SECTION 1: ICU. SECTION 2: Physiology of Critically Ill Patient

Transcription

1 CONTENTS SECTION 1: ICU 1. Setting Up an ICU 3 Initial Planning 3; Infrastructure 3; Indian Society of Critical Care Medicine (ISCCM) Provide Guidelines for Each Level ICU Planning in India 4; Other Issues 6 SECTION 2: Physiology of Critically Ill Patient 2. Critically Ill Patient and Oxygenation 9 Oxygen Cascade 9; Tissue Oxygenation 12 SECTION 3: Vascular Access and Hemodynamic Monitoring 3. Peripheral Arterial Catheterization 17 Indications 17; Equipment 17; Monitoring Sites 17; Technique Peripheral Venous Catheterization 24 Insertion Techniques 24; Precautions 24; Equipment 24; Principle 24; Midline Catheters Central Venous Catheterization 27 Applied Anatomy 28; Techniques 30; Ultrasound-Guided Techniques Pulmonary Artery Catheterization 43 History 43; Perioperative Indications 44; Physiological Variables with PA Catheterization Hemodynamic Monitoring 51 Thoracic Bioimpedance Plethysmography 51; Esophageal and Transcutaneous Doppler Monitoring 51; Mucosal Tonometry 53; Systolic Pressure Variation 58; Limitations of Dynamic Parameters 59

2 xiv ICU Manual SECTION 4: Shock 8. An Overview of Shock 65 Definition 65; Classification 65; Clinical Features Hypovolemic Shock 71 Etiology 71; Pathophysiology 71; Key Elements of Managing Hemorrhagic Shock Obstructive Shock 77 Causes 77; Pathophysiology 77; Clinical Features 77; Air Embolism Cardiogenic Shock 81 Definition 81; Characteristics 81; Pathogenesis 82; Clinical Features 82; High-risk Patients for Cardiogenic Shock 82; Left Heart Catheterization and Angiography 83; Invasive Procedures in Cardiogenic Shock 84; Vasopressors Multiple Organ Dysfunction Syndrome 87 Definition 87; Etiology 87; Pathophysiology 87; Clinical Syndromes 89; Scoring Systems 89 SECTION 5: Infection and Immune Disorders in ICU 13. Approach to Nosocomial Infections 97 Risk Factors 97; Mechanisms of Drug Resistance 98; Nosocomial Pneumonia Urinary Tract Infections 108 Definitions 108; Risks 108; Common Organisms Causing Urinary Tract Infection 109; Prevention of CAUTI Recommendations by HICPAC (Healthcare Infection Control Practices Advisory Committee) 2009 Guidelines Sepsis and Septic Shock 115 Definitions 115; Pathogenesis 115; Sepsis 117; Severe Sepsis 117; Antimicrobial Therapy 121; Hemodynamic Support Principles of Antibiotic Use in ICU 127 Principles of Antibiotic Prescription 127; Common Causes of Infection in ICU 128; Pharmacokinetic Principles 128; Steps Taken to Prevent Antibiotic Resistance 131

3 Contents xv 17. Tropical Infections 134 Jenu Santhosh Severe Malaria 134; Dengue Anaphylaxis 140 Definitions 140; Etiology and Predisposing Factors 140; Clinical Manifestations 141; Role of Epinephrine in Anaphylaxis 144 SECTION 6: Poisoning and Envenomation 19. General Principles of Poisoning 149 Jenu Santhosh Manifestations 149; Neurological Examination 149; Cardiovascular 150; Metabolic 150; Management Poisoning 153 Jenu Santhosh, Organophosphorus and Carbamate Poisoning 153; Organochlorine and Pyrethroid Poisoning Drug Overdose 159 Jenu Santhosh, Sedatives and Hypnotics 159; Antidepressants 159; Acetaminophen Poisoning 160; Opioids 160; Beta-blockers Envenomation 162 Jenu Santhosh Scorpions (Scorpionidae) 162; Caterpillars and Moths (Lepidoptera) 162; Reptile Bites 163 SECTION 7: Burns 23. Classification and Evaluation of Burns 173 Classification 173; Physiological Disturbances 173; Burns Assessment 174; Secondary Survey Management of Burns 180 Early Resuscitative Phase 180; Wound Management Phase 182; Rehabilitative Phase 183; Management of Carbon Monoxide Poisoning 183; Complications 184 SECTION 8: Respiratory Diseases in ICU 25. Approach to Acute Respiratory Failure 187 Pathophysiology 188; Clinical Presentation 188; Treatment Acute Lung Injury and Acute Respiratory Distress Syndrome 193 Definition 193; Pathophysiology 194; Management 195; Weaning Protocol for ARDS 196; Fluid Management 197; Nutritional Support 197

