Ebook Evidence-based critical care (3rd edition): Part 1

(BQ) Part 1 book Evidence-based critical care presents the following contents: Evidence based critical care, critical care medicine, admission discharge criteria, fluid responsiveness and fluid resuscitation, assessment of cardiac function and cardiac output, management of pain, agitation and delirium,...

Evidence-Based Critical Care

Paul Ellis Marik

Third Edition

Evidence-Based Critical Care

Third Edition

ISBN 978-3-319-11019-6 ISBN 978-3-319-11020-2 (eBook)

DOI 10.1007/978-3-319-11020-2

Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014956872

© Springer International Publishing Switzerland 2015

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Division of Pulmonary and Critical Care Medicine

Eastern Virginia Medical School

Norfolk , VA , USA

To cure sometimes, to relieve often, to comfort always

—Hippocrates, Greek Physician, Father of Western Medicine (460–370 BC )

of my father, Colin Sigmund Marik,

a man of great intellect and wit

After completing the Second Edition of The Handbook of Evidence Based Critical

Care in 2009, I swore that I would rather stick needles in both my eyes than author

another updated version of the book But here we are in 2015 with the Third Edition

of Evidence - Based Critical Care (no longer a handbook) So what made me change

my mind? Most importantly, you, my dedicated readers, have implored me to update the book; I was told, “Medicine as we know it would be incomplete without an updated version.” Your enthusiastic and positive feedback was the driving factors which led me to consider writing this revision In addition, in the last 5 years we have witnessed a remarkable refi nement in the management strategies of critically ill patients best characterized as “Less is More” (see Chap 2 ) At the same time we have realized that while many of our patients survive their ICU stay, many have signifi cant residual functional and cognitive disabilities These changes in our approach and understanding of critical illness have necessitated the updated Third

Edition of Evidence - Based Critical Care

However, the basic guiding principles of Critical Care Medicine have not changed; compassionate, dedicated and thoughtful clinicians, who evaluate the functioning of the “whole” patient, ponder their disease processes and pathophysi-

ology and provide the highest level of Evidence - Based interventions with the goal

of restoring the patient to a quality of life which he/she values

Due to the vast number of therapeutic interventions that ICU physicians make

daily, the topics are presented as narrative summaries of the best available evidence

rather than as systematic reviews of each and every intervention In keeping with the goal of providing an evidence-based approach to critical care, references are provided to support the evidence presented In writing this book my goal has been

to take issues that appear complex and make them as simple as possible

It appears to me that those who really don’t have a good understanding of the complexities of physiology, pathophysiology and patient care make things so com-plicated that they themselves don’t understand what they are trying to convey This concept is exemplifi ed by the following quotes:

Make everything as simple as possible, but not simpler

If you can’t explain it simply, you don’t understand it well enough

Albert Einstein, Theoretical Physicist, 1879–1955

Evidence - Based Critical Care is not a reference text but presents a practical evidence - based approach to the management of critically ill ICU patients The

focus of this book is on issues that pertain specifi cally to the ICU As such, the reader is referred to standard medical and surgical texts as well as online resources for more complete information on the wide spectrum of conditions and diseases from which ICU patients may suffer While all attempts have been made to be current, due to the exponential growth of medical knowledge some of the informa-tion presented may already be outdated when this book comes to print The reader should therefore keep up-to-date with the current medical literature

The guidelines presented in the book are not meant to replace clinical judgment, but rather to provide a framework for patient management Individual clinical situ-ations can be highly complex and the judgment and wisdom of an experienced and knowledgeable intensivist with all available information about a specifi c patient is essential for optimal clinical management

This book recognizes my mentors and students who have taught me everything

I know and inspired me to learn even more

The author and publisher have made every attempt to check information and dosages for accuracy Because information and the science of pharmacology is continually advancing, our knowledge base continues to expand Therefore, we recommend that the reader check all information and all product information for changes, especially changes in dosages or administration before administering any medication

