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T H E R E Q U I S I T E S TM T H E R E Q U I S I T E S 1600 John F. Kennedy Blvd. T H E R E Q U I S I T E S Ste 1800 T H E R E Q U I S I T E S Philadelphia, PA 19103-2899 T H E R E Q U I S I T E S THE REQUISITESis a proprietary trademark CRITICAL CARE: THE REQUISITES IN ANESTHESIOLOGY ISBN 0-323-02262-6 of Mosby, Inc. Copyright ©2005, Mosby, Inc. All rights reserved.No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. NOTICE Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book. Library of Congress Cataloging-in-Publication Data Critical care : the requisites in anesthesiology / [edited by] Peter J. Papadakos, James E. Szalados.—1st ed. p. ; cm. — (Requisites in anesthesiology series) ISBN 0-323-02262-6 1. Anesthesiology. 2. Critical care medicine. 3. Intensive care units. I. Papadakos, Peter. II. Szalados, James E. III. Series. [DNLM: 1. Critical Care—methods. 2. Anesthesia, General. 3. Anesthesiology — methods. 4. Critical Illness. 5. Intensive Care Units. 6. Perioperative Care. WX 218 C93647 2005] RD81.C828 2005 617.9′6–dc22 2004059742 Acquisitions Editor:Natasha Andjelkovic Developmental Editor:Anne Snyder Project Manager:David Saltzberg Design Manager:Steven Stave Marketing Manager:Emily McGrath-Christie Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 I would like to thank all those who have believed in my dreams, supported my aspirations, and tolerated my pursuit of them. To my parents, whose spirit of discovery, determination, and resilience in the face of challenge instilled in me a desire to always do my best and make the world a better place; and to my sister Elisabeth, her husband Michael, and their children Justin, Benjamin, and Nathan who are the future; and most of all to my wife Doris for always being there for me. J. E. Szalados, M.D. I wish this work to honor the many teachers, students, residents, and fellows who over the years have made me think and grow in the subject of critical care. I especially wish to honor the contributions of two great teachers: the late Dr. Thomas Iberti M.D. who taught me to ask the key question of clinical medicine, “why?”; and Prof. Dr. Lachmann who made me into a scientist. To truly balance one’s life we need love and support, and without the great love of my wife Susan and son Yanni I would not be able to find my inner strength. And to my father who taught and guided me that with hard work you always win, a special thanks. Also to my friends Allan Ross and Anne Snyder at Elsevier who supported me in this and many other projects, we did it again. P. J. Papadakos, M.D. Contributors Michael J. Apostolakos,MD Sanjeev V. Chhangani,MD, MBA Associate Professor of Medicine Associate Professor of Anesthesiology Director, Adult Critical Care University of Rochester School of Medicine University of Rochester Medical Center and Dentistry Rochester, New York Rochester, New York Medical Director Timothy J. Barreiro,DO Surgical Intensive Care Unit, Assistant Clinical Professor Rochester General Hospital Department of Medicine Rochester, New York Northeast Ohio College of Medicine Youngstown, Ohio Ashwani Chhibber,MD Rinaldo Bellomo,MD, FRACP, FCCP Associate Professor Professorial Fellow Anesthesiology and Pediatrics University of Melbourne Medical School Vice Chair Anesthesiology Melbourne University of Rochester Victoria, Australia Rochester, New York Director of Intensive Care Research Austin Hospital Guglielmo Consales,MD Melbourne Senior Specialist Victoria, Australia Department of Anesthesia and Intensive Care Ali Borhan,MD University of Florence Urology Resident Azienda Ospedaliero-Universitaria Careggi University of Rochester Medical Center Florence Rochester, New York Italy Lynn K. Boshkov,MD Susan E. Dantoni,MD, FACOG Associate Professor of Pathology and Medicine Clinical Assistant Professor of Obstetrics Department of Pathology and Gynecology Oregon Health & Science University University of Rochester Portland, Oregon Rochester, New York Ewan M. Cameron,MD Clinical Adjunct Professor Health Professions Clinical Assistant Professor of Anesthesiology Rochester Institute of Technology Tufts Medical School Rochester, New York Boston, Massachusetts Attending Physician Senior Physician Highland Hospital, Strong Memorial Hospital, Lahey Clinic Park Ridge Hospital Burlington, Massachusetts Rochester, New York vii viii CONTRIBUTORS A. Raffaele De Gaudio,MD Jack J. Haitsma,MD, PhD Professor of Anesthesiology and Intensive Care Visiting Research Fellow Director, Section of Anesthesiology and Division Critical Care Medicine Intensive Care University of Rochester Azienda Ospedaliero-Universitaria Careggi Rochester, New York University of Florence Member Department of Anesthesiology Florence Erasmus MC-Faculty Italy Rotterdam The Netherlands Joseph Dooley,MD Associate Professor