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13 critical care secrets 6th edition 2019


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2015v1.0


CRITICAL CARE



CRITICAL CARE

SIXTH EDITION
POLLY E. PARSONS, MD

E. L. Amidon Professor and Chair of
Medicine
Robert Larner College of Medicine at
the University of Vermont
Burlington, VT

JEANINE P. WIENER-KRONISH, MD
Henry Isaiah Dorr, Professor of
Research and Teaching in
Anesthetics and Anesthesia
Department of Anesthesia, Critical
Care and Pain Medicine
Harvard Medical School;
Anesthetist-in-Chief
Massachusetts General Hospital
Boston, MA

RENEE D. STAPLETON, MD, PHD

Associate Professor of Medicine
University of Vermont, Larner College
of Medicine
Burlington, VT

LORENZO BERRA, MD

Anesthesiologist and Critical Care
Physician
Department of Anesthesia, Critical
Care and Pain Medicine,
Medical Director of Respiratory Care
Massachusetts General Hospital;
Assistant Professor
Harvard Medical School
Boston, MA


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

CRITICAL CARE SECRETS, SIXTH EDITION

ISBN: 978-0-32351064-6

Copyright © 2019 by Elsevier, Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
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This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances in
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To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for
any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products, instructions, or ideas contained in the material
herein.

Previous editions copyrighted 2013, 2007, 2003, 1998 and 1992.
Library of Congress Cataloging-in-Publication Data
Names: Parsons, Polly E., 1954-editor. | Wiener-Kronish, Jeanine P., 1951-editor. | Stapleton, Renee Doney,
editor. | Berra, Lorenzo, editor.
Title: Critical care secrets / [edited by] Polly E. Parsons, Jeanine P. Wiener-Kronish, Renee D. Stapleton,
Lorenzo Berra.
Other titles: Secrets series.
Description: Sixth edition. | Philadelphia, PA : Elsevier, [2019] | Series: Secrets series | Includes bibliographical
references and index.
Identifiers: LCCN 2017061385| ISBN 9780323510646 (pbk.) | ISBN 9780323527897 (ebook)
Subjects: | MESH: Critical Care | Examination Questions
Classification: LCC RC86.9 | NLM WX 18.2 | DDC 616.02/8—dc23 LC record available at
https://lccn.loc.gov/2017061385
Content Strategist: James Merritt
Content Development Specialist: Meghan B. Andress
Publishing Services Manager: Deepthi Unni
Project Manager: Beula Christopher
Design Direction: Bridget Hoette

Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1


To our spouses Jim, Daniel, and Jonathan, and to all our colleagues in
the ICU, as well as our patients, students, residents, and fellows.
This book is dedicated to the patients that we have had the privilege
to care for, to the ICU nurses who have been so important in the
care of the patients, and to the medical students, residents, and
fellows who have helped in caring for all the patients. Thank you
all for allowing us to work and be with you.
Polly E. Parsons, MD
Jeanine P. Wiener-Kronish, MD
Renee D. Stapleton, MD, PhD
Lorenzo Berra, MD


CONTRIBUTORS
Varun Agrawal, MD, FACP, FASN
Assistant Professor of Medicine
Division of Nephrology and Hypertension
University of Vermont
Burlington, VT
Paul H. Alfille, MD
Executive Vice Chairman
Department of Anesthesia, Critical Care and Pain
Management
Massachusetts General Hospital
Boston, MA
Gilman B. Allen, MD
Pulmonary Critical Care Department
University of Vermont
Burlington, VT
Michael N. Andrawes, MD
Instructor
Harvard Medical School;
Adult Cardiothoracic Anesthesiology Fellowship
Program Director
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Amir Azarbal, MD
Fellow
Cardiology Unit, Department of Medicine
University of Vermont-Larner College of Medicine
Burlington, VT
Aranya Bagchi, MBBS
Assistant in Anesthesia
Massachusetts General Hospital;
Instructor in Anesthesia
Harvard Medical School
Boston, MA
Keith Baker, MD, PhD
Associate Professor of Anesthesia
Harvard Medical School;
Vice Chair for Education
Department of Anesthesia, Critical Care and
Pain Medicine
Massachusetts General Hospital
Boston, MA

vi

Rita N. Bakhru, MD, MS
Assistant Professor
Wake Forest University School of Medicine
Department of Internal Medicine
Pulmonary, Critical Care Medicine, Allergy and
Immunology
Medical Center Blvd
Winston-Salem, NC
Arna Banerjee, MD, FCCM
Associate Professor of Anesthesiology/Critical Care
Associate Professor of Surgery, Medical Education
and Administration
Assistant Dean for Simulation in Medical Education
Director, Center for Experiential Learning and
Assessment
Nashville, TN
Caitlin Baran, MD
University of Vermont
Burlington, VT
Pavan K. Bendapudi, MD
Instructor in Medicine
Harvard Medical School;
Division of Hematology
Massachusetts General Hospital
Boston, MA
William J. Benedetto, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Sheri Berg, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Lorenzo Berra, MD
Anesthesiologist and Critical Care Physician
Department of Anesthesia, Critical Care and Pain
Medicine
Medical Director of Respiratory Care
Massachusetts General Hospital;
Assistant Professor
Harvard Medical School
Boston, MA


