2015 handbook of ICU therapy 3rd ed

Handbook of ICU Therapy
Third edition



Handbook of ICU
Therapy
Third edition
Edited by

John Fuller MD FRCPC

Professor in the Department of Anesthesia and Perioperative Medicine, and Division of Critical Care (Department of Medicine),
Western University, London, ON, Canada

Jeff Granton MD FRCPC

Associate Professor in the Department of Anesthesia and Perioperative Medicine, Division of Critical Care (Department of Medicine),
Western University, London, ON, Canada

Ian McConachie MB ChB FRCA FRCPC

Associate Professor in the Department of Anesthesia and Perioperative Medicine, Division of Critical Care (Department of Medicine),
Western University, London, ON, Canada


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Library of Congress Cataloging in Publication data
Handbook of ICU therapy / edited by John Fuller, Jeff Granton, Ian
McConachie. – Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-107-64190-7 (Paperback)
I. Fuller, John, 1955-editor. II. Granton, Jeff, editor.
III. McConachie, Ian, editor.
[DNLM: 1. Intensive Care–methods–Handbooks. WX 39]
RC86.8
616.020 8–dc23 2014018828
ISBN 978-1-107-64190-7 Paperback
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............................................................................................
Every effort has been made in preparing this book to provide accurate
and up-to-date information which is in accord with accepted standards
and practice at the time of publication. Although case histories are
drawn from actual cases, every effort has been made to disguise the
identities of the individuals involved. Nevertheless, the authors, editors
and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or
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Contents
List of contributors vii
Preface to the third edition xiii

Section 1 – Basic principles
1.

Oxygen delivery, cardiac function
and monitoring 1
Lois Champion

2.

Shock 13

Philip M Jones

3.

Oxygen therapy 20
Ahmed F Hegazy and Ian
McConachie

4.

Central venous access 28
Ken Blonde and Robert Arntfield

5.

Fluid therapy in ICU 38
Janet Martin, John Fuller and Ian
McConachie

12. Principles of IPPV and care of the
ventilated patient 131
Mohit Bhutani and Ian McConachie
13. Modes of ventilation and ventilator
strategies 144
Tania Ligori
14. Discontinuing mechanical
ventilation 152
Ron Butler

6.

Anemia and blood transfusion
Shane W English and Lauralyn
McIntyre

7.

Coagulation problems in the
critically ill 68
Alejandro Lazo-Langner

8.

Airway management in critically ill
patients 78
Titus C Yeung and Donald EG
Griesdale

9.

Noninvasive mechanical
ventilation 88
Mark Soth and Thomas
Piraino

10. Nutrition 95
Ilya Kagan and Pierre Singer

11. Electrolyte and metabolic acid–base
problems 105

Harneet Kaur, Julio P Zavala Georffino,
Daniel Castro Pereira, Bhupesh Khadka,
Joseph Dreier and Clay A Block

53

15. Vasoactive drugs
Daniel H Ovakim

161

16. Optimizing antimicrobial therapy in
the ICU 173
Stephen Y Liang and Anand Kumar
17. Sedation, analgesia and
neuromuscular block 187
Brian Pollard
18. Continuous renal replacement
therapy 197
A Ebersohn and Rudi Brits
19. Chronic critical illness
David Leasa

209

20. Recognizing and responding to the
deteriorating patient 221
John Kellett, Christian P Subbe and
Rebecca P Winsett

v


vi

Contents

21. ICU rehabilitation 235
Linda Denehy and Sue Berney
22. Palliative care, withholding and
withdrawal of life support in the
intensive care unit 252
Lois Champion and Valerie Schulz

Section 2 – Specific problems
23. The injured patient in the ICU 261
Neil Parry and W Robert Leeper
24. Neurotrauma 277
Ari Ercole, Jessie R Welbourne and
Arun K Gupta
25. Acute coronary syndromes 290
Kala Kathirgamanathan and Jaffer
Syed
26. Heart failure 303
Christopher W White, Darren H Freed,
Shelley R Zieroth and Rohit K Singal
27. Arrhythmias 319
Umjeet Singh Jolly and Jaimie
Manlucu

31. The patient with gastrointestinal
problems 374
Biniam Kidane and Tina Mele
32. The comatose patient: neurological
aspects 391
G Bryan Young
33. The obstetric patient in the
ICU 403
Carlos Kidel and Alan McGlennan
34. The critically ill asthmatic
Ian M Ball

35. Endocrine problems in critical
illness 427
Wael Haddara
36. The cardiac surgical patient in the
ICU 433
Jeff Granton
37. Care of the organ donor 442
Mowaffaq Almikhlafi and Michael
D Sharpe
38. The patient with cardiac arrest
Osama Al-muslim

28. The patient with sepsis 334
Jennifer Vergel Del Dios, Tom
Varughese and Ravi Taneja
29. Acute kidney injury
RT Noel Gibney

348

30. Acute lung injury and ARDS 361
Raj Nichani, MJ Naisbitt and Chris
Clarke

416

Index

461

451


Contributors
Mowaffaq Almikhlafi MD FRCPC
Fellow, Critical Care Western, Schulich
School of Medicine and Dentistry, Western
University, London Health Sciences Centre,
London, Ontario, Canada
Osama Al-muslim MD, MRCP (UK)
Critical Care Consultant, Director of Life
Support Training Center, King Fahad
Specialist Hospital, Dammam, Saudi
Arabia
Robert Arntfield MD FRCPC FCCP FACEP
Assistant Professor, Schulich School of
Medicine and Dentistry, Western
University, Director, Critical Care

