Evidence-Based Critical Care

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Evidence-Based

Critical Care

Paul Ellis Marik

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Paul Ellis Marik

Evidence-Based Critical Care

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ISBN 978-3-319-11019-6 ISBN 978-3-319-11020-2 (eBook) DOI 10.1007/978-3-319-11020-2

Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014956872 © Springer International Publishing Switzerland 2015

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law.

The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speciﬁ c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Paul Ellis Marik

Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School

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Learning without thinking is useless. Thinking without learning is dangerous.

—Confucius, Chinese Philosopher (551–479 BC )

To cure sometimes, to relieve often, to comfort always.

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This book is dedicated to the memory

of my father, Colin Sigmund Marik,

a man of great intellect and wit.

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Preface to T hird Edition

After completing the Second Edition of The Handbook of Evidence Based Critical

Care in 2009, I swore that I would rather stick needles in both my eyes than author

another updated version of the book. But here we are in 2015 with the Third Edition of Evidence - Based Critical Care (no longer a handbook). So what made me change my mind? Most importantly, you, my dedicated readers, have implored me to update the book; I was told, “Medicine as we know it would be incomplete without an updated version.” Your enthusiastic and positive feedback was the driving factors which led me to consider writing this revision. In addition, in the last 5 years we have witnessed a remarkable reﬁ nement in the management strategies of critically ill patients best characterized as “Less is More” (see Chap. 2 ). At the same time we have realized that while many of our patients survive their ICU stay, many have signiﬁ cant residual functional and cognitive disabilities. These changes in our approach and understanding of critical illness have necessitated the updated Third Edition of Evidence - Based Critical Care .

However, the basic guiding principles of Critical Care Medicine have not changed; compassionate, dedicated and thoughtful clinicians, who evaluate the functioning of the “whole” patient, ponder their disease processes and pathophysi-ology and provide the highest level of Evidence - Based interventions with the goal of restoring the patient to a quality of life which he/she values.

Due to the vast number of therapeutic interventions that ICU physicians make daily, the topics are presented as narrative summaries of the best available evidence rather than as systematic reviews of each and every intervention. In keeping with the goal of providing an evidence-based approach to critical care, references are provided to support the evidence presented. In writing this book my goal has been to take issues that appear complex and make them as simple as possible.

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It appears to me that those who really don’t have a good understanding of the complexities of physiology, pathophysiology and patient care make things so com-plicated that they themselves don’t understand what they are trying to convey. This concept is exempliﬁ ed by the following quotes:

Make everything as simple as possible, but not simpler

If you can’t explain it simply, you don’t understand it well enough

Albert Einstein, Theoretical Physicist, 1879–1955

Evidence - Based Critical Care is not a reference text but presents a practical evidence - based approach to the management of critically ill ICU patients. The focus of this book is on issues that pertain speciﬁ cally to the ICU. As such, the reader is referred to standard medical and surgical texts as well as online resources for more complete information on the wide spectrum of conditions and diseases from which ICU patients may suffer. While all attempts have been made to be current, due to the exponential growth of medical knowledge some of the informa-tion presented may already be outdated when this book comes to print. The reader should therefore keep up-to-date with the current medical literature.

The guidelines presented in the book are not meant to replace clinical judgment, but rather to provide a framework for patient management. Individual clinical situ-ations can be highly complex and the judgment and wisdom of an experienced and knowledgeable intensivist with all available information about a speciﬁ c patient is essential for optimal clinical management.

Norfolk, VA, USA Paul Ellis Marik

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Acknowledgements

This book recognizes my mentors and students who have taught me everything I know and inspired me to learn even more.

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A Note to the Reader

The author and publisher have made every attempt to check information and dosages for accuracy. Because information and the science of pharmacology is continually advancing, our knowledge base continues to expand. Therefore, we recommend that the reader check all information and all product information for changes, especially changes in dosages or administration before administering any medication.

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Part I General ICU Topics

1 Evidence Based Critical Care ... 3

References ... 6

2 “Less Is More”: The New Paradigm in Critical Care ... 7

References ... 8

3 “Classic” Papers ... 13

4 Critical Care Medicine 101 ... 19

Factors to Consider When a Patient is Admitted to the ICU ... 20

Initial “Generic” Treatment Orders ... 20

Reference ... 21

5 House Officers Guidelines 1: Housekeeping ... 23

Admission History and Physical Examination ... 23

Daily Examination ... 24

General ... 24

Vital Signs (24 h Min and Max and Current) ... 24

Additional Observations ... 24 The Ventilator ... 25 Heart ... 25 Chest ... 25 Abdomen ... 25 CNS ... 26

Importance of the Daily Neurological Examination ... 26

Laboratory Tests ... 26

Imaging ... 27

Presenting on Daily Rounds ... 27

New Admissions ... 27

Community-Acquired MRSA Pneumonia (CA-MRSA) ... 266 Aspiration Pneumonia ... 267 Nursing Home-Acquired Pneumonia ... 269 Persistent Temperature/Failure to Respond to Rx ... 269 Unusual Pathogens ... 270 Complicated Pleural Effusion/Empyema ... 271 References ... 271 18 Fever ... 275 Common Misconception and Fables ... 275 Pathogenesis of Fever ... 276 Treatment of Fever ... 276 Causes of Fever in the ICU ... 278