CONTRIBUTORS  vii
Edward A. Bittner, MD, PhD, MSEd
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
M. Dustin Boone, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
William E. Charash, MD, PhD
Associate Professor
Division of Acute Care Surgery,
Director
Trauma Critical Care
University of Vermont Larner College of Medicine
Burlington, VT
Sreedivya Chava, MD, FACC
Interventional Cardiology
Tricity Cardiology consultants
Mesa, AZ
Katharine L. Cheung, MD, MSc, FRCPC
Assistant Professor of Medicine
Division of Nephrology
Larner College of Medicine at The University of
Vermont
Burlington, VT
Hovig V. Chitilian, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Jaina Clough, MD
Assistant Professor of Medicine
University of Vermont College of Medicine
University of Vermont Medical Center
Burlington, VT
Ryan Clouser, DO
Assistant Professor of Medicine, Critical Care/
Neurocritical Care
University of Vermont Medical Center
Burlington, VT
Lane Crawford, MD
Instructor
Harvard Medical School;
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA

Jerome Crowley, MD, MPH
Staff Intensivist and Anesthesiologist
Clinical Instructor
Harvard Medical School;
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Adam A. Dalia, MD, MBA
Clinical Instructor in Anesthesia
Division of Cardiac Anesthesiology
Department of Anesthesia, Critical Care and Pain
Medicine
The Massachusetts General Hospital-Harvard Medical
School
Boston, MA
Harold L. Dauerman, MD
Professor of Medicine
University of Vermont Larner College of Medicine;
Network Director
UVM Health Network Interventional Cardiology
McClure 1 Cardiology
Burlington, VT
Hill A. Enuh, MD
Department of Pulmonary Critical Care
University of Vermont
Burlington, VT
Peter J. Fagenholz, MD, FACS
Assistant Professor of Surgery
Harvard Medical School;
Attending Surgeon
Department of Surgery
Division of Trauma, Emergency Surgery and Surgical
Critical Care
Massachusetts General Hospital
Boston, MA
Joshua D. Farkas, MD, MS
Department of Pulmonary and Critical Care
Medicine
University of Vermont
Burlington, VT
Corey R. Fehnel, MD, MPH
Department of Neurology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA
Amanda Fernandes, MD
Clinical Instructor
Larner College of Medicine at The University of
Vermont
Burlington, VT
Daniel F. Fisher, MS, RRT
Department of Respiratory Care
Boston Medical Center
Boston, MA


viii  CONTRIBUTORS
Michael G. Fitzsimons, MD
Assistant Professor
Harvard Medical School;
Director
Division of Cardiac Anesthesia
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Joseph D. Frasca, MD
Clinical Instructor
University of Vermont College of Medicine
Burlington, VT
Zechariah S. Gardner, MD
Assistant Professor of Medicine
Division of Hospital Medicine
University of Vermont College of Medicine
University of Vermont Medical Center
Burlington, VT
Garth W. Garrison, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
University of Vermont Medical Center
Burlington, VT
Matthew P. Gilbert, DO, MPH
Associate Professor of Medicine
Larner College of Medicine at The University of
Vermont
Burlington, VT
Christopher Grace, MD, FIDSA
Professor of Medicine, Emeritus
University of Vermont College of Medicine;
Infectious Diseases Unit
University of Vermont Medical Center
Burlington, VT
Cornelia Griggs, MD
Chief Resident
Department of Surgery
Massachusetts General Hospital
Boston, MA
Dusan Hanidziar, MD, PhD
Attending Anesthesiologist and Intensivist
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital;
Instructor in Anesthesia
Harvard Medical School
Boston, MA
Michael E. Hanley, MD
Professor of Medicine
University of Colorado Denver School of Medicine;
Staff Physician
Pulmonary and Critical Care Medicine
Denver Health Medical Center
Denver, CO

T.J. Henry, MD
Resident
Department of Surgery
University of Iowa
Iowa City, IA
Dean Hess, PhD
Respiratory Care
Massachusetts General Hospital;
Teaching Associate in Anesthesia
Harvard Medical School
Boston, MA
David C. Hooper, MD
Department of Medicine
Division of Infectious Diseases
Massachusetts General Hospital
Boston, MA
Catherine L. Hough, MD, MSc
Professor of Medicine
Division of Pulmonary, Critical Care and Sleep
Medicine
University of Washington
Seattle, WA
James L. Jacobson, MD
Professor
Department of Psychiatry
Larner College of Medicine at The University of
Vermont and University of Vermont Medical Center
Burlington, VT
Paul S. Jansson, MD, MS
Department of Emergency Medicine
Massachusetts General Hospital
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA
Daniel W. Johnson, MD
Assistant Professor
Department of Anesthesiology
University of Nebraska Medical Center
Omaha, NE
Robert M. Kacmarek, PhD, RRT
Department of Respiratory Care
Department of Anesthesia, Critical Care, and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Rebecca Kalman, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA


CONTRIBUTORS  ix
Brinda B. Kamdar, MD
Program Director
Regional Anesthesia and Pain Medicine Fellowship,
Instructor
Harvard Medical School;
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
David A. Kaminsky, MD
Pulmonary Critical Care Department
University of Vermont
Burlington, VT
Mark T. Kearns, MD
Assistant Professor of Medicine
University of Colorado Denver School of Medicine;
Staff Physician
Pulmonary and Critical Care Medicine
Denver Health Medical Center
Denver, CO
C. Matthew Kinsey, MD, MPH
Director, Interventional Pulmonary
University of Vermont Medical Center;
Assistant Professor
Larner College of Medicine at the University of
Vermont
Division of Pulmonary and Critical Care
Burlington, VT
Themistoklis Kourkoumpetis, MD
Gastroenterology and Hepatology Fellow
Department of Medicine, Section of Gastroenterology
Baylor College of Medicine
Houston, TX
Erin K. Kross, MD
Associate Professor of Medicine
Division of Pulmonary, Critical Care and Sleep
Medicine
University of Washington
Seattle, WA
Leandra Krowsoski, MD
Division of Trauma, Emergency Surgery and
Surgical Critical Care
Department of Surgery
Massachusetts General Hospital
Boston, MA
Abhishek Kumar, MD
Assistant Professor of Medicine/Transplant Medicine
Division of Nephrology and Hypertension
University of Vermont
Burlington, VT

