CRITICAL CARE. Jaypee Brothers

Transcription

1 CRITICAL CARE

2 CRITICAL CARE Chief Editors Narendra Rungta MD FISCCM FCCM FICCM President Indian Society of Critical Care Medicine Association of SAARC Critical Care Societies Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Rajesh Pande MD PDCC (SGPG IMS) FICCM FCCM (USA) Director Critical Care and Emergency Medicine Editors Manish Munjal MD FICCM Vice President Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Sudhir Khunteta MD Chief Internist and Critical Care Specialist Shubh Hospital Jaipur, Rajasthan, India Foreword Shirish Prayag MD FCCM The Health Sciences Publisher New Delhi London Panama Philadelphia

3 Medical Publishers (P) Ltd Headquarters Medical Publishers (P) Ltd. 4838/24, Ansari Road, Daryaganj New Delhi , India Phone: Fax: Overseas Offices J.P. Medical Ltd. 83, Victoria Street, London SW1H 0HW (UK) Phone: Fax: +44(0) Jaypee Medical Inc. The Bourse 111 South Independence Mall East Suite 835 Philadelphia, PA 19106, USA Phone: Medical Publishers (P) Ltd. Bhotahity, Kathmandu, Nepal Phone: Jaypee-Highlights Medical Publishers Inc. City of Knowledge, Bld. 237, Clayton Panama City, Panama Phone: Fax: Medical Publishers (P) Ltd. 17/1-B, Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: Website: Website: , Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Critical Care First Edition: 2016 ISBN: Printed at

4 Dedicated to My wife Dr Neena Rungta, children Arpita and Jay and to the contributors of the book. Without them this book would not have been there. Narendra Rungta My parents who have given me great values and have always been my pillars of strength and to my patients who have given me the opportunity to evolve as a clinician. I express my gratitude to my wife Maitree and kids Anirud and Dhruv for supporting me during this project. Rajesh Pande

5 Contributors Diptimala Agarwal MD Consultant Anesthesiologist Intensivist OXIM Anesthesia and Critical Care Associate, Agra, Uttar Pradesh, India Vandana Agarwal MD FRCA Associate Professor Anesthesiology and Critical Care Tata Memorial Hospital Mumbai, Maharashtra, India Vimal K Agarwal MS MCH Consultant Neurosurgeon Armin Ahmed MD PDCC Research Fellow SGPGIMS Lucknow, Uttar Pradesh, India Nayana Amin MD Associate Professor Anesthesiology and Critical Care Tata Memorial Hospital Mumbai, Maharashtra, India Pravin Amin MD FCCM Physician Intensivist Bombay Hospital Institute of Medical Sciences Mumbai, Maharashtra, India Rahul Kumar Anand MD Attending Consultant Max Superspeciality Hospital Patparganj, Mullai Baalaaji AR MD DM Senior Resident Department of Pediatrics Advanced Pediatric Centre, PGIMER Chandigarh, Punjab, India Rohini Arora MD IDCCM Senior Resident Critical Care Medicine Afzal Azim MD PDCC FICCM Additional Professor SGPGIMS Lucknow, Uttar Pradesh, India Khusrav Bajan MD EDIC Consultant Physician and Intensivist Department of Medicine and Critical Care, PD Hinduja Hospital Mumbai, Maharashtra, India AK Baronia MD Professor and Head SGPGIMS Lucknow, Uttar Pradesh, India Anupam Basumatari MD IDCCM Consultant Critical Care Medicine Yogesh Batra MD DM Director Gastroenterology and Hepatology Rajesh Bhagchandani MD Consultant Intensivist Apex Hospital Bhopal, Madhya Pradesh, India Ashish Bhalla MD Additional Professor Department of Internal Medicine PGIMER Chandigarh, Punjab, India Manish Bharti MD Fellow in Critical Care Indraprastha Apollo Hospital Kapil Borawake MD Consultant critical care Prayag hospital Pune, Maharashtra, India Sati Chakrabarti MSC PhD Director Nursing Medica Superspeciality Hospital Kolkata West Bengal, India CCNS Chairperson, Eastern Zone Anamika Chaudhary DA IDCCM Associate Consultant Department of Critical Care Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Dhruva Chaudhry MD DNB DM FICP FICCM Dean Faculty of Medical Superspeciality Senior Professor and Head PCCM University of Health Sciences Rohtak, Haryana, India Rajesh Chawla MD EDIC EDRM FICCM FCCM Chancellor Indian College of Critical Care Medicine Ex-President Indian Society of Critical Care Medicine Senior Consultant Respiratory Medicine and Critical Care Indraprastha Apollo Hospital TD Chugh FAMS MD PhD FRCPath (London) FAAM Emirtus Professor, National Academy of Medical Sciences, India Ex-Professor and Head PGIMS Rohtak, Haryana, India Avijatri Datta Senior Manager Clinical Research Member Secretary CREC Senior Registrar MICC Medical Superspeciality Hospital Kolkata, West Bengal, India Pratibha Dileep MD Director Department of Critical Care and Emergency Medicine Sterling Hospital Ahmedabad, Gujarat, India

