Authors John J Marini MD Professor of Medicine Critical Care Medicine Regions Hospital University of Minnesota Minneapolis/St Paul, Minnesota David J Dries MSE, MD Professor of Surgery John F Perry Jr Professor of Trauma Surgery Clinical Adjunct Professor of Emergency Medicine Regions Hospital University of Minnesota Minneapolis/St Paul, Minnesota Dedication This fifth edition of Critical Care Medicine—The Essentials is dedicated to my admired friend and coauthor of the initial four, Arthur P Wheeler Over the years, he was first my resident and fellow, then my collaborator and colleague To those who knew him well, Art was an inspiring example of what is best in academic medical practice—a brilliant, incisively logical, well informed, straight shooting, innovative physician whose intellectual honesty and capability was matched by his empathy for his students, coworkers, and patients With these qualities, Art contributed immensely to the Vanderbilt medical community and rose quickly to national prominence in our field of intensive care Because he was practically minded, we could always count on him to drill to the core of the problem and then work to resolve it Among many notable accomplishments, he shared leadership of the ARDS Network studies that helped set durable standards of care regarding safe ventilator settings, fluid management, and vascular catheter use As an educator, Art had few peers and garnered numerous teaching awards, locally and at the national level In his later years, he poured his energy and talents into the development of an outstanding advanced practice nursing program at Vanderbilt, years before the concept had taken hold in our field and gained its current enthusiastic attention As was often the case, he saw the logic and need for such action well before the rest of us As director of the Vanderbilt Medical ICU for more than two decades, he was recognized across disciplines by trainees, physicians, and nurses alike as a master intensivist gifted with rare bedside abilities Devoted to his family and a man for all seasons, Art loved varied forms of music and became an instrumentrated airplane pilot as well as a hobby farmer With high-level accomplishments coupled to his adventuresome spirit, engaging personality, ready humor, wisdom, and dedication to what's best in medicine, Art left a lingering example in science, education, and patient care for all to remember and emulate John J Marini Preface Critical care is a high-stakes activity—from both outcome and cost perspectives What should a young intensivist be taught and a seasoned practitioner ideally know? Our worlds of medical education and practice continue to change quickly While electronic retrieval of patient records and information from scientific literature is of immeasurable help, electronically facilitated submission, peer review, and production methods have accelerated publication turnover Pressures to shorten time in hospital and improve documentation tug the team toward the computer desk and away from the patient, placing strains on face-to-face communications among doctor, patient, family, and nurse Because of mandated and pragmatic changes in practice, there has been a dramatic shift in care from a “one doctor-one patient” relationship to one in which there are frequent personnel changes The chances for error or miscommunication in this evolving system are magnified Simultaneously, older patients with chronic multisystem dysfunction and attendant complex problems account for a growing fraction of those admitted While practicing on the cutting edge of intensive care medicine has always been challenging, there now seems more to know and too much to keep track of At times, we not seem to be keeping up Another worrisome trend seems clear In this exciting age of molecular medicine, mastery of bedside examination and physiology has been deemphasized Simultaneously, clinical research has shifted from exploration of everyday problems confronted at the bedside to large population-based interventional trials When well done (and we are steadily getting better at them), these studies hold considerable value and often help decide initial “best practice” for many patients Yet, clinical trials will never inform all decisions, and it is incumbent upon the practitioner to know when published clinical research does not apply to the patient at hand and to recognize when the course suggested by trial results should be ignored or highly modified Physicians who apply “best practice” to the individual cannot rely only on protocols and the latest guidelines Recommendations come into and drop out of favor, but physiologic principles and fundamentals of critical care change very little Because real-world problems are complex and treatment decisions interwoven, well-honed analytical skills are indispensable To personalize critical care requires gathering and integration of a broad information stream, interpreted against a nuanced physiological background Management must be guided by informed judgment, applying the best information presently known, and influenced by core physiological principles Once made, the intervention must often be revised, guided by thoughtful observation of the patient's idiosyncratic response Multidisciplinary cooperation among caregivers is essential to the success of these efforts Cardiorespiratory physiology forms the logical base for interpreting vital observations and delivering effective critical care Committed to short-loop feedback and “midcourse” corrections, the intensivist should be aware of population-based studies of similar problems but not enslaved to their results Likewise, it is important to realize that treatments that improve physiological end points not always translate into improved patient outcomes and that failure of a patient to respond as expected to a given treatment does not invalidate that intervention for future patients Add to these considerations the traits of cost consciousness, empathy, and effective communication, and you are well positioned to deliver cost-effective, quality care in our demanding practice environment Multiauthored books—even the best of them—have chapters of varying style and quality that are often lightly edited We believe that a book intended for comprehension is best written with a single voice and consistent purpose Therefore, every chapter in this book was written and revised by the two authors After many years of working together in clinical practice, research, and education, we have felt free to comment freely, quibble, complain, and edit each other's work Sadly, the coauthor of the first four editions, Art Wheeler—a brilliant physician, leader, and close friend, passed on prematurely years ago Fortunately, his place has been taken for this fifth edition by another, David Dries, whose expertise in surgery and trauma has added immeasurably to the depth of this latest edition Consistent with our P.viii specialties, we practice in different dedicated ICUs of the same referral and community general hospital (Regions Hospital, St Paul, MN) Yet, as investigators and professors of Medicine and Surgery of the University of Minnesota, our research and educational interests are well aligned Close collaboration between medical and surgical professors in an educational effort of this type is quite unusual and may be unique Whatever the truth of that, this diversity adds breadth and helps keep perspective on what is “essential”—or at least what's valuable and interesting to know in today's practice Since our last edition, major insights and changes in practice have enriched our evolving field Among the most prominent of these are neurological critical care, bedside ultrasonography, and interventional radiology There has been dawning awareness and prioritization of the need to be less invasive and to prevent the postintensive care syndrome Although these now receive special emphasis, virtually every chapter has been thoroughly revised and updated Trauma and surgical critical care material, as well as illustration content, have been markedly expanded and refined As before, we have tried to extract what seem to be those grounding bits of knowledge that have shaped and reshaped our own approaches to daily practice We titled this book “ The Essentials” when it was first written, but admit