rigor, 85 Methotrexate, use of, in critically ill patient, 1251 Methotrexate pneumonitis, rheumatoid arthritis and, 1244 Methylprednisolone, spinal injuries and, 1150 MHLA-DR, 555–556 Microcosting, 42 Microhematuria, 1166 Microscopic injury, 440–441 Microvascular pressure, 1048 Midazolam, 152 for refractory status epilepticus, 786 for status epilepticus, 785 Miliaria, 1304, 1304f Miliaria crystallina, 1304, 1304f Minimal conscious, 830 Minitracheostomy, 395 Mirizzi syndrome, 999 Mitochondrial myopathy, 828 Mitral regurgitation, 350–351, 350f clinical presentation in, 350–351 diagnostic evaluation in, 351 etiology in, 350 management of, 351 pathophysiology in, 350 Mitral stenosis, 348–350 clinical presentation of, 349 diagnostic evaluation of, 349 management of, 349 pathophysiology of, 348–349, 349f Mitral valve, systolic anterior motion of, 1069 Mitral valve operations, 1069 Mixed antagonists response syndrome (MARS), 551 Mobile computing, 52–53, 53f Mobility, sepsis and, 575 Mobilization of critically ill patient, 163 Model of End-Stage Liver Disease (MELD), 1097 Models of quality, 11 Modular Emergency Medical System (MEMS), 59, 61, 61ft Monoclonal antibodies, 604 Monocyte dysfunction, 555 /: / a k s tt p h Index.indd 1347 t c Monomorphic ventricular tachycardia, 284–285 Monotherapy, 547 Morbidity, preventing, in intensive-care unit, 32–37, 33f, 35f, 36f integrated approach to patient safety, 36 preventable versus inevitable harm, 32 safety, taxonomy of patient issues, 33–36, 34t, 35f Morel-Lavallee lesion, 1172, 1172f Morphine, 150–151 Mortality probability model at zero hours, sepsis and, 569 Mortality Probability Model (MPM) scoring system, 89 Mortality Probability Model (MPM II) scoring system, 85, 88, 91 Motility agents, 137 Motility as host defense, 704 Mucomycosis, 976 Multidetector computed tomography (MDCT), 1141 Multidrug resistant tuberculosis (MDR-TB), 635 Multifactorial respiratory failure, 487–495, 492t Multinational Association for Supportive Care in Cancer (MASCC), 603 Multiorgan donor, 1108–1115 declaration of brain death, 1109 evaluation of potential, 1110–1113 cardiac evaluation, 1111–1112, 1112t donor-related malignancies, 1111, 1112t liver, 1113 pulmonary, 1112–1113, 1112t renal, 1113, 1113f screening for infectious agents, 1110–1111, 1111t management of, 1113–1115 request for consent, 1109–1110 Multiorgan dysfunction, effects of, 1237 Multiple autoantibodies and multisystem inflammatory disease, 1245 Multiple-dose activated charcoal (MDAC), 1204 Multiple myeloma, 947 Multiple Organ Dysfunction Score (MODS), 89 Multisystem trauma deciding on surgical intervention, 1121 priorities in, 1116–1121 adequacy of perfusion, 1118–1119, 1119t airway, oxygenation, ventilation, and cervical spine control, 1117 cervical spine protection, 1118 detailed systematic assessment and definitive care, 1120 fracture stabilization, 1120 locating source of internal hemorrhage, 1119 neurologic status, 1119–1120 reevaluation and monitoring patient, 1120–1121 surgical airway, 1117–1118, 1117f ventilation, 1118 / ri h a t r/ e s /r u 1347 23-01-2015 15:33:53 1348 Index Mumps virus, 674 Monro-Kellie doctrine, 788 Murray Valley encephalitis virus, 672 Muscle relaxants and airway management in intensive-care unit, 388 Myasthenia gravis (MG), 821, 825–826, 1265 Mycobacterium avium complex, 640–641 Mycobacterium tuberculosis, 635–636, 675 during pregnancy, 1265 Mycophenolate mofetil, 1089 use of, in critically ill patient, 1251 Mycoplasma pneumoniae, 675, 676 Mycotic aneurysms, 597, 686–687 Myelitis, 665 Myeloid cells, soluble triggering receptor expressed on, 567 Myeloid sarcoma, 867 Myeloma, multiple, 947 Myelosuppression, 601–603, 602f, 893–894, 894t Myocardial acidosis, 272 Myocardial function, maximizing, 315–316 Myocardial hypoxia, 272 Myocardial infarction, 294 induced hypothermia in, 177 Myocardial ischemia, 272, 293–308, 1069 cardiac biomarkers, 295–296 echocardiography, 296 electrocardiogram, 295 hemodynamic monitoring, 296–297, 296t management of angina, 297–298 non-ST elevation myocardial infarction, 302–305 pathophysiology, 294, 294f signs and symptoms, 294–295 silent, 295 ST-elevation myocardial infarction, 298– 302 terminology, 293–294 Myoclonic jerks, 781 Myoclonus in postanoxic coma, 781 Myoglobin, 1178 Myonecrosis, 690, 694–695, 694f etiology, 694 management of, 695 pathogenesis of, 694 presentation of, 694–695 Myopathy, 768, 768t Myotonia, 1062 Myxedema coma diagnosis of, 988, 989t pulmonary and cardiovascular complications, 988–989 thyroid disease and, 988–990, 989t treatment of, 989–990 s tt p N Naloxone, 1196 Narrative, use of, by medical anthropologists, 116 Nasopharynx, 404 Nasotracheal intubation, 389 National Quality Forum, 11 Native valve endocarditis (NVE), 594 Near-infrared spectroscopy (NIRS), 244 Neck, life-threatening infections of, 676–688 Neuromuscular junction blockade, prolonged, 768–769 Neuroprotection, spinal injuries and, 1150 Neuropsychological morbidities, healthrelated quality of life and, 105–106 Neurosurgical management issues, spinal injuries and, 1146–1147, 1146f, 1147f, 1148f, 1149–1150, 1149f Neutropenia, 601–603, 602f, 893–894 in burn patients, 1187 Neutropenic fevers, 606–615 diagnosis of, 606–608, 607t, 608f empirical antimicrobial therapy for, 609–615, 610t, 611t, 614t infections and bacterial pathogens causing, 605–606 risk assessment in, 608–609 Neutropenic host, infection prevention in, 622–624 Neutropenics, 603 Neutrophilic eccrine hidradenitis, 1285 New directions, sepsis and, 575–576 Nicardipine, 364 Nikolsky sign, 1291, 1294, 1298 Nipah virus, 674 Nitrates, 297, 301 Nitric oxide, 316–317 Nitric oxide inhibitor, 1279 No Code order, 128 Nondepolarizing neuromuscular blocking agents (NMBs), 154 Nondialytic supportive care of acute renal failure, 931–932, 932t Nonhemorrhagic hypovolemia, 237 Noninflammatory diarrhea, 706 Noninvasive leg studies in diagnosing pulmonary embolic disorders, 325 Noninvasive positive pressure ventilation (NPPV), 501 in critically ill traveler, 715–716 Noninvasive ventilation, 160, 377–384 acute exacerbation of chronic respiratory failure in, 379–381 cardiogenic pulmonary edema in, 381 epidemiology of, 378–379, 378f equipment in, 379 fiberoptic bronchoscopy in, 383–384 hypoxemic respiratory failure in, 381–382 new modes of, 383 patients who should not be intubated, 383 patients with severe acute asthma, 383 postextubation respiratory failure in, 383 postoperative respiratory failure in, 383 preoxygenation before intubation, 382 rationale and objective in, 377–378 subgroups in, 382 trauma in, 384 weaning in, 383 Nonobstructive jaundice, 999 Nonocclusive mesenteric ischemia, 1039 Nonphysician providers, intensive-care unit staffing of, as physician extenders, 17–19, 17t, 18t Nonpolio enteroviruses, 673 a t r/ e s /r u t c a k /: / h Index.indd 1348 Neck surgery emergencies, 1076 Necrosis, 328 cellular, 1124 Necrotizing enterocolitis, 616–617, 868 Necrotizing fasciitis, 690, 691–694, 692f, 693f, 1296–1297, 1297f etiology of, 692 management of, 693–694 pathogenesis of, 691–692 presentation of, 692–693 sepsis and, 567 Needle cricothyroidotomy, 392 Negative pressure ventilation, 380 Neisseria meningitides, meningitis due to, 652 Neonatal encephalitis, 670 Neonatal thyrotoxicosis, thyroid disease and, 995–996 Neostigmine, 1007–1008 Nephritis, acute focal bacterial, 700 Nephrogenic systemic sclerosis, risk of, 209 Nephrostomy, percutaneous, 211–212, 211f, 212f Nephrotoxic injury, 920 Neurally adjusted ventilatory assistance, 438 Neuraxial opiate analgesia, 147–148 Neurocognitive impairments, 111–113 Neurogenesis, 1124 Neurogenic hypotension, 1144 Neurogenic shock, 260 Neuroleptic malignant syndrome, 560–561 Neurologic, electrical trauma and, 1178 Neurological outcome, spinal injuries and, 1152 Neurologic complications, 899–900 Neurologic criteria, declaration of death using, 838 Neurologic emergencies, 875–877, 875t, 876t Neurologic examinations, 831–832 Neurologic injury after carotid revascularization, 1075–1076, 1075t extremity trauma and, 1173–1174 Neurologic manifestations in HIV-infected patients, 637–638, 637–638t Neurologic states resembling brain death, 839 Neuromonitoring issues, head injury and, 1129 Neuromuscular blockade, 1061 complications of, 155 monitoring level of, 154–155 Neuromuscular blocking agents, 154–155 nondepolarizing, 154 for tetanus, 732 Neuromuscular diseases leading to respiratory failure, 821–828 general assessment and management, 821–828, 821t, 822t of acute respiratory failure secondary to, 823–828 respiratory muscle weakness, 821–823, 823f Neuromuscular dysfunction, 106, 106f Neuromuscular injury, adjunctive testing for, 766–769, 767f, 768t / 9 r i h 23-01-2015 15:33:53 1349 Index Non-Q-wave myocardial infarction, 294 Non-ST elevation myocardial infarction, 302–305 Nonsteroidal anti-inflammatory drugs (NSAIDS), acute renal failure and, 921–922 Nonthyroidal illness syndrome, thyroid disease and, 987 Nonvariceal hemorrhage, 1014–1018 No-reflow phenomenon, 1038 Normal colonizing flora as host defense, 704 Normothermia, maintaining, 840 Nosocomial sinusitis, 686 Nuclear scintigraphy, 219, 219f Null hypothesis, 47 Number needed to treat (NNT), 46 Nurses, bedside, 19–21 Nursing staffing ratios in intensive-care unit, 24 Nutrition, 1046–1047 in acute pancreatitis, 1034 in