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7 irwin rippe s manual of intensive care medicine, 6th edition 2014





Editors

Richard S. Irwin,

MD

Professor of Medicine and Nursing
University of Massachusetts and Graduate School of Nursing
Chair, Critical Care Operations
UMass Memorial Medical Center
Worcester, Massachusetts

Craig M. Lilly,

MD

Vice Chair, Critical Care Operations

Director, elCU Program
UMass Memorial Medical Center
Professor of Medicine, Anesthesia, and Surgery
Departments of Medicine and Surgery
University of Massachusetts Medical School
Worcester, Massachusetts

James M. Rippe,

MD

Professor of Biomedical Sciences
University of Central Florida
Orlando, Florida
Founder and Director
Rippe Lifestyle Institute
Shrewsbury, Massachusetts/Orlando, Florida
Founder and Director
Rippe Health
Orlando, Florida

T h i s e d i t i o n is based on Irwin and Rippe's Intensive Care Medicine,
seve nth ed i t i o n , ed ited by R i c h a rd S. I rw i n a n d Ja mes M . R i ppe.



.

I

Wolters Kluwer Lippincott Williams & Wilkins
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Sixth Edition
Copyright© 20 14 by Richard S. Irwin, MD and James M. Rippe, MD

Two Commerce Square
200 I Market Street
Philadelphia, PA 19103

All rights reserved. This book is protected by copyright. No part of chis book may be reproduced or trans­
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Library of Congress Cataloging-in-Publication Data
I [edited by] Richard S. Irwin, Craig M. Lilly and James M. Rippe. - Sixth

Manual of intensive care medicine
edition.
p. ; cm.

Preceded by Manual of intensive care medicine

I

edited by Richard S. Irwin, James M. Rippe.

5th ed. c2010.
Abridgement of: Irwin and Rippe's intensive care medicine

I

editors, Richard S. Irwin, James

M. Rippe. 7ch ed. c2012.
Includes bibliographical references and index.
ISBN 978-1-4511-8500-3

I. Irwin, Richard S., editor of compilation. II. Rippe, James M., editor.

[DNLM: 1. Intensive Care-Handbooks. 2. Intensive Care Units-Handbooks. WX 39]

RC86.7

616.02'8-dc23
2013019315
DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in chis book and make no warranty, expressed or implied,


with respect to the currency, completeness, or accuracy of the contents of the publication. Application of chis
information in a particular situation remains the professional responsibility of the practitioner; the clinical
treatments described and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure char drug selection and dosage sec
forth in chis text are in accordance with the current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of informa­
tion relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug
for any change in indications and dosage and for added warnings and precautions. This is particularly impor­
tant when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in chis publication have U.S. Food and Drug Administration
(FDA) clearance for limited use in restricted research settings. le is the responsibility of the health care provid­
ers to ascertain the FDA status of each drug or device planned for use in their clinical practice.
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To Our Families
Diane, Rachel, Sara, Jamie, Rebecca, Andrew K, Andrew M,
and Adam; Leslie, Jonathan, Catherine, Stephanie,
Hart, Jaelin, Devon, and Jamie



C o ntributors
KonstantinAbramov, MD

Joshua M. Ammerman, MD

Assistant Professor ofInternal Medicine
Division ofRenal Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts

Clinical Assistant Professor ofNeurosurgery
Department ofNeurological Surgery
George Washington University School of
Medicine
Washington, District of Columbia

Christopher D. Adams, PharmD,

BCPS

Gustavo G. Angaramo, MD

Clinical Pharmacy Specialist
Department ofPharmacy Services
Brigham and Womens Hospital
Boston, Massachusetts

Assistant Professor
Department ofAnesthesiology and Critical
Care
Former Instructor in Surgery and
Cardiothoracic Surgery
Department ofSurgery
University ofMassachusetts Medical School
Worcester, Massachusetts

DeepAdhikari, MD

Renal Division
University ofMassachusetts Medical School
Worcester, Massachusetts
SrinathAdusumalli, MD

Resident Physician
Department ofInternal Medicine
Massachusetts General Hospital
Boston, Massachusetts
Sumera R. Ahmad, MD

Department ofPulmonary and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
David H. Ahrenholz, MD, FACS

Associate Professor ofSurgery
University ofMinnesota Medical School
Minneapolis, Minnesota
Burns Program Director
Regions Burn Center
Regions Hospital
St. Paul, Minnesota
SewitAmde, MD

Medical Fellow
Department ofSurgery
University ofMinnesota
Minneapolis, Minnesota

Kevin E. Anger, PharmD, BCPS

Clinical Pharmacist Specialist
Department ofPharmacy Services
Brigham and Womens Hospital
Boston, Massachusetts
AntonioAponte-Feliciano, MD

Assistant Professor ofAnesthesiology, Surgery,
and Critical Care Medicine
Department ofAnesthesiology
University ofMassachusetts Medical
School
Worcester, Massachusetts
NeilAronin, MD

Professor and Chief
Division ofEndocrinology and Metabolism
Department ofMedicine
University ofMassachusetts Medical
School
Worcester, Massachusetts
Seth M. Arum, MD, FACE

Assistant Professor ofMedicine
Division of Endocrinology and Metabolism
University ofMassachusetts Medical School
Worcester, Massachusetts

vii


viii

I

Contr i b utors

Gerard P. Aurigemma, MD

Isabelita R. Bella, MD

Professor ofMedicine and Radiology
University ofMassachusetts Medical School
Director, Noninvasive Cardiology
UMass Memorial Medical Center
Worcester, Massachusetts