that in places it now goes into considerable depth and quite a bit beyond basic knowledge; hence, the slightly modified title Our own tips and tricks—useful pearls that we think give insight to practice—have been sprinkled liberally throughout This book was written to be read primarily for durable understanding; it is not intended for quick lookup on-the-fly It is not a book of quick facts, bullet points, checklists, options, or directions It would be difficult to find a white coat pocket big enough to carry it along on rounds Depth of treatment has not been surrendered in our attempt to be clear and concise The field of critical care and the authors, both once young and inexperienced, have now matured Fortunately, we remain committed to caring for the sickest patients, discovering new ways to understand and more effectively confront disease, and passing on what we know to the next generation Many principles guiding surgery and medicine are now time-tested and more or less interchangeable For the fifth edition, we have carefully examined and updated the content of each chapter, added and modified many illustrations, expanded content, and in a few cases, discarded what no longer fits Mostly, however, we fine-tuned and built upon a solid core This really is no surprise—physiologically based principles endure It is gratifying that most of what was written four editions ago still seems accurate—and never more relevant John J Marini David J Dries Acknowledgments Of all the paragraphs in this book, this one is among the most difficult to write Perhaps it is because so many have helped me reach this point—some by their inspiring mentorship, some by spirited collaboration, some by invaluable support, and some by enduring friendship I hope that those closest to me already know the depth of my gratitude A special few have given me far more than I have yet given back The debts I owe to Len Hudson, Bruce Culver, Luciano Gattinoni, and Elcee Conner cannot easily be repaid By their clear examples, they have shown me how to combine love for applied physiology, scientific discovery, and education-never forgetting that the first priorities of medicine are to express compassion for and connection with others while advancing patient welfare “Each wave owes the essence of its line only to the withdrawal of the preceding one.” (Andre Gide) John J Marini As word of my involvement in this book spread around our hospital, many colleagues offered advice and support ranging from images and algorithms to reality checks and encouragement I would like to acknowledge the following individuals in this regard: Kim Cartie-Wandmacher, PharmD; Hollie Lawrence, PharmD; Jeffrey Evens, TSC; Jody Rood, RN; Carol Droegemueller, RN; Christine Johns, MD; Azhar Ali, MD; Don Wiese, MD; Andy Baadh, MD; Richard Aizpuru, MD; and Haitham Hussein, MD To Barbara and my family, please accept my thanks for prayers, guidance, and support Our children and grandchildren have blessed and inspired us Finally, thanks to my colleagues on the faculty and staff at Regions Hospital for all they have taught me David J Dries Special Thanks The authors gratefully acknowledge collaboration of the following contributors on this Fifth Edition: Dr Andrew Hartigan for help in the revision of Chapter 11; Kim Cartie-Wandmacher, PharmD, for the revision of Chapter 15; and Julie Jasken, RD, for the revision of Chapter 16 The expert, uplifting and tireless contributions of Sherry Willett at Regions Hospital, as well as those of the well-tuned production team of Keith Donnellan, Timothy Rinehart, and Jennifer Clements are sincerely appreciated John J Marini David J Dries TABLE OF CONTENTS Section I - Techniques and Methods in Critical Care Chapter - Hemodynamics Chapter - Hemodynamic Monitoring Chapter - Shock and Support of the Failing Circulation Chapter - Arrhythmias, Pacing, and Cardioversion Chapter - Respiratory Monitoring Chapter - Airway Intubation Chapter - Elements of Invasive and Noninvasive Mechanical Ventilation Chapter - Practical Problems and Complications of Mechanical Ventilation Chapter - Positive End-Expiratory and Continuous Positive Airway Pressure Chapter 10 - Discontinuation of Mechanical Ventilation Chapter 11 - Intensive Care Unit Imaging Chapter 12 - Acid-Base Disorders Chapter 13 - Fluid and Electrolyte Disorders Chapter 14 - Blood Conservation and Transfusion Chapter 15 - Pharmacotherapy Chapter 16 - Nutritional Support and Therapy Chapter 17 - Analgesia, Sedation, Neuromuscular Blockade, and Delirium Chapter 18 - General Supportive Care Chapter 19 - Quality Improvement and Cost Control Section II - Medical and Surgical Crises Chapter 20 - Cardiopulmonary Arrest Chapter 21 - Acute Coronary Syndromes Chapter 22 - Hypertensive Emergencies Chapter 23 - Venous Thromboembolism Chapter 24 - Oxygenation Failure, ARDS, and Acute Lung Injury Chapter 25 - Obstructive Disease and Ventilatory Failure Chapter 26 - ICU Infections Chapter 27 - Sepsis and Septic Shock Chapter 28 - Thermal Disorders Chapter 29 - Acute Kidney Injury and Renal Replacement Therapy Chapter 30 - Clotting Problems, Bleeding Disorders, and Anticoagulation Therapy Chapter 31 - Hepatic Failure Chapter 32 - Endocrine Disturbances in Critical Care Chapter 33 - Drug Overdose and Poisoning magnesium infusion, 451 management algorithm, 452 nitrates, 450 oral anticoagulants, 460 statin and alternative cholesterol management, 459 outcome, 460 physical examination, 446 primary percutaneous coronary intervention, 454 455 456 457 Status epilepticus, 715 716 717 Sternal fracture, 750 Strength and muscle reserve endurance measures, 122 123 maximal inspiratory pressure, 122 vital capacity, 121 122 Stress cardiomyopathy, Stress index, 108 109 109 Stroke characteristics, 718 complications, 727 728 embolic, 723 724 hemorrhagic clinical presentations, 725 726 computed tomography studies, 725 726 727 magnetic resonance imaging studies, 725 726 727 nonvascular risk factors, 725 occurrence, 725 725 risk factors, 726 seizures, 725 726 sites and characteristics, 725 726 725 treatment of intracerebral, 726 726 warfarin and heparin, 725 initial evaluation, 718 719 ischemic acute, initial management algorithm, 719 720 aspirin, 723 clinical syndromes, 721 endarterectomy, 723 endovascular therapy, 723 homonymous hemianopsia, 723 incidence of, 721 recombinant tissue type plasminogen activator, 723 sensory and motor deficits, 722 723 in small perforating vessels, 721 transient ischemic attacks, 721 722 722 lacunar, 724 725 mimics of, 718 pathophysiology, 718 patient care glucose control, 719 720 721 normalizing blood pressure, 719 prophylactic anticonvulsant therapy, 719 presentations of, 719 721 subarachnoid hemorrhage, 727 727 728 volume determinants afterload, contractility, diastolic dysfunction, heart rate, pleural pressure and afterload, preload, 5 transmural pressure, Stylet-guided intubation, 133 Subarachnoid hemorrhage (SAH), 727 727 728 Subcutaneous gas/emphysema, 248 Subdural hematoma, acute, 737 Subpleural air cysts, 245 246 Subxiphoid pericardiotomy, 18 Supraglottic airways King airway and Combitube, 126 laryngeal mask airway, 126 nasopharyngeal airways, 126 oropharyngeal airways, 125 126 Supraventricular tachycardias (SVT), nonsinus, 71 72 73 74 75 atrial fibrillation, 74 75 atrial flutter (flutter), 75 ectopic atrial tachycardia, 73 74 nomenclature, 71 reentrant, 71 72 73 SVR (systemic vascular resistance), SVRI (systemic vascular resistance indices), 38 SVT nonsinus See Supraventricular tachycardias (SVT), nonsinus Swan-Ganz catheter cardiac output determination Fick principle, 35 36 technical considerations and potential errors, 36 37 38 39 thermodilution, 36 central and mixed-venous blood sampling mixed-venous oxygen saturation, 40 41 40 oxygen supply and demand, 39 40 insertion-related complications catheter malpositioning, 41 42 catheter-related arrhythmias, 41 pulmonary artery rupture, 42 pulmonary infarction, 42 long-term catheterization complications infection, 42 thrombosis, 42 pulmonary vascular pressures arterial occlusion (wedge) pressure, 30 31 artery pressure, 29 30 central venous pressure, 29 dynamic requirements, 28 29 29 measurement, 27 pleural pressure, 34 35 static requirements, 27 28 28 wedge pressure, 31 32 33 34 Synchronized intermittent mandatory ventilation (SIMV), 147 148 228 See also Weaning