Tải bản đầy đủ

2015 clinical intensive care medicine


Clinical Intensive
Care Medicine

P640_9781848163881_tp.indd 1

14/7/14 4:55 pm


May 2, 2013

14:6

BC: 8831 - Probability and Statistical Theory

This page intentionally left blank

PST˙ws


Introductory Series in Medicine Vol. 1

Series Editor: Nadey Hakim

Clinical Intensive
Care Medicine

Editor

Carlos M H Gómez

St Mary’s Hospital and Hammersmith Hospital, UK

ICP
P640_9781848163881_tp.indd 2

Imperial College Press

14/7/14 4:55 pm


Published by
Imperial College Press
57 Shelton Street
Covent Garden
London WC2H 9HE
Distributed by
World Scientific Publishing Co. Pte. Ltd.
5 Toh Tuck Link, Singapore 596224
USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

Library of Congress Cataloging-in-Publication Data
Clinical intensive care medicine / edited by Carlos M.H. Gómez.
p. ; cm. -- (Introductory series in medicine ; volume 1)
Includes bibliographical references and index.
ISBN 978-1-84816-388-1 (hardcover : alk. paper) -- ISBN 978-1-84816-389-8 (electronic)
I. Gómez, Carlos M. H., editor. II. Series: Introductory series in medicine ; v. 1.
[DNLM: 1. Intensive Care. 2. Clinical Medicine. 3. Critical Illness--therapy. WX 218]
RC86.7
616.02'8--dc23
2014026685


British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library.

Copyright © 2015 by Imperial College Press
All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
electronic or mechanical, including photocopying, recording or any information storage and retrieval
system now known or to be invented, without written permission from the Publisher.

For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance
Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy
is not required from the publisher.

Typeset by Stallion Press
Email: enquiries@stallionpress.com
Printed in Singapore

JQuek - Clinical Intensive Care Medicine.indd 1

14/7/2014 1:36:38 PM


b1739 Clinical Intensive Care Medicine

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

b1739_FM.indd v

14-07-2014 19:36:46


May 2, 2013

14:6

BC: 8831 - Probability and Statistical Theory

This page intentionally left blank

PST˙ws


b1739 Clinical Intensive Care Medicine

Contents

Foreword from the Series Editor
Foreword
Preface
List of Authors

xix
xxi
xxiii
xxvii

1 History of Intensive Care
Jennifer Jones

1

References

6

2 Cardiovascular Physiology
Ian Webb and David Treacher

9

2.1 Introduction
2.2 The Cardiac Cycle
2.3 Ventricular Performance and the Determinants
of Cardiac Output
2.4 Coronary Blood Flow
2.5 Peripheral Circulation
2.6 The Microcirculation
2.7 Clinical Case
References

9
10
16
26
30
34
36
38

vii

b1739_FM.indd vii

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

viii

Contents

3 Respiratory Physiology
Nicholas Lees and Neil Soni
3.1
3.2
3.3
3.4
3.5
3.6

Introduction
Regulation of Respiration
Mechanics of Ventilation
Work of Breathing
Ventilation–Perfusion
Carbon Dioxide and Interpretation of
Expired Alveolar Gas
3.7 Blood Gases
3.8 Physiological Effects of Positive-Pressure Ventilation
References
4 Cellular Physiology in Critical Care
David Brealey and David Howell
4.1 Oxygen Delivery and Cellular Utilisation
4.2 Cell Death in Critical Care
4.3 Conclusion
4.4 Clinical Scenario
References
5 Cardiovascular Monitoring
Parind Patel
5.1 Purpose of Monitoring
5.2 Clinical Examination and Non-Invasive Monitoring
5.3 Pulse Oximetry
5.4 Venous Saturations
5.5 Pulmonary Artery Flotation Catheter
5.6 Pulse Contour Analysis
5.7 Oesophageal Doppler
5.8 Echocardiography
5.9 Current Approach to Monitoring the Critically Ill Patient
5.10 Clinical Case
References

b1739_FM.indd viii

41
41
41
45
46
49
55
56
57
63
71
71
83
87
87
90
93
93
94
95
96
97
99
101
103
104
106
108

