OXFORD MEDICAL PUBLICATIONS Oxford Handbook of Critical Care THIRD EDITION Published and upcoming Oxford Handbooks Oxford Handbook of Acute Medicine 2/e Oxford Handbo ok of Anesthesia 2/e Oxford Handbook of Applied Dental Sciences Oxford Handbook of Cardiolo gy Oxford Handbook of Clinical and Laboratory Investigation 2/e Oxford Handbook of Clinical Dentistry 4/e Oxford Handbook of Clinical Diagnosis 2/e Oxford Handbook of Clinical Examin ation and Practical Skills Oxford Handbook of Clinical Hematology 3/e Oxford Handbook of Cl inical Immunology and Allergy 2/e Oxford Handbook of Clinical Medicine \200\223 Mini Editi on 7/e Oxford Handbook of Clinical Medicine 7/e Oxford Handbook of Clinical Drugstore Oxfor d Handbook of Clinical Rehabilitation 2/e Oxford Handbook of Clinical Specialties 8/e Oxfor d Handbook of Clinical Surgery 3/e Oxford Handbook of Complementary Medicine Oxford Handboo k of Critical Care 3/e Oxford Handbook of Dental Patient Care 2/e Oxford Handbook of Dialys is 3/e Oxford Handbook of Emergency Medicine 3/e Oxford Handbook of Endocrinology and Diabe tes 2/e Oxford Handbook of ENT and Head and Neck Surgery Oxford Handbook of Expedition and Wilderness Medicine Oxford Handbook for the Foundation Program 2/e Oxford Handbook of Gastr oenterology and Hepatology Oxford Handbook of General Practice 3/e Oxford Handbook of Genit ourinary Medicine, HIV and AIDS Oxford Handbook of Geriatric Medicine Oxford Handbook of In fectious Diseases and Microbiology Oxford Handbook of Key Clinical Evidence Oxford Handbook of Medical Sciences Oxford Handbook of Nephrology and Hypertension Oxford Handbook of Neur ology Oxford Handbook of Nutrition and Dietetics Oxford Handbook of Obstetrics and Gynecolo gy 2/e Oxford Handbook of Occupational Health Oxford Handbook of Oncology 2/e Oxford Handbo ok of Ophthalmology Oxford Handbook of Pediatrics Oxford Handbook of Palliative Care 2/e Ox ford Handbook of Practical Drug Therapy Oxford Handbook of Pre-Hospital Care Oxford Handboo k of Psychiatry 2/e Oxford Handbook of Public Health Practice 2/e Oxford Handbook of Reprod uctive Medicine and Family Planning Oxford Handbook of Respiratory Medicine 2/e Oxford Hand book of Rheumatology 2/e Oxford Handbook of Sport and Exercise Medicine Oxford Handbook of Tropical Medicine 3/e Oxford Handbook of Urology 2/e Oxford Handbook of Critical Care THIRD EDITION Mervyn Singer Professor of Intensive Care Medicine; Director, Bloomsbury Institute of Inten sive Care Medicine, University College London London, UK Andrew R. Webb Medical Director and Consultant Physician, Department of Intensive Care, Uni versity College London Hospitals, London, UK 1 1 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the Univer sity \200\231s objective of excellence in research, scholarship, and education by publishin g worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico Cit y Nairobi New Delhi Shanghai Taipei Toronto With of \201 ces in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan P oland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York Oxford University Press, 2009 The moral rights of the authors have been asserted Database right Oxford University Press ( maker) First edition published 1997 Second edition published 2005 Third edition published 2009 All rights reserved. No part of this publication may be reproduced, stored in a retrieval s ystem, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with t he appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, a t the address above You must not circulate this book in any other binding or cover and you must impose this sam e condition on any acquirer British Library Cataloging in Publication Data Data available Library of Congress Cataloging-in-Publication-Data Data available Typeset by Cepha Imaging Private Ltd., Bangalore, India Printed in Italy on acid-free paper by L.E.G.O. S.p.A. \200\224Lavis TN ISBN 978 \200\2230 \200\22319 \200\223923533 \200\2239 10 9 8 7 6 5 4 3 2 1 Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and c linical procedures with the most up-to-date published product information and data sheets p rovided by the manufacturers and the most recent codes of conduct and safety regulations. T he authors and publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misap- plication of material in this work. v Contents Foreword vii Preface to the previous editions ix Preface to this edition x Abbreviations xi Detailed contents xxi 1. Critical care organization and management 2. Respiratory therapy techniques 3. Cardiovas cular therapy techniques 4. Renal therapy techniques 5. Gastrointestinal therapy techniques 6. Nutrition and metabolic therapy 7. Wound and pressure area management 8. Respiratory mo nitoring 9. Cardiovascular monitoring 10. Neurological monitoring 11. Laboratory