Associate Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts

RiadAzar, MD

Consultant Cardiologist
Department of Cardiology
Imperial College Healthcare
NHS Trust
Hammersmith Hospital
London, United Kingdom

Associate Professor ofMedicine
Washington University School ofMedicine
Division of Gastroenterology
Department ofInternal Medicine
Barnes-Jewish Hospital - North Campus
St. Louis, Missouri

Michael F. Bellamy, MD, MRCP

David Cachia, MD

Director, Leukemia Program
Massachusetts General Hospital
Boston, Massachusetts

ChiefResident
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts

Gisela I. Banauch, MD, MS

Jason P. Caplan, MD

Karen K. Ballen, MD

Assistant Professor ofMedicine
Division ofPulmonary, Allergy, Critical
Care, and Sleep Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Daniel T. Baran, MD

Adjunct Professor ofMedicine and
Orthopedics
University ofMassachusetts Medical School
Worcester, Massachusetts
Director, Medical Affairs
Merck & Co., Inc.
Upper Gwynedd, Pennsylvania
Michael L. Barretti, DO

Fellow, Pulmonary and Critical Care
Medicine
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
David M. Bebinger, MD

Assistant Professor ofMedicine
Division ofInfectious Diseases and Immunology
University ofMassachusetts Medical School
Worcester, Massachusetts

Associate Professor ofPsychiatry
ChiefofPsychiatry
Creighton University School ofMedicine at
St. Joseph's Hospital and Medical Center
Phoenix, Arizona
RaphaelA. Carandang, MD

Assistant Professor ofNeurology and Surgical
Critical Care
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Stewart R. Carter, MD

Resident
Department of Surgery
Loyola University Health System
Maywood, Illinois
DavidA. Chad, MD

Associate Professor ofNeurology
Harvard Medical School
Massachusetts General Hospital
EMC Laboratory
Neuromuscular Diagnostic Center
Boston, Massachusetts


Cont r i b utors

Dinesh Chandokt, MD, FACC,

Adam Cuker, MD, MS

FSCAI

Assistant Professor ofMedicine
Division of Cardiology
University ofMassachusetts Medical School
Worcester, Massachusetts

Assistant Professor ofMedicine and
Pathology and Laboratory Medicine
Perelman School ofMedicine
University ofPennsylvania
Philadelphia, Pennsylvania

ix

Nikolaos Chandolias, MD

Adam D. Currier, MD

Fellow
Department ofSurgery
University ofMinnesota
Minneapolis, Minnesota

Assistant Professor
Department ofAnesthesiology
University ofMassachusetts Medical School
Worcester, Massachusetts

Sonia N. Chimienti, MD

Jennifer S. Daly, MD

Medical Director, Solid Organ Transplant
Program
Division ofInfectious Diseases
UMass Memorial Medical Center
Worcester, Massachusetts
Felicia C. Chu, MD

Assistant Professor
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts
Ana Cojocaru, MD

Fellow
Division ofPulmonary and Critical Care
University ofMassachusetts Medical School
Worcester, Massachusetts
Elifce 0. Cosar, MD

Clinical Associate Professor
Co-Director of Thoracic Anesthesia
University ofMassachusetts Medical
School
Worcester, Massachusetts
Eric Cucchi, PA-C

Adjunct Professor, Massachusetts College of
Pharmacy
Physician Assistant Lecturer at Bay Path
College
University ofMassachusetts Medical
School
Worcester, Massachusetts

Professor ofMedicine, Microbiology,
and Physiological Sciences
Clinical Chief, Infectious Diseases and
Immunology
University ofMassachusetts Medical
School
Worcester, Massachusetts
Raul Davaro, MD

Associate Clinical Professor
Department ofMedicine
University ofMassachusetts Medical
School
Worcester, Massachusetts
LauraA. Davis, MB, BCh, BAO

Resident
Department of Cardiac Surgery
Yale University School ofMedicine
Yale University
Surgical Director
Yale-New Haven Hospital - Heart &
Vascular Center
New Haven, Connecticut


x

I

Contr i b utors

JamesA. de Lemos, MD

Gina R. Dorlac, MD

Professor ofMedicine
University of Texas Southwestern Medical
Center
Cardiology Service Chief
Parkland Memorial Hospital
Kern Wildenthal, MD, PhD, Distinguished
Chair in Cardiology
University of Texas Southwestern Medical
Center
Dallas, Texas

Colonel, US Air Force
Director, Critical Care Air Transport
Advanced Course
Associate Professor
Division of Trauma/Critical Care
University of Cincinnati
Cincinnati, Ohio

G. William Dec, MD

Chief
Division of Cardiology
Massachusetts General Hospital
Boston, Massachusetts
Paul F. Dellaripa, MD

Assistant Professor ofMedicine
Harvard Medical School
Division ofRheumatology and Immunology
Brigham and Womens Hospital
Boston, Massachusetts
Thomas G. DeLoughery, MD, FACP,

FAWM

Professor ofMedicine, Pathology, and
Pediatrics
Divisions ofHematology/Medical Oncology
and Laboratory Medicine
Oregon Health and Sciences University
Portland, Oregon
Akshay S. Desai, MD, MPH

Instructor in Medicine, Harvard Medical
School
Associate Physician, Advanced Heart Disease
Section
Cardiovascular Division
Brigham and Womens Hospital
Boston, Massachusetts
Leslie J. Domalik, MD