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

Contents

6 Vasoactive Agents
Gayathri Satkurunath, Raha Rahman West
and Andrew Rhodes
6.1
6.2
6.3
6.4
6.5
6.6

Definitions
The Pressure versus Flow Dilemma
Tissue Oxygen Consumption and Supply
Vasodilators: Rationale and Current Treatments
Vasoconstrictors: Rationale and Current Agents
Cardiac Output: Advantages and Disadvantages
of Pharmacological Augmentation
6.7 A Rational Evidence-Based Approach to Inotropes
6.8 Clinical Case
References
7

8

b1739_FM.indd ix

ix

113

113
113
114
117
121
126
129
130
131

Mechanical Ventilation
Amisha V. Barochia, Charles Natanson and Peter Q. Eichacker

137

7.1 Overview
7.2 Acute Lung Injury (ALI)/Acute Respiratory Distress
Syndrome (ARDS)
7.3 Asthma
7.4 Chronic Obstructive Pulmonary Disease
7.5 Weaning
7.6 Clinical Case
References

137
137
146
153
157
160
162

Non-Invasive Ventilation
Borja G. Cosío and José M. Echave Sustaeta

179

8.1 Principles of Non-Invasive Ventilation
8.2 Procedures in Non-Invasive Ventilation
8.3 Modes and Equipment
8.4 Special Indications
8.5 Summary
References

179
181
186
188
199
200

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

x

9

10

11

Contents

Nutrition
Richard Leonard

205

9.1 Introduction
9.2 Why do we Feed Patients in Intensive Care?
9.3 Which Patients Need to be Fed?
9.4 When Should Feeding Start?
9.5 How Much Feed Should Critically Ill Patients Receive?
9.6 Which Route Should be Used to Feed ICU Patients?
9.7 What Should the Feed Contain?
References

205
206
208
208
209
211
220
223

Microbiology and Infection Control
Annette Jepson

229

10.1 Introduction
10.2 Pathophysiology of ICU-Acquired Infections
10.3 Implicated Organisms
10.4 Specific Nosocomial Infections
10.5 Investigations
10.6 Antimicrobial Therapy on the ICU
References

229
229
230
231
237
238
248

Radiological Imaging in Intensive Care
Kanupriya Agrawal and Andrew R. Wright

253

11.1
11.2
11.3
11.4
11.5
11.6

253
254
266
274
285

Introduction
The Chest Radiograph
Ultrasound
Cranial Imaging in the ICU Patient
Computed Tomography of the Chest in the ICU Patient
Computed Tomography of the Abdomen in the
ICU Patient
References

b1739_FM.indd x

295
312

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

Contents

12 Biochemistry in Intensive Care
Paul Holloway
12.1 Introduction
12.2 Role in Diagnosis
12.3 The Role of the Chemical Pathologist/Clinical Scientist
12.4 Specific Clinical Areas
References
13 Haematology in Intensive Care
Lesley Kay

14

b1739_FM.indd xi

xi

317
317
317
322
323
345
355

13.1 Introduction
13.2 Haematological Aspects of the ICU Patient
13.3 Haemostasis
13.4 Haemostatic Problems in ICU Patients
13.5 Thromboelastography
13.6 Drug-Induced Bleeding and how to Prevent it
13.7 Acquired Inhibitors of Coagulation
13.8 Anaemia on the ICU Not Due to Bleeding
13.9 Platelets, Thrombosis and how to Avoid it
13.10 Other Aspects of Venous Thrombosis on the ICU
13.11 Clinical Case
References

355
355
356
357
359
360
361
362
364
368
369
371

Peri-Operative Intensive Care Medicine
S. Ramani Moonesinghe and Michael G. Mythen