critically ill, 132–141 achieving access, 136 assessing tolerance, 136 importance of maintaining gastrointestinal integrity, 135 readiness for enteral nutrition, 135 relationship of gastrointestinal tract, immune system, and ischemia/ reperfusion injury, 133, 133f, 134f, 135 screening and assessment, 135–136 strategies to maximize benefits and minimize risks of enteral nutrition, 136–141 in head injury, 1136–1137 glycemic control in, 1136–1137 thyroid function in, 1137 obesity and, 1310 in pregnancy, 1269 sepsis and, 574 spinal injuries and, 1151 Observational studies, 45 in glycemic control, 143 Obstructive jaundice, 999 Obstructive shock, 258 Occupational health, intensive-care unit and, 30 Oculocephalic reflex, 834 Oculovestibular reflexes, 834 Odontoid fractures, 1147 Ogilvie syndrome, pathogenesis of, 1007 Olanzapine, 153 Omega-3 fatty acids, 138–139 Omsk hemorrhagic fever, 738 Oncologic emergencies, 872–881 cardiac tamponade, 880, 880f leukostasis, 878–879 metabolic, 877–878, 878f neurologic, 875–877, 875t, 876t respiratory, 873–874, 873f superior vena cava syndrome, 879–880, 879f Open heart surgery, cardiac surgery emergencies and, 1067–1077, 1068f, 1071f, 1073t, 1074f, 1076t, 1077t Open intensive-care unit, 16 Open pneumothorax, 1154–1155, 1155f Opioids, 1219 Opportunistic filamentous fungal infections, 619 Opportunistic infections, 640–641 Opportunity costs, 40 Oral direct thrombin inhibitors, 849, 855 Organ dysfunction in sepsis, 565–566 Organ failure, management of, and treatment-related complications, 864–865 Organophosphate and carbamate insecticides, 1219–1220, 1219t Organophosphate toxicity, 828 Organ perfusion pressure, 242 Organ systems assessment of perfusion, 252–253 individual, 260–261 pathophysiology of shock, 260–261 Organ transplantation See specific organ Oropharyngeal mucosal and esophageal infections, 615–616 Oropharynx, 404 Orotracheal intubation, 388–389 Orthomyxoviridae, 673–674 Osler nodes, 1299, 1299f Osmolality, 944 Osmotic demyelination syndrome, 950 Osmotic edema, 794 Ossification, heterotopic, 109, 109f Osteogenesis imperfecta, 1062 Osteoporosis, 327 Otitis externa, malignant, 686 Outcome measures, 39–40 Outcome validated, 13 Oxazolidinones, 548, 548t Oxidant injury, 454 Oximetry arterial pulse, 242–243, 243f tissue, 244–245 /: / a k s tt p O Obesity cardiovascular effects and, 1306–1307 drug dosing and, 1310 nutritional support and, 1310 pulmonary effects and, 1307–1308 respiratory failure and, 1308–1309, 1309f vascular access and, 1310 weight loss and, 1311 Obesity epidemic, 1305–1311 defining, 1305 magnitude of problem, 1305–1306, 1306f management of respiratory failure, 1308–1309, 1309f physiologic effects of extreme, 1306–1308, 1306t cardiovascular effects, 1306–1307 pulmonary effects, 1307–1308 problems in delivery of critical care, 1310, 1310t weight loss and, 1311 Obscure bleeding, 1020–1021 lesions associated with, 1021 h Index.indd 1349 t c P Pacemaker and defibrillator infections, 598 Pacing modality, choice of, 290 Paclitaxel, 897 Pain assessment and management, in palliative care, 122–123 Palliative care in intensive-care units, 120–123, 121f, 124t interface between end-of-life care, critical care and, 121 pain assessment and management in, 122–123 spiritual support in, 122–123 Pancreatic injuries, 1163 Pancreatic pseudocyst, 1163 Papilledema, 799 Paradoxical gas embolism, 1321 Paraganglioma, 1076 Paralysis/paresis, after thoracic aortic surgery, 1072 Paramyxoviridae, 674 Paranasal sinusitis, 658 Parapneumonic effusions, 583 Parathyroid crisis, 960 Parenteral nutrition maximizing benefits and minimizing risks of, 140–141 role of, 139–140 sepsis and, 574 Parenteral nutrition-associated cholestasis, 1000–1001 Pareto, Vilfredo, 38f Pareto optimal, 38 Parotitis, suppurative, 669f, 683 Paroxysmal sympathetic hyperactivity, 1127 Passive leg raising (PLR), 264 Passive range of motion, 163 Pathogens, 742 preventing transmission of, between intensive-care unit personnel and patients, 28–30, 29t Pathophysiology of circulation in critical illness, 228–241, 229f, 230f, 231ft, 233f, 234f, 236t, 238f, 239f, 240ft, 241f Patient health record (PHR), 55 Patients with coagulation or platelet disorders, 332 diagnostic approach to sepsis, 566–567 ensuring all receive therapy, 33 monitoring of, in interventional radiology, 209 preventing transmission of pathogens between intensive-care unit personnel and, 28–30, 29t Patient safety integrated approach to, 36 taxonomy of, 33–36, 34t, 35f Patient Self-Determination Act (PSDA) (1988), 128 Patient-ventilator synchrony, 432, 432f, 435 / ri h a t r/ e s /r u venous, 243–244, 244t Oxygen, sickle cell disease and, 912 Oxygen countercurrent exchange, 1037 23-01-2015 15:33:53 1350 Index Pattern recognition receptors (PRRs), 552 Pediatric cardiac arrest, 167 Pediatric Risk of Mortality (PRISM) score, 85 Pelvic ring injuries, 1168–1172, 1168t anatomy, 1168–1169, 1169f clinical assessment, 1170, 1171f complications, 1172, 1172f management of, 1170–1172, 1171f mechanism and injury classification, 1169–1170, 1180f radiographic assessment, 1170, 1171f Pemphigus vulgaris, 1290–1292, 1291f Penicillins, 545, 549t Pentamidine, 632 Pentax AWS™, 390 Pentobarbital, 1135 Pentobarbital coma, 810 Peptic ulcers, endoscopic therapy for, 1014–1017, 1015f, 1016f Percutaneous abscess drainage, 209–211, 210f Percutaneous cholecystostomy, 212–214, 213f, 214f Percutaneous dilational tracheostomy, 399 technique of, 399–400 Percutaneous nephrostomy, 211–212, 211f, 212f Percutaneous tracheostomy, 394–395 Performance, 33 measuring, 33 statistical control charts for monitoring, 9t, 10 Pericardial diseases, 336–343 acute pericarditis, 336–338 diagnosis of, 336–337, 337ft management of, 337–338 cardiac tamponade, 338–340 diagnosis of, 338–339, 338f invasive hemodynamics, 339, 339f pathophysiology, 338 pericardiocentesis, 339–340, 339f constrictive pericarditis, 340–342 cardiac catheterization, 342 clinical evaluation, 341 echocardiography, 341–342, 342f pathophysiology, 340, 341f treatment of, 342 Pericardial effusions, 880 Pericardial friction rub, 337 Pericardial tamponade, 198, 200f Pericardiocentesis, 305, 339–340, 339f Pericardium, 336 Pericranial infections, 685–686, 685t Periengraftment respiratory distress syndrome, 887 Perinephric abscess, 700 Perioperative lung dysfunction, predicting, 1052 Perioperative management, sickle cell disease and, 912 Perioperative respiratory failure, 1048–1053 pulmonary edema, 1048–1049 alveolar hypoventilation, 1051–1052 s tt p h Index.indd 1350 aspiration, 1052 atelectasis, 1049–1051, 1049f, 1052ft predicting and preventing perioperative lung dysfunction, 1052 treatment principles for perioperative respiratory failure, 1052–1053 Perioperative ß-blockade, 1056 Peripheral nerve injuries, 1178 Perirectal infections, 617 Peritonitis primary, 1079–1080 secondary bacterial, 1080–1082, 1081t, 1082f Peritonsillar abscesses, 407, 680f, 683–684 Persistent fever, 557–562 differential diagnosis of fever in ICU, 558, 558t epidemiology and impact of, 557–558 selected infectious causes of, 558–559 selected noninfectious causes of hyperthermia and, 559–561 temperature regulation and measurement, 557, 557f treatment of, 561 Persistent vegetative state, 829–830 prognosis and, 838–839 Pharmacists, intensive-care unit staffing by, 21–22 Pharmacodynamic modeling, 1226–1227 Pharmacodynamics in critically ill patients, 544–545, 544f Pharmacogenetics, 1234t, 1235, 1235t, 1236 Pharmacokinetics in critically ill patients, 544–545, 544f Pharmacologic agents, 107 Pharmacologic anticoagulants, 854–855 Pharmacologic control of blood pressure, 363–365 acute management of, 363–364, 363t chronic management of, 364 definitive management of, 364–365, 365f Pharmacologic therapy of cardiac arrest, 173, 173t Pharmacology See Critical care pharmacology Phase II enzyme polymorphism, 1236 Phenobarbital for status epilepticus, 784–785 Pheochromocytoma, 260, 1076 Phosphorus, 962–965 hyperphosphatemia, 964–965, 965t hypophosphatemia, 962–964, 963t, 964t metabolism, 962 renal handling of, 962 Physical therapy, 162–166 active range of motion, 163–164 assistive technologies, 165 bed rest and immobility, 162 early mobilization, 164–165 inactivity and muscle weakness, 162–163 inactivity and other organ system injury, 163 mobilization of critically ill patient, 163 passive range of motion, 163 practical implementation of an exercise and mobilization program in acute care intensive-care unit, 165–166 survivorship, 162 /: / a k t c a t r/ e s /r u Physician-assisted death (PAD), 128 Physician extenders, nonphysician providers as, 17–19, 17t, 18t Physician orders for life-sustaining treatment (POLST), 127 Physiological regulation of blood glucose, 142, 142f Physiologic response to anemia, 842 PiCCO™ system, 247, 248 Picornaviridae, 672–673 Picture Archiving and Communication System (PACS), 55 Pinch-off phenomenon, 225, 225f Pinch purpura, 1294 Plague, 719, 745–747 Plasmapheresis/therapeutic plasma exchange in critically ill patient, 1253 Plasma viral load, 626 Platelet activating factor (PAF), 565 Platelet-derived growth factor (PDGF), 566 Platelet disorders, 332, 849–853, 850t, 851t Platelet glycoprotein receptors, disorders of, 846 Platelet physiology and function, 846 Platelet transfusion, 856 Pleural effusion, 507, 507f Pleural