Part I General ICU Topics

1 Evidence Based Critical Care 3

References 6

2 “Less Is More”: The New Paradigm in Critical Care 7

References 8

3 “Classic” Papers 13

4 Critical Care Medicine 101 19

Factors to Consider When a Patient is Admitted to the ICU 20

Initial “Generic” Treatment Orders 20

Reference 21

5 House Officers Guidelines 1: Housekeeping 23

Admission History and Physical Examination 23

Daily Examination 24

General 24

Vital Signs (24 h Min and Max and Current) 24

Additional Observations 24

The Ventilator 25

Heart 25

Chest 25

Abdomen 25

CNS 26

Importance of the Daily Neurological Examination 26

Laboratory Tests 26

Imaging 27

Presenting on Daily Rounds 27

New Admissions 27

Follow Up Patients 28

Clinical Pearls 28

References 28

6 House Officers Guidelines 2: Procedures 29

Murphy’s Laws of Procedures 29

Central Venous Access 30

Subclavian Vein Catheterization 31

Internal Jugular Vein Catheterization 32

Femoral Vein Catheterization 33

Complications of Central Venous Access 34

Arterial Catheters 34

Naso/Oro Gastric Tubes 35

Feeding Tubes 36

Thoracentesis and Paracentesis 36

Clinical Pearls 37

References 37

7 Admission-Discharge Criteria 39

ICU Admission Criteria 39

Prioritization of Potential ICU Admissions 40

Priority 1 40

Priority 2 40

Priority 3 40

Priority 4 41

Transfer from Another Hospital: Variable Priority 41

Disease Specifi c Indications for ICU Admission 41

Cardiovascular System 41

Pulmonary System 42

Neurological Disorders 42

Drug Ingestion and Drug Overdose 42

Gastrointestinal Disorders 43

Endocrine 43

Renal Disorders 43

Postoperative Care 44

Miscellaneous 44

Physiologic Indication for ICU Admission 44

Discharge Criteria 44

Reference 45

8 Chronic Critical Illness and the Long Term Sequela of Critical Care 47

Neuromuscular Abnormalities 49

Critical Illness Polyneuropathy 49

Critical Illness Myopathy (See also Chap 32 on Nutrition) 49

Brain Dysfunction 51

“Prevention” of CCI 51

Management of CCI 52

Testing 52

General Management 53

Stress Hyperglycemia 53

Metabolic Bone Disease 53

Anabolic Steroids 54

Exercise Program 54

References 54

9 Fluid Responsiveness and Fluid Resuscitation 57

Echocardiographic Assessment of Fluid Responsiveness 66

Static Echocardiographic Parameters 66

Dynamic Echocardiographic Parameters 66

Passive Leg Raising (PLR) 67

The Fluid Challenge 69

Fluid Boluses in Volume Responsive Patients 71

What Type of Fluid? 72

Lactated Ringer’s (Hartmann’s Solution) vs 0.9 % NaCl (Ab-Normal Saline) 72

Complications Associated with 0.9 % NaCl vs Lactate Ringers Solution 73

Renal Failure 73

Hyperchloremic Metabolic Acidosis and DEATH 73

Lactate Generates HCO3 73

Ringer’s Lactate and Kidney Disease 74

Ringers Lactate and Liver Disease 75

Coagulopathy 75

Lactate as a Metabolic Fuel 75

Albumin 76

Hetastarches (HES) 77

So, Which Fluid? 78

Resuscitation in Specifi c Disease States 78

Hemorrhage 78

Traumatic Brain Injury 79

Dehydration 79

Sepsis (and SIRS) 80

Burns 80

Management of Oliguria 80

Management of Volume Overload/Acute Pulmonary Edema 81

References 81

10 Assessment of Cardiac Function and Cardiac Output 89

Echocardiographic Assessment of Cardiac Function 89

Methods of Measuring Cardiac Output 90

Pulmonary Artery Catheter 90

Transpulmonary Thermodilution 91

Pulse Contour Analysis 92

Esophageal Doppler 93

USCOM 93

Bioreactance 94

Utility of Cardiac Output monitoring 94

Determining Fluid and Inotrope Responsiveness 94

Driving up CI to Supranormal Values 94

References 95

11 Peri-operative Fluid Optimization 99

References 104

12 Sepsis 107

Bacteriology and Sites of Infection 108

Pathophysiology of Sepsis 109

Septic “Cardiomyopathy” 109

Complications Associated with Sepsis 111

Clinical Features and Diagnosis of Sepsis 112

Organ Dysfunction in Severe Sepsis/Septic Shock 112

Management of Sepsis 115

Antibiotic Therapy 118

Fluid Therapy (See also Chap 9) 119

Vasopressors and Inotropic Agents 124

B-Blockers and Phenylephrine in Septic Shock 128

Resuscitation End-Points 129

The Dangers of a HIGH CVP 130

Does Tissue Hypoxia and Mitochondrial Dysfunction Exist in Sepsis? 133

Case Example 136

References 137

13 The Stress Response, Stress Hyperglycemia and Stress Hyperlactemia 149

The Stress Response 149

Cardiovascular Effects of the Stress Response 152

Immune Effects of the Stress Response 152

Metabolic Effects of the Stress Response 153

Stress Hyperglycemia 153

Treatment of “Stress Hyperglycemia” 155

So What to Do! 157

How to Achieve These Goals? 157

Glucose Control and Steroids 158

Stress Hyperlactemia 158

Lactate Metabolism 159

Lactate as a Marker of Illness Severity 160

Lactate as a Marker of Metabolic Stress 161

Lactate as a Metabolic Fuel 162

Heart Metabolism and Lactate 163

Brain Metabolism and Lactate 163

References 164

14 Understanding the Vital Signs: BP, HR, RR, TEMP, SaO 2 … and SV 169

Blood Pressure 169

The Brain-Heart Distance and the Giraffe Theory of Blood Pressure Determination in Humans 170

What’s a Normal Blood Pressure? 171

BP Thresholds for the Intensivist/Anesthesiologist 172

Non-Invasive Blood Pressure (NIBP) vs Arterial Line Blood Pressure (IAP) and Systolic Blood Pressure (SBP) vs Mean Arterial Pressure (MAP) 172