Assistant Professor
Department ofMedicine
Division ofDiabetes
University ofMassachusetts Medical School
Worcester, Massachusetts

DavidA. Drachman, MD

Professor ofNeurology, Chairman Emeritus
University ofMassachusetts Medical School
Worcester, Massachusetts
Ty B. Dunn, MD, MS, FACS

Assistant Professor
Division of Transplantation
Department of Surgery
University ofMinnesota
Minneapolis, Minnesota
Kevin M. Dushay, MD, FCCP

Assistant Professor ofMedicine
Alpert Medical School ofBrown University
Pulmonary, Critical Care & Sleep Medicine
Rhode Island Hospital
Providence, Rhode Island
Kevin M. Dwyer, MD, FACS

Director of Trauma
Vice-Chair ofSurgery
Stamford Hospital
Stamford, Connecticut
James M. Ecklund, MD, FACS

Chairman, Department ofNeurosciences
!nova Faiifax Hospital
Professor ofNeurosurgery
George Washington University
Professor ofSurgery
Uniformed Services University
Falls Church, Virginia
Richard T. Ellison III, MD

Professor ofMedicine, Microbiology,
and Physiological Systems
Division ofInfectious Diseases
Department ofMedicine
University ofMassachusetts Medical School
Worcester, Massachusetts


Cont r i b utors

xi

Ashkan Emadi, MD, PhD

John Fanikos, RPh, MBA

Associate Professor ofMedicine
University ofMaryland Greenebaum Cancer
Center
Baltimore, Maryland

Director ofPharmacy Business
Department ofPharmacy Services
Brigham and Womens Hospital
Boston, Massachusetts

TimothyA. Emhoff, MD, FACS

Khaldoun Faris, MD

Chief, Trauma and Surgical Critical Care
Department ofSurgery
Division of Trauma
University ofMassachusetts Medical School
Worcester, Massachusetts

Clinical Associate Professor ofAnesthesiology
and Surgery
University ofMassachusetts Medical School
Worcester, Massachusetts

Maurice Enriquez-Sarano, MD,

FACC, FAHA

Professor ofMedicine
Mayo Medical School
Director, Valvular Heart Disease Clinic
Consultant, Cardiovascular Diseases and
Internal Medicine
Division of Cardiovascular
Mayo Clinic
Rochester, Minnesota
Laurence M. Epstein, MD

Chief, Arrhythmia Service
Cardiovascular Division
Brigham and Womens Hospital
Associate Professor ofMedicine
Harvard Medical School
Boston, Massachusetts
Suzana K. Everett Makowski, MD,

MMM

Assistant Professor ofMedicine
Co-ChiefofPalliative Medicine
University ofMassachusetts Medical
School
Worcester, Massachusetts
Pang-Yen Fan, MD

Associate Professor of Clinical Medicine
Division ofRenal Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts

Alan P. Farwell, MD

Associate Professor ofMedicine
Interim Chief, Section ofEndocrinology,
Diabetes, and Nutrition
Boston University School ofMedicine
Boston Medical Center
Boston, Massachusetts
Adam S. Fein, MD

Fellow
Cardiac Electrophysiology
Department ofMedicine
Division of Cardiology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts
Philip Fidler, MD, FACS

Associate Professor of Surgery
Georgetown School ofMedicine
Co-Director
The Burn Center at MedStar Washington
Hospital Center
Washington, District of Columbia
KimberlyA. Fisher, MD

Assistant Professor ofMedicine
Division ofPulmonary/Critical Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Patrick F. Fogarty

Assistant Professor ofMedicine
Director
Penn Comprehensive Hemophilia and
Thrombosis Center
Hospital ofthe University ofPennsylvania
Philadelphia, Pennsylvania


xii

I

Cont r i b utors

Nancy M. Fontneau, MD

Terry B. Gernsheimer, MD

Associate Professor of Clinical Neurology
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts

Professor ofMedicine
Division ofHematology
University of Washington School of
Medicine
Seattle, Washington

Joseph J. Frassica, MD, FAAP, FCCP

Mitra Ghasemi, MD, FCCP

Vice President and ChiefMedical Informatics
Officer/Chief Technology Officer
Philips Healthcare-Patient Care and
Clinical Informatics
Andover, Massachusetts
Senior Consultant
Massachusetts General Hospital
Boston, Massachusetts
Research Affiliate
Massachusetts Institute of Technology
Cambridge, Massachusetts

Assistant Professor ofMedicine
Department ofMedicine
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical
School
Worcester, Massachusetts

Julia M. Gallagher, MD

Palliative Care Physician
Division ofPalliative Care
University ofMassachusetts Medical School
UMass Memorial Medical Center
Worcester, Massachusetts
Brian J. Gallay, MD, PhD

Associate Professor ofMedicine
Department ofMedicine
UC Davis School ofMedicine
University of California, Davis Medical
Center
Sacramento, California
Neeta Garg, MD

Clinical Associate Professor ofNeurology
Multiple Sclerosis Center
University ofMassachusetts Medical Center
Worcester, Massachusetts
Eli V. Gelfand, MD, FACC

Assistant Professor ofMedicine
Harvard Medical School
Director ofAmbulatory Cardiology
Cardiovascular Division
Beth Israel Deaconess Medical Center
Boston, Massachusetts