Infectious Causes of Fever in the ICU ... 279 Non-Infections Causes of Fever in the ICU ... 279 Non-Infectious Causes of Fever ... 279 An Approach to the Febrile ICU Patient ... 286 Clinical Pearls ... 288 References ... 288 19 Mechanical Ventilation 101 ... 291 Alveolar Overdistension Damages Normal Lungs ... 293 Ventilator Variables and Modes of Ventilation ... 293 Ventilator Variables (See Table 19.1) ... 297 Common Modes of Mechanical Ventilation ... 299 Positive End-Expiratory Pressure (PEEP) ... 303 Auto-PEEP ... 305 Monitoring Patients Undergoing Mechanical Ventilation ... 306 Sudden Increase in Airway Pressure and/or Fall

in Arterial Saturation ... 307 When to Perform a Tracheostomy ... 307 Timing of Tracheostomy in the Critically Ill ... 308 References ... 308 20 Non-invasive Ventilation ... 311 Set Up ... 312 Initial Settings ... 312 Indications of NIV ... 313 COPD Exacerbations ... 313 Acute Cardiogenic Pulmonary Edema ... 313 Facilitating Extubation in COPD Patients ... 313 Immunocompromised Patients ... 314 Post-operative Patients ... 314 When to Use NIV ... 315 Hypercapnic Respiratory Failure ... 315 Hypoxemic Respiratory Failure ... 315

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Contraindications to NIPPV ... 315 Success and Failure Criteria for NIPPV ... 316 References ... 316 21 Liberation (Weaning from Mechanical Ventilation) ... 319 General Concepts ... 319 Effect of Liberation on Oxygen Consumption and Cardiac Function .. 320 Fluid Overload and Liberation Failure ... 320 Vasopressors and Inotropic Agents and Weaning ... 321 Mechanical Ventilation Liberation Process ... 322 “Readiness” Testing ... 322 Spontaneous Breathing Trials ... 323 Causes of Liberation Failure ... 324 Early Extubation Followed by NIV in COPD ... 324 NIV for Persistent Liberation Failure ... 324 Extubation Failure ... 325 Patients at High Risk of Extubation Failure ... 325 The Cuff Leak Test ... 326

Corticosteroids for the Prevention of Post-extubation Stridor ... 326 References ... 326 22 Arterial Blood Gas Analysis ... 329 Indications for ABG Sampling ... 329 ABG Sampling ... 330 ABG Analysis ... 331 Alveolar Ventilation ... 332 Oxygenation ... 332 Acid-Base Balance ... 334 A Step Wise Approach to Acid-Base Disorders ... 335 Common Acid Base Disturbances in the ICU ... 338

Metabolic Acidosis ... 338 Metabolic Alkalosis ... 341 Venous Blood Gas Analysis (VBGs) ... 342 Mixed Venous/Central Venous Oxygen Saturation ... 343 References ... 344 23 ARDS ... 349 Deﬁ nition, Causes and Assessment of Severity ... 349

Deﬁ nition of ALI According the American European Consensus ... 349 Acute Lung Injury (ALI) ... 349 Acute Respiratory Distress Syndrome (ARDS) ... 350 Pathophysiological Deﬁ nition of ARDS ... 350 Causes of ALI ... 351 Management of the Acute Phase of ARDS ... 351 Ventilatory Strategy ... 352 Pressure Controlled Ventilation... 355

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Airway Pressure Release Ventilation ... 357 Permissive Hypercapnia ... 359 Best PEEP ... 359 Recruitment Maneuvers ... 361 Non-Ventilatory Adjuncts to Gas Exchange ... 361 Prone Positioning ... 361 Neuromuscular Blocking Agents ... 362 ECMO ... 362 Corticosteroids ... 363 Inhaled Nitric Oxide ... 365 Nebulized Prostacyclin ... 365

β2-Adrenergic Receptor Agonists ... 365 Surfactant ... 365 Omega-3 Enteral Nutrition... 366 “Our” Approach to Refractory Hypoxemia ... 366 References ... 367 24 COPD Exacerbation ... 373 Common Precipitating Events ... 374 Indications for Hospitalization ... 375 Indications for ICU Admission ... 375 Treatment ... 375 Indications for NPPV ... 377 Indications for Endotracheal Intubation ... 377 Mechanical Ventilation in COPD ... 377 Suggested Initial Settings ... 378 References ... 378 25 Acute Severe Asthma ... 381 Indications for Admission to the ICU ... 382 Initial Treatment ... 382 Other Therapeutic Options ... 383 Complications of Acute Asthma ... 384 Noninvasive Positive-Pressure Ventilation in Status Asthmaticus ... 384 Indications for Intubation ... 385 Sedation Post-intubation ... 386 Mechanical Ventilation... 386 Initial Ventilator Settings... 387 References ... 388 26 Pleural Effusions and Atelectasis ... 391 Pleural Effusions ... 391 Pathophysiology ... 391 Drainage of Pleural Effusion ... 392 Hepatic Hydrothorax ... 393

