16 comprehensive critical care adult second edition

ComprehensiveCriticalCare:Adult
SecondEdition

PamelaR.Roberts,MD,FCCM,FCCPEditor
S.RobTodd,MD,FACS,FCCM,Editor


Copyright2017SocietyofCriticalCareMedicine,exclusiveofanyU.S.Governmentmaterial.
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ManagingEditor:KathyWard
EditorialAssistant:DanielleStone
PrintedintheUnitedStatesofAmerica
FirstPrinting,May2017
SocietyofCriticalCareMedicine
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Contributors
PamelaR.Roberts,MD,FCCM,FCCP,Editor
ProfessorandViceChair
SectionChiefofCriticalCareMedicine
DirectorofResearch
JohnA.MoffittEndowedChair
DepartmentofAnesthesiology
TheUniversityofOklahomaHealthSciencesCenter
OklahomaCity,Oklahoma
AmericanSocietyofAnesthesiologists,committeemember;ASPEN,committeemember
S.RobTodd,MD,FACS,FCCM,Editor
ProfessorofSurgery
Chief,AcuteCareSurgery
BaylorCollegeofMedicine
Chief,GeneralSurgeryandTrauma
BenTaubHospital
Houston,Texas

Nodisclosures
ChristineCocanour,MD,FACS,FCCM,SectionEditor
ProfessorofSurgery
DivisionofTraumaandCriticalCare
UniversityofCaliforniaDavisMedicalCenter
Sacramento,California
Nodisclosures
StephenO.Heard,MD,SectionEditor
Professor
UniversityofMassachusettsMedicalSchool
UniversityofMassachusettsMemorialMedicalCenter
Worcester,Massachusetts
Nodisclosures
JudithJacobi,BCPS,PharmD,MCCM,SectionEditor
CriticalCarePharmacist
IndianaUniversityHealthMethodistHospital
Indianapolis,Indiana
AmericanCollegeofClinicalPharmacypastpresident
RosemaryKozar,MD,PhD,SectionEditor
Professor
RAdamsCowleyShockTraumaCenter
UniversityofMaryland
Baltimore,Maryland
AmericanAssociationfortheSurgeryofTrauma,AmericanCollegeofSurgeons,NationalTraumaInstitute
DrewA.MacGregor,MD,SectionEditor


ProfessorofInternalMedicineandAnesthesiology
ProgramDirector,CriticalCareMedicineFellowship
WakeForestUniversityHealthScience

Winston-Salem,NorthCarolina
Nodisclosures
FrederickA.Moore,MD,MCCM,SectionEditor
Head,AcuteCareSurgery
UniversityofFlorida
Gainesville,Florida
Nodisclosures
LauraMoore,MD,SectionEditor
ChiefofSurgicalCriticalCare
UniversityofTexasHealthScienceCenteratHouston
Houston,Texas
Nodisclosures
MehmetOzcan,MD,SectionEditor
TheUniversityofOklahomaHealthSciencesCenter
OklahomaCity,Oklahoma
AmericanSocietyofAnesthesiologists,NeuroanestheisaCommitteeMember;SocietyofNeurosciencesin
AnesthesiologyandCriticalCare,ScientificCommitteeMember
GretaPiper,MD,SectionEditor
NewYorkUniversityLangoneMedicalCenter
NewYork,NewYork
EasternAssociationforSurgeryofTraumacommittee
JaniceL.Zimmerman,MD,MCCM,FCCP,SectionEditor
Head,DivisionofCriticalCare
HoustonMethodistHospital
Houston,Texas
ACCP,ACP,WFSICCM,PAIF
AdilM.Abuzeid,MBBS
AssistantProfessorofSurgery
MedicalCollegeofGeorgia
SectionofTrauma/SurgicalCriticalCare

AugustaUniversityMedicalCenter
Augusta,Georgia
Nodisclosures
RaviAgarwala,MD,FRCPC
AssistantProfessor
DepartmentofAnesthesiology
SectiononCriticalCare
WakeForestUniversitySchoolofMedicine
Winston-Salem,NorthCarolina
Nodisclosures
NestorArita,MD
BaylorCollegeofMedicine


Houston,Texas
Nodisclosures
VinodP.Balachandran,MD
Resident,DepartmentofSurgery
NewYorkPresbyterianHospital
WeillCornellMedicalCollege
NewYork,NewYork
BristolMeyersSquibb,grant
RobertA.Balk,MD
J.BaileyCarter,MDProfessorofMedicine
Director,DivisionofPulmonaryandCriticalCareMedicine
RushMedicalCollegeandRushUniversityMedicalCenter
Chicago,Illinois
Nodisclosures
DebasreeBanerjee,MD,MS
BrownUniversityRhodeIslandHospital

