2015 clinical intensive care medicine

Gómez LMS FRCA MD EDICM FFICM Consultant and Honorary Senior Lecturer in Intensive Care and Anaesthesia St Mary’s and Hammersmith Hospitals Imperial College Healthcare NHS Trust Clinical

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Imperial College Press

Clinical Intensive Care Medicine

Editor

Carlos M H Gómez

St Mary’s Hospital and Hammersmith Hospital, UK

World Scientific Publishing Co Pte Ltd.

5 Toh Tuck Link, Singapore 596224

USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601

UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

Library of Congress Cataloging-in-Publication Data

Clinical intensive care medicine / edited by Carlos M.H Gómez.

p ; cm (Introductory series in medicine ; volume 1)

Includes bibliographical references and index.

ISBN 978-1-84816-388-1 (hardcover : alk paper) ISBN 978-1-84816-389-8 (electronic)

I Gómez, Carlos M H., editor II Series: Introductory series in medicine ; v 1.

[DNLM: 1 Intensive Care 2 Clinical Medicine 3 Critical Illness therapy WX 218]

RC86.7

616.02'8 dc23

2014026685

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

Copyright © 2015 by Imperial College Press

All rights reserved This book, or parts thereof, may not be reproduced in any form or by any means,

electronic or mechanical, including photocopying, recording or any information storage and retrieval

system now known or to be invented, without written permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance

Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA In this case permission to photocopy

is not required from the publisher.

Typeset by Stallion Press

Email: enquiries@stallionpress.com

Printed in Singapore

To Carlos, Luis and TomásWonderful, glorious boys: my soul, my spirit, my life

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List of Authors xxvii

2.3 Ventricular Performance and the Determinants

3.6 Carbon Dioxide and Interpretation of

References 63

David Brealey and David Howell

6 Vasoactive Agents 113

Gayathri Satkurunath, Raha Rahman West

and Andrew Rhodes

6.6 Cardiac Output: Advantages and Disadvantages

Borja G Cosío and José M Echave Sustaeta

References 200

9 Nutrition 205

Richard Leonard

Kanupriya Agrawal and Andrew R Wright

11.5 Computed Tomography of the Chest in the ICU Patient 285

11.6 Computed Tomography of the Abdomen in the

References 312

12 Biochemistry in Intensive Care 317

Paul Holloway

References 371

S Ramani Moonesinghe and Michael G Mythen

14.4 Peri-Operative Monitoring and Management of

References 393

15 Post-Operative Intensive Care 403

Umeer Waheed and Mark G A Palazzo

15.5 Sepsis and the Systemic Inflammatory Response

References 484

Marius Gota, Allen Bashour and Michael O’Connor

References 544

Sarah L Stirling and Mark J D Griffiths

21 Vascular Intensive Care 595

Susan Jain and Carlos M H Gómez

21.2 Physiological Impact of Major Vascular Surgery

References 617

Julia Wendon and Patrick Ward

Shaikh A Nurmohamed, Marc G Vervloet

and A B Johan Groeneveld

23.5 Non-Renal Indications for Continuous Renal

23.7 Future Trends: Renal Cell Therapy and the

25.3 Advanced Ventilatory Techniques in Infants and Children 718

25.4 Diagnosis and Management of Meningococcal Disease

26.5 Timing of Fracture Fixation and Surgery (Damage Control) 770

Lena C Andersson, Hans C Nettelblad and Folke Sjoeberg

27.2 Clinical Presentation of Burn Injuries and Management

Strategies 78827.3 Initial Assessment of Injuries and Treatment

Principles — The Resuscitation (Initial 48-Hour) Phase 78927.4 Further Clinical Assessment of Injuries and Treatment

29 Transfer of the Critically Ill 873

Simon Munk and Andrew Hartle

Sunil Grover and Carlos M H Gómez

References 926

Index 933

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Foreword from the Series Editor

