Evidence Based Critical Care A Case Study Approach - 2nd Edition Reference Book Download
Evidence Based Critical Care A Case Study Approach - 2nd Edition Reference Book Download
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For Silka, Katie, and Marnie
Robert C. Hyzy
We are very pleased to present this second edition of Evidence-Based Critical Care: A Case
Study Approach. We believe that effective learning takes place when individuals challenge
themselves and work through realistic clinical problems. This textbook capitalizes on this
active approach by beginning each chapter with a real case from the authors’ clinical practice.
At the conclusion of each case, a question is asked to allow the reader to reflect on clinical
management before reading the answer and consolidating knowledge from experts in the field.
We feel strongly that the current practice of critical care medicine requires a deep knowl-
edge of existing evidence. However, our knowledge of the field is continuously evolving, and
there are many gaps in the existing literature as well as areas of controversy despite existing
research in the area. To highlight this balance, the chapters contain two distinct sections: the
“Principles of Management” section and the “Evidence Contour” section. The “Principles of
Management” section focuses on the standard practice of diagnosis and management within
critical care with an emphasis on evidence-based care when available. The “Evidence Contour”
section highlights areas of uncertainty and active debate in the literature. This strategy allows
the reader to understand the strength of evidence underlying our current approach to diagnosis
and management within critical care medicine.
This unique approach will benefit critical care providers at all stages in their careers, from
junior trainees to seasoned providers. The spectrum of topics covered in this text also makes
this book a useful tool for board examination preparation.
We would like to thank the many providers who purchased the first version of this textbook.
We would also like to thank our many friends and colleagues who contributed to this book. The
section editors and authors have contributed their time and expertise to create a valuable
resource for practicing clinicians who seek to provide the best care possible to critically ill
patients. We would also like to thank the editors and staff at Springer for their guidance and
support in completing this project.
vii
Contents
ix
x Contents
45 Traditional and Novel Tools for Diagnosis of Acute Kidney Injury��������������������� 361
Fadi A. Tohme and John A. Kellum
46 Management of Acute Kidney Injury��������������������������������������������������������������������� 367
Fadi A. Tohme and John A. Kellum
47 Rhabdomyolysis ������������������������������������������������������������������������������������������������������� 375
Saraswathi Gopal, Amir Kazory, and Azra Bihorac
48 Hyponatremia����������������������������������������������������������������������������������������������������������� 381
Lenar Yessayan and Ryan E. Krahn
49 Hypernatremia ��������������������������������������������������������������������������������������������������������� 389
Kenneth B. Christopher
50 Hyperkalemia ����������������������������������������������������������������������������������������������������������� 393
Ryann Sohaney and Michael Heung
Part X Surgical
105 Interdisciplinary Care and Communication in the Intensive Care Unit������������� 785
Jonathan Ludmir, Judy Davidson, and Giora Netzer
106 End of Life Care in the ICU������������������������������������������������������������������������������������� 793
Debasree Banerjee, Sameer Shah, and Nicholas S. Ward
Contents xv
Index������������������������������������������������������������������������������������������������������������������������������������� 819
Part I
ER-ICU Shock and Resuscitation
Cardiac Arrest Management
1
Nathan L. Haas and Robert W. Neumar
high compression rates and leaning on the chest during the Vasopressors During CPR
relaxation phase of CPR [1]. However, data is mixed on
whether these devices improve the rate of ROSC, and no Vasopressor therapy during CPR optimizes the ability to
studies have demonstrated improved survival or neurologic achieve ROSC by improving myocardial perfusion through
outcome [1]. increased coronary perfusion pressure. Epinephrine 1.0 mg
Physiologic parameters can also be used to monitor the every 3–5 min is currently recommended during CPR based
efficacy of CPR in real time. The most commonly used on randomized clinical trials demonstrating improved ROSC
parameter is end-tidal CO2 (PETCO2) using continuous wave- and survival [11, 12]. In randomized clinical trials, epineph-
form capnography. In the low flow state of CPR, when venti- rine at higher doses did not improve outcomes [4]. Similarly,
lation is held constant, changes in PETCO2 correlate with vasopressin alone or in combination with epinephrine did not
changes in cardiac output. Technology and portability have improve outcomes compared to epinephrine alone in ran-
improved, allowing capnography to be measured by side- domized clinical trials [4]. However, all of these studies were
stream in non-intubated patients and mainstream in intubated performed without physiologic monitoring. The benefit of
patients. The goal of maintaining PETCO2 of at least 20 mmHg titrating vasopressor therapy during CPR based on intra-
has been proposed based on the association with achieving arterial blood pressure has not been studied (see evidence
ROSC [3]. Conversely, an PETCO2 less than 10 mmHg for contour).
20 min has been proposed as a criteria to consider termina-
tion of resuscitation efforts, although it should not be used in
isolation [4]. A rapid rise in PETCO2 with chest compressions anagement of Ventricular Fibrillation/
M
(for example, from 10 to 35 mmHg) may signal return of Pulseless Ventricular Tachycardia
spontaneous circulation (ROSC) [4].
Myocardial blood flow during CPR is directly propor- Defibrillation
tional to coronary perfusion pressure (CPP). CPP during Defibrillation is indicated for ventricular fibrillation (VF)
CPR is calculated as aortic diastolic (relaxation) pressure or pulseless ventricular tachycardia (VT). Although tradi-
minus right atrial diastolic (relaxation) pressure [5]. In the tionally monophasic defibrillators have been used to admin-
only human study that has correlated CPP with ROSC, a ister a counter shock, biphasic defibrillators are preferred
CPP of 15 mmHg or greater was required to achieve ROSC due to the greater first shock success. Newer waveforms
[6]. Since CPP monitoring during CPR is technically chal- have been studied which provide patient-specific imped-
lenging, monitoring arterial diastolic pressure has been pro- ance current delivery using biphasic truncated exponential,
posed as an alternative [3]. In a pediatric ICU population, an rectilinear biphasic or pulsed biphasic wave. At this time
arterial diastolic blood pressure >30 mmHg during CPR was there is no specific recommendation regarding which wave-
associated with survival and favorable neurologic outcome form is superior. Current recommendations are to adminis-
[7]. Using arterial diastolic pressure to guide the frequency ter a single counter shock at an optimal energy level
and dosing of vasopressor therapy during CPR may be a rea- (between 120 and 360 J for biphasic defibrillators) with
sonable strategy to optimize therapy (see evidence contour). minimal interruptions in CPR before and after the shock
[4]. In situations requiring repeated defibrillations, manu-
facturers’ guidelines should be followed, and escalating
Ventilation and Oxygenation energy may be considered.
Management of Pulseless Electrical Activity occurs, initial BVM ventilation is appropriate. Attempts to
establish an advanced airway may be postponed to maximize
Pulseless electrical activity (PEA) is defined as the absence other resuscitation efforts, unless BVM ventilation is inef-
of a pulse when electrical cardiac activity is present. This can fective or airway protection is obviously needed. The absence
further be classified as electromechanical dissociation of a capnography waveform during BVM ventilation should
(EMD; no pulse, presence of an electrical signal, no evidence trigger a transition to an advanced airway. Supraglottic air-
of cardiac activity detected by echocardiography) versus way devices are a reasonable advanced airway strategy dur-
pseudo-EMD (no pulse, presence of an electrical signal, car- ing CPR, and may be superior to endotracheal intubation in
diac activity observed by echocardiography). EMD repre- settings where initial intubation success rates are low [21]. If
sents an electromechanical uncoupling of cardiac cells, with endotracheal intubation is performed during CPR, it should
propagation of an electrical signal but no coordinated ven- be initially attempted without interrupting chest compres-
tricular contraction. This situation is usually seen in severe sions when feasible.
hypoxia, acidosis or necrosis. In pseudo-EMD, there is an
electrical signal and weak cardiac contractions (with no pal-
pable pulse) due to conditions such as hypovolemia, massive Hemodynamic-Directed Resuscitation
pulmonary embolism or other mechanical impediments to
flow. In these situations, the predominant rhythm is a tachy- Hemodynamic directed resuscitation (or patient-centric car-
dysrhythmia. A mnemonic to remind clinicians of the com- diopulmonary resuscitation) is a concept whereby chest
mon precipitants of PEA is “4Hs-4Ts:” hypoxia, compressions and vasopressor therapy are guided by con-
hypovolemia, hypo/hyperkalemia, hypothermia, thrombosis tinuously monitored hemodynamic variables rather than a
(pulmonary embolism), tamponade (cardiac), toxins, and one-size-fits-all approach. Animal studies have demonstrated
tension pneumothorax [15]. Distinguishing EMD from improved outcomes when chest compressions and vasopres-
pseudo-EMD can help guide therapy aimed at treating sor therapy are titrated to achieve a systolic blood pressure of
reversible causes during CPR [16]. Bedside echocardiogra- 90 mmHg and a coronary perfusion pressure of 20 mmHg
phy and intra-arterial blood pressure monitoring are the most during CPR [22]. As noted above, real time monitoring of
reliable strategies to distinguish EMD from pseudo-EMD CPP is challenging in the clinical setting. Therefore, using an
(see evidence contour). arterial diastolic blood pressure target of 30–35 mmHg may
be reasonable. This approach is most feasible when intra-
arterial pressure monitoring is in place prior to cardiac arrest
Quality Assurance onset, but placing a femoral arterial line during CPR is fea-
sible when adequate personnel are available. Whether hemo-
The quality of care should be assessed and debriefed after dynamic directed resuscitation leads to improved outcomes
every cardiac arrest resuscitation [17]. Short debriefing ses- in humans remains to be determined.
sions after a resuscitation have been shown to improve team
performance and outcomes [18]. The ability of rescuers to
retain critical resuscitation skills wanes as early as 6 months Bedside Ultrasound During CPR
after training, and health care providers often perform sub-
optimal chest compression rates [19]. Implementing simu- Bedside ultrasound may be used to investigate the underly-
lated resuscitations has been demonstrated to be useful in ing etiology of cardiac arrest. For instance, a subcostal view
retaining skills [20]. may reveal a large pericardial effusion with diastolic col-
lapse of the right ventricle representing cardiac tamponade.
Alternatively, a parasternal short axis view may demonstrate
Evidence Contour bowing of the intra-ventricular septum, the so called “D-sign”
appearance of the left ventricle being compressed by a
Airway Management During Cardiac Arrest volume-overloaded right ventricle contracting against a mas-
sive pulmonary embolism. It is essential to minimize inter-
The optimal airway strategy during CPR remains uncertain. ruptions in chest compressions, and every effort should be
Reasonable options include bag-valve-mask (BVM) ventila- made to assure that the compression fraction is not compro-
tion, supraglottic airways, and endotracheal intubation. In mised by performing ultrasound. Transesophageal echocar-
patients without an airway in place when cardiac arrest diography (TEE) is also under investigation as an alternative
6 N. L. Haas and R. W. Neumar
Mechanical CPR