Providence,RhodeIsland
CHEST,women’shealthnetworkmember;CHESTPulmonaryArterialHypertension2015(Actelion),grant
MichaelL.Bentley,PharmD,FCCM,FCCP,FNAP
VirginiaTechCarilionSchoolofMedicine
Roanoke,Virginia
Director,GlobalHealthScience
TheMedicalAffairsCompany,
Kennesaw,Georgia,representing
TheGlobalHealthScienceCenter,
TheMedicinesCompany
Parsippany,NewJersey
AmericanCollegeofClinicalPharmacy,committees;NationalAcademiesofPractice,committee
M.CamillaBermudez,MD
AssociateProgramDirector
GeisingerMedicalCenter
Danville,Pennsylvania
Nodisclosures
AlishaBhatia,MD
DepartmentofAnesthesiology
RushUniversityMedicalCenter
Chicago,Illinois
Nodisclosures
NatalieBradford,MD
ClinicalFellowinElectrophysiology
DepartmentofMedicine
SectiononCardiology
WakeForestUniversitySchoolofMedicine
Winston-Salem,NorthCarolina
Nodisclosures

TimothyG.Buchman,MD,PhD,MCCM
FoundingDirector,EmoryCenterforCriticalCare
EmoryUniversityHospital
Atlanta,Georgia
Nodisclosures
RamonF.Cestero,MD,FACS
AssociateProfessorofSurgery
MedicalDirector,SurgicalTraumaICU
ProgramDirector,SurgicalCriticalCareFellowship
DepartmentofSurgery/DivisionofTraumaandEmergencySurgery
TheUniversityofTexasHealthScienceCenterSanAntonio
SanAntonio,Texas
Nodisclosures
AnnaChen,MD
GeisingerMedicalCenter
Danville,Pennsylvania
Nodisclosures
SherryH-Y.Chou,MD,MMSc,FNCS
DepartmentofCriticalCareMedicine
UniversityofPittsburghMedicalCenter
Pittsburgh,Pennsylvania
Nodisclosures
CraigM.Coopersmith,MD
AssociateDirector,EmoryCenterforCriticalCare
EmoryUniversitySchoolofMedicine
Atlanta,Georgia
Nodisclosures
JohnCrommett,MD
AssociateProfessor

MDAndersonCancerCareCenter
Houston,Texas
Nodisclosures
JamesM.Cross,MD,FACS
ProfessorofSurgery
UniversityofTexasMedicalSchoolatHouston
Houston,Texas
Nodisclosures
QuinnA.Czosnowski,PharmD
ClinicalPharmacySpecialist,CriticalCare
IndianaUniversityHealth–MethodistHospital
Indianapolis,Indiana
Nodisclosures
KimberlyA.Davis,MD,MBA
ProfessorofSurgery
ViceChairmanofClinicalAffairs


ChiefoftheSectionofGeneralSurgery,Trauma,andSurgicalCriticalCare
YaleSchoolofMedicine
TraumaMedicalDirector
SurgicalDirectorQualityandPerformanceImprovement
Yale-NewHavenHospital
NewHaven,Connecticut
AAST,EAST,ACS,ACSCOT,CTTraumaConferenceInc,SCCPDS
R.PhillipDellinger,MD,MCCM
Chairman/Chief,DepartmentofMedicine
SeniorCriticalCareAttending
CooperUniversityHospital
Camden,NewJersey

Nodisclosures
GozdeDemiralp,MD
AssistantProfessor
Director,CriticalCareAnesthesiologyFellowship
MedicalDirector,PreoperativeAnesthesiaUnit
DivisionofCriticalCareMedicine
DepartmentofAnesthesiology
UniversityofOklahomaHealthSciencesCenter
OklahomaCity,Oklahoma
Nodisclosures
SylviaY.Dolinski,MD,FCCP
ProfessorofAnesthesiologyandCriticalCare
DepartmentofAnesthesiology
MedicalCollegeofWisconsin
DepartmentofAnesthesiology
ClementJ.ZablockiVAMedicalCenter
Milwaukee,Wisconsin
AmericanBoardofAnesthesiology,ASA,IARS,SOCCA
SoumitraR.Eachempati,MD,FACS,FCCM
Professor,DepartmentofSurgery
WeillMedicalCenterofCornellUniversity
NewYork,NewYork
Nodisclosures
BrianErstad,PharmD,MCCM
ProfessorandHead
UniversityofArizonaCollegeofPharmacy
Tucson,Arizona
AmericanCollegeofClinicalPharmacy,Treasurer
EtienneGayat,MD,PhD
LariboisiereUniversityHospital

Paris,France
Nodisclosures
FredricGinsberg,MD,FACC,FCCP
MedicalDirector,CooperHeartInstitute


CooperUniversityHospital
AssociateProfessorofMedicine
CooperMedicalSchoolofRowanUniversity
Camden,NewJersey
Nodisclosures
AmandaM.Gomes,MD
UniversityofOklahomaHealthSciencesCenter
OklahomaCity,Oklahoma
ASA,BloodManagementCommittee
MarcosEmanuelGomes,MD
AssistantProfessorofAnesthesiologyandCriticalCareMedicine
MedicalDirectorofthePACU
DepartmentofAnesthesiology
TheUniversityofOklahomaSciencesCenter
OklahomaCity,Oklahoma
Nodisclosures
SaraR.Gregg,MHA
SeniorCenterAdministrator
EmoryCriticalCareCenter
Atlanta,Georgia
ACHE,member;HFMA,member
RebecaL.Halfon,BS,PharmD
HoustonMethodistHospital
Houston,Texas