Ultrasound, Division of Critical Care
(Department of Medicine), London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada
Ian M Ball MD DABEM FCCP FRCPC
Assistant Professor, Queen’s University,
Kingston, Department of Emergency
Medicine, Department of Biomedical and
Molecular Sciences, Program in Critical
Care Medicine, Consultant Toxicologist,
Ontario Poison Information, Kingston
General Hospital, Kingston, Ontario,
Canada
Sue Berney PhD PT
Associate Professor, Department of
Physiotherapy, Melbourne School of
Health Sciences, The University of
Melbourne, Parkville, Victoria,
Australia
Mohit Bhutani MD FRCPC FCCP
Associate Professor, Division of Pulmonary
Medicine, Department of Medicine,
University of Alberta, Edmonton, Alberta,
Canada

Clay A Block MD
Associate Professor, Department of
Medicine (Nephrology section), Geisel
School of Medicine, Dartmouth, NH, USA
Ken Blonde MD

Critical Care Fellow, Faculty of Medicine,
University of Calgary, Calgary, Alberta,
Canada
Rudi Brits MB ChB FRCA FICM
Consultant Anaesthetist, Tygerberg
Hospital, Cape Town, South Africa
Ron Butler MD FRCPC
Associate Professor, Department of
Anesthesia and Perioperative Medicine and
Division of Critical Care (Department of
Medicine), Schulich School of Medicine
and Dentistry, Western University, London
Health Sciences Centre and St. Joseph’s
Healthcare London, London, Ontario,
Canada
Lois Champion MD FRCPC
Professor, Department of Anesthesia and
Perioperative Medicine and Division of
Critical Care (Department of Medicine),
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada
Chris Clarke FRCA
Consultant in Anaesthesia and Critical
Care, Blackpool Teaching Hospitals NHS
Foundation Trust, Blackpool, UK
Linda Denehy PhD PT
Professor and Head, Department of
Physiotherapy, Melbourne School of

Health Sciences, The University of
Melbourne, Parkville, Victoria, Australia
vii


viii

List of contributors

Joseph Dreier MD
Department of Medicine (Nephrology
section), Geisel School of Medicine,
Dartmouth, NH, USA
A Ebersohn MB ChB, DA, Dip Obs
Department of Anaesthesia, Tygerberg
Hospital, Cape Town, South Africa
Shane W English BSc MSc MD FRCPC
Assistant Professor, Dept of Medicine
(Critical Care), University of Ottawa,
Clinical Associate, Dept of Critical Care,
The Ottawa Hospital, Associate Scientist,
Ottawa Hospital Research Institute, Centre
for Transfusion Research, Clinical
Epidemiology Program, Ottawa, Canada
Ari Ercole MB BChir MA PhD FRCA FFICM
Consultant in Neurocritical Care,
Neurosciences Critical Care Unit,
Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK
Darren H Freed MD PhD FRCSC

Associate Professor of Surgery and
Physiology, Head, Surgical Heart Failure
Program, Cardiac Sciences Program, St.
Boniface Hospital, Winnipeg, Manitoba,
Canada
John Fuller MD FRCPC
Professor, Department of Anesthesia and
Perioperative Medicine and Division of
Critical Care (Department of Medicine),
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada
Julio P Zavala Georffino MD
Department of Medicine (Nephrology
section), Geisel School of Medicine,
Dartmouth, NH, USA
RT Noel Gibney MB FRCPC
Professor, Division of Critical Care
Medicine, Faculty of Medicine and
Dentistry, University of Alberta,
Edmonton, Alberta, Canada

Jeff Granton MD FRCPC
Associate Professor, Department of
Anesthesia and Perioperative Medicine and
Division of Critical Care (Department of
Medicine), Schulich School of Medicine and
Dentistry, Western University, London
Health Sciences Centre and St. Joseph’s

Healthcare London, London, Ontario, Canada
Donald EG Griesdale MD MPH FRCPC
Assistant Professor, Department of
Anesthesia, Pharmacology and
Therapeutics, Department of Medicine,
Division of Critical Care Medicine,
University of British Columbia, Vancouver,
British Columbia, Canada
Arun K Gupta MBBS MA PhD FFICM
FRCA FHEA
Director of Postgraduate Education,
Academic Health Sciences Centre, Cambridge
University Health Partners, Consultant in
Anaesthesia and Neurointensive Care,
Cambridge University Hospitals NHS
Foundation Trust, Cambridge, UK
Wael Haddara BSc MD FRCPC
Associate Professor, Department of
Medicine, (Division of Endocrinology and
Metabolism and Division of Critical Care
Medicine), Schulich School of Medicine
and Dentistry, Western University,
London, Ontario, Canada
Ahmed F Hegazy
Assistant Professor, Department of
Anesthesia and Perioperative Medicine,
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada

Umjeet Singh Jolly BSc MD FRCPC
Cardiology Fellow, Schulich School of
Medicine and Dentistry, Western
University, Division of Cardiology
(Department of Medicine), University
Hospital, London Health Sciences Centre,
London, Ontario, Canada


List of contributors

ix

Philip M Jones MD FRCPC
Associate Professor, Department of
Anesthesia and Perioperative Medicine
and Division of Critical Care (Department
of Medicine), and Department of
Epidemiology & Biostatistics, Schulich
School of Medicine and Dentistry, Western
University, London Health Sciences Centre
and St. Joseph’s Healthcare London,
London, Ontario, Canada

Therapeutics, University of Manitoba,
Winnipeg, Manitoba, Canada

Ilya Kagan MD
Senior Physician, General Intensive Care
Department, Rabin Medical Centre,

Beilinson Campus, Petah Tikva, Israel

David Leasa MD FRCPC
Professor of Medicine, Schulich School of
Medicine and Dentistry, Western
University, Consultant, Divisions of
Critical Care Medicine and Respirology,
Department of Medicine and Critical Care,
London Health Sciences Centre, London,
Ontario, Canada