4 xvi ICU Manual 27. Acute Exacerbation of Chronic Obstructive Pulmonary Disease 199 Risk Factors 199; Pathophysiology 199; Diagnosis 200; Clinical Assessment Acute Severe Asthma 206 Clinical Features 206; Diagnosis 206; Management Deep Venous Thrombosis and Pulmonary Embolism 214, Marun Raj Pathophysiology 214; Clinical Features and Diagnosis 214; Prevention 218; Treatment Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome 225 History 225; Obstructive Sleep Apnea 226; Obesity Hypoventilation Syndrome 227 SECTION 9: Approach to Mechanical Ventilation 31. Basics of Mechanical Ventilation 233, S Yuvaraj Negative Pressure Ventilation 233; Positive Pressure Ventilation 233; Ventilator Design 233; Nomenclatures and their Significance 234; Breath Type Initiation of Ventilation 239 Initial Ventilator Settings Modes of Ventilation 245 Basic Modes of Ventilation 245; Pressure Support Ventilation Weaning from Mechanical Ventilation 258 Definition of Weaning 258; Weaning Criteria Patient Ventilator Asynchrony 264 Variables Contributing to Asynchrony Noninvasive Ventilation 269, S Yuvaraj Equipment (Interface) 269; Protocol for Managing Patients Planned for NIPPV 269; Asthma 272; Pneumonia 272 SECTION 10: Cardiovascular Diseases in ICU 37. Cardiac Arrhythmias 277 Surendran GD Supraventricular Arrhythmias 277; Ventricular Arrhythmias 286

5 Contents xvii 38. Acute Heart Failure 296 Surendran GD Definition 296; Classification 296; Pathophysiology 296; Clinical Features 296; Biomarkers 297; Specific Therapies for Acute Heart Failure 299; Vasodilators 299; Other Drugs Used in the Treatment of Acute Heart Failure Approach to Acute Myocardial Infarction 306 Surendran GD Definition 306; Universal Definition of Myocardial Infarction 306; Universal Myocardial Infarction Classification of Type 306; Clinical Features 307; ECG Manifestations of Ischemia in the Setting of LBBB 310; Antiplatelet Therapy 312; Pain Control 313; Limitations of Infarct Size 315; Percutaneous Coronary Intervention Hypertensive Crisis 322 Surendran GD Definition 322; Hypertensive Emergency (Previously Malignant Hypertension) 322; Hypertensive Urgency 323; Investigations Cardiac Tamponade 328 Surendran GD Definition 328; Pathophysiology 328; Precipitating Factors 328; Clinical Features 328; Becks Triad (Useful Clue for Diagnosis of Tamponade) 329; Differential Diagnosis 329; Investigations 329; Management 330 SECTION 11: Renal and Electrolyte Disturbances in ICU 42. Acute Kidney Injury 335 Jenu Santhosh, Characteristics 335; Categories 335; Diagnosis 337; Markers for Renal Dysfunction in AKI Renal Replacement Therapy 342 G Ninoo George Access 343; Hemodialysis Versus Peritoneal Dialysis 344; Intermittent Hemodialysis Versus Slow Low Efficiency Dialysis 344; Slow Low Efficiency Dialysis Versus Continuous Renal Replacement Therapy 344; Adverse Effects of Renal Replacement Therapy Hyponatremia 346 Causes 346; Pseudohyponatremia 347; True Hyponatremia (< 275 mosm/kg) 347; Asymptomatic Hyponatremia 348; Symptomatic Hyponatremia 348; Osmotic Demyelination Syndrome 349; Hypernatremia 349; Management of Diabetes Insipidus Potassium 353, Sushma Vijay Pingale Potassium Balance in Health and Disease 353; Hypokalemia 353; Hyperkalemia 355