Nodisclosures
JenniferE.Hofer,MD
UniversityofChicago
Chicago,Illinois
Nodisclosures
DavidT.Huang,MD,MPH
UniversityofPittsburgh
Pittsburgh,Pennsylvania
LaJolla,consultant;ACEP,sepsiscommittee
ChristopherG.Hughes,MD
AssociateProfessorofAnesthesiology
VanderbiltUniversitySchoolofMedicine
Nashville,Tennessee
Nodisclosures
ToddHuzar,MD
AssistantProfessorofSurgery
UniversityofTexasHealthScienceCenteratHouston
Houston,Texas
Nodisclosures
NabilM.Issa,MD
AssociateProfessorofSurgery


NorthwesternUniversityFeinbergSchoolofMedicine
DivisionofTraumaandCriticalCare
NorthwesternMemorialHospital
Chicago,Illinois
ACS,ASE,COT
HeatherJ.Johnson,PharmD
UniversityofPittsburghSchoolofPharmacy

Pittsburgh,Pennsylvania
AmericanCollegeofClinicalPharmacy,memberandspeaker;AmericanSocietyofHealthSystem
Pharmacy,speaker,ownstockinPfizer
ChristinaC.Kao,MD
BaylorCollegeofMedicine
Houston,Texas
Nodisclosures
LillianS.Kao,MD,MS
UniversityofTexasMedicalSchoolatHouston
UniversityofTexasHealthCenteratHouston
Houston,Texas
Nodisclosures
ShravanKethireddy,MD
GeisingerHealthSystem
Danville,Pennsylvania
Nodisclosures
MarkA.Kleman,DO
NephrologyFellow
GeisingerHealthSystem
Danville,Pennsylvania
Nodisclosures
ScottE.Kopec,MD,FCCP
AssociateProfessorofMedicine
DivisionofPulmonary,Allergy,andCriticalCareMedicine
UniversityofMassachusettsMedicalSchool
Worcester,Massachusetts
Nodisclosures
AnandKumar,MD
Professor
UniversityofManitoba

SouthWinnipeg,Canada
Nodisclosures
JenniferA.LaRosa,MD,FCCM,FCCP
PatientSafetyandQualityOfficer
RutgersUniversitySchoolofMedicine
BerkeleyHeights,NewJersey
ACCP,writerandspeaker
GeoffreyS.F.Ling,MD,PhD,FAAN


ProfessorofNeurology
JohnsHopkinsUniversitySchoolofMedicine
Baltimore,Maryland
AmericanAcademyofNeurology,AmericanAssociationNeurologists,NeuroCriticalCareSociety
FelixY.Lui,MD
AssociateProfessorofSurgery
SectionofGeneralSurgery,TraumaandSurgicalCriticalCare
YaleSchoolofMedicine
NewHaven,Connecticut
Nodisclosures
NeilR.MacIntyre,MD
ProfessorofMedicine
DukeUniversityMedicalCenter
Durham,NorthCarolina
BreatheTechnologyandVentecCorp.,consultant;AlanaHealthCare,consultant;ACCP,ATS,AARC
LindaL.Maerz,MD,FACS,FCCM
FellowshipDirector
YaleUniversitySchoolofMedicine
NewHaven,Connecticut
Nodisclosures

PaulE.Marik,MD,FCCM,FCCP
ChiefofPulmonaryandCriticalCareMedicine
EasternVirginiaMedicalSchool
Norfolk,Virginia
Nodisclosures
ScottA.Marshall,MD
VascularNeurologyandCriticalCare
NeuroscienceCriticalCare
IntermountainMedicalCenter
SaltLakeCity,Utah
Nodisclosures
TheofilosP.Matheos,MD
AssistantProfessorofAnesthesiaandSurgery
UniversityofMassachusettsMedicalSchool
Worcester,Massachusetts
Nodisclosures
JeffreyMazer,MD
RhodeIslandHospitalatBrownUniversity
Albuquerque,NewMexico
Nodisclosures
StuartMcGrane,MBChB,MSCI
AssistantProfessorofAnesthesiology
VanderbiltUniversitySchoolofMedicine
Nashville,Tennessee
Nodisclosures


CourtneyMcKinney,PharmD
IntermountainMedicalCenter
SaltLakeCity,Utah

Nodisclosures
AlexandreMebazaa,MD,PhD
DepartmentofAnesthesiologyandCriticalCare
HopitalLariboisiere
Paris,France
Nodisclosures
YatinMehta,MD
GeisingerHealthSystem
Danville,Pennsylvania
Nodisclosures
MarieT.Mullen,MD
PulmonaryandCriticalCareFellow
DivisionofPulmonary,Allergy,andCriticalCareMedicine
UniversityofMassachusettsMedicalSchool
Worcester,Massachusetts
Nodisclosures
TashingaMusonza,MD
BaylorCollegeofMedicine
Houston,Texas
Nodisclosures
AndrewM.Naidech,MD,MSPH
AssociateProfessor
NorthwesternUniversity
Evanston,Illinois
Nodisclosures
JosephL.Nates,MD,MBA,FCCM
Professor,DeputyChair,DirectorICUs
MDAndersonCancerCenter
UniversityofTexas
Houston,Texas