Central vs Peripheral Blood Pressure Measurement 173

Blood Pressure Autoregulation 174

MAP, Organ Failure and Death 175

Circulatory Shock 176

Pulse Rate 177

Respiratory Rate (& Pattern) 178

Temperature 179

Pulse Oximetry 179

Too Much Oxygen Kills 184

Analysis of the Oximetric Waveform 188

Stroke Volume: The 6th Vital Sign 189

Putting the Vital Signs Together 190

Early Warning Scoring Systems and Rapid Response Teams 191

References 192

15 Management of Pain, Agitation and Delirium 197

Assessing the Level of Pain and Sedation 200

The Ramsey Sedation Scale 201

The Richmond Agitation-Sedation Scale (RASS) 201

Sedation Vacations 202

Non-pharmacologic Interventions 202

Delirium 202

Sedative and Analgesics Agents 205

Lorazepam 205

Midazolam 206

Propofol 206

Dexmedetomidine 207

Haloperidol 208

Fentanyl 208

Morphine 208

Meperidine 208

Neuromuscular Blockade 209

Neuromuscular Blocking Agents 209

References 210

16 Hospital Acquired Infections and Their Prevention 213

Colonization with Multidrug Resistant Organisms 215

Handwashing and Infection Control Measures 216

Handwashing 216

Chlorhexidine Bathing 216

Gloves and Gowns and Healthcare Provider Apparel 217

Universal Screening for MDR’s and “Protective Isolation” 217

Oropharyngeal and Gastrointestinal Decolonization 218

Private Rooms and Environmental Control 219

Central Line Associated Blood Stream Infection 220

Management of CLABSI’s 224

Antibiotics Lock Therapy 225

Prevention of CLABSI 225

Catheter Associated Urinary Tract Infection 227

Ventilator Associated Pneumonia 229

Pathogenesis of VAP 230

Diagnosis of VAP 232

Treatment 234

General Concepts for the Antimicrobial Treatment of VAP 234

Empiric Antibiotic Choices 235

“Specifi c” Interventions for Prevention of VAP 235

Clostridium diffi cile Infection 239

Laboratory Diagnosis 241

Sigmoidoscopy 242

Treatment 243

Fidaxomicin 244

Adjunctive Treatment Options 244

Probiotics 245

Surgical Intervention 245

Nosocomial Rhinosinusitus 246

References 248

Part II Pulmonary

17 The Bacterial Pneumonias: A New Treatment Paradigm 261

Unifi ed Treatment Algorithm 263

No Risk Factors for a CAP-DRP 263

Risk Factors for CAP-DRPs 264

Infl uenza (Co-Existent or Infl uenza Pneumonia) 264

Diagnostic Testing of Hospitalized Patients with Pneumonia 265

Non-Infectious Diseases Masquerading as Pneumonia 265

Special Considerations 266

Severe CAP with no MDR Risk Factors 266

Community-Acquired MRSA Pneumonia (CA-MRSA) 266 Aspiration Pneumonia 267 Nursing Home-Acquired Pneumonia 269 Persistent Temperature/Failure to Respond to Rx 269 Unusual Pathogens 270 Complicated Pleural Effusion/Empyema 271 References 271

18 Fever 275

Common Misconception and Fables 275 Pathogenesis of Fever 276 Treatment of Fever 276 Causes of Fever in the ICU 278 Infectious Causes of Fever in the ICU 279 Non-Infections Causes of Fever in the ICU 279 Non-Infectious Causes of Fever 279

An Approach to the Febrile ICU Patient 286 Clinical Pearls 288 References 288

19 Mechanical Ventilation 101 291

Alveolar Overdistension Damages Normal Lungs 293 Ventilator Variables and Modes of Ventilation 293 Ventilator Variables (See Table 19.1) 297 Common Modes of Mechanical Ventilation 299 Positive End-Expiratory Pressure (PEEP) 303 Auto-PEEP 305 Monitoring Patients Undergoing Mechanical Ventilation 306 Sudden Increase in Airway Pressure and/or Fall

in Arterial Saturation 307 When to Perform a Tracheostomy 307 Timing of Tracheostomy in the Critically Ill 308 References 308

20 Non-invasive Ventilation 311

Set Up 312 Initial Settings 312 Indications of NIV 313 COPD Exacerbations 313 Acute Cardiogenic Pulmonary Edema 313 Facilitating Extubation in COPD Patients 313 Immunocompromised Patients 314 Post-operative Patients 314 When to Use NIV 315 Hypercapnic Respiratory Failure 315 Hypoxemic Respiratory Failure 315

Contraindications to NIPPV 315 Success and Failure Criteria for NIPPV 316 References 316

21 Liberation (Weaning from Mechanical Ventilation) 319

General Concepts 319 Effect of Liberation on Oxygen Consumption and Cardiac Function 320 Fluid Overload and Liberation Failure 320 Vasopressors and Inotropic Agents and Weaning 321

Mechanical Ventilation Liberation Process 322

“Readiness” Testing 322 Spontaneous Breathing Trials 323 Causes of Liberation Failure 324 Early Extubation Followed by NIV in COPD 324 NIV for Persistent Liberation Failure 324 Extubation Failure 325 Patients at High Risk of Extubation Failure 325 The Cuff Leak Test 326 Corticosteroids for the Prevention of Post-extubation Stridor 326 References 326

22 Arterial Blood Gas Analysis 329

Indications for ABG Sampling 329 ABG Sampling 330 ABG Analysis 331 Alveolar Ventilation 332 Oxygenation 332 Acid-Base Balance 334

A Step Wise Approach to Acid-Base Disorders 335 Common Acid Base Disturbances in the ICU 338 Metabolic Acidosis 338 Metabolic Alkalosis 341 Venous Blood Gas Analysis (VBGs) 342 Mixed Venous/Central Venous Oxygen Saturation 343 References 344