from mechanical ventilation Systemic gas embolism, 166 Systemic inflammatory response syndrome (SIRS), 575 576 Systemic vascular resistance (SVR), Systemic vascular resistance indices (SVRI), 38 Systolic pressure, 16 17 T Tachyarrhythmias narrow complex, treatment, 73 sinus tachycardia, 71 supraventricular tachycardias, nonsinus, 71 72 73 74 75 atrial fibrillation, 74 75 atrial flutter (flutter), 75 ectopic atrial tachycardia, 73 74 nomenclature, 71 reentrant, 71 72 73 ventricular extrasystoles, 76 ventricular tachycardia, 76 77 78 Tachycardias, 432 Temperature correction factors, blood pH and gas measurements, 815 816 Tension pneumothorax, 247 TGI (tracheal gas insufflation), 520 520 P.838 Thermal disorders extreme hyperthermia syndromes (see Extreme hyperthermia syndromes) hyperthermia, 602 hypothermia (see Hypothermia) normal temperature regulation, 595 596 temperature measurement devices types, 596 sites, 596 Thermistor position, 36 Thermodilution, 36 Thoracic electrical bioimpedance, 37 Thoracic trauma See Chest trauma Thoracostomy, 170 171 172 Thrombocytopenia causes, 628 629 629 drug-induced, 630 heparin-induced, 635 636 635 immune-mediated, 630 impaired production, 629 630 platelet consumption, 630 thrombotic thrombocytopenic purpura-hemolytic uremia syndrome, 630 Thrombolytics, 43 44 Thrombosis, 42 Thrombotic thrombocytopenic purpura (TTP), 630 Thyroid disease critical illness and thyroid testing, 663 664 hyperthyroidism and thyroid storm antithyroid medications, 665 666 666 β-blockers, 667 causes heart failure, 667 critical care management of, 666 laboratory analysis, 665 pharmacologic treatment of, 665 666 666 propylthiouracil and methimazole, 666 667 severe hypothyroidism antidiuretic hormone secretion, 667 aspiration pneumonitis, 668 669 laboratory findings of, 667 risk factors, 668 669 sick euthyroid syndrome, 667 668 symptoms of, 667 syndromes in intensive care unit, 667 treatment of, 668 668 thyroid kinetics, 663 664 TIAs (transient ischemic attacks), 721 722 722 Tissue edema, Tissue oxygen delivery (DO2), 311 312 Tissue oxygenation acute respiratory distress syndrome and acute lung injuryventilation (see also Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)) extrapulmonary gas exchange, 518 519 high-frequency ventilation, 518 inhaled nitric oxide and prostacyclin, 522 lung-protective approach, 523 524 523 524 practical points, 521 522 522 prone positioning, 520 521 522 521 521 524 surfactant, 522 523 tracheal gas insufflation, 520 520 hemoglobin (Hgb) concentration, 509 oxygen therapy, 510 positive end-expiratory pressure technique, 510 recruiting maneuvers and positive end-expiratory pressure selection, 510 511 510 secretion management and bronchodilation, 511 therapeutic principles acute respiratory distress syndrome, multisystem disease, 508 misadventures prevention, 508 risk:benefit ratio, 507 508 techniques, 508 ventilation requirements, 511 511 TOA (tubo-ovarian abscess), 770 Tocainide, 80 Torsades De Pointes, 77 77 78 Toxic plants, 701 Tracheal gas insufflation (TGI), 520 520 Tracheostomy, 235 236 benefits and indications, 138 139 conventional variants minitracheostomy, 140 needle cricothyroidotomy, 139 percutaneous dilatational tracheostomy, 139 140 tube displacement, 140 Tracheostomy, airflow obstruction arterial pulsus paradoxus, 533 asthma, physical diagnosis, 532 533 CO2 retention/acidosis/cyanosis, 534 deteriorating mental status, 533 hyperinflation, 533 534 management corticosteroids, 535 536 fluids, 537 inhaled bronchodilators, 534 535 magnesium sulfate, 537 mechanical ventilation, 537 538 oxygen therapy, 534 positive end-expiratory pressure, 538 respiratory therapy, 537 sedation, 536 sedation, paralytics, and iatrogenic neuromyopathy, 536 theophylline, 536 537 Transcutaneous photometric oximetry, 92 Transesophageal echocardiography, 45 Transfusion associated lung injury (TRALI), 323 324 Transfusion-related immune modulation (TRIM), 324 Transient ischemic attacks (TIAs), 721 722 722 Translaryngeal intubation vs tracheostomy, 138 Transmural pressure afterload, 6 preload, 5 ventricular volume loops, Tricuspid regurgitation, 36 Triggering dyssynchrony, 190 TRIM (transfusion-related immune modulation), 324 Trophic feeding, 346 TTP (thrombotic thrombocytopenic purpura), 630 Tubes and catheters placement central venous catheters, 242 chest tubes, 243 gastric access tubes, 244 intra-aortic balloon, 244 pacing wires, 243 pulmonary artery catheter, 242 243 tracheal tube position, 241 242 241 Tubo-ovarian abscess (TOA), 770 Tubular necrosis, acute, 615 616 Two-dimensional (real-time) echocardiography, 43 44 45 U UAO See Upper airway obstruction (UAO) UFH See Unfractionated heparin (UFH) Ulcer disease, 790 791 Ultrasound acute care abdominopelvic ultrasound and FAST scanning, 267 268 267 cardiovascular, 263 264 265 263 264 thoracic ultrasound, 265 266 265 266 vascular catheter placement, 267 intensive care unit imaging, 253 P.839 Unfractionated heparin (UFH), 442 443 482 483 484 492 632 641 642 Unstable angina (UA), 436 Upper airway obstruction (UAO), 125 528 529 530 531 528 529 530 diagnostic tests, 529 530 529 530 management, 530 signs and symptoms, 528 529 528 tracheostomy care, 531 Upper gastrointestinal (GI) bleeding angiography, 790 burn injury, 809 causes of aortoenteric fistulas, 796 796 gastritis, 791 Mallory-Weiss tear, 791 792 peptic ulcer disease, 790 791 791 vascular malformations, 796 chronic liver failure, 660 computed tomography scanning, 789 diagnosis of, 788 789 789 endoscopic injection and thermal therapy, 790 esophagogastroduodenoscopy, 789 790 indications, 785 786 medication options, 786 patient evaluation assessing bleeding severity, 787 examination, 786 787 history, 786 initial treatment, 787 788 physical examination, 786 plain abdominal radiographs, 789 pneumonia risk, 786 portal hypertension and variceal bleeding causes of, 792 792 decompressive shunting, 795 796 at gastroesophageal junction, 792 792 liver transplant, 796 managing plan for, 793 793 obliteration, 795 pharmacotherapy, 793 794 tamponade, 794 prevention, 785 786 prognosis, 797 recurrent risks, 789 sources, 788 789 789 surgical intervention, 796 797 Urinary tract infections (UTI) diagnosis, 548 549 pathogenesis, 548 treatment, 549 V Vancomycin, 563 VAP See Ventilator-associated pneumonia (VAP) VAPS (volume-assured pressure support), 150 151 Vascular resistance indices, 38 Vascular tone failure (vasoplegia), 50 Vasoactive and inotropic drugs, 57 58 59 60 61 58 calcium chloride, 61 catecholamine receptor stimulators dobutamine, 60 dopamine, 59 60 epinephrine, 59 isoproterenol, 59 neo-synephrine, 59 norepinephrine, 59 in hypertensive congestive heart failure, 65 66 levosimendan, 61 noncatecholamine-based age amrinone and milrinone, 60 glucagon and insulin, 61 glucocorticoids, 60 61 vasopressin, 60 principles of, 57 58 58 Vasopressin, 58 Vasopressors, 21 25 38 Vecuronium, 368 Venous thromboembolism (VTE) deep venous thrombosis (see Deep venous thrombosis (DVT)) diagnostic plan, 489 490 mechanisms, 480 481 prevalence, 482 pulmonary embolism (see Pulmonary embolism (PE)) Venous thromboembolism prophylaxis, 483 Ventilation adaptive support, 154 alterations, arterial blood gases hypercapnia, 277 278 hypocapnia, 278 controlled mechanical, 147 distribution, 385 high-frequency, 518 applications of, 155 description, 154 monitoring, carbon dioxide and dead space, 97 98 98 dead space fraction, 98 99 99 exchange efficiency, 97 exhaled gas monitoring, 99 100 101 100 kinetics and estimates, 96 97 97 and oxygenation, positive endexpiratory pressure, 208 pressure-support, 148 advantages, 148 description, 148 disadvantages, 148 proportional assist, 150 151 weaning from mechanical (see Weaning from mechanical ventilation) Ventilation-assisted intubation, 129 130 Ventilation-associated barotrauma, 165 Ventilator setup humidifier and respiratory circuit, 148 149 inspired oxygen fraction, 149 pressure or volume assist-control modes, 149 150 151 152 Ventilator withdrawal ABCDE bundle, 225 conducting the trial, 225 226 extubation, 225 spontaneous breathing trial, 225 Ventilator-associated pneumonia (VAP) characteristics, 186 187 diagnosis and treatment, 187 188 predispositions, 187 risk factors, 187 Ventilator-induced diaphragmatic dysfunction (VIDD), 188 Ventilator-induced lung injury (VILI), 105 106 179 513 514 airway and