Kala Kathirgamanathan MD FRCPC
Division of Cardiology, Department of
Medicine, Schulich School of Medicine and
Dentistry, Western University, London,
Ontario, Canada
Harneet Kaur MD
Department of Medicine (Nephrology
Section), Geisel School of Medicine,
Dartmouth, NH, USA
John Kellett MD FRCPI
Consultant Physician, Nenagh Hospital,
Nenagh, County Tipperary, Ireland
Bhupesh Khadka MD
Department of Medicine (Nephrology
section), Geisel School of Medicine,
Dartmouth, NH, USA
Biniam Kidane MD MSc FRCSC
Thoracic Surgery Fellow, Department of
Surgery, University of Toronto, Toronto,

Ontario, Canada
Carlos Kidel MB ChB FRCA
Obstetric Anaesthetic Fellow, Department
of Anaesthesia, Royal Free Hospital,
London, UK
Anand Kumar MD FRCPC
Professor, Departments of Medicine,
Medical Microbiology and Pharmacology/

Alejandro Lazo-Langner MD MSc
Assistant Professor of Medicine, Oncology,
and Epidemiology and Biostatistics,
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada

W Robert Leeper MD FRCSC
Trauma and Acute Care Surgery Johns
Hopkins Hospital, Baltimore, MD, USA
Stephen Y Liang MD
Instructor, Divisions of Infectious Diseases
and Emergency Medicine, Washington
University School of Medicine, St. Louis,
Missouri, USA
Tania Ligori BSc MD FRCPC
Assistant Clinical Professor, Department of
Anesthesia and Department of Critical Care,
St Joseph’s Healthcare, Hamilton, McMaster
University, Hamilton, Ontario, Canada

Jaimie Manlucu MD, FRCPC
Assistant Professor, Schulich School of
Medicine and Dentistry, Western
University, Clinical Cardiac
Electrophysiologist, Division of Cardiology
(Department of Medicine), University
Hospital, London Health Sciences Centre,
London, Ontario, Canada
Janet Martin PharmD, MSC(HTA&M),
PhD
Director, Medical Evidence | Decision
Integrity | Clinical Impact (MEDICI),


x

List of contributors

Co-Director, Evidence-Based Perioperative
Clinical Outcomes Research (EPiCOR),
Assistant Professor, Department of
Anesthesia and Perioperative Medicine and
Department of Epidemiology and
Biostatistics, Schulich School of Medicine
and Dentistry, Western University,
London, Ontario, Canada
Ian McConachie MB ChB FRCA FRCPC
Associate Professor, Department of
Anesthesia and Perioperative Medicine,
Schulich School of Medicine and

Dentistry, Western University, London
Health Sciences Centre and St. Joseph’s
Healthcare London, London, Ontario,
Canada
Alan McGlennan MB BS FRCA
Consultant Anaesthetist, Department of
Anaesthesia, Royal Free Hospital,
London, UK
Lauralyn McIntyre MD MSc FRCPC
Assistant Professor, Department of
Medicine (Critical Care), Ottawa Hospital,
Scientist, Ottawa Hospital Research
Institute, Centre for Transfusion and
Critical Care Research, Adjunct
Scientist, Canadian Blood Services, Ottawa,
Canada
Tina Mele MD, PhD FRCSC
Assistant Professor, Department of Surgery
and Division of Critical Care (Department
of Medicine), Schulich School of Medicine
and Dentistry, Western University, London
Health Sciences Centre and St. Joseph’s
Healthcare London, London, Ontario,
Canada
MJ Naisbitt FRCA FFICM DICM
Consultant in Critical Care, Salford Royal
Foundation Trust, Salford, UK
Raj Nichani FRCA
Consultant in Anaesthesia and Critical
Care, Blackpool Teaching Hospitals NHS

Foundation Trust, Blackpool, UK

Daniel H Ovakim MD MSc FRCPC
Critical Care Medicine, Vancouver Health
Island Health Authority, Victoria, British
Columbia, Canada; Medical Toxicology,
British Columbia Drug and Poison
Information Center Vancouver, British
Columbia, Canada
Neil Parry MD FRCSC
General Surgery, Trauma and Critical Care,
Director of Trauma, LHSC, Associate
Professor of Surgery, Western University,
London Health Sciences Centre and St.
Joseph’s Healthcare London, London,
Ontario, Canada
Daniel Castro Pereira MD
Department of Medicine (Nephrology
section), Geisel School of Medicine,
Dartmouth, NH, USA
Thomas Piraino RRT
Assistant Clinical Professor (Adjunct),
Department of Anesthesia (Critical Care),
Faculty of Health Sciences, McMaster
University, Best Practice Clinical Educator,
Respiratory Therapy Services, St. Joseph’s
Healthcare, Hamilton, Ontario, Canada
Brian Pollard BPharm MB ChB MD FRCA
MEWI
Professor of Anaesthesia, Manchester

Medical School, The University of
Manchester, Consultant in Anaesthesia and
Intensive Care, Manchester Royal
Infirmary, Manchester, UK
Valerie Schulz MD FRCPC MPH
Associate Professor, Department of
Anesthesia and Perioperative Medicine,
Schulich School of Medicine and Dentistry,
Western University, Director of Palliative
Care, London Health Sciences Centre and
St. Joseph’s Healthcare London, London,
Ontario, Canada
Michael D Sharpe MD FRCPC
Professor, Department of Anesthesia and
Perioperative Medicine and Division of


List of contributors

Critical Care (Department of Medicine),
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre, London, Ontario, Canada
Rohit K Singal MD MSc FRCSC
Assistant Professor of Surgery, Cardiac
Sciences Program, St. Boniface Hospital,
Winnipeg, Manitoba, Canada
Pierre Singer MD
Professor, Director General Intensive Care
Department, Rabin Medical Center,