Alexander S. Kuo, MS, MD
Assistant in Anesthesia
Department of Anesthesia, Critical Care, and Pain
Medicine
Massachusetts General Hospital;
Instructor
Harvard Medical School
Boston, MA
David Kuter, MD, DPhil
Professor of Medicine
Harvard Medical School;
Chief, Division of Hematology
Massachusetts General Hospital
Boston, MA
Jean Kwo, MD
Assistant Professor
Department of Anesthesia, Critical Care and Pain
Medicine
Harvard Medical School
Massachusetts General Hospital
Boston, MA
Daniela J. Lamas, MD
Brigham and Women’s Hospital
Division of Pulmonary and Critical Care Medicine,
Instructor in Medicine
Harvard Medical School;
Associate Faculty
Ariadne Labs
Boston MA
Stephen E. Lapinsky, MBBCh, MSc, FRCPC
Director
Intensive Care Unit
Mount Sinai Hosptal;
Professor of Medicine
University of Toronto
Toronto, Canada
John L. Leahy, MD
Professor of Medicine
Larner College of Medicine
The University of Vermont
Burlington, VT
Timothy Leclair, MD
Department of Medicine, Division of Pulmonary
and Critical Care Medicine
University of Vermont Medical Center
Burlington, VT
Jarone Lee, MD, MPH
Medical Director Blake 12 ICU
Massachusetts General Hospital/Harvard Medical
School
Boston, MA


x  CONTRIBUTORS
Robert Y. Lee, MD
Senior Fellow
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington
Seattle, WA

Anthony Massaro, MD
Department of Medicine
Pulmonary and Critical Care
Brigham and Women’s Hospital
Boston, MA

Martin M. LeWinter, MD
Professor of Medicine and Molecular Physiology
and Biophysics
Cardiology Unit, Department of Medicine
University of Vermont-Larner College of Medicine
Burlington, VT

Alexis McCabe, MD
Resident
Department of Emergency Medicine
Massachusetts General Hospital/Harvard Medical
School
Boston, MA

Eva Litvak, MD
Fellow in Adult Cardiothoracic Anesthesia
Division of Cardiac Anesthesia
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA

Prema R. Menon, MD, PhD
Assistant Professor of Medicine
University of Vermont
Burlington, VT

Kathleen D. Liu, MD, PhD, MAS
Professor
Divisions of Nephrology and Critical Care Medicine
Departments of Medicine and Anesthesia
University of California, San Francisco
San Francisco, CA
Yuk Ming Liu, MD, MPH
Clinical Assistant Professor
Department of Surgery, Division of Acute Care Surgery
University of Iowa
Iowa City, IA
Lowell J. Lo, MD
Associate Professor
Division of Nephrology
Department of Medicine
University of California, San Francisco
San Francisco, CA
Johnathan P. Mack, MD, MSc, FRCPC
Assistant Director of Blood Transfusion Service
Department of Pathology
Massachusetts General Hospital
Boston, MA
Annis Marney, MD, MSCI
Diabetes and Endocrinology
The Frist Clinic
Nashville, TN
Annachiara Marra, MD, PhD
University of Naples Federico II
Naples, Italy;
Visiting Research Fellow
Division of Allergy, Pulmonary and Critical Care
Medicine
Vanderbilt University Medical Center
Nashville, TN

Katherine Menson, DO
Fellow
Division of Pulmonary and Critical Care Medicine
University of Vermont Medical Center
Burlington, VT
Matthew J. Meyer, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Lydia Miller, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Jimmy L. Moss, MD
Fellow, Anesthesia Critical Care Program
Massachusetts General Hospital;
Clinical Fellow in Anesthesia
Harvard Medical School
Boston, MA
Marc Moss, MD
Professor
University of Colorado School of Medicine
Division of Pulmonary Sciences and Critical Care
Medicine
Aurora, CO
Maged Muhammed, MD
Research Fellow
Harvard Medical School;
Division of Infectious Diseases and Division of
Gastroenterology
Boston Children’s Hospital;
Department of Adult Inpatient Medicine, Department
of Medicine
Newton Wellesley Hospital
Newton, MA


CONTRIBUTORS  xi
Eleftherios Mylonakis, MD, PhD, FIDSA
Charles C.J. Carpenter Professor of Infectious Disease
Chief, Infectious Diseases Division
Alpert Medical School of Brown University;
Division of Infectious Diseases
Rhode Island Hospital
Providence, RI
Jennifer Nelli, MD
Department of Anesthesia
Hamilton General Hospital
McMaster University
Hamilton, ON
Cindy Noyes, MD
Assistant Professor of Medicine, Infectious Disease
University of Vermont Medical Center/University of
Vermont College of Medicine
Burlington, VT
Ala Nozari, MD, PhD
Associate Professor
Harvard Medical School;
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Haitham Nsour, MD
Assistant Professor of Medicine
Larner College of Medicine
University of Vermont
Burlington, VT