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xxiv Alelectasis ... 393 Respiratory Therapy ... 394 Mucolytics ... 394 Bronchoscopy ... 395 Bilevel/APRV ... 395 References ... 396 27 Venous Thromboembolic Disease: DVT and PE ... 399 Pregnancy, Venous Thromboembolism and Thrombophilias ... 399 Site of Venous Thrombosis ... 400 The Veins of the Lower Limb ... 401 Suggested DVT Prophylaxis Protocols ... 405 Diagnosis of DVT ... 405 Distal Lower Extremity DVT ... 406 Upper Extremity DVT ... 406 Superﬁ cial Phlebitis ... 407 Pulmonary Embolism... 408 Diagnosis of Pulmonary Embolism ... 408 Treatment of Thromboembolic Disease ... 411 Thrombolytic Therapy ... 413 Catheter Directed Clot Fragmentation and Aspiration ... 418 Inhaled Nitric Oxide ... 418 Vena Caval Interruption ... 419 “Absolute Contraindications” for Anticoagulation with Heparin ... 419 References ... 419 Part III Cardiac

28 Hypertensive Crises ... 429 Deﬁ nitions ... 429 Pathophysiology ... 430 Clinical Presentation ... 431 Initial Evaluation ... 432 Initial Management of Blood Pressure ... 433

Resident (or Hospitalist) Called to the Floor for High

Blood Pressure: What to Do? ... 434 Drugs to AVOID ... 436 Recommended Antihypertensive Agents ... 437 Acute Postoperative Hypertension ... 439 Pre-operative Hypertension ... 440 Posterior Reversible Encephalopathy Syndrome (PRES) ... 441 Pregnancy-Induced PRES ... 441 Drugs Associated with PRES ... 442 References ... 442

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29 Acute Decompensated Cardiac Failure ... 445 Conﬁ rm the Diagnosis of Cardiac Failure ... 446 Evaluation of the Patient with Cardiac Failure ... 447 B-Type Natriuretic Peptides ... 447 Echocardiography ... 448 Laboratory Testing ... 448 Hemodynamic Monitoring ... 448 Precipitating Factors ... 449 Treatment ... 449 Acute Phase of Treatment ... 449 Treatment of ADHF: Summary ... 456 Long-Term Management ... 456 Systolic Heart Failure ... 457 Management of Patients with Heart Failure with Preserved Ejection Fraction (HFpEF) ... 461 Takotsubo Cardiomyopathy ... 462

Stressors Reported to Trigger Takotsubo

Cardiomyopathy ... 462 Mayo Clinic Criteria for Takotsubo Cardiomyopathy ... 464 References ... 465 30 Acute Coronary Syndromes ... 471 Unstable Angina/NSTEMI ... 471 Canadian Cardiovascular Classiﬁ cation of Angina ... 472 Types of Presentations of Unstable Angina ... 472 Differential Diagnosis ... 472 Electrocardiography ... 472 Tropinins ... 473 Management of UA/NSTEMI ... 473 Risk Stratiﬁ cation... 473 Thrombolysis in Myocardial Infarction

(TIMI) Risk Score ... 473 Global Registry of Acute Coronary Events (GRACE)

Risk Model ... 474 Treatment Approach for UA and NSTEMI

(PER AHA Guidelines) ... 474 Class I Recommendations ... 474 Class II Recommendations ... 475 Treatment Approach to STEMI (PER AHA Guidelines) ... 475 Class I Recommendations ... 475 Class II Recommendations ... 476 Complications Following STEMI ... 477 Recurrent Chest Pain Post-AMI ... 477 Mitral Regurgitation ... 477

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Left Ventricular Failure and Low Output States ... 478 Right Ventricular Infarction ... 478 Atrial Fibrillation ... 478 References ... 479 31 Arrhythmias ... 481 Arrhythmias and Electrolyte Disturbances ... 481 Acute Atrial Fibrillation/Flutter ... 482 Urgent Cardioversion ... 483 Rate Control ... 483 Pharmacologic Cardioversion ... 484 Anticoagulation ... 484 Multifocal Atrial Tachycardia (MAT) ... 485 Paroxysmal Supraventricular Tachycardia (PSVT) ... 485 Management ... 486 SVT Mediated by Accessory Pathways ... 486 Sinus Bradycardia ... 487 Sick-Sinus Syndrome ... 487 Accelerated Idioventricular Rhythm ... 487 Ventricular Premature Complexes and Bigeminy ... 487 Nonsustained Ventricular Tachycardia ... 488 Sustained Ventricular Tachycardia ... 488 Polymorphic Ventricular Tachycardia (Torsades De Pointes) ... 489 Management ... 489 References ... 490 Part IV Gastrointestinal