23 ARDS 349

Defi nition, Causes and Assessment of Severity 349 Defi nition of ALI According the American European Consensus 349 Acute Lung Injury (ALI) 349 Acute Respiratory Distress Syndrome (ARDS) 350 Pathophysiological Defi nition of ARDS 350 Causes of ALI 351 Management of the Acute Phase of ARDS 351 Ventilatory Strategy 352 Pressure Controlled Ventilation 355

Airway Pressure Release Ventilation 357 Permissive Hypercapnia 359 Best PEEP 359 Recruitment Maneuvers 361 Non-Ventilatory Adjuncts to Gas Exchange 361 Prone Positioning 361 Neuromuscular Blocking Agents 362 ECMO 362 Corticosteroids 363 Inhaled Nitric Oxide 365 Nebulized Prostacyclin 365

β2-Adrenergic Receptor Agonists 365 Surfactant 365 Omega-3 Enteral Nutrition 366 “Our” Approach to Refractory Hypoxemia 366 References 367

24 COPD Exacerbation 373

Common Precipitating Events 374 Indications for Hospitalization 375 Indications for ICU Admission 375 Treatment 375 Indications for NPPV 377 Indications for Endotracheal Intubation 377 Mechanical Ventilation in COPD 377 Suggested Initial Settings 378 References 378

25 Acute Severe Asthma 381

Indications for Admission to the ICU 382 Initial Treatment 382 Other Therapeutic Options 383 Complications of Acute Asthma 384 Noninvasive Positive-Pressure Ventilation in Status Asthmaticus 384 Indications for Intubation 385 Sedation Post-intubation 386 Mechanical Ventilation 386 Initial Ventilator Settings 387 References 388

26 Pleural Effusions and Atelectasis 391

Pleural Effusions 391 Pathophysiology 391 Drainage of Pleural Effusion 392 Hepatic Hydrothorax 393

Alelectasis 393 Respiratory Therapy 394 Mucolytics 394 Bronchoscopy 395 Bilevel/APRV 395 References 396

27 Venous Thromboembolic Disease: DVT and PE 399

Pregnancy, Venous Thromboembolism and Thrombophilias 399 Site of Venous Thrombosis 400 The Veins of the Lower Limb 401 Suggested DVT Prophylaxis Protocols 405 Diagnosis of DVT 405 Distal Lower Extremity DVT 406 Upper Extremity DVT 406 Superfi cial Phlebitis 407 Pulmonary Embolism 408 Diagnosis of Pulmonary Embolism 408 Treatment of Thromboembolic Disease 411 Thrombolytic Therapy 413 Catheter Directed Clot Fragmentation and Aspiration 418 Inhaled Nitric Oxide 418 Vena Caval Interruption 419 “Absolute Contraindications” for Anticoagulation with Heparin 419 References 419

Part III Cardiac

28 Hypertensive Crises 429

Defi nitions 429 Pathophysiology 430 Clinical Presentation 431 Initial Evaluation 432 Initial Management of Blood Pressure 433 Resident (or Hospitalist) Called to the Floor for High

Blood Pressure: What to Do? 434 Drugs to AVOID 436 Recommended Antihypertensive Agents 437 Acute Postoperative Hypertension 439 Pre-operative Hypertension 440 Posterior Reversible Encephalopathy Syndrome (PRES) 441 Pregnancy-Induced PRES 441 Drugs Associated with PRES 442 References 442

29 Acute Decompensated Cardiac Failure 445

Confi rm the Diagnosis of Cardiac Failure 446 Evaluation of the Patient with Cardiac Failure 447 B-Type Natriuretic Peptides 447 Echocardiography 448 Laboratory Testing 448 Hemodynamic Monitoring 448 Precipitating Factors 449 Treatment 449 Acute Phase of Treatment 449 Treatment of ADHF: Summary 456 Long-Term Management 456 Systolic Heart Failure 457 Management of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF) 461 Takotsubo Cardiomyopathy 462 Stressors Reported to Trigger Takotsubo

Cardiomyopathy 462 Mayo Clinic Criteria for Takotsubo Cardiomyopathy 464 References 465

30 Acute Coronary Syndromes 471

Unstable Angina/NSTEMI 471 Canadian Cardiovascular Classifi cation of Angina 472 Types of Presentations of Unstable Angina 472 Differential Diagnosis 472 Electrocardiography 472 Tropinins 473 Management of UA/NSTEMI 473 Risk Stratifi cation 473 Thrombolysis in Myocardial Infarction

(TIMI) Risk Score 473 Global Registry of Acute Coronary Events (GRACE)

Risk Model 474 Treatment Approach for UA and NSTEMI

(PER AHA Guidelines) 474 Class I Recommendations 474 Class II Recommendations 475 Treatment Approach to STEMI (PER AHA Guidelines) 475 Class I Recommendations 475 Class II Recommendations 476 Complications Following STEMI 477 Recurrent Chest Pain Post-AMI 477 Mitral Regurgitation 477

Left Ventricular Failure and Low Output States 478 Right Ventricular Infarction 478 Atrial Fibrillation 478 References 479

31 Arrhythmias 481

Arrhythmias and Electrolyte Disturbances 481 Acute Atrial Fibrillation/Flutter 482 Urgent Cardioversion 483 Rate Control 483 Pharmacologic Cardioversion 484 Anticoagulation 484 Multifocal Atrial Tachycardia (MAT) 485 Paroxysmal Supraventricular Tachycardia (PSVT) 485 Management 486 SVT Mediated by Accessory Pathways 486 Sinus Bradycardia 487 Sick-Sinus Syndrome 487 Accelerated Idioventricular Rhythm 487 Ventricular Premature Complexes and Bigeminy 487 Nonsustained Ventricular Tachycardia 488 Sustained Ventricular Tachycardia 488 Polymorphic Ventricular Tachycardia (Torsades De Pointes) 489 Management 489 References 490