Nodisclosures
MichaelF.O’Connor,MD,FCCM
UniversityofChicago
Chicago,Illinois
AQI,CommitteeonDataUse
PratikP.Pandharipande,MD,MSCI
ProfessorofAnesthesiologyandSurgery
VanderbiltUniversitySchoolofMedicine
Nashville,Tennessee
AmericanDeliriumSociety,President;Researchgranttoinstituteforstudydrug(dexmedetomidine)from
HospiraIncincollaborationwithNIHonRO1fundedstudy
JosephE.Parrillo,MD,FACC,MCCM


Chairman,HeartandVascularHospital
HackensackUniversityMedicalCenter
ProfessorofMedicine
RutgersNewJerseyMedicalSchool
Hackensack,NewJersey
Beckman-Coulter,consultant;Artisan,consultant;AmericanHeartAssociation;AmericanCollegeof
Cardiology
DeepaM.Patel,MD
Fellow,EmoryUniversityHospital
Atlanta,Georgia
Nodisclosures
GourangPatel,PharmD,MSc
ClinicalPharmacist–CriticalCare
RushUniversityMedicalCenter
Chicago,Illinois
Nodisclosures

KarenC.Patterson,MD
CHESTandATSconferences
JonathanPerez,MD
GeisingerMedicalCenter
Danville,Pennsylvania
Nodisclosures
MichaelR.Pinsky,MD,CM,Drh.c.,FCCP,MCCM
Professor,DepartmentofCriticalCareMedicine
UniversityofPittsburghSchoolofMedicine
Pittsburgh,Pennsylvania
EdwardsLifeSciences,consultantandlecturer;LiDCO,consultant;Masimo,consultantandlecturer;
CheetahMedical,lecturer;HemodynamicmonitoringPostGraduateCoursesforEuropeanSocietyof
IntensiveCareMedicineandtheInternationalSymposiumforIntensiveCareandEmergencyMedicine
MaryJaneReed,MD,FCCM
CriticalCareMedicine
GeisingerMedicalCenter
Danville,Pennsylvania
CHEST,disasternetworkvicechair
FredRincon,MD,MSc,MBE,FACP,FCCP,FCCM
AssociateProfessorNeurologyandNeurologicalSurgery
DepartmentofNeurologicalSurgery
Sidney-KimmelCollegeofMedicineofThomasJeffersonUniversity
DivisionofCriticalCareandNeurotrauma
Philadelphia,Pennsylvania
BardMedical,consultant;PortolaPharmaceutical,consultant;NCS,boardofdirectors
DavidM.Rothenberg,MD,FCCM
DepartmentofAnesthesiology
RushUniversityMedicalCenter
Chicago,Illinois

Nodisclosures
PatricioAndresSanchez-Cueva,MD
GeisingerHealthSystem
Danville,Pennsylvania
Nodisclosures
MartinA.Schreiber,MD,FACS
ProfessorofSurgery
OregonHealthandSciencesUniversity
DivisionofTrauma,CriticalCare,andAcuteCareSurgery
DepartmentofSurgery
OregonHealthandScienceUniversity
Portland,Oregon
Nodisclosures
MichaelSirimaturos,PharmD,BCNSP,BCCCP,FCCM
CriticalCareClinicalSpecialist
HoustonMethodistHospital
Houston,Texas
Nodisclosures
SherrySixta,MD
SurgicalCriticalCareAssociates
Newark,Delaware
Nodisclosures
AntoinetteSpevetz,MD,FCCM,FACP
Director,IntermediateCareUnit
CooperUniversity
Camden,NewJersey
Nodisclosures
JasonA.Stamm,MD
GeisingerHealthSystem

Danville,Pennsylvania
ATSmember,ACCPfellow,ACPfellow
JayaSugunaraj,MD
GeisingerMedicalCenter
Danville,Pennsylvania
Nodisclosures
AshitaJ.Tolwani,MD,MSc
DepartmentofMedicine,DivisionofNephrology
UniversityofAlabamaatBirmingham
Birmingham,Alabama
Nodisclosures
EricUrsprung,MD
UniversityofMassachusettsMedicalSchool
Worcester,Massachusetts
Nodisclosures


GloriaVazquez-Grande,MD
FellowinCriticalCareUniversityofManitoba
PhDcandidateinMedicalMicrobiologyUniversityofManitoba
Nodisclosures
MarioRaulVillalba,MD,FACS
AssistantProfessorofSurgery
OaklandUniversity-WilliamBeaumontSchoolofMedicine
AttendingSurgeon/Intensivist
DepartmentofSurgery
BeaumontHealth-RoyalOak
RoyalOak,Michigan
Nodisclosures
Jean-LouisVincent,MD,PhD,FCCM

