ACCP Critical Care Medicine Board Review: 21st Edition The American Board of Internal Medicine (ABIM) is not affiliated with, nor does it endorse, preparatory examination review programs or other continuing medical education The content of the ACCP Critical Care Medicine Board Review: 21st Edition is developed independently by the American College of Chest Physicians (ACCP), which has no knowledge of or access to ABIM examination material The views expressed herein are those of the authors and not necessarily reflect the views of the ACCP Use of trade names or names of commercial sources is for information only and does not imply endorsement by the ACCP The authors and the publisher have exercised great care to ensure that drug dosages, formulas, and other information presented in this book are accurate and in accord with the professional standards in effect at the time of publication However, readers are advised to always check the manufacturer’s product information sheet packaged with the respective products to be fully informed of changes in recommended dosages, contraindications, etc, before prescribing or administering any drug Downloaded From: http://books.publications.chestnet.org/ on 07/19/2012 Copyright Ó 2012 by the AMERICAN COLLEGE OF CHEST PHYSICIANS Copyright not claimed on material authored by the US Government All rights reserved No part of this book may be reproduced in any manner without permission of the publisher Published by the American College of Chest Physicians 3300 Dundee Road Northbrook, IL 60062-2348 Telephone: (847) 498-1400; Fax: (847) 498-5460 ACCP Website: www.chestnet.org Printed in the United States of America First Printing ISBN - 978-0-916609-97-9 Downloaded From: http://books.publications.chestnet.org/ on 07/19/2012 Contents Chapter Endocrine Emergencies Robert C Hyzy, MD, FCCP Chapter Postoperative Crises 11 David L Bowton, MD, FCCP, FCCM Chapter Mechanical Ventilation 21 Gregory A Schmidt, MD, FCCP Chapter Hypertensive Emergencies and Urgencies 35 R Phillip Dellinger, MD, MSc, FCCP; and Jean-Sebastien Rachoin, MD Chapter Pregnancy and Critical Illness 47 Mary E Strek, MD, FCCP Chapter Venous Thromboembolic Disease 63 R Phillip Dellinger, MD, MSc, FCCP; and Wissam B Abouzgheib, MD, FCCP Chapter Acute Coronary Syndromes 75 Phillip A Horwitz, MD; and Hjalti Gudmundsson, MD Chapter Heart Failure and Cardiac Pulmonary Edema 91 Steven M Hollenberg, MD, FCCP Chapter Acute and Chronic Liver Failure in the ICU 103 Jesse B Hall, MD, FCCP Chapter 10 Hemodynamic Monitoring 111 John P Kress, MD, FCCP Chapter 11 Tachycardia and Bradycardia in the ICU 123 Frank Zimmerman, MD Chapter 12 Infections in AIDS Patients and Other Immunocompromised Hosts 135 George H Karam, MD, FCCP Chapter 13 Liberation From Mechanical Ventilation 163 John F McConville, MD Chapter 14 Trauma and Burns 169 Bennett P deBoisblanc, MD, FCCP Chapter 15 Airway Management, Sedation, and Paralytic Agents 175 John P Kress, MD, FCCP Chapter 16 Acute Lung Injury/Acute Respiratory Distress Syndrome 187 Jesse B Hall, MD, FCCP Chapter 17 Coma and Delirium 197 John F McConville, MD Chapter 18 The Acute Abdomen, Pancreatitis, and the Abdominal Compartment Syndrome 201 Bennett P deBoisblanc, MD, FCCP Chapter 19 Hypothermia/Hyperthermia and Rhabdomyolysis 205 Janice L Zimmerman, MD, FCCP Downloaded From:Critical http://books.publications.chestnet.org/ 07/19/2012 ACCP Care Medicine Board Review:on21st Edition iii Chapter 20 Ventilatory Crises 219 Gregory A Schmidt, MD, FCCP Chapter 21 Poisonings and Overdoses 227 Janice L Zimmerman, MD, FCCP Chapter 22 Anemia and RBC Transfusion in the ICU 243 Karl W Thomas, MD, FCCP Chapter 23 Shock 259 John P Kress, MD, FCCP Chapter 24 Coagulopathies, Bleeding Disorders, and Blood Component Therapy 271 Karl W Thomas, MD, FCCP Chapter 25 Gastrointestinal Bleeding in the ICU 285 Nikhil R Asher, MD; Kevin McGrath, MD; and Douglas B White, MD, MAS Chapter 26 Nutrition 293 Brian K Gehlbach, MD Chapter 27 Resuscitation: Cooling, Drugs, and Fluids 299 Brian K Gehlbach, MD Chapter 28 Ethical Issues in Intensive Care Medicine 305 Douglas B White, MD, MAS Chapter 29 Interpreting Clinical Research and Understanding Diagnostic Tests in Critical Care Medicine 311 Douglas B White, MD, MAS Chapter 30 Imaging 317 Brian K Gehlbach, MD Chapter 31 Approach to Acid-Base Disorders 323 Harold M Szerlip, MD, MS, FCCP Chapter 32 Severe Pneumonia 337 Michael S Niederman, MD, MS, FCCP Chapter 33 ICU Guidelines, Best Practices, and Standardization 357 Arthur P Wheeler, MD, FCCP Chapter 34 Status Epilepticus, Stroke, and Increased Inracranial Pressure 369 Arthur P Wheeler, MD, FCCP Chapter 35 Derangements of Serum