Part IV Gastrointestinal

32 Nutrition in the ICU: It’s Whey Cool 493

Myths of Nutritional Support 494 Important Points to Digest 495 How Many Calories and How Much Protein to Give? 498 Muscle Wasting in Critical Illness 499 Factors That Activate Muscle Synthesis by the mTOR Pathway 502 Bolus vs Continuous Feeding 504 So! What is the Best Way to Feed Critically Ill Patients? 506 The Obese Patient 507 The Refeeding Syndrome 507 References 508

33 Stress Ulcer Prophylaxis 513

Does SUP Reduce GI Bleeding? 514 Enteral Nutrition and Stress-ulcer Prophylaxis 515 Complications Associated with Acid Suppressive Therapy 516 So! What to Do? 517 Complications Associated with Specifi c Drugs 517

H2 Receptor Antagonists (H2RA) 517 Proton Pump Inhibitors (PPIs) 518 Sucralfate 518 References 519

34 Acute and Chronic Liver Disease 523

Chronic Liver Failure 523 Causes of Cirrhosis 524 Metabolic/Hematologic Derangements in Cirrhosis 525 Spontaneous Bacterial Peritonitis 525 Hepatic Encephalopathy 527 Grades of Hepatic Encephalopathy 528 Hepatorenal Syndrome 529 Hepatorenal Syndrome: Diagnostic Criteria 530 Diagnostic Approach 530 Treatment of HRS 531 Hepato-adrenal Syndrome 532 Pulmonary Consequences of Portal Hypertension 532 Infection and Cirrhosis 532 Supportive Care of the Hospitalized Cirrhotic 533 The Coagulopathy of Chronic Liver Disease 534 Portal Vein Thrombosis 535 Acute-on-chronic Liver Failure 537 Alcoholic Hepatitis 538 Differential Diagnosis 539 Management 539 Fulminant Hepatic Failure 540 Causes of Fulminant Hepatic Failure 541 Workup of Patients Presenting with FHF 541 Cerebral Edema in FHF 542 Management of Increased ICP 543 Supportive Measures 545 Indications for Liver Transplantation 545 Kings Criteria 546 References 546

35 GI Bleeding 551

Initial Assessment 551 Initial Resuscitation 553 Triage of Patients Who to Admit to the ICU? 555 Upper GI Bleeding 555 The Major Causes of UGIB Include 556 Further Management of Upper GI Bleeding (See Fig 35.1) 556 Further Management of Bleeding Peptic Ulcers 557 Recurrent Hemorrhage 559

Further Management of Esophageal Varices 559 Management of Patients with Lower GI Bleeding 560 References 562

36 Pancreatitis 565

Diagnosis 566 Risk Stratifi cation 567 Complications 568 Management 569 References 571

37 Diarrhea & Constipation 575

Diarrhea 575 Infectious Diarrhea 575 “Non-Infectious” Diarrhea 576 Antibiotic Associated Diarrhea (AAD) 576 Enteral Feeding-Associated Diarrhoea 576 Management of “Non-Infectious” Diarrhoea 576 The Use of Probiotics and Prebiotics 577 Constipation 579 References 580

Part V Miscellaneous

38 Transfusion of Blood and Blood Products 585

Red Blood Cell Transfusions 585 Why Transfuse? 586 Risks Associated with Blood Transfusion (See Fig 38.1) 586 Risks Associated with Blood Transfusion 587 Transfusion-Associated Immunomodulation 588 “Age” of Transfused Red Blood Cells 590 Tolerance to Anemia 596 Weighing the Risks and Benefi ts of Blood Transfusion 596

So, When Should Patients’ Be Transfused? 597 Coagulation Disorders in the ICU 598 Fresh Frozen Plasma 600 FFP Prior to Invasive Bedside Procedures or Surgery 601 Paracentesis 604 Management of Non-therapeutic INRs With or Without Bleeding

(Due to Coumadin Therapy) 604 Platelet Transfusion 606 Heparin Associated Thrombocytopenia 610 Thrombotic Thrombocytopenic Purpura (TTP) 612 Cryprecipitate 614 References 614

39 Adrenal Insufficiency 621

Causes of Adrenal Insuffi cient/Circi 622 Clinical Features of Adrenal Insuffi ciency/Circi 623 Diagnosis of Adrenal Insuffi ciency/Circi 624 Factors Affecting the Response to Corticosteroid Treatment 625 The Immune Status of the Host 625 Timing of Corticosteroids 626 Dose and Dosing Strategy 626 Acute Rebound After Discontinuation of Corticosteroids 627 Genetic Polymorphisms 627 Abnormalities of the Glucocorticoid Receptor 628 Treatment of Adrenal Insuffi ciency/CIRCI 628 Who to Treat with Steroids? 628 Adverse Effects of Corticosteroids 630 References 631

