Pocket ICU Pocket ICU Edited by GYORGY FRENDL, MD, PhD Assistant Professor of Anesthesia Harvard Medical School Director of Research, Surgical Critical Care Brigham and Women’s Hospital Boston, Massachusetts RICHARD D URMAN, MD, MBA Assistant Professor of Anesthesia Harvard Medical School Director, Procedural Sedation Management and Safety Brigham and Women’s Hospital Boston, Massachusetts Acquisitions Editor: Brian Brown Product Manager: Nicole Dernoski Production Manager: Alicia Jackson Senior Manufacturing Manager: Benjamin Rivera Marketing Manager: Lisa Lawrence Design Coordinator: Doug Smock Production Service: Aptara, Inc © 2013 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved This book is protected by copyright No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews Materials appearing in this book prepared by individuals as part of their official duties as U.S government employees are not covered by the above-mentioned copyright Printed in China Library of Congress Cataloging-in-Publication Data Pocket ICU / [edited by] Gyorgy Frendl, Richard D Urman p ; cm – (Pocket notebook series) Includes bibliographical references and index ISBN 978-1-4511-0984-9 (alk paper) I Frendl, Gyorgy II Urman, Richard D III Series: Pocket notebook [DNLM: Intensive Care–methods–Handbooks Individualized Medicine–Handbooks Intensive Care Units–Handbooks WX 39] 616.02′8–dc23 2012010729 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication Application of the information in a particular situation remains the professional responsibility of the practitioner The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly important when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320 International customers should call (301) 223-2300 Visit Lippincott Williams & Wilkins on the Internet: at LWW.com Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to pm, EST 10 CONTRIBUTORS Rae Allain Harvard Medical School Boston, Massachusetts Edwin Pascal Alyea, III Harvard Medical School Boston, Massachusetts Karim Awad Harvard Medical School Boston, Massachusetts Lindsey Baden Harvard Medical School Boston, Massachusetts Rebecca M Baron, MD Harvard Medical School Boston, Massachusetts Sheri Berg Harvard Medical School Boston, Massachusetts Tarun Bhalla, MD, FAAP The Ohio State University Medical Center Columbus, Ohio Wenya Linda Bi, MD, PhD Harvard Medical School Boston, Massachusetts Nathan E Brummel, MD Vanderbilt University School of Medicine Nashville, Tennessee Phillip Camp Harvard Medical School Boston, Massachusetts Kenneth B Christopher, MD Harvard Medical School Boston, Massachusetts Marcus D Darrabie, MD Duke University Medical Center Durham, North Carolina Christian Denecke, MD Innsbruck Medical University Innsbruck, Austria J Rodrigo Diaz-Siso Harvard Medical School Boston, Massachusetts Karim Djekeidel Drexel University College of Medicine Philadelphia, Pennsylvania Anquenetta L Douglas Johns Hopkins School of Medicine Baltimore, Maryland Ian F Dunn Harvard Medical School Boston, Massachusetts Brian Edlow Harvard Medical School Boston, Massachusetts Ali A El-Solh University at Buffalo Buffalo, New York E Wesley Ely, MD, MPH Vanderbilt University Medical Center Nashville, Tennessee Peter J Fagenholz, MD Harvard Medical School Boston, Massachusetts Michael G Fitzsimons Harvard Medical School Boston, Massachusetts Gyorgy Frendl Harvard Medical School Boston, Massachusetts Dragos M Galusca, MD Johns Hopkins Medical Institutions Baltimore, Maryland Samuel M Galvagno, Jr., DO, PhD University of Maryland School of Medicine Baltimore, Maryland Brett Glotzbecker Harvard Medical School Boston, Massachusetts William B Gormley Harvard Medical School Boston, Massachusetts David Greer Harvard Medical School Boston, Massachusetts Michael Gropper University of California San Francisco San Francisco, California Hiroto Hatabu Harvard Medical School Boston, Massachusetts Joaquim M Havens, MD Harvard Medical School Boston, Massachusetts Galen V Henderson Harvard Medical School Boston, Massachusetts Kathryn A Hibbert, MD Harvard Medical School Boston, Massachusetts Jennifer Hofer, MD The University of Chicago Medical Center Chicago, Illinois Peter C Hou, MD Harvard Medical School Boston, Massachusetts Danny O Jacobs Duke University School of Medicine Durham, North Carolina George Kasotakis, MD Harvard Medical School Boston, Massachusetts Edward Kelly