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CRITICAL CARE
SIXTH EDITION
POLLY E. PARSONS, MD
E. L. Amidon Professor and Chair of Medicine
Robert Larner College of Medicine at the University of Vermont Burlington, VT
JEANINE P. WIENER-KRONISH, MD
Henry Isaiah Dorr, Professor of Research and Teaching in Anesthetics and Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Harvard Medical School; Anesthetist-in-Chief
Massachusetts General Hospital Boston, MA
RENEE D. STAPLETON, MD, PHD
Associate Professor of Medicine
University of Vermont, Larner College of Medicine
Burlington, VT
LORENZO BERRA, MD
Anesthesiologist and Critical Care Physician
Department of Anesthesia, Critical Care and Pain Medicine, Medical Director of Respiratory Care
Massachusetts General Hospital; Assistant Professor
Harvard Medical School Boston, MA
1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899
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Previous editions copyrighted 2013, 2007, 2003, 1998 and 1992.
Library of Congress Cataloging-in-Publication Data
Title: Critical care secrets / [edited by] Polly E. Parsons, Jeanine P. Wiener-Kronish, Renee D. Stapleton, Lorenzo Berra.
Other titles: Secrets series.
Description: Sixth edition. | Philadelphia, PA : Elsevier, [2019] | Series: Secrets series | Includes bibliographical references and index.
Identifiers: LCCN 2017061385| ISBN 9780323510646 (pbk.) | ISBN 9780323527897 (ebook)
Subjects: | MESH: Critical Care | Examination Questions
Classification: LCC RC86.9 | NLM WX 18.2 | DDC 616.02/8—dc23 LC record available at https://lccn.loc.gov/2017061385
Content Strategist: James Merritt
Content Development Specialist: Meghan B. Andress
Publishing Services Manager: Deepthi Unni
Project Manager: Beula Christopher
Design Direction: Bridget Hoette
Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To our spouses Jim, Daniel, and Jonathan, and to all our colleagues in the ICU, as well as our patients, students, residents, and fellows. This book is dedicated to the patients that we have had the privilege to care for, to the ICU nurses who have been so important in the care of the patients, and to the medical students, residents, and fellows who have helped in caring for all the patients. Thank you all for allowing us to work and be with you.
Polly E. Parsons, MD
Jeanine P. Wiener-Kronish, MD
Renee D. Stapleton, MD, PhD
Lorenzo Berra, MD
CONTRIBUTORS
Varun Agrawal, MD, FACP, FASN
Assistant Professor of Medicine
Division of Nephrology and Hypertension University of Vermont Burlington, VT
Paul H. Alfille, MD
Executive Vice Chairman
Department of Anesthesia, Critical Care and Pain Management
Massachusetts General Hospital Boston, MA
Gilman B. Allen, MD
Pulmonary Critical Care Department University of Vermont Burlington, VT
Michael N. Andrawes, MD
Instructor
Harvard Medical School; Adult Cardiothoracic Anesthesiology Fellowship Program Director
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Amir Azarbal, MD
Fellow
Cardiology Unit, Department of Medicine
University of Vermont-Larner College of Medicine Burlington, VT
Aranya Bagchi, MBBS
Assistant in Anesthesia
Massachusetts General Hospital; Instructor in Anesthesia
Harvard Medical School Boston, MA
Keith Baker, MD, PhD
Associate Professor of Anesthesia
Harvard Medical School; Vice Chair for Education
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Rita N. Bakhru, MD, MS
Assistant Professor
Wake Forest University School of Medicine
Department of Internal Medicine
Pulmonary, Critical Care Medicine, Allergy and Immunology
Medical Center Blvd Winston-Salem, NC
Arna Banerjee, MD, FCCM
Associate Professor of Anesthesiology/Critical Care
Associate Professor of Surgery, Medical Education and Administration
Assistant Dean for Simulation in Medical Education
Director, Center for Experiential Learning and Assessment Nashville, TN
Caitlin Baran, MD University of Vermont Burlington, VT
Pavan K. Bendapudi, MD
Instructor in Medicine
Harvard Medical School; Division of Hematology
Massachusetts General Hospital Boston, MA
William J. Benedetto, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Sheri Berg, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Lorenzo Berra, MD
Anesthesiologist and Critical Care Physician
Department of Anesthesia, Critical Care and Pain Medicine
Medical Director of Respiratory Care
Massachusetts General Hospital; Assistant Professor
Harvard Medical School Boston, MA
Edward A. Bittner, MD, PhD, MSEd
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
M. Dustin Boone, MD
Department of Anesthesia, Critical Care and Pain Medicine
Beth Israel Deaconess Medical Center
Harvard Medical School Boston, MA
William E. Charash, MD, PhD
Associate Professor
Division of Acute Care Surgery, Director
Trauma Critical Care
University of Vermont Larner College of Medicine Burlington, VT
Sreedivya Chava, MD, FACC
Interventional Cardiology
Tricity Cardiology consultants Mesa, AZ
Katharine L. Cheung, MD, MSc, FRCPC
Assistant Professor of Medicine
Division of Nephrology
Larner College of Medicine at The University of Vermont Burlington, VT
Hovig V. Chitilian, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Jaina Clough, MD
Assistant Professor of Medicine
University of Vermont College of Medicine University of Vermont Medical Center Burlington, VT
Ryan Clouser, DO
Assistant Professor of Medicine, Critical Care/ Neurocritical Care
University of Vermont Medical Center Burlington, VT
Lane Crawford, MD
Instructor
Harvard Medical School; Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Jerome Crowley, MD, MPH
Staff Intensivist and Anesthesiologist
Clinical Instructor
Harvard Medical School; Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Adam A. Dalia, MD, MBA
Clinical Instructor in Anesthesia Division of Cardiac Anesthesiology
Department of Anesthesia, Critical Care and Pain Medicine
The Massachusetts General Hospital-Harvard Medical School Boston, MA
Harold L. Dauerman, MD Professor of Medicine
University of Vermont Larner College of Medicine; Network Director
UVM Health Network Interventional Cardiology McClure 1 Cardiology Burlington, VT
Hill A. Enuh, MD Department of Pulmonary Critical Care
University of Vermont Burlington, VT
Peter J. Fagenholz, MD, FACS Assistant Professor of Surgery
Harvard Medical School; Attending Surgeon Department of Surgery
Division of Trauma, Emergency Surgery and Surgical Critical Care
Massachusetts General Hospital Boston, MA
Joshua D. Farkas, MD, MS Department of Pulmonary and Critical Care Medicine
University of Vermont Burlington, VT
Corey R. Fehnel, MD, MPH Department of Neurology
Beth Israel Deaconess Medical Center
Harvard Medical School Boston, MA
Amanda Fernandes, MD
Clinical Instructor
Larner College of Medicine at The University of Vermont Burlington, VT
Daniel F. Fisher, MS, RRT Department of Respiratory Care
Boston Medical Center Boston, MA
viii CONTRIBUTORS
Michael G. Fitzsimons, MD
Assistant Professor Harvard Medical School; Director Division of Cardiac Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Joseph D. Frasca, MD Clinical Instructor
University of Vermont College of Medicine Burlington, VT
Zechariah S. Gardner, MD
Assistant Professor of Medicine Division of Hospital Medicine
University of Vermont College of Medicine University of Vermont Medical Center Burlington, VT
Garth W. Garrison, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
University of Vermont Medical Center Burlington, VT
Matthew P. Gilbert, DO, MPH
Associate Professor of Medicine
Larner College of Medicine at The University of Vermont Burlington, VT
Christopher Grace, MD, FIDSA Professor of Medicine, Emeritus University of Vermont College of Medicine; Infectious Diseases Unit University of Vermont Medical Center Burlington, VT
Cornelia Griggs, MD Chief Resident Department of Surgery
Massachusetts General Hospital Boston, MA
Dusan Hanidziar, MD, PhD
Attending Anesthesiologist and Intensivist Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital; Instructor in Anesthesia
Harvard Medical School Boston, MA
Michael E. Hanley, MD Professor of Medicine
University of Colorado Denver School of Medicine; Staff Physician
Pulmonary and Critical Care Medicine
Denver Health Medical Center Denver, CO
T.J. Henry, MD Resident Department of Surgery University of Iowa Iowa City, IA
Dean Hess, PhD Respiratory Care
Massachusetts General Hospital; Teaching Associate in Anesthesia Harvard Medical School Boston, MA
David C. Hooper, MD Department of Medicine Division of Infectious Diseases
Massachusetts General Hospital Boston, MA
Catherine L. Hough, MD, MSc Professor of Medicine
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington Seattle, WA
James L. Jacobson, MD Professor Department of Psychiatry Larner College of Medicine at The University of Vermont and University of Vermont Medical Center Burlington, VT
Paul S. Jansson, MD, MS Department of Emergency Medicine
Massachusetts General Hospital Brigham and Women’s Hospital Harvard Medical School Boston, MA
Daniel W. Johnson, MD
Assistant Professor Department of Anesthesiology University of Nebraska Medical Center Omaha, NE
Robert M. Kacmarek, PhD, RRT Department of Respiratory Care
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital Boston, MA
Rebecca Kalman, MD Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Brinda B. Kamdar, MD
Program Director
Regional Anesthesia and Pain Medicine Fellowship, Instructor
Harvard Medical School; Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
David A. Kaminsky, MD
Pulmonary Critical Care Department University of Vermont Burlington, VT
Mark T. Kearns, MD
Assistant Professor of Medicine
University of Colorado Denver School of Medicine; Staff Physician
Pulmonary and Critical Care Medicine
Denver Health Medical Center Denver, CO
C. Matthew Kinsey, MD, MPH Director, Interventional Pulmonary University of Vermont Medical Center; Assistant Professor Larner College of Medicine at the University of Vermont
Division of Pulmonary and Critical Care Burlington, VT
Themistoklis Kourkoumpetis, MD
Gastroenterology and Hepatology Fellow
Department of Medicine, Section of Gastroenterology
Baylor College of Medicine Houston, TX
Erin K. Kross, MD
Associate Professor of Medicine
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington Seattle, WA
Leandra Krowsoski, MD
Division of Trauma, Emergency Surgery and Surgical Critical Care Department of Surgery
Massachusetts General Hospital Boston, MA
Abhishek Kumar, MD
Assistant Professor of Medicine/Transplant Medicine
Division of Nephrology and Hypertension
University of Vermont Burlington, VT
Alexander S. Kuo, MS, MD
Assistant in Anesthesia Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital; Instructor Harvard Medical School Boston, MA
David Kuter, MD, DPhil Professor of Medicine
Harvard Medical School; Chief, Division of Hematology
Massachusetts General Hospital Boston, MA
Jean Kwo, MD
Assistant Professor Department of Anesthesia, Critical Care and Pain Medicine
Harvard Medical School
Massachusetts General Hospital Boston, MA
Daniela J. Lamas, MD
Brigham and Women’s Hospital Division of Pulmonary and Critical Care Medicine, Instructor in Medicine
Harvard Medical School; Associate Faculty Ariadne Labs Boston MA
Stephen E. Lapinsky, MBBCh, MSc, FRCPC Director
Intensive Care Unit
Mount Sinai Hosptal; Professor of Medicine University of Toronto Toronto, Canada
John L. Leahy, MD Professor of Medicine
Larner College of Medicine The University of Vermont Burlington, VT
Timothy Leclair, MD
Department of Medicine, Division of Pulmonary and Critical Care Medicine
University of Vermont Medical Center Burlington, VT
Jarone Lee, MD, MPH
Medical Director Blake 12 ICU
Massachusetts General Hospital/Harvard Medical School Boston, MA
Robert Y. Lee, MD Senior Fellow
Division of Pulmonary, Critical Care and Sleep Medicine
University of Washington Seattle, WA
Martin M. LeWinter, MD
Professor of Medicine and Molecular Physiology and Biophysics
Cardiology Unit, Department of Medicine
University of Vermont-Larner College of Medicine Burlington, VT
Eva Litvak, MD Fellow in Adult Cardiothoracic Anesthesia Division of Cardiac Anesthesia
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Kathleen D. Liu, MD, PhD, MAS Professor
Divisions of Nephrology and Critical Care Medicine Departments of Medicine and Anesthesia
University of California, San Francisco San Francisco, CA
Yuk Ming Liu, MD, MPH
Clinical Assistant Professor
Department of Surgery, Division of Acute Care Surgery University of Iowa Iowa City, IA
Lowell J. Lo, MD Associate Professor Division of Nephrology Department of Medicine University of California, San Francisco San Francisco, CA
Johnathan P. Mack, MD, MSc, FRCPC Assistant Director of Blood Transfusion Service Department of Pathology
Massachusetts General Hospital Boston, MA
Annis Marney, MD, MSCI Diabetes and Endocrinology
The Frist Clinic Nashville, TN
Annachiara Marra, MD, PhD University of Naples Federico II Naples, Italy; Visiting Research Fellow
Division of Allergy, Pulmonary and Critical Care Medicine
Vanderbilt University Medical Center Nashville, TN
Anthony Massaro, MD Department of Medicine
Pulmonary and Critical Care
Brigham and Women’s Hospital Boston, MA
Alexis McCabe, MD Resident
Department of Emergency Medicine
Massachusetts General Hospital/Harvard Medical School Boston, MA
Prema R. Menon, MD, PhD
Assistant Professor of Medicine University of Vermont Burlington, VT
Katherine Menson, DO Fellow
Division of Pulmonary and Critical Care Medicine University of Vermont Medical Center Burlington, VT
Matthew J. Meyer, MD Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Lydia Miller, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Jimmy L. Moss, MD Fellow, Anesthesia Critical Care Program Massachusetts General Hospital; Clinical Fellow in Anesthesia Harvard Medical School Boston, MA
Marc Moss, MD Professor University of Colorado School of Medicine Division of Pulmonary Sciences and Critical Care Medicine Aurora, CO
Maged Muhammed, MD Research Fellow
Harvard Medical School; Division of Infectious Diseases and Division of Gastroenterology
Boston Children’s Hospital; Department of Adult Inpatient Medicine, Department of Medicine
Newton Wellesley Hospital Newton, MA
Eleftherios Mylonakis, MD, PhD, FIDSA
Charles C.J. Carpenter Professor of Infectious Disease Chief, Infectious Diseases Division
Alpert Medical School of Brown University; Division of Infectious Diseases Rhode Island Hospital Providence, RI
Jennifer Nelli, MD Department of Anesthesia Hamilton General Hospital McMaster University Hamilton, ON
Cindy Noyes, MD
Assistant Professor of Medicine, Infectious Disease University of Vermont Medical Center/University of Vermont College of Medicine Burlington, VT
Ala Nozari, MD, PhD
Associate Professor Harvard Medical School; Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Haitham Nsour, MD
Assistant Professor of Medicine Larner College of Medicine University of Vermont Burlington, VT
Jacqueline C. O’Toole, DO
Pulmonary and Critical Care Fellow
Johns Hopkins University Division Pulmonary and Critical Care Medicine Baltimore, MD
Pratik Pandharipande, MD, MSCI, FCCM Professor of Anesthesiology and Surgery Chief, Division of Anesthesiology Critical Care Medicine
Vanderbilt University Medical Center Nashville, TN
Alan C. Pao, MD
Assistant Professor Departments of Medicine and Urology
Stanford University School of Medicine
Veterans Affairs Palo Alto Health Care System Palo Alto, CA
Kapil Patel, MD
Assistant Professor of Medicine
Director, Center for Advanced Lung Disease Division of Pulmonary and Critical Care Medicine Morsani College of Medicine, University of South Florida Tampa, FL
Alita Perez-Tamayo, MD University of Vermont Medical Center Burlington, VT
Kristen K. Pierce, MD
Associate Professor of Medicine Division of Infectious Diseases University of Vermont College of Medicine Burlington, VT
Louis B. Polish, MD
Associate Professor of Medicine Division of Infectious Diseases Director, Internal Medicine Clerkship University of Vermont College of Medicine Burlington, VT
Nitin Puri MD, FCCP Program Director Critical Care Medicine Fellowship Cooper University Hospital; Associate Professor Medicine Cooper Medical School of Rowan University Camden, NJ
Molly L. Rovin, MD
Psychiatry Resident Department of Psychiatry Larner College of Medicine at The University of Vermont and University of Vermont Medical Center Burlington, VT
Sten Rubertsson, MD, PhD, EDIC, FCCM, FERC Professor
Anaesthesiology and Intensive Care Medicine
Department of Surgical Sciences/Anaesthesiology and Intensive Care Medicine Uppsala University Uppsala, Sweden
Noelle N. Saillant, MD Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital Harvard Medical School Boston, MA
Jason L. Sanders, MD, PhD Department of Medicine Massachusetts General Hospital Boston, MA
Joel J. Schnure, MD FACE, FACP Director
Division of Endocrinology and Diabetes University of Vermont Medical Center; Professor of Medicine Larner College of Medicine The University of Vermont Burlington, VT
Kenneth Shelton, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Tao Shen, MBBS
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Erica S. Shenoy, MD, PhD Department of Medicine Division of Infectious Diseases
Massachusetts General Hospital Boston, MA
Stephanie Shieh, MD
Assistant Professor
Division of Nephrology, Department of Medicine
Veterans Affairs St. Louis Health Care System; Division of Nephrology, Department of Medicine St. Louis University St. Louis, MO
Bryan Simmons, MD Critical Care Fellow
Massachusetts General Hospital Boston, MA
Alexis C. Smith, DO Fellow
Wake Forest University School of Medicine Department of Internal Medicine
Pulmonary, Critical Care, Allergy and Immunology Medical Center Blvd Winston-Salem, NC
Lindsay M. Smith, MD
Assistant Professor of Medicine Division of Infectious Diseases
Director, Antimicrobial Stewardship University of Vermont College of Medicine Burlington, VT
Peter D. Sottile, MD
Assistant Professor University of Colorado School of Medicine Division of Pulmonary Sciences and Critical Care Medicine Aurora, CO
Peter S. Spector, MD Professor of Medicine
Director of Cardiac Electrophysiology
The University of Vermont Medical Center Burlington, VT
Antoinette Spevetz, MD, FCCM, FACP Professor of Medicine
Cooper Medical School of Rowan University; Designated Institution Official Graduate Medical Education, Director
Intermediate Care Unit
Section of Critical Care Medicine
Cooper University Hospital Camden, NJ
Krystine Spiess, DO Assistant Professor of Medicine
University of Vermont College of Medicine; Infectious Diseases Unit University of Vermont Medical Center Burlington, VT
Renee D. Stapleton, MD, PhD
Associate Professor of Medicine University of Vermont, Larner College of Medicine Burlington, VT
Scott C. Streckenbach, MD Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Benjamin T. Suratt, MD
Professor of Medicine and Cell and Molecular Biology Vice Chair of Medicine for Academic Affairs Associate Chief, Pulmonary and Critical Care Medicine University of Vermont College of Medicine Burlington, VT
Charlotte C. Teneback, MD Associate Professor of Medicine University of Vermont, College of Medicine Burlington, VT
Susan A. Vassallo, MD
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Mario J. Velez, MD Assistant Professor University of Vermont College of Medicine Burlington, VT
Rodger White, MD Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital Boston, MA
Elizabeth Cox Williams, MD Instructor in Anesthesia
Massachusetts General Hospital Boston, MA
Elliott L. Woodward MB, Bch, BAO, MSc
Cardiothoracic Anesthesia Fellow
Massachusetts General Hospital Boston, MA
D. Dante Yeh, MD
Ryder Trauma Center
University of Miami Miller School of Medicine
DeWitt Daughtry Family Department of Surgery/ Division of Trauma Miami, FL
Jing Zhao, MD, PhD
Anesthesiologist
Department of Anesthesia
Xijing Hospital
Xi’an, China
Hui Zhang, MD, PhD
Anesthesiologist
Department of Anesthesia
Xijing Hospital
Xi’an, China
Pierre Znojkiewicz, MD
Assistant Professor, Cardiac Electrophysiology
The University of Vermont Medical Center
Burlington, VT
PREFACE
Since publishing the first edition of Critical Care Secrets in 1992, critical care medicine has continued to become increasingly complex. Medical knowledge, clinical skills, and understanding of technology required to care for critically ill patients continue to transcend subspecialties, so in this edition we have again included chapters from a wide range of specialists, including intensivists, pulmonologists, surgeons, anesthesiologists, psychiatrists, pharmacists, and infectious disease and palliative care experts. The chapters in this edition contain key questions in critical care followed by succinct answers so practitioners can identify effective solutions to their patients’ medical and ethical problems.
A broad understanding of anatomy, physiology, immunology, and inflammation is fundamentally important to effectively care for critically ill patients. For example, it is hard to imagine understanding the principles of mechanical ventilation without being aware of the principles of gas and fluid flow, pulmonary mechanics, and electronic circuitry. Accordingly, the authors have again incorporated these key elements into this edition. In addition, critical care medicine requires knowledge of protocols and guidelines that are continuously evolving and that increasingly dictate best practices.
In this sixth edition of Critical Care Secrets, we continue to be fortunate that many clinical and thought leaders in critical care have contributed chapters in their areas of expertise. In addition to substantially revising and updating chapters from the previous edition, we have included new chapters on timely topics such as neurologic monitoring, obesity in the intensive care unit (ICU), new ultrasound practices, ICU survivorship, and the latest cardiac technology such as ventricular assist and percutaneous support devices.
We immensely appreciate all the authors who contributed their time and expertise to this edition. We believe they have captured the essence of critical care medicine and have presented it in a format that will be useful to everyone, from students to experienced clinicians.
Polly E. Parsons, MD
Jeanine P. Wiener-Kronish, MD
Renee D. Stapleton, MD, PhD
Lorenzo Berra, MD
TOP SECRETS
1. Hyperglycemia is common in critically ill patients and has been independently associated with increased ICU mortality.
2. Oral medications and noninsulin injectable therapies should not be used to treat hyperglycemia in critically ill patients.
3. An intravenous insulin infusion is the safest and most effective way to treat hyperglycemia in critically ill patients.
4. ICU-acquired weakness is a syndrome characterized by the development of generalized diffuse muscle weakness after onset of critical illness and is defined by standard functional muscle tests.
5. Early mobilization of critically ill patients is safe, feasible, and can improve short-term outcomes including functional status.
6. Delirium monitoring and management is critically important since it is a strong risk factor for increased time on mechanical ventilation, length of ICU and hospital stay, cost of hospitalization, long-term cognitive impairment, and mortality.
7. Psychoactive medications, and in particular benzodiazepines, may contribute to delirium.
8. In delirious patients pharmacologic treatment should be used only after giving adequate attention to correction of modifiable contributing factors. The ABCDEF bundle (Attention to analgesia, Both awakening and breathing trials, Choosing right sedative, Delirium monitoring and management, Early exercise and Family involvement) is recommended and associated with improved outcomes including reduction in delirium.
9. Inadequate analgesia is common in the ICU and has detrimental effects on patients.
10. Critically ill patients are often especially vulnerable to adverse side effects and toxicity from both opioid and nonopioid analgesic drugs.
11. Early, high-quality, and interdisciplinary communication improves shared decision making around end-of-life care in the ICU.
12. When difficult cases are causing moral distress and/or conflict among family members or team members, consider an ethics consultation to alleviate these issues.
13. Lung protection ventilation is less guided by volume than lung pressures. Minimizing both volumes and pressures is essential for a lung protective ventilation strategy.
14. Managing patient-ventilator interactions is crucial to outcome. The more control granted to a patient during assisted ventilation, the greater the patient-ventilator synchrony.
15. Definition of high-flow nasal cannula (HFNC). HFNC oxygen therapy uses an air/oxygen blender, active humidifier, heated tubing, and a nasal cannula capable of high flows (Fig. 9.1). The HFNC delivers adequately heated and humidified gas at flows up to 60 L/min. The traditional oxygen cannula is limited to a flow of 6 L/min because higher flows are not tolerated. Due to the conditioning of the gas and the design of the prongs, the HFNC is comfortable at high flows.
16. Patient population that benefits most for use of NIV. The strongest evidence for use of NIV is for patients with exacerbation of chronic obstructive pulmonary disease (COPD). For such patients, the use of NIV has a mortality benefit, with a relative risk of 0.56
(95% CI 0.38–0.82), which translates to a number needed to treat (NNT) of 16. The use of NIV for acute cardiogenic pulmonary edema is associated with a relative risk of 0.64 (95% CI 0.45–0.90), with a NNT of 16. Available evidence also supports a mortality benefit for NIV in patients with postoperative acute respiratory failure (NNT 11) and prevention of postextubation acute respiratory failure (NNT 12).
17. High-flow nasal cannula use immediately following extubation may decrease risk for reintubation in patients who remain in the ICU and at risk for recurrent respiratory failure.
18. The primary goal of hemodynamic monitoring is to assess the ability of the cardiovascular system in delivering oxygen to organs and peripheral tissues to meet metabolic demands.
19. Fluid responsiveness refers to an increase in stroke volume in response to a fluid challenge. Methods used to predict fluid responsiveness include the passive leg raise test as well as systolic pressure, pulse pressure, and stroke volume variation.
20. Neuroprognostication after cardiac arrest depends on a combination of history of arrest, clinical exam, electroencephalography features, evoked potentials, and magnetic resonance imaging findings. The depth of temperature management also can have a major impact on how these tools can be used to make a prognosis.
21. Point-of-care ultrasound by intensivists is a vital tool in the rapid assessment of critically ill patients presenting with shock, respiratory failure, or cardiac arrest.
22. PVADs improve cardiac function by unloading a failing ventricle, thereby reducing ventricular wall stress and oxygen consumption, and augmenting systemic perfusion pressure to maintain end-organ perfusion.
23. Left-sided PVADs require a well-functioning right ventricle (otherwise biventricular support is indicated), no evidence of respiratory compromise, and structural anatomy that is amenable to insertion.
24. IABP improves coronary blood flow by increasing perfusion pressure during diastole.
25. The major benefit of the IABP may be the reduction in myocardial oxygen consumption via a reduction in the isovolumic contraction phase of systole.
26. There is little evidence that an IABP improves outcomes in myocardial infarction complicated by cardiogenic shock. There is some indication that management of mechanical complications of myocardial infarction such as papillary muscle rupture associated or ventricular septal rupture may be an indication for an IABP.
27. ECMO is a method for providing temporary oxygenation, ventilation and circulatory support for patients with lung or heart diseases.
28. ECMO is not identical to cardiopulmonary bypass in that ECMO does not have a reservoir for additional fluid, there are no pumps for the administration of cardioplegia and the heart chambers are not vented while on peripherally cannulated ECMO.
29. VA ECMO primarily supports cardiopulmonary failure while VV ECMO only supports the failing lungs.
30. Never push a rigidly styletted ETT against resistance if the ETT tip is not in view.
31. Most ETTs have an identifiable mark 1 to 2 cm from the cuff. Maintaining the video view of the glottic opening during ETT insertion and placing this mark at the vocal cords will guard against main stem intubation (and virtually guarantee against esophageal intubation).
32. Upper airway obstruction can be addressed with humidified air followed by racemic epinephrine, heliox, and, ultimately, surgical airway placement if airway patency cannot be secured via the laryngeal route.
33. Bleeding from a tracheostomy site 48 hours after procedure should always prompt investigation for tracheoarterial fistula formation.
34. Bronchoalveolar lavage should be considered when there is a suspected atypical pneumonia or nonresolving infiltrate.
35. Bronchoscopy has limited value in the diagnosis of idiopathic interstitial pneumonias.
36. Exercise therapy has significant benefits in both the acute and chronic setting for patients with COPD. It can be started in the ICU and continued on an outpatient basis in a formal pulmonary rehabilitation program.
37. Many patients with COPD and acute respiratory failure can be supported with noninvasive ventilatory support; however, intubation when needed is relatively well tolerated.
38. The five causes of hypoxemia are:
• V/Q (ventilation/perfusion) mismatch
• Alveolar hypoventilation
• Shunt: physiologic (alveolar level) and anatomic (proximal to lung)
• Diffusion limitation
• Low inspired oxygen fraction
39. Two therapies proven to reduce mortality in patients with ARDS are:
• Low tidal volume ventilation (6mL/kg predited body weight)
• Prone positioning
40. Death from massive hemoptysis is more commonly due to asphyxiation than exsanguination.
41. Bronchial embolization is the initial treatment of choice for most patients with massive hemoptysis.
42. Clinical findings, including laboratory and EKG results, are neither sensitive nor specific for the diagnosis of PE. CT chest angiography or V/Q scan is necessary to confirm the diagnosis.
43. Duration of therapy in an unprovoked PE in a low-risk bleeding patient is at least 3 months, with a recommendation for life-long anticoagulation and annual reassessment of the risk versus benefit of long-term anticoagulation.
44. Clinical assessment of volume status and perfusion is critical in treatment of acute decompensated heart failure.
45. Valve replacement is the only treatment for symptomatic severe aortic stenosis. No medical options have been shown to be effective.
46. It is important to distinguish hemodynamically unstable arrhythmias that need immediate cardioversion/defibrillation from more stable rhythms.
47. In patients with out-of-hospital cardiac arrest who have recovered a perfusing rhythm but have neurologic deficits, therapeutic hypothermia has been shown to dramatically improve outcomes.
48. Aortic dissection carries high morbidity and mortality if untreated and should be suspected in a patient presenting with acute onset severe chest, back, or abdominal pain.
49. All patients presenting with aortic dissection should be immediately evaluated by a surgeon. Type A dissections require emergent open repair. Type B dissections complicated by end-organ ischemia, rupture, rapidly expanding dissection or aneurysm, or intractable pain or hypertension require surgery; endovascular repair is preferable if possible.
50. Pericardial tamponade is a medical emergency, diagnosed based upon clinical physiology, and treated by emergent pericardiocentesis or drainage.
51. Pericarditis can result in diffuse ST and T wave changes on ECG, and mild troponin elevation, without coronary artery disease.
52. Early diagnosis and initiation of treatment for sepsis is associated with improved outcomes.
53. Obtain 2 to 3 sets of blood cultures before giving antibiotics in cases of suspected endocarditis.
54. Streptococcus pneumoniae remains the most common cause of community acquired bacterial meningitis and treatment directed to this should be included in initial empiric antibiotic regimens.
55. Most patients do not require CT scan prior to lumbar puncture; however, signs and symptoms that suggest elevated intracranial pressure should prompt imaging. They include: new onset neurologic deficits, new onset seizure and papilledema. Severe cognitive impairment and immune compromise are also conditions that warrant consideration for imaging.
56. Refractory fever among critically ill patients despite proper antibiotics may warrant antifungal introduction for possible fungal infection.
57. Reducing multidrug-resistant bacteria can only be accomplished by reduced use of antibiotics, not by increased use.
58. During influenza season, all persons admitted to the ICU with respiratory illness should be presumed to have influenza and be tested and treated.
59. Patients with influenza may develop secondary bacterial infections and should be treated with ceftriaxone and vancomycin pending cultures.
60. In a patient presenting with hypertensive crisis (SBP 200 or DBP 120 mm Hg), the presence of acute end organ injury (cerebral, renal, or cardiac) constitutes “hypertensive emergency” and should be immediately treated in the intensive care unit.
61. Short-acting titratable intravenous antihypertensive agents such as nicardipine, clevidipine, labetalol, esmolol, or phentolamine are administered in hypertensive emergency to prevent further end organ injury.
62. Chronic renal failure is more likely than acute kidney injury to be associated with anemia, hypocalcemia, normal urine output, and small shrunken kidneys on ultrasound examination.
63. While contrast dye can be removed with hemodialysis, there is no evidence that this is beneficial, perhaps because the volume of contrast administered is minimal and delivery of contrast to the kidney is almost immediate.
64. Hypokalemia can be caused by low potassium intake, intracellular potassium shift, gastrointestinal potassium loss (diarrhea), and renal potassium loss. Hyperkalemia can be caused by high potassium intake, extracellular potassium shift, and low renal potassium excretion.
65. Drugs that can cause hyperkalemia include those that release potassium from cells (succinylcholine or, rarely, b -blockers), those that block the renin-angiotensinaldosterone system (spironolactone, angiotensin-converting enzyme inhibitors, heparin, or nonsteroidal anti-inflammatory drugs), and those that impair sodium and potassium exchange in cells (digitalis) or specifically in the distal nephron (calcineurin inhibitors, amiloride, or trimethoprim).
66. Upper endoscopy is the first diagnostic tool used in patients with suspected upper gastrointestinal bleeding and can also be used therapeutically.
67. For localized lower gastrointestinal bleeding refractory to endoscopic or angiographic intervention, segmental resection of the intestine involved in the bleeding is the usual treatment.
68. Steroids should be considered for the treatment of severe alcoholic hepatitis.
69. Management of variceal bleeding should include antibiotics to prevent spontaneous bacterial peritonitis.
70. The most common cause of thrombocytopenia in the intensive care unit is idiopathic.
71. Platelets should only be transfused in the setting of active bleeding, indications for a procedure, or an absolute value less than 10,000/mm3
72. Although disseminated intravascular coagulation (DIC) typically presents with bleeding or laboratory abnormalities suggesting deficient hemostasis, hypercoagulability and accelerated thrombin generation actually underlie the process.
73. The use of blood products in the treatment of DIC should be reserved for patients with active bleeding, those requiring invasive procedures, or those otherwise at high risk for bleeding. Heparin, via its ability to reduce thrombin generation, may be useful in some patients with DIC and bleeding that has not responded to the administration of blood products.
74. The immediate approach to the comatose patient includes measures to protect the brain by providing adequate cerebral blood flow and oxygenation, reversing metabolic derangements, and treating potential infections and anatomic or endocrine abnormalities.
75. The differential diagnosis for coma is broad and includes structural injury, metabolic and endocrine derangements, and physiologic brain dysfunction.
76. Brain death is the irreversible loss of both brain and brainstem function from a known cause.
77. Brain death is a clinical diagnosis.
78. Status epilepticus is defined as a seizure lasting 5 minutes or more or recurrent seizure activity between which there is incomplete recovery of consciousness or function.
79. Benzodiazepine therapy is the first-line treatment for seizure termination.
80. Blood pressure should not be treated in acute ischemic stroke unless it is greater than 220/110 mm Hg or SBP greater than 185/110 mm Hg if intravenous tissue plasminogen activator is to be administered.
81. If a patient diagnosed with delirium tremens becomes sedated following low-dose benzodiazepine, reconsider the diagnosis.
82. If intravenous lorazepam is re-dosed before the previous dose took full effect, this may eventually lead to oversedation (“dose-stacking”).
83. Only second- and third-degree injuries count for calculation of total body surface area and Parkland resuscitation.
85. The patient’s own palmar surface is the equivalent of 1% body surface area and can be used to quickly assess scattered areas of burns.
86. Effective responses to large-scale disasters, both natural and man-made, depend upon extensive communication and collaboration between local, state, and federal agencies.
87. Biologic and epidemiologic factors make influenza the single greatest infectious threat to global health.
88. The standard hallmarks of death do not apply in a hypothermic patient—no one is dead until WARM (.35°C) and dead.
89. Therapeutic hypothermia for a comatose patient following cardiac arrest and return of spontaneous circulation is no longer recommended—temperature should be targeted to avoid hyperthermia.
90. In an individual from a hot environment or undergoing strenuous exercise who presents with an altered mental status, think of heat stroke.
91. Heat stroke is a true medical emergency requiring immediate action: delay in cooling increases mortality.
92. A standardized approach focusing on airway, breathing, circulation, disability, exposure, and expert consultation should be used for all critically ill poisoned patients.
93. Poisonings with antidotes must be recognized and treatment initiated promptly. Focusing on toxidromes can expedite this process.
94. Sedation and intubation in a salicylate-intoxicated patient can be a precursor to rapid clinical decompensation and increased mortality.
95. Administering an additional NAC bolus or extending the 6.25 mg/kg per hour infusion beyond 21 hours may be indicated in a persistent acetaminophen-toxic patient.
96. The toxic alcohols are methanol, ethylene glycol, isopropyl alcohol, and propylene glycol; like ethanol, they are metabolized in the liver by the enzyme alcohol dehydrogenase (ADH).
97. The mainstay of toxic alcohol ingestion involves limiting the amount of toxic metabolites produced, either by competitive inhibition of ADH by fomepizole or ethanol, or by dialysis in severe cases.
98. Cardiovascular medications should be chosen based on their characteristics, evidence of effectiveness in specific conditions, and the pathophysiology of the individual patient.
99. Use of cardiovascular medications necessitates adequate monitoring, including continuous cardiac telemetry, invasive blood pressure monitoring, and continuous pulse oximetry.
100. Although radiologic investigations and drug treatment may carry some risk of harm to the fetus, necessary tests and treatment should never be avoided in the pregnant woman.
101. Intubation in the critically ill pregnant woman may be very difficult due to airway edema and friability, as well as rapid oxygen desaturation despite optimal preoxygenation.
102. Fever may be the only sign of serious infection in oncologic patients with neutropenia. Patients with low absolute neutrophil counts lack the ability to mount appropriate inflammatory response. For example, patients with intra-abdominal catastrophe may not have peritonitis clinically. Erythema, swelling, or tenderness may be absent in patients with soft tissue infection. Chest radiograph may be without infiltrates in patients with pneumonia.
103. Patients with cancer have a four-fold increase in venous thromboembolism; their risk is further increased when they have indwelling vascular catheters, they receive chemotherapy, they undergo recent surgeries or when they are immobile.
104. It is important for clinicians treating patients in the intensive care unit and after critical illness to recognize that life does not return to normal for most survivors of critical illness.
105. Impairments in physical, cognitive, and mental health domains may burden patients and families for months or even years after critical illness.
106. The diagnosis of sepsis includes a widely heterogeneous patient population that has hitherto been treated with a “one size fits all” approach, with a notable lack of success. Leveraging the tools of modern technology and “big data” should allow a more biologically sound classification of the different subgroups of patients with sepsis, paving the way for rational therapies.
I General IntensIve Care UnIt Care
GLYCEMIC CONTROL IN THE INTENSIVE CARE UNIT
Matthew P. Gilbert and Amanda Fernandes
1. Who is at risk for development of hyperglycemia?
Hyperglycemia can occur in patients with known or undiagnosed diabetes mellitus. Hyperglycemia during acute illness can also occur in patients with previously normal glucose tolerance, a condition called stress hyperglycemia.
2. How common is hyperglycemia in critically ill patients?
Acute hyperglycemia is common in critically ill patients. It is estimated that 90% of all patients develop blood glucose concentrations greater than 110 mg/dL during critical illness. Stress-induced hyperglycemia has been associated with adverse clinical outcomes in patients with trauma, acute myocardial infarction, and subarachnoid hemorrhage.
3. What causes hyperglycemia in critically ill patients?
In healthy individuals, blood glucose concentrations are tightly regulated within a narrow range. The cause of hyperglycemia in critically ill patients is multifactorial. Glucose toxicity and activation of inflammatory cytokines, and counterregulatory hormones such as cortisol and epinephrine cause an increase in peripheral insulin resistance and hepatic glucose production. The use of glucocorticoids and parenteral and enteral nutrition is an important contributor to hyperglycemia.
4. What is the relationship between hyperglycemia and acute illness?
The relationship between hyperglycemia and acute illness is complex. Severe hyperglycemia (.250 mg/dL) has been shown to have a negative impact on the vascular, hemodynamic, and immune systems. Hyperglycemia can also lead to electrolyte imbalance, mitochondrial injury, and both neutrophil and endothelial dysfunction. Acute illness increases the risk for hyperglycemia through the release of counterregulatory hormones, increased insulin resistance, and immobility. Fig. 1.1 illustrates the relationship between acute illness and hyperglycemia.
5. Should oral medications used to treat diabetes be continued in the intensive care unit?
Given the high incidence of renal and hepatic impairment, oral medication to treat diabetes should not be continued in the intensive care unit (ICU). Medications such as metformin are contraindicated in patients with renal and/or hepatic dysfunction and congestive heart failure. Long-acting formulations of sulfonylureas have been associated with episodes of prolonged severe hypoglycemia in hospitalized patients. Oral medications are not easily titrated to meet glycemic targets and may take weeks to effectively lower blood glucose levels.
6. Should noninsulin, injectable medications be used in the intensive care unit?
Noninsulin, injectable medications such as glucagon-like peptide-1 receptor agonists (GLP-1 RAs) stimulate insulin release in a glucose dependent manner. These medications have been shown to cause nausea and emesis and slow gastric emptying. GLP-1 RAs have similar limitations as oral agents with regards to titration and should not be used in the ICU setting.
7. What is the most effective way to treat hyperglycemia in the intensive care unit?
An intravenous insulin infusion using regular insulin is the safest and most effective way to treat hyperglycemia in critically ill patients. Because of the short half-life of circulating insulin (minutes), an insulin infusion can be frequently adjusted to match the often-variable insulin requirements of critically ill patients. Intravenous insulin therapy should be administered by validated written or computerized protocols that outline predefined adjustments in the insulin dose based on frequent blood glucose measurements.
8. When should treatment with an intravenous insulin infusion be initiated?
Intravenous insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at a blood glucose concentration of no greater than 180 mg/dL.
Adverse effects
Circulatory
• Fluid depletion (osmotic diuresis)
• Hypoperfusion
• Electrolyte loss
Cellular
• Mitochondr ial injury
• Neutrophilic dysfunction
• Endothelial dysfunction
Molecular
• Oxidative injury
• Compliment inhibition
Acute illness
Acute responses
Endogenous
• Release of counterregulator y hor mones
• Elevated inflammator y cytokines
• Increased insulin resistance
• Reduced glucose uptake
Exogenous
• Medications (glucocor ticoids)
• Parenteral and enteral nutrition
• Immobility
Hyperglycemia
9. What is the appropriate glycemic target for critically ill patients?
Recognizing the importance of glycemic control in critically ill patients, a number of professional societies have developed treatment guidelines and/or consensus statements that provide evidence-based glycemic targets. Although the glycemic targets are not identical, all of the groups advocate for good glycemic control while avoiding hypoglycemia (Table 1.1).
10. What is the evidence supporting the current glycemic targets?
The first randomized controlled trial (RCT) comparing tight glycemic control (target blood glucose concentration of 80–110 mg/dL) with conventional insulin therapy (target blood glucose concentration of 180–200 mg/dL) was conducted by Van den Berghe and colleagues (2001). This single-center trial enrolled more than 1500 surgical ICU patients and showed a 34% reduction in mortality associated with tight glycemic control. However, subsequent studies in both medical and surgical ICU populations have not shown consistent reductions in mortality with tight glycemic control. A meta-analysis of RCTs that included 8432 critically ill adult patients did not show a significant difference in mortality between tight glycemic control and control groups.
11. What was the normoglycemia in intensive care evaluation–survival using glucose algorithm regulation study?
The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICESUGAR) was a multicenter, multinational RCT that evaluated the effect of tight glycemic control (target glucose level of 81–108 mg/dL) to conventional glucose control (,180 mg/dL) on a number of clinical outcomes in 6104 critically ill adults, greater than 95% of whom required mechanical ventilation. The 90-day mortality was significantly higher in the tight glycemic control group (78 more deaths;
Summary of Glycemic Targets from the Medical Literature
Figure 1-1. Hyperglycemia and acute illness.
Table 1-1.
27.5% vs. 24.9%; P 5 .02). Cardiovascular mortality and severe hypoglycemic events were also more common in the tight glycemic control group. The results of the NICE-SUGAR trial have resulted in a shift from tight glycemic control to good control in critically ill patients, and standard of care is now to target glucose level between 140 and 180 mg/dL.
12. How should patients be transitioned from an intravenous insulin infusion to subcutaneous insulin therapy?
Patients should be transitioned from an insulin infusion to a subcutaneous insulin program when clinically stable. In patients who are eating, once- or twice-daily administration of basal insulin in combination with scheduled mealtime rapid-acting insulin and a supplemental (correction) component has been shown to maintain adequate glycemic control without clinically significant hypoglycemia. Subcutaneous insulin therapy should be initiated at least 2 hours before the discontinuation of the insulin infusion to reduce the risk of hyperglycemia. The use of a sliding-scale insulin regimen as the sole means of treatment of hyperglycemia is ineffective and should be avoided.
13. How is hypoglycemia defined?
Hypoglycemia is defined as any blood glucose level less than 70 mg/dL. This level correlates with the initial release of counterregulatory hormones. Cognitive impairment begins at a blood glucose concentration of approximately 50 mg/dL, and severe hypoglycemia occurs when blood glucose concentrations are less than 40 mg/dL.
14. What is the clinical impact of hypoglycemia?
Hypoglycemia has been associated with mortality, although whether it serves as a marker of illness or a causal agent remains to be established. Patients with diabetes who experience hypoglycemia during hospitalization have longer lengths of stay, higher costs, and greater odds of being discharged to a skilled nursing facility than their counterparts without hypoglycemia. Insulin-induced hypoglycemia and subsequent endothelial injury, abnormal coagulation, and increases in counterregulatory hormones are all associated with increased risk for cardiovascular events and sudden death. The true incidence of inpatient hypoglycemia is underestimated because of a lack of standardized definitions and varying models of data collection and reporting among hospitals. Despite this, iatrogenic hypoglycemia remains a top source of inpatient adverse drug events.
15. How do we prevent severe hypoglycemic events in the intensive care unit?
Critically ill patients are likely not able to report symptoms of hypoglycemia; thus it is important that patients be closely monitored. Early recognition and treatment of mild hypoglycemia can prevent the adverse outcomes associated with severe hypoglycemia. The establishment of a system for documenting the frequency and severity of hypoglycemic events and the implementation of policies that standardize the treatment of hypoglycemia are essential components of an effective glycemic management program.
16. Is intensive treatment of hyperglycemia cost-effective?
Intensive treatment of hyperglycemia not only reduces morbidity and mortality but is also cost-effective. The cost savings have been attributed to reductions in laboratory and radiology costs, decreased ventilator days, and reductions in ICU and hospital length of stay.
ACKNOWLEDGMENT
The authors wish to acknowledge Dr. Alison Schneider, MD, for the valuable contributions to the previous edition of this chapter.
KEY POINTS: GLYCEMIC CONTROL IN THE INTENSIVE CARE UNIT
Management of Hyperglycemia in Critically Ill Patients
1. Hyperglycemia is common in critically ill patients and has been independently associated with increased ICU mortality.
2. Oral medications and noninsulin injectable therapies should not be used to treat hyperglycemia in critically ill patients.
3 An intravenous insulin infusion is the safest and most effective way to treat hyperglycemia in critically ill patients.
4. A glycemic target of 140 to 180 mg/dL is recommended for critically ill patients.
5 Early recognition and treatment of mild hypoglycemia can prevent the adverse outcomes associated with severe hypoglycemia.
BiBliography
1. Chow E, Bernjak A, Williams S, et al. Risk of cardiac arrhythmias during hypoglycemia in patients with type 2 diabetes and cardiovascular risk. Diabetes. 2014;63:1738.
2. Clement S, Braithwaite S, Magee M, et al. Management of diabetes and hyperglycemia in hospitals. Diab Care. 2004;27:856.
3. Cryer P, Davis S, Shamoon H. Hypoglycemia in diabetes. Diab Care. 2003;26:1902.
4. Curkendall SM, Natoli JL, Alexander CM, Nathanson BH, Haidar T, Dubois RW. Economic and clinical impact of inpatient diabetic hypoglycemia. Endocr Pract. 2009;15:302.
5. Dellinger R, Levy M, Carlet J, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:1394.
6. Egi M, Bellomo R, Stachowski E, et al. Hypoglycemia and outcomes in critically ill patients. Mayo Clin Proc. 2010; 85:217.
7. Egi M, Finfer S, Bellomo R. Glycemic control in the ICU. Chest. 2011;140:212.
8. Farrokhi F, Smiley D, Umpierrez GE. Glycemic control in non-diabetic critically ill patients. Best Pract Res Clin Endocrinol Metab. 2011;25:813.
9. Goto A, Arah OA, Goto M, Terauchi Y, Noda M. Severe hypoglycemia and cardiovascular disease: systemic review and meta-analysis with bias analysis. BMJ. 2013;347:f4533.
10. Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med. 2006;355:1903.
11. Lazar H, McDonnnell M, Chipkin S, et al. The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87:663.
12. Levetan C, Salas J, Wilets I, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med. 1995;99:22.
13. McCowen K, Malhotra A, Bistrian B. Stress-induced hyperglycemia. Crit Care Clin. 2001;17:107.
14. Moghissi E, Korytkowski M, DiNardo M, et al. AACE/ADA consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:1.
15. NICE-SUGAR Study Investigators; Finfer S, Chittock D, Su S, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283.
16. Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154:260.
17. Umpierrez G, Smiley M, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2007;30:2181.
18. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359.
19. Wiener R, Wiener D, Larson R. Benefits and risk of tight glucose control in critically ill adults: a meta-analysis. JAMA 2008;300:933.