Alita Perez-Tamayo, MD
University of Vermont Medical Center
Burlington, VT
Kristen K. Pierce, MD
Associate Professor of Medicine
Division of Infectious Diseases
University of Vermont College of Medicine
Burlington, VT
Louis B. Polish, MD
Associate Professor of Medicine
Division of Infectious Diseases
Director, Internal Medicine Clerkship
University of Vermont College of Medicine
Burlington, VT
Nitin Puri MD, FCCP
Program Director Critical Care Medicine Fellowship
Cooper University Hospital;
Associate Professor Medicine
Cooper Medical School of Rowan University
Camden, NJ
Molly L. Rovin, MD
Psychiatry Resident
Department of Psychiatry
Larner College of Medicine at The University of
Vermont and University of Vermont Medical
Center
Burlington, VT

Jacqueline C. O’Toole, DO
Pulmonary and Critical Care Fellow
Johns Hopkins University
Division Pulmonary and Critical Care Medicine
Baltimore, MD

Sten Rubertsson, MD, PhD, EDIC, FCCM, FERC
Professor
Anaesthesiology and Intensive Care Medicine
Department of Surgical Sciences/Anaesthesiology
and Intensive Care Medicine
Uppsala University
Uppsala, Sweden

Pratik Pandharipande, MD, MSCI, FCCM
Professor of Anesthesiology and Surgery
Chief, Division of Anesthesiology Critical Care
Medicine
Vanderbilt University Medical Center
Nashville, TN

Noelle N. Saillant, MD
Division of Trauma, Emergency Surgery and
Surgical Critical Care
Massachusetts General Hospital
Harvard Medical School
Boston, MA

Alan C. Pao, MD
Assistant Professor
Departments of Medicine and Urology
Stanford University School of Medicine
Veterans Affairs Palo Alto Health Care System
Palo Alto, CA

Jason L. Sanders, MD, PhD
Department of Medicine
Massachusetts General Hospital
Boston, MA

Kapil Patel, MD
Assistant Professor of Medicine
Director, Center for Advanced Lung Disease
Division of Pulmonary and Critical Care Medicine
Morsani College of Medicine, University of South
Florida
Tampa, FL

Joel J. Schnure, MD FACE, FACP
Director
Division of Endocrinology and Diabetes
University of Vermont Medical Center;
Professor of Medicine
Larner College of Medicine
The University of Vermont
Burlington, VT


xii  CONTRIBUTORS
Kenneth Shelton, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Tao Shen, MBBS
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Erica S. Shenoy, MD, PhD
Department of Medicine
Division of Infectious Diseases
Massachusetts General Hospital
Boston, MA
Stephanie Shieh, MD
Assistant Professor
Division of Nephrology, Department of Medicine
Veterans Affairs St. Louis Health Care System;
Division of Nephrology, Department of Medicine
St. Louis University
St. Louis, MO
Bryan Simmons, MD
Critical Care Fellow
Massachusetts General Hospital
Boston, MA
Alexis C. Smith, DO
Fellow
Wake Forest University School of Medicine
Department of Internal Medicine
Pulmonary, Critical Care, Allergy and Immunology
Medical Center Blvd
Winston-Salem, NC
Lindsay M. Smith, MD
Assistant Professor of Medicine
Division of Infectious Diseases
Director, Antimicrobial Stewardship
University of Vermont College of Medicine
Burlington, VT
Peter D. Sottile, MD
Assistant Professor
University of Colorado School of Medicine
Division of Pulmonary Sciences and Critical Care
Medicine
Aurora, CO
Peter S. Spector, MD
Professor of Medicine
Director of Cardiac Electrophysiology
The University of Vermont Medical Center
Burlington, VT

Antoinette Spevetz, MD, FCCM, FACP
Professor of Medicine
Cooper Medical School of Rowan University;
Designated Institution Official
Graduate Medical Education,
Director
Intermediate Care Unit
Section of Critical Care Medicine
Cooper University Hospital
Camden, NJ
Krystine Spiess, DO
Assistant Professor of Medicine
University of Vermont College of Medicine;
Infectious Diseases Unit
University of Vermont Medical Center
Burlington, VT
Renee D. Stapleton, MD, PhD
Associate Professor of Medicine
University of Vermont, Larner College of Medicine
Burlington, VT
Scott C. Streckenbach, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Benjamin T. Suratt, MD
Professor of Medicine and Cell and Molecular Biology
Vice Chair of Medicine for Academic Affairs
Associate Chief, Pulmonary and Critical Care Medicine
University of Vermont College of Medicine
Burlington, VT
Charlotte C. Teneback, MD
Associate Professor of Medicine
University of Vermont, College of Medicine
Burlington, VT
Susan A. Vassallo, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Mario J. Velez, MD
Assistant Professor
University of Vermont College of Medicine
Burlington, VT
Rodger White, MD
Department of Anesthesia, Critical Care and Pain
Medicine
Massachusetts General Hospital
Boston, MA
Elizabeth Cox Williams, MD
Instructor in Anesthesia
Massachusetts General Hospital
Boston, MA


CONTRIBUTORS  xiii
Elliott L. Woodward MB, Bch, BAO, MSc
Cardiothoracic Anesthesia Fellow
Massachusetts General Hospital
Boston, MA
D. Dante Yeh, MD
Ryder Trauma Center
University of Miami Miller School of Medicine
DeWitt Daughtry Family Department of Surgery/
Division of Trauma
Miami, FL
Jing Zhao, MD, PhD
Anesthesiologist
Department of Anesthesia
Xijing Hospital
Xi’an, China

Hui Zhang, MD, PhD
Anesthesiologist
Department of Anesthesia
Xijing Hospital
Xi’an, China
Pierre Znojkiewicz, MD
Assistant Professor, Cardiac Electrophysiology
The University of Vermont Medical Center
Burlington, VT