Harvard Medical School Boston, Massachusetts Emily Z Keung, MD Harvard Medical School Boston, Massachusetts George Koenig Jefferson Medical College Philadelphia, Pennsylvania Yasser El Kouatli University of Michigan Health System Ann Arbor, Michigan John P Kress University of Chicago Chicago, Illinois Kelly B Kromer Harvard Medical School Boston, Massachusetts Peggy S Lai, MD Harvard Medical School Boston, Massachusetts Col Geoffrey S.F Ling Medical Corps, US Army Arlington, Virginia Tensing Maa, MD Ohio State University Medical Center Columbus, Ohio Sayeed K Malek, MD, FACS Harvard Medical School Boston, Massachusetts Atul Malhotra Harvard Medical School Boston, Massachusetts Ernest I Mandel, MD Harvard Medical School Boston, Massachusetts Oveys Mansuri University of Nebraska College of Medicine Omaha, Nebraska Shannon S McKenna, MD Harvard Medical School Boston, Massachusetts Brijesh P Mehta, MD Harvard Medical School Boston, Massachusetts Alessandro M Morandi Vanderbilt University School of Medicine Nashville, Tennessee Lena M Napolitano University of Michigan Health System Ann Arbor, Michigan Emily Nelson Harvard Medical School Brigham and Women’s Hospital Boston, Massachusetts Patrice K Nicholas Massachusetts General Hospital Boston, Massachusetts Chong Nicholls Harvard Medical School Boston, Massachusetts Heikki Nikkanen Harvard Medical School Boston, Massachusetts John J O’Connor, Jr., MD South Shore Hospital South Weymouth, Massachusetts Michael F O’Connor, MD, FCCM University of Chicago Medical Center Chicago, Illinois Yuka Okajima Harvard Medical School Boston, Massachusetts David Oxman Jefferson Medical College Philadelphia, Pennsylvania Bhakti K Patel University of Chicago Chicago, Illinois Mary Pennington Brigham and Women’s Hospital Boston, Massachusetts Sujatha Pentakota, MD Harvard Medical School Boston, Massachusetts Bohdan Pomahac, MD Harvard Medical School Boston, Massachusetts Pankajavalli Ramakrishnan Harvard Medical School Boston, Massachusetts Mary B Rice, MD Harvard Medical School Boston, Massachusetts Steven A Ringer Harvard Medical School Boston, Massachusetts Angela J Rogers, MD Harvard Medical School Boston, Massachusetts Selwyn O Rogers, Jr., MD, MPH Harvard Medical School Boston, Massachusetts Allan Ropper Harvard Medical School Boston, Massachusetts Daniel S Rubin, MD University of Chicago Chicago, Illinois Amod Sawardekar Northwestern University Feinberg School of Medicine Chicago, Illinois Raghu Seethala Harvard Medical School Boston, Massachusetts Mouhsin Shafi Harvard Medical School Boston, Massachusetts Sajid Shahul Harvard Medical School Boston, Massachusetts Peter H Stone Harvard Medical School Boston, Massachusetts Daniel S Talmor, MD, MPH Harvard Medical School Boston, Massachusetts Candice Tam University of California San Francisco San Francisco, California Stefan G Tullius, MD, PhD, FACS Harvard Medical School Boston, Massachusetts Avery Tung University of Chicago School of Medicine Chicago, Illinois postoperative management surgical complication surgical technique Pancreatitis, severe acute Paracentesis Parkland formula Patient- and family-centered care and cultural issues definition interventions communication family presence during codes family’s level of involvement flexible visitation policy key concepts objective rationale Patient transport by air assessment and preparation ground transportation infusion devices during inter-hospital intra-hospital monitoring during risks and benefits PDE-5 inhibitors PE See Pulmonary embolism (PE) Pediatric advanced life support (PALS) Pediatric intensive care abdominal injury acute chest syndrome acute lung injury acute respiratory distress syndrome bronchiolitis central diabetes insipidus cerebral salt wasting diabetic ketoacidosis drug and blood product dosing extracorporeal membrane oxygenation head injury non-accidental trauma non-pharmacologic modalities normal physiologic values orthopedic injury pain management pediatric sedation pharmacologic modalities sepsis shock spinal cord injury and vertebral injury status asthmaticus status epilepticus syndrome of inappropriate secretion of antidiuretic hormone thoracic injury trauma tumor lysis syndrome Penicillins Pentazocine (Talwin) Pentobarbital pediatrics dosing Percutaneous transtracheal jet ventilation Percutaneous VADs Pericardial tamponade causes clinical findings differential diagnosis management