6 viii Critical Care Subhal Dixit MD IDCCM FICCM Director Critical Care Sanjeevan and MJM Hospital Pune, Maharashtra, India Harjit Dumra MD Senior Consultant Pulmonology and Critical Care Sterling Hospital Ahmedabad, Gujarat, India Mohammad Omar Faruq MD Professor of Critical Care Medicine Birden General Hospital and Ibrahim Medical College Dhaka, Bangladesh President, BSCCM Ashish Garg MD DNB Fellow in Gastroenterology Department of Gastroenterology and Hepatology Neeru Gaur DA IDCCM Associate Consultant Department of Critical Care Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Supradip Ghosh MD DNB MNAMS EDIC Senior Consultant and Head Fortis Escorts Hospital Faridabad, Haryana, India Manoj K Goel MD Diploma in Interventional Pulmonology Director Pulmonology and Sleep Medicine FMRI, Gurgaon, Haryana, India Palepu B Gopal MD FRCA CCST FICCM Senior Consultant Critical Care Medicine Care Hospitals Director, Axon Criticare Hyderabad, Andhra Pradesh, India Deepak Govil MD FICCM FCCM EDIC Associate Director Institute of Critical Care Medicine Medanta, The Medicity Gurgaon, Haryana, India Abhinav Gupta MD DNB FNB EDIC Additionl Medical Superintendent Head Critical Care and Emergency School of Medical Sciences and Research Sharda University Greater Noida, Uttar Pradesh, India Babita Gupta MD Associate Professor Trauma Anesthesia and Critical Care JP Apex Trauma Center AIIMS, Manish Gupta MD FNB Senior Consultant Max Superspeciality Hospital Patparganj, Mukesh Kumar Gupta MD FNB Senior Consultant Institute of Critical Care and Anesthesiology Medanta the Medicity Gurgaon, Haryana, India Mukesh M Gupta MD DM Senior Consultant in Neurointensive Care Patparganj, Rakesh Gupta MD EDIC Senior Consultant Respiratory and Critical Care Metro Hospitals Noida, Uttar Pradesh, India Sachin Gupta MD Senior Resident SGPGIMS Lucknow, Uttar Pradesh, India Vivek Gupta DA DNB MNAMS FACTA Consultant Cardiac Anesthesia and Intensive Care Hero DMC Hospital Ludhiana, Punjab, India Sushma Gurav DNB IDCCM Consultant Neurotrauma Unit Grant Medical Foundation Ruby Hall Clinic Pune, Maharashtra, India Mohan Gurjar MD PDCC FICCM Associate Professor SGPGIMS Lucknow, Uttar Pradesh, India Yash Javeri MBBS DA IDCCM Consultant Institute of Critical Care Medicine Max Healthcare Saket, SP Kalantri MD MPH Director Professor of Medicine Department of Internal Medicine JLN Medical College Wardha Wardha, Maharashtra, India Poonam Malhotra Kapoor MD Professor of Cardiac Anesthesia AIIMS, Arindam Kar MD DNB FNB EDIC Director Medica Institute of Critical Care Medicine Medica Superspeciality Hospital Kolkata, West Bengal, India Pritpal Kaur MD Attending Consultant Critical Care Medicine Vipin Kauts MD EDIC Consultant ICU King Hamad University Hospital Bahrain, UAE Puneet Khanna MD IDCCM FCCP Consultant in Respiratory Medicine Khalid Khatib MD Intensivist and Associate Professor Department of Medicine SK Nalve Medical College and General Hospital Pune, Maharashtra, India Parveen Khilnani MD FCCM Director Pediatric Critical Care

