Critical Care: A Volume in the Requisites in Anesthesiology Series

451 Pages·2005·7.476 MB·English

by  Peter Papadakos

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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