Pericardiocentesis Peripartum cardiomyopathy Peripheral vascular disease Peritoneal dialysis Persistent pulmonary hypertension of newborn (PPHN) Persistent vegetative state (PVS) Phenobarbital pediatrics dosing Phentolamine Phenylephrine in heart and lung transplantation pediatrics dosing Phenytoin Phosgene oxide Pigment nephropathy Plasmapheresis Plastic surgical critical care free flaps (See also Free flaps, postoperative monitoring of) pedicle flaps Platelet transfusion complications indications for technical aspects related to Plethysmography Pleural effusions, radiographic findings Pneumocystis pneumonia, radiographic findings Pneumomediastinum, radiographic findings Pneumonia admission to ICU, criteria for diagnostic testing and treatment duration of treatment non-responding prevention radiographic findings types of, and pathogens Pneumothorax radiographic findings Positive end expiratory pressure (PEEP) Posterior cord syndrome Posterior reversible encephalopathy syndrome (PRES) Post-obstructive pulmonary edema (POPE) PPHN See Persistent pulmonary hypertension of newborn (PPHN) Prasugrel, for UA/NSTEMI Prednisolone Prednisone Pregabalin Pressure control ventilation (PCV) Pressure support ventilation (PSV) Pressure ulcers epidemiology pathogenesis risk assessment and mitigation risk factors specific interventions staging of support surfaces for Primidone Problems, common, in ICU arrhythmias fever hyperkalemia hypotension hypoxemia low urine output, in acute renal failure mental status change, acute pericardial tamponade sepsis shock tension pneumothorax Procainamide Prolonged neuromuscular blockade Propafenone Propofol dosing in obese patient pediatrics dosing as sedative agent in withdrawal of care Propranolol Prostacyclins Prosthetic valves bioprosthetic mechanical Protein–energy malnutrition Kwashiorkor-type marasmus-type Protein intake requirements Proton pump inhibitors (PPIs), for stress ulcers Pulmonary artery catheter insertion Pulmonary artery occlusion pressure (PAOP) Pulmonary capillary wedge pressure (PCWP) Pulmonary edema, radiographic findings Pulmonary embolism (PE) diagnostic tests for radiographic findings treatment of Pulmonary tuberculosis, radiographic findings Pulmonary vasodilators Pulmonary veno-occlusive disease Pulse oximetry Pulse wave analysis PVS See Persistent vegetative state (PVS) Q Quetiapine, for delirium Quinidine R Radiocontrast nephropathy (RCN) Radiologic imaging chest CT adverse reaction to contrast media contrast enhanced CT, indications for contrast-induced anaphylaxis prevention, recommendation for contrast-induced nephrotoxicity evaluation before contrast injection chest X-rays central venous catheter chest drainage tube endotracheal tube interpreting approach intra-aortic counterpulsion balloon catheter nasogastric tube portable CXR characteristics recommended indications Swan-Ganz catheter for thoracic diseases acute lung injury acute pulmonary embolism acute respiratory distress syndrome alveolar pneumonia aortic dissection brain CT brain herniation bronchopneumonia cortical contusion epidural hematoma hematoma herpes simplex encephalitis hyperacute cerebral infarction intracerebral hemorrhage mycoplasma pneumonia pleural effusions pneumocystis pneumonia pneumomediastinum pneumonia pneumothorax pulmonary edema pulmonary tuberculosis respiratory viral pneumonia subarachnoid hemorrhage subdural hematoma systematic viral pneumonia thoracic aortic aneurysm traumatic rupture of thoracic aorta Ranson’s criteria, for severe pancreatitis Rapidly progressive glomerulonephritis (RPGN) Recruitment maneuvers Rectal temperature Red blood cell (RBC) transfusion complications indications for in patients with bleeding/hemorrhagic shock technical aspects related to Remifentanil Renal calculations Renal problems acute interstitial nephritis acute kidney injury acute tubular necrosis electrolyte abnormalities with diabetes insipidus hyperkalemia hypernatremia hyponatremia general workup obstruction rapidly progressive glomerulonephritis treatment approach/strategies TTP-HUS tumor lysis Renal replacement therapy for hyperkalemia Renal transplant See Kidney transplantation, postoperative management Respiratory acidosis case examples of causes of Respiratory alkalosis case examples of causes of Respiratory distress syndrome Respiratory formulas Respiratory management, of newborn Respiratory quotient (RQ) Respiratory viral pneumonia, radiographic findings Restrictive cardiomyopathy Retrograde tracheal intubation Revised trauma score Rhabdomyolysis Richmond Agitation Sedation Scale (RASS) Rigid laryngoscopes Riker Sedation-Agitation Scale (SAS) Ringer’s lactate, for fluid resuscitation Risperidone, for delirium Rivaroxaban Rocuronium pediatrics dosing Rufinamide “Rule of nines” RV ventricular device (RVAD) S Saline vs Albumin Fluid Evaluation (SAFE) study SCI See Spinal cord injury (SCI) Scoring systems APACHE MELD score revised trauma score SAPS SOFA STS risk calculator SE See Status epilepticus (SE) Sedation agents for assessment of level of pediatrics dosing principles of management of SEDLine monitor Seizures See also Status epilepticus (SE) antiepileptic drugs choosing of commonly used comorbid conditions and differential diagnosis of drugs causing provoked, etiology of workup of Sepsis causes investigations in management and muscle weakness surviving sepsis guidelines 2012 Septic shock Sequential organ failure assessment (SOFA) Severe acute pancreatitis Shock clinical manifestations differential diagnosis management Shunt Sildenafil Silver nitrate Silver sulfadiazine Simplified acute physiology score (SAPS) Single nucleotide polymorphism (SNP) Skin, anatomy of Slow continuous ultrafiltration (SCUF) Slow low-efficiency dialysis (SLED) The Society of Critical Care Medicine (SCCM) Sodium bicarbonate, pediatrics dosing Sodium valproate Soft tissue crush injuries Sotalol Spinal cord injury (SCI) classification complications incomplete SCI syndromes initial management of long-term management of muscle groups to assess in neurological assessment radiographic evaluation of steroid therapy for surgical management Spinal shock Spontaneous awakening trial (SAT) Spontaneous breathing trials (SBT) Statins in acute ischemic strokes for UA/NSTEMI Statistics and evidence-based medicine (EBM) EBM internet sources evaluation of published research guidelines for EBM evaluation and application Status epilepticus (SE) diagnosis of generalized convulsive adult, treatment for mortality prediction score for nonconvulsive Steroid myopathy Steroids for hypercalcemia pediatrics dosing for spinal cord injury Stress ulcers definition epidemiology prophylaxis risk factors STS risk calculator Subarachnoid hemorrhage, radiographic findings Subcortical vascular dementia Subcutaneous heparin Subdural hematoma, radiographic findings Subfalcine herniation Sublimaze See Fentanyl Succinylcholine pediatrics dosing Sucralfate, for stress ulcers Sulfonamide, dosing in obese patient Supraglottic airways Suprapubic cystostomy Surgical critical care plastic thoracic vascular Surgical procedures, bedside Sympathetic storms Synchronized intermittent mandatory ventilation (SIMV) Syncope Systemic inflammatory response syndrome (SIRS) criteria Systolic pulse contour analysis, with transpulmonary thermodilution calibration T Tachycardia algorithm Tacrolimus (Prograf), in liver transplantation Tandemheart device TBI See Traumatic brain injury (TBI) Temperature monitoring Tension pneumothorax causes clinical findings differential diagnosis management Terbutaline, pediatrics dosing Tetanus, and muscle weakness Therapeutic hypothermia protocol Thiazides Thienopyridines Thiopental pediatrics dosing Thoracentesis Thoracic aortic aneurysm, radiographic findings Thoracic electrical bioimpedance Thoracic surgical critical care acute respiratory distress syndrome atelectasis and secretion retention atrial fibrillation bronchopleural fistula hypotension massive hemoptysis pain management pulmonary hypertension leading to right heart failure Thoracic trauma investigations for chest X-ray clinical examination other ultrasound specific injuries cardiac trauma chest wall injury esophageal injury great vessel injury hemothorax pneumothorax Thrombin inhibitors Thrombolysis, for acute ischemic strokes Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, (TTP-HUS) Thyroid disease hyperthyroidism hypothyroidism Tiagabine Ticagrelor for UA/NSTEMI Tinzaparin (Innohep) Tirofiban, for UA/NSTEMI Tobramycin, dosing in obese patient Tocainide Tocolytic-induced pulmonary edema Tonsillar herniation Topiramate Torsemide Total body surface area (TBSA) Total parenteral nutrition (TPN) in trauma Toxicology cardiovascular toxins calcium channel blockers digoxin decontamination activated charcoal enhanced