of Anesthesiology David Kaufman,MD, FCCM and Neurosurgery Associate Professor of Surgery, Anesthesia, University of Rochester Medicine and Medical Humanities Rochester, New York University of Rochester Attending Physician, Anesthesiology Medical Director, Surgical Intensive and Critical Care Medicine Care Unit University of Rochester Medical Center Strong Memorial Hospital Rochester, New York Rochester, New York D. Jay Duong,MD John A. Kellum,MD, FACP, FCCP Resident in Anesthesiology Associate Professor of Critical Care Medicine, University of Rochester Anesthesiology and Medicine Rochester, New York University of Pittsburgh Department of Critical Care Medicine Jason Dziak,MD CRISMA (Clinical Research Investigation Assistant Professor and Systems Modeling of Acute Illness) Department of Anesthesiology Pittsburgh, Pennsylvania University of Rochester Intensitist, Cardiothoracic and Liver Transplant Rochester, New York Intensive Care Units University of Pittsburgh Medical Center Dina M. Elaraj,MD Pittsburgh, Pennsylvania Senior Resident Department of Surgery Heidi B. Kummer,MD, MPH University of Rochester Assistant Clinical Professor of Rochester, New York Anesthesiology Erdal Erturk, MD Tufts Medical School Professor of Urology Boston, Massachusetts Director of Kidney Stone Senior Physician Treatment Center Lahey Clinic University of Rochester Medical Center Burlington, Massachusetts Rochester, New York Burkhard Lachmann,MD, PhD Curtis E. Haas,PharmD Director of Anesthesia Research Assistant Professor Professor of Anesthesiology Department of Pharmacy Practice Erasmus MC-Faculty University of Pharmacy and Rotterdam Pharmaceutical Sciences The Netherlands University of Buffalo Buffalo, New York Jaclyn M. LeBlanc,PharmD Clinical Assistant Professor Critical Care Pharmacy Department of Surgery Research Fellow School of Medicine and Dentistry College of Pharmacy University of Rochester The Ohio State University Rochester, New York Columbus Ohio Contributors ix Christopher W. Lentz,MD, FACS †Iqbal Mustafa,MD, PhD Director, Strong Regional Burn Center Professor of Anesthesiology Associate Professor, Department of Surgery Intensive Care Unit and Pediatrics Harapan Kita Cardiaovascular Center University of Rochester Jakarta Rochester, New York Indonesia Xavier M. Leverve,MD, PhD Roger R. Ng,MD Laboratoire de Bioénergétique Fondamentale Resident et Appliqué Department of Anesthesiology Université Joseph Fourier University of Rochester Also: Service de Réanimation Médicale Rochester, New York Hospital A. Michallon Centre Hospitalier Universitaire Craig Nicholson, MD Grenoble Urology Resident France University of Rochester Medical Center Carlos J. Lopez III,MD Rochester, New York Associate Professor of Anesthesiology and Critical Care Peter J. Papadakos,MD, FCCP, FCCM Section Chief, Anesthesia Critical Care Director, Division of Critical Upstate Medical University Care Medicine Syracuse, New York Professor of Anesthesiology, Surgery, Attending Intensitist, Attending Anesthesiologist and Neurosurgery Co-Director, Surgical Intensive Care Unit University of Rochester School of Medicine University Hospital at and Dentistry Upstate Medical University Rochester, New York Syracuse, New York Charles R. Phillips,MD Stephen M. Luczycki,MD, MBA Assistant Professor of Medicine Assistant Professor Department of Pulmonary and Critical Department of Anesthesiology Care Medicine Yale University School of Medicine Oregon Health and Science University New Haven, Connecticut Portland, Oregon Stewart J. Lustik,MD Associate Professor of Anesthesiology Simone Rinaldi,MD University of Rochester School of Medicine Research Fellow in Anesthesiology and and Dentistry Intensive Care Rochester, New York University of Florence Strong Memorial Hospital Florence Rochester, New York Italy Ralph Madeb, MD Claudio Ronco, MD, PhD Urology Resident Lecturer University of Rochester Medical Center University of Padua Medical School Rochester, New York Padua Italy Edward M. Messing, MD, FACS Director of Nephrology W.W. Scott Professor San Bortolo Hospital, Professor of Oncology and Pathology Vicenza Chairman, Department of Urology Italy Deputy Director, James P. Wilmot Cancer Center University of Rochester Medical Center Rochester, New York †Deceased x CONTRIBUTORS Marc J. Shapiro,MD, FACS, FCCM Per A. J. Thorborg,MD, PhD Professor of Surgery and Anesthesiology Associate Professor State University of New York Department of Anesthesiology and Stony Brook, New York Perioperative Medicine Chief, General Surgery Trauma, Critical Care and Burns Oregon Health and Science University University Hospital Portland, Oregon Stony Brook, New York Jean-Louis Vincent, MD, PhD Jeffrey Spike,PhD Professor of Intensive Care Associate Professor of Medical Humanities Free University of Brussels Florida State University College of Medicine