pressure, dynamic predictors relying on perturbing, 264–265 Pneumococcal meningitis, 652–653 Pneumocystis jiroveci pneumonia, 629–635 clinical and radiologic features, 630, 635f diagnosis of, 630–631 management of, 632, 632–634t prognosis, 634–635 Pneumonia, 559, 576–587 bronchiolitis obliterans organizing, 888 community-acquired complications, 583–584 criteria for ICU, 582, 582t diagnosis of, 581–582, 581t epidemiology, 580 etiologic spectrum, 580–581, 581t prevention of, 584 treatment of, 583, 583t community-acquired pneumonia, 580–584 as complication of drowning, 1325 general treatment strategies antibiotic, 580 septic shock, 580 ventilatory support, 580 health-care associated, 584–585 definition, 584 epidemiology of, 584 etiologic spectrum and recommended antibiotic therapy, 584–585 hospital-acquired, 585–587 altered pathogenesis and pathophysiology, 585 antibiotic therapy, 586–587, 586t diagnosis of, 585, 585t etiologic spectrum, 585–586 prevention, 587, 587t / 9 r i h 23-01-2015 15:33:53 Index pathogenesis, 577 aspiration in, 577–578, 578f bacterial milieu, 577, 577t host defense, 578–579 pathophysiology bacterial responses, 579, 579f host response, 579 hypotension, 579 hypoxemia, 579 respiratory failure, 579 Pneumocystis jiroveci, 629–635 clinical and radiologic features, 630, 635f diagnosis of, 630–631 management of, 632, 632–634t prognosis, 634–635 ventilator-associated, 388, 424, 520–535, 570, 629 diagnosis of, 525–529, 526f, 527f difficulty in, 14 difficulty in diagnosing, 14 epidemiology of, 521–522 evidence of, 46 predisposing factors, 522–525, 523t prevention of, 532–535 sensitive indicator for, treatment of, 529–532 Pneumothorax, 185, 505, 1156 open, 1154–1155, 1155f tension, 1154, 1154f Pocket infection, 591 Poison control centers, 1203 Poisoning, 1208–1210 Poliovirus, 672 Polymorphic ventricular tachycardia, 285–286 Polymyositis, 821, 826–827 Polymyositis/dermatomyositis, 1244 Polymyxins, 547, 549t Polyneuromyopathy, 768 Polyneuropathy, critical illness and, 106–107, 767–768, 767t Portal hypertensive gastropathy, 223 Portal vein patency, verification of, 223 Portopulmonary hypertension, 1028 Positive end-expiratory pressure (PEEP), 439, 441, 443 Positive pressure ventilation, complications of, 378 Posterior reversible edema syndrome (PRES), 819 Postextubation respiratory failure, 383 Postextubation stridor, 408 Postherpetic neuralgia, 670 Postinfarction ischemia, 305 Postintubation hypotension, 501 Postoperative critical care, 1067–1077, 1068f, 1071f, 1073t, 1074f, 1075t, 1076t general postoperative and trauma care and surgical emergencies, 1062–1067, 1063–1065t, 1066t immediate postanesthesia, 1061–1062, 1062t emergence, 1061 malignant hyperthermia, 1061–1062, 1062t postoperative extubation, 1061 principles of, 1060–1077 principles of open heart surgery and cardiac surgery emergencies, 1067–1077, 1068f, 1071f, 1073t, 1074, f Postoperative hyponatremia, 948 Postoperative ileus, 1006 Postoperative pain, as risk factor for delirium, 1054–1055, 1054t Postoperative respiratory failure, 383 Postpericardiotomy syndrome, 1072 Post-randomized confounding, 45–46 Postrenal acute renal failure, 919 Postreperfusion syndrome, 1075–1076, 1075t Postthrombotic syndrome, 218 Posttransfusion purpura, 852 Posttraumatic stress disorder (PTSD), 111, 1189 corticosteroids in treating, 985 family members risk for, 117 Posturing, 800, 800f Potassium, 950–957 hypokalemia, 951–954, 951t, 953f metabolism, 950–951, 950f Powassan virus, 672 Practice, translating evidence into, 33 Pragmatic effectiveness trials, 40 Prasugrel, 300 Preeclampsia, 927, 1261–1263 Pregnancy acute renal failure and, 927 in critical illness, 1254–1269 circulatory disorders of, 1256–1264, 1256t, 1257ft, 1258t, 1260t, 1262t, 1266t physiology of, 1254–1256, 1254t, 1255t respiratory disorders of, 1264–1268 pulmonary embolism in, 332 thyroid storm in, 993 Pregnancy-associated thrombotic thrombocytopenic purpura, 860 Preoperative assessment of high-risk surgical patient, 1053–1060 of cardiac morbidity for noncardiac surgery, 1055, 1055t of perioperative central nervous system risk, 1054–1055, 1054t risk modification, 1055–1057 of risk of postoperative pulmonary complications, 1057–1060 screening, 1053–1054, 1054t Preoperative coronary revascularization, 1055–1056 Preoperative respiratory failure, treatment principles for, 1052–1053 Preoxygenation before intubation, 382 Preparedness for catastrophe, 56–62 hazard vulnerability analysis and, 57–58, 58t integration of intensive-care unit into hospital and community emergency planning, 59–61, 60ft, 62f intensive care units and, 57–58, 58t modeling for medical surge patients and resources, 58–59 preparation and planning, 57 /: / a k s tt p h Index.indd 1351 t c role of exercises related to intensive-care unit needs for medical surge, 58 surging critical care resources, 59 Prerenal azotemia, 917–918 Pressure Recording Analytical Method (PRAM), 248 Pressure-targeted breaths enhancements on volume feedback control of, 437–438 volume feedback control of, 437 Pressure ulcers, 1304 Priapism, sickle cell disease and, 912 Primary hyperparathyroidism, 960 Primary PCI in acute myocardial infarction, 299–300, 299t, 300ft Primary peritonitis, 1079–1080 Primary survey, 250–253 airway in, 250–251, 251t breathing in, 251 circulation in, 251–252, 252f Proarrhythmia, 279 Procalcitonin, 582 sepsis and, 567–568, 568t Procedural proficiency, 18 Process of care, 11 Progressive bacterial synergistic gangrene, 690 Project IMPACT, 11 Prophylactic hyperventilation, 812 Prophylaxis against venous thromboembolism, 332–333 Propofol, 152, 1133, 1135 Proportional assist ventilation, 437–438 Prostaglandin E1 (PGE1, alprostadil), 316–317 Prostanoid, 316 Prostatic abscess, 701 Prostatitis, acute, 701 Prosthetic valve dysfunction, 352–354 structural failure of prosthetic valves, 354 thrombosis, 353–354, 353f Prosthetic valve thrombosis, 353–354, 353f Proteases, 565 Prothrombin time (PT), 847 Protocol-driven resuscitations, consequences of, 2–3 Protozoan, 675–676 PROWESS SHOCK, 92 Pseudohyponatremia, 947 Pseudomonas bacteremia, 1298, 1298f Pseudoobstruction, 1006–1008 treatment of colonic, 1007 Psoriasis, 1292–1293, 1292f Pseudothrombocytopenia, 849–850 Psychiatric morbidity, 110–111 Psychogenic polydipsia, 948 Psychological problems, high-risk situations for relatives to develop, 117 Psychological stress and damage, strategies for preventing, 117–119, 119t Public health, impact of critically ill travelers on, 720–721 Public health informatics, 50 / ri h a t r/ e s /r u 1351 23-01-2015 15:33:53 1352 Index Public Health Service Panel on CostEffectiveness in Health and Medicine, United States (PCEHM), 39 Public reporting of quality metrics, 10–11 Pulmonary angiography in diagnosing pulmonary embolic disorders, 326 Pulmonary artery catheters, 24–25, 24t, 245–246, 456–457 in burn patients, 1186 distal tip thermistor, 246 in diagnosing right heart syndromes, 312 Pulmonary artery hypertension, 259 Pulmonary artery occlusion pressure, 263 Pulmonary artery pressure, hypercapnia and, 317 Pulmonary barotrauma, 1321 Pulmonary capillary permeability, 1048–1049 Pulmonary circulation edema, 239–240, 240f pressures, flow, and resistance in pulmonary vessels, 238–239, 239f Pulmonary crackles, 259 Pulmonary edema, 239–240, 240f, 1048–1049 diagnosis and management of, 200–201 Pulmonary effects, obesity and, 1307–1308 Pulmonary embolic disorders See Air embolism; Fat embolism; Pulmonary thromboembolism Pulmonary embolism, 221, 873–874, 873f ECMO for, 481 spinal injuries and, 1151 Pulmonary evaluation in organ transplantation, 1112–1113, 1112t Pulmonary fibrosis, 517–520 acute cardiopulmonary failure, 518 cardiovascular management of, 519 detecting reversible features, 519, 519t effects on pulmonary circulation, 518 gas exchange, 518 laboratory abnormalities, 517–518 long-term management of idiopathic, 520 outcome, 518–519 oxygen therapy, 519 respiratory mechanics, 518 ventilator management of, 519–520 Pulmonary function abnormalities, 109 Pulmonary gas exchange, abnormalities in, 372–373 Pulmonary hypertension, 312, 1103, 1307 acute-on-chronic, 314, 314t scleroderma and, 1243 sickle cell disease and, 910–911, 911f Pulmonary infiltrates in HIV-infected individuals, 636–638, 637–638t Pulmonary overpressurization, 1321 Pulmonary resection surgery, evaluation of risk prior to, 1057–1058 Pulmonary risk, clinical assessment of, 1057–1060 Pulmonary system, electrical trauma and, 1178 Pulmonary thromboembolism, 318–333 clinical manifestations history, examination, and laboratory data, 321, 321t s tt p h Index.indd 1352 signs from more invasive monitoring, 321–322 diagnosis of empirical, 324f, 326 risk factors, 322, 323f special problems in intensive-care unit, 322, 323f tests, 323–326, 324f, 325t epidemiology of, in intensive-care unit, 318–321 pathophysiology, 319–321, 319f, 320f, 321f prophylaxis against venous thromboembolism, 332–333 air embolism, 333–335 fat embolism, 335–336, 335t special considerations chronic obstructive pulmonary disease, 332 patients with coagulation or platelet disorders, 332 pregnancy, 332 treatment of, 326–332 anticoagulation, 327–329 prognosis and intensity of, 326–327 supportive care, 327 Pulmonary toxicity, 894–896, 895t Pulmonary vasodilator therapy, 259 Pulmonary venoocclusive disease, 895 