375

14.1 Surgery and Resources: A Global Health Problem
14.2 The High-Risk Surgical Population
14.3 The High-Risk Surgical Patient
14.4 Peri-Operative Monitoring and Management of
High-Risk Surgical Patients
14.5 The Multi-Modal Approach to Peri-Operative Care
14.6 Conclusion
References

375
376
377
383
392
392
393

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

xii

15

Contents

Post-Operative Intensive Care
Umeer Waheed and Mark G. A. Palazzo

403

15.1
15.2
15.3
15.4
15.5

403
404
408
417

Introduction
Stress Response to Surgery
Analgesia and Sedation
Post-Operative Respiratory Management
Sepsis and the Systemic Inflammatory Response
Syndrome
15.6 Clinical Case
References
16

Sepsis
Richard Stümpfle

431

16.1 Introduction
16.2 Pathophysiology
16.3 Treatment
16.4 Past and Future
References

431
433
439
449
450

17 Airway Management in Intensive Care
Virinder S. Sidhu
17.1 Introduction
17.2 Prediction of Airway Difficulty
17.3 Conduct of Endotracheal Intubation
17.4 Induction of Anaesthesia and Choice of Drugs
17.5 Complications of Endotracheal Intubation
17.6 Unanticipated Failed Intubation
17.7 ‘Can’t Intubate, Can’t Ventilate’ (CICV) Scenario
17.8 Anticipated Difficult Intubation
17.9 Special Consideration — ‘The Narrowed Airway’
17.10 Extubation
17.11 Tracheostomy
17.12 Non-Invasive Ventilation (NIV)
17.13 Lung Isolation Techniques
17.14 Clinical Case
References

b1739_FM.indd xii

420
423
426

457
457
457
459
461
462
462
464
468
469
472
472
482
482
483
484

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

Contents

18

Neurocritical Care
Nicholas Hirsch, Christopher Taylor and Martin Smith

491

18.1 Introduction
18.2 Traumatic Brain Injury
18.3 Cerebral Haemorrhage
18.4 Ischaemic Stroke
18.5 Management of Spinal Cord Injury
18.6 Status Epilepticus
18.7 Neuromuscular Diseases in the ICU
18.8 Clinical Case
References

491
491
500
504
506
508
509
514
515

19 Cardiopulmonary Intensive Care
Marius Gota, Allen Bashour and Michael O’Connor
19.1 Introduction
19.2 The Initial Post-Operative Period
19.3 Neurological Complications
19.4 Respiratory Management and Complications
19.5 Gastrointestinal Complications
19.6 Acute Kidney Dysfunction
19.7 Heart and Lung Transplantation
19.8 Ventricular Assist Devices
References
20 Respiratory Intensive Care
Sarah L. Stirling and Mark J. D. Griffiths
20.1 Acute Respiratory Failure
20.2 Post-Operative Respiratory Failure
20.3 Pneumonia
20.4 Specific Lung Diseases
20.5 Investigations
20.6 Conclusions
20.7 Clinical Case
References

b1739_FM.indd xiii

xiii

519
519
520
531
532
537
538
539
542
544
551
551
555
561
568
580
584
584
587

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

xiv

Contents

21 Vascular Intensive Care
Susan Jain and Carlos M. H. Gómez
21.1 Introduction
21.2 Physiological Impact of Major Vascular Surgery
and Post-Operative Complications
21.3 Peri-Operative and Post-Operative Complications
21.4 Endovascular Repair
21.5 Spinal Cord Protection
21.6 Monitoring Limb Ischaemia
References
22 Liver Intensive Care
Julia Wendon and Patrick Ward

595
595
598
600
608
612
616
617
625

22.1 Definition and Introduction
22.2 Acute Liver Failure
22.3 Critically Ill Cirrhotic (CIC)
22.4 Variceal Bleeding
22.5 Hepatic Encephalopathy
22.6 Alcoholic Hepatitis
22.7 Elective Surgery
22.8 Prognostication
22.9 Liver Transplantation
References