PREFACE
Since publishing the first edition of Critical Care Secrets in 1992, critical care medicine has continued
to become increasingly complex. Medical knowledge, clinical skills, and understanding of technology
required to care for critically ill patients continue to transcend subspecialties, so in this edition we have
again included chapters from a wide range of specialists, including intensivists, pulmonologists, surgeons,
anesthesiologists, psychiatrists, pharmacists, and infectious disease and palliative care experts. The chapters in this edition contain key questions in critical care followed by succinct answers so practitioners can
identify effective solutions to their patients’ medical and ethical problems.
A broad understanding of anatomy, physiology, immunology, and inflammation is fundamentally
important to effectively care for critically ill patients. For example, it is hard to imagine understanding the
principles of mechanical ventilation without being aware of the principles of gas and fluid flow, pulmonary
mechanics, and electronic circuitry. Accordingly, the authors have again incorporated these key elements
into this edition. In addition, critical care medicine requires knowledge of protocols and guidelines that are
continuously evolving and that increasingly dictate best practices.
In this sixth edition of Critical Care Secrets, we continue to be fortunate that many clinical and
thought leaders in critical care have contributed chapters in their areas of expertise. In addition to substantially revising and updating chapters from the previous edition, we have included new chapters on
timely topics such as neurologic monitoring, obesity in the intensive care unit (ICU), new ultrasound
practices, ICU survivorship, and the latest cardiac technology such as ventricular assist and percutaneous
support devices.
We immensely appreciate all the authors who contributed their time and expertise to this edition.
We believe they have captured the essence of critical care medicine and have presented it in a format
that will be useful to everyone, from students to experienced clinicians.
Polly E. Parsons, MD
Jeanine P. Wiener-Kronish, MD
Renee D. Stapleton, MD, PhD
Lorenzo Berra, MD

xiv


TOP SECRETS
1. Hyperglycemia is common in critically ill patients and has been independently associated
with increased ICU mortality.
2. Oral medications and noninsulin injectable therapies should not be used to treat
hyperglycemia in critically ill patients.
3. An intravenous insulin infusion is the safest and most effective way to treat hyperglycemia
in critically ill patients.
4. ICU-acquired weakness is a syndrome characterized by the development of generalized diffuse muscle weakness after onset of critical illness and is defined by standard
functional muscle tests.
5. Early mobilization of critically ill patients is safe, feasible, and can improve short-term
outcomes including functional status.
6. Delirium monitoring and management is critically important since it is a strong risk factor
for increased time on mechanical ventilation, length of ICU and hospital stay, cost of
hospitalization, long-term cognitive impairment, and mortality.
7. Psychoactive medications, and in particular benzodiazepines, may contribute to
delirium.
8. In delirious patients pharmacologic treatment should be used only after giving adequate
attention to correction of modifiable contributing factors. The ABCDEF bundle (Attention
to analgesia, Both awakening and breathing trials, Choosing right sedative, Delirium
monitoring and management, Early exercise and Family involvement) is recommended
and associated with improved outcomes including reduction in delirium.
9. Inadequate analgesia is common in the ICU and has detrimental effects on patients.
10. Critically ill patients are often especially vulnerable to adverse side effects and toxicity
from both opioid and nonopioid analgesic drugs.
11. Early, high-quality, and interdisciplinary communication improves shared decision making
around end-of-life care in the ICU.
12. When difficult cases are causing moral distress and/or conflict among family members
or team members, consider an ethics consultation to alleviate these issues.
13. Lung protection ventilation is less guided by volume than lung pressures. Minimizing
both volumes and pressures is essential for a lung protective ventilation strategy.
14. Managing patient-ventilator interactions is crucial to outcome. The more control granted
to a patient during assisted ventilation, the greater the patient-ventilator synchrony.
15. Definition of high-flow nasal cannula (HFNC). HFNC oxygen therapy uses an air/oxygen
blender, active humidifier, heated tubing, and a nasal cannula capable of high flows
(Fig. 9.1). The HFNC delivers adequately heated and humidified gas at flows up to
60 L/min. The traditional oxygen cannula is limited to a flow of 6 L/min because higher
flows are not tolerated. Due to the conditioning of the gas and the design of the
prongs, the HFNC is comfortable at high flows.
16. Patient population that benefits most for use of NIV. The strongest evidence for use of
NIV is for patients with exacerbation of chronic obstructive pulmonary disease (COPD).
For such patients, the use of NIV has a mortality benefit, with a relative risk of 0.56