DepartmentofIntensiveCare
ErasmeUniversityHospital
UniversitéLibredeBruxelles
Brussels,Belgium
Nodisclosures
StylianosVoulgarelis,MD
AssistantProfessorofPediatricandCardiacAnesthesiology
MedicalCollegeofWisconsin
Children’sHospitalofWisconsin
DepartmentofAnesthesiology
ClementJ.ZablockiVAMedicalCenter
Milwaukee,Wisconsin
AmericanSocietyofAnesthesiology,SocietyofCardiacAnesthesiology,SocietyofPediatricAnesthesiology
MichaelH.Wall,MD,FCCM
JJBuckleyProfessorandChairman
UniversityofMinnesota
Minneapolis,Minnesota
ASA,ABA,SCA,IARS,AUS,SOCCA
NicholasWard,MD
AssociateProfessorofMedicine
RhodeIslandHospital
Providence,RhodeIsland
Nodisclosures
JeremyL.Ward,MD
AssistantProfessor
MichaelE.DeBakeyDepartmentofSurgery
BaylorCollegeofMedicine
Houston,Texas
Nodisclosures
NicholasC.Watson,MD

AssistantProfessor
MichiganStateUniversityCollegeofHumanMedicine
AnesthesiaPracticeConsultants,PC


GrandRapids,Michigan
AmericanBoardofAnesthesiologyexamquestionauthor
SeanPatrickWhalen,MD
AssociateProfessor
DepartmentofMedicine
SectiononCardiology(Electrophysiology)
WakeForestSchoolofMedicine
Winston-Salem,NorthCarolina
Nodisclosures
CraigB.Whitman,PharmD,BCPS,BCCCP
ClinicalAssociateProfessorofPharmacyPractice
TempleUniversitySchoolofPharmacy
ClinicalPharmacist,CriticalCare
TempleUniversityHospital
Philadelphia,Pennsylvania
Nodisclosures
KennethE.Wood,DO
Director,MarylandCriticalCareNetwork,ShockTrauma
UniversityofMarylandMedicalSystem
Baltimore,Maryland
Nodisclosures
RyoYamamoto,MD
TraumaSurgeryFellow
DepartmentofSurgery/DivisionofTraumaandEmergencySurgery
TheUniversityofTexasHealthScienceCenteratSanAntonio

SanAntonio,Texas
Nodisclosures
SachinYende,MD,MS
DepartmentofCriticalCareMedicine
UniversityofPittsburgh
Pittsburgh,Pennsylvania
BristolMyersSquibb,grantsupport


Contents
Part1:NeurologicalCriticalCare
Chapter1:AlteredMentalStatusDuringCriticalIllness:DeliriumandComa
StuartMcGrane,MBChB,MSCI,PratikP.Pandharipande,MD,MSCI,andChristopherG.Hughes,MD
Chapter2:Seizures,Stroke,andOtherNeurologicalEmergencies
FredRincon,MD,MSc,MBE,FACP,FCCP,FCCM
Chapter3:CriticalCareManagementofTraumaticBrainInjury
ScottA.Marshall,MD,andGeoffreyS.F.Ling,MD,PhD,FAAN
Chapter4:NeurologicalCriteriaforDeathinAdults
SherryH-Y.Chou,MD,MMSc,FNCS

Part2:CardiovascularCriticalCare
Chapter5:Shock:Classification,PathophysiologicalCharacteristics,andManagement
AntoinetteSpevetz,MD,FCCM,FACP,andJosephE.Parrillo,MD,FACC,MCCM
Chapter6:HemodynamicMonitoring
MichaelR.Pinsky,MD,CM,Drh.c.,FCCP,MCCM
Chapter7:CardiacArrestandResuscitation
FelixY.Lui,MD,andKimberlyA.Davis,MD,MBA
Chapter8:SevereHeartFailure,CardiogenicShock,andPericardialTamponade
(IncludingPrinciplesofIntra-aorticBalloonPumpsandVentricularAssistDevices)
EtienneGayat,MD,PhD,andAlexandreMebazaa,MD,PhD

Chapter9:SepsisandSepticShock:Epidemiology,Pathophysiology,Diagnosis,andManagement
SachinYende,MD,MS,DavidT.Huang,MD,MPH,andR.PhillipDellinger,MD,MCCM
Chapter10:HypovolemicandHemorrhagicShock
DeepaM.Patel,MD,andCraigM.Coopersmith,MD
Chapter11:AcuteMyocardialInfarctionandAcuteCoronarySyndromes
FredricGinsberg,MD,FACC,FCCP,andJosephE.Parrillo,MD,FACC,MCCM
Chapter12:ArrhythmiasandRelatedDevices
RaviAgarwala,MD,FRCPC,SeanPatrickWhalen,MD,andNatalieBradford,MD
Chapter13:ValvularHeartDisease,AcuteAorticDissection,andPatientCare
AfterCardiacSurgery
MichaelH.Wall,MD,FCCM,andPamelaR.Roberts,MD,FCCM
Chapter14:HypertensiveCrises
AmandaM.Gomes,MD
Chapter15:Anaphylaxis
MarcosEmanuelGomes,MD,andPamelaR.Roberts,MD,FCCM,FCCP
Chapter16:ExtracorporealMembraneOxygenation
StylianosVoulgarelis,MD,andSylviaY.Dolinski,MD,FCCP