Pulseless electrical activity, 170, 170t Pulse oximetry, 243 arterial blood gases and, 498 Pulse pressure waveform analysis, 247–248 Pump failure, 309 Pumpless, extracorporeal lung assist (PECLA), 471 Pupillary reflex, 833 Purpura, 1294, 1294t, 1295f posttransfusion, 852 Push enteroscopy, 1020–1021 Puumala virus, 742 P values, 9, 46–47 confidence intervals, and power, 46–47 Pyelonephritis, emphysematous, 701 Pyocystitis, 701 Pyonephrosis, 212, 700 Pyuria, 696 a k t c /: / Q Q fever, 751 QRS complexes, 280 Qualitative data, role in critical care research and, 48 Quality defining, indicators in, 8–9, 8t models of, 11 reasons for measuring, 7–8 Quality assurance, Quality indicators in critical care, 12–15, 14t Quality measurement research concepts relevant to, 9–10, 9t bias in, 9, 9t chance, 9, 9t confounding measures, 9t, 10 regression to the mean, 9–10, 9t / 9 R Rabies virus, 673 Radiography in diagnosing right heart syndromes, 311 Radiology, interventional, 209 RAMPART trial, 784 Ramsay Hunt syndrome, 670 Ramsay Sedation Score, 148 Randomized controlled trials, 45–46 Range of motion active, 163–164 passive, 163 Rapidly progressive glomerulonephritis, 922 Rapid response teams, 77–83 conditions reviewed and interventions performed, 81 deterioration of patients, 80, 81f evidence for effectiveness of, 81–83, 82f nomenclature surrounding, 81 outcomes of cardiac arrests, 80 principles underlying, 80–81, 80f, 81t serious adverse events in hospitalized patients, 77, 78t preceded by signs of instability, 77, 78–79t, 79–80, 80f Rate-based indicator, 8–9 Rebleeding, 776 Recluse spider bite, 1223 Recombinant human activated protein C, sepsis and, 574 Recompression therapy, in decompression illness, 1322–1323, 1323f Red blood cell transfusions, 842 in critical illness, 843 during initial resuscitation, 252 Reduced intensity conditioning (RIC), 603 Refractory angina, 298 Refractory hepatic hydrothorax, 223 Refractory hypoxemia, 517 Refractory status epilepticus (RSE), 780, 785, 875 Regionalization, 62 barriers in, 64, 64t evidence in, 63–64 implementation strategies in, 64, 65ft potential benefits in, 63 role of intensivists in, 64 special challenges in, 68 unintended consequences in, 63 Regional techniques for analgesia, 147–148 Regression to the mean, 9–10, 9t Rehabilitation, spinal injuries and, 1152 Reliability, 85 a t r/ e s /r u secular trends, 9t, 10 statistical control charts for performance monitoring, 10 sources of variability in, 11 Quality metrics, public reporting of, 10–11 Quality of life, health-related, 104–105 Quality scale, 11 Questioning approach, learning and using, in critical care, Quetiapine, 153 Q-wave myocardial infarction, 294 r i h 23-01-2015 15:33:53 Index Remifentanil, 151 Remote monitoring, 64 Renal abscess, 700 sickle cell disease and, 907 Renal adaptation in pregnancy, 1255 Renal cysts, 700–701 Renal dysfunction, electric trauma and, 1177–1178 Renal evaluation, in organ transplantation, 1113, 1113f Renal excretion, 1230–1232 Renal failure acid-base balance and, 971–972 assessment of, 208 systemic lupus erythematosus and, 1242 Renal function, monitoring, in intensive care unit, 922–923, 923f RenalGuard system, 921 Renal insufficiency, interventional radiology and, 209 Renal replacement therapy, 549–550 defined, 933 dose of therapy, 938–939, 940t future directions, 942–943 indications for and timing of initiation, 933–934, 933t, 935t in intensive care unit, 932–943 modality of acid-base disturbance, 937 acute liver failure, 936–937 acute-neurologic injury, 937 diffusive versus convective therapies, 938 hyperphosphatemia, 937 intermittent versus continuous delivery, 934–936 severe sepsis, 937–938 supportive care medication dosing, 942 nutritional support, 941–942 sepsis and, 574–575 technical aspects access, 939–940 anticoagulation, 940–941 Renal salt wasting, 1128 Renal syndrome, hemorrhagic fever with, 742–743 Renal toxicities, 898–899, 899t Renal transplantation, acute renal failure and, 928 Renal tubular acidosis, 972–973 acid-base balance and, 972–973 Renal vasodilators in acute renal failure, 930–931, 930f Renal vein thrombosis, 922 Reperfusion therapy, 307 Rescue therapies for life-threatening hypoxia minimizing ventilatorinduced lung injury, 447–448, 448f Research concepts relevant to quality measurement, 9–10, 9t bias in, 9, 9t chance in, 9, 9t confounding measures in, 9t, 10 regression to the mean in, 9–10, 9t secular trends in, 9t, 10 statistical control charts for performance monitoring in, 9t Respiratory abnormalities, ventilator management of, 458–459, 458f, 459f, 460f, 461ft, 462t, 463ft, 464t, 465t, 467f Respiratory acid-base disorders acid-base balance and, 974 pathophysiology of, 974 Respiratory alkalosis, 497, 951, 974 Respiratory complications, with spinal injuries, 1143–1144, 1143f Respiratory conditions requiring extracorporeal membrane oxygenation (ECMO), 470, 471t Respiratory disease complicating HIV infection, 629, 629f Respiratory disorders acid-base balance and, 969 in pregnancy, 1264–1268 in sepsis, 565 Respiratory failure neuromuscular diseases leading to, 23–828 obesity and, 1308–1309, 1309f polymyositis/dermatomyositis and, 1244 Respiratory infections in pregnancy, 1265–1266 Respiratory management, head injury and, 1125–1126 Respiratory mechanics, abnormalities in, 373–374, 373f, 374f Respiratory muscle fatigue, 485, 516 Respiratory muscle weakness, 821–823, 823f Respiratory syncytial virus, infection control and, 30–31 Respiratory system, adaptation of, in pregnancy, 1255, 1255t Respiratory therapists, intensive-care unit staffing by, 21–22 Respiratory therapy equipment and nasogastric tubes, 25–26, 26t Respiratory tract infection, 645 Respiratory virus infections, 617 Restaurant syndromes, 1275 Reston ebolavirus, 740 Restrictive cardiomyopathy, 198 Restrictive disease of respiratory system, 513–520 acute cardiopulmonary failure, 515 etiology, 515–516 hemodynamic management of, 516 intubation and mechanical ventilation, 516–517 long-term management of, 517 noninvasive ventilation, 516 outcome, 515 oxygen therapy, 516 pulmonary fibrosis, 517–520 acute cardiopulmonary failure, 518 cardiovascular management of, 519 /: / a k s tt p h Index.indd 1353 t c detecting reversible features, 519, 519t effects on pulmonary circulation, 518 gas exchange, 518 laboratory abnormalities, 517–518 long-term management of idiopathic, 520 outcome, 518–519 oxygen therapy, 519 respiratory mechanics, 518 ventilator management of, 519–520 thoracic cage deformity, 513–515, 513t, 514f effects on pulmonary circulation, 515 gas exchange, 515 respiratory mechanics, 514, 514f, 515f Resuscitation catheters and monitoring during initial, 254 red blood cell transfusion during, 252 Resuscitation goals, in burn patients, 184, 1185f Reteplase, 299 Reticular activating system, 830–831 Retiform purpura, 1294, 1295f Retinoic acid syndrome, 895 Retroperitoneal hemorrhage, 1166 Retropharyngeal abscesses, 683 Reynold pentad, 999 Rhabdomyolysis, 977, 1213 Rhabdoviridae, 673 Rheumatoid arthritis, 409, 826, 1244–1245 Rheumatoid factor, 1249 Rheumatologic diseases in intensive care unit (ICU), outcomes of patients with, 1245 Rheumatology in intensive care unit (ICU), 1241–1253 abdominal pain and elevated erythrocyte sedimentation rate, 1246 autoinflammatory diseases, 1245 central nervous system dysfunction, 1246–1247 elderly patient with elevated sedimentation rate, 1246 empirical therapy for suspected rheumatic disease, 1253 interpretation of rheumatology laboratory abnormalities in, 1247–1250 ischemic digits, 1247 lung infiltrates and elevated sedimentation rate, 1247 lung infiltrates in renal failure, 1246 multiple autoantibodies and multisystem inflammatory disease, 1245 outcomes of patients with rheumatologic diseases in, 1245 polymyositis/dermatomyositis, 1244 rheumatoid arthritis, 1244–1245 scleroderma, 1243–1244 systemic lupus erythematosus, 1242–1243 use of corticosteroids, immunosuppressives and anti-inflammatory drugs in critically ill patient, 1250–1253 / ri h a t r/ e s /r u 1353 23-01-2015 15:33:53 1354 Index Rhinocerebral mucomycosis, 686 Rib fractures, 1160 Richmond Agitation-Sedation Scale (RASS), 148, 148t, 759 Ricin toxin, 751 Rickettsial diseases, 718–719 Rocky Mountain spotted fever as, 718–719 Rifabutin, 641 RIFLE classification of acute kidney injury, 916, 916f modification of, 916–917 Rift Valley fever, 718, 741 Right atrial pressure, 263 Right heart dysfunction, 309 Right heart syndromes pathophysiology of, 309–312, 309f, 310t, 311f, 312ft recognizing, 310–312, 310t Right ventricle afterload, reducing, 316–317 Right ventricle dilation, 312–313 Right ventricle ischemia, reducing, 316–317 Right ventricular dysfunction, mechanisms and management of, 275–276 Right ventricular failure, 258, 1103 diagnosis and management of, 258–259 Right ventricular infarction, 198–199, 306, 312–313 Right ventricular overload, infarction and, 236t, 237–238 Right ventricular physiology, 309 Riker Sedation-Agitation Scale, 759 Risk-adjusted CUSUM charts, 13 Risk-adjusted p charts, 13 Risk ratio, 46 Risperidone, 153 Rituximab, 604 Robustness, sensitivity analysis and, 42–43, 43f Rocky Mountain spotted fever, 676, 718–719, 1299 Rocuronium, 154 Rubella virus, 673 Rumack-Matthew nomogram, 1207, 1207f, 1208 s tt p h S Saaremaa virus, 742 SAFE clinical trial, 572 Safety