Bongard Frederic , Darryl Sue. Diagnosis and Treatment Critical Care

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a LANGE medical book

CURRENT

Diagnosis & Treatment

Critical Care

THIRD EDITION

Edited by

Frederic S. Bongard, MD

Professor of Surgery

David Geffen School of Medicine

University of California, Los Angeles

Chief, Division of Trauma and Critical Care

Director of Surgical Education

Harbor-UCLA Medical Center

Torrance, California

Darryl Y. Sue, MD

Professor of Clinical Medicine

David Geffen School of Medicine

University of California, Los Angeles

Director, Medical-Respiratory Intensive Care Unit

Division of Respiratory and Critical Care Physiology and Medicine

Associate Chair and Program Director

Department of Medicine

Harbor-UCLA Medical Center

Torrance, California

Janine R. E. Vintch, MD

Associate Clinical Professor of Medicine

David Geffen School of Medicine

University of California, Los Angeles

Divisions of General Internal Medicine and Respiratory and Critical Care Physiology and Medicine

Harbor-UCLA Medical Center

Torrance, California

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iii

Contents

Authors vii

Preface xi

1. Philosophy & Principles of Critical Care 1

Darryl Y. Sue, MD, & Frederic S. Bongard, MD

General Principles of Critical Care 1

Role of the Medical Director of the Intensive

Care Unit 8

Critical Care Scoring 10

Current Controversies &

Unresolved Issues 12

2. Fluids, Electrolytes, & Acid-Base 14

Darryl Y. Sue, MD, & Frederic S. Bongard, MD

Disorders of Fluid Volume 14

Disorders of Water Balance 22

Disorders of Potassium Balance 34

Disorders of Phosphorus Balance 42

Disorders of Magnesium Balance 47

Disorders of Calcium Balance 51

Acid-Base Homeostasis & Disorders 56

3. Transfusion Therapy 71

Elizabeth D. Simmons, MD

Blood Components 71

Blood Component Administration 79

Complications of Transfusion 79

Current Controversies &

Unresolved Issues 82

4. Pharmacotherapy 88

Darryl Y. Sue, MD

Pharmacokinetic Parameters 88

Pharmacokinetic Considerations 88

Medication Errors & Prevention in

the ICU 95

5. Intensive Care Anesthesia & Analgesia 97

Tai-Shion Lee, MD, & Biing-Jaw Chen, MD

Physiologic Effects of Anesthesia in

the Critically Ill 97

Airway Management 101

Pain Management in the ICU 103

Muscle Relaxants in Intensive Care 106

Sedative-Hypnotics for the

Critically Ill 110

Malignant Hyperthermia 115

6. Nutrition 117

John A. Tayek, MD

Nutrition & Malnutrition in the Critically Ill

Patient 117

Nutritional Therapy 126

Nutritional Support in Specific Diseases 130

New Treatment Strategies for the Malnourished

Critically Ill Patient 134

7. Imaging Procedures 137

Kathleen Brown, MD, Steven S. Raman, MD,

& Nam C. Yu, MD

Imaging Techniques 137

Iodinated Contrast Agents 138

Use of Central Venous Catheters for Contrast

Injection 139

Imaging of Support & Monitoring Devices

in the ICU 139

Imaging in Pulmonary Diseases 144

Imaging in Pleural Disorders 161

Imaging of the Abdomen & Pelvis 167

Imaging of Acute Gallbladder & Biliary

Tract Disorders 181

Imaging in Emergent & Urgent Genitourinary

Conditions 184

8. Intensive Care Monitoring 187

Kenneth Waxman, MD, Frederic S. Bongard, MD,

& Darryl Y. Sue, MD

Electrocardiography 187

Blood Pressure Monitoring 188

Central Venous Catheters 193

Pulmonary Artery Catheterization 196

Cardiac Output 199

Pulse Oximetry 201

Airway CO

Monitoring 203

Transcutaneous Blood Gases 204

Respiratory Mechanics 204

Respired Gas Analysis 206

Clinical Applications 206

9. Transport 208

Samuel J. Stratton, MD, MPH

Interhospital Transport 208

Equipment & Monitoring 211

Education & Training 212

Reimbursement Standards & Costs 213

Current Controversies & Unresolved Issues 214

For more information about this title, click here



CONTENTS

10. Ethical, Legal, & Palliative/End-of-Life

Care Considerations 215

Paul A. Selecky, MD

Ethical Principles 215

Conflicts Between Ethical Principles 216

Ethical Decision Making 216

Advance Care Planning 217

Medicolegal Aspects of Decision Making 217

Withholding & Withdrawing Life Support 218

Organ Donation 219