monitoring 12. Miscellaneous monitoring 13. Fluids 14. Respiratory drugs 15. Cardiovascular drugs 16. Renal drugs 17. Gastrointestinal drugs 18. Neurological drugs 19. Hematological drugs 20. Miscellaneous drugs 21. Resuscitation 22. Respiratory disorders 1 37 93 107 117 125 135 143 161 199 209 231 241 253 263 279 285 301 317 325 337 345 CONTENTS vi 23. Cardiovascular disorders 24. Renal disorders 25. Gastrointestinal disorders 26. Hepatic disorders 27. Neurological disorders 28. Hematological disorders 29. Metabolic disorders 3 0. Poisoning 31. Infection and in \202 ammation 32. Trauma and burns 33. Physical disorder s 34. Pain and post-operative critical care 35. Oncological critical care 36. Obstetric eme rgencies 37. Transportation of the critically ill 38. Death and the dying patient 379 397 405 427 437 467 481 519 543 581 599 617 623 633 643 651 Index 659 vii Foreword I am delighted, for several reasons, to write the foreword for the third edition of this ha ndbook of critical care medicine. Firstly, both authors were former colleagues whose career s have blossomed very considerably since we all worked together. Secondly, the fact that th ree editions have been produced in the past 12 years with total sales of 30,000 re \202 ec ts the rapidly emerging importance of intensive care as a specialty in its own right. Third ly, the fact that about 20% of the material in this current edition is new re \202 ects ho w quickly intensive care is changing. Although this book is designed to \201 t the pocket it contains an enormous amount of cle arly presented and important information. It is essential reading for nurses and doctors of all grades who are involved in looking after the critically ill. Many acutely ill patients are still being cared for in general wards without ever being adm itted to an intensive care unit. The popularity of the two previous editions of this book s uggests it is being read by staff working in these non-critical care areas and I do believe this will assist them considerably in improving patient care. The layout of the book lends itself extremely well to an electronic format, a move which I thoroughly endorse. I wish the book the success it thoroughly deserves. David Bennett Visiting Professor of Intensive Care Medicine King \200\231s College London This page intentionally left blank ix Preface to the previous editions Of all the medical specialities, few, if any, are as exacting and complex as critical care medicine. The required knowledge of physiology, pathophysi- ology, biochemistry, technology , and pharmacology; the unpredictability; the need to act and react decisively; the ability to communicate clearly with colleagues, patients, and relatives, often in stressful situat ions; the importance of working cohesively within an expanded team drawn from different bac kgrounds; and the regular occurrences of ethical and life- and-death dilemmas, all place he avy demands on the intensive care staff member. This book does not aim to be a panacea; many areas of uncertainty in diagnosis and manageme nt remain. However, current best practice (at least as practiced by us!) is described in su ccinct, concise, clinically orien- tated sections, covering therapeutic and monitoring, dru gs and \202 uids, spe- ci \201 c organ system disorders and complications, and general m anagement philosophies. Ample space is provided to append or amend sections to suit your pa rticular practice. It will hopefully serve the consultant, junior doctor, nurse, or other para- medical staff as a reference book, aide memoire, and handy pocket book, providing rationales and solution s to most of the problems encountered. Buoyed by the positive feedback we received after publication of the 1st edition of this bo ok, we endeavored to maintain the style and, where appropriate, changed the substance for t he 2nd edition. This involved the addition of some new sections to describe recent innovati ons in either thought and/or process. However, many of the existing chapters were updated t o re \202 ect the rapid rate of change in ICU management that has occurred since we last p ut pen to paper. Mervyn Singer Andrew R. Webb 1996/2004 x Preface to this edition This new edition embraces the many recent developments occurring in critical care medicine, in particular the burgeoning number of randomized, multicentre trials and the increasing u nderstanding of underlying basic science mechanisms. While not necessarily providing de \201 nitive answers, these studies have contributed signi \201 cantly to our knowledge bas e and highlighted both the complexity of critical illness and the variation in indi- vidual response. They frequently demonstrate the need to recognize and treat deterioration prompt ly, and \202 ag up the many detrimental effects of our