elimination multiple dose activated charcoal plasmapheresis urinary pH, manipulation of whole bowel irrigation hepatic and GI toxins acetaminophen caustics metabolic toxins cyanide salicylates toxic alcohols neurotoxins carbon monoxide INH (isoniazid) lithium TPN See Total parenteral nutrition (TPN) Tracheal intubation See also Airway management complications of drugs for equipment for indications for Tracheotomy Tranexamic acid Transfusion-associated acute lung injury (TRALI) The Transfusion Requirements in Critical Care (TRICC) Trial Transient global amnesia (TG A) Transient tachypnea of newborn (TTN) Transitioning from acute care to rehabilitation evaluation for suitability of transfer need of outcomes post acute care facilities, types of inpatient rehabilitation long-term acute care (LTAC) skilled nursing facilities (SNF) steps for successful transfer Transplantation bone marrow and stem cell kidney liver pancreas Transthoracic echocardiography (TTE), for PE Trauma abdominal and abdominal compartment syndrome airway cervical spine clearance damage control surgery death from emergency airway management algorithm extremity injuries FAST in hemorrhage/hemorrhagic shock immediate life threatening conditions cardiac tamponade massive hemothorax pelvic fracture tension pneumothorax initial assessment and management nutritional support in primary survey and rhabdomyolysis scoring systems in secondary survey thoracic training in trauma organization and ATLS guidelines triage and surveillance VTE prophylaxis in vena caval filters for Trauma center classification criteria for transfer to Traumatic brain injury (TBI) cerebral contusions cerebral perfusion and classification diffuse axonal injury duret hemorrhage epidural hematomas initial management intracranial hypertension consequences of management of intracranial pressure and intraparenchymal hematomas neuro-imaging in neurologic assessment prognosis secondary brain injury skull fractures subarachnoid hemorrhage subdural hematomas Traumatic coagulopathy, hemostatic resuscitation for Trepostinil Triamcinolone Trisomy 21 (Down syndrome) Trisomy 18 (Edward syndrome) Trisomy 13 (Patau syndrome) Troponin I Troponin T Trousseau’s sign U UFH See Unfractionated heparin (UFH) Ultrasound-guided therapy and procedures CVC placement echocardiography in pump failure in septic shock in shock management in tamponade Umbilical arterial catheter (UAC) Umbilical venous catheter (UVC) Uncal herniation Unfractionated heparin (UFH) for STEMI for UA/NSTEMI for VTE United Network for Organ Sharing (UNOS) Unstable angina (UA) Urinary catheter placement Urinary tract infection V VADs See Ventricular assist devices (VADs) Valganciclovir Valproic acid Vancomycin for clostridium difficile colitis dosing in obese patient neonatal dosing VAP See Ventilator-associated pneumonia (VAP) Vascular surgical critical care aortic dissection carotid artery stenosis perioperative risk peripheral vascular disease Vasculitis Vasopressin in heart and lung transplantation Vecuronium pediatrics dosing Vegetative state permanent persistent Vena caval filters (IVC filters), in trauma patients Venous duplex ultrasound, for VTE Venous thromboembolism (VTE) diagnostic tests for epidemiology ICU-acquired prevention prophylaxis, obesity and prophylaxis by indication risk assessment and thromboprophylaxis risk factors for and special considerations in trauma patients treatment of Ventilation modes of monitoring patients on Ventilation–perfusion relationships Ventilator-associated pneumonia (VAP) definition diagnosis epidemiology lower rates, interventions for microbiology pathogenesis practices not be routinely employed prevention treatment Ventilator induced lung injury (VILI) Ventricular assist devices (VADs) complications components indications management physiologic benefits types Verapamil Volume Control Plus (VC+) Volume Support Plus (VS+) V/Q mismatch VTE See Venous thromboembolism (VTE) W “Wake up & Breathe Flowchart” Warfarin Warfarin therapy, for HIT Whole bowel irrigation (WBI) Withdrawing care Wong-Baker Visual Scale World Health Organization, on malnutrition Wound care algorithm X Xeroform Z Zonisamide [...]