1


2  TOP SECRETS
(95% CI 0.38–0.82), which translates to a number needed to treat (NNT) of 16.
The use of NIV for acute cardiogenic pulmonary edema is associated with a relative
risk of 0.64 (95% CI 0.45–0.90), with a NNT of 16. Available evidence also supports
a mortality benefit for NIV in patients with postoperative acute respiratory failure
(NNT 11) and prevention of postextubation acute respiratory failure (NNT 12).
17. High-flow nasal cannula use immediately following extubation may decrease risk for
reintubation in patients who remain in the ICU and at risk for recurrent respiratory failure.
18. The primary goal of hemodynamic monitoring is to assess the ability of the cardiovascular system in delivering oxygen to organs and peripheral tissues to meet metabolic
demands.
19. Fluid responsiveness refers to an increase in stroke volume in response to a fluid challenge. Methods used to predict fluid responsiveness include the passive leg raise test
as well as systolic pressure, pulse pressure, and stroke volume variation.
20. Neuroprognostication after cardiac arrest depends on a combination of history of arrest, clinical exam, electroencephalography features, evoked potentials, and magnetic
resonance imaging findings. The depth of temperature management also can have a
major impact on how these tools can be used to make a prognosis.
21. Point-of-care ultrasound by intensivists is a vital tool in the rapid assessment of critically
ill patients presenting with shock, respiratory failure, or cardiac arrest.
22. PVADs improve cardiac function by unloading a failing ventricle, thereby reducing
ventricular wall stress and oxygen consumption, and augmenting systemic perfusion
pressure to maintain end-organ perfusion.
23. Left-sided PVADs require a well-functioning right ventricle (otherwise biventricular
support is indicated), no evidence of respiratory compromise, and structural anatomy
that is amenable to insertion.
24. IABP improves coronary blood flow by increasing perfusion pressure during diastole.
25. The major benefit of the IABP may be the reduction in myocardial oxygen consumption
via a reduction in the isovolumic contraction phase of systole.
26. There is little evidence that an IABP improves outcomes in myocardial infarction complicated by cardiogenic shock. There is some indication that management of mechanical
complications of myocardial infarction such as papillary muscle rupture associated or
ventricular septal rupture may be an indication for an IABP.
27. ECMO is a method for providing temporary oxygenation, ventilation and circulatory
support for patients with lung or heart diseases.
28. ECMO is not identical to cardiopulmonary bypass in that ECMO does not have a reservoir for additional fluid, there are no pumps for the administration of cardioplegia and
the heart chambers are not vented while on peripherally cannulated ECMO.
29. VA ECMO primarily supports cardiopulmonary failure while VV ECMO only supports the
failing lungs.
30. Never push a rigidly styletted ETT against resistance if the ETT tip is not in view.
31. Most ETTs have an identifiable mark 1 to 2 cm from the cuff. Maintaining the video
view of the glottic opening during ETT insertion and placing this mark at the vocal
cords will guard against main stem intubation (and virtually guarantee against
esophageal intubation).
32. Upper airway obstruction can be addressed with humidified air followed by racemic
epinephrine, heliox, and, ultimately, surgical airway placement if airway patency cannot
be secured via the laryngeal route.
33. Bleeding from a tracheostomy site 48 hours after procedure should always prompt
investigation for tracheoarterial fistula formation.


TOP SECRETS  3
34. Bronchoalveolar lavage should be considered when there is a suspected atypical
pneumonia or nonresolving infiltrate.
35. Bronchoscopy has limited value in the diagnosis of idiopathic interstitial pneumonias.
36. Exercise therapy has significant benefits in both the acute and chronic setting for patients
with COPD. It can be started in the ICU and continued on an outpatient basis in a formal
pulmonary rehabilitation program.
37. Many patients with COPD and acute respiratory failure can be supported with noninvasive
ventilatory support; however, intubation when needed is relatively well tolerated.
38. The five causes of hypoxemia are:
• V/Q (ventilation/perfusion) mismatch
• Alveolar hypoventilation
• Shunt: physiologic (alveolar level) and anatomic (proximal to lung)
• Diffusion limitation
• Low inspired oxygen fraction
39. Two therapies proven to reduce mortality in patients with ARDS are:
• Low tidal volume ventilation (6mL/kg predited body weight)
• Prone positioning
40. Death from massive hemoptysis is more commonly due to asphyxiation than
exsanguination.
41. Bronchial embolization is the initial treatment of choice for most patients with massive
hemoptysis.
42. Clinical findings, including laboratory and EKG results, are neither sensitive nor specific
for the diagnosis of PE. CT chest angiography or V/Q scan is necessary to confirm the
diagnosis.
43. Duration of therapy in an unprovoked PE in a low-risk bleeding patient is at least 3 months,
with a recommendation for life-long anticoagulation and annual reassessment of the risk
versus benefit of long-term anticoagulation.
44. Clinical assessment of volume status and perfusion is critical in treatment of acute
decompensated heart failure.
45. Valve replacement is the only treatment for symptomatic severe aortic stenosis. No medical
options have been shown to be effective.
46. It is important to distinguish hemodynamically unstable arrhythmias that need immediate
cardioversion/defibrillation from more stable rhythms.
47. In patients with out-of-hospital cardiac arrest who have recovered a perfusing rhythm
but have neurologic deficits, therapeutic hypothermia has been shown to dramatically
improve outcomes.
48. Aortic dissection carries high morbidity and mortality if untreated and should be suspected in a patient presenting with acute onset severe chest, back, or abdominal pain.
49. All patients presenting with aortic dissection should be immediately evaluated by a surgeon.
Type A dissections require emergent open repair. Type B dissections complicated by
end-organ ischemia, rupture, rapidly expanding dissection or aneurysm, or intractable
pain or hypertension require surgery; endovascular repair is preferable if possible.
50. Pericardial tamponade is a medical emergency, diagnosed based upon clinical physiology,
and treated by emergent pericardiocentesis or drainage.
51. Pericarditis can result in diffuse ST and T wave changes on ECG, and mild troponin
elevation, without coronary artery disease.
52. Early diagnosis and initiation of treatment for sepsis is associated with improved
outcomes.