Beilinson Campus, Petah Tikva, Israel
Mark Soth MD FRCPC
Associate Professor, Department of
Medicine, McMaster University, Chief,
Department of Critical Care, St Joseph’s
Healthcare, Hamilton, Ontario, Canada
Christian P Subbe DM FRCP
Senior Clinical Lecturer, School of Medical
Sciences, Bangor University, Consultant
Acute, Respiratory and Critical Care
Medicine, Ysbyty Gwynedd, Bangor, UK
Jaffer Syed MD, MEd, FRCPC
Division of Cardiology, Department of
Medicine, McMaster University, Hamilton,
Ontario, Canada
Ravi Taneja FFARCSI, FRCA, FRCPC
Associate Professor, Department of
Anesthesia and Perioperative Medicine and
Division of Critical Care (Department of
Medicine), Schulich School of Medicine
and Dentistry, Western University, London
Health Sciences Centre and St. Joseph’s
Healthcare London, London, Ontario,
Canada
Tom Varughese MD
Department of Anesthesia and
Perioperative Medicine and Division of
Critical Care (Department of Medicine),
Schulich School of Medicine and Dentistry,

xi

Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada
Jennifer Vergel Del Dios MD
Department of Anesthesia and
Perioperative Medicine and Division of
Critical Care (Department of Medicine),
Schulich School of Medicine and Dentistry,
Western University, London Health
Sciences Centre and St. Joseph’s Healthcare
London, London, Ontario, Canada
Jessie R Welbourne MB ChB FRCA
Consultant in Intensive Care Medicine,
Derriford Hospital, Plymouth Hospitals
NHS Trust, Plymouth, UK
Christopher W White MD
Cardiac Sciences Program, St. Boniface
Hospital, Winnipeg, Manitoba,
Canada
Rebecca P Winsett PhD RN
Nurse Scientist, St. Mary’s Medical Center,
Evansville, IN, USA
Titus C Yeung MD FRCPC
Department of Medicine, Division of
Critical Care Medicine, University of
British Columbia, Vancouver British
Columbia, Canada
G Bryan Young MD, FRCPC

Departments of Clinical Neurological
Sciences and Medicine (Critical Care),
Schulich School of Medicine and Dentistry,
Western University, London, Ontario,
Canada
Shelley R Zieroth MD FRCPC
Assistant Professor of Medicine, Director,
St. Boniface Hospital Heart Failure and
Transplant Clinics, Head, Medical Heart
Failure Program, Cardiac Sciences
Program, St. Boniface Hospital, Winnipeg,
Manitoba, Canada



Preface to the third edition
 This text is aimed primarily at trainees working in intensive care – especially
multidisciplinary trainees being exposed to the intensive care unit (ICU) for the first
time. It may also be of interest to ICU nurses looking for information on modern
medical (in the strictest sense) approaches to ICU therapy. A basic knowledge of
physiology and pharmacology is assumed, as well as either a medical background or
advanced nursing experience in intensive care.
 It may also be a useful “aide memoire” for specialist ICU examinations.
 The editors have enlisted a multinational team of contributors active in both practice
and training from institutions on both sides of the Atlantic and beyond. The aim has
therefore been to produce a text of international relevance.
 The authors are all either experienced ICU practitioners or invited experts on specialist
issues. Being involved in ICU research was not a pre-requisite although many of the
authors have been or are involved in ICU research.
 This text aims to provide practical information on the management of common and/or

important problems in the critically ill patient, as well as sufficient background
information to enable understanding of the principles and rationale behind their
therapy. We hope it will prove useful at the bedside, but we would like to emphasize that
this, or any other book, is no substitute for experienced supervision, support and
training.
 Throughout, the importance of cardiac function is emphasized.
 This text does not aim to cover all of ICU practice and is not a substitute to the major
ICU reference textbooks. For example, practical aspects of monitoring techniques are
not covered (best learnt at the bedside), but the philosophy of monitoring is covered
where necessary to illustrate important management points. Similarly, pathophysiology
is included to help understand management principles.
 The third edition contains several new chapters on topical aspects of ICU therapy, as
well as revisions of older chapters – many have been completely rewritten.
 The format is designed to provide easy access to information presented in a concise
manner. We have tried to eliminate all superfluous material. Selected important or
controversial references are presented, as well as suggestions for further reading.

xiii



Section 1
Chapter

1

Basic principles

Oxygen delivery, cardiac function
and monitoring

Lois Champion

Oxygen delivery
The purpose of the circulatory system is ultimately the delivery of oxygen and nutrients to
cells, with removal of waste and carbon dioxide. Oxygen delivery depends on blood flow
(cardiac output) and the amount of oxygen in the blood.
Oxygen delivery ¼ cardiac output × oxygen content in arterial blood
Oxygen is carried in the blood in two forms:
1. Bound to hemoglobin (the amount of oxygen bound to hemoglobin depends on oxygen
saturation)
2. Dissolved in plasma (the amount of oxygen dissolved in plasma depends on the arterial
partial pressure of oxygen (PaO2) and the solubility of oxygen)
Arterial oxygen content ¼ oxygen bound to hemoglobin + oxygen dissolved in plasma
Most of the oxygen in blood is carried bound to hemoglobin, and only a small fraction is
dissolved. Clinically, this means that an arterial oxygen saturation of 90% (corresponding to
a PaO2 of ~60 mmHg) provides essentially normal arterial oxygen content. Oxygen
saturation is measured noninvasively using pulse oximetry.
Arterial oxygen content ¼ oxygen bound to hemoglobin + oxygen dissolved in plasma
Arterial oxygen content (CaO2) ¼ (hemoglobin)(oxygen saturation) (1.34)
+ (PaO2) (0.031)
The usual arterial oxygen saturation is close to 100%, and PaO2 is approximately 90 mmHg.
Arterial blood normally contains approximately 200 mL of oxygen per liter of blood. If we
assume a cardiac output of ~5 L/min then this is an oxygen delivery of ~1 L/min.