Role of the Health Care Professional 219

Web Sites for Health Care Ethics Information

& Policies 221

11. Shock & Resuscitation 222

Frederic S. Bongard, MD

Hypovolemic Shock 222

Distributive Shock 230

Cardiac Shock 242

12. Respiratory Failure 247

Darryl Y. Sue, MD, & Janine R. E. Vintch, MD

Pathophysiology of Respiratory Failure 247

Treatment of Acute Respiratory Failure 253

Acute Respiratory Failure

from Specific Disorders 280

13. Renal Failure 314

Andre A. Kaplan, MD

Nondialytic Therapy for Acute Renal Failure 330

Dialytic Therapy for the Critically Ill Patient 334

Critical Illness in Patients with Chronic

Renal Failure 342

14. Gastrointestinal Failure in the ICU 345

Gideon P. Naudé, MD

Pancreatitis 345

Bowel Obstruction 351

Obstruction of the Large Bowel 354

Adynamic (Paralytic) Ileus 355

Diarrhea & Malabsorption 356

Pancreatic Insufficiency 357

Lactase Deficiency 357

Diarrhea 357

15. Infections in the Critically Ill 359

Laurie Anne Chu, MD, & Mallory D. Witt, MD

Sepsis 359

Community-Acquired Pneumonia 362

Urosepsis 365

Infective Endocarditis 367

Necrotizing Soft Tissue Infections 370

Intraabdominal Infections 372

Infections in Special Hosts 373

Principles of Antibiotic Use in the ICU 376

Evaluation of the ICU Patient with New Fever 379

Nosocomial Pneumonia 379

Urinary Catheter–Associated Infections 382

Intravenous Catheter–Associated Infections 384

Clostridium Difficile–Associated Diarrhea 386

Hematogenously Disseminated Candidiasis 388

Antimicrobial Resistance in the ICU 389

Botulism 392

Tetanus 394

16. Surgical Infections 397

Timothy L. Van Natta, MD

Evaluation and Management of Infection by

Body Site 400

17. Bleeding & Hemostasis 409

Elizabeth D. Simmons, MD

Approach to the Bleeding Patient 427

Current Controversies & Unresolved Issues 427

18. Psychiatric Problems 431

Stuart J. Eisendrath, MD,

& John R. Chamberlain, MD

Delirium 431

Depression 436

Anxiety & Fear 438

Staff Issues 440

19. Care of the Elderly Patient 443

Shawkat Dhanani, MD, MPH,

& Dean C. Norman, MD

Physiologic Changes with Age 443

Management of the Elderly Patient in the ICU 445

Special Considerations 447

20. Critical Care of the Oncology Patient 451

Darrell W. Harrington, MD, & Darryl Y. Sue, MD

Central Nervous System Disorders 451

Metabolic Disorders 457

Superior Vena Cava Syndrome 465

21. Cardiac Problems in Critical Care 467

Shelley Shapiro, MD, PhD,

& Malcolm M. Bersohn, MD, PhD

Atrial Arrhythmias 486

Ventricular Arrhythmias 488



CONTENTS

Heart Block 491

Cardiac Problems During Pregnancy 493

Toxic Effects of Cardiac Drugs 494

22. Coronary Heart Disease 498

Kenneth A. Narahara, MD

Physiologic Considerations 498

Myocardial Ischemia (Angina Pectoris) 499

Acute Coronary Syndromes: Unstable Angina

and Non-ST-Segment-Elevation

Myocardial Infarction 502

Acute Myocardial Infarction with

ST-Segment Elevation 505

23. Cardiothoracic Surgery 514

Edward D. Verrier, MD, & Craig R. Hampton, MD

Aneurysms, Dissections, & Transections

of the Great Vessels 514

Postoperative Arrhythmias 518

Bleeding, Coagulopathy, & Blood Product

Utilization 520

Cardiopulmonary Bypass, Hypothermia,

Circulatory Arrest, & Ventricular

Assistance 525

Postoperative Low-Output States 529

24. Pulmonary Disease 534

Darryl Y. Sue, MD, & Janine R. E. Vintch, MD

Status Asthmaticus 534

Life-Threatening Hemoptysis 540

Deep Venous Thrombosis & Pulmonary

Thromboembolism 545

Anaphylaxis 562

Angioedema 563

25. Endocrine Problems in the

Critically Ill Patient 566

Shalender Bhasin, MD, Piya Ballani, MD,

& Ricky Phong Mac, MD

Thyroid Storm 566

Myxedema Coma 570

Acute Adrenal Insufficiency 572

Sick Euthyroid Syndrome 576

26. Diabetes Mellitus, Hyperglycemia,

& the Critically Ill Patient 581

Eli Ipp, MD, & Chuck Huang, MD

Diabetic Ketoacidosis 581

Hyperglycemic Hyperosmolar

Nonketotic Coma 593

Management of the Acutely Ill Patient

with Hyperglycemia or Diabetes Mellitus 594

Hyperglycemia 594

Hypoglycemia 595

Other Complications of

Diabetes Mellitus 597

27. HIV Infection in the Critically Ill

Patient 598

Mallory D. Witt, MD, & Darryl Y. Sue, MD

Complications of HIV Disease:

An Overview 598

Other Infectious Causes of Pneumonia and

Respiratory Failure 604

28. Dermatologic Problems

in the Intensive Care Unit 609

Kory J. Zipperstein, MD

Common Skin Disorders 609

Drug Reactions 612

Purpura 619

Life-Threatening Dermatoses 623

Cutaneous Manifestations of Infection 626

29. Critical Care of Vascular Disease

& Emergencies 632

James T. Lee, MD, & Frederic S. Bongard, MD

Vascular Emergencies in the ICU 632

Critical Care of the Vascular

Surgery Patient 651

30. Critical Care of Neurologic Disease 658

Hugh B. McIntyre, MD, PhD, Linda Chang, MD,

& Bruce L. Miller, MD

Encephalopathy & Coma 658

Seizures 662

Neuromuscular Disorders 666

Cerebrovascular Diseases 673

31. Neurosurgical Critical Care 680

Duncan Q. McBride, MD

Head Injuries 680

Aneurysmal Subarachnoid Hemorrhage 686

Tumors of the Central Nervous System 688

Cervical Spinal Cord Injuries 690

32. Acute Abdomen 696

Allen P. Kong, MD, & Michael J. Stamos, MD

Specific Pathologic Entities 700

Current Controversies & Unresolved Issues 701



CONTENTS

33. Gastrointestinal Bleeding 703

Sofiya Reicher, MD, & Viktor Eysselein, MD

Upper Gastrointestinal Bleeding 703

Lower Gastrointestinal Bleeding 710

34. Hepatobiliary Disease 714

Hernan I. Vargas, MD

Acute Hepatic Failure 714

Acute Gastrointestinal Bleeding from

Portal Hypertension 716

Ascites 717

Hepatorenal Syndrome 719

Preoperative Assessment & Perioperative

Management of Patients with Cirrhosis 720

Liver Resection in Patients with Cirrhosis 720

35. Burns 723

David W. Mozingo, MD, William G. Cioffi, Jr., MD,

& Basil A. Pruitt, Jr., MD

I. Thermal Burn Injury 723

Initial Care of the Burn Patient 727

Principles of Burn Treatment 730

Care of the Burn Wound 735

Postresuscitation Period 741

Nutrition 743

II. Chemical Burn Injury 749

III. Electrical Burn Injury 750

36. Poisonings & Ingestions 752

Diane Birnbaumer, MD

Evaluation of Poisoning in the Acute Care

Setting or ICU 752

Treatment of Poisoning in the ICU 754

Management of Specific Poisonings 757

37. Care of Patients with

Environmental Injuries 786

James R. Macho, MD, & William P. Schecter, MD

Heat Stroke 786

Hypothermia 788

Frostbite 791

Near-Drowning 793

Envenomation 795

Electric Shock & Lightning Injury 798

Radiation Injury 800

38. Critical Care Issues in Pregnancy 802

Marie H. Beall, MD, & Andrea T. Jelks, MD

Physiologic Adaptation to Pregnancy 802

General Considerations in the Care of the

Pregnant Patient in the ICU 804

Management of Critical Complications

of Pregnancy 807

39. Antithrombotic Therapy 821

Elizabeth D. Simmons, MD

Physical Measures 821

Antiplatelet Agents 821

Anticoagulants 825

New Anticoagulants 831

Defibrinating Agents 832

Oral Anticoagulants 832

Thrombolytic Therapy 836

Antithrombotic Therapy in Pregnancy 838

Antiphospholipid Antibody Syndrome 839

Thrombosis in Cancer Patients 840

Future Directions 840

Index 843

vii

Authors

Piya Ballani, MD

Southern California Endocrine Medical Group, Anaheim,

California

piyaballani@hotmail.com

Endocrine Problems in the Critically Ill Patient

Marie H. Beall, MD

Clinical Professor of Obstetrics and Gynecology, David

Geffen School of Medicine, University of California,