32 Nutrition in the ICU: It’s Whey Cool ... 493 Myths of Nutritional Support ... 494 Important Points to Digest ... 495 How Many Calories and How Much Protein to Give? ... 498

Muscle Wasting in Critical Illness ... 499 Factors That Activate Muscle Synthesis by the mTOR Pathway ... 502 Bolus vs. Continuous Feeding ... 504 So! What is the Best Way to Feed Critically Ill Patients? ... 506 The Obese Patient ... 507 The Refeeding Syndrome ... 507 References ... 508 33 Stress Ulcer Prophylaxis ... 513 Does SUP Reduce GI Bleeding? ... 514 Enteral Nutrition and Stress-ulcer Prophylaxis ... 515 Complications Associated with Acid Suppressive Therapy ... 516 So! What to Do? ... 517 Complications Associated with Speciﬁ c Drugs ... 517

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H2 Receptor Antagonists (H2RA) ... 517 Proton Pump Inhibitors (PPIs) ... 518 Sucralfate ... 518 References ... 519 34 Acute and Chronic Liver Disease ... 523 Chronic Liver Failure ... 523 Causes of Cirrhosis ... 524 Metabolic/Hematologic Derangements in Cirrhosis ... 525 Spontaneous Bacterial Peritonitis ... 525 Hepatic Encephalopathy ... 527 Grades of Hepatic Encephalopathy ... 528 Hepatorenal Syndrome ... 529 Hepatorenal Syndrome: Diagnostic Criteria ... 530 Diagnostic Approach ... 530 Treatment of HRS ... 531 Hepato-adrenal Syndrome ... 532 Pulmonary Consequences of Portal Hypertension ... 532 Infection and Cirrhosis ... 532 Supportive Care of the Hospitalized Cirrhotic ... 533 The Coagulopathy of Chronic Liver Disease ... 534 Portal Vein Thrombosis ... 535 Acute-on-chronic Liver Failure ... 537 Alcoholic Hepatitis ... 538 Differential Diagnosis ... 539 Management ... 539 Fulminant Hepatic Failure ... 540 Causes of Fulminant Hepatic Failure ... 541 Workup of Patients Presenting with FHF ... 541 Cerebral Edema in FHF ... 542 Management of Increased ICP ... 543 Supportive Measures ... 545 Indications for Liver Transplantation ... 545 Kings Criteria ... 546 References ... 546 35 GI Bleeding ... 551 Initial Assessment ... 551 Initial Resuscitation ... 553 Triage of Patients. Who to Admit to the ICU? ... 555 Upper GI Bleeding ... 555

The Major Causes of UGIB Include ... 556 Further Management of Upper GI Bleeding (See Fig. 35.1) ... 556 Further Management of Bleeding Peptic Ulcers ... 557 Recurrent Hemorrhage ... 559

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Further Management of Esophageal Varices... 559 Management of Patients with Lower GI Bleeding ... 560 References ... 562 36 Pancreatitis ... 565 Diagnosis ... 566 Risk Stratiﬁ cation... 567 Complications ... 568 Management ... 569 References ... 571 37 Diarrhea & Constipation ... 575 Diarrhea ... 575 Infectious Diarrhea ... 575 “Non-Infectious” Diarrhea ... 576 Antibiotic Associated Diarrhea (AAD) ... 576 Enteral Feeding-Associated Diarrhoea ... 576 Management of “Non-Infectious” Diarrhoea ... 576 The Use of Probiotics and Prebiotics ... 577 Constipation ... 579 References ... 580 Part V Miscellaneous

38 Transfusion of Blood and Blood Products ... 585 Red Blood Cell Transfusions ... 585 Why Transfuse? ... 586 Risks Associated with Blood Transfusion (See Fig. 38.1) ... 586

Risks Associated with Blood Transfusion... 587 Transfusion-Associated Immunomodulation ... 588 “Age” of Transfused Red Blood Cells ... 590 Tolerance to Anemia ... 596 Weighing the Risks and Beneﬁ ts of Blood Transfusion ... 596 So, When Should Patients’ Be Transfused? ... 597 Coagulation Disorders in the ICU ... 598 Fresh Frozen Plasma ... 600 FFP Prior to Invasive Bedside Procedures or Surgery ... 601 Paracentesis ... 604 Management of Non-therapeutic INRs With or Without Bleeding

(Due to Coumadin Therapy) ... 604 Platelet Transfusion ... 606 Heparin Associated Thrombocytopenia ... 610 Thrombotic Thrombocytopenic Purpura (TTP) ... 612 Cryprecipitate ... 614 References ... 614