6 xviii ICU Manual 46. Calcium 359 Calcium Metabolism 359; Hypocalcemia 359; Chvostek s Sign 360; Trousseau Sign 360; Hypercalcemia 361; Diagnostic Workup Phosphorus 366 Metabolism 366; Hypophosphatemia 366; Hyperphosphatemia Magnesium 372 Hypomagnesemia 372; Hypermagnesemia 374 SECTION 12: Gastrointestinal Diseases in ICU 49. Upper Gastrointestinal Bleeding 379 Peptic Ulcer 379; Variceal Bleed 379; Mallory-Weiss Tear 380; Boerhaave s Syndrome 380; Vascular Anomalies 380; Management 380; Pharmacologic Therapy 382; Endoscopy 382; Specific Conditions Lower Gastrointestinal Bleeding 385 Etiology 385; Investigations 386; Treatment 386; Specific Measures Acute Pancreatitis 389 General Considerations 389; Etiology 389; Pathogenesis 389; Clinical Features 390; Investigations 390; Radiology 391; Differential Diagnosis 392; Management Acute Liver Failure 394 Classification 394; Causes of Acute Liver Failure 394; Pathophysiology 395; Clinical Features 395; Associations of Acute Hepatic Failure 395; Prognosis 398; Treatment 398; Liver Transplantation Abdominal Infections in ICU 402 Classification 402; Pathophysiology 403; Clinical Features 403; Investigations 404; Management 404; Duration of Treatment 406 SECTION 13: Hematological Disorders in ICU 54. Hemolytic Anemia and Sickle Cell Crisis 411 Vinoj Hemolytic Anemia 411; Sickle Cell Crisis Disseminated Intravascular Coagulation and Heparin-induced Thrombocytopenia 416 Vinoj Disseminated Intravascular Coagulation 416; Heparin-induced Thrombocytopenia 418

7 Contents xix 56. Immune Thrombocytopenic Purpura 420 Vinoj Pathogenesis 420; Classification of Immune Thrombocytopenic Purpura 420; Clinical Features 421; Laboratory Finding 421; Treatment 422; Emergency Treatment of Acute Bleeding 423 SECTION 14: Endocrine Disorders in ICU 57. Diabetic Ketoacidosis 427 Vinoj, G Ninoo George Precipitating Factors 428; Basic Pathophysiology of Diabetic Ketoacidosis 428; Clinical Features 428; Management Goals 429; Assessment and Monitoring 430; Fluid Replacement 430; Insulin Therapy 430; Electrolyte Correction Hyperosmolar Hyperglycemic State 432 Vinoj, G Ninoo George Pathophysiology 432; Clinical Features Diabetes Insipidus 435 Vinoj, G Ninoo George Vasopressin: Neural Hormone 435; Etiology 436; Complications Syndrome of Inappropriate Secretion of Antidiuretic Hormone 441 Vinoj, G Ninoo George Pathophysiology Thyroid Emergencies 449 Vinoj, G Ninoo George Thyroid Storm 449; Myxedema Coma 451; Pathogenesis Adrenal Emergencies 455 Vinoj, G Ninoo George Adrenal Crisis 455; Primary ( ACTH) 455 SECTION 15: Obstetric Emergencies 63. Obstetric Hemorrhage 463 Causes of Obstetric Hemorrhage 463; Classification 463; Antepartum Hemorrhage 464; Postpartum Hemorrhage Hypertensive Disorders of Pregnancy 469 Classification of Hypertensive Disorders in Pregnancy 469; Definitions 469; Pre-eclampsia 469; HELLP Syndrome 473; Eclampsia Acute Fatty Liver of Pregnancy 476 Pathophysiology 476; Clinical Presentation 476; Lab Investigations 476; Differential Diagnosis 476; Complications 477; Management 477