My collaboration with Imperial College Press dates back to 1995 when I was

commissioned to write a book on transplantation entitled Introduction to

Organ Transplantation I have since edited several textbooks on different

sur-gical fields including a second edition of Introduction to Organ Transplantation

in 2012 Collating a series of textbooks introducing different specialties is a

challenge I have undertaken with the hope that the knowledge and expertise

presented will spur the next generation on to even greater knowledge I

envis-age the series to be useful to physicians and surgeons at all levels of training

and experience, extending the tradition of textbook excellence and leadership

I have invited experts to put together volumes to ensure a full display of the

state-of-the-art of several surgical and associated specialties in order to provide

a complete coverage of current practice as well as a glimpse of the future

This first volume, selected and brought together by Dr Carlos Gómez,

explores the latest in current intensive care practice in a broad range of

areas Intensive care is a specialty which has evolved and progressed

expo-nentially over the last few years, and this timely volume will be an

important guide for current and future doctors

Professor Nadey Hakim, MD, PhD

Imperial College London

Honorary Secretary Royal Society of Medicine

Past President International College of Surgeons

June 2014

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Foreword

It is a great pleasure for me to write the foreword to Clinical Intensive Care

Medicine and to congratulate Carlos Gómez and colleagues — all of whom

are hands-on, practicing clinicians — on this outstanding achievement As

a vascular surgeon with an interest in complex aortic disease, I have plenty

of reasons to thank the current generation of expert intensivists This book

enshrines today’s approach to the management of the critically ill patient

and as such it demonstrates the authors’ desire to spread best current

prac-tice as well as a commitment to teaching the next generation Dr Gómez

believes this book is relevant to everyone from medical student to

inten-sive care unit chief I would add that it is useful also for those working in

the most technologically advanced hospitals to those in field or temporary

establishments

Critical care has come of age in the last two decades and the specialty

continues to expand its role It does not take too much imagination to see

the hospitals of the future as one where expensive in-patient real-estate

can only be justified for patients with critical care needs That patients are

getting ever older and ever more sick with ever more multi-system disease

only adds to this vision It means that developed societies are likely to need

more people with critical care skills As well as continuing to improve

out-comes, the challenges for intensive care unit practitioners now are to

optimise training of the next generation — it surely cannot all be done on

the job — and to develop an evidence base to underpin each of the

mas-sive range of pharmacological, interventional, monitoring and supportive

strategies now available To me both of these make the case for the

promo-tion of academic intensive care unit medicine throughout the developed

world

A final word about governance and resource allocation; in the future —

consistent with the rising role of intensive care unit medicine — intensivists

must become more involved in the running of the hospitals in which they

work Only by doing this will they be able to appropriately direct and

under-stand intensive care unit care, its costs and the context of funding in an

increasingly competitive health care world

I am happy to see that most of my questions are addressed in this

excellent book Good luck to all who read it, especially those about to

embark on a career in clinical medicine I suggest you learn from Dr

Gómez and his colleagues The time for intensive care medicine is now

N J Cheshire MD FRCS

Professor of Vascular Surgery

Head of Circulation & Renal Sciences

Imperial College Healthcare

London

June 2014

Preface

The book is intended as an authoritative guide to practical intensive care

medicine written by acknowledged specialist practitioners from the UK,

Europe and North America, most of whom are also internationally

acclaimed authors Target audiences are medical students, trainees in

intensive care medicine and other acute specialties, consultants wishing to

remain up to date on all branches of this vast specialty and other allied

professionals practising in intensive care, including nurses and

physiother-apists The book therefore has a practical and educational common thread

rather than an encyclopaedic approach

Intensive care patients are the sickest and most challenging in any

hospital and use up a disproportionate amount of resources The specialty

is relatively young, only about 40 years old, and expanding worldwide as

patients grow older, harbour greater expectations and present increased

demands on already stretched health systems

The older generation of intensivists is approaching retirement The

middle generation trained in various medical and surgical specialties and

then subspecialised in intensive care These doctors now lead the way in

clinical practice, research, management and training The younger

genera-tion of intensivists includes an ever increasing number of doctors who, for