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39 Adrenal Insufficiency ... 621 Causes of Adrenal Insuffi cient/Circi ... 622 Clinical Features of Adrenal Insuffi ciency/Circi ... 623 Diagnosis of Adrenal Insuffi ciency/Circi ... 624 Factors Affecting the Response to Corticosteroid Treatment ... 625 The Immune Status of the Host ... 625 Timing of Corticosteroids ... 626 Dose and Dosing Strategy ... 626 Acute Rebound After Discontinuation of Corticosteroids ... 627 Genetic Polymorphisms ... 627 Abnormalities of the Glucocorticoid Receptor ... 628 Treatment of Adrenal Insuffi ciency/CIRCI ... 628 Who to Treat with Steroids? ... 628 Adverse Effects of Corticosteroids ... 630 References ... 631 40 Electrolyte Disturbances... 635 Sodium and Water ... 635 Rules of the Game ... 635 Hyponatremia ... 635 Hypernatremia ... 640 Hypokalemia ... 641 Hyperkalemia ... 641 Hypophosphatemia ... 642 Management ... 643 Hypomagnesemia ... 643 Management of Hypomagnesemia ... 644 Disorders of Calcium Homeostasis ... 645 Hypocalcemia ... 646 Should Hypocalcemia Be Corrected in Critically Ill Patients? ... 647 Treatment ... 647 Hypercalcemia ... 648 Treatment ... 649 Second Line ... 649 Additional Therapies ... 650 References ... 650 41 Acute Kidney Injury ... 653 Pre-Renal Azotemia ... 654 Contrast Agents and the Kidney ... 655 Prevention of Contrast Induced AKI ... 655 “Common” Nephrotoxic Agents ... 656 Management of Established Acute Renal Failure ... 657 When to Initiate Renal Replacement Therapy (RRT) ... 657

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Mode of Renal Replacement Therapy ... 658 Advantages of CRRT Therapy Include ... 658 Dosing of RRT ... 659 Summary of Recommendations for RRT

in Patients with AKI ... 659 Rhabdomyolysis ... 659 Epidemiology ... 660 Etiology ... 660 Pathophysiology ... 663 Mechanisms of Acute Renal Failure in Rhabdomyolysis Patients ... 663 Clinical Manifestations ... 663 Laboratory Findings ... 664 Management ... 664 Dialysis ... 665 References ... 666 42 Acute Ischemic Stroke ... 669 Stroke ICU’s, Medical ICU’s or Stroke Units... 670 Proﬁ les Predictive of Futility After Devastating Stroke ... 670 Acute Ischemic Stroke (AIS) ... 671

Imaging ... 671 Thrombolytic Therapy ... 672 Treatment of Acute Ischemic Stroke With Intravenous rtPA ... 674 Endovascular Interventions ... 675

Antiplatelet Therapy and Anti-Coagulation ... 676 Anticoagulation in Cardio-Embolic Stroke ... 676 Raised ICP and Decompressive Surgery ... 677 Treatment of Hyperglycemia ... 678 Treatment of Fever ... 678 Treatment of Post Stroke Hypertension ... 678 Supportive Medical Therapy ... 680 References ... 681 43 Intracerebral and Subarachnoid Hemorrhage ... 685 Intracerebral Hemorrhage ... 685 Medical Management ... 687 Blood Pressure Control ... 689 Surgical Interventions ... 690 Subarachnoid Hemorrhage ... 692 Diagnosis and Evaluation... 693 Initial Management ... 693 Speciﬁ c Therapeutic Issues ... 698 Antiﬁ brinolytic Therapy ... 698 Surgical and Endovascular Methods of Treatment ... 698 Management of Cerebral Vasospasm ... 698 Transpulmonary Thermodilution (TPTD)

Hemodynamic Assessment ... 701

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Subdural Hematoma ... 702 Epidural Hematoma ... 703 Increased Intracranial Pressure (ICP) ... 703 Measurement of ICP ... 704 Indications for ICP Monitoring ... 704 Management of Raised ICP ... 705 References ... 708 44 Seizures & Status Epilepticus ... 717 Seizures in the ICU ... 717 Seizures Occurring as a Complication of Critical Illness ... 718 Seizures from Primary Neurological Disease ... 719 Management ... 719 Seizure Therapy ... 719 Status Epilepticus ... 720 Etiology ... 721 Common Causes of Status Epilepticus Include ... 721 Pathophysiology ... 722 Complications of Generalized Status Epilepticus ... 722 Diagnosis ... 722 Treatment ... 723 General Measures ... 723 Pharmacotherapy ... 724 Management of Refractory Status Epilepticus ... 726 The Management of Nonconvulsive Status Epilepticus ... 727 Prevention of Seizure Recurrence Once Status

Epilepticus is Terminated ... 728 References ... 728 45 Toxicology ... 731 General Measures ... 731 Technique for Performing Gastric Lavage ... 732 Activated Charcoal ... 732 Hemodialysis/Hemoperfusion ... 733 Common Agents Responsible for ... 734 Common Intoxications ... 735 Acetaminophen ... 735 Salicylates ... 738 Tricyclic Antidepressants ... 738 Acute Ethanol Intoxication ... 739 Ethylene Glycol and Methanol Poisoning ... 740 Ethylene Glycol ... 740 Methanol ... 741 Isopropyl Alcohol ... 742 Digitalis ... 743 Phenytoin ... 743 Lithium ... 744 Contents