John G. Gianopoulos, MD

The Mary Isabelle Caestecker Professor and
Chair
Department of Obstetrics and Gynecology
Loyola University Stritch School ofMedicine
Loyola University Health System
Maywood, Illinois
Michael M. Givertz, MD

Medical Director
Heart Transplant and Circulatory Assist
Associate Professor ofMedicine
Harvard Medical School
Cardiovascular Division
Brigham and Womens Hospital
Boston, Massachusetts
Richard H. Glew, MD

Professor ofMedicine, Microbiology, and
Physiological Systems
Vice Chair ofMedicine, Undergraduate
Medical Education and Faculty Affairs
University ofMassachusetts Medical School
Worcester, Massachusetts
Richard P. Goddeau Jr, DO

Assistant Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts


Contr i b utors

Michael R. Gold, MD, PhD

David M. Harlan, MD

Chiefof Cardiology
Michael E. Assry Professor ofMedicine
Division of Cardiology
Medical University of South Carolina
Charleston, South Carolina

Professor
Division ofDiabetes
Department ofMedicine
University ofMassachusetts Medical
School
Worcester, Massachusetts

Darrell M. Gray II, MD

Clinical Fellow
Division of Gastroenterology
Washington University School of
Medicine
St. Louis, Missouri
BarthA. Green, MD, FACS

Professor and Chairman
Department ofNeurosurgery
University ofMiami
Lois Pope LIFE Center
Miami, Florida
Bonnie C. Greenwood, PharmD,

BCPS

Clinical Pharmacy Practice Manager
Department ofPharmacy Services
Brigham and Womens Hospital
Boston, Massachusetts
C. Prakash Gyawali, MD, MRCP

Professor ofMedicine
Division of Gastroenterology
Washington University in St. Louis
St. Louis, Missouri
Wiley Hall, MD

Director ofNeurocritical Care
Department ofNeurology
UMass Memorial Medical Center
Worcester, Massachusetts
TarekAbou Hamdan, MD

Gastroenterology and Interventional
Endoscopy Consultant
Division of Gastroenterology
Clemenceau Medical Center Affiliated with
johns Hopkins International
Beirut, Lebanon

xii i

Lawrence J. Hayward, MD, PhD

Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts
Stephen 0. Heard, MD

Professor ofAnesthesiology and Surgery
Chair ofAnesthesiology
Department ofAnesthesiology
University ofMassachusetts Medical
School
Worcester, Massachusetts
Nils Henninger, MD

Assistant Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Helen M. Hollingsworth, MD

Associate Professor ofMedicine
Pulmonary Center
Boston University Medical Center
Boston, Massachusetts
Dorrough G. Howard, MD

Consultant Rheumatologist
Department ofRheumatology
St. jamess Hospital
Dublin, Ireland
Vanessa Humphreville, MD

General Surgery Staff
Transplant Surgery Fellow
Department of Transplant Surgery
University ofMinnesota
Minneapolis, Minnesota


x iv

Contr i b u tors

Eric Iida, MD

Deirdre L. Kathman, DO

Assistant Professor ofMedicine
Division ofRenal Medicine
University ofMassachusetts Medical
School
Worcester, Massachusetts

Fellow
Division ofPulmonary, Allergy, and Critical
Care Medicine
UMass Memorial Medical Center
Worcester, Massachusetts

Richard S. Irwin, MD

Adam W. Katz, MPAS, PA-C

Professor ofMedicine and Nursing
University ofMassachusetts Medical School
and Graduate School ofNursing
Chair, Critical Care Operations
UMass Memorial Medical Center
Worcester, Massachusetts
Heba N. Iskandar, MD

Fellow in Gastroenterology
Department ofMedicine
Washington University in St. Louis
St. Louis, Missouri
Saef Izzy, MD

Neurology Resident
UMass Memorial Medical Center
Worcester, Massachusetts
Mayur Jayarao, MD, MSc

Resident Physician
Division ofNeurosurgery
University ofMissouri - Columbia School
ofMedicine
Columbia, Missouri
James C. Jeng, MD

Associate Director
The Burn Center
Washington Hospital Center
Washington, District of Columbia
JayA. Johannigman, MD, FACS

Professor of Surgery
Division of Trauma, Critical Care, and
Acute Care Surgery
University of Cincinnati - College of
Medicine
Cincinnati, Ohio

StaffPhysician Assistant
Department of Critical Care
UMass Memorial Medical Center
Worcester, Massachusetts
Jaudat Khan, MD

Fellow
Division ofRenal Medicine
UMass Memorial Medical Center
Worcester, Massachusetts
Muhib Khan, MD

Vascular Neurology Fellow
UMass Memorial Medical Center
Worcester, Massachusetts
DanielA. Kim, MD

Resident
Department ofMedicine
Johns Hopkins Bayview Medical Center
Baltimore, Maryland
IreneA. Kim, MD

EN T Resident
Department ofHead and Neck Surgery
University of California, Los Angeles
Los Angeles, California
Nam Heui Kim, MD

Assistant Professor
Department ofSurgery
Division of Trauma Services
University ofMassachusetts Medical School
Worcester, Massachusetts
Dagmar Klinger, MD

Assistant Professor ofMedicine
Division ofRenal Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts


Contr i b utors

xv

Scott E. Kopec, MD

N. Scott Litofsky, MD, FACS

Assistant Professor ofMedicine
Director, Pulmonary and Critical Care
Fellowship
University ofMassachusetts Medical School
Worcester, Massachusetts

