Ebook Oh''s intensive care manual (7/E): Part 1

OH’S INTENSIVE CARE MANUAL
SEVENTH EDITION


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Seventh Edition

OH’S INTENSIVE
CARE MANUAL
Edited by

Andrew D Bersten
MB BS MD FCICM

Director, Intensive Care Unit, Flinders Medical Centre
Professor and Head, Department of Critical Care Medicine
Flinders University
Adelaide, SA, Australia

Neil Soni

MB ChB MD FANZCA FRCA FCICM FFICM
Consultant in Intensive Care
Chelsea and Westminster Hospital
Honorary Senior Lecturer
Imperial College Medical School
London, United Kingdom

For additional online content visit expertconsult.com


© 2014 Elsevier Ltd. All rights reserved.
First edition 1979
Second edition 1985
Third edition 1990
Fourth edition 1997
Fifth edition 2003
Sixth edition 2009
Seventh edition 2014
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ISBN: 978-0-7020-4762-6
Ebook ISBN: 978-1-4557-5013-9

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Notices
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Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
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Printed in China

Last digit is the print number:â•… 9â•… 8â•… 7â•… 6â•… 5â•… 4â•… 3â•… 2â•… 1


Contents

List of Contributorsâ•… xiii
Prefaceâ•… xxi
Acknowledgementsâ•… xxii

Part One – Organisation Aspects



1

Design and organisation of intensive care unitsâ•… 3
Vineet V Sarode and Felicity H Hawker



2

Critical care outreach and rapid response systemsâ•… 10
John R Welch and Christian P Subbe



3

Severity of illness and likely outcome from critical illnessâ•… 16

Mark Palazzo



4

Transport of critically ill patientsâ•… 27
Evan R Everest and Matthew R Hooper



5

Physiotherapy in intensive careâ•… 38
Fiona H Moffatt and Mandy O Jones



6

Critical care nursingâ•… 47
John R Welch



7

Ethics in intensive careâ•… 55
Raymond F Raper and Malcolm M Fisher

8

Common problems after ICUâ•… 61
Carl S Waldmann and Evelyn Corner



9

Clinical information systemsâ•… 69
David Fraenkel



10

Clinical trials in critical careâ•… 75
Simon Finfer and Anthony Delaney



11

Palliative careâ•… 85
Sarah Cox and Neil Soni

12

ICU and the elderlyâ•… 90
Richard Keays



13

Health care team in intensive care medicineâ•… 98
Gerry O’Callaghan



14

Preparing for examinations in intensive care medicineâ•… 107
Carole Foot and Liz Hickson

Part Two – Shock


15

Overview of shockâ•… 115
Matthew J Maiden and Sandra L Peake


vi

Contents



16

Haemodynamic monitoringâ•… 122
David J Sturgess



17

Multiple organ dysfunction syndromeâ•… 138
Matthew J Maiden and Marriane J Chapman



18

Monitoring oxygenationâ•… 146
Thomas J Morgan and Balasubramanian Venkatesh



19

Lactic acidosisâ•… 158
D James Cooper, Alisa M Higgins and Alistair D Nichol

Part Three – Acute Coronary Care



20

Acute cardiac syndromes, investigations and interventionsâ•… 167
Bradley Power



21

Adult cardiopulmonary resuscitationâ•… 191
Peter T Morley



22

Management of cardiac arrhythmiasâ•… 200
Andrew Holt



23

Cardiac pacing and implantable cardioverter defibrillatorsâ•… 260
Aaisha Opel and Oliver R Segal

24

Acute heart failureâ•… 271
Nicholas Ioannou, Pratik Sinha and David Treacher



25

Valvular and congenital heart disease and bacterial endocarditisâ•… 289
Mary White and Susanna Price



26

Intensive care after cardiac surgeryâ•… 299
Raymond F Raper



27

Echocardiography in the intensive care unitâ•… 308
Guido Tavazzi and Susanna Price

Part Four – Respiratory Failure

28

Oxygen therapyâ•… 327
Adrian J Wagstaff



29

Airway management and acute airway obstructionâ•… 341
Gavin M Joynt and Gordon YS Choi



30

Acute respiratory failure in chronic obstructive pulmonary diseaseâ•… 354
Matthew T Naughton and David V Tuxen



31

Mechanical ventilationâ•… 364
Andrew D Bersten

32

Humidification and inhalation therapyâ•… 375
Steven T Galluccio and Andrew D Bersten



33

Acute respiratory distress syndromeâ•… 382
Andrew D Bersten



34

Pulmonary embolismâ•… 392
Andrew R Davies and David V Pilcher



35

Acute severe asthmaâ•… 401
David V Tuxen and Matthew T Naughton


Contents

36

Pneumoniaâ•… 414
Kai Man Chan and Charles D Gomersall



37

Non-invasive ventilationâ•… 429
Graeme J Duke and Andrew D Bersten



38

Respiratory monitoringâ•… 436
Andrew D Bersten



39

Imaging the chestâ•… 445
Simon PG Padley



40

Ultrasound in the ICUâ•… 461
Ubbo F Wiersema



41

Extracorporeal membrane oxygenation (ECMO)â•… 472
Vincent Pellegrino
41.1â•… ECMO for respiratory failureâ•… 472
41.2â•… ECMO for cardiac failureâ•… 479

Part Five – Gastroenterological Emergencies and Surgery



42

Acute gastrointestinal bleedingâ•… 487
Joseph JY Sung



43

Severe acute pancreatitisâ•… 495
Duncan LA Wyncoll

44

Liver failureâ•… 501
Christopher Willars and Julia Wendon
44.1â•… Acute hepatic failureâ•… 501
44.2â•… Cirrhosis and acute-on-chronic liver diseaseâ•… 512



45

Abdominal surgical catastrophesâ•… 520
Stephen J Streat



46

Solid tumours and their implications in the ICUâ•… 526
Timothy Wigmore and Pascale Gruber