the first time, enjoy a structured training programme with clinical

rota-tions, courses and exam qualifications

This book is aimed at this younger generation My vision is for this

book to become a useful resource for those wishing to study, practice and

excel in intensive care medicine

While conceiving this book I have reflected on the true challenges

which face the intensive care clinician They are of three types: clinical,

managerial and life challenges

On the clinical front there are several crucial decisions to be made and

revisited for every patient, every day What is acceptable physiology, what is

achievable and at what price? The clinician may, for example, decide that

intravascular volume is the priority He/she must therefore be prepared to

accept as a trade-off an increase in unwanted fluid in the form of

pulmo-nary (capillary), peripheral and cerebral oedema Equally, given a different

scenario — or a different clinician — perfusion pressure may become the

prime goal This will of necessity be at the expense of increased cardiac

work and also of peripheral vasoconstriction, the combination of these two

potentially giving rise to tissue hypoxia and acidaemia Finally,

normalisa-tion of acid-base chemistry may be the utmost priority Strategies targeted

to achieve this can lead to raised intrathoracic pressure (through increased

ventilatory settings), increased cardiac work and peripheral oedema

Also worth reflecting upon is the challenge of blending in with other

intensive care colleagues who might have somewhat different clinical

phi-losophies Changing treatment plans for the sake of change or in order to

prove a point seldom benefits the patient, often has a negative effect on

team morale and frequently causes undesirable confusion When taking

over the care of a human being who is making satisfactory clinical progress

but is perhaps being weaned differently, on inotropes which one would

not necessarily have chosen or on antibiotics not amongst one’s favourites,

the challenge facing the clinician is this: is it really necessary to change

these when they are being effective? Some of us refer to this phenomenon

as the ‘Monday syndrome’

Perhaps the most important decision facing the intensive care team is

to decide which patient requires immediate intervention and which

patient can and will benefit from masterful inactivity and close

observa-tion Which patient should be left alone? When should resident doctors be

encouraged to do nothing but just observe? One of the eminent

contribu-tors to this book once told me that it is just as important to do something

which causes benefit as it is to stop others from doing something which

may cause harm

On a philosophical note the reader will agree with me that there is

always the possibility of being wrong The problem here is not necessarily

the wrong itself but the consequence of not realising it The wise, humble

clinician is mindful of the possibility of being wrong, however

knowledge-able and experienced, and therefore is likely to recognise a wrong decision

early and thereby be better positioned to rectify it The less wise and

per-haps less humble intensivist displays an inability to entertain being wrong,

which can lead to catastrophe

The managerial front requires quite a different mind-set Gifted

administrators have an almost innate ability to get the most out of the

resources available to them Perhaps the greatest resource is time and I am

always admiring of colleagues who excel in time management The ability,

desire and vision to delegate the right task to the right individual seems

inextricably linked to that of successful time management One of the

hallmarks of good management is the creation of efficient and robust

sys-tems to ensure clinical safety and governance The ideal system practically

runs itself, accepts newcomers, is understood and appreciated by all and

can be modified as new standards develop For any system to function to

a high standard there must be good communication within its members

as well as with other clinical groups

Intensive care specialists are of course members of the human race

with a multitude of complex personal, professional and family

interac-tions which clearly are constantly undergoing evolution We bring

children, partners, wives, husbands, holidays, parties, funerals, weddings,

deaths, illness, injuries, rota difficulties and an endless list of life events to