Potassium, Sodium, Calcium, Phosphate, and Magnesium 387 Stephen P Kantrow, MD Chapter 36 Antibiotic Therapy in Critical Illness 403 Michael S Niederman, MD, FCCP Chapter 37 Transplant-Related Issues 419 Stephen P Kantrow, MD Chapter 38 Acute Kidney Injury in the ICU 435 Harold M Szerlip, MD, MS, FCCP Chapter 39 Nervous System Infections and Catheter Infections 447 George H Karam, MD, FCCP Downloaded ivFrom: http://books.publications.chestnet.org/ on 07/19/2012 Contents Authors Wissam B Abouzgheib, MD, FCCP Director of Interventional Pulmonary Program Pulmonary and Critical Care Department Cooper University Hospital Camden, NJ Phillip A Horwitz, MD Associate Professor of Internal Medicine University of Iowa Carver College of Medicine University of Iowa Iowa City, IA Nikhil R Asher, MD Clinical Fellow Department of Critical Care Medicine University of Pittsburgh Medical Center Pittsburgh, PA Robert C Hyzy, MD, FCCP Associate Professor Division of Pulmonary and Critical Care Medicine University of Michigan School of Medicine Ann Arbor, MI David L Bowton, MD, FCCP Professor and Head, Section on Critical Care Department of Anesthesiology Wake Forest University School of Medicine Winston-Salem, NC Bennett P deBoisblanc, MD, FCCP Professor of Medicine and Physiology Director, Critical Care Services Medical Center of Louisiana New Orleans, LA R Phillip Dellinger, MD, MSc, FCCP Professor of Medicine Cooper Medical College of Rowan University Vice Chief, Department of Medicine Head, Division of Critical Care Cooper University Hospital Camden, NJ Brian K Gehlbach, MD Associate Professor Division of Pulmonary, Critical Care, and Occupational Medicine Department of Internal Medicine University of Iowa Iowa City, IA Hjalti Gudmundsson, MD Fellow, Interventional Cardiology Cardiovascular Division University of Iowa Carver College of Medicine Iowa City, IA Jesse B Hall, MD, FCCP Professor of Medicine, Anesthesia, and Critical Care The University of Chicago Pritzker School of Medicine Chicago, IL Steven M Hollenberg, MD, FCCP Professor of Medicine Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey Director, Coronary Care Unit Cooper University Hospital Camden, NJ Stephen P Kantrow, MD Associate Professor of Medicine Section of Pulmonary and Critical Care Medicine LSU Health Sciences Center New Orleans, LA George H Karam, MD, FCCP Paula Garvey Manship Professor of Medicine Louisiana State University School of Medicine New Orleans, LA Head, Department of Internal Medicine Earl Long Medical Center Baton Rouge, LA John P Kress, MD, FCCP Associate Professor of Medicine Section of Pulmonary and Critical Care University of Chicago Chicago, IL John F McConville, MD Assistant Professor of Medicine Section of Pulmonary and Critical Care Medicine Director, Internal Medicine Residency Program University of Chicago Chicago, IL Kevin McGrath, MD Associate Professor of Medicine Director, GI Endoscopy Lab University of Pittsburgh Medical Center Pittsburgh, PA Michael S Niederman, MD, FCCP Chairman, Department of Medicine Winthrop University Hospital Mineola, NY Professor of Medicine Vice Chairman, Department of Medicine SUNY at Stony Brook Stony Brook, NY David Pitrak, MD Professor of Medicine Chief of Infectious Diseases The University of Chicago Chicago, IL Downloaded From:Critical http://books.publications.chestnet.org/ 07/19/2012 ACCP Care Medicine Board Review:on21st Edition Jean-Sebastien Rachoin, MD Assistant Professor of Medicine Cooper Medical School of Rowan University Department of Medicine, Division of Hospital Medicine Cooper University Hospital Camden, NJ Gregory A Schmidt, MD, FCCP Professor, Division of Pulmonary, Critical Care, and Occupational Medicine Department of Internal Medicine University of Iowa Iowa City, IA Mary E Strek, MD, FCCP Professor of Medicine Section of Pulmonary and Critical Care The University of Chicago Chicago, IL Harold M Szerlip, MD, MS, FCCP Professor and Vice-Chairman Department of Medicine, University of Arizona College of Medicine Chief of Medical Service, UAMC-SC University of Arizona/UPHH Consortium Tucson, AZ Karl W Thomas, MD, FCCP Clinical Professor Division of Pulmonary Diseases, Critical Care, and Occupational Medicine University of Iowa Iowa City, IA Arthur P Wheeler, MD, FCCP Professor of Medicine Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University School of Medicine Nashville, TN Douglas B White, MD, MAS Associate Professor Director, Program on Ethics and Decision Making in Critical Illness Department of Critical Care Medicine University of Pittsburgh Medical Center Pittsburgh, PA Frank Zimmerman, MD Assistant Professor of Pediatrics The University of Chicago