7 Contributors ix Gaurav Kochhar MD Consultant Intensivist Amol Kothekar MD Assistant Professor, Intensive Care Medicine, Advanced Center for Treatment Research and Education in Cancer (ACTREC), TMH Mumbai, Maharashtra, India Lakshmi N Kottu MBBS HCM Diploma in Cardiology, Institute of Cardiology, Medanta, The Medicity Gurgaon, Haryana, India Prashant Kumar MD IDCCM Fellow, Critical Care Medicine R Ramesh Kumar MD DNB Fellow PICU (IAP) DM Department of Pediatrics Advanced Pediatric Centre, PGIMER Chandigarh, Punjab, India Saptharishi LG MD DM Senior Resident Department of Pediatrics Advanced Pediatric Centre, PGIMER Chandigarh, Punjab, India Vikas Loomba MD Assistant Professor Department of Internal Medicine PGIMER Chandigarh, Punjab, India Vinay Malhotra MD DM Professor and Head Department of Nephrology SMS Medical College Jaipur, Rajasthan, India RK Mani MD MRCP FICCM Director, Department of Pulmonology Critical Care and Sleep Medicine Saket City Hospital Editor, Indian Journal of Critical Care Medicine Rungmei Marak MD Additional Professor Department of Microbiology SGPGIMS Lucknow, Uttar Pradesh, India Vikas Maurya MD FNB EDIC FCCP Consultant in Respiratory Medicine Mir Faisal Mazid MBBS DNB Clinical Associate Critical Care Medicine Yatin Mehta MD MNAMS FRCA FAMS FIACTA FTEE FISCCM Chairman, Institute of Critical Care and Anesthesiology Medanta the Medicity Gurgaon, Haryana, India Rajesh Chandra Mishra MD FNB EDIC FCCP Consultant Intensivist Ahmedabad, Gujarat, India Chander Mohan SM MBBS MD FICR FIAMS FIMSA FEISI FICGP MNAMS PDCC Radiodiagnosis Oncology Post Doctoral Training Vascular and Interventional Radiology Director Intervention Radiology Krishna Prasad Mulavisala MD FRCA CCST Senior Consultant and Head Cardiac Anesthesia Care Hospitals MD Axon Anesthesia Services Hyderabad, Andhra Pradesh, India Manish Munjal MD FICCM Vice President Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Sheila Nainan Myatra MD FICCM Professor of Anesthesia and Intensive Care Tata Memorial Hospital Mumbai, Maharashtra, India Monish Nakra MD Colonel and Senior Advisor Anesthesiology and Critical Care Northern Command Hospital Udhampur, Jammu & Kashmir, India Prashant Nasa MD FNB IDCCM EDIC FICCM FCCP Senior Intensivist and Co-ordinator Critical Care and Emergency Medicine Shri Balaji Action Medical Institute Vaibhav Kumar Nasa MD Consultant Critical Care Medicine Sanjay Kumar Nihlani MD Associate Consultant Max Superspeciality Hospital Patparganj, Maitree Pande MD Professor of Anesthesiology Lady Hardinge Medical College Rajesh Pande MD PDCC (SGPGIMS) FICCM FCCM (USA) Director Critical Care and Emergency Medicine Sunil P Pandya MD PDCC Head, Department of Anesthesiology Pain and Critical Care Fernandez Hospital Hyderabad, Andhra Pradesh, India Sauren Panja MD FNB Co-ordinator Critical Care and Head Internal Medicine Medica Superspeciality Hospital Kolkata, West Bengal, India Shikha Panwar MD Consultant Critical Care Medicine Atul Pathak MBBS DA Clinical Associate and IDCCM Fellow Critical Care Medicine Vijaya P Patil MD DA Professor, Anesthesiology and Critical Care, Tata Memorial Hospital Mumbai, Maharashtra, India

8 x Critical Care JV Peter MD Professor Christian Medical College Vellore, Tamil Nadu, India Neena Rungta MD Ex-Professor and Vice President Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India RK Singh MD PDCC FICCM Associate Professor SGPGIMS Lucknow, Uttar Pradesh, India R Pratheema MD IDCCM Consultant in Critical Care Apollo Hospital, Chennai, India Girish Rajpal MS MCH Consultant, Neurosurgeon N Ramakrishnan AB (Int Med) AB (Crit Care) AB (Sleep Med) MMM FACP FCCP FCCM FICCM Vice Chancellor Indian College of Critical Care Medicine President Indian Sleep Disorders Association Director, Critical Care Services Senior Consultant in Critical Care and Sleep Medicine Chennai Critical Care Consultants (CCCC) Apollo Hospitals, Chennai, India Suresh Ramasubban AB (CCM) FCCP Senior Consultant Apollo Gleneagles Hospital Kolkata, West Bengal, India V Ruth Adora Rao Critical Care Co-ordinator Medical Superspeciality Hospital Kolkata, West Bengal, India Rajul Rastogi MBBS, MD (Radiodiagnosis) MNAMS FIMSA FICRI Assistant Professor Department of Radiodiagnosis Teerthanker Mahaveer Medical College and Research Center Moradabad, Uttar Pradesh, India Narendra Rungta MD FISCCM FCCM FICCM President Indian Society of Critical Care Medicine Association of SAARC Critical Care Societies Jeevan Rekha Critical Care and Trauma Hospital Jaipur, Rajasthan, India Samir Sahu MD Senior Consultant Pulmonary and Critical Care Apollo Hospital Bhubneshawar, Odisha, India Srinivas Samvedam MD Consultant and Head Care Hospital Hyderabad, Andhra Pradesh, India Utpal Sarma MD Consultant Critical Care Medicine Prashant Saxena MD Senior Consultant Department of Pulmonology Critical Care and Sleep Medicine Saket City Hospital R Senthilkumar MD IDCCM EDIC Senior Consultant in Critical Care Apollo Hospital Chennai, Tamil Nadu, India Pinak Ashok Shrikhande MD FNB Director, Fortis Hospital Vasant Kunj and Shalimar Bagh Ajeet Singh MD IDCCM Fellow PGIMER, Rohtak, Haryana, India Balbir Singh MD DM FACC Chairman, Division of Electrophysiology Institute of Cardiology Medanta, The Medicity Gurgaon, Haryana, India DK Singh MD FICCM Professor in Trauma and Emergency Medicine AIIMS, Bhopal, India Manoj Singh MD DNB FCCP FNB Consultant Critical Care Apollo Hospitals International Limited Ahmedabad, Gujarat, India Yogendra Partap Singh MD Senior Consultant and Head Max Superspeciality Hospital Patparganj, Amit Kumar Singhal MD Senior Consultant Liver and Hepatobiliary Anesthesia Sunit Singhi MD FIAP FAMS FISCCM FICCM FCCM Professor and Head Department of Pediatrics Advanced Pediatric Centre, PGIMER Chandigarh, Punjab, India Mehul Solanki MD Spectrum Associates Apollo Hospital Ahmedabad, Gujarat, India Shrikanth Srinivasan MD DNB FNB EDIC Consultant Institute of Critical Care Medanta the Medicity Gurgaon, Haryana, India Akhil Taneja MD IDCCM Max Superspeciality Hospital Patparganj, George M Varghese MD DNB DTH &M Professor Department of Infectious Disease Christian Medical College Vellore, Tamil Nadu, India Abhishek Vishnu MD Consultant Critical Care Medicine Kapil Zirpe MD Director and Head Neurotrauma Unit Grant Medical Foundation Ruby Hall Clinic Pune, Maharashtra, India