the table of intensive care medicine The management of these

individu-ally and collectively and the support we give to but also draw from our

colleagues constitutes an important challenge in our life as a member of

an intensive care department

Life has thrown a couple of curve balls in my direction while editing

this book and I must forever thank Neville, David, Robert and Claire They

know how much they have helped

An endeavour of this kind requires a lot of activity behind the stage

My wonderful colleagues have challenged, criticised, amused, assisted and

supported me throughout Our nurses, physiotherapists and all members

of the wider team make it possible for care to be administered and have

over the years provided much clinical advice and feedback; many regularly

provide support and some have become friends Our residents no longer

live in the hospital but provide constant care and vigilance, vibrant energy,

an inquisitive and stimulating approach as well as a valuable source of

criticism and advice; with the nurses, they are an important gateway to the

outside world

My talented, dedicated and incredibly knowledgeable contributors

deserve enormous admiration It is right that they receive my most

pro-found gratitude If this book finds success then they will deserve immense

credit The faults, misgivings, errors and omissions are, however,

exclu-sively mine I am grateful to Nadey Hakim for inviting me to contribute

this book to his series Introductory Series in Medicine and for guiding me

through its various stages

Susanne, Annie, Patricia and now Robyn have been looking after me

and my affairs, and without them I would not be where I am today

The various publishing editors at Imperial College Press have

dis-played an unquantifiable amount of patience with me and have provided

invaluable advice and support throughout the various stages, delivered

with great professionalism Thank you Tasha D’Cruz, Sarah Haynes, Lizzie

Bennet and Lance Sucharov

Finally our patients and their families have my most heartfelt

sympa-thy and respect, especially those who did not survive the journey I wish

them all well and although it has been a privilege to care for them I am

sorry we had to meet in the circumstances that we did

Carlos M Gómez

London

June 2014

Laboratory of Asthma and Lung Inflammation

Cardiovascular and Pulmonary Branch/NHLBI

National Institutes of Health

David Brealey BSc PhD MRCP FRCA FFICM

Consultant in Anaesthesia and Intensive Care Medicine

University College Hospital

London, UK

Borja G Cosío MD PhD

Consultant in Respiratory Medicine

Hospital Universitario Son Espases

Palma de Mallorca, Spain

José M Echave Sustaeta MD

Critical Care Medicine Department

National Institutes of Health

Bethesda, MD, USA

Carlos M H Gómez LMS FRCA MD EDICM FFICM

Consultant and Honorary Senior Lecturer in Intensive Care and

Anaesthesia

St Mary’s and Hammersmith Hospitals

Imperial College Healthcare NHS Trust

Clinical Director of Intensive Care

Harley Street Clinic

Dr Mark J D Griffiths

Reader in Critical Care Medicine

National Heart and Lung Institute

Imperial College London

South Kensington Campus

Andrew Hartle MB ChB FRCA FFICM

Consultant Intensivist and Anaesthetist

Chairman, Clinical Risk Committee

Trust Lead for Mental Capacity

Imperial College Healthcare NHS Trust

London, UK

Nicholas Hirsch FRCA FRCP

Consultant in Neuroanaesthesia and Neurocritical Care

Honorary Senior Lecturer

The National Hospital for Neurology and Neurosurgery

University College London Hospitals

London, UK

Paul Holloway PhD BM BCh FRCPath EurClinChem

Consultant Chemical Pathologist and Honorary Senior Lecturer in

Metabolic Medicine Imperial College Healthcare NHS Trust

Medical School, St Mary’s Hospital,

London, UK

David Howell BSc (Hons) MBBS (Hons) PhD FFICM FRCP

Divisional Clinical Director, Critical Care

University College London Hospitals

London, UK

Susan Jain BSc MBBS MRCP FRCA

Locum Consultant Anaesthetist

University College London Hospitals NHS Trust

London, UK

Annette Jepson MA MSc PhD FRCPE FRCPath

Consultant Medical Microbiologist

Imperial College Healthcare NHS Trust

Lesley Kay FRCP FRCPath

Consultant Haematologist and Physician

The Princess Grace Hospital