Part Six – Acute Renal Failure



47

Acute kidney injuryâ•… 535
Rinaldo Bellomo

48

Renal replacement therapyâ•… 540
Rinaldo Bellomo

Part Seven – Neurological Disorders



49

Disorders of consciousnessâ•… 549
Balasubramanian Venkatesh



50

Status epilepticusâ•… 560
Helen I Opdam



51

Acute cerebrovascular complicationsâ•… 568
Bernard Riley and Thearina de Beer

vii


viii

Contents



52

Cerebral protectionâ•… 580
Victoria Heaviside and Michelle Hayes



53

Brain deathâ•… 591
Martin Smith



54

Meningitis and encephalomyelitisâ•… 597
Angus M Kennedy

55

Tetanusâ•… 607
Jeffrey Lipman



56

Deliriumâ•… 611
Timothy M Alce, Valerie Page and Marcela P Vizcaychipi



57

Neuromuscular diseases in intensive careâ•… 617
George Skowronski and Manoj K Saxena

Part Eight – Endocrine Disorders



58

Diabetic emergenciesâ•… 629
Richard Keays

59

Diabetes insipidus and other polyuric syndromesâ•… 637
Alastair C Carr



60

Thyroid emergenciesâ•… 652
Jonathan M Handy and Alexander M Man Ying Li



61

Adrenocortical insufficiency in critical illnessâ•… 660
Balasubramanian Venkatesh and Jeremy Cohen



62

Acute calcium disordersâ•… 666
Balasubramanian Venkatesh

Part Nine – Obstetric Emergencies

63

Preeclampsia and eclampsiaâ•… 677
Wai Ka Ming and Tony Gin



64

General obstetric emergenciesâ•… 684
Winnie TP Wan and Tony Gin



65

Severe pre-existing disease in pregnancyâ•… 692
Jeremy P Campbell and Steve M Yentis

Part Ten – Infections and Immune Disorders



66

Anaphylaxisâ•… 699
Malcolm M Fisher

67

Host defence mechanisms and immunodeficiency disordersâ•… 703
Steven McGloughlin and Alexander A Padiglione



68

HIV and acquired immunodeficiency syndromeâ•… 710
Alexander A Padiglione and Steve McGloughlin



69

Severe sepsisâ•… 716
A Raffaele De Gaudio



70

Nosocomial infectionsâ•… 724
James Hatcher and Rishi H-P Dhillon


Contents

71

Severe soft-tissue infectionsâ•… 733
Ilker Uçkay, Hugo Sax, Pierre Hoffmeyer, Daniel Lew and Didier Pittet



72

Principles of antibiotic useâ•… 738
Jeffrey Lipman



73

Tropical diseasesâ•… 743
Ramachandran Sivakumar and Michael E Pelly

ix

Part Eleven – Severe and Multiple Trauma



74

Severe and multiple traumaâ•… 755

James A Judson and Li C Hsee



75

Severe head injuriesâ•… 762
John A Myburgh and Manoj K Saxena



76

Faciomaxillary and upper-airway injuriesâ•… 777
Cyrus Edibam and Hayley Robinson



77

Chest injuriesâ•… 784
Ubbo F Wiersema



78

Spinal injuriesâ•… 795
Sumesh Arora and Oliver J Flower

79

Abdominal and pelvic injuriesâ•… 807
Colin McArthur and Pieter HW Lubbert

Part Twelve – Environmental Injuries



80

Submersionâ•… 817
Cyrus Edibam and Tim Bowles



81

Burnsâ•… 821
David P Mackie and Jacqueline EHM Vet



82

Thermal disordersâ•… 829
Stephen W Lam and Richard Strickland

83

Electrical safety and injuriesâ•… 844
Lester AH Critchley



84

Envenomationâ•… 851
James Tibballs



85

Ballistic injuryâ•… 861
Michael C Reade and Peter D (Toby) Thomas



86

Background information on ‘biochemical terrorism’â•… 871
Munita Grover and Michael Pelly

Part Thirteen – Pharmacologic Considerations

87

Pharmacokinetics, pharmacodynamics and drug monitoring in critical illnessâ•… 881
Christine Chung



88

Management of acute poisoningâ•… 892
David M Wood and Duncan LA Wyncoll



89

Sedation and pain management in intensive careâ•… 903
Luke E Torre


x

Contents



90

Inotropes and vasopressorsâ•… 912
John A Myburgh



91

Vasodilators and antihypertensivesâ•… 923
Anthony C Gordon and John A Myburgh

Part Fourteen – Metabolic Homeostasis



92

Acid–base balance and disordersâ•… 937
Thomas J Morgan



93

Fluid and electrolyte therapyâ•… 949
Anthony Delaney and Simon Finfer



94

Enteral and parenteral nutritionâ•… 960
Richard Leonard

Part Fifteen – Haematological Management



95

Blood transfusionâ•… 973
James P Isbister



96

Colloids and blood productsâ•… 987
Michael MG Mythen and Matthias Jacob



97

Therapeutic plasma exchange and intravenous immunoglobulin therapyâ•… 993
Ian Kerridge, David Collins and James P Isbister



98

Haemostatic failureâ•… 1003
Chee W Tan, Christopher M Ward and James P Isbister



99

Haematological malignancyâ•… 1017
Pascale Gruber and Timothy Wigmore

Part Sixteen – Transplantation



100

Organ donationâ•… 1031
Stephen J Streat



101

Liver transplantationâ•… 1040
Anish Gupta, Simon Cottam and Julia Wendon



102

Heart and lung transplantationâ•… 1053
Peter S Macdonald and Paul C Jansz

Part Seventeen – Paediatric Intensive Care



103

The critically ill childâ•… 1071
Shelley D Riphagen



104

Upper airway obstruction in childrenâ•… 1077
Paul James and Sara Hanna



105

Acute respiratory failure in childrenâ•… 1085
Tavey Dorofaeff and Kevin Plumpton



106

Paediatric fluid and electrolyte therapyâ•… 1096
Frank Shann


Contents

xi



107

Sedation and analgesia in childrenâ•… 1103
Geoff Knight



108

Shock and cardiac diseaseâ•… 1109
Johnny Millar



109

Neurological emergencies in childrenâ•… 1121
Anthony J Slater

110

Paediatric traumaâ•… 1133
Kevin McCaffery



111

Withholding and withdrawing life-sustaining medical treatment in childrenâ•… 1140
James Tibballs