625
625
629
633
635
636
637
637
639
640

23 Acute Kidney Injury in Intensive Care
Shaikh A. Nurmohamed, Marc G. Vervloet
and A. B. Johan Groeneveld

647

23.1
23.2
23.3
23.4
23.5

Defining Acute Renal Failure (ARF)
Pathogenesis and Prevention of Acute Renal Failure
Contrast-Induced Nephropathy
Renal Replacement Therapy
Non-Renal Indications for Continuous Renal
Replacement Therapy
23.6 Practical Issues
23.7 Future Trends: Renal Cell Therapy and the
Bioartificial Kidney

b1739_FM.indd xiv

647
649
652
656
664
668
672

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

Contents

23.8 Prognosis
23.9 Clinical Case
References
24 Obstetrics Problems in Intensive Care
Surbi Malhotra
24.1 Introduction
24.2 Physiological Changes of Pregnancy
24.3 Major Obstetric Haemorrhage
24.4 Cardiac Disease in Pregnancy
24.5 Asthma
24.6 Amniotic Fluid Embolism
References
25 Paediatric Intensive Care
Simon Nadel
25.1 Principles of Paediatric Intensive Care
25.2 Neonatal Sepsis
25.3 Advanced Ventilatory Techniques in Infants and Children
25.4 Diagnosis and Management of Meningococcal Disease
in Children
25.5 Congenital Heart Disease
25.6 Paediatric Trauma
25.7 The Terminally Ill Child on the PICU
25.8 Ethical Considerations
References
26 Trauma Intensive Care
Peter J. Shirley
26.1
26.2
26.3
26.4
26.5
26.6
26.7

b1739_FM.indd xv

xv

674
675
675
687
687
687
690
693
704
705
706
711
711
712
718
722
738
743
750
754
759
765

Introduction
765
Initial Management
766
Acute Fluid Resuscitation
767
Clearance of the Cervical Spine
769
Timing of Fracture Fixation and Surgery (Damage Control) 770
Admission to the ICU
770
Respiratory Support and Ventilation Strategies
771

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

xvi

Contents

26.8 Cardiovascular Support
26.9 Traumatic Brain Injury
26.10 Chest Trauma
26.11 Extremity Trauma
26.12 Abdominal Compartment Syndrome
26.13 Pelvic Trauma
26.14 Other Considerations
26.15 Summary
26.16 Clinical Case
References
27 Intensive Care of Burns Patients
Lena C. Andersson, Hans C. Nettelblad and Folke Sjoeberg
27.1 Introduction
27.2 Clinical Presentation of Burn Injuries and Management
Strategies
27.3 Initial Assessment of Injuries and Treatment
Principles — The Resuscitation (Initial 48-Hour) Phase
27.4 Further Clinical Assessment of Injuries and Treatment
Principles
27.5 Specific Assessment and Management of Burnt Areas
27.6 The Post-Resuscitation Period
27.7 Burns Treatment in Children
27.8 Electrical Burns and Lightning Strikes
References
28 Poisoning
David J. Watson
28.1 Introduction
28.2 Types of Poisoning
28.3 Diagnosis and Assessment
28.4 Principles of Management
28.5 Management of Specific Poisonings
References

b1739_FM.indd xvi

773
775
776
778
778
779
780
781
782
783
787
787
788
789
793
798
803
805
806
807
813
813
813
815
817
828
868