... to the ICU (Crit Care Med 1988;16:701; Cochrane Database Syst Rev 2009;Oct7;4:CD0 02013) • Nevertheless, monitoring oxygenation with pulse oximetry is a standard of care in the ICU Capnography (see www.capnography.com for more information) • Refers to the digital display of CO2 on a digital or analog monitor • Is a standard monitor for non-invasively measuring ventilation • Indications in the ICU • Confirmation... elevation of the tricuspid valve into the right atrium during early ventricular contraction • x descent: occurs before the T wave; caused by downward movement of the ventricle during systolic contraction • v wave: corresponds to T wave; reflects the pressure produced when the blood filling the right atrium comes up against a closed tricuspid valve • y descent: occurs when the tricuspid valve opens... “Cannon a waves:” atrioventricular dissociation (i.e., heart block or junctional rhythm) • Tricuspid regurgitation: c wave and x descent is replaced by a large positive wave of regurgitation as blood flows back into the right atrium during ventricular contraction • Cardiac tamponade: all pressures are elevated; absent y descent • Problems with CVP interpretation and use in the ICU • CVP does not accurate... CRITICALLY ILL PATIENT Emily Nelson and Gyorgy Frendl EMERGENCY DEPARTMENT TO ICU COMMUNICATION STRATEGIES Peter C Hou GENOMICS IN CRITICAL CARE Peggy S Lai and Angela J Rogers APPENDIX: ICU CALCULATORS, CALCULATIONS, DRUGS Sujatha Pentakota APPENDIX: STATISTICS AND EVIDENCE-BASED MEDICINE (EBM) Sujatha Pentakota INDEX COMMON ICU PROBLEMS RAGHU SEETHALA, MD HYPERKALEMIA Serum K > 5.0 mmol/l, severe hyperkalemia... regular: 100 J biphasic; if ineffective, increase J in a stepwise fashion • Wide irregular: Defibrillation dose (not synchronized) • Vagal maneuvers for supraventricular tachycardia • Adenosine 6 mg IV push (if regular) for paroxysmal supraventricular tachycardia • β-blocker – Metoprolol 2.5–5 mg IV • Calcium channel blocker – Diltiazem 0.25 mg/kg IV followed by infusion • Amiodarone 150 mg IV over 10... • Awareness under anesthesia is estimated to occur in 0.1%–0.2% of all patients undergoing general anesthesia; the risk may be higher for ICU patients who require prolonged sedation with or without muscle relaxation • Awareness during sedation or paralysis in the ICU has not been as thoroughly studied as in the general surgical population • Several brain monitors based on electroencephalographic (EEG)... hypoventilation syndrome • Neuromuscular weakness – myasthenia gravis, critical illness polyneuropathy, Guillain–Barre syndromé, hypophosphatemia • V/Q mismatch • Most common cause of hypoxemia in the ICU • Imbalance between lung perfusion and ventilation • Pneumonia, ALI/ARDS, pneumonitis, pulmonary edema, pulmonary embolism • Right to left shunt • Intracardiac shunt, pulmonary AVM, hepatopulmonary... rapidly severe, may lead to cardiovascular collapse) • Tracheal deviation to contralateral side • Absent breath sounds Management • Immediate needle decompression with 14–16 gauge needle in the midclavicular line of the second intercostal space of affected side • Followed by chest tube placement for definitive therapy ACUTE MENTAL STATUS CHANGE A spectrum of states including confusion, delirium, obtundation,... Investigations • Vitals signs • CT head • Labs – electrolytes, BUN, Cr, CBC, LFTs, ammonia, UA, ABG • Lumbar puncture to evaluate for meningitis/encephalitis • EEG to evaluate for nonconvulsive status epilepticus Management • Establish and maintain ABCs (airway, breathing, circulation) • Thiamine 100 mg IV (prior to dextrose to prevent precipitating acute Wernicke’s encephalopathy) • Dextrose 50 ml of D50W... adequately volume loaded can consider diuretic (furosemide) • Renal replacement therapy – in cases of acidosis, electrolyte abnormality, volume overload, uremia • Eliminate any nephrotoxins F EVER IN THE ICU Temperature >38.3°C (101.0°F) Differential Diagnosis • Infectious • Pneumonia • Catheter-related blood stream infections • Sinusitis • C difficile • Intra-abdominal (cholecystitis, abscess, peritonitis) .. .Pocket ICU Pocket ICU Edited by GYORGY FRENDL, MD, PhD Assistant Professor of Anesthesia Harvard Medical... Printed in China Library of Congress Cataloging-in-Publication Data Pocket ICU / [edited by] Gyorgy Frendl, Richard D Urman p ; cm – (Pocket notebook series) Includes bibliographical references and... readmissions to the ICU (Crit Care Med 1988;16:701; Cochrane Database Syst Rev 2009;Oct7;4:CD0 02013) • Nevertheless, monitoring oxygenation with pulse oximetry is a standard of care in the ICU Capnography