Oxygen consumption
Oxygen is carried to the tissues and delivered to cells via the capillaries, where oxygen is
taken up (consumed) by cells, so that venous blood contains less oxygen (and more carbon
dioxide) than arterial blood. The partial pressure of oxygen in the venous blood (PvO2) is,
on average, ~40 mmHg (this corresponds to an oxygen saturation of ~70–75% in the
venous blood).

Handbook of ICU Therapy, third edition, ed. John Fuller, Jeff Granton and Ian McConachie. Published
by Cambridge University Press. © Cambridge University Press 2015.
1


2

Section 1: Basic principles

The overall oxygen content of venous blood is ~150 mL of oxygen/liter of blood. Overall
oxygen consumption is ~250 mL of oxygen per minute; if delivery is ~1 L/min this means
we usually extract about 25% of the oxygen delivered.
 Oxygen consumption (demand) will increase with exercise or fever
 Sedation, paralysis and hypothermia decrease oxygen consumption.

Venous oxygen saturation
Venous oxygen saturation (SvO2) reflects oxygen supply and demand; venous oxygen
saturation will decrease if there is a decrease in oxygen delivery or an increase in oxygen
consumption, because cells will extract more oxygen from the blood to meet demand [1].
Venous oxygen saturation can be monitored either:
 Intermittently, with blood gas sampling from a central venous catheter in the superior
vena cava, or from the pulmonary artery using a pulmonary artery catheter.
Or
 Continuously, using a central venous or pulmonary artery catheter designed to
continuously measure venous oxygen saturation.
 Note that measuring venous oxygen saturation from a femoral venous catheter is not
reliable as an indicator of global perfusion since it reflects oxygen supply and demand
only from the lower extremity [2].
A decrease in venous oxygen saturation below the usual value of ~70–75% suggests
increased oxygen extraction and an oxygen supply/demand imbalance. Increasing oxygen

delivery with inotropic support, or red blood cell transfusion if the hemoglobin is low, may
improve patient outcomes in sepsis [3].
 A normal SvO2, however, does not necessarily reflect normal oxygen delivery because
venous oxygenation is a flow-weighted average of venous blood (no flow in means no
flow out of tissues).
 In some clinical situations, in particular sepsis, there is maldistribution of flow at the
microvascular level. A normal or high venous oxygen saturation may be associated with
a worse prognosis in these patients [4].
Lactic acid is a by-product of anaerobic metabolism. Monitoring lactate levels as an
indicator of tissue ischemia and anaerobic metabolism may also be used to monitor
response to therapy [5–7].

Cardiac function
Cardiac output
Cardiac output (CO) is the volume the heart ejects over time (usually expressed as L/min), a
normal cardiac output is about 5 L/min. Normal cardiac output varies with the size of a
patient (you would expect a 200 kg patient to have a higher cardiac output than a 50 kg
patient because of the increased body mass that must be perfused). In order to standardize
measurements cardiac output is divided by a patient’s body surface area (BSA) to calculate
the cardiac index (CI). The normal CI is 2.5–4 L/min/m2.


Chapter 1: Oxygen delivery, cardiac function and monitoring

3

Cardiac index (CI) ¼ CO/BSA
Stroke volume (SV) is the volume of blood ejected with a single contraction (because the
right and left ventricle are in series, it follows that the stroke volume of the right ventricle
must be the same as the left ventricle). Cardiac output over a minute therefore is the stroke

volume multiplied by the number of beats per minute (or heart rate).
CO ¼ SV × HR
Stroke volume is determined by:
1. Preload – the end-diastolic volume of the ventricle
2. Afterload – the wall tension the ventricle must develop to eject blood
3. Contractility (or inotropy) – the intrinsic performance of the heart at a given preload
and afterload.
Cardiac output

Heart rate

Stroke volume

Preload

Afterload

Contractility

Heart rate
Since cardiac output depends on heart rate it follows that a low heart rate (bradycardia) can
contribute to low cardiac output.
 An increase in heart rate increases the force of ventricular contraction (this is known as
the treppe phenomenon). This effect, however, is minimal or absent in a failing ventricle
with poor systolic function.
 An increase in heart rate increases myocardial oxygen demand, which may precipitate
cardiac ischemia, and decreases the time available for diastolic filling.
Overall, the optimal heart rate is determined by a combination of the treppe phenomenon
and the need for diastolic filling time, as well as other factors in individual patients such as
intrinsic contractility, and valvular or ischemic heart disease.

Stroke volume

The normal ventricle ejects approximately 70 mL of blood with each beat – this is the stroke
volume (SV). The ventricles do not empty completely with contraction, there is some
residual volume remaining at the end of systole (end-systolic volume). During diastole
the ventricles fill; a normal end-diastolic volume (EDV) is approximately 120 mL.

Ejection fraction
Ejection fraction is defined as the ratio of SV/EDV. A normal ejection fraction is 60–65%.


4

Section 1: Basic principles

Preload
Preload is defined as the end-diastolic volume (EDV) of the left ventricle.
The determinants of preload include:
 Circulating blood volume – more volume increases preload.
 Venous tone – venoconstriction increases preload. Venous tone determines venous
capacitance (the veins are the major reservoir for blood volume).
 Ventricular compliance – a more compliant ventricle can hold more blood at a given
pressure than a noncompliant (stiff) ventricle.
 Afterload – if afterload is increased acutely, less blood is pumped out with ventricular
contraction, which leaves more residual blood to add on to end-diastolic volume.
Preload therefore is increased (this is one of the acute compensatory responses to an
increase in afterload).
 Atrial contraction – especially in patients with stiff noncompliant ventricles, by forcing
some additional blood into the ventricles from the atria during late diastole.

