Critical CareHandbook of the MassachusettsGeneral Hospital

FIFTH EDITION

Critical CareHandbook of the MassachusettsGeneral HospitalSenior EditorLuca M. Bigatello, MD

Associate EditorsHasan B. Alam, MDRae M. Allain, MDEdward A. Bittner, MD, PhDDean R. Hess, PhD, RRTRichard M. Pino, MD, PhDUlrich Schmidt, MD, PhD

FIFTH EDITION

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Library of Congress Cataloging-in-Publication Data

Critical care handbook of the Massachusetts General Hospital / senior editor, Luca M. Bigatello ; associate editors, Hasan Alam . . . [et al.]. — 5th ed.

p. ; cm.Includes bibliographical references and index.ISBN 978-0-7817-9566-1 (alk. paper)

1. Critical care medicine—Handbooks, manuals, etc. I. Bigatello, Luca M. II.Massachusetts General Hospital.

[DNLM: 1. Critical Care—Handbooks. 2. Postoperative Complications—Handbooks.WX 39 C934 2009]

RC86.8C76 2009616.02 809744—dc22

2009033023

Care has been taken to confirm the accuracy of the information presented and todescribe generally accepted practices. However, the authors, editors, and publisher are notresponsible for errors or omissions or for any consequences from application of the informa-tion in this book and make no warranty, expressed or implied, with respect to the currency,completeness, or accuracy of the contents of the publication. Application of the informationin a particular situation remains the professional responsibility of the practitioner.

The authors, editors, and publisher have exerted every effort to ensure that drugselection and dosage set forth in this text are in accordance with current recommendationsand practice at the time of publication. However, in view of ongoing research, changes ingovernment regulations, and the constant flow of information relating to drug therapy anddrug reactions, the reader is urged to check the package insert for each drug for any changein indications and dosage and for added warnings and precautions. This is particularlyimportant when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in the publication have Food and DrugAdministration (FDA) clearance for limited use in restricted research settings. It is theresponsibility of the health care provider to ascertain the FDA status of each drug ordevice planned for use in their clinical practice.

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10 9 8 7 6 5 4 3 2 1

To Our Patients

The Critical Care Handbook of the Massachusetts General Hospital is a prag-matic review of the basis of adult critical care, designed for all trainees andpractitioners who are interested in working in an intensive care unit (ICU). Al-though our practice over many years has consisted primarily of surgical pa-tients, we always ensured that learning, teaching, and clinical plans of care bedeveloped with a multidisciplinary approach. For this reason, this Handbook isauthored by intensivists from anesthesia, surgery, and medicine, as well as crit-ical care nurses, respiratory therapists, and pharmacists. Over the years, theglue that has kept this diverse faculty together has been physiology, because thebody works the same way in patients admitted to a surgical, medical, or neu-rological ICU. The principles of physiology applied to critical care are illus-trated in the chapters that open the Handbook, including hemodynamic andrespiratory monitoring, acid—base, principles of mechanical ventilation, andthe bases of antimicrobial therapy and nutritional support. However, as thepractice of critical care evolves, we now have evidence from a number of well-designed trials to guide our therapeutic choices, so the Handbook emphasizesthe evidence that exists behind our recommendations. Further progress in pa-tient outcomes has been achieved by implementing safety in the ICU, wherethe fast pace and invasive procedures may at times hurt our patients. We haveadded chapters on prophylaxis of nosocomial complications, on the safe trans-port of critically ill patients, and on what intensivists offer outside the ICU.

As the Handbook has evolved over the years, its authors and its con-tents have changed, but part of the older information has been conserved,sometimes even verbatim. Here, we acknowledge all the authors of the pasteditions, many of whom have moved on to successful professional careers,and hopefully still cherish the chapters they wrote during their busy timesof residency and fellowship.

Finally, as I leave this famed institution after nearly 20 years, I thank theinnumerous individuals who have made our Ellison 4 Surgical ICU (and hervarious previous incarnations) an extraordinary place to work. First, I thankour patients and their families, who, through their suffering, have taught usabout their illness, allowing us to save some of those who followed. Then, Ithank our incredible staff—the nurses, doctors, respiratory therapists, unitassistants, students, and anyone of the thousands who over the years haveworked in this unit, not as spectators but as protagonists of this dream.