4  TOP SECRETS
53. Obtain 2 to 3 sets of blood cultures before giving antibiotics in cases of suspected
endocarditis.
54. Streptococcus pneumoniae remains the most common cause of community acquired
bacterial meningitis and treatment directed to this should be included in initial empiric
antibiotic regimens.
55. Most patients do not require CT scan prior to lumbar puncture; however, signs and
symptoms that suggest elevated intracranial pressure should prompt imaging. They
include: new onset neurologic deficits, new onset seizure and papilledema. Severe
cognitive impairment and immune compromise are also conditions that warrant consideration for imaging.
56. Refractory fever among critically ill patients despite proper antibiotics may warrant
antifungal introduction for possible fungal infection.
57. Reducing multidrug-resistant bacteria can only be accomplished by reduced use of
antibiotics, not by increased use.
58. During influenza season, all persons admitted to the ICU with respiratory illness should
be presumed to have influenza and be tested and treated.
59. Patients with influenza may develop secondary bacterial infections and should be
treated with ceftriaxone and vancomycin pending cultures.
60. In a patient presenting with hypertensive crisis (SBP 200 or DBP 120 mm Hg), the
presence of acute end organ injury (cerebral, renal, or cardiac) constitutes “hypertensive emergency” and should be immediately treated in the intensive care unit.
61. Short-acting titratable intravenous antihypertensive agents such as nicardipine, clevidipine,
labetalol, esmolol, or phentolamine are administered in hypertensive emergency to prevent
further end organ injury.
62. Chronic renal failure is more likely than acute kidney injury to be associated with
anemia, hypocalcemia, normal urine output, and small shrunken kidneys on ultrasound
examination.
63. While contrast dye can be removed with hemodialysis, there is no evidence that this
is beneficial, perhaps because the volume of contrast administered is minimal and
delivery of contrast to the kidney is almost immediate.
64. Hypokalemia can be caused by low potassium intake, intracellular potassium shift,
gastrointestinal potassium loss (diarrhea), and renal potassium loss. Hyperkalemia
can be caused by high potassium intake, extracellular potassium shift, and low renal
potassium excretion.
65. Drugs that can cause hyperkalemia include those that release potassium from
cells (succinylcholine or, rarely, b-blockers), those that block the renin-angiotensinaldosterone system (spironolactone, angiotensin-converting enzyme inhibitors,
heparin, or nonsteroidal anti-inflammatory drugs), and those that impair sodium and
potassium exchange in cells (digitalis) or specifically in the distal nephron (calcineurin
inhibitors, amiloride, or trimethoprim).
66. Upper endoscopy is the first diagnostic tool used in patients with suspected upper
gastrointestinal bleeding and can also be used therapeutically.
67. For localized lower gastrointestinal bleeding refractory to endoscopic or angiographic
intervention, segmental resection of the intestine involved in the bleeding is the usual
treatment.
68. Steroids should be considered for the treatment of severe alcoholic hepatitis.
69. Management of variceal bleeding should include antibiotics to prevent spontaneous
bacterial peritonitis.
70. The most common cause of thrombocytopenia in the intensive care unit is idiopathic.


TOP SECRETS  5
71. Platelets should only be transfused in the setting of active bleeding, indications for a
procedure, or an absolute value less than 10,000/mm3.
72. Although disseminated intravascular coagulation (DIC) typically presents with bleeding
or laboratory abnormalities suggesting deficient hemostasis, hypercoagulability and
accelerated thrombin generation actually underlie the process.
73. The use of blood products in the treatment of DIC should be reserved for patients with
active bleeding, those requiring invasive procedures, or those otherwise at high risk for
bleeding. Heparin, via its ability to reduce thrombin generation, may be useful in some
patients with DIC and bleeding that has not responded to the administration of blood
products.
74. The immediate approach to the comatose patient includes measures to protect the
brain by providing adequate cerebral blood flow and oxygenation, reversing metabolic
derangements, and treating potential infections and anatomic or endocrine abnormalities.
75. The differential diagnosis for coma is broad and includes structural injury, metabolic and
endocrine derangements, and physiologic brain dysfunction.
76. Brain death is the irreversible loss of both brain and brainstem function from a known
cause.
77. Brain death is a clinical diagnosis.
78. Status epilepticus is defined as a seizure lasting 5 minutes or more or recurrent seizure
activity between which there is incomplete recovery of consciousness or function.
79. Benzodiazepine therapy is the first-line treatment for seizure termination.
80. Blood pressure should not be treated in acute ischemic stroke unless it is greater than
220/110 mm Hg or SBP greater than 185/110 mm Hg if intravenous tissue plasminogen
activator is to be administered.
81. If a patient diagnosed with delirium tremens becomes sedated following low-dose
benzodiazepine, reconsider the diagnosis.
82. If intravenous lorazepam is re-dosed before the previous dose took full effect, this may
eventually lead to oversedation (“dose-stacking”).
83. Only second- and third-degree injuries count for calculation of total body surface area
and Parkland resuscitation.
84. Burn patients require aggressive fluid resuscitation with lactated Ringer solution.
85. The patient’s own palmar surface is the equivalent of 1% body surface area and can be
used to quickly assess scattered areas of burns.
86. Effective responses to large-scale disasters, both natural and man-made, depend upon
extensive communication and collaboration between local, state, and federal agencies.
87. Biologic and epidemiologic factors make influenza the single greatest infectious threat
to global health.
88. The standard hallmarks of death do not apply in a hypothermic patient—no one is dead
until WARM (.35°C) and dead.
89. Therapeutic hypothermia for a comatose patient following cardiac arrest and return of
spontaneous circulation is no longer recommended—temperature should be targeted
to avoid hyperthermia.
90. In an individual from a hot environment or undergoing strenuous exercise who presents
with an altered mental status, think of heat stroke.
91. Heat stroke is a true medical emergency requiring immediate action: delay in cooling
increases mortality.