8 xx ICU Manual 66. Amniotic Fluid Embolism 479 Pathophysiology 479; Clinical Features 479; Lab Investigations 480; Management 480 SECTION 16: Neurological Disorders in ICU 67. Cerebrovascular Diseases 483 Transient Ischemic Attack 483; Stroke 484; Ischemic Stroke (80%) 484; Clinical Features 485; Hemorrhagic Stroke 486; Clinical Features of Hemorrhagic Stroke 486; Management of Cerebral Edema Status Epilepticus 490 Definition 490; Etiology 490; Types 490; Convulsive 490; Simple Partial Status Epilepticus 491; Complications 491; Investigations 491; Treatment Meningitis and Encephalitis 494 Definition 494; Classification 494; Acute Bacterial Meningitis 494; Pathogenesis 495; Clinical Features 495; Investigations 496; Imaging 496; Differential Diagnosis 497; Treatment 497; Antibiotics Based on Organisms 497; Viral Meningitis 499; Investigations 500; Tubercular Meningitis 501; Fungal Meningitis 502; Viral Encephalitis 503; Treatment Alcohol Withdrawal Syndrome 506 Symptoms 506; Delirium Tremens 507; Management of Delirium Tremens Delirium in Intensive Care Unit 510 Definition 510; Clinical Features 510; Terminal Delirium 510 SECTION 17: Neuromuscular Disorders 72. Guillain-Barré Syndrome 517 General Considerations 517; Etiology 517; Pathogenesis 517; Clinical Features Myasthenia Gravis 521 Etiology 521; Pathogenesis 521; Clinical Features 522; Investigations 523; Treatment 524; Evaluating the Effectiveness of Treatment 526; Myasthenic Crisis Periodic Paralysis 528 Hypokalemic Periodic Paralysis 528; Hyperkalemic Periodic Paralysis 529; Anderson s Syndrome 530

9 Contents xxi 75. Critical Illness Polyneuropathy 531 Predisposing Factors 531; Pathology 531; Pathogenesis 531; Clinical Features 531; Treatment 533 SECTION 18: Approach to a Trauma Patient 76. Advanced Trauma Life Support 537 Airway 537; Breathing 539; Circulation 539; Massive Transfusion 541; Complications Open Fractures 545 K Gunalan Classification 545; Antibiotic Cover 546; Surgical Debridement and Irrigation 546; Wound Closure 547; Skeletal Fixation Pelvic Fractures 551 K Gunalan Advanced Trauma Life Support 552; Hemodynamic Status 552; Fracture Stability 552; Pneumatic Antishock Garment 553; Pelvic Binders 553; Anterior External Fixator 553; Acute Fracture Fixation 554; Angiography 554; Pelvic Packing 555; Open Pelvic Fractures Fat Embolism Syndrome 557 Sushma Vijay Pingale Etiology 557; Pathogenesis 557; Clinical Features 557; Diagnosis 558; Management Abdominal Trauma 560 Marun Raj Mechanism of Injury 560; Diagnostic Principles in General 560; Lab Investigations 562; Diagnostic Peritoneal Lavage 562; Angiography 563; Preoperative Management 563; Damage Control Surgery 564; Abdominal Compartment Syndrome Vascular Trauma of Extremities 567 Marun Raj Historical Perspective 567; Epidemiology 567; Clinical Presentation 568; Noninvasive Imaging 568; Management of Extremity Trauma 570; Compartment Syndrome Traumatic Head Injury 576 Sushma Vijay Pingale, V Thanga Thirupathi Rajan Primary Injury 576; Secondary Injury Thoracic Trauma 588 Sushma Vijay Pingale, Marun Raj Injury to Chest Wall 588; Injury to Pleura 589; Injury to Lung 591; Injury to Heart 591; Injury to Aorta 592; Injury to Esophagus 594