 Intrathoracic pressure – increased pressure in the thorax can reduce venous return to the
heart; intrathoracic pressure is increased with positive-pressure ventilation and the use of
positive end-expiratory pressure with mechanical ventilation. Hypovolemic patients may
become hypotensive with intubation and positive-pressure ventilation because of the
increased intrathoracic pressure and decreased venous return to the right ventricle.
An increase in preload (end-diastolic volume of the ventricle) and hence muscle-fiber length
increases resting tension, velocity of tension development and peak tension:
 This allows for greater stroke volume and therefore cardiac output. This is the
Frank–Starling relationship.
 Excessive ventricular volume, however, will eventually overwhelm the ventricle’s capacity
to pump blood forward, and lead to decompensation. As well, a ventricle with poor
systolic function has less capacity to improve contractility with an increase in preload.
Clinically we cannot easily measure preload. Central venous pressure or pulmonary capillary wedge pressure measurements provide information about ventricular filling pressures;
however, correlation with intravascular and intraventricular volume depends on many
factors, such as vascular tone and ventricular compliance.

Afterload
Afterload is the wall tension or stress the ventricle must develop to eject blood. The law of
Laplace states that tension is proportional to both the pressure and radius of a sphere,
divided by twice the wall thickness. This equation assumes that the ventricles are spheres.
Although the ventricles are not true spheres, pressure, radius and wall thickness contribute
to ventricular afterload.
Tension ~ (pressure × radius)/(wall thickness × 2)
 Afterload will therefore be increased if the ventricle generates higher pressures or
becomes larger (dilates). This means that the afterload for the left ventricle is normally
higher than for the right ventricle – it is larger and develops much higher pressures. This
is offset somewhat by the fact that the left ventricle is more muscular, with a thicker wall
than the right ventricle.

Chapter 1: Oxygen delivery, cardiac function and monitoring

5

 Afterload to the ventricle includes a component of preload (ventricular size or radius),
therefore afterload and preload are interdependent.
 In a normal heart, changes in afterload do not impact stroke volume until extreme
values are reached; however, a ventricle with decreased contractility (a “failing
ventricle”) is very sensitive to an increase in afterload.
Clinically, we often simplify the concept of afterload to refer to the pressure the ventricle
generates; we can measure blood pressure quite easily, but it is much more difficult to
quantify the size of a ventricle or its wall thickness.
 Typical conditions that will increase the afterload of the left ventricle are hypertension
and aortic stenosis (aortic stenosis produces a pressure gradient between the left
ventricle and aorta).
 Examples of diseases that increase afterload to the right ventricle include pulmonary
hypertension and pulmonary embolism.
 A chronic increase in afterload leads to compensatory ventricular hypertrophy. An acute
increase in afterload can cause acute cardiac dilatation.
 A clinical example is acute massive pulmonary embolism leading to increased pulmonary
artery pressures and acute right ventricular dilatation seen on echocardiography.

Compliance
Compliance is the relationship between volume and pressure.
Compliance ¼ Δ volume/Δ pressure
The concept of compliance applies to the heart and diastolic function.
 Ventricular volume can be increased in the normal ventricle with little change in
pressure, but as ventricular end-diastolic volume increases further, the diastolic
intraventricular pressure will increase.
 With a less compliant (stiffer or less distensible) ventricle, the same end-diastolic

volume is associated with a higher left-ventricular diastolic pressure.

Contractility
Inotropy or contractility is the intrinsic ability of cardiac muscle cells to shorten in response
to a stimulus (the stimulus is an action potential); shortening of cardiac muscle tissue
results in ejection of blood. An increase in contractility results in a higher stroke volume.
Inotropy can be acutely (myocardial infarction) or chronically (systolic heart failure)
reduced. Clinically this is seen as a reduction in ejection fraction of the left ventricle. The
autonomic nervous system is responsible for controlling the inotropic state of the heart.
 Increased levels of circulating catecholamines result in greater contractility and an
increase in heart rate (mediated by the adrenergic β-receptors), as well as increased
vascular resistance (vasoconstriction mediated by the adrenergic α-receptors).
 Inotropic medications (such as dopamine, dobutamine or epinephrine) can be given as
intravenous infusions to increase cardiac contractility.
 These medications, however, may cause tachycardia, arrhythmias and increased
myocardial oxygen consumption predisposing to myocardial ischemia [8].


6

Section 1: Basic principles

The right and left ventricles: similar but different
The right ventricle (RV) pumps blood to the relatively low-pressure, low-resistance pulmonary system. Pulmonary hypertension is defined as a mean pulmonary artery pressure of >25
mmHg, or a pulmonary vascular resistance of >3 Wood’s units); the left ventricle generates
higher pressures (the normal systemic mean arterial pressure is ~65 mmHg or more).
 The normal right ventricle is less muscular than the left ventricle (LV) anatomically. The
right ventricle may hypertrophy over time (for example in patients with chronic
pulmonary hypertension), just as the left ventricle may hypertrophy when faced with an
increase in afterload.

 The right ventricle may acutely dilate with a sudden increase in afterload. For example,
in a patient with acute pulmonary embolism a sudden increase in pulmonary artery
pressure can lead to acute right ventricular dilation and RV failure.
 With severe RV dilation the RV may “push” the interventricular septum over toward the
LV, impacting left ventricular diastolic filling, compliance and systolic function. This
phenomenon is known as “ventricular interdependence” [9].
Coronary blood flow to the right ventricle occurs throughout the cardiac cycle – during
both systole and diastole – because the right ventricle systolic pressures are not high enough
to compress the coronary blood vessels. Maximal coronary blood flow to the left ventricle,
however, occurs during early diastole. With the left ventricle there is actually a brief reversal
of coronary flow during systole, as the muscular left ventricle contracts and generates high
systolic pressures.
 Right heart failure is associated with an increase in right-sided pressures – clinically this
is seen as elevated jugular venous pressure or central venous pressure – this pressure
may be transmitted downstream causing congestion of the liver, ascites formation and
peripheral edema.
 Patients can have biventricular failure (both right and left ventricular failure), pure rightsided heart failure (for example, with chronic pulmonary hypertension), or left-sided failure.
 Note, however, that with chronic left-heart failure the left-sided pressures will be
increased, and the right ventricle will have to pump against these higher pressures,
eventually causing the right ventricle to fail also; in fact the most common cause of
right-sided failure is chronic left-heart failure.