6  TOP SECRETS
92. A standardized approach focusing on airway, breathing, circulation, disability, exposure,
and expert consultation should be used for all critically ill poisoned patients.
93. Poisonings with antidotes must be recognized and treatment initiated promptly. Focusing
on toxidromes can expedite this process.
94. Sedation and intubation in a salicylate-intoxicated patient can be a precursor to rapid
clinical decompensation and increased mortality.
95. Administering an additional NAC bolus or extending the 6.25 mg/kg per hour infusion
beyond 21 hours may be indicated in a persistent acetaminophen-toxic patient.
96. The toxic alcohols are methanol, ethylene glycol, isopropyl alcohol, and propylene
glycol; like ethanol, they are metabolized in the liver by the enzyme alcohol
dehydrogenase (ADH).
97. The mainstay of toxic alcohol ingestion involves limiting the amount of toxic metabolites
produced, either by competitive inhibition of ADH by fomepizole or ethanol, or by dialysis
in severe cases.
98. Cardiovascular medications should be chosen based on their characteristics, evidence
of effectiveness in specific conditions, and the pathophysiology of the individual patient.
99. Use of cardiovascular medications necessitates adequate monitoring, including continuous
cardiac telemetry, invasive blood pressure monitoring, and continuous pulse oximetry.
100. Although radiologic investigations and drug treatment may carry some risk of harm to
the fetus, necessary tests and treatment should never be avoided in the pregnant
woman.
101. Intubation in the critically ill pregnant woman may be very difficult due to airway edema
and friability, as well as rapid oxygen desaturation despite optimal preoxygenation.
102. Fever may be the only sign of serious infection in oncologic patients with neutropenia.
Patients with low absolute neutrophil counts lack the ability to mount appropriate
inflammatory response. For example, patients with intra-abdominal catastrophe may
not have peritonitis clinically. Erythema, swelling, or tenderness may be absent in
patients with soft tissue infection. Chest radiograph may be without infiltrates in
patients with pneumonia.
103. Patients with cancer have a four-fold increase in venous thromboembolism; their risk
is further increased when they have indwelling vascular catheters, they receive chemotherapy, they undergo recent surgeries or when they are immobile.
104. It is important for clinicians treating patients in the intensive care unit and after critical
illness to recognize that life does not return to normal for most survivors of critical illness.
105. Impairments in physical, cognitive, and mental health domains may burden patients
and families for months or even years after critical illness.
106. The diagnosis of sepsis includes a widely heterogeneous patient population that has
hitherto been treated with a “one size fits all” approach, with a notable lack of success.
Leveraging the tools of modern technology and “big data” should allow a more
biologically sound classification of the different subgroups of patients with sepsis,
paving the way for rational therapies.


I

General Intensive Care
Unit Care



Matthew P. Gilbert and Amanda Fernandes

CHAPTER 1

GLYCEMIC CONTROL
IN THE INTENSIVE CARE UNIT

1. Who is at risk for development of hyperglycemia?
Hyperglycemia can occur in patients with known or undiagnosed diabetes mellitus. Hyperglycemia
during acute illness can also occur in patients with previously normal glucose tolerance, a condition
called stress hyperglycemia.
2. How common is hyperglycemia in critically ill patients?
Acute hyperglycemia is common in critically ill patients. It is estimated that 90% of all patients develop
blood glucose concentrations greater than 110 mg/dL during critical illness. Stress-induced hyperglycemia has been associated with adverse clinical outcomes in patients with trauma, acute myocardial
infarction, and subarachnoid hemorrhage.
3. What causes hyperglycemia in critically ill patients?
In healthy individuals, blood glucose concentrations are tightly regulated within a narrow range. The
cause of hyperglycemia in critically ill patients is multifactorial. Glucose toxicity and activation of inflammatory cytokines, and counterregulatory hormones such as cortisol and epinephrine cause an increase in peripheral insulin resistance and hepatic glucose production. The use of glucocorticoids and
parenteral and enteral nutrition is an important contributor to hyperglycemia.
4. What is the relationship between hyperglycemia and acute illness?
The relationship between hyperglycemia and acute illness is complex. Severe hyperglycemia (.250 mg/dL)
has been shown to have a negative impact on the vascular, hemodynamic, and immune systems. Hyperglycemia can also lead to electrolyte imbalance, mitochondrial injury, and both neutrophil and endothelial
dysfunction. Acute illness increases the risk for hyperglycemia through the release of counterregulatory
hormones, increased insulin resistance, and immobility. Fig. 1.1 illustrates the relationship between acute
illness and hyperglycemia.
5. Should oral medications used to treat diabetes be continued in the intensive care unit?
Given the high incidence of renal and hepatic impairment, oral medication to treat diabetes should not
be continued in the intensive care unit (ICU). Medications such as metformin are contraindicated in
patients with renal and/or hepatic dysfunction and congestive heart failure. Long-acting formulations
of sulfonylureas have been associated with episodes of prolonged severe hypoglycemia in hospitalized patients. Oral medications are not easily titrated to meet glycemic targets and may take weeks
to effectively lower blood glucose levels.
6. Should noninsulin, injectable medications be used in the intensive care unit?
Noninsulin, injectable medications such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs)
stimulate insulin release in a glucose dependent manner. These medications have been shown to
cause nausea and emesis and slow gastric emptying. GLP-1 RAs have similar limitations as oral
agents with regards to titration and should not be used in the ICU setting.
7. What is the most effective way to treat hyperglycemia in the intensive care unit?
An intravenous insulin infusion using regular insulin is the safest and most effective way to treat hyperglycemia in critically ill patients. Because of the short half-life of circulating insulin (minutes), an insulin
infusion can be frequently adjusted to match the often-variable insulin requirements of critically ill patients. Intravenous insulin therapy should be administered by validated written or computerized protocols
that outline predefined adjustments in the insulin dose based on frequent blood glucose measurements.
8. When should treatment with an intravenous insulin infusion be initiated?
Intravenous insulin therapy should be initiated for the treatment of persistent hyperglycemia starting
at a blood glucose concentration of no greater than 180 mg/dL.

9


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