Brussels Tallahassee, Florida Belgium Head, Department of Intensive Care David Story,MD, FANZCA Erasme University Hospital Department of Anaesthesia Brussels Austin & Repatriation Medical Centre Belgium Melbourne Victoria, Australia Jacek A. Wojtczak,MD, PhD Associate Professor of Anesthesiology James E. Szalados,MD, JD, MBA, MHA, FCCP, FCCM University of Rochester School of Medicine Partner, Westside Anesthesiology Associates of and Dentistry Rochester, LLP Rochester, New York Attending in Anesthesiology, Critical Care and Medicine Medical Director of Respiratory Care Unity Health System at Park Ridge Hospital Adjunct Clinical Professor, Rochester Institute of Technology Rochester, New York Judit Szolnoki,MD Assistant Professor of Anesthesiology and Critical Care Department of Anesthesiology Upstate Medical University Syracuse, New York Attending Anesthesiologist VA Hospital of Syracuse and University Hospital in Syracuse Syracuse, New York Preface It is an incontrovertible fact that anesthesiology is the surgery is best positioned to understand the preopera- practice of medicine. Therefore, anesthesiologists must tive and postoperative issues. Every preoperative patient be fluent in the theories and techniques of preoperative requires that the anesthesiologist perform a careful and medical assessment, intraoperative cardiopulmonary life detailed assessment of their medical condition including support, and postoperative critical care intervention. coexisting illnesses, physical limitations, and their gen- Anesthesiology is the synthesis of the basic medical eral fitness for anesthesia and surgery. It is a seldom- sciences, including anatomy, physiology, biochemistry, voiced tacit understanding among anesthesiologists that pharmacology, and epidemiology; and is a bridge that each and every patient who undergoes elective surgery spans the disciplines of medicine and all its subspecial- becomes critically ill, albeit perhaps only for a limited ties, surgery, and obstetrics. The making of an anesthesi- time period. Of course, those patients who come to the ologist is therefore the culmination of premedical and operating room in the setting of severe trauma, over- medical schooling, a four-year intense postgraduate whelming organ dysfunction due to illness, or patients clinical residency program, and possibly thereafter a who present with severe comorbidities for emergency subspecialized fellowship. Most importantly, there then surgery are de facto critically ill and are likely to remain follows a lifetime commitment to learning and further so for some time postoperatively. There was once a time honing of technical skills. when patients could be deemed “too sick for surgery.” It is likely that no person will ever trust anyone else However, this adage is seldom employed today and anes- to the extent that they trust their anesthesiologist. The thesiologists, surgeons, as well as patients and their fam- patient undergoing surgery will depend on the anesthe- ilies in weighing the risks against the potential benefits siologist for safety and comfort during a time when their often determine that the short and intense stress of body is subjected to extreme stress. It is a remarkable surgery compares favorably to the alternative. Patients fact that most patients accept the risks of anesthesia come to the operating room in septic shock for the con- without questions, are incognizant of the fact that they trol of their septic source, following an acute myocardial will fully be on “life support” for the duration of their infarction for emergency coronary revascularization, in operation, and most do not remember the experience or multiple organ failure and end-stage liver disease for liver even the name of their anesthesiologist. That the public transplantation, and after massive trauma; each patient’s at large can have such trust and high expectations from condition can be further complicated by systemic dis- medical professionals who will only be transiently eases such as chronic lung disease, severe athero- involved in their care is a testament to the training, pro- sclerotic coronary and vascular disease, renal failure, fessionalism, and skill of anesthesiologists as well as a diabetes mellitus, malnutrition, and others. Therefore, reflection of the many technological advances in medical anesthesiology is unique in that there is no other spe- science which have made modern anesthesiology a safer cialty of medicine where every single patient encounter experience. requires both knowledge and application of advanced In order for the anesthesiologist to provide the level life-support skills. All these patient groups will require of medical care that will result in the best outcome for elements of mechanical ventilation, sedation and the patient, the anesthesiologist must be comfortable