current therapies and strategies. A balance needs to be sought between under- and over-treatment \200\224be it for \202 uid s, sedatives, antibiotics, pressors, ventilation, etc., and we will no doubt continue to re \201 ne this further in coming years, particularly with enhancements in monitoring and di agnostics. These studies further demonstrate the \200\230one size \201 ts all \200\231 paradigm on which traditional categorization of patients is based, e.g. those with sepsis is, perhaps, overly simplistic. We should follow local, national, and interna- tional guidelines on pati ent management, yet still retain the \202 exibility of thought and action to diverge shou ld an individual patient not follow the rules. We have thus provided a framework upon which a reasonable and rational practice can be based; this is clearly not the \201 nal word. We expect both healthy debate and continuing evolution! In line with advances in critical care, other specialities have new treat- ments and manage ment regimens for speci \201 c conditions that often bring affected patients to our attent ion. We gratefully acknowledge the input and advice received from Sheila Adam, Emma Morris, Alastair O \200\231Brien, Marie Scully, Penny Shaw, and Simon Woldman. Mervyn Singer Andrew R. Webb 2009 xi Abbreviations A&E A \200\223aDO2 ABE ACE ACMV ACT ACTH ADH AGE AIDS AIS ALI ALT ANCA AP APACHE APTT ARDS ASD AST ATP AV bd BiPAP BIS BNP BOOP bpm Ca2+ CABG CaCl2 Cal CAL CAM cAMP c-ANCA Accident and emergency Alveolar \200\223arterial oxygen difference Arterial base excess Ang iotensin converting enzyme Assist control mechanical ventilation Activated clotting time Ad renocorticotropic hormone Antidiuretic hormone Arterial gas embolism Acquired immunode \201 ciency syndrome Abbreviated injury score Acute lung injury Alanine aminotransferase An ti-nuclear cytoplasmic antibodies Anteroposterior Acute physiology and chronic health evalu ation Activated partial thromboplastin time Acute respiratory distress syndrome Atrio-septa l defect Aspartate aminotransferase Adenosine triphosphate Aortic valve Bis die (twice dail y) Bilevel positive airways pressure Bispectral index Brain natriuretic peptide Bronchiolit is obliterans with organizing pneumonia Beats per minute Calcium Coronary artery bypass gra fting Calcium chloride Calorie Chronic air \202 ow limitation Confusion assessment method Cyclic adenosine monophosphate Core anti-neutrophil cytoplasmic antibodies ABBREVIATIONS DETAILED CONTENTS xii CBF CBV CcO2 CD CDI CFM cGMP CJD CI CK Cl \200\223 CLL cm cmH2O CMRO2 CMV CMV CNS CO CO2 CO Hb COP CPAP CPK CPP CPR CRP CSF CT CVA CVP CVVH CVVHD CXR d D DA DDAVP DEAFF deoxyHb Cerebral blood \202 ow Cerebral blood volume End-capillary oxygen content Cluster of diff erentiation Cranial diabetes insipidus Cerebral function monitor Cyclic guanosine monophosp hate Creutzfeldt \200\223Jacob disease Cardiac index Creatine kinase Chloride Chronic lymph ocytic leukemia Centimeter Centimeters of water Cerebral metabolic rate for oxygen Controll ed mandatory ventilation Cytomegalovirus Central nervous system Carbon monoxide Carbon diox ide Carboxyhaemoglobin Colloid osmotic pressure Continuous positive airways pressure Creati ne phosphokinase Cerebral perfusion pressure Cardiopulmonary resuscitation C-reactive prote in Cerebrospinal \202 uid Computerized tomography Cerebrovascular accident Central venous pressure Continuous veno-venous haemo \201 ltration Continuous veno-venous haemodia \201 ltration Chest X-ray Day Dalton Dopamine 1-deamino-8-D-arginine vasopressin Detection of e arly antigen \202 uorescent foci Deoxyhaemoglobin DETAILED CONTENTS ABBREVIATIONS xiii DIC dL DNA DO2 DPG DS DVT dyn.s ECCO2R ECF ECG ECMO EEG EMG ENT EPAP ERCP ESBL ET EVLW FADH 2 FDP FEV1 FFP FiO2 fL Fr FRC FTc FVC g GBM GCS G-CSF GEDV GFR GI GGT GMP GTN Disseminated intravascular coagulation Decilitre Deoxyribonucleic acid Oxygen delivery Diph osphoglycerate Degree of substitution Deep vein thrombosis Dyne second Extracorporeal carbo n dioxide removal Extracellular \202 uid Electrocardiogram Extracorporeal membrane oxygen ation Electroencephalogram Electromyogram Ear, nose and throat Expiratory positive airway p ressure Endoscopic retrograde pancreatography Extended spectrum beta-lactamase Endotracheal Extravascular lung water Flavin adenine dinucleotide-H2 Fibrin degradation product Forced expired volume in 1 second Fresh frozen plasma Fractional inspired oxygen concentration Fem ptolitre French gauge Functional residual capacity Corrected \202 ow time Forced vital ca pacity Gram Glomerular basement membrane Glasgow coma score Granulocyte-colony stimulating factor Global end-diastolic volume Glomerular \201 ltration rate Gastrointestinal Gamma g lutamyl transaminase Guanosine monophosphate Glyceryl trinitrate