Children’s Hospital Chicago, IL Janice L Zimmerman, MD, FCCP Professor of Clinical Medicine Weill Cornell Medical College Division Head, Critical Care Department of Medicine Director, Medical ICU The Methodist Hospital Houston, TX v DISCLOSURE OF AUTHORS’ CONFLICTS OF INTEREST The American College of Chest Physicians (ACCP) remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our committee members It is not the intent of the ACCP to eliminate all situations of potential conflict of interest, but rather to enable those who are working with the ACCP to recognize situations that may be subject to question by others All disclosed conflicts of interest are reviewed by the educational activity course director/chair, the Education Committee, or the Conflict of Interest Review Committee to ensure that such situations are properly evaluated and, if necessary, resolved The ACCP educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science Through our review process, all ACCP CME activities are ensured of independent, objective, scientifically balanced information Disclosure of any or no relationships is made available for all educational activities The following authors of the ACCP Critical Care Medicine Board Review: 21st Edition have disclosed to the ACCP that a relationship does exist with the respective company/organization as it relates to their presentation of material and should be communicated to the participants of this educational activity: Authors Relationship Steven M Hollenberg, MD, FCCP Phillip A Horwitz, MD Speakers bureau: Novartis-Makers of Valsartan Grant monies (from industry related sources): Industry supported grants for clinical trials in Acute Coronary Syndrome subjects: AstraZeneca, GlaxoSmithKline, Schering Plough, Roche Grant monies (from industry related sources): Unrestricted research grant from Hospira Consultant fee, speaker bureau, advisory committee, etc: Hospira speaker bureau Grant monies (from sources other than industry): Nektar to study aerosolized amikacin in VAP therapy; Biomerieux to study procalcitonin Consultant fee, speakers bureau, advisory committee, etc: Pfizer, Merck, Ortho-McNeil, Nektar, Novartis, Bayer Product/procedure/technique that is considered research and is NOT yet approved for any purpose: Aerosolized amikacin Grant monies (from industry related sources): Spectral Diagnostics research grant CytoPherx research grant Product/procedure/technique that is considered research and is NOT yet approved for any purpose: glucagon, insulin for beta-blocker and calcium channel blocker overdose; lipid emulsion for overdose John P Kress, MD, FCCP Michael S Niederman, MD, FCCP Harold M Szerlip, MD, MS, FCCP Janice L Zimmerman, MD, FCCP The following authors of the ACCP Critical Care Medicine Board Review: 21st Edition have indicated to the ACCP that no potential conflict of interest exists with any respective company/organization, and this should be communicated to the participants of this educational activity: Wissam B Abouzgheib, MD, FCCP Nikhil R Asher, MD David L Bowton, MD, FCCP Bennett P deBoisblanc, MD, FCCP R Phillip Dellinger, MD, MS, FCCP Brian K Gehlbach, MD Hjalti Gudmundsson, MD Jesse B Hall, MD, FCCP Robert C Hyzy, MD, FCCP Stephen P Kantrow, MD George H Karam, MD, FCCP John F McConville, MD Kevin McGrath, MD Downloaded viFrom: http://books.publications.chestnet.org/ on 07/19/2012 Jean-Sebastien Rachoin, MD Gregory A Schmidt, MD, FCCP Mary E Strek, MD, FCCP Karl W Thomas, MD, FCCP Arthur P Wheeler, MD, FCCP Douglas B White, MD, MAS Frank Zimmerman, MD Needs Assessment Rely on the ACCP Critical Care Medicine Board Review 2012 to review the type of information you should know for the Critical Care Subspecialty Board Examination of the American Board of Internal Medicine (ABIM) Designed as the best preparation for anyone taking the exam, this comprehensive, exam-focused review will cover current critical care literature and management strategies for critically ill patients The ABIM Critical Care Subspecialty Board Examination tests knowledge and clinical judgment in crucial areas of critical care medicine This premier course will review the information you should know for the exam Course content mirrors the content of the exam, as outlined by the ABIM, and includes the following topics: Pulmonary disease Cardiovascular disorders Renal/endocrine/metabolism Infectious disease Neurologic disorders Surgical/trauma/transplantation Gastrointestinal disorders Hematologic/oncologic disorders Pharmacology/toxicology Research/administration/ethics Total 22.5% 17.5% 15% 12.5% 7.5% 7.5% 5% 5% 5% 2.5% 100% Target Audience * * * * * * * * Physicians in critical care and