9 Foreword It gives me a great pleasure to write the foreword to this new book on Critical Care. Whenever a new book on Critical Care arrives, the simplest question asked is Do we need another book on this subject? It is natural that a reader s first reaction could be this. It must be emphasized that there is a dearth of books on Critical Care with an all Indian Authorship. From this perspective, it is nice to welcome this new book in the libraries of all concerned. Critical Care as a discipline has grown in India in leaps and bounds over the last two decades. It is thus natural that this book will be in demand. Unfortunately, due to constraints of time, I could not go through the actual contents of the articles. This is really an impressive list of topics and the Editors need to be complimented for the same. The authors list is also impressive and consists of experienced and knowledgeable consultants in the field of Critical Care in India. One hopes that the contents of the article are as impressive and help the readers in their quest of appropriate knowledge. Critical Care is expanding and evolving very rapidly. Along with the science of evidence we need the wisdom of experience in dealing with situations which threaten life. One sincerely hopes that books like this keep an important balance in providing the information and insight into the challenging world of this fascinating specialty of Medicine. Shirish Prayag MD FCCM Ex-President, Indian Society of Critical Care Medicine Managing Director and Chief Consultant Critical Care Medicine Prayag Hospital Pune, Maharashtra, India

10 Preface During the last decade, intensive care in India has matured, gained tremendous experience and come of age. The momentum generated during the previous years has made us realize the need of a major Indian textbook in Critical Care Medicine, authored by young Indian intensivists, since we have mostly depended on western literature for our academic needs. We are certain that this book Critical Care would be lucid, readable, emphasize on practical aspects and serve as a basic specialty book on Critical Care in India. Eminent critical care physicians from India s top hospitals and institutions have contributed to the book. Medical Publishers (P) Ltd.,, has been kind enough to facilitate this project. Efforts have been made to include certain topics that are relevant to India like poisoning, tropical infections, end-of-life care and pregnancy-related issues. We have also tried to cover the practical aspects of mechanical ventilation for the readers. We are hopeful that the book would provide the essential information not only to the postgraduate students but will also be useful to the practicing intensivists in India. We express our gratefulness to Dr Shirish Prayag, a Doyen in Critical Care in India for writing the Foreword for this book. We also express our heartfelt gratitude to all the contributors for giving us their high quality manuscripts in time. We hope you will enjoy reading it! Narendra Rungta Rajesh Pande Manish Munjal Sudhir Khunteta

11 Acknowledgments We appreciate the contribution of the Medical Publishers (P) Ltd., in making this project a success. In particular mention are Mr Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Ms Chetna Malhotra Vohra (Associate Director) for their belief in our groups ability to deliver and Ms Saima Rashid (Project Manager) who did very well in making sure we catch up with the deadline.

12 Contents Section 1: General 1. Assessment of Critically Ill Patients 3 Kapil Zirpe, Sushma Gurav 2. Airway Management in ICU 9 Anamika Chaudhary, Manish Munjal, Neeru Gaur, Neena Rungta, Narendra Rungta 3. Hemodynamic Monitoring in ICU 23 Vijaya P Patil, Nayana Amin, Vandana Agarwal 4. Fluid Balance in Critically Ill Patients 37 Shikha Panwar 5. Vasopressors and Inotropes 46 Poonam Malhotra Kapoor 6. Multiple Organ Dysfunction Syndrome 57 R Pratheema, R Senthilkumar, N Ramakrishnan 7. Cardiopulmonary Resuscitation: A Paradigm Shift 64 Khusrav Bajan 8. Therapeutic Hypothermia 70 Pinak Ashok Shrikhande 9. Management of Organ Donor 75 Rajesh Pande 10. Scoring Systems in ICU 79 Avijatri Datta, Arindam Kar, Sauren Panja 11. Guidelines for ICU Planning and Designing in India 87 Narendra Rungta, Neena Rungta, Manish Munjal, Neeru Gaur, Anamika Chaudhary 12. Guidelines and Protocols in ICU 94 Manoj Singh, Mehul Solanki 13. Clinical Audit and Handoff in ICU 98 Mohammad Omar Faruq 14. Critical Care Nursing in India 104 Arindam Kar, Sati Chakrabarti, V Ruth Adora Rao, Manish Munjal, Neena Rungta, Narendra Rungta Section 2: Cardiac Care 15. Acute Coronary Syndrome 111 Suresh Ramasubban