Luca M. Bigatello

PREFACE

vi

vii

Hasan B. Alam, MDProgram Director, Fellowship in Surgical Critical CareDepartment of SurgeryMassachusetts General HospitalAssociate Professor of SurgeryHarvard Medical SchoolBoston, Massachusetts

Rae M. Allain, MDDirector, Vascular AnesthesiaDepartment of Anesthesia and Critical Care Massachusetts General HospitalAssistant Professor of Anesthesia Harvard UniversityBoston, Massachusetts

Kathrin Allen, MDClinical Fellow in Critical CareDepartment of Anesthesia and Critical CareMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Theodore A. Alston, MD, PhDAssociate AnesthetistDepartment of Anesthesia and Critical CareMassachusetts General HospitalAssistant Professor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Houman Amirfarzan, MDResident in AnesthesiologyAnesthesia DepartmentTufts New England Medical CenterBoston, Massachusetts

CONTRIBUTORS

Emily A. Apsell, MDResident in AnesthesiologyDepartment of Anesthesia and Critical CareMassachusetts General HospitalClinical Fellow in AnesthesiologyHarvard Medical SchoolBoston, Massachusetts

Aranya Bagchi, MDResident in AnesthesiologyDepartment of Anesthesia and Critical CareMassachusetts General HospitalClinical Fellow in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Karsten Bartels, MDResident in AnesthesiologyDepartment of Anesthesia and Critical CareMassachusetts General HospitalClinical Fellow in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

William J . Benedetto, MDAssistant in AnesthesiaMassachusetts General HospitalInstructor in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Lorenzo Berra, MDResident in Anesthesiology and Beecher Research ScholarDepartment of Anesthesia and Critical CareMassachusetts General Hospital Harvard Medical SchoolBoston, Massachusetts

Luca M. Bigatello, MDChief, Anesthesia and Critical Care ServiceVeterans Administration Boston Healthcare System Associate Vice ChairmanMassachusetts General Hospital Associate Professor of Anesthesia Harvard Medical SchoolBoston, Massachusetts

viii Contributors

Edward A. Bittner, MD, PhDProgram Director, Anesthesia-Critical Care FellowshipDepartment of Anesthesia and Critical CareMassachusetts General HospitalInstructor in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Ross Blank, MDClinical LecturerDivision of Critical CareDepartment of AnesthesiologyUniversity of Michigan Health SystemAnn Arbor, Michigan

Jonathan D. Bloom, MDResident in AnesthesiologyDepartment of Anesthesia and Critical Care Massachusetts General HospitalClinical Fellow in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Sharon E. Brackett, RN, BSStaff Nurse, Surgical ICUMassachusetts General HospitalBoston, Massachusetts

Jonathan E. Charnin, MDAssistant in AnesthesiaDepartment of Anesthesia and Critical careMassachusetts General HospitalInstructor in Anesthesia Harvard Medical SchoolBoston, Massachusetts

Sherry Chou Staff PhysicianDepartment of NeurologyBrigham and Women’s HospitalInstructor Harvard Medical SchoolBoston, Massachusetts

Contributors ix

Claudia Crimi Research Fellow Department of Anesthesia and Critical CareMassachusetts General HospitalHarvard Medical School Boston, Massachusetts

Ettore Crimi, MDResident in AnesthesiologyDepartment of Anesthesia and Critical CareMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Marc A. de Moya, MD, FACSDirector of Surgical Core Clerkship Department of SurgeryMassachusetts General HospitalAssistant Professor of Surgery Harvard Medical SchoolBoston, Massachusetts

Alan DiBiasio, RPhSenior Attending PharmacistDepartment of PharmacyMassachusetts General HospitalBoston, Massachusetts

Anahat Dhillon, MDStaff AnesthesiologistDepartment of AnesthesiologyRonald Regan Medical CenterAssistant ProfessorUniversity of California Los AngelesLos Angeles, California