Professor and Chief
Director, Radiosurgery and Neuro-Oncology
Division ofNeurosurgery
University ofMissouri - Columbia School
ofMedicine
Columbia, Missouri

BruceA. Koplan, MD, MPH

Instructor, Harvard Medical School
Cardiovascular Division
Brigham and Womens Hospital
Boston, Massachusetts
Kevin M. Korenblat, MD

Associate Professor ofMedicine
Division of Gastroenterology
Washington University School ofMedicine
St. Louis, Missouri
Stephen J. Krinzman, MD

Clinical Associate Professor ofMedicine
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Jason Kurland, MD

Assistant Professor ofMedicine
Division ofRenal Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Howard B. Levene, MD, PhD

Neurological Surgery Spine Fellow
University ofMiami Miller School ofMedicine
Department ofNeurological Surgery
Lois Pope LIFE Center
Miami, Florida
Craig M. Lilly, MD

Vice Chair, Critical Care Operations
Director, eIC U Program
UMass Memorial Medical Center
Professor ofMedicine, Anesthesia, and
Surgery
Departments ofMedicine and Surgery
University ofMassachusetts Medical School
Worcester, Massachusetts

Andrea Loiselle, MD, MPH

Instructor ofMedicine
Division ofPulmonary and Critical Care
Medicine
Washington University School ofMedicine
Barnes-Jewish Hospital
St. Louis, Missouri
Randall R. Long, MD, PhD

Medical Specialties/Neurology
Dartmouth-Hitchcock Keene
Keene, New Hampshire
FredA. Luchette, MD, MSc

The Ambrose and Gladys Bowyer Professor
ofSurgery
Department ofSurgery
Loyola University Medical Center
Maywood, Illinois
J. Mark Madison, MD

Professor ofMedicine and Microbiology and
Physiological System
Chief, Division ofPulmonary, Allergy, and
Critical Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Samir Malkani, MD

Associate Professor of Clinical Medicine
Diabetes Center ofExcellence
University ofMassachusetts Medical School
Worcester, Massachusetts
Michael D. Mancenido, DO, AAHNS

StaffPhysician
AIDS Care
Rochester, New York


xv i

Contr i b u tors

Sunil Mankad, MD, FACC, FCCP,

FaizA. Mirza, MD

PASE

Senior Fellow
Division of Gastroenterology
Washington University School ofMedicine
St. Louis, Missouri

Associate Professor ofMedicine
Mayo Clinic College ofMedicine
Director, Transesophageal Echocardiography
Associate Director, Cardiology Fellowship
Mayo Clinic
Rochester, Minnesota
Theofilos P. Matheos, MD

Assistant Professor ofAnesthesiology and
Surgery
Department ofAnesthesiology
Division of Critical Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Rairnis Matulionis, MD

Assistant Professor ofAnesthesiology and
Surgery
Department ofAnesthesiology
University ofMassachusetts Medical School
Worcester, Massachusetts

Ann L. Mitchell, MD

Associate Professor of Clinical Neurology
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Jahan Montague, MD

Assistant Professor ofMedicine
Division ofRenal Medicine
University ofMassachusetts Medical
School
Worcester, Massachusetts
Majaz Moonis, MD, MRCPI(I),

DM, FAAN

Pulmonary and Critical Care Fellow
Division ofPulmonary, Allergy, and Critical
Care Medicine
UMass Memorial Medical Center
Worcester, Massachusetts

Professor ofNeurology
Director, Stroke Services and Vascular
Fellowship Program
University ofMassachusetts Medical
School
Worcester, Massachusetts
Director, Sleep Center
Day Kimball Hospital
Putnam, Connecticut

Robert M. Mentzer Jr, MD

John P. Mordes, MD

Professor ofSurgery and Physiology
Wayne State University School ofMedicine
Detroit, Michigan

Professor ofMedicine and Endocrinology
Division ofEndocrinology and Metabolism
University ofMassachusetts Medical School
Worcester, Massachusetts

Avani T. Mehta, MD

Christopher P. Michetti, MD

Medical Director, Trauma Intensive Care
Unit
!nova Faiifax Hospital
Trauma Services
Falls Church, Virginia
Marco Mielcarek, MD

Associate Professor
Fred Hutchinson Cancer Research Center
Associate Professor ofMedicine
Department ofMedical Oncology
University of Washington
Seattle, Washington

Susanne Muehlschlegel, MD, MPH

Assistant Professor ofNeurology, Anesthesia/
Critical Care, and Surgery
Division ofNeurocritical Care
University ofMassachusetts Medical School
Worcester, Massachusetts
Marie Mullen, MD

Clinical Associate Professor ofEmergency
Medicine
Department ofEmergency Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts


Contr i b utors

SaoriA. Murakami, MD

Sean O'Reilly, MD

Attending Psychiatrist
Massachusetts General Hospital
Assistant Medical Director
Child and Adolescent Psychiatry Inpatient Unit
McLean Hospital
Brighton, Massachusetts

Assistant Professor ofMedicine
University ofMassachusetts Medical
School
UMass Memorial Sleep Disorders
Center
Worcester, Massachusetts

Ashok Nambiar, MD

Alan Orquiola, MD

Associate Clinical Professor
Department ofLaboratory Medicine
Director
Division of Transfasion Medicine
University of California, San Francisco
Medical Center
San Francisco, California
Shashidhara Nanjundaswamy, MD,