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Opiates ... 745 Cocaine ... 745 Carbon Monoxide Poisoning ... 748 References ... 750 46 Alcohol Withdrawal Syndrome ... 751

The Clinical Institute Withdrawal Assessment Scale

for Alcohol (CIWA-Ar) ... 753 Differential Diagnosis ... 753 Treatment ... 754 Other Treatment Considerations ... 755 Prevention of Post-operative DT’s ... 756 References ... 756 47 Pregnancy Related Disorders ... 759 Obstetrical Hemorrhage ... 760 Antepartum Hemorrhage ... 760 Postpartum Hemorrhage ... 760 Management ... 760 Hypertension ... 761 Pre-eclampsia ... 761 Diagnosis of Pre-eclampsia ... 762 HELLP Syndrome ... 764 Posterior Reversible Encephalopathy Syndrome (PRES) ... 765 Treatment of Pre-eclampsia ... 765 Anti-hypertensive Agents for the Treatment of Pre-eclampsia ... 766 Corticosteroids and Plasmapheresis as Adjunctive Treatment

of HELLP ... 767 Acute Fatty Liver of Pregnancy ... 768 Amniotic Fluid Embolus Syndrome ... 768 Sepsis in Pregnancy ... 768 Respiratory Failure in Pregnancy ... 769 References ... 770 48 The Geriatric ICU Patient ... 773 The Physiology of Aging ... 773 Cardiovascular Changes ... 774 Changes in Respiratory Function ... 775 Changes in Renal Function ... 775 Immune System Changes ... 776 Body Composition and Muscle Mass ... 776 The Outcome of Elderly Patients Admitted to the ICU ... 776 Trauma and the Elderly Patient ... 778 Surgery and the Elderly... 778 Delirium in the Elderly ... 779 Drug Dosing and Polypharmacy in the Elderly ... 780

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American Geriatric Society Beers Criteria ... 781 Drugs to Avoid in the Elderly ... 781 References ... 782 49 Obesity in the ICU ... 787 Effect of Obesity on Critical Care Outcomes ... 787 Respiratory Effects of Obesity ... 788 Ideal Body Weight ... 789 Cardiovascular Effects of Obesity ... 789 Hepatic and Renal Effects of Obesity ... 790 Drug Dosing in Obese Patients ... 790 Nutritional Requirements ... 790 Gaining Vascular Access ... 791 Radiological Procedures ... 791 Malignant Obesity Hypoventilation Syndrome (MOHS) ... 791 Major Criteria ... 792 Minor Criteria ... 792 Treatment of MOHS ... 792 References ... 793 50 Radiology ... 797 The Chest Radiograph ... 797 Position of Tubes and Catheters ... 798 Lung Parenchyma, Pleura and Mediastinum ... 798 Plain Abdominal Radiography ... 801 Computed Tomography (CT) ... 801 Indium Labeled Leukocye Scans ... 802 References ... 803 51 End-of-Life Issues ... 805 Palliative Care ... 806 “Principles” of Palliative Care ... 807 References ... 809 52 Words of Wisdom ... 811 References ... 812 Index ... 813

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Part I

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3 © Springer International Publishing Switzerland 2015

P.E. Marik, Evidence-Based Critical Care, DOI 10.1007/978-3-319-11020-2_1

Chapter 1 Evidence Based Critical Care

There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance.

—Hippocrates (c460–c377 BCE), Greek physician

Before medicine developed its scientiﬁ c basis of pathophysiology, clinical practice was learned empirically from the events of daily experience in diagnosing and treat-ing the maladies patients presented. Students learned as apprentices to clinicians, observing the phenomena of disease, the skill of diagnosis and treatment, and the outcomes of different remedies. Sir William Osler’s classic textbook of medicine was based almost entirely on his “ personal experience correlated with the general

experience of others ” [ 1 ]. With advances in our understanding of human physiology and the pathophysiologic basis of disease, these remedies fell by the wayside and treatment became based on modalities of treatment that were shown to interrupt or otherwise modify the disease process. Until recently, it was considered suffi cient to understand the disease process in order to prescribe a drug or other form of treat-ment. However, when these treatment modalities were subjected to randomized, controlled clinical trials (RCTs) examining clinical outcomes and not physiological processes, the outcome was not always favorable. The RCT has become the refer-ence in medicine by which to judge the effect of an intervention on patient outcome, because it provides the greatest justifi cation for conclusion of causality, is subject to the least bias, and provides the most valid data on which to base all measures of the benefi ts and risk of particular therapies [ 2 ]. Numerous ineffective and harmful ther-apies have been abandoned as a consequence of RCTs, while others have become integral to the care of patients and have become regarded as the standard of care.