40 Electrolyte Disturbances 635

Sodium and Water 635 Rules of the Game 635 Hyponatremia 635 Hypernatremia 640 Hypokalemia 641 Hyperkalemia 641 Hypophosphatemia 642 Management 643 Hypomagnesemia 643 Management of Hypomagnesemia 644 Disorders of Calcium Homeostasis 645 Hypocalcemia 646 Should Hypocalcemia Be Corrected in Critically Ill Patients? 647 Treatment 647 Hypercalcemia 648 Treatment 649 Second Line 649 Additional Therapies 650 References 650

41 Acute Kidney Injury 653

Pre-Renal Azotemia 654 Contrast Agents and the Kidney 655 Prevention of Contrast Induced AKI 655 “Common” Nephrotoxic Agents 656 Management of Established Acute Renal Failure 657 When to Initiate Renal Replacement Therapy (RRT) 657

Mode of Renal Replacement Therapy 658 Advantages of CRRT Therapy Include 658 Dosing of RRT 659 Summary of Recommendations for RRT

in Patients with AKI 659 Rhabdomyolysis 659 Epidemiology 660 Etiology 660 Pathophysiology 663 Mechanisms of Acute Renal Failure in Rhabdomyolysis Patients 663 Clinical Manifestations 663 Laboratory Findings 664 Management 664 Dialysis 665 References 666

42 Acute Ischemic Stroke 669

Stroke ICU’s, Medical ICU’s or Stroke Units 670 Profi les Predictive of Futility After Devastating Stroke 670 Acute Ischemic Stroke (AIS) 671 Imaging 671 Thrombolytic Therapy 672 Treatment of Acute Ischemic Stroke With Intravenous rtPA 674 Endovascular Interventions 675 Antiplatelet Therapy and Anti-Coagulation 676 Anticoagulation in Cardio-Embolic Stroke 676 Raised ICP and Decompressive Surgery 677 Treatment of Hyperglycemia 678 Treatment of Fever 678 Treatment of Post Stroke Hypertension 678 Supportive Medical Therapy 680 References 681

43 Intracerebral and Subarachnoid Hemorrhage 685

Intracerebral Hemorrhage 685 Medical Management 687 Blood Pressure Control 689 Surgical Interventions 690 Subarachnoid Hemorrhage 692 Diagnosis and Evaluation 693 Initial Management 693 Specifi c Therapeutic Issues 698 Antifi brinolytic Therapy 698 Surgical and Endovascular Methods of Treatment 698 Management of Cerebral Vasospasm 698 Transpulmonary Thermodilution (TPTD)

Hemodynamic Assessment 701

Subdural Hematoma 702 Epidural Hematoma 703 Increased Intracranial Pressure (ICP) 703 Measurement of ICP 704 Indications for ICP Monitoring 704 Management of Raised ICP 705 References 708

44 Seizures & Status Epilepticus 717

Seizures in the ICU 717 Seizures Occurring as a Complication of Critical Illness 718 Seizures from Primary Neurological Disease 719 Management 719 Seizure Therapy 719 Status Epilepticus 720 Etiology 721 Common Causes of Status Epilepticus Include 721 Pathophysiology 722 Complications of Generalized Status Epilepticus 722 Diagnosis 722 Treatment 723 General Measures 723 Pharmacotherapy 724 Management of Refractory Status Epilepticus 726 The Management of Nonconvulsive Status Epilepticus 727 Prevention of Seizure Recurrence Once Status

Epilepticus is Terminated 728 References 728

45 Toxicology 731

General Measures 731 Technique for Performing Gastric Lavage 732 Activated Charcoal 732 Hemodialysis/Hemoperfusion 733 Common Agents Responsible for 734 Common Intoxications 735 Acetaminophen 735 Salicylates 738 Tricyclic Antidepressants 738 Acute Ethanol Intoxication 739 Ethylene Glycol and Methanol Poisoning 740 Ethylene Glycol 740 Methanol 741 Isopropyl Alcohol 742 Digitalis 743 Phenytoin 743 Lithium 744

Opiates 745 Cocaine 745 Carbon Monoxide Poisoning 748 References 750

46 Alcohol Withdrawal Syndrome 751

The Clinical Institute Withdrawal Assessment Scale

for Alcohol (CIWA-Ar) 753 Differential Diagnosis 753 Treatment 754 Other Treatment Considerations 755 Prevention of Post-operative DT’s 756 References 756

47 Pregnancy Related Disorders 759

Obstetrical Hemorrhage 760 Antepartum Hemorrhage 760 Postpartum Hemorrhage 760 Management 760 Hypertension 761 Pre-eclampsia 761 Diagnosis of Pre-eclampsia 762 HELLP Syndrome 764 Posterior Reversible Encephalopathy Syndrome (PRES) 765 Treatment of Pre-eclampsia 765 Anti-hypertensive Agents for the Treatment of Pre-eclampsia 766 Corticosteroids and Plasmapheresis as Adjunctive Treatment

of HELLP 767 Acute Fatty Liver of Pregnancy 768 Amniotic Fluid Embolus Syndrome 768 Sepsis in Pregnancy 768 Respiratory Failure in Pregnancy 769 References 770

48 The Geriatric ICU Patient 773

The Physiology of Aging 773 Cardiovascular Changes 774 Changes in Respiratory Function 775 Changes in Renal Function 775 Immune System Changes 776 Body Composition and Muscle Mass 776 The Outcome of Elderly Patients Admitted to the ICU 776 Trauma and the Elderly Patient 778 Surgery and the Elderly 778 Delirium in the Elderly 779 Drug Dosing and Polypharmacy in the Elderly 780