Los Angeles; Vice Chair, Department of Obstetrics and

Gynecology, Harbor-UCLA Medical Center, Torrance,

California

mbeall@obgyn.humc.edu

Critical Care Issues in Pregnancy

Malcolm M. Bersohn, MD, PhD

Professor of Medicine, David Geffen School of Medicine,

University of California, Los Angeles; Director,

Arrhythmia Service, Veterans Administration Greater

Los Angeles Health Care System, Los Angeles, California

mbersohn@ucla.edu

Cardiac Problems in Critical Care

Shalender Bhasin, MD

Professor of Medicine, Boston University School of

Medicine; Chief, Section of Endocrinology, Diabetes, and

Nutrion, Boston Medical Center, Boston, Massachusetts

bhasin@bu.edu

Endocrine Problems in the Critically Ill Patient

Diane Birnbaumer, MD, FACEP

Professor of Clinical Medicine, David Geffen School of

Medicine, University of California, Los Angeles; Associate

Residency Program Director, Harbor-UCLA Medical

Center, Torrance, California

dianeb@emedharbor.edu

Poisonings & Ingestions

Frederic S. Bongard, MD

Professor of Surgery, David Geffen School of Medicine,

University of California, Los Angeles; Chief, Division of

Trauma and Critical Care, Director of Surgical

Education, Harbor-UCLA Medical Center, Torrance,

California

fbongard@ucla.edu

Philosophy & Principles of Critical Care; Fluids, Electrolytes,

& Acid-Base; Intensive Care Monitoring; Shock &

Resuscitation; Critical Care of Vascular Disease &

Emergencies

Kathleen Brown, MD

Professor of Clinical Radiology, David Geffen School

of Medicine, University of California,

Los Angeles, California

KBrown@mednet.ucla.edu

Imaging Procedures

John R. Chamberlain, MD

Assistant Clinical Professor, Department of Psychiatry,

University of California, San Francisco; Assistant

Director, Psychiatry and the Law Program, University

of California, San Francisco, San Francisco, California

JohnC@lppi.ucsf.edu

Psychiatric Problems

Linda Chang, MD

Professor of Medicine, John A. Burns School of Medicine,

University of Hawaii; Queens Medical Center, Honolulu,

Hawaii

lchang@hawaii.edu

Critical Care of Neurologic Disease

Biing-Jaw Chen, MD

Clinical Associate Professor, David Geffen School of

Medicine, University of California, Los Angeles,

Harbor-UCLA Medical Center, Torrance, California

jaws10321@yahoo.com

Intensive Care Anesthesia & Analgesia

Laurie Anne Chu, MD

Southern California Permanente Medical Group, Kaiser

Bellflower Medical Center, Bellflower, California

laurie.a.chu@kp.org

Infections in the Critically Ill

William G. Cioffi, Jr., MD

J. Murray Beardsley Professor & Chairman, Department

of Surgery, Brown Medical School; Surgeon-in-Chief,

Department of Surgery, Rhode Island Hospital,

Providence, Rhode Island

JPariseault@Lifespan.org

Burns

Shawkat Dhanani, MD, MPH

Associate Clinical Professor, David Geffen School of

Medicine, University of California, Los Angeles; Director,

Geriatric Evaluation and Management Unit, Veterans

Administration Greater Los Angeles Healthcare System,

Los Angeles, California

shawkat.dhanani@med.va.gov

Care of the Elderly Patient



AUTHORS

viii

Stuart J. Eisendrath, MD

Professor of Clinical Psychiatry, Department of Psychiatry,

University of California, San Francisco; Director of