Michael G. Fitzsimons, MDOperations Director, Cardiac AnesthesiaDepartment of Anesthesia and Critical CareMassachusetts General HospitalAssistant Professor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Jonathan Frederick Fox, MDClinical Fellow in Critical CareDepartment of Anesthesia and Critical CareHarvard Medical School Massachusetts General HospitalBoston, Massachusetts

x Contributors

Eugene Y. Fukudome, MDClinical Fellow in Surgery Department of SurgeryHarvard Medical SchoolMassachusetts General HospitalBoston, Massachusetts

Henning A. Gaissert, MDAssociate Visiting SurgeonDivision of Thoracic SurgeryMassachusetts General HospitalAssociate Professor of SurgeryHarvard Medical SchoolBoston, Massachusetts

Cosmin Gauran, MDStaff Anesthesiologist Department of Anesthesia and Critical CareMassachusetts General HospitalInstructor in Anesthesia Harvard Medical SchoolBoston, Massachusetts

Edward E. George, MD, PhDMedical DirectorPost Anesthesia Care Units Massachusetts General HospitalAssistant Professor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Fiona K. Gibbons, MDAssistant in Medicine Pulmonary and Critical Care UnitMassachusetts General Hospital Instructor in Medicine Harvard Medical School Boston, Massachusetts

Jeremy W. Goldfarb, MDResident in AnesthesiologyDepartment of Anesthesia and Critical Care Harvard Medical School Massachusetts General HospitalBoston, Massachusetts

Contributors xi

Robert L. Goulet, MS, RRTSenior Respiratory TherapistRespiratory Care ServicesMassachusetts General HospitalBoston, Massachusetts

David M. Greer, MD, MAAssistant in Neurology Department of Neurology Massachusetts General HospitalAssistant Professor of Neurology Harvard Medical SchoolBoston, Massachusetts

Robin K. Guillory, MDAssistant Professor of Anesthesiology Department of AnesthesiologyWashington University in St. Louis School of MedicineSt. Louis, Missouri

Robert Hallisey, MS, RPhDirector, Clinical SystemsDepartment of PharmacyMassachusetts General HospitalAssistant Professor of Clinical PharmacyMassachusetts College of Pharmacy and Health SciencesBoston, Massachusetts

Bishr Haydar, MDResident in AnesthesiologyDepartment of Anesthesia and Critical Care Massachusetts General HospitalBoston, Massachusetts

Judith HellmanDepartment of Anesthesia and Perioperative CareAssociate ProfessorUniversity of California, San FranciscoSan Francisco, California

xii Contributors

Dean R. Hess, PhD, RRTAssistant Director Respiratory Care ServicesAssociate Professor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Daniel W. Johnson, MDClinical Fellow in Critical CareDepartment of Anesthesia and Critical CareMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Kathryn Davis Kalafatas, RPhSenior Attending PharmacistDepartment of PharmacyMassachusetts General HospitalBoston, Massachusetts

Erik B. Kistler, MD, PhDAssistant Professor Department of AnesthesiaUniversity of California, San DiegoSan Diego, California

Corry "Jeb" Kucik, MDClinical Fellow in Critical CareDepartment of Anesthesia and Critical CareMassachusetts General HospitalInstructor in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Jean Kwo, MDDirector, Pre-Admission Testing ClinicDepartment of Anesthesia and Critical CareMassachusetts General HospitalAssistant Professor in Anesthesia Harvard Medical School Boston, Massachusetts

Contributors xiii

Laura H. Leduc, MDResident in AnesthesiologyDepartment of Anesthesia and Critical CareHarvard Medical School Massachusetts General HospitalBoston, Massachusetts

Nicolas MeloResident in Surgery Department of SurgeryHarvard Medical SchoolMassachusetts General HospitalBoston, Massachusetts

Beverly J . Newhouse, MDInstructor in Anesthesia and Critical Care Department of Anesthesia and Critical CareMassachusetts General HospitalClinical Instructor in AnesthesiologyHarvard Medical School Boston, Massachusetts