question of, 32 science of, 32–33, 33t Safety infrastructure, investing in, 34 Safety scorecard, 36–37 St Louis encephalitis, 672 Salicylates, 1220–1221, 1220t, 1221t Salvage therapy, for endoscopically uncontrolled bleeding, 1009–1010 SAPS II scoring system, 85, 89, 568 Sarcopenia of aging, 108 SARS, 57, 720 Scleroderma, 1243–1244 Index.indd 1354 ScvO2, 244, 244t Seasonal influenza, 716 Secondary bacterial peritonitis, 1080–1082, 1081t, 1082f Secondary data use for practice monitoring and research, 54, 54f Secular trends research concepts relevant to quality measurement and, 9t, 10 Sedation assessing adequacy of, 148, 148t drugs for, of mechanically ventilated patients, 149–153, 150f, 151t, 152t indications for, 145–146 sleep and, 160–161, 160t spinal injuries and, 1151 Sedation Agitation Scale (SAS), 148 Sedatives, 112–113 administering, in intensive-care unit, 148–149 Seizures in intensive care unit, 779–786 classification of, 780–781 clinical manifestations, 781–782 diagnostic approach, 782–783 epidemiology and outcome, 779–780, 779t management approach, 783–786, 783t, 785t pathogenesis and pathophysiology, 781 international League Against Epilepsy’s (ILAE) classification of, 780 Selected dermatoses miliaria, 1304, 1304f pressure ulcers, 1304 Selective serotonin reuptake inhibitors, 1221–1222, 1221t Self-contained underwater breathing apparatus (SCUBA), 1319 Selye, Hans, 980 Sensitivity analysis, 40, 42 robustness and, 42–43, 43f Sensitivity of test, 47 Sentinel bleed, postoperative hemorrhage and, 1067 Seoul virus, 742 Sepsis, 263, 562–576 abdomen as occult source of, 1083, 1083ft acute liver failure and, 1024 acute physiology and chronic health evaluation, 568 antibiotic therapy for, 569–570 biliary tract, 1080 biomarkers of, 567 brain injury associated with, 113 bundles, 573–574, 574t in burn patients, 1187 cardiac output and fluid responsiveness, 569 as cause of pulmonary hypertension, 313 central venous pressure, 569 cirrhosis and, 1030 corticosteroids, 573 C-reactive protein, 567 definitions and epidemiology, 562–564, 563ft /: / a k t c a t r/ e s /r u microbiological causes, 563 related epidemiological phenomena of, 563–564 sources of, 563 extravascular lung water, 569 fluid therapy for, 570–572, 571t glycemic control, 575 hemodynamic management of, 572–573 immunoparalysis and, 551–556 apoptosis, 555 appropriate diagnostic tools and monitoring, 555–556 clinical evidence and relevance of immunosuppression, 554 definition of systemic sepsisinduced, 553 evolution to immunoparalysis, 553, 553f future therapeutic approaches, 556 history—definition, 551 measurement of cell surface markers, 554–555 measurement of circulating mediators, 554 modification of, 554–556 natural history of infection and sepsis syndrome, 551–552 Interleukin-6 (IL-6), 567 laboratory studies and radiologic imaging, 567 mobility, 575 monitoring, hemodynamic and cardiopulmonary monitoring in, 569 mortality probability model at zero hours, 569 new directions, 575–576 nutrition and metabolism, 574 organ dysfunction in, 565–566 pathophysiology, 564–565, 564f microbiology, 564–565 patient presentation and diagnostic approach, 566–567 procalcitonin, 567–568, 568t recombinant human activated protein C, 574 renal replacement therapy, 574–575 sequential organ failure assessment, 568–569 sickle cell disease and, 911 simplified acute physiology score, 568 soluble triggering receptor expressed on myeloid cells, 567 source control for, 570 sources of, 563 systemic inflammatory response syndrome (SIRS) and, 107 venous oxygen saturation, 569 venous thromboembolism and stress ulcer prophylaxis, 575 Sepsis bundles, 573–574, 574t Septic encephalopathy, 818–819 Septic intracranial thrombophlebitis, 686–687 Septic myocardial dysfunction, 272 Septic myocardium, 236 / 9 r i h 23-01-2015 15:33:53 Index Septic shock, 229f, 236, 236t, 259, 563 in pregnancy, 1260–1261, 1260t Sequential Organ Failure Assessment (SOFA) scoring system, 85, 88, 89 sepsis and, 568–569 Serotonin syndrome, 560, 561t Severe sepsis, 937–938 Severity index score, 568, 568t Shingles, 670 Shock, 249–262 adrenal, 238 anaphylactic, 238, 260 cardiogenic, 229f, 236–237, 256–257t, 258–259, 306–307, 306f circulatory, 243 defined, 249–250 electric, 1176 establishing working diagnosis of cause of, 249–250, 250f hypovolemic, 237, 254–256, 254f, 255–256, 255f, 260 inflammatory component of, 260 multiple etiologies of, 238 neurogenic, 238, 260 obstructive, 258 organ system pathophysiology of, 260–261 right heart dysfunction as cause of, 309 role of fluids in, 263 septic, 229f, 236, 236t, 259, 563 spinal, 1145–1146 therapeutic interventions and, 261 treatment of, 728 types of, 254–256, 257t, 258–260 untreated, 261 urgent initial resuscitation, 250–254, 251t, 252f, 253t Shock liver, 1001 Shock lung, 261 Shock-wave lithotripsy, 213 Sickle cell anemia, 903 Sickle cell disease, 902–914, 903f baseline physiology, 904–905, 905t, 906ft common clinical problems, 906–907 eye disease, 906 heart disease, 906–907 hepatobiliary, 907 lung disease, 906 renal, 907 skeletal, 907 skin, 907 splenic, 907 stroke, 906 vaso-occlusive pain crisis, 906 general background for, 902–903 genetics and epidemiology, 903 homozygous, 903 pathophysiology, 904, 904t, 905f special problems in intensive care unit, 907–912, 907t acute chest syndrome, 907–908, 908t, 909f, 910, 910t perioperative management of, 912 priapism, 912 pulmonary hypertension, 910–911, 911f sepsis and meningitis, 911 splenic sequestration and infarction, 911–912 stroke, 911 treatments, 912–914 analgesics, 912–913, 912t, 913t glucocorticoids, 914 hydroxyurea, 914 incentive spirometry, 913 investigational, 914 oxygen and fluids, 912 transfusion, 913–914, 913t, 914t Silent ischemia, 295 Simple hemopneumothorax, 1160 Simplified acute physiology score, sepsis and, 568 Simplified Acute Physiology Score (SAPS II) scoring system, 93, 94, 379 Sinusitis, 524–525, 559 nosocomial, 686 Sinus tachycardia, 498 Sirolimus, 1089, 1100 Skeletal system, sickle cell disease and, 907 Skin, sickle cell disease and, 907 Skull fractures, 1122, 1122f Sleep, 155–161 after intensive care, 161 architecture, 156–157, 157f circadian rhythmicity in critically ill patient, 158–159 in critically ill patient, 159–161, 159t mechanical ventilation and, 159–160 physiologic changes during normal, 157–158 potential adverse effects of disruption in critically ill patients, 158, 158t promoting, in intensive-care unit, 161 sedation and, 160–161, 160t sleep-wake regulation, 156 Sleep deprivation, 157 Slow continuous ultrafiltration (SCUF), 933 Small bowel feeding, role of, 137 Small bowel obstruction, 1005–1006, 1020–1021 Smallpox, 749–750, 1302 Snake bite, 1222 Snare device, 226 Society of Interventional Radiology Guidelines, for use of inferior vena cava (IVC) filters, 221 Sodium, 944–950 hypernatremia, 945–947, 946ft, 947f hyponatremia, 947–950, 947f, 948ft metabolism, 944–945, 944t Sodium nitroprusside, 364 Sodium thiosulfate, 1215 Soft tissue infections, 688–695 classification of, 688–690, 689t major, 690–695 anaerobic cellulitis, 691 cellulitis, 690–691 myonecrosis, 694–695, 694f necrotizing fasciitis, 691–694, 692f, 693f /: / a k s tt p h Index.indd 1355 t c Solid organ infiltration, 868 Soluble clotting factors, coagulation cascade and, 846–847, 847t Soluble triggering receptor expressed on myeloid cells, sepsis and, 567 Source control, for sepsis, 570 South American hemorrhagic fevers, 739 Specificity of test, 47 Specific metabolic disorders, acid-base balance and, 969–970 Spectrum of disability, clinical phenotypes in critical illness and, 107–108, 108f Spider bite, 1222–1223 Spinal cord injuries, 1178 Spinal injuries, 1137–1152, 1138t, 1139f airway, breathing, and respiratory issues, 1142–1144 complications, 1143–1144, 1143f ventilator weaning and tracheostomy, 1144 bleeding and transfusion issues, 1146 cervical spine clearance, 1150 classification of vertebral injuries, 1138–1139, 1140t diagnostic imaging, 1141–1142, 1141f, 1142f epidemiology of, 1138 gastrointestinal tract issues, 1152 general management issues after acute, 1141 genitourinary tract issues, 1152 health care-associated infections, 1151 hemodynamic issues autonomic dysreflexia, 1145 cardiovascular complications and neurogenic shock, 1144–1146, 1145f management of instability, 1145 monitoring, 1144 spinal shock, 1145–1146 intensive care unit management, 1142 neurological outcome, 1152 neuroprotection, 1150 neurosurgical management issues, 1146–1147, 1146f, 1147f, 1148f, 1149–1150, 1149f nutritional support issues, 1151 glycemic control, 1151 primary versus secondary, 1139–1140 rehabilitation, 1152 sedation issues, 1151 temperature regulation and hypothermia, 1150–1151 venous thromboembolism, 1151 Spinal paralysis, 1320 Spinal shock, 1145–1146 Spiritual support, in palliative care, 122–123 Spleen injuries, 1165 Splenic abscess, 1082 Splenic sequestration, 911–912 sickle cell disease and, 912 Splenic system, sickle cell disease and, 907 Splinter hemorrhages, 1299 SpO2, clinical uses of, 243 / ri h a t r/ e s /r u 1355 23-01-2015 15:33:54 1356 Index Spontaneous bacterial peritonitis, ascites and, 1029–1030 Spontaneous breathing trial (SBT), ventilated patients receiving, 8, 536 Spontaneous subarachnoid hemorrhage (SAH), 771 Spurious thrombocytopenia, 849–850 S-ßo-Thalassemia, 903 