ABBREVIATIONS DETAILED CONTENTS xiv GVHD h H+ Hb HCl HCO3 He HELLP HFJV HFO HITS HIV HME H2O hpf HR Hrly HUS Hz IABP ICP id I:E ICP ICU Ig IM IMV INR IPAP IPPV IRS IS ISS ITBV ITP IU IV K+ KCl Graft versus host disease Hour Hydrogen ion Hemoglobin Hydrochloric acid Bicarbonate Helium Haemolysis, elevated liver enzymes & low platelets High frequency jet ventilation High fre quency oscillation Heparin-induced thrombocytopaenia syndrome Human immunode \201 ciency v irus Head and moisture exchanger Water High power \201 eld Heart rate Hourly Haemolytic u raemic syndrome Hertz Intra-aortic blood pressure Intracranial pressure Internal diameter I nspiratory : expiratory Intracranial pressure Intensive care unit Immunoglobulin Intramuscu lar Intermittent mandatory ventilation International normalized ratio Inspiratory positive airway pressure Intermittent positive pressure ventilation Immune reconstitution syndrome I nspiratory support Injury severity score Intrathoracic blood volume Idiopathic thrombocytop aenic purpura International unit Intravenous Potassium Potassium chloride \200\223 ABBREVIATIONS xv xv kDa kg kHz kIU kJ kPa kU L LA L-NMMA LBBB LDH LED LFPPV LFT L-NMMA LMW LP LVEDP LVF LVOT LV SW mcg mol M,C&S mA MAOI MAP MARS MCA MCV MDMA mEq metHb Mg Mg2+ MgSO4 MI min mL Kilodalton Kilogram Kilohertz Kallikrein inhibitor units Kilojoule Kilopascal Kilounit Lite r Left atrium L-NG-monomethyl arginine Left bundle branch block Lactate dehydrogenase Light emitting diode Low frequency positive pressure ventilation Liver function test L-N-mono-me thyl-arginine Low molecular weight Lumbar puncture Left ventricular end diastolic pressure Left ventricular failure Left ventricular out \202 ow tract Left ventricular stroke work M icrogram Micromole Microscopy, culture & sensitivity Milliamp Monoamine oxidase inhibitor M ean arterial pressure Molecular Adsorbent Recirculation System Middle cerebral artery Mean cellular volume 3,4 methylenedioxy-methamphetamine Milliequivalent Methaemoglobin Milligram Magnesium Magnesium sulfate Myocardial infarction Minute Milliliter ABBREVIATIONS xvi mmHg mmol MODS MOF mOsm MPAP MRSA MSSA ms MV V MW Na+ NAC NaCl NADH NaHCO3- ng NG NIRS nm NMS NO NSAID NYHA O2 O2ER od OPS PA PaCO2 PAF PAN PAO2 PaO2 PAWP PaCO2 PCI PCO2 PCR Millimeter of mercury Millimole Multiple organ dysfunction syndrome Multiple organ failure Milliosmole Mean pulmonary artery pressure Meticillin-resistant Staphylococcus aureus Metic illin-sensitive Staphylococcus aureus Millisecond Mitral valve Microvolt Molecular weight S odium N-acetylcysteine Sodium chloride Nicotinamide adenine dinucleotide-H Sodium bicarbona te Nanogram Nasogastric Near-infrared spectroscopy Nanometer Neuroleptic malignant syndrome Nitric oxide Non-steroidal anti-in \202 ammatory drug New York Heart Association Oxygen O xygen extraction ratio Once daily Orthogonal polarization spectroscopy Pulmonary artery Art erial partial pressure of carbon dioxide Platelet activating factor Polyarteritis nodosa Al veolar partial pressure of oxygen Arterial partial pressure of oxygen Pulmonary artery wedg e pressure Partial pressure of carbon dioxide Percutaneous coronary intervention Partial pr essure of carbon dioxide Polymerase chain reaction ABBREVIATIONS xvii PDE PEEP PEEPi PEG PEJ PGE1 PGI2 pHi PI PImax pKa PO PO2 3- PO4 PP ppm PPV PR prn PSV PT PTCA PTLD PTT PVL PVR qds Qs/Qt q.v. RA RAP RBBB RBC RCT RDS RQ rtPA RTS RV RVSW Phosphodiesterase Positive end expiratory pressure Intrinsic positive end expiratory pressu re (auto-PEEP) Percutaneous enterogastrostomy Percutaneous enterojejunostomy Prostaglandin E1 (Alprostadil) Prostaglandin I2 (Epoprostenol) Intramucosal pH Pulsatility index Maximu m inspiratory pressure Acid dissociation constant Per os (by mouth) Partial pressure of oxy gen Phosphate Pulse pressure Parts per million Pulse pressure variation Per rectum Pro re n ata (as required) Pressure support ventilation Prothrombin time Percutaneous transluminal c oronary angioplasty Post-transplant lymphoproliferative disorder Partial thromboplastin tim e Panton-Valentine Leukocidin Pulmonary vascular resistance Quater die sumendum (take four times daily) Shunt fraction Quod vide (which see) Right atrium Right atrial pressure Right bundle branch block Red blood cell Randomized controlled trial Respiratory distress syndrom e Respiratory quotient Recombinant tissue plasminogen activator Revised trauma score Right ventricle Right ventricular stroke work ABBREVIATIONS xviii s SAH SaO2 SC ScvO2 SDF SI SIADH Second Subarachnoid hemorrhage Arterial oxygen saturation Subcutaneously Central venous sat uration Sidestream dark \201 eld imaging Stroke index Syndrome of inappropriate antidiuret ic hormone secretion Synchronized intermittent mandatory ventilation Systemic in \202 amma tory