MBBS, MRCP, DM

Assistant Professor
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Ian J. Neeland, MD

Fellow in Cardiovascular Medicine
Division of Cardiology
University of Texas Southwestern Medical
Center
Dallas, Texas
Dominic J. Nompleggi, MD, PhD

Chief Gastroenterology Division
Associate Professor ofMedicine and
Surgery
University ofMassachusetts Medical
School
Worcester, Massachusetts
Paulo J. Oliveira, MD, FCCP

Assistant Professor ofMedicine
Director, Advanced Bronchoscopic and
Pleural Procedures
Medical Director, Respiratory Care
Department
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts

xv i i

Assistant Professor
Department ofAnesthesiology
University ofMassachusetts Medical School
Worcester, Massachusetts
Suchitra Pandey, MD

Assistant Professor
Department ofLaboratory Medicine
Assistant Medical Director
Transfasion Service and Blood Center
University of California, San Francisco
Medical Center
San Francisco, California
NereidaA. Parada, MD

Clinical Associate Professor ofMedicine
Section ofPulmonary Diseases, Critical
Care, and Environmental Medicine
Tulane University School ofMedicine
New Orleans, Louisiana
Rupal Patel, MD

General Surgery Resident
UMass Memorial Medical Center
Worcester, Massachusetts
Marie T. Pavini, MD, FCCP

Assistant Professor, Department of
Medicine
University of Vermont School ofMedicine
Assistant Director, Department of Critical
Care
Rutland Regional Medical Center
Rutland, Vermont
David Paydarfar, MD

Professor
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts


xv i i i

I

Cont r i b utors

Crescens Pellecchia, DO, MD

Paula D. Ravin, MD

Assistant Professor
Department ofMedicine
Division ofPulmonary, Allergy and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts

Clinical Associate Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts

CatherineA. Phillips, MD

Fellow
Department ofInternal Medicine
Division of Gastroenterology
Barnes Jewish Hospital
Washington University in St. Louis
St. Louis, Missouri

Clinical Associate Professor ofNeurology
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Jennifer K. Plichta, MD, MS

Resident
Department ofSurgery
Loyola University Medical Center
Maywood, Illinois
Yuri B. Pride, MD

Clinical Fellow in Medicine
Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, Massachusetts
John Querques, MD

Assistant Professor ofPsychiatry
Harvard Medical School
Associate Director
Psychosomatic Medicine/Consultation
Psychiatry Fellowship Program
Department ofPsychiatry
Massachusetts General Hospital
Boston, Massachusetts
Sunil Rajan, MD

Full partner
Pulmonary Associates ofRichmond, Inc.
Vice ChiefofStaff
Bon Secours St. Francis Medical Center
Midlothian, Virginia
Anil Rajendra, MD

Cardiology Fellow
Division of Cardiology
Medical University ofSouth Carolina
Charleston, South Carolina

KaraA. Regan, MD

Harvey S. Reich, MD, FACP, FCCP

Director, Critical Care Medicine
Rutland Regional Medical Center
Clinical Associate Professor ofMedicine
University of Vermont College of
Medicine
Rutland, Vermont
Jennifer Reidy, MS, MD

Palliative Care Physician
Division ofPalliative Care
Assistant Professor
University ofMassachusetts Medical
School
UMass Memorial Medical Center
Worcester, Massachusetts
Peter E. Rice, MD

Assistant Professor ofSurgery
University ofMedicine and Dentistry of
New Jersey
University Hospital New Jersey
Medical Center
New York, New York
Noah B. Rindos, MD

Resident
Department of Obstetrics & Gynecology
Boston Medical Center
Boston, Massachusetts


Contri b utors

James M. Rippe, MD

John L. Sapp Jr, MD, FRCPC

Professor ofBiomedical Sciences
University of Central Florida
Orlando, Florida
Founder and Director
Rippe Lifestyle Institute
Shrewsbury, Massachusetts/Orlando, Florida
Founder and Director
Rippe Health
Orlando, Florida

Director, Heart Rhythm
QE II Health Science Centre
Professor ofMedicine
Dalhousie University
Halifax, Nova Scotia, Canada

Peter N. Riskind, MD, PhD

Clinical Professor
Department ofNeurology
University ofMassachusetts Medical School
Worcester, Massachusetts
Anna G. Rudnicki, MD

Assistant Professor ofMedicine
Department ofMedicine
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Johnny S. Salameh, MD

Assistant Professor ofNeurology
Director ofNeuromuscular Division
and EMG Laboratory
University ofMassachusetts Medical School
Worcester, Massachusetts
Wayra Salazar-Moreno, MD

Infectious Disease Fellow
Division ofInfectious Disease
UMass Memorial Medical Center
Worcester, Massachusetts
Frantisek Sandor, MD, PhD

Pulmonary and Critical Care Fellowship
Internal Medicine - Pulmonary and
Critical Care
University ofMassachusetts Medical School
Worcester, Massachusetts
Pulmonary and Critical Care Physician
Penobscot Respiratory - Pulmonary and
Critical Care
Penobscot Respiratory - Eastern Maine
Medical Center
Bangor, Maine

xix

Diane M. F. Savarese, MD

Clinical Instructor ofMedicine
Harvard Medical School
Attending Physician
Division ofHematology Oncology
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Senior Deputy Editor
Up ToDate
Waltham, Massachusetts
Gregory S. Sayuk, MD, MPH