Many RCT’s are, however, inconclusive or provide confl icting results. In this situ-ation systematic reviews that are based on meta-analysis of published (and unpub-lished) RCTs are clearly the best strategy for appraising the available evidence. While meta-analyses have many limitations, they provide the best means of deter-mining the signifi cance of the treatment effect from inconclusive or confl icting RCTs (as well as trials that demonstrate a similar treatment effect). Furthermore, as a result of publication bias positive studies are more likely to be published and usually in more prestigious journals than negative studies. A clinician may base his/her thera-peutic decisions on these select RCTs which may then lead to inappropriate patient care. It is therefore important that common medical interventions be systematically

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reviewed and the strength of the evidence (either positive or negative) be evaluated. Although over 250,000 RCTs have been performed, for many clinical problems, there are no RCT’s to which we can refer to answer our questions. In these circum-stances, we need to base our clinical decisions on the best evidence available from experimental studies, cohort studies, case series and systematic reviews.

Every decision that the clinician makes must be based on sound scientiﬁ c evi-dence (a collection of anecdotes is not scientiﬁ c evievi-dence). Science is the continu-ing effort to discover and increase human knowledge and understandcontinu-ing through disciplined research. Using controlled methods, scientists collect observable evi-dence, record measurable data relating to the observations, and analyze this infor-mation to construct explanations of how things work [ 8]. Intuition, anecdotes, common sense, personal biases, and clinical experience is not considered “science” and cannot be used to justify clinical decision making or therapeutic policies.

Evidence is not static; both the strength and direction of evidence change as new evidence becomes available. It is therefore important to keep an open mind and reevaluate the scientiﬁ c basis and strength of what we think we know and how we practice. Furthermore, there is a hierarchy of evidence from anecdotes and “clinical experience” to strong irrefutable evidence (see Fig. 1.1 ).

Science progresses best when observations force us to alter our preconceptions

—Vera Rubin, Astronomer, 1928

As critical care medicine has evolved into a discreet specialty that crosses ana-tomical and other artiﬁ cial boundaries and deals with an enormous array of human

Alert

Be cautious in the interpretation of retrospective “before-after” studies and small single-center unblinded RCT’s [ 3 , 4 ]. The investigators of these studies may have a vested interest in the outcome of the study resulting in “misrepre-sentation” of the true data. Generally blinded studies show less of a treatment effect than unblinded studies evaluating the same intervention; both subcon-scious and consubcon-scious bias infl uence unblinded studies Before-after studies are particularly of questionable scientifi c value particularly if the variables and end-points are not defi ned prior to commencing the study, the data is collected retrospectively and there is no control arm (as other factors may infl uence the outcome). Prospective cluster controlled trials take these factors into account [ 5 ]. If a fi nding is true and valid it can be reproduced; that’s the amazing thing about scientifi c exploration. So be very wary of invalidated single studies no matter how robust they appear [ 6 ].

And lastly, If a study seem too good to be true, it is likely too good to be true [ 3 , 7 ].

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conditions, it has become evident that to achieve the best outcomes for our very complex patients, all our clinical decisions should be based on the best available

evidence. The complexity of the critically ill patient together with the vast

arma-mentarium of therapeutic options available makes it essential that we critically evaluate established and emerging clinical practices. It is important that we chal-lenge established dogma through thoughtful scientiﬁ c enquiry. Many of our current practices are based on anecdotes which have been passed down from teacher to student and assumed to be the undeniable truth. It is important to realize that noth-ing stays the same, that knowledge and understandnoth-ing march forward with no end in sight. Those who hang on to the past will get lost in the dark:

Life (and Medicine) is like riding a bicycle; you need to move forward to keep your balance —Albert Einstein, Theoretical physicist, 1879–1955

While Evidence Based Medicine (EBM) is frequently criticized as “cook-book” medicine, this is most certainly not the case. Rather, the best scientifi c evidence should be applied to the unique characteristics of each patient [ 2 ]. Each patient is unique, and the “art” of medicine is the ability to integrate and apply the best scien-tifi c knowledge to each patient. Checklists may be fi ne if you are fl ying a plane, however, patients are not planes and doctors are not pilots [ 9 , 10 ]. Clinical Practice Guidelines (CPG’s), which are evidence-based and up-to-date, are useful in provid-ing the clinician with direction, but should never be followed blindly. Rigid proto-cols and policies, have little place in clinical medicine.

Lastly, it is important to realize that Critical Care Medicine can only be practiced by close observation of the patient (at the bedside), by contemplation, and by the integration of a large data base of evidence-based medicine together with a good deal of humility.

Metaanalysis of ≥ 3 large multi-center RCT Low-bias Metaanalysis of ≥ 3 small RCT

≥ 2 multi-center RCT 1 large multi-center RCT Prospective Cluster Controlled Trial

Single small RCT Meta-analysis of cohort studies

Cohort studies Case Reports Before-After Studies

Anecdotes

Fig. 1.1 The hierarchy

of scientiﬁ c evidence

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6

References

1. Osler W. Preface. The principles and practice of medicine. 8th ed. New York: D. Appleton & Co.; 1918.

2. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM. New York: Churchill Livingstone; 1997.

3. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–77.

4. Whippy A, Skeath M, Crawford B, et al. Kaiser Permanente’s performance improvement sys-tem, part 3: multisite improvements in care for patients with sepsis. Jt Comm J Qual Patient Saf. 2011;37:483–93.