Richard Leonard FRCP FRCA FANZCA FCICM FFICM

Consultant and Honorary Senior Lecturer in Intensive Care and

Anaesthesia

St Mary’s Hospital

Imperial College Healthcare NHS Trust

London, UK

Surbi Malhotra MBBS FRCA

Anaesthesia and Critical Care Medicine

University College Hospital

Honorary Senior Lecturer

Anaesthesia and Critical Care Medicine

University College London

Michael G Mythen MBBS MD FRCA FFICM FCAI

Smiths Medical Professor of Anaesthesia and Critical Care

University College London

Director of Research and Development

University College London Hospitals

Research Support Centre

National Clinical Lead

Department of Health

Enhanced Recovery Partnership

London, UK

Department of Hand Surgery, Plastic Surgery and Burns

University Hospital Linköping

Chairman, Cleveland Clinic Anesthesia Institute

Department of Cardiothoracic Anesthesia

Cleveland Clinic Foundation

Cleveland, OH, USA

Mark G A Palazzo MB ChB FRCA FRCP FFICM MD

Clinical Program Director – Specialist Services

Imperial College Healthcare NHS Trust

London, UK

Parind Patel MBBS FRCA DMS EDICM FFICM

Consultant in Intensive Care Medicine

Honorary Clinical Senior Lecturer

Hammersmith Hospital

Imperial College Healthcare NHS Trust

Harley Street Clinic

Bupa Cromwell Hospital

London, UK

Andrew Rhodes FICM FRCA FRCP

Consultant in Intensive Care Medicine and Anaesthesia

Department of Intensive Care Medicine

St George’s Healthcare NHS Trust

Peter J Shirley FRCA FIMC RCS (ed) EDIC

Consultant in Intensive Care and Anaesthesia

Royal London Hospital

London, UK

Virinder S Sidhu MB BCh FRCP FRCA

Consultant and Honorary Clinical Senior Lecturer in Anaesthesia

and Intensive Care

Imperial College Healthcare NHS Trust

Harley Street Clinic

London, UK

Folke Sjoeberg MD

Department of Hand Surgery, Plastic Surgery and Burns

University Hospital Linköping

Linköping, Sweden

Martin Smith FRCA

Consultant in Neuroanaesthesia and Neurocritical Care

Honorary Reader in Anaesthesia and Critical Care

The National Hospital for Neurology and Neurosurgery

University College London Hospitals

London, UK

Neil Soni MB ChB FANZA MD

Consultant and Honorary Senior Lecturer in Intensive Care

and Anaesthesia

Chelsea and Westminster NHS Trust

London, UK

Sarah L Stirling MRCP FRCA

Consultant in Intensive Care & Anaesthesia

Harefield Hospital

London, UK

Richard Stümpfle MRCP FRCA EDIC FFICM

Consultant in Intensive Care and Anaesthesia

Hammersmith Hospital

Imperial Healthcare NHS Trust

London, UK

Christopher Taylor MRCP FRCA

Consultant in Neuroanaesthesia and Neurocritical Care

Honorary Senior Lecturer

The National Hospital for Neurology and Neurosurgery

University College London Hospitals

Marc G Vervloet MD

Internist Nephrologist

VU Medical Centre

Amsterdam, Netherlands

David J Watson BSc (Hons) MBBS FRCA FFICM

Honorary Professor of Intensive Care Education

Homerton University Hospital NHS Foundation Trust and Barts

The London School of Medicine and Dentistry

Queen Mary University of London

London, UK

Umeer Waheed FRCA EDICM FFICM

Consultant in Intensive Care

Department of Anaesthesia and Intensive Care

Hammersmith Hospital

Imperial Healthcare NHS Trust

London, UK

Patrick A Ward MB ChB BSc FRCA

Specialist Registrar in Anaesthetics

Imperial School of Anaesthesia, London

London, UK

Andrew R Webb MD FRCP

VP Medicine, Fraser Health Authority

Clinical Professor, UBC Faculty of Medicine

King’s College School of Medicine

King’s Health Partners

London, UK

Raha Rahman West MD

Department of Intensive Care Medicine

St George's Healthcare NHS Trust

Consultant Radiologist and Honorary Senior Lecturer

Imperial College Healthcare NHS Trust

London, UK

1

History of Intensive Care

Jennifer Jones

When the first World Congress of Intensive Care was held in London in

June 1974, it was attended by more than 2,000 delegates from all parts of

the globe and the astonished organisers had to hire extra space to

accom-modate them all The success of the event illustrated the fact that, over the

previous decade, the provision of care for critically ill patients in units

separate from general wards had been accepted as an essential feature of

hospitals throughout the world

How did this acceptance come about and what changes have taken

place since?