response syndrome Jugular bulb oxygen saturation Sublingually Systemic lupus erythemat osus Pulse oximeter oxygen saturation Species Systolic pressure variation Statim (immediate ly) Tissue oxyhaemoglobin concentration Stroke volume Mixed venous saturation Systemic vasc ular resistance Supraventricular tachycardia Stroke volume variation Tuberculosis Ter die s umendum (take three times daily) Thromboembolic disease Toxic epidermal necrolysis Transcut aneous electric nerve stimulation Tissue factor Tris-hydroxy-methyl-aminomethane Transjugul ar intrahepatic portosystemic stented shunt Therapeutic intervention scoring system Total p arenteral nutrition Transfusion-related acute lung injury Trauma injury severity score Thyr oid stimulating hormone Total static lung compliance Thrombin time Thrombotic thrombocytopa enic purpura SIMV SIRS SjO2 SL SLE SpO2 Spp SPV Stat StO2 SV SvO2 SVR SVT SVV TB Tds TED TEN TENS TF THA M TIPSS TISS TPN TRALI TRISS TSH TSLC TT TTP ABBREVIATIONS xix TURP TXA2 U U & E V VAC VC VCO2 VD Vd/Vt VDRL VF VHF VILI VO2 V/Q VRE VSD VSV VT VT W WBC W HO wk y Transurethral resection of prostate Thromboxane A2 Unit Urea and electrolytes Volt Vacuum-a ssisted closure Vital capacity Carbon dioxide production Dead space Dead space: tidal volum e ratio Venereal diseases reference laboratory Ventricular \201 brillation Viral haemorrh agic fever Ventilation-induced lung injury Oxygen consumption Ventilation/perfusion Vancomy cin-resistant Enterococcus Ventricular septal defect Volume support ventilation Tidal volum e Ventricular tachycardia Watt White blood cell World Health Organization Week Year This page intentionally left blank xxi Detailed contents Preface to the previous editions ix Preface to this edition x Abbreviations xi Detailed con tents xxi 1 Critical care organization and management 1 Critical Care Unit layout 2 Critical Care Unit staf \201 ng (medical) 4 Critical Care Unit staf \201 ng (nursing) 6 Outreach support 8 Critical Care Unit admission criteria 10 Surv ivor follow-up 12 Patient safety 14 Fire safety 16 Communication 18 Medicolegal aspects 20 Clinical governance 22 Audit 24 Critical care scoring systems 26 APACHE scoring 28 SAPS sco re 30 SOFA score 32 Trauma score 34 2 Respiratory therapy techniques 37 Oxygen therapy 38 Airway maintenance 40 Endotracheal intubation 42 Ventilatory support \200 \224indications 44 IPPV \200\224description of ventilators 46 IPPV \200\224modes of ventila tion 48 IPPV \200\224adjusting the ventilator 50 IPPV \200\224failure to tolerate ventilati on 52 DETAILED CONTENTS xxii IPPV \200\224failure to deliver ventilation 54 IPPV \200\224complications of ventilation 56 IPPV \200\224weaning techniques 58 IPPV \200\224assessment of weaning 60 High frequency je t ventilation 62 High frequency oscillatory ventilation 64 Positive end expiratory pressure (1) 66 Positive end expiratory pressure (2) 68 Continuous positive airway pressure 70 Lung recruitment 72 Prone positioning 74 Non-invasive respiratory support 76 Extracorporeal res piratory support 78 Tracheotomy 80 Mini-tracheotomy 82 Chest drain insertion 84 Pleural asp iration 86 Fibreoptic bronchoscopy 88 Chest physiotherapy 90 3 Cardiovascular therapy techniques 93 Electrical cardioversion 94 Temporary pacing (1) 96 Temporary pacing (2) 98 Therapeutic hyp othermia 100 Intra-aortic balloon counterpulsation 102 Coronary revascularisation technique s 104 4 Renal therapy techniques Haemo(dia) \201 ltration (1) 108 Haemo(dia) \201 ltration (2) 110 Peritoneal dialysis 112 Plasma exchange 114 107 5 Gastrointestinal therapy techniques 117 Sengstaken-type tube 118 Upper gastrointestinal endoscopy 120 Enteral feeding and drainage tubes 122 DETAILED CONTENTS xxiii 6 Nutrition and metabolic therapy Nutrition \200\224use and indications 126 Enteral nutriti on 128 Parenteral nutrition 130 Tight glycaemic control/intensive insulin therapy 132 125 7 Wound and pressure area management 135 Wound management principles 136 Dressing techniques 138 Special support surfaces 140 8 Respiratory monitoring 143 Pulse oximetry 144 CO2 monitoring 146 Pulmonary function tests 148 Volume-pressure relation ship 150 Blood gas machine 152 Blood gas analysis 154 Extravascular lung water measurement 156 Respiratory imaging 158 9 Cardiovascular monitoring 161 ECG monitoring 162 Blood pressure monitoring 164 Arterial cannulation 166 Central venous ca theter \200\224insertion 168 Central venous catheter \200\224use 170 Central venous cathete r \200\224complications 172 Pulmonary artery catheter \200\224insertion 174 Pulmonary arter y catheter \200\224use 176 Cardiac output \200\224central thermodilution 178 Cardiac output \200\224peripheral thermodilution 180 Cardiac output \200\224indicator dilution 182 Cardia c output \200\224Doppler ultrasound 184 Cardiac output \200\224pulse contour analysis 186 C ardiac output \200\224other techniques 188 Pressure and stroke volume variation 190 Echocar diography 192 DETAILED CONTENTS xxiv Tissue perfusion monitoring 194 Gut tonometry 196 10 Neurological monitoring 199 Intracranial pressure monitoring 200 Jugular venous bulb saturation 202 EEG/CFM monitoring 204 Other neurological monitoring 206 11 Laboratory monitoring Urea and creatinine 210 Electrolytes (Na+, K+, Cl \200\223, HCO3 C alcium, magnesium, and phosphate 214 Cardiac function tests 216 Liver function tests 218 Fu ll blood count 220 Coagulation monitoring 222 Bacteriology 224 Virology, serology, and assa ys 226 Toxicology 228 209 \200\223) 212 12 Miscellaneous monitoring 231 Urinalysis 232 Indirect calorimetry 234 Lactate 236 Colloid osmotic pressure 238 13 Fluids 241 Crystalloids 242 Sodium bicarbonate 244 Colloids 246 Blood transfusion 248 Blood products 2 50 14 Respiratory drugs Bronchodilators 254 Respiratory stimulants 256 Nitric oxide 258 Surfac tant 260 253 DETAILED CONTENTS xxv 15 Cardiovascular drugs 263 Inotropes 264 Vasodilators 266 Vasopressors 268 Hypotensive agents 270 Anti-arrhythmics 272 Chronotropes 274 Anti-anginal agents 276 16 Renal drugs Diuretics 280 Dopamine 282 279 17 Gastrointestinal drugs 285 H2 blockers and proton pump inhibitors 286 Sucralfate 288 Antacids 290 Anti-emetics 292 Gut motility agents 294 Anti-diarrhoeals 296 A nti-constipation agents 298 18 Neurological drugs 301 Non-opioid analgesics 302 Opioid analgesics 304 Epidural analgesia 306 Sedatives and tranquilisers 308 Muscle relaxants 310 Anticonvulsants 312 Neuroprotective agents 314 19 Hematological drugs Anticoagulants 318 Thrombolytics 320 Coagulants and anti \201 brino lytics 322 317 DETAILED CONTENTS xxvi 20 Miscellaneous drugs Antimicrobials 326 Corticosteroids 328 Prostaglandins 330 Immunomodu latory therapies in sepsis 332 Rituximab 334 325 21 Resuscitation 337 Basic resuscitation 338 Cardiac arrest 340 Fluid challenge 342 22 Respiratory disorders 345 Dyspnoea 346 Airway obstruction 348 Respiratory failure 350 Atelectasis and pulmonary colla pse 352 Chronic air \202 ow limitation 354 Acute chest infection (1) 356 Acute chest infec tion (2) 358 Acute respiratory distress syndrome (1) 360 Acute respiratory distress syndrom e (2) 362 Asthma \200\224general management 364 Asthma \200\224ventilatory management 366 P neumothorax 368 Haemothorax 370 Haemoptysis 372 Inhalation injury 374 Pulmonary embolus 376 23 Cardiovascular disorders 379 Hypotension 380 Hypertension 382 Tachyarrhythmias 384 Bradyarrhythmias 386 Acute coronary s yndrome (1) 388 DETAILED CONTENTS xxvii Acute coronary syndrome (2) 390 Heart failure \200\224assessment 392 Heart failure \200\224 management 394 24 Renal disorders Oliguria 398 Acute renal failure \200\224diagnosis 400 Acute renal failu re \200\224management 402 397 25 Gastrointestinal disorders Vomiting/gastric stasis 406 Diarrhea 408 Failure to open bowe ls 410 Upper gastrointestinal hemorrhage 412 Bleeding varices 414 Oesophageal perforation 4 16 Intra-abdominal bowel perforation and obstruction 418 Lower intestinal bleeding and coli tis 420 Abdominal sepsis 422 Pancreatitis 424 405 26 Hepatic disorders 427 Jaundice 428 Acute liver failure 430 Hepatic encephalopathy 432 Chronic liver failure 434 27 Neurological disorders 437 Coma 438 Acute weakness 440 Delirium 442 Generalized seizures 444 Meningitis 446 Intracrani al hemorrhage 448 Subarachnoid hemorrhage 450 Stroke 452 Raised intracranial pressure 454 G uillain \200\223Barr syndrome 456 DETAILED CONTENTS xxviii Myasthenia gravis 458 Critical care neuromuscular disorders 460 Tetanus 462 Botulism 464 28 Hematological disorders Bleeding disorders 468 Clotting disorders 470 Anemia 472 Sickle cell disease 474 Haemolysis 476 Platelet disorders 478 467 29 Metabolic disorders 481 Electrolyte management 482 Hypernatraemia 484 Hyponatraemia 486 Hyperkalaemia 488 Hypokalae mia 490 Hypomagnesaemia 492 Hypercalcaemia 494 Hypocalcaemia 496 Hypophosphataemia 498 Gene ral acid-base principles 500 Metabolic acidosis 502 Metabolic alkalosis 504 Hypoglycaemia 5 06 Hyperglycaemia 508 Diabetic ketoacidosis 510 Hyperosmolar diabetic emergencies 512 Thyro id emergencies 514 Hypoadrenal crisis 516 30 Poisoning 519 Poisoning \200\224general principles 520 Salicylate poisoning 522 Paracetamol poisoning 524 Sedative poisoning 526 DETAILED CONTENTS xxix Tricyclic antidepressant poisoning 528 Amphetamines and Ecstasy 530 Cocaine poisoning 532 I nhaled poisons 534 Household chemicals 536 Methanol and ethylene glycol 538 Organophosphate poisoning 540 31 Infection and in \202 ammation 543 Infection control \200\224general principles 544 Infection control \200\224HIV 546 Infectio n control \200\224dangerous pathogens 548 Routine changes of disposables 550 