5. Heyland DK, Murch L, Cahill N, et al. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013;41:2743–53.

6. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–67.

7. Ionnidis JP. Research accomplishments that are too good to be true. Intensive Care Med. 2014;40:99–101.

8. Science. Wikipedia. 2013. http://en.wikipedia.org/wiki/Science. Accessed 12 Mar 2013. 9. Rissmiller R. Patients are not airplanes and doctors are not pilots [Letter]. Crit Care Med.

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10. Laurance J. Peter Pronovost: champion of checklists in critical care. Lancet. 2009;374:443. 1 Evidence Based Critical Care

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7 © Springer International Publishing Switzerland 2015

P.E. Marik, Evidence-Based Critical Care, DOI 10.1007/978-3-319-11020-2_2

Chapter 2 “Less Is More”: The New Paradigm

in Critical Care

The art of medicine consists of amusing the patient while nature cures the disease

Voltaire, French writer and historian (1694–1778).

What appears to be the world’s fi rst ICU was established at the Municipal Hospital of Copenhagen in December of 1953 by the Danish anesthesiologist Bjorn Ibsen during the polio epidemic of 1952–1953 [ 1 ]. The fi rst patient admitted to the unit was a 43 year old man who had unsuccessfully attempted to hang himself. The patient had a tracheotomy performed and received manual positive pressure ventila-tion with 60 % oxygen in N 2 O [ 2 ]. The fi rst physician staffed ICU’s in the US were developed in 1958 by Max Harry Weil and Herbert Shubin at the Los Angles County General Hospital and by Peter Safar in Baltimore [ 3 , 4 ]. The introduction of the pulmonary artery catheter (PAC) in the early 1970s by Swan and colleagues became the monitoring tool that defi ned critical care medicine for the next four decades [ 5 , 6 ]. The PAC became synonymous with critical care medicine. The era of the PAC resulted in a style of medicine that can best be characterized as aggressive. If some care is good, more care is even better. However almost all medical interventions be they invasive procedures, diagnostic tests, imaging studies, mechanical ventilation, surgery or drugs have some risk of adverse effects [ 7 ]. In some cases, these harms outweigh the benefi ts. This may be particularly so in ICU patients who are highly vulnerable and at an increased risk of iatrogenic complications [ 8 ]. Beginning in 1996 the safety and effectiveness of the PAC came into question [ 9 ]. Subsequent studies demonstrated that the PAC provided misleading ( “physiologic variables”) that could lead to inappropriate therapeutic interventions and that the use of the PAC did not improve patient outcome [ 10 – 12 ]. The PAC has now all but been aban-doned [ 13 ]. In 2000 the ARDSnet group published their now landmark study which demonstrated that mechanical ventilation with low tidal volume of 6 mL/kg/IBW improved patient outcome as compared to the standard approach (12 mL/kg/IBW) [ 14 ]. The last decade has witnessed a slew of studies that have challenged conventional wisdom and which have led to a gentler, less invasive approach to the critically ill patient… this has led to the paradigm that “ Less may be More ” ( see list below ) [ 7 , 8 ]. We now realize that our goal as intensivists is too be supportive and allow the body to heal itself while at the same time limiting the harm we cause with are arsenal of therapeutic and diagnostic weapons.

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8

Interventions for which less has been shown to be associated with better outcomes: • Lower tidal volume and lower plateau pressures [ 14 ]

• Less blood [ 15 , 16 ]

• Less invasive hemodynamic monitoring [ 13 , 17 ] • Lees ﬂ uids [ 18 – 20 ]

• Less insulin and less intensive glycemic control [ 21 ]

• Less antibiotics; de-escalation of empiric therapy and shorter course [ 22 – 24 ] • Less sedation and less benzodiazepines [ 25 – 27 ]

• Less corticosteroids; 200 mg hydrocortisone (equ) daily for sepsis and COPD [ 28 – 31 ]

• Less CXR; no daily CXR [ 32 , 33 ]

• Less oxygen; hyperoxia kills (COPD) and damages the brain and lungs [ 34 – 43 ]

• Less calories and protein; trophic feeds may be safe; less protein = less muscle breakdown [ 44 , 45 ]

• Less antiarrhythmics; no prophylactic lidocaine in AMI [ 46 ] • Less stress ulcer prophylaxis (=less C. diff. and less HAP) [ 47 , 48 ] • Less intense renal replacement therapy [ 49 – 52 ]

• Less blood pressure control (in ischemic stroke) [ 53 , 54 ] • NO dopamine [ 55 – 57 ]

• NO “supranormal” hemodynamic targets [ 58 , 59 ] • NO TPN [ 60 , 61 ]

• NO diuretics for acute renal failure [ 62 ] • NO hetastarch [ 63 , 64 ]

• NO Activated Protein C [ 65 ]

• NO MRSA/MDRO screening and protective isolation [ 66 – 68 ] • NO therapeutic hypothermia [ 69 , 70 ]

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