14-07-2014 19:36:46


b1739 Clinical Intensive Care Medicine

Contents

29

Transfer of the Critically Ill
Harriet Wordsworth

873

29.1 Introduction
29.2 Physiological Factors Important in Patient Transfer
29.3 General Principles
References

873
873
876
890

30 Ethics in Critical Care
Simon Munk and Andrew Hartle
30.1 Introduction
30.2 Ethical Principles
30.3 Practical Aspects
30.4 Conclusion
References
31 Leadership and Management in Critical Care
Andrew R. Webb
31.1 Introduction
31.2 Leading
31.3 Managing
31.4 Illustrative Case: Change Leadership in Action
References
32 Evidence-Based Intensive Care
Sunil Grover and Carlos M. H. Gómez
32.1 Corticosteroids
32.2 Activated Protein C
32.3 Insulin
32.4 Albumin
32.5 Pulmonary Artery Catheterisation
32.6 Selective Digestive Decontamination
References
Index

b1739_FM.indd xvii

xvii

893
893
894
898
899
899
901
901
902
905
916
917
921
921
922
922
923
924
925
926
933

14-07-2014 19:36:47


May 2, 2013

14:6

BC: 8831 - Probability and Statistical Theory

This page intentionally left blank

PST˙ws


b1739 Clinical Intensive Care Medicine

Foreword from the Series Editor

My collaboration with Imperial College Press dates back to 1995 when I was
commissioned to write a book on transplantation entitled Introduction to
Organ Transplantation. I have since edited several textbooks on different surgical fields including a second edition of Introduction to Organ Transplantation
in 2012. Collating a series of textbooks introducing different specialties is a
challenge I have undertaken with the hope that the knowledge and expertise
presented will spur the next generation on to even greater knowledge. I envisage the series to be useful to physicians and surgeons at all levels of training
and experience, extending the tradition of textbook excellence and leadership.
I have invited experts to put together volumes to ensure a full display of the
state-of-the-art of several surgical and associated specialties in order to provide
a complete coverage of current practice as well as a glimpse of the future.
This first volume, selected and brought together by Dr Carlos Gómez,
explores the latest in current intensive care practice in a broad range of
areas. Intensive care is a specialty which has evolved and progressed exponentially over the last few years, and this timely volume will be an
important guide for current and future doctors.
Professor Nadey Hakim, MD, PhD
Imperial College London
Honorary Secretary Royal Society of Medicine
Past President International College of Surgeons
June 2014
xix

b1739_FM.indd xix

14-07-2014 19:36:47


May 2, 2013

14:6

BC: 8831 - Probability and Statistical Theory

This page intentionally left blank

PST˙ws


b1739 Clinical Intensive Care Medicine

Foreword

It is a great pleasure for me to write the foreword to Clinical Intensive Care
Medicine and to congratulate Carlos Gómez and colleagues — all of whom
are hands-on, practicing clinicians — on this outstanding achievement. As
a vascular surgeon with an interest in complex aortic disease, I have plenty
of reasons to thank the current generation of expert intensivists. This book
enshrines today’s approach to the management of the critically ill patient
and as such it demonstrates the authors’ desire to spread best current practice as well as a commitment to teaching the next generation. Dr Gómez
believes this book is relevant to everyone from medical student to intensive care unit chief. I would add that it is useful also for those working in
the most technologically advanced hospitals to those in field or temporary
establishments.
Critical care has come of age in the last two decades and the specialty
continues to expand its role. It does not take too much imagination to see
the hospitals of the future as one where expensive in-patient real-estate
can only be justified for patients with critical care needs. That patients are
getting ever older and ever more sick with ever more multi-system disease
only adds to this vision. It means that developed societies are likely to need
more people with critical care skills. As well as continuing to improve outcomes, the challenges for intensive care unit practitioners now are to
optimise training of the next generation — it surely cannot all be done on
the job — and to develop an evidence base to underpin each of the massive range of pharmacological, interventional, monitoring and supportive
xxi

b1739_FM.indd xxi

14-07-2014 19:36:47


b1739 Clinical Intensive Care Medicine

xxii

Foreword

strategies now available. To me both of these make the case for the promotion of academic intensive care unit medicine throughout the developed
world.
A final word about governance and resource allocation; in the future —
consistent with the rising role of intensive care unit medicine — intensivists
must become more involved in the running of the hospitals in which they
work. Only by doing this will they be able to appropriately direct and understand intensive care unit care, its costs and the context of funding in an
increasingly competitive health care world.
I am happy to see that most of my questions are addressed in this
excellent book. Good luck to all who read it, especially those about to
embark on a career in clinical medicine. I suggest you learn from Dr
Gómez and his colleagues. The time for intensive care medicine is now.
N. J. Cheshire MD FRCS
Professor of Vascular Surgery
Head of Circulation & Renal Sciences
Imperial College Healthcare
London
June 2014

b1739_FM.indd xxii

14-07-2014 19:36:47


b1739 Clinical Intensive Care Medicine

Preface

The book is intended as an authoritative guide to practical intensive care
medicine written by acknowledged specialist practitioners from the UK,
Europe and North America, most of whom are also internationally
acclaimed authors. Target audiences are medical students, trainees in
intensive care medicine and other acute specialties, consultants wishing to
remain up to date on all branches of this vast specialty and other allied
professionals practising in intensive care, including nurses and physiotherapists. The book therefore has a practical and educational common thread
rather than an encyclopaedic approach.
Intensive care patients are the sickest and most challenging in any
hospital and use up a disproportionate amount of resources. The specialty
is relatively young, only about 40 years old, and expanding worldwide as
patients grow older, harbour greater expectations and present increased
demands on already stretched health systems.
The older generation of intensivists is approaching retirement. The
middle generation trained in various medical and surgical specialties and
then subspecialised in intensive care. These doctors now lead the way in
clinical practice, research, management and training. The younger generation of intensivists includes an ever increasing number of doctors who, for
the first time, enjoy a structured training programme with clinical rotations, courses and exam qualifications.

xxiii

b1739_FM.indd xxiii

14-07-2014 19:36:47


b1739 Clinical Intensive Care Medicine

xxiv

Preface

This book is aimed at this younger generation. My vision is for this
book to become a useful resource for those wishing to study, practice and
excel in intensive care medicine.
While conceiving this book I have reflected on the true challenges
which face the intensive care clinician. They are of three types: clinical,
managerial and life challenges.
On the clinical front there are several crucial decisions to be made and
revisited for every patient, every day. What is acceptable physiology, what is
achievable and at what price? The clinician may, for example, decide that
intravascular volume is the priority. He/she must therefore be prepared to
accept as a trade-off an increase in unwanted fluid in the form of pulmonary (capillary), peripheral and cerebral oedema. Equally, given a different
scenario — or a different clinician — perfusion pressure may become the
prime goal. This will of necessity be at the expense of increased cardiac
work and also of peripheral vasoconstriction, the combination of these two
potentially giving rise to tissue hypoxia and acidaemia. Finally, normalisation of acid-base chemistry may be the utmost priority. Strategies targeted
to achieve this can lead to raised intrathoracic pressure (through increased
ventilatory settings), increased cardiac work and peripheral oedema.
Also worth reflecting upon is the challenge of blending in with other
intensive care colleagues who might have somewhat different clinical philosophies. Changing treatment plans for the sake of change or in order to
prove a point seldom benefits the patient, often has a negative effect on
team morale and frequently causes undesirable confusion. When taking
over the care of a human being who is making satisfactory clinical progress
but is perhaps being weaned differently, on inotropes which one would
not necessarily have chosen or on antibiotics not amongst one’s favourites,
the challenge facing the clinician is this: is it really necessary to change
these when they are being effective? Some of us refer to this phenomenon
as the ‘Monday syndrome’.
Perhaps the most important decision facing the intensive care team is
to decide which patient requires immediate intervention and which
patient can and will benefit from masterful inactivity and close observation. Which patient should be left alone? When should resident doctors be
encouraged to do nothing but just observe? One of the eminent contributors to this book once told me that it is just as important to do something

b1739_FM.indd xxiv

14-07-2014 19:36:47


Tài liệu bạn tìm kiếm đã sẵn sàng tải về

Tải bản đầy đủ ngay

×

×