S-ß+-Thalassemia, 903 StO2 vascular occlusion test, 245, 245t Stable angina, 294 Standard care, defining, 42 Standardized mortality rates (SMRs), 13 Standard precautions, 28 Staphylococcal scalded skin syndrome, 1297, 1298f Starling curve of the heart, 230–231, 230f Starling function curve, 268 Static echocardiographic, ultrasound predictors and, 263–264 Statistical control charts for performance monitoring, research concepts relevant to quality measurement and, 9t, 10 Status asthmaticus, 496–505 clinical presentation, differential diagnosis, and assessment of severity admission criteria, 498–500 measurement of airflow obstruction, 498 pulse oximetry and arterial blood gases, 498 radiographic studies, 498 management of intubated asthmatic administration of bronchodilators during mechanical ventilation, 504 extubation, 504 intubation, 501–504, 502f, 503f pathophysiology, 497 therapy prior to intubation noninvasive positive pressure ventilation, 501 pharmacotherapy, 499–500, 499t Status epilepticus, 780, 784–785, 875, 875t refractory, 785 ST-elevation myocardial infarction, 298–302 Sternal wound infection and dehiscence, 1071–1072, 1071f Steroids, 253 Stevens-Johnson syndrome and toxic epidermal necrolysis, 1287–1289, 1287f, 1288t, 1289t Stewart-Hamilton equation, 245 Stomach injuries, 1162 Stomatitis, 1284 Stone dissolution, 213 Store-and-forward, 64 Streptokinase, 299 Stress-related mucosal damage, 1017–1018 Stress ulcer prophylaxis, 523, 534 Stress ulcers, 575 in burn patients, 1187 s tt p h Index.indd 1356 Stroke induced hypothermia in, 177 sickle cell disease and, 906, 911 Stroke volume variation (SVV), 262 Structure, 11 Study on Efficacy of Nosocomial Infection Control (SENIC), 23 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT study), 92–93 Study validity, assessing, 45 Stuporous patient, 829 Subacute sclerosing panencephalitis (SSPE), 674 Subarachnoid hemorrhage, 1123, 1123f due to ruptured intracranial aneurysm, 775–778 Subdural empyema and epidural abscess, 661–663 clinical presentation, 661–662 diagnosis of, 662 epidemiology and etiology, 661 treatment of, 662–663 Subdural hematomas, 1122 Submandibular space infections, 679–681, 679f, 679t, 680f, 682f Subtentorial masses, 835 Sudan ebolavirus, 740 Superficial pyodermas, 690 Superior laryngeal nerve, 404 Superior mesenteric artery bypass, 1043 Superior mesenteric artery embolectomy, 1043 Superior vena cava syndrome, 879–880, 879f Super-refractory status epilepticus, 780 Supportive care, on ECMO, 475–476 Suppurative intracranial thrombophlebitis, 663–664 clinical presentation, 663–664 diagnosis of, 664 epidemiology and etiology, 663, 663f treatment of, 664 Suppurative jugular thrombophlebitis, 682–683, 682f Suppurative parotitis, 669f, 683 Supraglottic region, 404 Supraglottitis, 407 Supratentorial mass lesions, 835 Supraventricular tachyarrhythmias, 286–287, 287f evaluation of patient with, 287 management of, 287–288, 287f Supraventricular tachycardias, 295 Surface markers, measurement of, 554–555 Surgical drains, 1062–1063, 1063–1065t Surgical embolectomy, 331 Surgical intervention, 365–367 type A, 365–366, 365f, 366f type B, 366, 366f Surgical patients critically ill antidiuretic hormone and aldosterone, 1046 /: / a k t c a t r/ e s /r u endocrine response, 1046 hypercoagulable state, 1046 hypotension in, 1047, 1047f increased oxygen requirements, 1047, 1047f magnitude and duration of surgical insult, 1047 nutrition, 1046–1047 other considerations in, 1047–1048 third-space fluid sequestration, 1046 hypotension in, 1047, 1047f nutrition in, 1062 Surgical site infection, 559 Surgical tracheostomy, 394–395, 399 technique of, 399 Surgical trauma, 560 Surrogate outcomes measures, in critical care research, 46 Surveillance antibiotic resistance in intensive-care unit and, 27 in intensive-care unit, 23–24 Survivorship, 162 SvO2, 244, 244t clinical uses of, 244, 244t Symbiotics, 1003 Symptomatic hyponatremia, 949, 949f Syndrome of inappropriate antidiuretic hormone secretion (SIADH), 672, 945, 948, 1127–1128 Systematized nomenclature of medicine-clinical terms (SNOMED-CT), 54 Systemic corticosteroids, 1090 Systemic inflammatory response syndrome (SIRS), 95, 98, 563, 565 sepsis and, 107 Systemic lupus erythematosus (SLE), 826, 1242–1243 Systemic lupus erythematosus with vasculitis, differentiation of thrombotic thrombocytopenic purpura from, 863 Systemic sepsis, induced immunoparalysis, 553 Systemic (peripheral) vascular resistance (SVR), 250, 250f Systemic vessels, control of cardiac output by, 233–238, 233f, 234f, 235f, 236t Systolic dysfunction, 255f, 256 / 9 r i h T Tachyarrhythmias, 278–279, 279ft Tacrolimus, 1089 Tamponade, cardiac, 237 Targeted surveillance, in infection control, 23 Task Force for Mass Critical Care, 59 Teaching, in critical care, 5–7, 5t Team, working as, 33–34, 34t Teicoplanin, 548 Telemedicine, 17, 52, 53f, 62, 64–68, 66f 23-01-2015 15:33:54 Index barriers, 67 evidence, 67 implementation strategies, 67–69 potential benefits, 66–67 role of intensivists, 68 special challenges, 68–69 unintended consequences, 67 Temperature regulation and hypothermia, spinal injuries and, 1150–1151 Tempo of resuscitation, 254 Temporary pacing, indications for, in acute myocardial infarction, 307–308, 308t Tenecteplase, 299 Tension pneumothorax, 1154, 1154f Terlipressin, 927 Tertiary hyperparathyroidism, 960 Tetanus, 729–733 antimicrobial therapy for, 732 antitoxin therapy for, 731–732 cephalic, 730 clinical manifestations, 730 cephalic, 730 generalized, 730 localized, 730 diagnosis and laboratory testing, 731, 731t epidemiology of, 729 generalized, 730 localized, 730 minimizing muscle spasm for, 732 benzodiazepines, 732 neuromuscular blocking agents, 732 pathogenesis, 729–730 prognosis, 733 supportive care airway management of, 732 managing autonomic instability, 732–733 treatment of, 731, 731t wound management of, 731 Tetany, 959 Therapeutic drug monitoring, 1239 Therapeutic goals, defining, 3, 3f Therapeutic hypothermia, 174–179, 809–810 in cardiac arrest, 176–177, 176f, 177t clinical applications, 177–178 future of induced, 179 history of induced, 174–175 induced in myocardial infarction, 177 in stroke, 177 mechanisms of protection, 175–176, 175f risks of, 178 unresolved questions, 178–179 Therapeutic hypothesis, testing, 2, 3f Therapeutic interventions, shock and, 261 Therapeutic Intervention Scoring System (TISS) score, 90–91 Therapy, changing goal of, 4, 4t Thermal coil, 246 Thermal filament, 246 Thermoregulation, 557 Thiazide-induced hyponatremia, 948 Thienopyridines, 300 Thienopyridines-associated thrombotic thrombocytopenic purpura, 859–860 Third-space fluid sequestration, 1046 Third spacing phenomenon, 256, 544 Thoracic aortic cross clamping, 1158 Thoracic aortic surgery, paralysis/paresis after, 1072 Thoracic cage deformity, 513–515, 513t, 514f effects on pulmonary circulation, 515 gas exchange, 515 respiratory mechanics, 514, 514f, 515f Thoracic injuries requiring immediate intervention, 1153–1157 cardiac tamponade, 1155–1156 massive hemothorax, 1156 open pneumothorax, 1154–1155, 1155f tension pneumothorax, 1154, 1154f Thoracic surgery emergencies, 1073 Thoracic ultrasonography, lung and pleura, 205–206 Thoracostomy, 505–509 chest tube insertion, 507–508 catheter size, 507 contraindications, 508 placement, 508, 508f risks, 508 drainage systems and chest tube management, 508–509 indications for, 505 pleural effusion, 507, 507f pneumothorax, 505–507, 506f Thoracotomy anterolateral, 1157 emergency, 1157–1160 Three-phase time-sensitive model, of cardiac arrest therapy, 172–173, 172f Thrombin time, 847–848 Thrombocytopenia, 328, 849, 893 anemia and, 870, 870t correction of, and coagulopathy for routine bedside procedures, 857 dilutional, 850 drug and medication-induced, 850–851, 850t, 851t etiology of, in intensive care unit patients, 849–853, 850t, 851t heparin-induced, 851–852, 851t immune, 852 spurious, 849–850 Thrombocytopenia syndrome, severe fever with, 741–742 Thromboelastography, 848–849, 848f Thrombolysis, patient selection of, 331 Thrombolytic agents, 299 Thrombolytic therapy, 298–299, 299t, 329–332, 330t Thrombosis, cavernous sinus, 687 Thrombosis factors, vascular physiology and, 846 Thrombotic complications, 185, 901–902 Thrombotic microangiopathies, 852 acute renal failure and, 926 /: / a k s tt p h Index.indd 1357 t c Thrombotic thrombocytopenic purpura (TTP), 858, 859, 901–902 acquired, 858 diagnosis of, 861–863 differentiation of from hemolytic uremic syndrome, 862– 863, 862t from pregnancy-associated complications, 863 from systemic lupus erythematosus with vasculitis, 863 hereditary, 858 hereditary and acquired idiopathic, 859, 859f management of organ failure and treatment-related complications, 864–865 pregnancy-associated, 860 thienopyridines-associated, 859–860 treatment of, 863 Thymectomy, 826 Thymic hyperplasia, 826 Thymoma, 826 Thyroid disease, 986–996 amiodarone-induced thyrotoxicosis, 994–995, 995t decision to treat, 988, 988t goiter and acute airway obstruction, 990 hypothyroidism, 986–987 iodide-induced thyrotoxicosis, 996 levothyroxine overdose, 995 myxedema coma, 988–990, 989t neonatal thyrotoxicosis, 995–996 nonthyroidal illness syndrome, 987 risks and management in thyrotoxic patients, 993–994 thyroid function studies, 987–988, 987t thyroid hormone physiology in