13 xviii Critical Care 16. Heart Failure 117 Yatin Mehta, Mukesh Kumar Gupta 17. Cardiac Arrhythmias in ICU 129 Supradip Ghosh 18. Hypertensive Emergency 145 Yatin Mehta, Mukesh Kumar Gupta 19. Pacing in the ICU Setting 154 Balbir Singh, Lakshmi N Kottu 20. Pulmonary Embolism 160 Rajesh Chawla, Manish Bharti 21. Intensive Care Unit Management of Patients with Right Heart Failure 169 Harjit Dumra Section 3: Respiratory Care 22. Community Acquired Pneumonia 183 Rajesh Pande, Mir Faisal Mazid 23. Ventilator-Associated Pneumonia 190 Manoj K Goel 24. Acute Respiratory Distress Syndrome 195 Rajesh Pande, Vipin Kauts Section 4: Liver and Digestive System 25. Acute Liver Failure 203 Utpal Sarma, Vaibhav Kumar Nasa, Amit Kumar Singhal 26. Acute Pancreatitis 216 Yogesh Batra, Ashish Garg 27. Hepatorenal and Hepatopulmonary Syndromes 226 Rajesh Pande 28. Anesthesia for Liver Transplantation 233 Vaibhav Kumar Nasa, Utpal Sarma, Amit Kumar Singhal 29. Critical Care Aspects in Adult Liver Transplantation 253 Shrikanth Srinivasan, Deepak Govil Section 5: Renal Care 30. Diagnosis of Acute Kidney Injury 263 Vinay Malhotra 31. Renal Replacement Therapy 267 Rajesh Pande

14 Contents xix 32. Critical Care Management of Renal Transplant Recipients 273 Sachin Gupta, Deepak Govil 33. Acid-Base Disorders in Critical Care 276 Palepu B Gopal, Krishna Prasad Mulavisala 34. Disorders of Potassium 289 Yogendra Pratap Singh, Sanjay Kumar Nihlani, Rahul Kumar Anand 35. Sodium Disorders 296 Yogendra Pratap Singh, Manish Gupta, Akhil Taneja 36. Disorders of Calcium and Magnesium 306 Khalid Khatib, Subhal Dixit, Kapil Borawake Section 6: Neurological Care 37. Management of Critically Ill Trauma Patients 313 Babita Gupta 38. Management of Spinal Injury 329 Samir Sahu 39. Neurocritical Care Management of Subarachnoid Hemorrhage 337 Mukesh M Gupta, Vimal K Agarwal, Girish Rajpal 40. Intensive Care Management of Postoperative Neurosurgical Patients 346 Mukesh M Gupta Section 7: Obstetric Critical Care 41. Physiology of Pregnancy 357 Rajesh Chandra Mishra, Pratibha Dileep, Srinivas Samvedam, Sunil P Pandya 42. Respiratory Disorders During Pregnancy 364 Rajesh Chandra Mishra, Pratibha Dileep, Srinivas Samvedam, Sunil P Pandya 43. Liver Disease Complicating Pregnancy 369 Rajesh Chandra Mishra, Pratibha Dileep, Srinivas Samvedam, Sunil P Pandya 44. Peripartum and Postpartum Intensive Care in Pregnancy 372 Rajesh Chandra Mishra, Pratibha Dileep, Srinivas Samvedam, Sunil P Pandya Section 8: Pediatric Critical Care 45. Recognition and Assessment of Critically Ill Child 381 Praveen Khilnani 46. Pediatric Septic Shock 387 Saptharishi LG, Sunit Singhi 47. Status Epilepticus 398 Mullai Baalaaji AR, Sunit Singhi