Clinical Services, Langley Porter Psychiatric Hospital

and Clinics, San Francisco, California

StuartE@lppi.ucsf.edu

Psychiatric Problems

Viktor Eysselein, MD

Professor of Medicine, David Geffen School of Medicine,

University of California, Los Angeles; Clinical Professor

of Medicine, Harbor-UCLA Medical Center, Torrance,

California

veysselein@labiomed.org

Gastrointestinal Bleeding

Craig R. Hampton, MD

Staff Surgeon, St. Luke’s Cardiothoracic Surgical Associates,

St. Luke's Hospital, Duluth, Minnesota

champton@slhduluth.com

Cardiothoracic Surgery

Darrell W. Harrington, MD

Chief, Division of General Internal Medicine,

Harbor-UCLA Medical Center, Torrance, California

dharrington@ladhs.org

Critical Care of the Oncology Patient

Chuck Huang, MD

Private Practice, Internal Medicine and Endocrinology,

Grants Pass, Oregon

Diabetes Mellitus, Hyperglycemia, & the Critically Ill Patient

Eli Ipp, MD

Professor, David Geffen School of Medicine, University

of California, Los Angeles; Head, Section of Diabetes

and Metabolism, Harbor-UCLA Medical Center,

Torrance, California

ipp@labiomed.org

Diabetes Mellitus & the Critically Ill Patient

Andrea T. Jelks, MD

Associate Clinical Professor, Stanford University Medical

Center; Maternal Fetal Medicine Specialist, Santa Clara

Valley Medical Center, San Jose, California

andrea.jelks@hhs.sccgov.org

Critical Care Issues in Pregnancy

Andre A. Kaplan, MD

Professor of Medicine, University of Connecticut Health

Center; Chief, Blood Purification, John Dempsey

Hospital, Farmington, Connecticut

Kaplan@nso.uchc.edu

Renal Failure

Allen P. Kong, MD

Resident Physician, Department of Surgery,

University of California, Irvine, Orange, California

konga@uci.edu

Acute Abdomen

James T. Lee, MD

Fellow, Peripheral Vascular and Endovascular Surgery,

Division of Vascular Surgery, Harbor-UCLA Medical

Center, Torrance, California

jtlee@humc.edu

Critical Care of Vascular Disease & Emergencies

Tai-Shion Lee, MD

Clinical Professor, David Geffen School of Medicine,

University of California, Los Angeles, Harbor-UCLA

Medical Center, Torrance, California

tsleeharbor@yahoo.com

Intensive Care Anesthesia & Analgesia

Ricky Phong Mac, MD

Clinical Endcrinology Fellow, Division of Endocrinology,

Metabolism and Molecular Medicine, Charles R. Drew

University of Medicine and Science, Los Angeles,

California

Endocrine Problems in the Critically Ill Patient

James R. Macho, MD, FACS

Emeritus Professor of Surgery, University of California, San

Francisco; Director, Bothin Burn Center and Chief of

Critical Care Medicine, Saint Francis Memorial Hospital,

San Francisco, California

Jmacho@mac.com

Care of Patients with Environmental Injuries

Duncan Q. McBride, MD

Associate Professor of Clinical Neurosurgery, Department

of Neurosurgery, David Geffen School of Medicine,

University of California, Los Angeles; Chief, Division of

Neurosurgery, Harbor-UCLA Medical Center, Torrance,

California

DMcBride@mednet.ucla.edu

Neurosurgical Critical Care

Hugh B. McIntyre, MD

Professor of Neurology, David Geffen School of Medicine,

University of California, Los Angeles, Harbor-UCLA

Medical Center, Torrance, California

hbmcintyre@pol.net

Critical Care of Neurologic Disease