112

Paediatric poisoningâ•… 1148
James Tibballs



113

Paediatric cardiopulmonary resuscitationâ•… 1158
James Tibballs



Appendix 1

Normal biochemical valuesâ•… 1168



Appendix 2

Système International (SI) unitsâ•… 1171



Appendix 3

Respiratory physiology symbols and normal valuesâ•… 1173



Appendix 4

Physiological equationsâ•… 1176



Appendix 5

Plasma drug concentrations and American nomenclatureâ•… 1179



Appendix 6

Confirmation of intubationâ•… 1183



Appendix 7

Parameters monitored and measured by the PiCCO monitorâ•… 1184



Appendix 8

Mortality/dysfunction risk scores and modelsâ•… 1185



Appendix 9

Therapeutic hypothermia



Appendix 10

The Child-Pugh classification
Indexâ•… 1190


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List of Contributors

Timothy M Alce BSc MB BS PhD
Clinical Research Fellow, Department of Anaesthesia,
Chelsea and Westminster Hospital, London, UK

Gordon YS Choi BSc MB BS FHKCA (IC) CICM
Consultant, Intensive Care Unit, Prince of Wales
Hospital, Shatin, NT, Hong Kong

Sumesh Arora MD EDIC FCICM
Staff Specialist, Intensive Care Medicine, Prince of
Wales Hospital; Conjoint Lecturer, University of
New South Wales, Sydney, NSW, Australia

Christine Chung BPharm MSc
Lead Directorate Pharmacist, Imaging and
Anaesthetics, Department of Pharmacy,
Chelsea and Westminster NHS Foundation Trust,
London, UK

Thearina de Beer MBchB FRCA DICM FFICM
Consultant AICU, Neuro-ICU and Anaesthetics,
Department of Critical Care, Nottingham University
Hospitals NHS Trust, Nottingham, UK
Rinaldo Bellomo MB BS FRACP MD FCICM
Professor, The University of Melbourne, Honorary
Professor, Monash University, Melbourne; Honorary

Professor, Sydney University, Sydney, NSW,
Australia; Concurrent Professor, University of
Nanjing, Nanjing, China
Andrew D Bersten MB BS MD FCICM
Director, Intensive Care Unit, Flinders Medical
Centre; Professor and Head, Department of
Critical Care Medicine, Flinders University,
Adelaide, SA, Australia
Tim Bowles BSc (Hons) MB BS FRCA
Senior Registrar, Intensive Care Unit, Royal Perth
Hospital, Perth, WA, Australia
Jeremy P Campbell MB ChB (Hons) MRCS FRCA
Consultant Anaesthetist, Queen Charlotte’s and
Chelsea Hospital, Imperial College Healthcare NHS
Trust, London, UK
Alastair C Carr MB ChB MSc DA FRCA DICM FFICM MBA
Consultant in Intensive Care Medicine, The Royal
Marsden Hospital, London, UK
Marianne J Chapman BM BS PhD FCICM
Associate Professor, Discipline of Acute Care
Medicine, University of Adelaide; Director of
Research and Senior Staff Specialist, Intensive Care
Unit, Royal Adelaide Hospital, Adelaide, SA,
Australia
Kai Man Chan MBChB FHKCA (IC) FHKCA FHKAM FCICM
Associate Consultant, Department of Anaesthesia
and Intensive Care, Prince of Wales Hospital,
Shatin, NT, Hong Kong

Jeremy Cohen FRCA MRCP FCICM PhD

Department of Intensive Care, Royal Brisbane and
Ipswich Hospitals, University of Queensland,
Brisbane, QLD, Australia
David Collins

BSc (Hons) MN MAppMgt (Nursing) Grad Dip

Haem Nursing

Clinical Nurse Consultant – Apheresis, Northern
Sydney Cancer Centre, Royal North Shore Hospital,
Sydney, NSW, Australia
D James Cooper BM BS MD FRACP FCICM
Professor of Intensive Care Medicine, Director,
Australian and New Zealand Intensive Care Research
Centre, Monash University and Alfred Hospital,
Melbourne, VIC, Australia
Evelyn Corner BSc (Hons) MRes MCSP
Clinical Lead Respiratory Physiotherapist, Chelsea
and Westminster NHS Foundation Trust; Research
Fellow, Imperial College Medical School, London, UK
Simon Cottam MB ChB FRCA
Consultant Anaesthetist, King’s College Hospital,
London, UK
Sarah Cox BSc MB BS FRCP
Consultant in Palliative Medicine, Chelsea and
Westminster NHS Foundation Trust and Trinity
Hospice; Honorary Senior Lecturer, Imperial College
School of Medicine, London, UK
Lester AH Critchley MD FFARCSI FHKAM

Professor, Honorary Consultant, Specialist
Anaesthetist, Department of Anaesthesia and
Intensive Care, The Chinese University of Hong
Kong, Shatin, NT, Hong Kong
Andrew R Davies MB BS FRACP FCICM
Intensive Care Specialist, Melbourne, VIC, Australia


xiv

List of Contributors

Anthony Delaney MB BS MSc FACEM FCICM
Staff Specialist in Intensive Care, Royal North Shore
Hospital; Senior Lecturer, Northern Clinical School,
Sydney Medical School, University of Sydney,
Sydney, NSW, Australia
Rishi H-P Dhillon MB ChB FRCPath MRCP DTM&H
Consultant in Microbiology, Public Health Wales
Microbiology, University Hospital of Wales,
Cardiff, Wales, UK
Tavey Dorofaeff MB ChB FRACP (NZ) CICM
Senior Lecturer, University of Queensland; Specialist
Paediatric Intensivist, PICU Royal Children’s
Hospital, Brisbane, QLD, Australia
Graeme J Duke MB BS MD FCICM FANZCA
Senior Staff Specialist, Intensive Care Department,
Box Hill Hospital, Box Hill, VIC, Australia
Cyrus Edibam MB BS (UWA) FANZCA FCICM DDU
Director, Intensive Care Medicine, Royal Perth

Hospital, Perth, WA, Australia
Evan R Everest BSc MB ChB FRACP FCICM
Senior Consultant Intensive and Critical Care Unit,
Flinders Medical Centre; Retrieval Consultant,
MedSTAR Emergency Retrieval Service;
Operations Manager, SA State Rescue Helicopter
Service; Senior Lecturer, Department of Intensive
Care School of Medicine, Flinders University,
Adelaide, SA, Australia
Simon Finfer MB BS FRCP FRCA FCICM MD
Professor, Sydney Medical School, University of
Sydney; Senior Staff Specialist in Intensive Care,
Intensive Care Unit, Royal North Shore Hospital,
Pacific Highway, St Leonards, NSW, Australia
Malcolm M Fisher AO MB ChB MD FCICM FRCA
Clinical Professor, Departments of Medicine
and Anaesthesia, University of Sydney,
Sydney, NSW, Australia
Oliver J Flower BMedSci MB BS FCICM
Staff Specialist, Royal North Shore Hospital,
Clinical Lecturer, University of Sydney,
Sydney, NSW, Australia
Carole Foot MB BS (Hons) MSc FACEM FCICM
Intensive Care Specialist, Royal North Shore Hospital;
Clinical Associate Professor, University of Sydney,
Sydney, NSW, Australia
David Fraenkel BM BS FRACP FCICM
Senior Staff Specialist, Department of Intensive
Care, Princess Alexandra Hospital,
Brisbane, QLD, Australia

Steven T Galluccio MB BS FCICM FRACP PGDipClinUS
Consultant, Department of Intensive and
Critical Medicine, Flinders Medical Centre,
Adelaide, SA, Australia
A Raffaele De Gaudio MD
Professor of Anesthesiology and Intensive Care,
Department of Health Sciences, University of
Florence, Florence, Italy
Tony Gin MB ChB FRCA FANZCA FHKAM MD
Chairman, Department of Anaesthesia and Intensive
Care, The Chinese University of Hong Kong, Hong
Kong; COS and Head of Department, Department of
Anaesthesia and Intensive Care, Prince of Wales
Hospital, Shatin, NT, Hong Kong
Charles D Gomersall

BSc MB BS FRCA EDIC FCICM FHKCA

(IC) FHKAM FRCP (Glasg)

Professor, Department of Anaesthesia and Intensive
Care, The Chinese University of Hong Kong,
Shatin, NT, Hong Kong
Anthony C Gordon MB BS MD FRCA FFICM
Clinical Senior Lecturer, Section of Anaesthetics, Pain
Medicine and Intensive Care, Faculty of Medicine,
Imperial College, London, UK
Munita Grover BSc (Hons) MB BS FRCA MD FFICM
Consultant Intensivist, North West London Hospitals

NHS Trust, Northwick Park Hospital, Watford, UK
Pascale Gruber MB BS MRCP FRCA EDIC FFICM
Consultant in Intensive Care Medicine and
Anaesthesia, The Royal Marsden NHS Foundation
Trust, London, UK
Anish Gupta BSc MB BS FRCA
Consultant Anaesthetist, King’s College Hospital,
London, UK
Jonathan M Handy BSc MB BS FRCA EDIC FFICM
Consultant, Magill Department of Anaesthetics,
Intensive Care and Pain Management, Chelsea and
Westminster Hospital; Honorary Senior Lecturer,
Imperial College School of Medicine, London, UK
Sara Hanna MB B Chir MRCPCH
Consultant, Intensive Care, Evelina Children’s
Hospital, Guy’s and St Thomas’ Foundation Trust,
London, UK
James Hatcher MBChB DTM&H MRCP
Specialty Registrar in Infectious Diseases and Medical
Microbiology, Chelsea and Westminster NHS
Foundation Trust, London, UK
Felicity H Hawker MB BS FCICM
Intensive Care Specialist, Cabrini Hospital,
Melbourne, VIC, Australia


List of Contributors
Michelle Hayes MD FRCA FFICM
Consultant in Anaesthetics and Intensive Care, Magill
Department of Anaesthetics, Chelsea and Westminster

Hospital, London, UK
Victoria Heaviside MB BS FRCA FFICM
Consultant in Intensive Care Medicine and
Anaesthesia, St Bartholomew’s Hospital, Barts and
The London NHS Trust, London, UK
Liz Hickson MB ChB (Hons) MMedSci MRCP (UK) FCICM
Intensive Care Specialist, Royal North Shore Hospital;
Clinical Senior Lecturer, University of Sydney,
Sydney, NSW, Australia
Alisa Higgins MPH BPhysio (Hons)
Research Fellow, Australian and New Zealand
Intensive Care Research Centre, Department of
Epidemiology and Preventive Medicine, Monash
University, Melbourne, VIC, Australia
Pierre Hoffmeyer MD
Professor and Head, Division of Orthopaedics
and Traumatology; Chair, Department of
Surgery, Geneva University Hospital,
Geneva, Switzerland
Andrew Holt MB BS FCICM
Critical Care Specialist, Department of Critical
Care Medicine, Flinders Medical Center,
Bedford Park, SA, Australia
Matthew R Hooper MB BS DipIMC RCS (Ed) FACEM FCICM
PGCertClinUS

Associate Professor, Anton Breinl Centre, James
Cook University, Townsville; Senior Consultant,
MedSTAR Emergency Medical Retrieval Service;
Senior Staff Specialist, Intensive and Critical Care

Unit, Flinders Medical Centre; Squadron Leader,
Royal Australian Air Force Specialist Reserve,
Adelaide, SA, Australia
Li C Hsee BSc MB BCh BAO LRCP LRCS (I) FRACS
Consultant Trauma and Acute Care Surgeon,
Trauma Service, Auckland City Hospital,
Auckland, New Zealand
Nicholas Ioannou BA MB BS MA MRCP FRCA FFICM
Consultant Intensivist and Anaesthetist, Guy’s and
St Thomas’ NHS Foundation Trust, London, UK
James P Isbister BSc (Med) MB BS FRACP FRCPA
Consultant in Haematology and Transfusion
Medicine, Clinical Professor of Medicine, Sydney
Medical School, Royal North Shore Hospital
of Sydney; Adjunct Professor, University of
Technology, Sydney; Adjunct Professor of
Medicine, Monash University,
Melbourne, VIC, Australia

xv

Matthias Jacob MD PhD
Associate Professor, Department of Anaesthesiology,
University Hospital Munich, Munich, Germany
Paul James BSc MBBCh FRCA
Consultant in Paediatric Intensive Care and
Anaesthesia, Evelina Children’s Hospital, Guys and
St Thomas NHS Trust, London, UK
Paul Cassius Jansz MB BS FRACS PhD
Senior Cardiothoracic Surgeon, Heart and Lung

Transplant Unit, St Vincent’s Hospital,
Sydney, NSW, Australia
Mandy O Jones MSc PhD MCSP SRP
Course Director Physiotherapy, School of Health
Science and Social Care, Brunel University,
London, UK
Gavin M Joynt MB BCh FFA (SA)(CritCare) FHKCA (IC) CICM
Professor, Department of Anaesthesia and Intensive
Care, The Chinese University of Hong Kong; Head,
Intensive Care Unit, Prince of Wales Hospital,
Shatin, NT, Hong Kong
James A Judson MNZM MB ChB FFARACS FCICM
Honorary Specialist Intensivist, Department of
Critical Care Medicine, Auckland City Hospital,
Auckland, New Zealand
Richard Keays MB BS MD FRCP FRCA FFICM
Director of Intensive Care, Magill Department of
Anaesthetics and Intensive Care, Chelsea and
Westminster Hospital, London, UK
Angus M Kennedy MB BS MRCP MD
Consultant Neurologist, Department of Neurology,
Chelsea and Westminster Hospital, London, UK
Ian Kerridge BA BMed (Hons) MPhil (Cantab) FRACP FRCPA
Associate Professor, Haematology Department,
Royal North Shore Hospital, St Leonards,
Sydney, NSW, Australia
Geoff Knight MMBS FRACP FCICM
Director, Paediatric Intensive Care, Princess Margaret
Hospital for Children, Perth, WA, Australia
Stephen W Lam MB BS (Hons) FRACP FCICM

Consultant, Department of Critical Care Medicine,
Flinders Medical Centre, Adelaide, SA, Australia
Richard Leonard MB BChir FRCP FRCA FANZCA FCICM FFICM
Consultant, Adult Intensive Care Unit, St Mary’s
Hospital, Imperial College Healthcare NHS Trust,
London, UK
Daniel Lew MD
Director, Infectious Diseases Service, Department of
Internal Medicine, Geneva Hospitals and Faculty of
Medicine, Geneva, Switzerland


xvi

List of Contributors

Alexander M Man Ying Li MA (Cantab) MB BChir MRCP
FRCA EDIC FCICM FICM

Consultant, Magill Department of Anaesthetics,
Intensive Care and Pain Management,
Chelsea and Westminster Hospital, London, UK
Jeffrey Lipman MB BCh DA FFA(Crit Care) FCICM MD
Head of Anaesthesiology and Critical Care, University
of Queensland; Director ICU, Royal Brisbane and
Women’s Hospital, Brisbane, QLD, Australia
Pieter HW Lubbert MD PhD
Fellow, Trauma Service, Department of Surgery,
Auckland City Hospital, Auckland, New Zealand
Peter S Macdonald MB BS MD PHD FRACP

Professor of Medicine, University of New South
Wales; Head, Transplantation Research Laboratory,
Victor Chang Cardiac Research Institute; Senior Staff
Cardiologist, Heart and Lung Transplant Unit,
St Vincent’s Hospital, Sydney, NSW, Australia
David P Mackie MB ChB FRCA
Anesthesiologist/Intensivist, Department of Intensive
Care, Red Cross Hospital, Beverwijk, The Netherlands
Matthew Maiden BSc BM BS FCICM FACEM
Intensive Care Physician, Royal Adelaide Hospital,
Adelaide, SA, Australia; Emergency Physician,
Barwon Health, Geelong, VIC, Australia
Colin McArthur MB ChB FANZCA FCICM
Clinical Director, Department of Critical Care
Medicine, Auckland City Hospital,
Auckland, New Zealand
Kevin McCaffery MB ChB MRCP (UK) FCICM
Senior Staff Specialist in Paediatric Intensive Care
Medicine, Royal Hospital for Sick Children and Mater
Children’s Hospital, Brisbane, Australia; Honorary
Senior Lecturer, University of Queensland,
Brisbane, QLD, Australia
Steve McGloughlin BMed FRACP FCICM
Intensive Care Physician, The Alfred Hospital,
Melbourne, VIC, Australia
Johnny Millar MB ChB PhD MRCP FRACP FCICM
Head of Cardiac Intensive Care, Royal Children’s
Hospital, Melbourne, VIC, Australia
Wai Ka Ming MB ChB FHKCA (IC)
Resident Specialist, Department of Anaesthesia and

Intensive Care, Prince of Wales Hospital,
Shatin, NT, Hong Kong
Fiona H Moffatt BSc (Hons) MSc MCSP SRP
Lecturer University of Nottingham, School of
Nursing, Midwifery and Physiotherapy,
Nottingham, UK

Thomas J Morgan FCICM
Senior Lecturer, School of Medicine, Anaesthesiology
and Critical Care, University of Queensland; Senior
Critical Care Physician, Mater Adult Hospital,
Brisbane, QLD, Australia
Peter T Morley MB BS FRACP FANZCA FCICM
Associate Professor, Department of Medicine, Director
of Medical Education, Senior Specialist, Intensive
Care, Royal Melbourne Hospital and Royal
Melbourne Hospital Clinical School, University of
Melbourne, Melbourne, VIC, Australia
John A Myburgh MB BCh FCICM PhD
Professor of Critical Care Medicine, University of
New South Wales, Department of Intensive Care
Medicine, St George Hospital; Director, Division of
Critical Care and Trauma, The George Institute for
Global Health, Sydney, NSW, Australia
Michael MG Mythen MB BS FRCA MD FFICM
Smiths Medical Professor of Anaesthesia and Critical
Care, University College London (UCL), London, UK
Matthew T Naughton MD FRACP
Head, General Respiratory and Sleep Medicine
Service, Department of Allergy, Immunology and

Respiratory Medicine, The Alfred Hospital; Adjunct
Professor of Medicine, Monash University,
Melbourne, VIC, Australia
Alistair D Nichol

MB BCh BAO BA PhD FCICM FJFICMI

FCARCSI

Professor of Critical Care Medicine, School of
Medicine and Medical Sciences, University College
Dublin, Ireland; Associate Professor, Department of
Epidemiology and Preventive Medicine, Monash
University, Australia; Consultant Intensivist/
Anaesthetist, St Vincent’s University Hospital Dublin,
Ireland; Honorary Intensivist, Alfred Hospital,
Melbourne, VIC, Australia
Gerry O’Callaghan MB FCARCSI FCICM
Senior Consultant in Intensive Care Medicine,
Flinders Medical Centre; Senior Lecturer Faculty of
Health Sciences, Flinders University of South
Australia, Adelaide, SA, Australia
Helen I Opdam MB BS FRACP FCICM
Intensive Care Specialist, Austin Hospital,
Heidelberg, VIC, Australia
Aaisha Opel BSc MB BS MRCP PhD
Specialist Registrar in Cardiology, University College
London, London, UK
Alexander A Padiglione MB BS FRACP PhD
Infectious Diseases Physician, Department of

Infectious Diseases, The Alfred Hospital and Monash
Medical Centre, Melbourne, VIC, Australia


List of Contributors

xvii

Simon PG Padley BSc MB BS MRCP FRCR
Consultant Radiologist, Chelsea and Westminster
Hospital and Royal Brompton Hospital; Reader in
Radiology, Imperial College School of Medicine,
London, UK

Raymond F Raper AM MB BS BA MD FRACP FCICM
Head, Department of Intensive Care Medicine,
Royal North Shore Hospital, Sydney, NSW, Australia

Valerie Page MB BCh FRCA FFICM
Consultant in Anaesthesia and Critical Care,
Department of Anaesthesia, West Hertfordshire
Hospitals NHS Trust, Watford General Hospital,
Watford, UK

Lieutenant Colonel, Joint Health Command,
Australian Defence Force; Professor of Military
Medicine and Surgery, University of Queensland;
Consultant Intensivist, Royal Brisbane and Women’s
Hospital, Brisbane, QLD, Australia

Mark Palazzo MB ChB FRCA FRCP FFICM MD
Consultant Critical Care Medicine, Department of
Critical Care Medicine, Imperial College Healthcare
NHS Trust, London, UK

Bernard Riley BSc MBE FRCA FFICM
Consultant in Adult Critical Care, Queen’s Medical
Centre, Nottingham University Hospitals NHS Trust,
Nottingham, UK

Sandra L Peake BSc (Hons) BM BS FCICM PhD
Associate Professor, School of Medicine,
University of Adelaide; Adjunct Associate
Professor, School of Epidemiology and Preventive
Medicine, Monash University, Victoria; Senior Staff
Specialist, Department of Intensive Care Medicine,
The Queen Elizabeth Hospital,
Adelaide, SA, Australia

Shelley D Riphagen MBChB Dip Obs (SA) FCP (Paeds) SA
Consultant, Paediatric Intensive Care,
Evelina Children’s Hospital, London, UK

Vincent Pellegrino MB BS FRACP FCICM
Senior Intensivist, Alfred Hospital,
Melbourne, VIC, Australia
Michael E Pelly MSc (Clin Trop Med) FRCP DTM&H
Consultant Physician, Chelsea and Westminster
Hospital, London, UK
David Pilcher MB BS FCICM

Associate Professor, Department of Intensive
Care Medicine, The Alfred Hospital,
Melbourne, VIC, Australia
Didier Pittet MD MS
Director, Infection Control Program, WHO
Collaborating Centre on Patient Safety, University of
Geneva Hospitals and Faculty of Medicine,
Geneva, Switzerland
Kevin Plumpton MB ChB FRACP FCICM
Senior Staff Specialist, Paediatric Intensive Care,
Royal Children’s Hospital and Mater Children’s
Hospital; Honorary Senior Lecturer, University of
Queensland, Brisbane, QLD, Australia
Brad Power MB BS FRACP FCICM
Intensive Care Specialist, Department of Intensive
Care, Sir Charles Gairdner Hospital,
Perth, WA, Australia
Susanna Price BSc MB BS MRCP PhD EDICM FFICM FESC
Consultant Cardiologist and Intensivist, Royal
Brompton Hospital; Honorary Senior Lecturer,
Imperial College, London, UK

Michael C Reade

MB BS MPH DPhil DIMCRCSEd DMCC

FANZCA FCICM

Hayley Robinson BMedSci (Hons) MB BS (Hons)
Intensive Care Registrar, Intensive Care Unit, Royal

Perth Hospital, Perth, WA, Australia
Vineet V Sarode MB BS MD IDCCM FCICM PGCertCU (Melb)
Specialist Intensive Care Physician, Cabrini Hospital,
Melbourne, VIC, Australia
Hugo Sax MD
Private Docent, Division of Infectious Diseases and
Hospital Epidemiology, University Hospital of Zurich,
Zurich, Switzerland
Manoj K Saxena BSc MB BChir MRCP (UK) FRACP (AUS)
FCICM

Intensive Care Physician, St George Hospital,
Kogarah; Conjoint Lecturer, University of
New South Wales; Honorary Fellow,
The George Institute for Global Health,
Kogarah, NSW, Australia
Oliver R Segal MD FRCP FHRS
Consultant Electrophysiologist, The Heart
Hospital, University College London Hospitals,
London, UK
Frank Shann AM MB BS MD FRACP FCICM
Professor of Critical Care Medicine, Department of
Paediatrics, University of Melbourne; Staff Specialist
in Intensive Care, Royal Children’s Hospital,
Melbourne, VIC, Australia
Pratik Sinha BSc (Hons) MB ChB MCEM PhD
Specialist Registrar, Intensive Care and Emergency
Medicine, Guy’s and St Thomas’ NHS Foundation
Trust, London, UK
Ramachandran Sivakumar MD FRCP

Consultant Physician, Colchester Hospital University
NHS Foundation Trust, Colchester, UK


xviii

List of Contributors

George Skowronski MB BS (Hons) FRCP FRACP FCICM
Director, ICU, St George Private Hospital, Sydney;
Senior Specialist, ICU, St George (Public) Hospital,
Sydney; Conjoint Associate Professor, Critical Care,
University of New South Wales,
Sydney, NSW, Australia
Anthony J Slater FRACP FCICM
Director, Paediatric Intensive Care Unit, Royal
Children’s Hospital, Herston, QLD, Australia
Martin Smith MB BS FRCA FFICM
Consultant and Honorary Professor, Department of
Neurocritical Care, The National Hospital for
Neurology and Neurosurgery, University College
London Hospitals, London, UK
Neil Soni MB ChB MD FANZCA FRCA FCICM FFICM
Consultant in Intensive Care, Chelsea and
Westminster Hospital; Honorary Senior Lecturer,
Imperial College Medical School, London, UK
Stephen J Streat MB ChB FRACP
Intensivist, Department of Critical Care Medicine;
Clinical Director, Organ Donation New Zealand,
Auckland District Health Board,

Auckland, New Zealand
Richard Strickland FACEM FCICM DDU
Consultant, Critical Care, Royal Adelaide Hospital,
Adelaide, SA, Australia
David J Sturgess MB BS PhD PGDipCU FRACGP FANZCA
FCICM

Senior Lecturer, Discipline of Anaesthesiology and
Critical Care, School of Medicine, The University of
Queensland; Specialist Anaesthetist and Intensive
Care Physician, Mater Health Services, Raymond
Terrace; Program Leader, Improving Acute Care
Program, Mater Medical Research Institute,
Brisbane, QLD, Australia
Christian P Subbe DM MRCP
Senior Clinical Lecturer, Consultant Acute,
Respiratory and Critical Care Medicine, School of
Medical Sciences, Bangor University,
Bangor, Wales, UK
Joseph JY Sung MD PhD
Mok Hing Yiu Professor of Medicine, The Chinese
University of Hong Kong, Shatin, NT, Hong Kong
Chee Wee Tan MB BS (Hons) FRACP FRCPA
Consultant Haematologist, Department of
Haematology, Royal Adelaide Hospitalâ•›/â•›Institute of
Medical and Veterinary Science,
Adelaide, SA, Australia
Guido Tavazzi MD
University of Pavia, Department of Anaesthesia and
Intensive Care I, Foundation Policlinico San Matteo

IRCCS, Pavia, Italy; Echocardiography Fellow, Royal
Brompton Hospital, London, UK

Peter D (Toby) Thomas MB BS FRACP FANZCA FCICM
Colonel, 3rd Health Support Battalion, Royal
Australian Army Medical Corps; Director, Intensive
Care Unit, Lyell McEwin Hospital, Elizabeth Vale, SA,
Australia
James Tibballs

BMedSc (Hons) MB BS MEd MD MBA

MHlth&MedLaw PGDipArts (Fr) DALF FANZCA FCICM FACLM

Deputy Director, Paediatric Intensive Care Unit, The
Royal Children’s Hospital; Associate Professor,
Departments of Paediatrics and Pharmacology, The
University of Melbourne, Melbourne, VIC, Australia
Luke E Torre MB BS (Hons) FCICM FANZCA
Associate Professor, School of Medicine, Notre Dame
University, Fremantle; Intensivist, Sir Charles
Gairdner Hospital, Nedlands; Anaesthetist, Joondalup
Health Campus, Joondalup, WA, Australia
David Treacher MA FRCP
Consultant Physician, Intensive Care and Respiratory
Medicine, Guy’s and St Thomas’ NHS Foundation
Trust, London, UK
David V Tuxen MB BS MD FRACP DipDHM FJFICM
Senior Intensivist, Intensive Care, The Alfred
Hospital, Melbourne, VIC, Australia

Ilker Uçkay MD
Senior Attending, Infection Control Program,
Service of Infectious Diseases, Orthopaedic
Surgery Service, University of Geneva Hospitals,
Geneva, Switzerland
Balasubramanian Venkatesh

MB BS MD (IntMed) FRCA

(UK) FFARCSI MD(UK) FCICM (ANZ)

Professor in Intensive Care, Princess Alexandra and
Wesley Hospitals, University of Queensland,
Brisbane, QLD; Honorary Professor, University of
Sydney, Sydney, NSW, Australia
Jacqueline EHM Vet MD
Anaesthesiologist-intensivist, Department of
Intensive Care, Red Cross Hospital,
Beverwijk, The Netherlands
Marcela P Vizcaychipi MD PhD FRCA EDIC FFICM
Consultant in Anaesthesia and Intensive Care,
Honorary Clinical Senior Lecturer, Chelsea and
Westminster Hospital, Imperial College,
London, UK
Adrian J Wagstaff BSc MB BS MD FFICM
Consultant in Anaesthesia and Intensive Care,
Humphrey Davy Department of Anaesthesia,
University Hospitals, Bristol, UK
Carl S Waldmann MA MB BChir FRCA EDIC FFICM
Consultant in Intensive Care and Anaesthesia, Royal

Berkshire Hospital, Reading, UK


List of Contributors
Christopher M Ward MB ChB PhD
Associate Professor, Sydney Medical School,
Sydney, Australia; Head and Director of Research,
Department of Haematology and Transfusion
Medicine, Royal North Shore Hospital,
Sydney, NSW, Australia
John R Welch BSc (Hons) MSc RGN ENB 100
Consultant Nurse, Critical Care, University College
London Hospitals NHS Foundation Trust; Honorary
Senior Lecturer, City University, London, UK
Julia Wendon MB ChB FRCP
Professor of Hepatolgy and Consultant in Intensive
Care, Liver Intensive Care Unit, King’s College
Hospital, London, UK
Mary White MB BAO BCh MSc FCAI PhD
Consultant Intensivist and Anaesthetist, Royal
Brompton Hospital, London, UK
Ubbo F Wiersema MB BS FRACP FCICM
Intensive Care Consultant, Intensive and Critical Care
Unit, Flinders Medical Centre, Adelaide, SA, Australia
Timothy Wigmore MA FRCA FCICM FFICM
Consultant Anaesthetist and Intensivist, Critical Care
Department, Royal Marsden Foundation Trust,
London, UK

xix

Christopher Willars MB BS FRCA FFICM
Consultant Intensivist, Liver Intensive Care Unit,
King’s College Hospital, London, UK
Wan Tsz Pan Winnie MB ChB FHKCA (IC) FHKAM FCICM
Resident Specialist, Department and Anaesthesia and
Intensive Care, Prince of Wales Hospital,
Shatin, NT, Hong Kong
David M Wood MD FACMT FBPharmacolS FRCP
Consultant Physician and Clinical Toxicologist, Guy’s
and St Thomas’ NHS Foundation Trust and King’s
Health Partners; Senior Lecturer, King’s College
London, London, UK
Duncan LA Wyncoll MB BS FRCA EDIC DipICM FFICM
Consultant Intensivist, Guy’s and St Thomas’ NHS
Trust, London, UK
Steve M Yentis BSc MB BS FRCA MD MA
Consultant Anaesthetist, Chelsea and Westminster
Hospital, Honorary Reader, Imperial College,
London, UK


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Preface
The first edition of Oh’s Intensive Care Manual was published in 1979, when intensive care may not have been
in its infancy but it certainly wasn’t far beyond. Teik
Oh, with tremendous foresight, brought together the
fundamental elements of managing the critically ill in

a particularly pragmatic manner, which could be considered a guideline for the development of the specialty. Thirty-four years on, the seventh edition reflects
both the maturation of that specialty and the phenomenal progress medically, technically, scientifically, ethically and educationally in all areas of management of
the critically ill.
As with previous editions, each and every chapter
has been updated, and there are many areas where new
sections reflect the changing nature of the specialty and
the subtle shifts in emphasis in the workplace. These
include the growing interest in critical care both before
and after the intensive care unit, including the role of
palliative care. There is increasing focus on the ethical
dilemmas, which cannot be separated from legal considerations that beset critical care in all age groups.
Team working is fundamental to delivering intensive
care and this is formally addressed, as is education and
examination. As bedside ultrasound has been incorporated into clinical examination and many procedures,
this is now recognised in addition to the chapter on
echocardiography. Extracorporeal membrane oxygenation (ECMO) is increasingly being used for both respiratory and circulatory support, with a unique double
chapter dedicated to this area. Almost every chapter

has new developments while in some, such as liver
failure, there are new sections to address the increasing
complexity of the field as it impacts on intensive care.
Malignant disease is a common co-morbidity or cause
for admission postoperatively so this has been included,
as has delirium, which is a common problem.
There has been discussion about the relevance of the
paediatric section in this era of specialisation. It is the
editors’ contention that populations outside of hospital
include paediatrics and so a working knowledge of
paediatric intensive care should be an integral part of
any intensivist’s knowledge. With this in mind, this

section has been significantly, and in our opinion
impressively, updated.
We sincerely hope that this edition will achieve
several goals. It will update the previous edition in
terms of the changing knowledge base, it will address
emerging issues in intensive care, it will be of use to
both medical and paramedical staff, but most importantly it will adhere to the pragmatic and clinically
useful style so effectively promulgated by Teik Oh
when it was originally published 34 years ago. If clinicians can reach for it in the early hours of the morning,
easily locate the information they require and feel either
guided or reassured, it will have served its purpose. If
those passing examinations can say it helped, that
would be gilding the lily.
ADB
NS


ACKNOWLEDGEMENTS
It is a fitting time to use this opportunity to acknowledge the tremendous achievement of Teik Oh in the
creation of this book back in 1979 and for many editions
following. It has been a massive asset in the development of the specialty, especially in the early days, and
there are hundreds, indeed thousands, of intensivists
across much of the world, including both of us, who
have been the benefactors of the enthusiasm, energy
and sheer work that Teik put into this book. The real
beneficiaries have been the countless patients over all
those years whose management was enhanced by
access to this book either during training or when it has
been reached for on the intensive care unit.
ADB

NS


Part One
Organisation Aspects

  1 Design and Organisation of Intensive Care
Unitsâ•… 3
  2 Critical Care Outreach and Rapid Response
Systemsâ•… 10
  3 Severity of Illness and Likely Outcome from
Critical Illnessâ•… 16
  4 Transport of critically ill patientsâ•… 27
  5 Physiotherapy in Intensive Careâ•… 38
  6 Critical Care Nursingâ•… 47
  7 Ethics in Intensive Careâ•… 55
  8 Common Problems After ICUâ•… 61
  9 Clinical Information Systemsâ•… 69
10 Clinical Trials in Critical Careâ•… 75
11 Palliative Careâ•… 85
12 ICU and the Elderlyâ•… 90
13 Health Care Team in Intensive Care
Medicineâ•… 98
14 Preparing for Examinations in Intensive Care
Medicineâ•… 107


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