Assistant Professor
Department ofMedicine and Psychiatry
Associate Program Director, GI Fellowship
Program
Washington University School ofMedicine
Saint Louis, Missouri
Oren P. Schaefer, MD

Clinical Associate Professor ofMedicine
University ofMassachusetts Medical
School
Mass Lung & Allergy, P. C.
Worcester, Massachusetts
Vanessa Schroder, MD

Surgical Critical Care Fellow
Department ofSurgery
Duke University Medical Center
Durham, North Carolina
Benjamin M. Scirica, MD, MPH

Investigator, TIMI Study Group
Levine Cardiac Intensive Care Unit
Assistant Professor ofMedicine
Harvard Medical School
Associate Physician
Cardiovascular Division
Brigham and Womens Hospital
Boston, Massachusetts


xx

I

Contr i b utors

Gail Scully, MD

NathanaelA. Slater, DO

Assistant Professor
Division ofInfectious Disease and Immunology
Department ofMedicine
University ofMassachusetts Medical School
Worcester, Massachusetts

Assistant Professor ofAnesthesiology and
Surgery
Department ofAnesthesiology/Critical Care
Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts

Raghu R. Seethala, MD

Instructor in Medicine
Harvard Medical School
Department ofEmergency Medicine
Department ofSurgery
Division of Trauma, Burn, and Surgical Care
Brigham and Womens Hospital
Boston, Massachusetts
Hani Seoudi, MD, FACS

Associate Professor of Surgery
Department ofSurgery
Virginia Commonwealth University School
ofMedicine
Falls Church, Virginia
Mark L. Shapiro, MD, FACS

Associate Professor of Surgery
Chief, Acute Care Surgery
Associate Director, Trauma
Duke University Medical Center
Durham, North Carolina

Heidi L. Smith, MD, PhD
Assistant Professor ofMedicine
Mass Biologics
Boston, Massachusetts
NicholasA. Smyrnios, MD, FACP,

FCCP

Associate Chief, Division ofPulmonary,
Allergy, and Critical Care Medicine
Director, Medical Intensive Care Units
Professor ofMedicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Piotr Sobieszczyk, MD, RVT

Associate Director
Cardiac Catheterization Laboratory
Cardiovascular Division
Brigham and Womens Hospital
Boston, Massachusetts
Suman L. Sood, MD

Resident
Department of General Surgery
Loyola University Medical Center
Maywood, Illinois

Assistant Professor ofMedicine
Department ofInternal Medicine
Division ofHematology/Oncology
University ofMichigan School ofMedicine
Ann Arbor, Michigan

Bruce J. Simon, MD

Andres F. Sosa, MD

Michael Sigman, MD

Associate Professor
Department ofSurgery
Division of Trauma Services
University ofMassachusetts Medical School
Worcester, Massachusetts
Nathan William Skelley, MD

Resident Physician
Washington University in St. Louis School
ofMedicine
Barnes-Jewish Hospital
Saint Louis, Missouri

Assistant Professor
Interventional Pulmonary
Division ofPulmonary, Allergy and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
David D. Spragg, MD

Assistant Professor ofMedicine
Division of Cardiology
Johns Hopkins Bayview Medical Center
Baltimore, Maryland


Contri b utors

Aruna Sree, MD

xxi

Karen E. Thomas, MD

Infectious Disease Consultant
Department ofInfectious Disease/Internal
Medicine
Somerset Medical Centre
Somerville, New Jersey
JFK Medical Centre
Edison, New Jersey

Clinical Instructor
Department ofMedicine
Cardiovascular Division
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, Massachusetts

TheodoreA. Stern, MD

Professor ofMedicine
Division of Cardiology
University ofMassachusetts Medical School
Worcester, Massachusetts

Chief Avery D. Weisman Psychiatry
Consultation Service
Director, Office for Clinical Careers
Massachusetts General Hospital
Ned H. Cassem Professor ofPsychiatry in the
field ofPsychosomatic Medicine/Consultation
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Donald S. Stevens, MD

Director
Center for Pain Management
Marlborough Hospital
Marlborough, Massachusetts
William G. Stevenson, MD

Professor ofMedicine
Harvard Medical School
Director, Cardiac Electrophysiology Program
Brigham and Womens Hospital
Boston, Massachusetts
Michael B. Streiff, MD, FACP

Associate Professor ofMedicine and Pathology
Johns Hopkins University School ofMedicine
Baltimore, Maryland
Thejas N. Swamy, MD

Renal Fellow
Division ofRenal Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Mya Sanda Thein, MD

Post-Doctoral Fellow
Department ofHematology/Medical Oncology
University ofMaryland Greenebaum Cancer
Center
Baltimore, Maryland

DennisA. Tighe, MD, FACC, FASE

Ulises Torres, MD, FACS

Assistant Professor of Surgery
Department ofSurgery
Director, Trauma Education and Outreach
Associate Program Director
General Surgery Residency
University ofMassachusetts Medical School
Worcester, Massachusetts
Christoph Troppmann, MD, FACS

Professor
Division of Transplantation
Department ofSurgery
University of California, Davis Medical
Center
Sacramento, California
Susan Hongha T. Vu, MD

Gastroenterology Fellow
Washington University in St. Louis
St. Louis, Missouri
J. Matthias Walz, MD, FCCP

Associate Professor ofAnesthesiology
and Surgery
Department ofAnesthesiology
Division of Critical Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Michael Y. Wang, MD, FACS