alveolar pressures, 175 176 177 178 175 gravitational gradient of transalveolar pressures, 176 management, 184 185 186 186 pathogenesis, 174 175 176 177 178 179 180 181 182 183 propagation and positioning, 183 184 185 184 systemic organs dysfunction, 185 vascular transmural pressure, 182 Ventilator-induced pulmonary edema, 174 175 176 177 178 179 180 181 182 183 184 185 186 Ventilator-related lung rupture, 169 Ventilatory capability and demand, mechanical ventilation alveolar ventilation, 216 central drive, 216 217 218 CO2 production, 215 216 extrinsic factors, 217 218 intrinsic factors, 217 217 muscular performance contractile fiber properties, 218 endurance, 218 219 muscle rest, 219 strength, 218 voluntary measures cough, expiratory pressure and maximal expiratory flow, 222 maximal inspiratory pressure, 221 vital and inspiratory capacity, 221 222 Ventilatory failure airflow obstruction asthma (see Asthma) chronic obstructive pulmonary disease (see Chronic obstructive pulmonary disease (COPD)) P.840 obesity-hypoventilation syndrome, 532 obstructive sleep apnea, 531 532 531 upper airway obstruction, 528 529 530 531 528 529 530 chest wall configuration flail chest, 544 kyphoscoliosis, 544 545 obesity and ascites, 544 pleural effusion and pneumothorax, 544 management of, 526 527 correcting reversible factors, 527 528 527 mechanical support, 528 muscular strength and coordination diaphragm, 545 skeletal muscle weakness and paralysis, 545 546 neuromuscular dysfunction functional anatomy, 542 543 muscular coordination, 543 544 muscular strength, 543 thoracic configuration, 543 543 pathogenesis causes, 526 definition, 526 mechanisms, 526 Ventricular extrasystoles, 76 Ventricular fibrillation (VF), 462 Ventricular septal defect (VSD), 465 Ventricular tachycardia (VT), 76 77 78 78 461 462 defibrillation, 429 pulseless, 430 torsades de pointes, 429 Verapamil, 80 VF(ventricular fibrillation), 462 Vigilance, 698 VILI See Ventilator-induced lung injury (VILI) Viral hepatitis, acute hepatic failure, 650 651 Viral pneumonia, 555 556 Vitamins, 345 346 deficiency, 342 Volume-assured pressure support (VAPS), 150 151 Volutrauma, 174 175 176 177 178 179 180 181 182 183 184 185 186 Von Willebrand disease (vWD), 627 639 von Willebrand factor (vWF), 630 VSD (ventricular septal defect), 465 VT See Ventricular tachycardia (VT) VTE (venous thromboembolism) deep venous thrombosis (see Deep venous thrombosis (DVT)) diagnostic plan, 489 490 mechanisms, 480 481 prevalence, 482 pulmonary embolism (see Pulmonary embolism (PE)) vWD (von Willebrand disease), 627 639 vWF (von Willebrand factor), 630 W Warfarin, 637 642 643 643 Weaning from mechanical ventilation conducting trials, 225 226 evaluation, 220 integrative weaning indices, 222 223 222 predictors, 220 reintubation muscle training, 234 235 noninvasive ventilation, 235 tracheostomy, 235 236 unweanable patient, 234 235 234 spontaneous breathing trial, 225 strategies and methods general principles, 226 227 pressure support ventilation, 228 229 pressure support ventilation vs synchronized intermittent mandatory ventilation, 229 priorities, 227 self-adjusting modes, 229 230 231 232 synchronized intermittent mandatory ventilation, 228 teams and protocols, 227 228 227 unsupported (“T-piece”), 228 ventilator withdrawal ABCDE bundle, 225 conducting the trial, 225 226 extubation, 225 spontaneous breathing trial, 225 withdrawing preparations, 223 224 225 223 Wedge pressure See Pulmonary arterial occlusion (wedge) pressure Wiskott-Aldrich syndrome, 627 Z Zeroing, transducer, 27 28 28 Zolpidem, 233 234 Zyvox, 549 ... arteries) nourishes the interventricular septum, the conduction system below the AV node, and the anterior and lateral walls of the LV If the heart were to relax completely, the difference between... and by the pressure distending the ventricle (the transmural pressure) Transmural pressure is the difference between the intracavitary and juxtacardiac pressures In comparison to the LV, the normal... and therefore, the function of the compromised LV The paradoxical pulse observed during acute asthma results in part from inspiratory afterloading of the LV When the pressure that surrounds the