Part3:RespiratoryCriticalCare
Chapter17:AirwayManagement
NicholasC.Watson,MD,andStephenO.Heard,MD
Chapter18:ArterialBloodGasInterpretation,Capnography,andPulseOximetry
EricUrsprung,MD,andTheofilosP.Matheos,MD
Chapter19:AcuteRespiratoryFailure
DebasreeBanerjee,MD,MS,JeffreyMazer,MD,andNicholasWard,MD
Chapter20:ICUManagementofObstructiveAirwayDisease
JenniferA.LaRosa,MD,FCCM,FCCP,andR.PhillipDellinger,MD,MCCM
Chapter21:PrinciplesofMechanicalVentilation
NeilR.MacIntyre,MD

Chapter22:PulmonaryEmbolismandPulmonaryHypertensionintheICU
KennethE.Wood,DO,andJasonA.Stamm,MD
Chapter23:Hemoptysis,Pneumothorax,andInhalationalInjuries
ScottE.Kopec,MD,FCCP,andMarieT.Mullen,MD
Chapter24:ImmunologicalLungDisease
RobertA.Balk,MD

Part4:CriticalCareInfectiousDiseases
Chapter25:NosocomialInfectiousDiseasesintheIntensiveCareUnit
RyoYamamoto,MD,andRamonF.Cestero,MD,FACS
Chapter26:Antibiotic,Antifungal,andAntiviralTherapies
GourangPatel,PharmD,MSc,andAnandKumar,MD
Chapter27:InfectionsintheImmunosuppressedandImmunocompromisedPatient
GloriaVazquez-Grande,MD,andAnandKumar,MD
Chapter28:SpecificInfectionsWithImplicationsforCriticalCare
ShravanKethireddy,MD,AnnaChen,MD,JonathanPerez,MD,andMaryJaneReed,MD,FCCM

Part5:Hepatic,Gastrointestinal,Hematologic/OncologicDiseasein
theICU
Chapter29:LiverFailure,GastrointestinalBleeding,andAcutePancreatitis
VinodP.Balachandran,MD,andSoumitraR.Eachempati,MD,FACS,FCCM
Chapter30:AbdominalProblemsintheIntensiveCareUnit
AdilM.Abuzeid,MBBS,andNabilM.Issa,MD
Chapter31:Coagulopathies,ThromboticDisorders,andBloodComponentTherapy
MarioRaulVillalba,MD,FACS,andMartinA.Schreiber,MD,FACS
Chapter32:OncologicalEmergencies
JohnCrommett,MD,andJosephL.Nates,MD,MBA,FCCM

Part6:RenalandMetabolicDisordersintheICU

Chapter33:AcuteandChronicRenalFailureandManagement(IncludingHemodialysisand
ContinuousRenalReplacementTherapies)
MichaelL.Bentley,PharmD,FCCM,FCCP,FNAP,andAshitaJ.Tolwani,MD,MSc
Chapter34:AcuteAcid-BaseDisorders
AlishaBhatia,MD,andDavidM.Rothenberg,MD,FCCM
Chapter35:ElectrolyteandMetabolicAbnormalities
LindaL.Maerz,MD,FACS,FCCM
Chapter36:Hyperglycemia,Hypoglycemia,andAcuteDiabeticEmergencies
GozdeDemiralp,MD,andPamelaR.Roberts,MD,FCCM,FCCP
Chapter37:Pituitary,Adrenal,andThyroidDiseasesintheCriticallyIllPatient
NestorArita,MD,JeremyL.Ward,MD,andPaulE.Marik,MD,FCCM,FCCP
Chapter38:NutritionalTherapiesinCriticallyIllPatients
PamelaR.Roberts,MD,FCCM,FCCP

Part7:EnvironmentalandToxicologicInjury
Chapter39:CriticalCareManagementoftheSeverelyBurnedPatient
ToddHuzar,MD,andJamesM.Cross,MD,FACS
Chapter40:PoisoningandToxicologyintheCriticallyIll
MichaelSirimaturos,PharmD,BCNSP,BCCCP,FCCM,RebecaL.Halfon,BS,PharmD,and
JaniceL.Zimmerman,MD,MCCM,FCCP
Chapter41:Hypothermia,Hyperthermia,andNearDrowning
JaniceL.Zimmerman,MD,MCCM,FCCP

Part8:PharmacologicIssuesintheICU
Chapter42:Sedatives,Analgesics,andNeuromuscularBlockadeintheICU
QuinnA.Czosnowski,PharmD,andCraigB.Whitman,PharmD,BCPS,BCCCP
Chapter43:SpecialCaveatsofDrugsUsedinCriticalCareMedicine
BrianL.Erstad,PharmD,MCCM,andCourtneyMcKinney,PharmD