in analgesia, neuromuscular blockade, intravascular volume the role of a “perioperative physician.” That physician replacement, management of electrolytes, hemo- who cares for patients as they undergo the stress of dynamic support and monitoring, monitoring of and xi xii PREFACE replacement of blood and coagulation factors, as well as operating room. Therefore, new advances in modes of related monitoring and interventions directed at mini- mechanical ventilation, new understanding regarding mizing secondary injuries. optimization of oxygen delivery to tissues, new perspec- It is because anesthesiology is also the practice of tives on the evaluation and management of severe critical care medicinethat this textbook summarizes for comorbidities, as well as preparedness for emerging anesthesiologists the state-of-the-art and the standard of threats such as biological and chemical terrorism are care for the management of critically ill patients. matters of interest to all anesthesiologists. Finally, for It is incumbent on anesthesiologists to understand and those physicians who also practice in the intensive care apply the principles of critical care medicine that are unit, this book is intended to highlight established relevant to the management of intraoperative patients as principles, evolving standards of care, and new well as their continued postoperative care. We recog- opportunities to provide excellence in patient care. nize that not all anesthesiologists will participate in the care of patients in the intensive care unit. However, all Peter J. Papadakos, M.D. anesthesiologists will use critical care principles in the James E. Szalados, M.D. 1 CHAPTER Sepsis: The Systemic Inflammatory Response JEAN-LOUIS VINCENT, M.D., Ph.D Definition and Diagnosis increasing as the size of the problem increases. This Pathophysiology chapter briefly considers some of the basic features and Inflammatory Mediators the latest developments in this critically important field Pro-inflammatory Cytokines of sepsis in terms of diagnosis, pathophysiology, and Anti-inflammatory Cytokines management. Other Mediators Coagulation and Inflammation Management of Sepsis DEFINITION AND DIAGNOSIS Hemodynamic Stabilization Immunomodulating Therapy For many years definitions of sepsis have relied on Conclusion those proposed by the ACCP/SCCM consensus confer- ence published back in 1992. This conference intro- Sepsis, the inflammatory response to infection, is duced the systemic inflammatory response syndrome perhaps the most common disease encountered by the (SIRS) concept, whereby a patient was said to have SIRS critical care physician, complicating some 30 to 40% of if they met two or more of the following conditions: intensive care unit (ICU) admissions and accounting for temperature greater than 38°C or less than 36°C, tachy- considerable morbidity and mortality. The exact inci- cardia, tachypnea, white blood cell count greater than dence of sepsis is difficult to determine because of dif- 12,000 cells/mm3or less than 4000 cells/mm3. Sepsis was ferences in definitions and populations. An international then defined as infection plus SIRS, severe sepsis as sep- study across eight countries involving 14,364 ICU patients sis plus organ dysfunction, and septic shock as severe reported that there were 3034 infectious episodes giving sepsis with hypotension despite adequate fluid resusci- a crude incidence of infections of 21.1%. Interestingly, tation and evidence of perfusion abnormalities. However, one-fifth of these infections did not fit into any of the def- the SIRS criteria are very sensitive, and are met by most inition categories proposed by the ACCP/SCCM classifi- ICU patients and many general ward patients, making cation, which has been widely used in studies of sepsis. them of little practical value in identifying the patient The mortality rate in patients with repeated infectious with sepsis. episodes was 53.6% compared to 16.9% in non-infected Recently, a sepsis definitions conference involving patients. A recent study, the Sepsis Occurrence in 29 physicians from Europe and North America was held Acutely Ill Patients (SOAP), involving 3147 patients in in Washington, DC, to improve and standardize defini- 24 European countries, reported that 37.4% of patients tions in the field of sepsis. The conference participants were infected at some point during their ICU stay. agreed with the 1992 definitions in that sepsis should be Interestingly, the occurrence of sepsis ranged from 17.5 to definedas infection plus signs of systemic inflammation, 72.5% between countries. Importantly, the incidence of but felt that the SIRS criteria were too non-specific and sepsis seems to be increasing with one study reporting proposed rather a much longer list of possible signs of an annual increase of 8.7% in the USA, from 82.7 cases sepsis (Table 1-1). Unfortunately, as yet, no individual per 100,000 population in 1979 to 240.4 per 100,000 sign is specific for sepsis and clinical diagnosis relies on population in 2000. Thus, although the risk of death per the combined presence of several signs and symptoms that individual case may be falling, overall mortality rates are together confirm the likelihood of sepsis as the diagnosis. 