15 xx Critical Care 48. Raised Intracranial Pressure in Children with an Acute Brain Injury: Monitoring and Management 406 R Ramesh Kumar, Sunit Singhi Section 9: Infections 49. Extended Spectrum Beta Lactam Producing Infections in Intensive Care Unit 421 Afzal Azim, AK Baronia 50. Infections in Immunocompromised Patients in ICU 427 AK Baronia, Afzal Azim, RK Singh 51. Invasive Fungal Infections in Critically Ill Patients 434 AK Baronia, Armin Ahmed, Afzal Azim, Mohan Gurjar, Rungmei Marak 52. Febrile Neutropenia 443 Rajesh Pande 53. Fever in the ICU 448 Rajesh Pande 54. Cytomegalovirus Infection in Critically Ill Patients 454 Armin Ahmed, Afzal Azim, Mohan Gurjar, AK Baronia 55. Tropical Infections in ICU 456 Prashant Nasa, Dhruva Chaudhry 56. Tropical Fever Management Guidelines ISCCM Tropical Fever Group 465 Sunit Singhi, Dhruva Chaudhary, George M Verghese, Ashish Bhalla, SP Kalantri, JV Peter, Rajesh Chandra Mishra, Rajesh Bhagchandani, TD Chugh, Narendra Rungta, Manish Munjal Section 10: Ethics and End-of-Life Care Issues 57. Bioethical Considerations 475 RK Mani, Prashant Saxena 58. End-of-Life Care Practices in the World 478 RK Mani, Prashant Saxena Section 11: Miscellaneous 59. Burns, Inhalation and Electrical Injury 483 Diptimala Agarwal 60. Diabetic Ketoacidosis 494 DK Singh 61. Oncological Emergencies 498 Sheila Nainan Myatra, Amol Kothekar 62. Post-cardiac Arrest Syndrome 508 Yash Javeri

16 Contents xxi 63. Intra-abdominal Hypertension and Abdominal Compartment Syndrome 516 Rajesh Pande, Puneet Khanna 64. Nutrition in a Critically Ill Patients 521 Pravin Amin 65. Approach to an Unknown Poisoning 525 Vikas Loomba, Ashish Bhalla 66. Specif ic Intoxications 531 Ajeet Singh, Dhruva Chaudhry 67. Fatal Envenomations 543 Prashant Kumar, Dhruva Chaudhry 68. Care of Obese Patient in ICU 550 Gaurav Kochhar, Abhinav Gupta 69. Imaging in Intensive Care Unit 555 Chander Mohan, Rajul Rastogi Section 12: Mechanical Ventilation 70. Respiratory Mechanics: Basics 569 Rajesh Pande, Vipin Kauts 71. Principles of Mechanical Ventilation 573 Rajesh Pande, Maitree Pande 72. Basic Modes of Ventilation 576 Maitree Pande, Rohini Arora 73. Ventilator Graphics 580 Rajesh Pande, Puneet Khanna 74. Newer Modes of Ventilation 587 Rajesh Pande, Vipin Kauts 75. Weaning/Liberation from Mechanical Ventilation 592 Rajesh Pande, Monish Nakra 76. Non-Invasive Ventilation 596 Rajesh Pande, Rakesh Gupta 77. Ventilation Strategy in Obstructive Airway Disease 602 Rajesh Pande, Atul Pathak 78. Ventilation Strategy in Trauma 605 Vikas Maurya 79. Rescue Strategies in ARDS Recruitment Maneuvers 610 Rajesh Pande, Anupam Basumatari 80. Rescue Therapy in ARDS: Prone Ventilation and High Frequency Oscillation Ventilation (HFOV) 613 Rajesh Pande, Abhishek Vishnu

17 xxii Critical Care 81. Extracorporeal Membrane Oxygenation 616 Rajesh Pande, Vivek Gupta, Abhishek Vishnu 82. Aerosol Delivery Systems in Mechanical Ventilation 621 Rajesh Pande, Pritpal Kaur APPENDICES Appendix 1: Hemodynamic Formulae and Values 627 Appendix 2: Respiratory Formulae and Values 629 Appendix 3: Acid-Base Balance, Renal Formulae and Values 631 Appendix 4: Scoring System Used in ICU 633 Appendix 5: Spectrum of Commonly Used Antibiotic in ICU 636 Index 637

18 CHAPTER Weaning/Liberation from Mechanical Ventilation Rajesh Pande, Monish Nakra INTRODUCTION Mechanical ventilation costs $2,000 per day in US. Six percent of ventilated patients require prolonged ventilation, but consume 37% of ICU resources. Time spent on weaning is 40 50% of the entire duration of mechanical venti lation. Unplanned extubations, %; in 83% cases, it is initiated by the patient, 17% being accidental. Mortality is 12% if there is no delay in extubation, but 27% when it is delayed. Mortality increases with increasing duration of ventilation: ventilator-associated pneumonia (VAP) and airway trauma. Weaning remains one of the most challenging problems in intensive care. Following discontinuation of mechanical ventilation, 25% of patients have severe respiratory distress requiring reinstitution of ventilatory support. Premature extubation may lead to: Loss of airway protection (aspiration) Hypoxemia Sympathetic discharge cardiovascular stress Muscular fatigue and acidosis Reintubation into an edematous airway (risk of hypoxic brain injury, etc). Prolonged ventilation may result in: Nosocomial pneumonia Stretch injury and barotraumas Airway trauma Prolonged sedation Along with the obvious increase in costs associated with prolonged ventilation. Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube, including relevant aspects of terminal care (Fig. 1). 75 Fig. 1: Schematic representation of the different stages occurring in a mechanically ventilated patient. (ARF: Acute respiratory failure; SBT: Spontaneous breathing test). Treatment of acute respiratory failure: Period of care and resolution of disorder that caused respiratory failure and prompted the mech anical ventilation. Suspicion: The point at which the clinician suspects that the patient may be ready to begin the weaning process. Assessing readiness to wean: Daily testing of physiological measures of readiness of weaning [maximal inspiratory pressure (MIP), frequency to tidal volume ratio (f/vt)] to determine probability of weaning success. Spontaneous beathing trial: Assessment of pati ent s ability to breathe. Extubation: Removal of endotracheal tube. Reintubation: Replacement of endotracheal tube for patients who are unable to sustain spontaneous ventilation.