American Geriatric Society Beers Criteria 781 Drugs to Avoid in the Elderly 781 References 782

49 Obesity in the ICU 787

Effect of Obesity on Critical Care Outcomes 787 Respiratory Effects of Obesity 788 Ideal Body Weight 789 Cardiovascular Effects of Obesity 789 Hepatic and Renal Effects of Obesity 790 Drug Dosing in Obese Patients 790 Nutritional Requirements 790 Gaining Vascular Access 791 Radiological Procedures 791 Malignant Obesity Hypoventilation Syndrome (MOHS) 791 Major Criteria 792 Minor Criteria 792 Treatment of MOHS 792 References 793

50 Radiology 797

The Chest Radiograph 797 Position of Tubes and Catheters 798 Lung Parenchyma, Pleura and Mediastinum 798 Plain Abdominal Radiography 801 Computed Tomography (CT) 801 Indium Labeled Leukocye Scans 802 References 803

51 End-of-Life Issues 805

Palliative Care 806 “Principles” of Palliative Care 807 References 809

52 Words of Wisdom 811

References 812

Index 813

Part I

© Springer International Publishing Switzerland 2015

P.E Marik, Evidence-Based Critical Care, DOI 10.1007/978-3-319-11020-2_1

Evidence Based Critical Care

There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance

—Hippocrates (c460–c377 BCE), Greek physician

Before medicine developed its scientifi c basis of pathophysiology, clinical practice was learned empirically from the events of daily experience in diagnosing and treat-ing the maladies patients presented Students learned as apprentices to clinicians, observing the phenomena of disease, the skill of diagnosis and treatment, and the outcomes of different remedies Sir William Osler’s classic textbook of medicine

was based almost entirely on his “ personal experience correlated with the general

experience of others ” [ 1 ] With advances in our understanding of human physiology and the pathophysiologic basis of disease, these remedies fell by the wayside and treatment became based on modalities of treatment that were shown to interrupt or otherwise modify the disease process Until recently, it was considered suffi cient to understand the disease process in order to prescribe a drug or other form of treat-ment However, when these treatment modalities were subjected to randomized, controlled clinical trials (RCTs) examining clinical outcomes and not physiological processes, the outcome was not always favorable The RCT has become the refer-ence in medicine by which to judge the effect of an intervention on patient outcome, because it provides the greatest justifi cation for conclusion of causality, is subject to the least bias, and provides the most valid data on which to base all measures of the benefi ts and risk of particular therapies [ 2 ] Numerous ineffective and harmful ther-apies have been abandoned as a consequence of RCTs, while others have become integral to the care of patients and have become regarded as the standard of care Many RCT’s are, however, inconclusive or provide confl icting results In this situ-ation systematic reviews that are based on meta-analysis of published (and unpub-lished) RCTs are clearly the best strategy for appraising the available evidence While meta-analyses have many limitations, they provide the best means of deter-

mining the signifi cance of the treatment effect from inconclusive or confl icting RCTs

(as well as trials that demonstrate a similar treatment effect) Furthermore, as a result

of publication bias positive studies are more likely to be published and usually in more prestigious journals than negative studies A clinician may base his/her thera-peutic decisions on these select RCTs which may then lead to inappropriate patient care It is therefore important that common medical interventions be systematically

reviewed and the strength of the evidence (either positive or negative) be evaluated Although over 250,000 RCTs have been performed, for many clinical problems, there are no RCT’s to which we can refer to answer our questions In these circum-

stances, we need to base our clinical decisions on the best evidence available from

experimental studies, cohort studies, case series and systematic reviews

Every decision that the clinician makes must be based on sound scientifi c dence (a collection of anecdotes is not scientifi c evidence) Science is the continu-ing effort to discover and increase human knowledge and understanding through disciplined research Using controlled methods, scientists collect observable evi-dence, record measurable data relating to the observations, and analyze this infor-mation to construct explanations of how things work [ 8] Intuition, anecdotes, common sense, personal biases, and clinical experience is not considered “science” and cannot be used to justify clinical decision making or therapeutic policies Evidence is not static; both the strength and direction of evidence change as new evidence becomes available It is therefore important to keep an open mind and reevaluate the scientifi c basis and strength of what we think we know and how we practice Furthermore, there is a hierarchy of evidence from anecdotes and “clinical experience” to strong irrefutable evidence (see Fig 1.1 )

Science progresses best when observations force us to alter our preconceptions

—Vera Rubin, Astronomer, 1928

As critical care medicine has evolved into a discreet specialty that crosses tomical and other artifi cial boundaries and deals with an enormous array of human

Alert

Be cautious in the interpretation of retrospective “before-after” studies and small single-center unblinded RCT’s [ 3 , 4 ] The investigators of these studies may have a vested interest in the outcome of the study resulting in “misrepre-sentation” of the true data Generally blinded studies show less of a treatment effect than unblinded studies evaluating the same intervention; both subcon-scious and conscious bias infl uence unblinded studies Before-after studies are particularly of questionable scientifi c value particularly if the variables and end-points are not defi ned prior to commencing the study, the data is collected retrospectively and there is no control arm (as other factors may infl uence the outcome) Prospective cluster controlled trials take these factors into account [ 5 ] If a fi nding is true and valid it can be reproduced; that’s the amazing thing about scientifi c exploration So be very wary of invalidated single studies no matter how robust they appear [ 6 ]