10 xxii ICU Manual SECTION 19: Ultrasonography 84. Role of Ultrasound in Critical Care 597 Physics of Ultrasound 598; Ultrasound Image Characteristics 600; Needle Orientation 602; Pulmonary Embolism 603; Procedural Uses of Ultrasound 608 SECTION 20: Acid-Base Disorders 85. Basics of Acid-Base Balance 617 Sushma Vijay Pingale Basic Concepts and Terminologies Metabolic and Respiratory Acid-Base Disorders 623 Sushma Vijay Pingale Metabolic Acidosis Interpretation of Acid-Base Disorder 631 Sushma Vijay Pingale Stepwise Approach for Interpretation of ABG 631; Arterial Blood Gas Exercises 632 SECTION 21: Nutritional Support 88. Nutrition and Metabolism in Critically Ill Patients 639 Sushma Vijay Pingale Pathophysiology of Nutrition in Illness 639; Nutritional Assessment Enteral and Parenteral Nutrition 647 Sushma Vijay Pingale Timing of Nutritional Support 647; Routes for Giving Nutritional Support 647; Refeeding Syndrome 653 SECTION 22: Sedation and Analgesia in ICU 90. Sedation and Analgesia for Critical Care Patients 657 Issues to be Addressed for Management of Pain and Sedation in ICU 657; Pain and Sedation Considerations 657; Assessment of Pain 658; Pain Scales Patient-Controlled Analgesia 670 Pre-requisites 670; Mechanics about the Device 670; How to Write an Order for PCA? 670 SECTION 23: Airway Management in ICU 92. Rapid Sequence Induction 677 Essential Components of Rapid Sequence Induction 677; Indications of Rapid Sequence Induction 678; Cricoid Pressure 678

11 Contents xxiii 93. Endotracheal Intubation in Critical Care 680, Dianitta Devapriya Veronica Basic Anatomy 680; Fast-track Evaluation and Airway Assessment before Intubation 680; Adjuncts for Airway Management 682; Intubation Techniques 687; Management of Difficult Airway 688; Care of Endotracheal Tube in ICU Tracheostomy 693 A Meenakshi Sundaram Emergency Tracheostomy 693; Elective Tracheostomy 694; Types of Tracheostomy 695; Cricothyroidotomy/Minitracheostomy 696 SECTION 24: Transfusion Practice in ICU 95. Blood Transfusion: Components and Indications 703 Component Separation Complications of Blood Transfusion 709 Adverse Reactions to Transfusion 709; Massive Blood Transfusion 713 SECTION 25: Fluid Management 97. Perioperative Fluid Balance 717 Basic Physiology of Fluid Balance Fluid Resuscitation 722 Fluid Management in Perioperative Patients 722 SECTION 26: Cardiopulmonary Resuscitation 99. Basic Life Support 731 Physiology of Cardiopulmonary Resuscitation 732; Adult Basic Life Support Sequence 733; Sequence of Adult Basic Life Support Skills 734; Airway Management Advanced Cardiac Life Support 739 Adjuncts for Airway Management 740; Management of Adult Cardiac Arrest Cardiac Arrest in Special Situations 750 Anaphylaxis 750; Pregnancy 751; Trauma 752; Hypothermia 753; Asthma 754; Drowning 755; Percutaneous Coronary Intervention 756; Cardiac Tamponade 756; Cardiac Surgery 756

12 xxiv ICU Manual SECTION 27: Brain Death 102. Care of a Brain Dead Patient 761 Sumathy,, Deepalakshmi Definition 761; Physiology of Brain Death 761; Steps for Determining Brain Death 763; Diagnostic Criteria for the Clinical Diagnosis of Brain Death 764; Management of Heartbeating Brain Death Organ Donor 766; Management of 2nd Phase 768; Management of Respiratory System 769; Management of Endocrine System 770; Quadruple Hormonal Replacement Therapy 770 SECTION 28: Medical Ethics 103. Ethics in Critical Care 775 End-of-life Care 775 SECTION 29: Appendices 1. Normal Biochemical Values 781 Reference Values for Laboratory Tests Clinical Scores, Indices and Equations 789 APACHE II Scoring System 789; MODS Scoring System 790; SOFA Scoring System 790; Gold Criteria for Grading Severity of COPD 791; Levels of Risk Associated with Increasing Body Mass Index 791; Waist Circumference and Risk 791; SF-MPQ (Short Form Mcgill Pain Questionnaire) 792; Ramsay Sedation Scale (RSS) 793; Richmond Agitation Sedation Scale (RASS) Drugs, Dosages and Side Effects 797 Cardiovascular System 797; Respiratory System 801; Electrolyte Imbalance 803; Endocrine Disorders 804; Gastrointestinal Disorders 806; Hepatic Dysfunction 806; Hematopoietic Disorders 807; Central Nervous System 807; Infectious Diseases ICU Rounds 815 Essential Data and Assessment for Management of Critically Ill Patients 815 Index 817