It had been recognised for many years that there were advantages in

treating patients with the greatest need for care in one place In the

Crimean War, Florence Nightingale’s insistence on keeping the sickest

patients closest to the central nursing station may be regarded as an early

example of the practice Before the Second World War recovery rooms

adjacent to operating theatres were introduced ‘Shock wards’ were

established during the war to treat the most severely injured casualties,

and coronary care units after the war demonstrated that mortality from

acute myocardial ischemia could be reduced by treating the victims in a

single area

Mechanical ventilation of the lungs was introduced to treat victims

of poliomyelitis and tetanus It was originally believed that negative

pres-sure ventilation (NPV) was the ‘physiological’ way to ventilate the lungs,

and machines were designed to enclose the patient from the neck down

in a box from which air was rhythmically pumped in and out to mimic

expiration and inspiration The first electrically driven device was the

‘iron lung’ devised in the USA by Drinker and Shaw and introduced into

were set up to meet the country’s needs for artificial respiration

Intermittent positive pressure ventilation (IPPV) combined with

tra-cheostomy (which is very difficult to manage in combination with a

tank respirator) was introduced during the poliomyelitis epidemic in

Copenhagen in 1952 Lassen, who was in charge of the hospital for

infec-tious diseases, which lacked enough tank respirators to deal with the influx

of patients, asked an anaesthetist, Ibsen, if techniques used in the

operat-ing theatre could be applied to the management of patients with

respiratory failure on the wards To begin with, positive pressure

ventila-tion was provided manually, using a to-and-fro breathing system, by relays

of medical students [2]

Later, the students were superseded by the Engstrom ventilator

During the course of the Copenhagen epidemic, Astrup’s work on

blood gas analysis made it possible to assess the adequacy of alveolar

ven-tilation and established the superiority of IPPV over NPV in this regard

[3] It also became clear that another — and perhaps the greatest —

advantage of IPPV was the ease of access to the patient that it offered to

nursing staff Lassen’s account of the epidemic stresses the need for

humidification of inspired gas in preventing encrustation of respiratory

secretions in a patient with a trachcostomy and physiotherapy in airway

management, although both were improved in later years

The importance of the poliomyelitis epidemic in Copenhagen in the

development of intensive care was, therefore, profound It not only

dem-onstrated the superiority of IPPV over NPV in respiratory support, but

introduced the concept of a multidisciplinary approach to the

manage-ment of very sick patients and involved anaesthetists in the provision of

their care Some intensive care specialists today might not consider the

latter an advantage

The introduction of the Salk vaccine in 1955, which consists of

injected inactivated poliomyelitis virus, and of the oral Sabin vaccine in

1957, which uses an attenuated live virus, has eradicated poliomyelitis from

support continued to increase, driven by the needs of patients with tetanus

and chest injuries and, perhaps most importantly, by the proliferation of

cardiac surgery As mechanical ventilators were increasingly used to

support patients with acute pulmonary disease, their design became more

Chapters 7 and 8)

Awareness of the dangers of IPPV grew at the same time The

intro-duction of positive end-expiratory pressure (PEEP) to improve arterial

oxygenation rapidly showed that excessive intrathoracic pressures could be

associated with barotrauma in the shape of pneumothorax or mediastinal

emphysema or with a reduction in cardiac output, which could be

over-come by expanding the circulating volume to improve venous return [5]

Methods of assessing ‘best PEEP’ for optimising oxygen delivery to the

tissues were explored [6]

More recently, it has been recognised that over-distension of the alveoli

during IPPV with excessive tidal volumes may result in pulmonary

dam-age, and lower than traditional tidal volumes have gained acceptance [7]

Ventilator-associated pneumonia is a common nosocomial infection

which has been shown to be associated with prolonged intensive care stay

and a marked increase in mortality [8]

The intensive care units set up in the 1960s and 1970s were, for the

most part, small A report from the British Medical Association [9], which

confined itself to recommendations, envisaged that only 1% of acute

hos-pital beds would need to be set aside for intensive care, although it clearly

saw that such beds would need huge amounts of space, staff and services

Most of these intensive care units were run by anaesthetists, the majority

of whom regarded intensive care as a hobby in addition to their sessions

in the operating theatre and almost all of whom learned on the job There

was no recognition of intensive care as a specialty, no supervised training

programmes and no literature

One of the most important sequels to the first World Congress of

Intensive Care is that these points have been addressed Intensive care is

now recognised internationally as a specialty, training programmes are

ubiquitous and there are a huge number of journals of critical care

Standards for space and facilities exist at national and international levels

The question of whether intensive care units should be ‘open’ or ‘closed’