3 4 CRITICAL CARE: THE REQUISITES IN ANESTHESIOLOGY Predisposing conditions – As with any disease Table 1-1 Diagnostic Criteria for Sepsis process, there are certain conditions that predispose a patient to developing sepsis. These include individual Infection, documented or suspected, and some of the following: characteristics, such as age, presence of chronic disease General variables processes (e.g., cancer), chronic administration of certain Fever or hypothermia medications (e.g., immunodepressant drugs), history of Tachycardia alcohol abuse, etc., which may influence a patient’s Tachypnea Significant edema or unexplained positive fluid balance response to infection and/or suggest which therapies Inflammatory variables may be most appropriate in that patient. Recentattention Leukocytosis or leukopenia has focused on genetic polymorphisms that may influ- Increased plasma C-reactive protein (CPR), procalcitonin (PCT) ence a patient’s susceptibility to develop sepsis or affect or interleukin-6 (IL-6) levels their outcome if they do develop it. Various potential Hemodynamic alterations Arterial hypotension genetic factors have already been elucidated. Hyperkinetic state (high cardiac index – high SvO2) A polymorphism of the tumor necrosis factor alpha Decreased capillary refill or mottling (TNF-α) gene, the TNF-2 allele, is associated with increased Hyperlactatemia serum levels of TNF and a greater risk of mortality from Organ dysfunction variables septic shock. A polymorphism within the intron 2 of Arterial hypoxemia Creatinine increase or acute oliguria the interleukin-1 receptor antagonist (IL-1ra) gene Altered mental status (IL-1RN*2) has been associated with reduced IL-1ra Thrombocytopenia – coagulation abnormalities production and increased mortality rates. Similarly poly- Hyperbilirubinemia morphisms of the Toll-like receptor 4 (TLR4) and Ileus mannose-binding lectin (MBL) genes that seem to Hyperglycemia in the absence of diabetes increase susceptibility to sepsis have also been identified. Gender may also influence susceptibility to and outcome from sepsis. Clearly, this is an area of ongoing research Definitions of severe sepsis and septic shock remained and the complex interaction of these predisposing fac- unchanged from the 1992 publication. tors requires more research to determine which carry In addition to discussing problems of definition, the par- most weight and how knowledge of increased risks can ticipants at the Washington conference also developed a be translated into improved clinical outcomes. new system to characterize and stage patients with sepsis, Insult – The insult in sepsis is infection and specific to enable patients to be stratified according to their base- characteristics of the infection that will influence the line risk of an adverse outcome and their potential to patient’s immune response to that infection and likely respond to therapy. Such systems are used widely in other outcome and response to treatment include the site of areas of medicine, the prototypical system perhaps being infection (e.g., urinary tract versus respiratory versus intra- the tumor/nodes/metastases (TNM) staging system for abdominal), the specific organism (e.g., Gram-positive malignant tumors developed by Pierre Denoix in the versus Gram-negative), the size of the inoculum, the sus- 1940s. The PIRO system stratifies patients according to ceptibility of the organism to antimicrobial agents, and their Predisposing conditions, the nature and extent of the the severity of the infection. Insult, the nature and magnitude of the host Response, and Response – The host response to sepsis can be the degree of concomitant Organ dysfunction (Table 1-2). assessed according to the presence or absence of various Table 1-2 The PIRO System Clinical Laboratory P: predisposition Age, alcoholism, chronic diseases, steroid or Genetic factors immunosuppressive therapy, gender, etc. I: insult Site (urinary tract, lungs, abdomen, etc.) Bacteriology, assay of microbial products (lipopolysaccharide, mannan, bacterial DNA, etc.) R: response Temperature, heart rate, respiratory rate, White blood cell count, blood lactate, C-reactive arterial pressure, etc. protein, procalcitonin, etc. O: organ dysfunction Arterial pressure, urine output, Glasgow coma PaO/FIO, creatinine, bilirubin, platelet count, etc. 2 2 scale, etc.
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