Monitoring
Monitoring may be described as the intermittent or continuous observation of a patient
using clinical examination and appropriate equipment to assess progress of the condition:
 The most useful and reproducible monitor remains a thorough and repeated clinical
examination by the doctor.
 Not all critical care environments are the same, and all models of monitoring equipment
are slightly different. The clinician must take time to become familiar with the
equipment in his or her own hospital.

Monitoring may allow us to:
 intervene therapeutically in emergency situations,
 guide and plan future therapy,


Chapter 1: Oxygen delivery, cardiac function and monitoring

7

 establish diagnoses,
 establish prognosis.
Monitoring, however, is not a therapy in itself; in order for monitoring to improve outcome
it must be correctly interpreted and acted upon, and done with the minimum of
complications.

Oxygen saturation monitoring (pulse oximetry)
Oxygen saturation monitors (pulse oximetry) use two different wavelengths of light in the
red and infrared spectrum, which are absorbed differentially by oxyhemoglobin and
deoxyhemoglobin. The pulse oximeter separates the pulsatile component of the absorption
signal from the nonpulsatile component – the assumption being that the pulsatile component represents arterial blood.
 If a patient is hypotensive or severely vasoconstricted, the pulse oximeter may not be
able to detect an accurate signal.
 The pulse oximeter shines the light through tissue (usually a finger, but earlobe, nose
etc. can be used) and then determines how much of each wavelength was absorbed – and
calculates the oxygen saturation.
 Since the absorption spectrum of carboxyhemoglobin (COHb) and oxyhemoglobin with
the light wavelengths used in pulse oximetry are similar, the oximeter will give a falsely
high oxygen saturation reading with carbon monoxide poisoning. Similarly
methemoglobinemia may interfere with accurate pulse oximetry [10].

Noninvasive blood pressure monitoring
NIBP stands for noninvasive blood pressure and uses a blood pressure cuff, with a machine
that automatically inflates and deflates the cuff. Noninvasive blood pressure devices provide
systolic, diastolic and mean arterial pressure, as well as an audible alarm system, and can be
programmed to measure BP as often as required clinically (as often as every minute in an
unstable patient). The measurement is based on oscillometry; variations in the pressure in
the BP cuff due to arterial pulsations are sensed by the monitor (if you take a blood pressure
manually you will note these oscillations yourself as small deflections in the sphygmomanometer as you deflate the cuff). The pressure at which oscillations are maximal correlates
with mean arterial pressure; systolic and diastolic pressures are calculated using a formula
based on the peak of the oscillations.
 Automated NIBP measurements correlate closely with directly measured BP (standards
require that error be less than 5 ± 8 mmHg with respect to reference standard); in
severely hypotensive patients it may be imp
466

Index

inspiratory positive airway
pressure (IPAP),
88, 91
inspiratory to expiratory ratio,
421
insulin, 429
Intensive Care Society, 405
intermittent positive-pressure
ventilation (IPPV)
beneficial effects, 139
cardiovascular effects, 137–8
contraindications, 136–7
goals, 139

indications for, 135–6
initial settings, 140–1
limitations, 139
management plan/checklist,
133
principles of, 135
respiratory effects, 138
VILI, 141–2
intermittent renal replacement
therapy (IRT), 198
versus CRRT, 203–4
internal jugular vein, 28, 281
intra-abdominal hypertension
(IAH), 380–1
intra-aortic balloon pump
(IABP), 298, 312
intrathoracic pressure (ITP), 4,
8, 137
intravascular volume, 9–10
ischemic colitis, 378
ischemic heart disease, 62–3
ischemic stroke, 394, 437
isoflurane, 189
isoproterenol, 164, 167
ketamine, 81, 423
labetalol, 170, 407
lactic acidosis, 58
laryngeal mask airway (LMA),
83
left ventricle (LV), 6

LEMON evaluation tool, 78–9
levosimendan, 312
lidocaine, 271, 327–8
life support, 253
withdrawal protocol, 257–8
withholding and withdrawal,
257
linezolid, 177
lipids, 98
long-bone fracture fixation, 269
lorazepam, 396

low tidal volume ventilation,
148
lung injury score (LIS), 361
lung-protective ventilator
strategy, 147
lung recruitment, 366
lung volume, limiting, 365
magnesium disorders, 124–5
hypermagnesemia, 126
hypomagnesemia, 125–6
magnesium sulfate, 422
major obstetric hemorrhage,
410–12
mannitol, 283
maternal critical care, 404–6
mechanical circulatory support
(MCS), 312–15
mechanical ventilation.