critical illness, 987, 987f thyroid storm, 991–993, 991t, 992t thyrotoxicosis, 990–991, 990t Thyroid function, head injury and, 1137 Thyroid function studies, thyroid disease and, 987–988, 987t Thyroid hormone physiology in critical illness, thyroid disease and, 987, 987f Thyroiditis, 826 Thyroid storm precipitating factors, 991 thyroid disease and, 991–993, 991t, 992t treatment of, 991–993, 992t Thyrotoxicosis amiodarone-induced, 994–995, 995t iodide-induced, 996 neonatal, 995–996 thyroid disease and, 990–991, 990t Ticagrelor, 303 Ticarcillin-clavulanic acid, 699 Tick-borne encephalitis virus (TBE), 672 Tick paralysis, 828 Tigecycline, 548, 699 Timing it right (TIR) framework, 110 Tissue corticosteroid resistance during critical illness, 982 / ri h a t r/ e s /r u 1357 23-01-2015 15:33:54 1358 Index Tissue hypoxia, 842 Tissue oximetry, 244–245 Tissue oxygenation, 242–245, 243f, 244t, 245f Tobramycin, 547 Tocolytic therapy in pregnancy, 1266 Togaviridae, 673 Tonicity, 944 Torsade de pointes, 281 Torso trauma, 1152–1168, 1153f abdominal injuries in, 1160–1161 classification of, 1153 emergency thoracotomy, 1157–1160 aortic rupture, 1159–1160, 1159f blunt cardiac injury, 1159 cardiac tamponade, 1157–1158 diaphragmatic rupture, 1160 esophageal disruption, 1160 indications, 1157 lung contusion, 1158 rib fractures, 1160 simple hemopneumothorax, 1160 massively bleeding patient, 1156–1157 flail chest, 1157 pneumothorax and tracheobronchial injury, 1156–1157 traumatic air embolism, 1157 specific abdominal injuries, 1162–1168 duodenal, 1162–1163, 1162f extrahepatic biliary tract, 1165–1166 genitourinary, 1166–1167 intestinal, 1163–1164 liver, 1164–1165 pancreatic, 1163 retroperitoneal hemorrhage, 1166 spleen, 1165 stomach, 1162 traumatic abdominal compartment syndrome, 1167–1168 thoracic injuries requiring immediate intervention, 1153–1157 cardiac tamponade, 1155–1156 massive hemothorax, 1156 open pneumothorax, 1154–1155, 1155f tension pneumothorax, 1154, 1154f Toxicology in adults, 1192–1223 detoxification, 1203–1206 activated charcoal, 1203–1204 extracorporeal removal of toxins, 1205–1206 forced diuresis and urinary manipulations, 1204–1205, 1204t gastric emptying, 1203 whole-bowel irrigation, 1204 diagnosis of toxic ingestion, 1198–1203 history and physical examination, 1198–1199, 1198t, 1199t, 1200t laboratory evaluation, 1199–1202, 1200t, 1201t toxicology screening, 1202–1203, 1202t, 1203t indications for intensive care unit admission, 1206 initial supportive measures, 1194–1198, 1194t, 1195t s tt p h Index.indd 1358 agitated or seizing patient, 1197, 1197t alterations in temperature, 1197–1198, 1197t coma cocktail, 1196–1197 poison control centers, 1203 specific intoxications, 1206–1223 acetaminophen, 1206–1210, 1207f, 1209t amphetamines, 1210 barbiturates, 1210 benzodiazepines, 1210–1211 calcium-channel blockers, 1211–1212 carbon monoxide, 1212 cocaine, 1212–1214, 1213f cyanide, 1214–1215 cyclic antidepressants, 1215–1216 digoxin, 1216–1217, 1216t envenomations, 1222–1223 lithium, 1217–1218 methemoglobinemia, 1218–1219 opioids, 1219 organophosphate and carbamate insecticides, 1219–1220, 1219t salicylates, 1220–1221, 1220t, 1221t selective serotonin reuptake inhibitors, 1221–1222, 1221t ß-blockers, 1211 γ-hydroxybutyrate, 1217 Toxicology screening, 1202–1203, 1202t, 1203t Toxic shock syndrome (TSS), 564, 1297, 1297t Toxidrome, 1198 Toxoplasma gondii, 675–676 Toxoplasmosis, 675–676 Trachea, 404 Tracheal deviation, 505 Tracheal intubation, 384 Tracheo-innominate fistula, 395, 400 Tracheostomy, 394–395, 396–404, 1309 areas of continued controversy and future study, 403 benefits and risks of, 397–398, 397t complications of, 395 emergency cricothyroidotomy and, 400 indications for, 394, 396–397, 397t management of, 400–401 minitracheostomy, 395 percutaneous versus surgical, 394–395 selection of tube, 401 speech and swallowing, 403 technique of, 399–400 timing of, 398 weaning from, and decannulation, 401, 402f, 403 Tracheostomy tube, selection of, 401 TRAF-associated kinase (TAK), 552 Tranexamic acid, 1279 Tranexamic acid and aminocaproic acid, 857 Transcalvarial herniation, 1123 Transesophageal echocardiography, 1056 Transforming growth factor (TGF), 566 Transfused red blood cells, transfusion-related immunomodulation and age of, 843–844 /: / a k t c a t r/ e s /r u Transfusion, sickle cell disease and, 913–914, 913t, 914t Transfusion-related immunomodulation and age of transfused red blood cells, 843–844 Transjugular intrahepatic portosystemic shunt (TIPS) procedure, 24f, 223–225, 928, 1009 Translational research in rehabilitation after critical illness, 110 Transmission-based precautions, 28–30, 29t Transplant patient, 1087–1108 heart transplantation, 1102–1108 indications and outcomes, 1102 infectious complications, 1104–1107, 1105ft, 1107t postoperative complications, 1103–1104, 1104t postoperative management, 1102–1103 procedures, 1102 immunosuppression, 1088–1090, 1088f antilymphocyte antibodies, 1089–1090 calcineurin inhibitors and related compounds, 1089 new agents, 1090 proliferation inhibitors, 1089 systemic corticosteroids, 1090 liver transplantation, 1097–1102 changes in donor demographic and management, 1098 indications and outcomes, 1097–1098, 1097t, 1098ft postoperative complications, 1100–1102, 1100t, 1101t procedure, 1098–1099 lung transplantation, 1090–1096 indications and outcomes, 1090–1092, 1090t, 1091ft, 1092ft postoperative complications, 1093–1096, 1094t, 1095t, 1096f postoperative management, 1093, 1094t procedure, 1093 Transplant surgery emergencies, 1074–1075, 1076t Transportation, of critically ill patient, 69–76 prior to transfer, 69–75, 70t, 71–7271t, 74ft, 75f special circumstances/clinical conditions, 75–76, 76t Transpulmonary indicator dilution, 247 Transtentorial uncal herniation, 1123 Trauma See also Torso trauma ECMO in, 481, 481t electric, 1175–1180, 1176t, 1177t cardiac, 1177 extremity and wound, 1178–1179 gastrointestinal, 1178 initial evaluation, 1176–1177 late sequelae of injury, 1179–1180 lightning injury, 1179 neurologic, 1178 pulmonary, 1178 renal, 1177–1178 extremities, 1172–1175 complications in, 1173–1175, 1174f electrical, 1178 / 9 r i h 23-01-2015 15:33:54 1359 Index fracture assessment, 1172, 1173t treatment of, 1173, 1173t multisystem deciding on surgical intervention, 1121 priorities in, 1116–1121 adequacy of perfusion, 1118–1119, 1119t airway, oxygenation, ventilation, and cervical spine control, 1117 cervical spine protection, 1118 detailed systematic assessment and definitive care, 1120 fracture stabilization, 1120 locating source of internal hemorrhage, 1119 neurologic status, 1119–1120 reevaluation and monitoring patient, 1120–1121 surgical airway, 1117–1118, 1117f ventilation, 1118 nutrition and, 1062 in pregnancy, 1259 Traumatic abdominal compartment syndrome, 1167–1168 Traumatic air embolism, 1157 Traumatic brain injury (TBI), 1122 operative management of, and decompressive craniectomy, 1134–1135 primary and secondary, 1124, 1124f Triage Index, 91–92 TRICC trial, 843 Tricuspid regurgitation, 198, 199f, 351–352 clinical presentation, 352 diagnostic evaluation, 352 etiology, 351, 352f management of, 352 pathophysiology, 352 TRISS trauma score, 89 Tuberculosis (TB), infection control and, 30 Tularemia, 719–720, 747, 748 typhoidal, 747 ulceroglandular, 747 Tumor lysis syndrome, 871, 871t, 877–878, 878f, 926, 965 Tumor necrosis factor inhibition, use of, in critically ill patient, 1252 Tumor necrosis factor-α (TNF-α), 604 Tunnel infection, 591 2009 influenza A (H1N1) severe ARDS, ECMO and, 479–481 Type I error, 47 Type I (immediate) hypersensitivity reactions, 1282–1283 Type II error, 47 Type IV, delayed-type hypersensitivity reactions, 1283–1284 Typhlitis, 616–617 Typhoidal tularemia, 747 Ulcer node syndromes, 719–720 plague, 719 tularemia, 719–720 Ulceroglandular tularemia, 747 Ultrafiltration, 933 Ultrasound predictors, static echocardiographic and, 263–264 Uncontrolled bleeding, salvage therapy for endoscopically, 1009–1010 Uniform Determination of Death Act, 838 United Network for Organ Sharing (UNOS), 1097 U.S Strategic National Stockpile (SNS), 57 Unstable angina, 294 Upper airway obstruction, 404–411 anatomy of upper airway, 404, 405f causes of laryngeal, 407–409 nasal and pharyngeal, 406–410, 408t oropharyngeal, 406–407 clinical presentation and initial evaluation, 405–406 complications of, 411 pathophysiology of upper airway obstruction, 405 fixed upper airway obstruction, 405 variable extrathoracic obstruction, 405 variable intrathoracic obstruction, 405 treatment of, 410–411 Upper gastrointestinal bleeding, 218, 219f, 1010 Upper respiratory tract, life-threatening infections of, 676–688 Urinalysis in patients with acute kidney injury, 924–925 Urinary catheters, 25, 25t Urinary tract infections (UTIs), 559, 645, 649, 696–703 catheter-associated bacteriuria and candiduria, 702–703 due to bacteria, 696–701, 697t, 698t antimicrobial therapy, 698–700 complications, 700–701 emerging antimicrobial resistance in enterobacteriaceae, 697–698, 697t enterococci as urinary pathogens, 698 microbiology, 696 due to Candida, 701–702 Urolithiasis, 211 a k /: / s tt p h U Ubiquitous injury, 107–108, 108f Ulcer(s) Meleney, 691 peptis, 1014–1017, 1015f, 1016f pressure, 1304 stress, 575 Index.indd 1359 t c V Vaccine, oral