And lastly, If a study seem too good to be true, it is likely too good to be true [ 3 7 ]

conditions, it has become evident that to achieve the best outcomes for our very

complex patients, all our clinical decisions should be based on the best available

evidence The complexity of the critically ill patient together with the vast

arma-mentarium of therapeutic options available makes it essential that we critically evaluate established and emerging clinical practices It is important that we chal-lenge established dogma through thoughtful scientifi c enquiry Many of our current practices are based on anecdotes which have been passed down from teacher to student and assumed to be the undeniable truth It is important to realize that noth-ing stays the same, that knowledge and understanding march forward with no end

in sight Those who hang on to the past will get lost in the dark:

Life (and Medicine) is like riding a bicycle; you need to move forward to keep your balance

—Albert Einstein, Theoretical physicist, 1879–1955

While Evidence Based Medicine (EBM) is frequently criticized as “cook-book” medicine, this is most certainly not the case Rather, the best scientifi c evidence should be applied to the unique characteristics of each patient [ 2 ] Each patient is unique, and the “art” of medicine is the ability to integrate and apply the best scien-tifi c knowledge to each patient Checklists may be fi ne if you are fl ying a plane, however, patients are not planes and doctors are not pilots [ 9 , 10 ] Clinical Practice Guidelines (CPG’s), which are evidence-based and up-to-date, are useful in provid-ing the clinician with direction, but should never be followed blindly Rigid proto-cols and policies, have little place in clinical medicine

Lastly, it is important to realize that Critical Care Medicine can only be practiced

by close observation of the patient (at the bedside), by contemplation, and by the integration of a large data base of evidence-based medicine together with a good deal of humility

Metaanalysis of ≥ 3 large multi-center RCT Low-bias Metaanalysis of ≥ 3 small RCT

≥ 2 multi-center RCT

1 large multi-center RCT Prospective Cluster Controlled Trial

Single small RCT Meta-analysis of cohort studies Cohort studies Case Reports Before-After Studies Anecdotes

Fig 1.1 The hierarchy

of scientifi c evidence

5 Heyland DK, Murch L, Cahill N, et al Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial Crit Care Med 2013;41:2743–53

6 van den Berghe G, Wouters P, Weekers F, et al Intensive insulin therapy in critically ill patients

N Engl J Med 2001;345:1359–67

7 Ionnidis JP Research accomplishments that are too good to be true Intensive Care Med 2014;40:99–101

8 Science Wikipedia 2013 http://en.wikipedia.org/wiki/Science Accessed 12 Mar 2013

9 Rissmiller R Patients are not airplanes and doctors are not pilots [Letter] Crit Care Med 2006;34:2869

10 Laurance J Peter Pronovost: champion of checklists in critical care Lancet 2009;374:443

© Springer International Publishing Switzerland 2015

P.E Marik, Evidence-Based Critical Care, DOI 10.1007/978-3-319-11020-2_2

“Less Is More”: The New Paradigm

in Critical Care

The art of medicine consists of amusing the patient while nature cures the disease

Voltaire, French writer and historian (1694–1778)

What appears to be the world’s fi rst ICU was established at the Municipal Hospital

of Copenhagen in December of 1953 by the Danish anesthesiologist Bjorn Ibsen during the polio epidemic of 1952–1953 [ 1 ] The fi rst patient admitted to the unit was a 43 year old man who had unsuccessfully attempted to hang himself The patient had a tracheotomy performed and received manual positive pressure ventila-tion with 60 % oxygen in N 2 O [ 2 ] The fi rst physician staffed ICU’s in the US were developed in 1958 by Max Harry Weil and Herbert Shubin at the Los Angles County General Hospital and by Peter Safar in Baltimore [ 3 , 4 ] The introduction of the pulmonary artery catheter (PAC) in the early 1970s by Swan and colleagues became the monitoring tool that defi ned critical care medicine for the next four decades [ 5 , 6 ] The PAC became synonymous with critical care medicine The era of the PAC resulted in a style of medicine that can best be characterized as aggressive If some care is good, more care is even better However almost all medical interventions be they invasive procedures, diagnostic tests, imaging studies, mechanical ventilation, surgery or drugs have some risk of adverse effects [ 7 ] In some cases, these harms outweigh the benefi ts This may be particularly so in ICU patients who are highly vulnerable and at an increased risk of iatrogenic complications [ 8 ] Beginning in

1996 the safety and effectiveness of the PAC came into question [ 9 ] Subsequent studies demonstrated that the PAC provided misleading ( “physiologic variables”) that could lead to inappropriate therapeutic interventions and that the use of the PAC did not improve patient outcome [ 10 – 12 ] The PAC has now all but been aban-doned [ 13 ] In 2000 the ARDSnet group published their now landmark study which demonstrated that mechanical ventilation with low tidal volume of 6 mL/kg/IBW improved patient outcome as compared to the standard approach (12 mL/kg/IBW) [ 14 ] The last decade has witnessed a slew of studies that have challenged conventional wisdom and which have led to a gentler, less invasive approach to the critically ill

patient… this has led to the paradigm that “ Less may be More ” ( see list below ) [ 7 , 8 ]

We now realize that our goal as intensivists is too be supportive and allow the body

to heal itself while at the same time limiting the harm we cause with are arsenal of therapeutic and diagnostic weapons