Ara Nozari, MD, PhDInstructor in Anesthesia Department of Anesthesia and Critical CareMassachusetts General HospitalInstructor in AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Amy Ortman, MDChief ResidentDepartment of Anesthesia and Critical CareMassachusetts General HospitalInstructor in Anesthesia Harvard Medical SchoolBoston, Massachusetts

Robert L. Owens, MDClinical and Research Fellow Pulmonary and Critical Care UnitMassachusetts General HospitalInstructor in AnesthesiologyHarvard Medical School Boston, Massachusetts

xiv Contributors

Richard M. Pino, MD, PhDAssociate Anesthetist Department of Anesthesia and Critical CareMassachusetts General HospitalAssociate Professor Harvard Medical SchoolBoston, Massachusetts

Steven J . Russell, MD, PhDAssistant in Medicine Department of Medicine, Endocrine DivisionMassachusetts General HospitalInstructor of Medicine Harvard Medical SchoolBoston, Massachusetts

Elizabeth A. Sailhamer, MD, MMScResident in General SurgeryDepartment of SurgeryMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

Ulrich Schmidt, MD, PhDDirector, Surgical Intensive Care UnitDepartment of Anesthesia and Critical CareMassachusetts General HospitalAsistant Professor of AnesthesiaHarvard Medical SchoolBoston, Massachusetts

Lee H. Schwamm, MD, FAHAVice-Chairman Department of NeurologyMassachusetts General HospitalAssociate Professor Harvard Medical School Boston, Massachusetts

Todd A. Seigel, MDClinical AssociateDepartment of Anesthesia and Critical Care Massachusetts General Hospital Assistant Professor in Emergency Medicine Brown University Providence, Rhode Island

Contributors xv

Robert L. Sheridan, MDChief, Burn Surgery Service Shriner’s Hospitals for Children—BostonAssociate Professor of Surgery Harvard Medical SchoolBoston, Massachusetts

Kevin N. Sheth, MDAssistant Professor Departments of NeurologyUniversity of Maryland School of MedicineBaltimore, Maryland

Jagmeet Singh Cardiac Arrhythmia ServiceMassachusetts General HospitalAssistant Professor Harvard UniversityBoston, Massachusetts

David J .R. Steele, MDAssistant Physician Department of MedicineMassachusetts General HospitalAssistant Professor Harvard Medical SchoolBoston, Massachusetts

H. Thomas Stelfox, MD, PhDDepartments of Critical Care MedicineMedicine and Community Health SciencesFoothills Medical CentreAsistant ProfessorUniversity of AlbertaCalgary, Alberta

Dorothea Strozyk, MDVascular Neurology and Critical Care Fellow Department of NeurologyMassachusetts General HospitalClinical and Research Fellow Harvard Medical School Boston, Massachusetts

xvi Contributors

B. Taylor Thompson, MDChief, Medical Intensive Care Unit Pulmonary and Critical Care UnitMassachusetts General HospitalAssociate Professor of Medicine Harvard Medical School Boston, Massachusetts

Arthur J . Tokarczyc, MDAssistant Anesthesiologist Department of AnesthesiologyNorth Shore University Health System Clinical Instructor University of Chicago Chicago, Illinois

Jeffrey S. Ustin, MD, MSFellow Trauma, Emergency Surgery, Surgical Critical CareMassachusetts General HospitalInstructor in SurgeryHarvard Medical School Boston, Massachusetts

Jason A. Wertheim, MD, PhDResident in Surgery Department of SurgeryHarvard Medical SchoolMassachusetts General HospitalBoston, Massachusetts

Susan R. Wilcox, MDClinical Fellow in Critical CareDepartment of Anesthesia and Critical Care Massachusetts General Hospital Harvard Medical School Boston, Massachusetts