Part9:SurgicalandObstetricalCriticalCare
Chapter44:SolidOrganTransplantationintheICU
YatinMehta,MD,JayaSugunaraj,MD,MarkA.Kleman,DO,M.CamillaBermudez,MD,HeatherJ.
Johnson,PharmD,PatricioAndresSanchez-Cueva,MD,andMaryJaneReed,MD,FCCM
Chapter45:ManagementoftheSeverelyInjuredTraumaPatient
SherrySixta,MD,andRosemaryKozar,MD,PhD
Chapter46:CriticalCareIssuesinthePostoperativePeriod
ChristinaC.Kao,MD,TashingaMusonza,MD,LillianS.Kao,MD,MS,andS.RobTodd,MD
Chapter47:ObstetricCriticalCare
JenniferE.Hofer,MD,KarenC.Patterson,MD,andMichaelF.O’Connor,MD,FCCM


Part10:AdministrativeandEthicalIssuesintheCriticallyIll
Chapter48:APerspectiveonICUAdministration
SaraR.Gregg,MHA,andTimothyG.Buchman,MD,PhD,MCCM
Chapter49:SeverityofIllnessScoringSystems
Jean-LouisVincent,MD,PhD,FCCM
Chapter50:PrinciplesofStatisticsandEvidence-BasedMedicine
AndrewM.Naidech,MD,MSPH
Chapter51:EthicalConcernsintheManagementofCriticallyIllPatients
FredRincon,MD,MSc,MBE,FACP,FCCP,FCCM


CHAPTER1

AlteredMentalStatusDuringCriticalIllness:
DeliriumandComa
StuartMcGrane,MBChB,MSCI,PratikP.Pandharipande,MD,MSCI,and
ChristopherG.Hughes,MD

Key words:delirium,coma,ConfusionAssessmentMethodfor
the Intensive Care Unit (CAM-ICU), Intensive Care Delirium
Screening Checklist (ICDSC), Richmond Agitation-Sedation
Scale(RASS)
Critically ill patients often manifest varying degrees of altered mental status
secondarytotheiracutediseaseprocessesorasaconsequenceofthetherapies
used to treat disease. These mental status changes range from coma to
hyperactive delirium. A comatose patient is unresponsive to physical or verbal
stimuli,whereas deliriumis anacuteandfluctuatingdisorderofconsciousness
characterizedbyinattention,disorganizedthinking,andperceptualdisturbances
(Figure 1). Alterations in mental status have traditionally been considered
expected consequences of critical illness, and clinicians are increasingly aware
that these mental status changes are manifestations of acute brain organ
dysfunction that are associated with worse clinical outcomes. Early studies
evaluatingcomaanddeliriumwerehamperedbythemanydifferentterms(eg,
confusionalstate,ICUpsychosis,acutebraindysfunction,andencephalopathy)
used to describe altered mental status during critical illness. Additionally, the
lack of validated bedside tools (besides the comprehensive Diagnostic and
Statistical Manual of Mental Disorders) to diagnose delirium prevented the
incorporationofdeliriummonitoringintoroutineclinicalcareintheICU.
Figure1.Delineationbetweendeliriumandcoma,highlightingthecardinalsymptomsofdelirium


aOptionalsymptomsofdelirium(maybepresentbutarenotrequiredforthediagnosisof

delirium).

DIAGNOSISOFACUTEBRAINDYSFUNCTION
Traditionally,manyscaleshavebeenavailabletoassessthelevelofsedationand
agitationinICUpatients,includingtheRamsayscale,RikerSedation-Agitation

Scale(SAS),motoractivityassessmentscale,andRichmondAgitation-Sedation
Scale (RASS). The recent guidelines on pain, agitation, and delirium from the
SocietyofCriticalCareMedicinerecommendtheuseoftheRASSandSASdue
totheirpsychometricpropertiesandvalidityincriticallyillpatients.TheRASS
(Figure 2) also has been shown to detect variations in the patient’s level of
consciousnessovertimeorinresponsetochangesinsedativeandanalgesicdrug
use.Asafirststepinassessingthelevelofconsciousness,asedation-agitation
scaleshouldbeused.Patientswhoareunresponsivetoverbalcommands(eg,a
RASS -4 or-5) are considered to be in a coma and cannot be evaluated for
deliriumatthattime.Patientswhoareresponsivetoverbalstimuli(eg,RASS-3
andlighter)canfurtherbeevaluatedforthecontentofthatarousalviatheuseof
deliriummonitoringinstruments.
Figure2.TheRichmondAgitation-SedationScale(RASS)


Score Term

Description

+4

Combative

Overtlycombative,violent,immediatedangertostaff

+3

Very
agitated

Pullsorremovestubesorcatheters;aggressive

+2

Agitated

Frequentnonpurposefulmovement,fightsventilator

+1

Restless

Anxiousbutmovementsnotaggressiveorvigorous

0

Alertand
calm



-1

Drowsy

Notfullyalertbuthassustainedawakening(eye-openingor
eyecontact)tovoice(≥10seconds)