19 Chapter 75: Weaning/Liberation from Mechanical Ventilation 593 Weaning failure: Failure of spontaneous breathing trial (SBT) or the need for reintu bation within 48 hours. Failure of SBT can be classified as per the objective and subjective criteria. Simple weaning: Patient who proceed from initiation of weaning to successful extubation on the first attempt without difficulty. Difficult weaning: Patients who fail initial weaning and require up to three SBTs or as long as 7 days from the first SBT to achieve successful weaning. Prolonged weaning: Patients who fail at least three weaning attempts or require more than 7 days of weaning. FACTORS AFFECTING WEANING Respiratory Load Clinical assessment: Hemodynamically stable, awake, the disease process has been treated adequately Indices of minimal ventilator dependency are present: FIO 2 0.5, positive-end expiratory pressure (PEEP) 8 cm H 2 O, PaO 2 /FIO mm Hg, arterial oxygen saturation (SaO 2 ) 90%. Success of weaning will depend on ability of respiratory muscle pump to tolerate work of breathing (WOB). Resistance < 5 cm H 2 O L 1 s 1 Static compliance L cm H 2 O -1 A maximum inspiratory pressure value of 20 to 25 cm H 2 O is associated with successful weaning. Pmax: Excellent negative predictive value if < 20 (in one study 100% failure to wean at this value). An acceptable Pmax, however, has a poor positive predictive value (40% failure to wean in one study with a Pmax > 20). Some predictors of successful weaning are listed in Table 1, although no single factor has been found to independently predict weaning success. Cardiac Load Patients with ischemic heart disease, valvular heart disease, and systolic or diastolic dysfunction present before, or identified during critical illness. Patients with subtle and less easily recognized myocardial dysfunction are the difficult ones. Increased cardiac workload: Dynamic hyperinflation Increased serum lactate and low ScVO 2 are predictors of poor weaning. Table 1: Predictors of weaning outcome. Predictor Value Evaluation of ventilatory drive: P 0.1 <6 cm H 2 O Ventilatory muscle capability: Vital capacity >10 ml/kg Maximum inspiratory pressure < 30 cm H 2 O Ventilatory performance: Minute ventilation Maximum voluntary ventilation Rapid shallow breathing index Respiratory rate Unoptimized cardiovascular function: Arrhythmias Fluid overload Myocardial contractility. Neuromuscular Causes Decreased central drive Peripheral neuromuscular dysfunction Critical illness neuromuscular abnormalities (CINMA) Neuromuscular transmission is normal. Decreased motor action potentials and fibrillation potentials may resemble a motor axonopathy. Improves over weeks, but some residual deficit may be there. CNS Causes Delirium: Modifiable risk factors: Use of psychoactive drugs Untreated pain Sleep deprivation Prolonged immobilization Hypoxemia Sepsis Anemia Prolonged ICU stay Predictor of higher mortality up to 6 months after discharge. Anxiety and depression: Contributors: Dyspnea Inability to communicate Sleep fragmentation (patients are unable to rest or sleep) Minimize anxiety: Improvement in speech Ventilating with bi-level pressure support ventilation (PSV) Reducing noise when they sleep. <10 L/min >3 times V E <100 <30/min