polio, 672 Valvular dysfunction, 258, 275 Valvular heart disease, 343–356 aortic regurgitation, 347–348 clinical presentation, 347 diagnostic evaluation, 347–348 etiology, 347, 347f management of, 348 pathophysiology, 347 aortic stenosis, 344–347 clinical presentation, 345 diagnostic evaluation, 345, 345t etiology, 344, 344f natural history, 344 pathophysiology, 344 / ri h a t r/ e s /r u infective endocarditis, 354–356 clinical presentation, 354, 355f etiology, 354 pathophysiology, 354 mitral regurgitation, 350–351, 350f clinical presentation, 350–351 diagnostic evaluation, 351 etiology, 350 management of, 351 pathophysiology, 350 mitral stenosis, 348–350 clinical presentation, 349 diagnostic evaluation, 349 management of, 349 pathophysiology, 348–349, 349f prosthetic valve dysfunction, 352–354 structural failure of prosthetic valves, 354 thrombosis, 353–354, 353f tricuspid regurgitation, 351–352 clinical presentation, 352 diagnostic evaluation, 352 etiology, 351, 352f management of, 352 pathophysiology, 352 Vancomycin, 548, 550 Vancomycin intermediate Staphylococcus aureus (VISA), 547 Variability, sources of, in quality measurement, 11 Variceal bleeding, 221, 223 Variceal hemorrhage, 1010–1014 acute, 1030–1031 endoscopic therapy, 1012–1013 management, 1010–1012, 1011ft pharmacotherapy, 1012 salvage therapy for endoscopically uncontrolled bleeding, 1009–1010 Varicella zoster virus (VZV), 670, 1300–1302, 1301f infection control and, 30 Vascular access, obesity and, 1310 Vascular causes of acute renal failure, 922 Vascular dysfunction, in sepsis, 565 Vascular injury, extremity trauma and, 1173, 1174f Vascular occlusion test (VOT), 245 Vascular physiology, thrombosis factors and, 846 Vascular surgery emergencies, 1075–1076, 1075t Vasculitis, 1247 Vasoactive drug therapy, 315 Vasogenic edema, 794 corticosteroids for, 812–813 Vaso-occlusive crisis (VOC), 904 Vaso-occlusive pain crisis, sickle cell disease and, 906 Vasopressin, 316 as option in endovascular treatment, 220–221 Vasopressin antagonists, role of, 950 Vasopressin-induced skin necrosis, 1286, 1286f 23-01-2015 15:33:54 1360 Index Vasopressin in Septic Shock Trial (VASST), 263 Vasopressors, 252–253, 572–573, 1145 Vasospasm, 243, 777 VCAM-1, 908 Vegetative state, 829–830 VEGF-targeted tyrosine kinase inhibitors, 897 Vena caval interruption, 329 Venezuelan equine encephalitis virus (VEEV), 673 Venezuelan hemorrhagic fever, 739 Veno-arterial extracorporeal membrane oxygenation (ECMO), 474 Venoocclusive disease, 223 Venous air embolism, in pregnancy, 1266–1267 Venous oximetry, 243–244, 244t Venous oxygen saturation, sepsis and, 569 Venous return cardiac function curves and, 233–234, 233f, 234f control of, by systemic vessels, 269–270 decreased, 254–256, 255f resistance to, 234, 234f Venous thromboembolism, 221, 560 in pregnancy, 1268 prophylaxis, 1135–1136 prophylaxis against, 332–333 reducing risk of recurrence, 221 risk of, 1308 spinal injuries and, 1151 stress ulcer prophylaxis, sepsis and, 575 Venous thrombosis, 319f, 320f, 321f Venous ultrasonography, in diagnosing pulmonary embolic disorders, 325 Ventilated patient cardiopulmonary interactions, 425 choosing ventilator mode, 425–430, 428f, 429f management of, 424–434, 430–433, 431f, 432ft prevention, the ventilator bundle, 424 ventilator-induced diaphragm dysfunction, 425 ventilator-induced lung injury, 425 Ventilation perfusion lung scan, in diagnosing pulmonary embolic disorders, 325–326 Ventilator, management during ECMO, 475 Ventilator-associated pneumonia (VAP), 388, 424, 520–535, 570, 629 diagnosis of, 525–529, 526f, 527f difficulty in diagnosing, 14 epidemiology of, 521–522, 522t evidence of, 46 predisposing factors, 522–525, 523t prevention, 532–535 sensitive indicator for, treatment of, 529–532 Ventilator discontinuation process, patient ventilator synchrony, 435, 435f s tt p h Index.indd 1360 Ventilator-induced lung injury, 434–435, 434f, 439–448, 439t, 440t, 470 acute respiratory distress syndrome and, 439–440 biotrauma, 444 decompartmentalization, 444–445 high airway pressures/large tidal volumes and, 441–442, 441f, 442f lung-protective strategies, no harm, 445–447, 446t macroscopic injury, 440 rescue therapies for life-threatening hypoxia minimizing vili, 447–448, 448f role of end-expiratory pressure, 442–444, 443f Ventilator management of respiratory abnormalities, 458–459, 458f, 459f, 460f, 461ft, 462t, 463ft, 464t, 465t, 467f Ventilator waveforms, 411–424 to facilitate lung-protection in acute respiratory distress syndrome, 420–421, 420f, 421f flow waveforms, 414–415, 415f hemodynamic interpretation and, 421–422, 421f, 422f obstructed patient, 415–418, 415f, 416f, 417f, 418f patient asynchrony, 418, 419f, 420, 420f pressure at the airway opening, 412–414, 412f, 423ft unusual problems revealed by analysis, 423, 423f Ventilatory failure, 250–251 hypoxemic versus, 372, 373t Ventilatory impairment, diseases of, 974 Ventricular dysfunction in critical illness, 229–233, 229f, 230f, 231ft, 266–278 acute on chronic heart failure, 276–277, 277t clinical features, 277 management of, 277 precipitating factors, 276–277 assessment of cardiac dysfunction, 266–269, 266f central venous and right heart catheters, 268 clinical examination, 266, 267t echocardiographic examination, 266–268 decreased cardiac output due to cardiac dysfunction or decreased venous return, 268–270 control of venous return by systemic vessels, 269–270 definition of cardiac pump function and its relation to venous return, 268–270 ventricular systolic and diastolic function, 268–269, 269f mechanisms and management of left ventricular dysfunction, 270–275 abnormal heart rate and rhythm, 275 decreased left ventricular systolic contractility, 270–273, 271f, 272t increased diastolic stiffness, 274 /: / a k t c a t r/ e s /r u special effects of altered afterload on ventricular function in critical illness, 274–275 valvular dysfunction, 275 mechanisms and management of right ventricular dysfunction, 275–276 decreased right ventricular systolic function, 275 disorders of right ventricular preload, afterload, valves and rhythm, 275–276, 276t ventricular interaction, 276 Ventricular dysrhythmias, 1177 Ventricular fibrillation and pulseless VT, 286 Ventricular fibrillation/ventricular tachycardia without a pulse, 169–170 Ventricular filling disorders, diastolic V-P curve and, 231, 231ft Ventricular free wall rupture, 305 Ventricular hypertrophy, 310 Ventricular interaction, diagnosis of interdependence, 276 Ventricular interdependence, treatment of, 276 Ventricular proarrhythmia, risk of, 279 Ventricular septal rupture, 305 Ventricular tachyarrhythmias, 280–286, 281f, 282t, 283t, 284ft, 285f, 286f management of, 283–286, 284ft Ventricular tachycardia with a pulse, 169 Ventricular-vascular coupling, 229–230, 229f Ventriculostomy infections, 1136 Venturi effect, 1069 Vertebral injuries, classification of, 1138–1139, 1140t Viatorr™ stent, 224 Vibrio cholerae, in noninflammatory diarrhea, 706 Video capsule endoscopy, 1021 Vigileo™, 248 Viral hemorrhagic fevers, 717–718, 733–743, 734–7353, 736t, 750–751 dengue as, 717–718 Ebola/Marburg as, 718 flaviviridae as, 734–736, 738 hantavirus as, 718 Viral infections, 1300–1302 herpes simplex, 1300, 1300ft, 1301f human immunodeficiency virus, 1302, 1302t smallpox, 1302 varicella zoster, 1300–1302, 1301f Virtual autopsy, 36 Visceral abscess, 1082–1083, 1082t, 1083f VISICU system, assessing, 17 Vitamin K antagonists, 854–855 Volume, 252 Volume feedback control of pressure-targeted breaths, 437 Volume responsiveness, detection of, 243 VolumeView, 247 Von Willebrand disease, 846, 854 Von Willebrand factor (VWF) deficiency of, 854 qualitative deficiency of, 846 Von Zumbusch psoriasis, 1292–1293, 1292f Voriconazole, 649–650 VT/VF electrical storm, 286 / 9 r i h 23-01-2015 15:33:54 Index W Waldenström macroglobulinemia, 947 Warfarin, 1285–1286, 1286f Waterhouse-Friderichsen syndrome, 260 Weakness See Intensive care unit-Acquired weakness Weaning off ECMO, 476, 476f Weaponization of Venezuelan hemorrhagic fever (VHF) agents, 743 Wedge artery occlusion pressure, 263 Weight loss, obesity and, 1311 Western equine encephalitis virus (WEEV), 673 West Nile virus (WNV), 671–672 White blood cell count, 567 Whole-bowel irrigation, 1204 Wolff-Parkinson-White syndrome, 279, 286–287, 295 Wound care in burn patients, 1188 postoperative infections and, 1065–1067, 1066t /: / a k s tt p Y Yeast infections, 624 Yellow fever, 718, 737–738 Yesinia pestis, 746 Young-Burgess classification, 1169–1170, 1170t Z Zaire ebolavirus, 740 Ziprasidone, 153 / ri h a t r/ e s /r u t c 1361 h Index.indd 1361 23-01-2015 15:33:54 ... Crit Care Med 20 12; 187 :23 8 -24 6 •• De Jonghe B, Sharshar T, Lefaucheur JP, et al Paresis acquired in the intensive care unit: a prospective multicenter study JAMA 20 02; 288 :28 59 -28 67 •• Hermans... At least 20 % of patients with status epilepticus die ,21 ,22 and up to 61% of patients developing SE during hospitalization not survive .23 SE in and of itself confers a mortality rate of 26 % to adults... 20 07;6 :21 5 -22 2 REFERENCES Complete references available online at www.mhprofessional.com/hall 1 /23 /20 15 12: 55:35 PM CHAPTER 85: Seizures in the Intensive Care Unit CHAPTER 85 Seizures in the Intensive Care
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