See also intermittent
positive-pressure
ventilation (IPPV),
noninvasive positivepressure ventilation
(NIPPV)
assisted modes, 145–7
asthmatic, 420
controlled modes, 145
discontinuing. See weaning
inspiratory breath
characteristics, 144
modes of, 144
prolonged, 210, 213
sepsis-induced ARDS, 343
strategies, 147–50
meropenem, 176
MET syndromes, 227–8
metabolic acidosis
acid–base analysis, 107
anion gap, 106
approach to, 105
asthma, 105, 119, 129, 380,
417
causes, 105
definition, 105
nonanion gap, 106
treatment, 108
metabolic alkalosis
clinical features, 109
definition, 108

investigations, 109
pathophysiology, 108
treatment, 109
methicillin-resistant
Staphylococcus aureus
(MRSA), 33–4

methyl prednisolone, 371
metoclopramide, 99
metronidazole, 379
micafungin, 178
midazolam, 189, 396
milrinone, 164, 166–7, 312
minimum inhibitory
concentration (MIC), 180
mixed venous oxygen
saturation SvO2, 16
mobilization, early, 156, 272
monitoring, 6
central venous pressure, 8–9
direct arterial BP, 7
noninvasive blood
pressure, 7
pulmonary artery catheters,
10–11
pulse oximetry, 7
pulse pressure variation, 9
shock, 15–17
morphine, 190
MUD PILES, 106

multiorgan failure, 205–6
muscle biopsies, 240
muscle relaxation.
See neuromuscular
blockade
muscle testing, 238
myocardial infarction, 290,
See also acute coronary
syndromes (ACS)
hypotension and shock,
15–16
myocardial ischemia, 92
narcotics, 258, 434
nasal cannulae, 21
nasal mask, 89
nasal tracheal tubes, 134–5
National Institute for Health
and Care Excellence
(NICE), 406
natriuretic peptides, 305
neostigmine, 387
nephrogenic diabetes insipidus
(DI), 115–16
neurally adjusted ventilatory
assist (NAVA), 146
neurocognitive interventions,
248
neurogenic shock, 266
neurological determination of
death (NDD), 442–4

neurological injury, 267
blood transfusions, 63


Index

post-cardiac surgery, 437
spinal cord, 285–6
neuromonitoring, 280–1
neuromuscular blockade, 81,
193
agents, 193–4
ARDS, 370
monitoring, 194
problems, 193
neurotransmitters, 162
neurotrauma. See spinal-cord
injury (SCI), traumatic
brain injury (TBI)
nitric oxide, inhaled, 369
nitroglycerin, 164, 169
nonanion gap metabolic
acidosis, 106
noninvasive blood pressure
(NIBP) monitoring, 7
noninvasive positive-pressure
ventilation (NIPPV), 88–94
ACPE management, 91
ARDS management, 92
choosing an interface, 89–90

COPD management, 91
immunosuppression
management, 93
indications/
contraindications, 137
initiating, 90
interfaces, 89
pneumonia management, 92
weaning adjunct, 93
noninvasive ventilation (NIV)
asthmatics, 419–20
weaning and, 157
nonocclusive mesenteric
ischemia (NOMI), 384
non-rebreathing masks, 22
norepinephrine, 18, 163–4, 340
normo-osmolar hyponatremia,
111
NSAIDs, 294
NSTEMI, 290–1
nutrition, 95–102,
See also enteral nutrition
acute pancreatitis, 383
acute respiratory failure, 100
CCI patient, 214–15
critically ill patient, 96
early or late feeding, 96
energy and protein
requirements, 97
hyperglycemia, 100

nonprotein requirements, 97
novel substrates, 100–2

oral feeding, 98
other requirements, 98
sepsis, 342
nutritional status, 96
assessment, 96
Ω-3 fatty acids, 100
obstetric patient
amniotic fluid embolism,
409–10
cardiac arrest, 413, 456
cardiovascular system, 404
changes in pregnancy, 403
eclampsia and pre-eclampsia,
406–7
HELLP syndrome, 407
major hemorrhage, 410–12
maternal critical care, 404–6
parturient, 413–14
renal system, 404
respiratory infections, 412
respiratory system, 403
sepsis, 412
trauma, 412
VTE, 407–9
obstructive shock, 14
octreotide, 376
Ogilvie’s syndrome, 385–8

open-lung concept, 365
oral feeding, 215
oral tracheal tubes, 134–5
organ donors
investigations, 445
monitoring, 444
NDD, 442–4
therapeutic interventions,
445–9
organ dysfunction, 336
outcomes measures, 229
oxygen cascade, 20
oxygen consumption, 1, 55
oxygen delivery, 1–2, 54
blood transfusion and, 58–9
oxygen saturation monitoring.
See pulse oximetry
oxygen therapy, 20–6
asthmatic patient, 420
delivery devices, 21–3
hazards of, 24–6
physiology and pathology,
20–1
specific illnesses, 23–4
oxygen toxicity, 24–5
oxyhemoglobin dissociation
curve (ODC), 55
oxytocin, 411

467

palliative care, 217, 252
components of high quality,
254
definition, 253
integration models, 253
key components in ICU,
254–6
practical approach in ICU,
256
pancuronium, 194
paracetamol (acetaminophen),
190
parasympathetic nervous
system, 161
parenteral nutrition, 97, 99–100
paroxysmal supraventricular
tachycardias, 327–8
parturient patient, 413–14
pericardial complications, 298
permissive hypercapnia, 421
permissive hypoxemia, 26
pharmacodynamics, 180–1
pharmacokinetics, 179–81
phentolamine, 170
phenylephrine, 164–5, 341
phosphorus disorders, 127–8
hyperphosphatemia, 129–30
hypophosphatemia, 128–9
physician-assisted suicide, 253

physiotherapy, 216
piperacillin, 176
PIRO staging system, 335
plasma, 40
Plasmodium aeruginosa, 175
platelet abnormalities, 75
platelet count, 68
platelet function defects, 74
platelet transfusions, 75
pneumonia
NIPPV management, 92
ventilator-associated, 174
pneumothorax
CVC complication, 31
tension, 266
positive end-expiratory
pressure (PEEP), 8, 20,
146–7, 421
ventilatory strategies, 148–9
post-intensive care syndrome
(PICS), 235–6
post-intubation management,
84
post-partum hemorrhage, 411
post-traumatic shock
hemorrhagic sources, 265
neurogenic, 266