-2

Light
sedation

Brieflyawakenswitheyecontacttovoice(<10seconds)

-3

Moderate
sedation

Movementoreyeopeningtovoice(butnoeyecontact)

-4

Deep
sedation

Noresponsetovoicebutmovementoreyeopeningto
physicalstimulation

-5



Verbal
Stimulation

Verbal
Stimulation

Unarousable Noresponsetovoiceorphysicalstimulation

Thescaleisa10-pointscalewithdiscretecriteriatodistinguishlevelsofagitationandsedation.
IfRASSis-4or-5,thenstopandreassessthepatientatalatertimefordelirium,sincethepatient
iscomatose.IfRASSisabove-4(-3through+4),proceedtodeliriumassessment.
ReproducedwithpermissionfromDr.E.WesleyEly(www.icudelirium.org).

The validation of the Confusion Assessment Method for the ICU (CAM-ICU)
(Figure3)andtheIntensiveCareDeliriumScreeningChecklist(ICDSC)(Table
1) has resulted in a significant increase in delirium diagnosis, monitoring, and
research.TheCAM-ICUassesses4featuresofbrainfunction:acutechangeor
fluctuation in mental status (feature 1), inattention (feature 2), disorganized
thinking (feature 3), and an altered level of consciousness (feature 4). The
diagnosis of delirium using the combination of the RASS scale and the CAMICUrequiresthefollowing:
1. RASSscoreof-3orhigherand
2. Feature1ofCAM-ICU(acutechangeorfluctuationinmentalstatus)and
3. Feature2ofCAM-ICU(inattention)and


4. Oneofthefollowing:
a. Feature3(disorganizedthinking)or
b. Feature4(alteredlevelofconsciousness)
Figure3.ConfusionAssessmentMethodfortheIntensiveCareUnit(CAM-ICU)

PatientsareconsideredtohavedeliriumiftheyhaveRichmondAgitation-SedationScalescores
of-3andabove(seeFigure2)andareconsideredCAM-ICUpositivebyhavingfeatures1and2
presentandeitherfeature3orfeature4positive.
Adapted with permission the Society of Critical Care Medicine. ICU Liberation.
www.iculiberation.org.January2013.
Table1.IntensiveCareDeliriumScreeningChecklista

PatientEvaluation

Characteristics

Yes No

Alteredlevelof
consciousness

A:Noresponse(0)
B:Responsetointenseandrepeatedstimulation(loudvoice
andpain)(0)
C:Responsetomildormoderatestimulation(1)
D:Normalwakefulness(0)
E:Exaggeratedresponsetonormalstimulation(1)

1

0

Inattention

Difficultyinfollowingaconversationorinstructions

1

0

Easilydistractedbyexternalstimuli
Difficultyinshiftingfocuses

Disorientation

Anyobviousmistakeintime,place,orperson

1

0

Hallucinations,
delusion,psychosis

Unequivocalhallucinationorbehaviorlikelydueto
hallucinationordelusion

1

0

Psychomotoragitation
orretardation

Hyperactivityrequiringadditionalsedativedrugsorrestraints 1

0

Inappropriatespeech
ormood

Inappropriate,disorganized,orincoherentspeech

Sleep-wakecycle
disturbance

Sleeping<4horwakingfrequentlyatnight(notinitiatedby
medicalstafforloudenvironment)

Grossimpairmentinrealitytesting

Hypoactivityorclinicallynoticeablepsychomotorslowing
1

0

1

0

Fluctuationofthemanifestationofanyitemorsymptomover 1
thecourseof24h

0

Inappropriatedisplayofemotionrelatedtoeventsor
situation

Sleepingduringmostoftheday
Symptomfluctuation

aTotalscore(0-8).Ascore≥4indicatesdelirium.

TheICDSCuses8diagnosticfeaturestoevaluatebrainfunction.Adiagnosisof
deliriumrequires4ormorefeaturesfromthechecklisttobepresentduringthe
evaluation period. Additionally, patients who have some features from the
ICDSCbutwhodonotmeetalltherequisitecriteriafordeliriumdiagnosisare
considered to have subsyndromal delirium. This part of the spectrum of acute
braindysfunctionhasnotbeenfullycharacterizedbutlikelyliesbetweennormal
and full feature delirium and is associated with worse outcomes than normal
cognitionbutbetteroutcomesthandelirium.Acompletedescriptionofdelirium
monitoring tools and training materials (including clinical vignettes and
translationsoftheCAM-ICU)canbefoundatwww.icudelirium.org.
PREVALENCEANDPATHOGENESISOFBRAINDYSFUNCTION
The prevalence of acute brain dysfunction in the ICU varies according to the
nature and severity of illness in the population studied. Rates of delirium in
critically ill, mechanically ventilated patients are upward of 50%, and many
studies in medical, surgical, trauma, and burn ICUs report rates between 50%
and80%.Ratesofdeliriumarebetween20%and40%incardiacICUpatients
andinICUpatientswithlowerseverityofillnesswhodonotrequiremechanical