20 594 Section 12: Mechanical Ventilation Daily sedation interruption or sedation vacation Boluses rather than infusions Dexmedetomidine: Used in difficult weaning: Beneficial in extubating agitated patients Previous failed weaning attempts Shorter extubation times Fewer ventilator days More successful extubation. Function of Other Organs Body temperature: 1 increases CO 2 production and O 2 consumption by 5% Normal electrolytes: Potassium, magnesium, phosphate and calcium. Adequate nutritional status: Under- or over-feeding Optimized renal, acid-base, liver and GI functions. CONSIDERATIONS FOR ASSESSING READINESS TO WEAN Clinical Assessment Adequate cough Absence of excessive tracheobronchial secretions Resolution of disease acute phase for which the patient was intubated. Objective Measurement Clinical Stability Stable cardiovascular status [heart rate (HR) 140 beat min 1, systolic blood pressure (SBP) mm Hg, no/minimum vasopressors] Stable metabolic status. Adequate Oxygenation SaO 2 > 90% on FiO (or PaO 2 /FiO 2 150), PEEP 8 cm H 2 O. Adequate Pulmonary Function Frequency 35 breaths min 1 MIP 20 to 25 cm H 2 O Tidal volume (VT) > 5 ml kg 1 Vital capacity (VC) > 10 ml kg 1 f/vt < 105 breaths min 1 L 1 No significant respiratory acidosis. Adequate Mentation No sedation or adequate mentation on sedation (or stable neurological patient) Maximal inspiratory pressure: Pmax: Excellent negative predictive value if less than 20 (in one study 100% failure to wean at this value). An acceptable Pmax however has a poor positive predictive value (40% failure to wean in one study with a Pmax > 20). Rapid shallow breathing index (Yang, Tobin. RSBI. N Engl J Med. 1991;324: ): It is determined during the first minute immediately after disconnection from ventilatory support while patients are still intubated and breathing spontaneously on room air. A threshold value of 105 bpm/l for the Rapid shallow breathing index (RSBI) can best discriminate between successful and failure weaning outcome. When f/vt > 105, 95% weaning attempts were unsuccessful and when f/vt < 105, 80% were successful. It is one of the most predictive bedside parameters. Failure Criteria of Spontaneous Breathing Trials Clinical Assessment and Subjective Indices Agitation and anxiety Depressed mental status Diaphoresis Cyanosis Evidence of increasing effort Increased accessories muscle activity Facial signs of distress Dyspnea. Objective Measurement PaO mm Hg on FIO or SaO 2 < 90% PaCO 2 > 50 mm Hg or an increase in PaCO 2 > 8 mm Hg ph < 7.32 or a decrease in ph 0.07 Rapid shallow breathing index [respiratory frequency to tidal volume (fr/vt)] > 105 breaths min 1 L 1 fr > 35 breaths min 1 or increased by 50% HR > 140 beats min 1 or increased by 20% SBP > 180 mm Hg or 20% SBP < 90 mm Hg Cardiac arrhythmias. Spontaneous Breathing Trial Trials of spontaneous breathing usually last 2 hours, but patients who fail usually show signs of poor

21 Chapter 75: Weaning/Liberation from Mechanical Ventilation 595 tolerance earlier. A prospective, multicenter study in 526 ventilator-supported patients to compare trials of spontaneous breathing lasting 30 or 120 minutes. The percentage of patients who remained extubated for 48 hours did not differ between the two groups (75.9% vs 73.0%, P = 0.43). If the patient fails a spontaneous breathing trial, a 24 hour rest period should be provided before the next trial is undertaken. T-tube or Pressure Support Spontaneous breathing with a T-tube system may fail the test because they must work harder. Therefore, some inves tigators advocate PSV to counte ract this extra work. The mean value of pressure support (PS) needed to compensate for the increased WOB caused by the venti latory circuit and endotracheal tube was found to be 7 cm H 2 O. Studies have compared between the use of a T-tube vs PS (7 cm H 2 O) in trials of spontaneous breathing in adult patients. Although, more patients in the T-tube group failed the trial (22% vs 14%, P = 0.03). There was no difference in percentage of patients who remained extubated after 48 hours (63% in the T-tube group vs 70% in PS group, P = 0.14). TWO-STAGE APPROACH TO WEANING Systematic measurement of predictors, including f/vt, followed by a single daily trial of SBT was compa red with conventional management in a randomized trial. Patients in single daily trial of SBT were weaned twice as rapidly. The rate of complications and the costs of intensive care were also lower with two-stage management than with conventional management. ROLE OF NONINVASIVE VENTILATION IN WEANING Noninvasive ventilation (NIV) offers the following advantages: Reduces mortality Reduces incidence of VAP Reduces ICU stay Reduces hospital stay Reduces time on endotracheal mechanical ventilation (ETMV) Reduction in proportion of weaning failure. It has a good role in the following situations: Extubation in chronic obstructive pulmonary disease (COPD) patients Postextubation respiratory failure Weaning patients off the ventilator (failing T tube trial but otherwise fit for extubation). Noninvasive ventilation may be used to expedite weaning in uncomplicated patients of COPD who fail an SBT (promising but evidence insufficient). NIV for reducing reintubation rate for postextubation failure is not recommended except in pati ents of COPD. Routine NIV application postextubation to preempt respiratory failure is not recommended. APPLICATIONS OF NONINVASIVE VENTILATION This approach to weaning should be applied in a highly monitored environment When patient fails SBT, first stabilize him with full support for at least 1 hour. Then extubate patient to NIV Initially, apply NIV continuously Monitor closely Gradually, reduce time on NIV For COPD patients, who develop postextubation failure, use NIV if there are no contraindications and the patient is compliant. SUMMARY The prerequisite for weaning is reversal of the indication of mechanical ventilation. The readiness for weaning should be checked based on subjective and objective criteria. RSBI and maximum inspiratory pressure are good predictors of weaning. Patients should be given 30 minutes to 2 hours SBT, and ventilatory discontinuation should be done if patient tolerates SBT for minutes. Patient who fails an SBT should receive a stable, nonfatiguing, comfortable form of ventilatory support. There may be substantial benefits to early extubation and institution of noninvasive positive pressure ventilation. The use of liberation and weaning protocol facilitates the process and decreases the ventilator length of stay. Tracheostomy should be considered in situations of prolonged ventilatory failure. BIBLIOGRAPHY 1. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335: