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Principles of
Adult Surgical
Critical Care
Niels D. Martin
Lewis J. Kaplan
Editors
123
Principles of Adult Surgical Critical Care
Niels D. Martin • Lewis J. Kaplan
Editors
Principles of Adult Surgical
Critical Care
Editors
Niels D. Martin
Perelman School of Medicine
University of Pennsylvania
Philadelphia
Pennsylvania
USA
Lewis J. Kaplan
Perelman School of Medicine
University of Pennsylvania
Philadelphia
Pennsylvania
USA
ISBN 978-3-319-33339-7 ISBN 978-3-319-33341-0 (eBook)
DOI 10.1007/978-3-319-33341-0
Library of Congress Control Number: 2016953672
© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature
The registered company is Springer International Publishing AG Switzerland
Foreword
Critically ill surgical patients are a diverse lot. So too are the maladies that befall them, or may
if not prevented. Such patients may have widely divergent patterns of injury, or immunosuppression from injury, transfusion, neoplastic disease, or therapy (e.g., glucocorticoids, solid
organ transplantation). Critically ill surgical patients have diverse (abnormal) physiology and
responsiveness to stress, especially at the extremes of age. Elderly patients, in particular, have
senescent immunity and impaired wound healing, and may have cardiovascular disease or
diabetes mellitus that may impair responsiveness to injury-related stress, or disorders of mobility that may impede recovery.
Despite this diversity, there are crucial commonalities among the disease states of critically
ill surgical patients and the care provided to them. Acute care surgery (trauma, emergency
general surgery, surgical critical care) is inherently invasive. Incisions, percutaneous interventions, and physiologic monitoring catheters all breach epithelial barriers that protect the host
against invasion by pathogens, posing incremental risk to a vulnerable population. Many
patients require several such interventions, often in short order. Nosocomial infection is an
ever-present risk, which in turn has been associated with increased risk of morbidity and mortality related to multiple organ dysfunction syndrome. The human and fi nancial burdens are
enormous, and survivors of complicated ICU courses may need months or years to achieve full
functional recovery and return to productive society, if ever.
That the most unstable, at-risk patients often need the most aggressive, invasive care to
achieve favorable outcomes is the great paradox of critical surgical illness. Great expertise is
needed to restore homeostasis while also preventing the next potential complication. The experienced acute care surgeon must be facile and adroit with normal and pathologic anatomy,
physiology, biochemistry, pharmacology, and immunology, and must possess the requisite
technical skill to intervene effectively while not placing the patient at further risk. Knowledge
of monitors, devices, medical imaging, and biomaterials requires familiarity with biomedical
engineering. Profi ciency with rehabilitation medicine, medical ethics, communication skills,
and team building serves to keep information fl owing to facilitate effective functioning of the
team of physicians, nurses, therapists, nutritionists, dieticians, and family members that is
integral to the decision making necessary for the successful outcome of every single patient.
Some patients may be unable to recover; they too must be treated with skill and compassion in
their time remaining.
Across the intensive care unit, complex integration of pathophysiology and therapy to balance risk and benefi t must occur continuously and in parallel for multiple issues in several
patients, and must often be accompanied or followed by decisive interventions. There is no
substitute for experience, especially in that computerized decision support systems and artifi cial intelligence engines remain in their infancy.
This volume is directed appropriately and suited especially to medical students, surgery
residents, and fellows in acute care surgery or surgical critical care. Described herein are all of
the common maladies that may require surgical critical care, and the complications that may
develop. Described are procedures that may be indicated in daily practice in the surgical
v
vi
intensive care unit or the trauma bay. It is hoped that the readership will be guided and inspired
to master these “pearls of wisdom” and techniques, and to incorporate them into their own
practices.
Much more than just a “how-to” manual, disease-state information is provided herein to
orient the reader to the appropriate use of interventions. Mastery of these techniques combined
with command of a vast body of knowledge is needed to practice acute care surgery effectively
and safely.
Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS
Professor of Surgery
Professor of Public Health in Medicine
Weill Cornell Medicine, Attending Surgeon
Chief, Preston A. (Pep) Wade Acute Care Surgery Service
NewYork-Presbyterian Hospital/Weill Cornell Medical Center
New York, NY, USA
Foreword
Foreword
As the volume and complexity of available information appropriate for intensivists explode,
the bedside clinician would benefi t from a structure from which to evaluate that information.
Accordingly, this work is designed to provide the underpinnings upon which we all rely while
providing bedside care, didactic education, or family counseling. Trainees, fellows, and attending staff alike will fi nd an easily digestible exploration of relevant topics spanning from nutrition support to advanced ventilation: from antimicrobial stewardship to palliative care. This
textbook is timely and incorporates current information to provide clinicians, regardless of
parent training discipline, the key data needed to provide high value and high quality bedside
care. The authorship refl ects a multi-professional approach to education in deliberate parallel
to the multi-professional fashion in which we help patients, families and each other navigate
the complexity of critical illness. In this fashion, Drs. Martin and Kaplan have infused their
text with the dedication, passion, and sensitivity that drew them and each of us to the ICU to
serve the critically ill and injured to the very best of our abilities.
Patrick M. Reilly, MD, FACS
Professor of Surgery and Chief
Division of Traumatology, Surgical Critical Care, and Emergency Surgery
University of Pennsylvania, Perelman School of Medicine
Philadelphia, PA, USA
vii
Pref ace
This 1st edition textbook Principles of Adult Surgical Critical Care is intended to fi ll the litera-
ture gap that exists between standard medical critical care and the surgical complexities that
coincide with critical illness. In the past decade, the value of surgical critical care has been
realized in practices throughout the world, resulting in an infl ux of practitioners and trainees,
all with a need for an advanced yet concise source of current information.
This textbook is focused on practitioners embarking on the fi nal stages of training as well
as those maintaining or expanding their existing clinical skillset. It therefore is not a basic text,
but instead assumes a working knowledge of the underpinnings of critical care. Our format
embraces evidence-based topic reviews focused on the care of the critically ill or injured surgical patient.
Refl ecting the multi-professional nature of our bedside teams for optimal care, the contents
target multiple practitioner domains across the critical care continuum. As a result, the chapter
authors have included subject matter designed to comprehensively expand the reader’s knowledge base for immediate bedside use, as well as objective test preparation.
For ease of use, this textbook is organized by organ systems, special populations, and pertinent topic sections. Each section contains several chapters addressing relevant disorders and
monitoring and treatment modalities, as well as outcomes. Chapter authors have been personally selected based on national or international acclaim within their respective areas of expertise. As editors, we humbly offer thanks for the innumerable hours our authors have spent in
preparation and refi nement of their work. Without their efforts, this comprehensive volume
would only be a dream instead of the learning tool we envision.
Finally, we would like to dedicate this textbook to all those in the fi nal stages of training
who are preparing to embark on a rewarding career caring for critically ill and injured patients.
On a personal note, we are deeply indebted to our families for supporting us through the countless hours we devoted to this book on top of the hours we spent at the bedside – just like each
of you do on a daily basis.
Philadelphia, PA, USA Niels D. Martin , MD, FACS, FCCM
Philadelphia, PA, USA Lewis J. Kaplan , MD, FACS, FCCM, FCCP
ix
Contents
1 Pain, Agitation, Delirium, and Immobility in the ICU . . . . . . . . . . . . . . . . . . . . . . . 1
Juliane Jablonski
2 Bedside Neurologic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Bryan J. Moore and Jose L. Pascual
3 Status Epilepticus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emily J. Gilmore and Emad Nourollahzadeh
4 Traumatic Brain Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Sofya H. Asfaw and Niels Douglas Martin
5 Care of the Spinal Cord-Injured Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Christine E. Lotto and Michael S. Weinstein
6 Nontraumatic Neurological Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Christopher R. Becker and Jose L. Pascual
7 Hemodynamic Monitoring and Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Patrick J. Neligan and Jiri Horak
8 Hemodynamic Monitoring in Surgical Critical Care . . . . . . . . . . . . . . . . . . . . . . . 77
Brett M. Howard and D. Benjamin Christie III
9 Cardiovascular Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
J. Trent Magruder and Glenn J. Whitman
10 Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal
Carbon Dioxide Removal (ECCO 2 R) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Nicole Lena Werner and Pauline K. Park
11 Acute Respiratory Distress Syndrome and Lung Protective Ventilation . . . . . . . 115
Sarah E. Greer , Rebecca E. Duncan , Molly R. Deane , Nader M. Habashi ,
and Maureen McCunn
12 Noninvasive Ventilation in the Perioperative Period . . . . . . . . . . . . . . . . . . . . . . . 127
Kimberly M. Ramonell , Richard P. Ramonell , and Kevin W. McConnell
13 Care of the Surgical ICU Patient with Chronic Obstructive
Pulmonary Disease and Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . 137
Stacey M. Kassutto and Joshua B. Kayser
14 Diagnosis and Management of Acute Kidney Injury . . . . . . . . . . . . . . . . . . . . . . 149
Neesh Pannu and Matthew T. James
15 Renal Replacement Therapy in the Critically Ill Surgical Patient . . . . . . . . . . . . 159
Kevin K. Chung and Ian J. Stewart
xi
xii
16 Gastrointestinal Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Michael A. Samotowka
17 Critical Care Management of Severe Acute Pancreatitis . . . . . . . . . . . . . . . . . . . 181
Ronald Tesoriero and Jose J. Diaz
18 Hepatic Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Mario Rueda and Pamela A. Lipsett
19 Abdominal Compartment Hypertension and Abdominal
Compartment Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Patrick Maluso and Babak Sarani
20 Nutrition in the Surgical ICU Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Beth E. Taylor and Craig M. Coopersmith
21 Antibiotic Strategy and Stewardship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Sarah M. Kolnik and Heather L. Evans
22 Sepsis, Severe Sepsis, and Septic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Andrew C. Gaugler and Nicholas Namias
23 Source Control and Supporting Therapeutics: Integrating
Bacterial Invasion, Host Defense, and Clinical Interventions
with Source Control Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Lewis J. Kaplan , Addison K. May , and Lena M. Napolitano
Contents
24 Soft Tissue Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Addison K. May
25 Anemia in the Surgical ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Aryeh Shander , Lena M. Napolitano , and Margit Kaufman
26 Coagulopathies and Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
Jeremy W. Cannon
27 Thrombocytopenia in the Surgical Intensive Care Unit . . . . . . . . . . . . . . . . . . . . 327
Noelle N. Saillant and Carrie A. Sims
28 Venous Thromboembolism in the Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . 335
Lisa M. Kodadek and Elliott R. Haut
29 Glycemic Control and Insulin Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Richard N. Lesperance and Oscar D. Guillamondegui
30 Critical Illness-Related Corticosteroid Insufficiency
in the Intensive Care Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Noelle N. Saillant and Carrie Sims
31 Thyroid Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Scott B. Grant and Stanley Z. Trooskin
32 Hyperadrenergic Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Lindsay E. Kuo and Douglas L. Fraker
33 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
D. Joshua Mancini , Mark J. Seamon , and C. William Schwab
34 Immunocompromised Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Judith Anesi and Valerianna Amorosa