pulmonary medicine Physicians in EDs Physicians in anesthesiology Physicians in surgery Advanced critical care nurse practitioners Advanced respiratory therapy practitioners Physician assistants Pharmacists General Publications Disclaimer The American College of Chest Physicians (‘‘ACCP’’) and its officers, regents, executive committee members, members, related entities, employees, representatives and other agents (collectively, ‘‘ACCP Parties’’) are not responsible in any capacity for, not warrant and expressly disclaim all liability for, any content 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diabetes insipidus; diabetic ketoacidosis; hyperosmolar hyperglycemic state; hypoglycemia; myxedema coma; pheochromocytoma; thyroid storm Synopsis: Many endocrine emergencies require admission to the ICU Although not necessarily common as a primary diagnosis requiring ICU admission, many endocrine emergencies occur in the context of ongoing illness and comorbidities, where the stress of intercurrent illness serves to exacerbate and unmask the underlying condition Hence, the practicing intensivist needs not only to be able to diagnose and manage these conditions as presenting diagnoses but also to recognize endocrine emergencies in the context of critical care more generally Diabetic Ketoacidosis Clinically significant hyperglycemic syndromes consist of diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmotic state (HHS), frequently also referred to as hyperosmotic nonketotic syndrome The American Diabetes Association definitions for these conditions are given in Table Serum glucose level is usually below 800 mg/dL in DKA, whereas in HHS a glucose level in excess of 1,000 mg/dL is not uncommon DKA is characterized by a syndrome of hyperglycemia, ketonemia, and an anion gap metabolic acidosis, usually in excess of 20 Anion gap ẳ serum sodium serum chloride ỵ serum bicarbonateÞ The degree of acidosis and magnitude of the increase in anion gap are contingent on the rate Downloaded From:Critical http://books.publications.chestnet.org/ 07/19/2012 ACCP Care Medicine Board Review:on21st Edition of ketoacid production and urinary excretion Hyperglycemia produces glycosuria and an osmotic diuresis, resulting in extracellular fluid volume depletion, which can be profound and result in hypotension Many of the symptoms of DKA result in large measure from this: polyuria, polydipsia, tachycardia, and lethargy The degree of acidosis is the primary determinant of depressed sensorium In addition, other symptoms such as nausea, vomiting, abdominal pain, and Kussmaul respirations with a characteristic fruity breath may be present DKA is usually diagnosed in known diabetics who present to the emergency room with either noncompliance or with a concomitant stressful illness, especially infection, which has resulted in progressively worsened glycemic control and the onset of ketogenesis Occasionally, a patient, usually an adolescent or young adult, will present with DKA as the initial presentation of their diabetes Other causes of ketoacidosis include alcohol and starvation, which should be in the differential diagnosis in patients without a known history of diabetes Besides elevations in serum glucose and the presence of ketones in serum in urine, laboratory abnormalities seen at presentation in DKA include: a low serum bicarbonate, elevated anion gap, leukocytosis, hyperkalemia, elevated BUN and creatinine (suggesting prerenal azotemia), and elevated amylase and lipase Leukocytosis is proportionate to the degree of acidemia and can confuse the clinical picture as regards the presence of infection Hyperkalemia, due to extracellular osmotic shifting and insulin deficiency, is common despite a deficit in total body potassium, largely from urinary losses Serum sodium is variable in DKA and reflects a balance between osmotic dilution in the serum from hyperglycemia and urinary losses due to osmotic diuresis Pseudohyponatremia may be seen in patients with concomitant hyperlipidemia Although pancreatitis is uncommon, patients with ... Self-study products, including ACCP- SEEK n Evidence-based clinical practice guidelines n ACCP NetWorks n ACCP e-Community n Downloadable publications n ACCP Career Connection n ACCP Store n Patient and... http://books.publications.chestnet.org/ 07/19 /2012 ACCP Care Medicine Board Review:on21st Edition vii ACCP Member Benefts So Many Reasons to Join Find Yours Today The ACCP is the global leader in providing... that form the ACCP community Together, ACCP members serve society by helping people make the most of each breath Downloaded From: http://books.publications.chestnet.org/ on 07/19 /2012 Chapter