Contributors xvii

xix

Preface viContributors vii

PART I: GENERAL PRINCIPLES 1

1 Hemodynamic Monitoring 1Erik Kistler and Luca Bigatello

2 Respiratory Monitoring 17Ettore Crimi and Dean Hess

3 Use of Ultrasound in the ICU 39Robin Guillory and Marc de Moya

4 Airway Management 50Jonathan Charnin, Robert Goulet, and Richard Pino

5 Principles of Mechanical Ventilation 78Claudia Crimi and Dean Hess

6 Hemodynamic Management 100Jonathan Fox and Edward Bittner

7 Sedation and Analgesia 113Houman Amirfarzan, Ulrich Schmidt, and Luca Bigatello

8 Fluids, Electrolytes, and Acid–Base Management 127Cosmin Gauran and David Steele

9 Critical Care of the Trauma Patient 150Jeffrey Ustin and Hasan Alam

CONTENTS

xx Contents

10 Critical Care of the Neurologic Patient 166Kevin Sheth and Lee Schwamm

11 Nutrition 177Elizabeth Sailhamer and Hasan Alam

12 Infectious Disease—General Considerations 187Laura Leduc and Judith Hellman

13 Quality Improvement and Prophylaxis 199Karsten Bartels and Ulrich Schmidt

14 Ethical and Legal Issues in ICU Practice 209Rae Allain and Sharon Brackett

15 Evidence-Based Practice and Basic Statistics in Critical Care 225Ala Nozari, H. Thomas Stelfox, and Edward Bittner

16 Transport of the ICU Patient 236Emily Apsell and Michael Fitzsimons

PART II: SPECIFIC CONSIDERATIONS 244

17 Coronary Artery Disease 244Corry “Jeb” Kucik and Michael Fitzsimons

18 Valvular Heart Disease 258Jonathan Bloom and Theodore Alston

19 Cardiac Dysrhythmias 270Cosmin Gauran and Jagmeet Singh

20 The Acute Respiratory Distress Syndrome 288Kathrin Allen and Luca Bigatello

21 Chronic Obstructive Pulmonary Disease and Asthma 299Robert Owens and Fiona Gibbons

22 Pulmonary Embolism and Deep Venous Thrombosis 314B. Taylor Thompson

23 Discontinuation of Mechanical Ventilation 322Bishr Haydar and Jean Kwo

24 Acute Kidney Injury 333Beverly Newhouse

25 Liver Dysfunction 353Daniel Johnson and William Benedetto

26 Coagulopathy and Hypercoagulability 364Lorenzo Berra and Rae Allain

27 Acute Gastrointestinal Diseases 379Eugene Fukudome and Jean Kwo

28 Endocrine Disorders and Glucose Management 398Steven Russell and B. Taylor Thompson

29 Infectious Diseases—Specific Considerations 424Aranya Bagchi and Judith Hellman

30 Nonantibiotic Therapies for Sepsis 447Anahat Dhillon and Edward Bittner

31 Stroke, Seizures, and Encephalopathy 456Dorothea Strozyk and Lee Schwamm

32 Acute Weakness 478David Greer and Edward George

33 Drug Overdose, Poisoning, and Adverse Drug Reactions 487Susan Wilcox and Richard Pino

34 Adult and Pediatric Resuscitation 505Arthur Tokarczyk and Richard Pino

35 Transfusion Medicine 521Jeffrey Ustin and Hasan Alam

36 Neurological Trauma 532Sherry Chou and Marc de Moya

Contents xxi

37 The Burned Patient 551Nicolas Melo and Rob Sheridan

38 Disaster Preparedness in the ICU 566Todd Seigel and Edward George

39 ICU Care After Vascular Surgery 579Ross Blank and Rae Allain

40 ICU Care After Thoracic Surgery 593Kathrin Allen, Henning Gaissert, and Luca Bigatello

41 ICU Care Following Liver, Kidney, and Lung Transplantation 605Jason Wertheim and William Benedetto

42 ICU Care of the Obese Patient 616Jeremy Goldfarb and Jean Kwo

43 The Intensivist Outside the ICU 626Edward George and Edward Bittner

44 Obstetric Critical Care 636Amy Ortman and Richard Pino

Appendix A: Supplemental Drug Information 653Alan DiBiasio, Robert Hallisey, Jr., and Kathryn Kalafatas Davis

Index 701

xxii Contents