Infection \200 \224diagnosis 552 Infection \200\224treatment 554 Systemic in \202 ammation/multi-organ fa ilure \200\224causes 556 Systemic in \202 ammation/multi-organ failure \200\224management 558 Sepsis and septic shock \200\224treatment 560 Multi-resistant infections 562 Necrotisin g fasciitis 564 HIV-related disease 566 Malaria 568 SARS, VHF, and H5N1 570 Rheumatic disor ders 572 Vasculitis 574 Toxic epidermal necrolysis 576 Anaphylactoid reactions 578 32 Trauma and burns 581 Multiple trauma (1) 582 Multiple trauma (2) 584 Head injury (1) 586 Head injury (2) 588 Spi nal cord injury 590 Burns \200\224 \202 uid management 592 Burns \200\224general managemen t 594 Blast injury 596 DETAILED CONTENTS xxx 33 Physical disorders Hypothermia 600 Pyrexia \200\224causes 602 Pyrexia \200\224management 604 Hyperthermia 606 Electrocution 608 Near-drowning 610 Rhabdomyolysis 612 Raised intra-a bdominal pressure 614 599 34 Pain and post-operative critical care 617 Pain 618 Post-operative critical care 620 35 Oncological critical care Pain and comfort 624 Effects of chemo- and radiotherapy 626 Ne utropaenia and infection 628 Leukemia/lymphoma 630 623 36 Obstetric emergencies 633 Pre-eclampsia and eclampsia 632 HELLP syndrome 634 Post-partum hemorrhage 638 Amniotic \202 uid embolus 640 37 Transportation of the critically ill Intra-hospital transportation 644 Inter-hospital tr ansportation \200\224road 646 Inter-hospital transportation \200\224air 648 643 38 Death and the dying patient 651 Brain stem death 652 Withdrawal and withholding treatment 654 Care of the potential organ/t issue donor 656 Index 659 1 Chapter 1 Critical care organization and management Critical Care Unit layout 2 Critical Care Unit staf \201 ng (medical) 4 Critical Care Unit staf \201 ng (nursing) 6 Outreach support 8 Critical Care Unit admission criteria 10 Surv ivor follow-up 12 Patient safety 14 Fire safety 16 Communication 18 Medicolegal aspects 20 Clinical governance 22 Audit 24 Critical care scoring systems 26 APACHE scoring 28 SAPS sco re 30 SOFA score 32 Trauma score 34 2 CHAPTER 1 Critical care organization Critical Care Unit layout The Critical Care Unit should be easily accessible by departments from which patients are admitted and close to departments which share engi- neering servic es. In a new hospital, all critical care facilities should ideally be proximal to operating theaters, emergency department, laboratories, and imaging suites. It is desirable that critically ill patients are separated from those in the recovery phase or needing coronary care where a quieter environ- ment is needed. Providing intensive care and high dependency care in the same Critical Care Unit allows \202 exibility of staf \201 ng, although the differing requirements of these patients may limit such \202 exibil ity. Size of unit Requirements depend on the activity of the hospital with additional beds requi red for regional specialties such as cardiothoracic surgery or neurosurgery. Very small (<6 beds) or very large (>14 beds) units may be dif \201 cult to manage, although larger unit s may be divided operationally and allow better concentration of resources. Patient areas \200 Patient areas must provide unobstructed passage around the bed with a \202 oor space of 2 6m2 per bed and bed centers of at least 4.6m. Curtains or screens are required for privacy. Floors and ceilings must be constructed to support heavy equipment (some may weigh >1000kg ). Doors must allow for passage of bulky equipment as well as wide beds. A wash hand basin with elbow-operated or proximity-operated mixer taps, soap, and antiseptic dispensers shoul d be close to every bedspace. The speci \201 cation should include 50% of beds as isolatio n cubicles. Air pressure control in cubicles should ensure effective patient isolation. Ser vices must include adequate electricity supply (at least 28 sockets per bed) with an uninte rruptable power supply for essential equipment. Oxygen (4), medical air (2), and high (2) a nd low (2) pressure suction outlets must be available for every bed. The bed areas should h ave natural daylight and patients and staff should ideally have an outside view. Communicat ions systems include an adequate number of telephones, intercom systems to allow bed-to-bed communication, and a system to control entry to the department. Computer networks should e nable communication with central hospital administration, laboratory and radiology systems, and the internet. \200 Other areas required Other areas include adequate storage space, separate clean-treatment a nd dirty utility/sluice areas, of \201 ces, laboratory, seminar room, cleaners \200\231 ro om, staff rest room, staff change and locker room, toilets and shower facilities, relatives \200\231 area including a quiet area for grieving family, and an interview room. CRITICAL CARE UNIT LAYOUT 3 See also: Infection control \200\224general principles, p544. 