Professor
Department ofNeurosurgery and
Rehabilitation Medicine
University ofMiami School ofMedicine
Lois Pope LIFE Center
Miami, Florida


xxi i

J

Cont r i b utors

John P. Weaver, MD

Jorge D. Yarzebski, BA, NREMT-P

Associate Professor
Department ofNeurosurgery
University ofMassachusetts Medical School
Worcester, Massachusetts

Faculty, Interprofessional Center for
Experiential Learning and Stimulation
Manager
Office of Continuing Medical Simulation
Center
University ofMassachusetts Medical School
Worcester, Massachusetts

Cynthia E. Weber, MD

Resident
Department of General Surgery
Loyola University Medical Center
Maywood, Illinois
Mark M. Wilson, MD

Associate Professor ofMedicine
Associate Director ofMedical Intensive Care
Unit
Division ofPulmonary, Allergy, and Critical
Care Medicine
University ofMassachusetts Medical School
Worcester, Massachusetts
Joshua J. Wind, MD

Resident
Department ofNeurological Surgery
George Washington University Medical Center
Washington, District of Columbia
Dietmar H. Wittmann, MD, PhD,

FACS

Professor Emeritus
Medical College of Wisconsin
Milwaukee, Wisconsin
Mary M. Wolfe, MD

Assistant Clinical Professor of Surgery
UCSF-Fresno Medical Education Program
Community Regional Medical Center
Fresno, California
Yee Wong, MD

Resident
Department ofSurgery
Loyola University Medical Center
Maywood, Illinois

Robert W. Yeh, MD, MSc

Instructor in Medicine
Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts
Luke Yip, MD

Department of Veterans Affairs
National Center for Patient Safety
Ann Arbor, Michigan
David D. Yuh, MD

Professor and Chief, Section of Cardiac
Surgery
Yale University School ofMedicine
Surgical Director
Yale-New Haven Hospital - Heart &
Vascular Center
New Haven, Connecticut
Jiaying Zhang, MD

Vascular Neurology Fellow
Department ofNeurology
University ofMassachusetts Medical
School
Worcester, Massachusetts
Iva Zivna, MD

Assistant Professor ofInfectious Disease and
Immunology
Division ofInfectious Diseases and
Immunology
University ofMassachusetts Medical School
Worcester, Massachusetts


Preface
We are delighted to present the sixth edition of the Manual ofIntensive Care Medicine.
Previous editions have established this Manual as a leading source of information in
the ever-evolving, diverse, and complicated field of critical care and intensive care
medicine. The practical format and user-friendly, portable size of the Manual have
made it a particularly valuable aid in the bedside practice of intensive care and a valu­
able reference for students, interns, residents, fellows, nurse practitioners and physi­
cian assistants, nurses, and respiratory care practitioners practicing in the critical care
medicine environment.
As in the previous edition of this work, the sixth edition of the Manual is intended
to parallel our major textbook Irwin and Rippe's Intensive Care Medicine. This latter,
hardcover book is now in its seventh edition and continues to be a leading source of
intensive care knowledge both in the United States and throughout the world.
We are pleased to announce that the sixth edition of the Manual will be avail­
able not only in print but also online and as an app for e-readers. Choice of format
allows busy bedside providers access to the information they need the way they like
to receive it. These resources allow immediate access to the information that allows
busy professionals to optimally manage the complicated issues encountered in the care
of critically ill adults. As in previous editions, we have challenged the section editors
and authors to not only update all the content contained within the Manual, such
as the important role that bedside ultrasonography plays in caring for the critically
ill, but also emphasize salient concepts and focus on key, clinically relevant points.
Annotated references are provided at the close of each chapter to guide the interested
reader through key articles in the relevant literature. Each chapter reflects the best
available evidence with a focus on patient safety, and, where appropriate, videos have
been added to exemplify points and findings.
The Manual of Intensive Care Medicine opens with an extensive section on Pro­
cedures and Techniques. The remaining 1 5 sections are divided among organ system
problems and other common and important issues, such as palliative care and ethical
issues, and transplantation. In each chapter within these sections, discussions of key
conditions that present in the intensive care unit environments are presented together
with targeted discussions focusing on treatment.
We are delighted to welcome new section editors in the following areas: Dr. Gail
Scully in Infectious Disease Problems; Dr. Samir Malkani in Endocrine Problems;
Dr. Timothy A. Emhoff in Shock and Trauma; Dr. Sonia Chimienti, who joined
Dr. Christoph Troppmann as a co-section editor in the Transplantation section; and
Dr. Jennifer Reidy, who is the section editor of a new section in the book on Palliative
Care and Ethical Issues in the Intensive Care Unit.
As in the previous edition, the management of overdoses and poisonings is cov­
ered so comprehensively in the Pharmacology, Overdoses, and Poisonings section that
the section mimics a textbook unto itself. For this, we have special thanks to the
section editor Luke Yip, who created the easy-to-use tabular format of this section.
We are also indebted to our other section editors who have continued to contribute
in an extraordinary way by updating their sections: Dr. Stephen 0. Heard, who has
overseen the Procedures and Techniques and Minimally Invasive Monitoring sec­
tion; Dr. Akshay S. Desai, Cardiovascular Problems and Coronary Care; Dr. J. Mark
Madison, Pulmonary Problems; Dr. Pang-Yen Fan, Renal Problems; Dr. Dominic
]. Nompleggi, Gastrointestinal and Hepatobiliary Problems; Dr. Patrick F. Fogarty,
x xii i


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