4 CHAPTER 1 Critical care organization Critical Care Unit staf \201 ng (medical) Critical care has evolved from its early success in simple mechanical ventilation of the lungs of polio victims to the present day where pa tients usually have, or are at risk of developing, failure or dysfunction of one or more or gan systems requiring mechanical and pharmacological support and monitoring. The unit shoul d have dedicated consultant sessions allo- cated for direct patient care with additional se ssions for management, teaching, and audit activities. These sessions should be divided bet ween several critical care-trained specialists who should be supported by trainee doctors p roviding round-the-clock cover on a rota which provides adequate rest. Required skills of critical care medical staff Management Senior medical staff, assisted by senior nursing and drugstore colleagues, command the primary responsibility for the struct ural and \201 nancial management of the unit. It is through their actions that treatment of the critically ill is initiated and perpetuated; they are ultimately responsible for the activity of the unit and patient outcome. Decision-making In the Critical Care Unit, most decisions are made by team consensus. Clini cal decisions fall under three categories: (i) decisions relating to common or routine prob lems for which a unit policy exists; (ii) decisions relating to uncommon problems requiring discussion with all currently involved staff, and (iii) decisions of an urgent nature take n by critical care staff without delay. Practical skills Expertise in the management of complex equipment, monitoring proce- dures and performance of invasive procedures are required. Clinical experience Medical staff require experience in the recognition, prevention and man agement of critical illness, infection control, anesthesia, analgesia, and organ support. Technical knowledge The critical care specialist has an important role in the choice of equ ipment used in the unit. Advice should be sought from non-medical colleagues. Pharmacological knowledge Drug therapy regimens are clearly open to the problems of drug in ter- actions, while pharmacokinetics are often severely altered by the effects of major org an system dysfunction, particularly involving the liver and kidneys. Adverse reactions are common. Teaching and training The modern critical care specialist has acquired skills that cannot b e gained outside the Critical Care Unit. Therefore, it is necessary to impart this knowledg e to doctors training in the specialty. CRITICAL CARE UNIT STAFFING (MEDICAL) 5 6 CHAPTER 1 Critical care organization Critical Care Unit staf \201 ng (nursing) Critically ill patients require close nursing su pervision. Many will require high-intensity nursing throughout a 24h period while others ar e of a lower dependency and can share nurses. In addition to the bedside nurses, the depart ment needs additional staff to manage the day-to-day running of the unit, to assist in lift ing and handLing of patients, to relieve bedside nurses for rest periods, and to collect dr ugs and equipment. These additional nurses (or nurse assistants) can be termed the \200 \230 \201 xed nursing establish- ment \200\231 and the nature of their duties is such that they will usually include the higher grade nurses. The bedside nurses are a \200\230varia ble establishment \200\231 and their numbers are dependent on activity such that more patie nts require higher numbers. Most departments \201 x part of their variable establishment by assuming an average activity. Fixed establishment Providing one nurse per shift requires a rota of 5.5 nurses. In additio n, staff handover, annual leave, study leave, and sickness are usually calculated at 22% su ch that one additional nurse is required. Thus, the provision of one nurse in charge of eac h shift and one nurse to support the bedside nurses requires 11 nurses in those two roles a lone. In larger units, there may be a need for additional nurses supporting the nurse in ch arge. Variable establishment The same principles apply for the provision of bedside nurses. Thus, to provide 1:1 nursing for a bed requires 5.5 nurses and to provide 1:2 nursing requires 2 .75 nurses. The total number required depends on the occupancy and the nurse-to-patient rat io for each occupied bed. One of the dif \201 culties in staf \201 ng a Critical Care Uni t relates to the variable dependency and occupancy. An average dependency weighted occupanc y (average occupancy x average nurse-to-patient ratio) should be used to set the establishm ent of bedside nurses with additional nurses being drafted in from a bank or agency to cove r peak demands.