Professional Documents
Culture Documents
P R I N C I P L E S O F
INTERNAL
MEDICINE
275 ST-Segment Elevation Myocardial Infarction............... 2053 Lonny Yarmus, David Feller-Kopman
Elliott M. Antman, Joseph Loscalzo
276 Percutaneous Coronary Interventions and
Other Interventional Procedures................................... 2066 PART 8 Critical Care Medicine
David P. Faxon, Deepak L. Bhatt
277 Hypertension................................................................ 2072 SECTION 1 Respiratory Critical Care
Theodore A. Kotchen 300 Approach to the Patient with Critical Illness.................. 2217
278 Renovascular Disease.................................................... 2088 Rebecca M. Baron, Anthony F. Massaro
Stephen C. Textor 301 Acute Respiratory Distress Syndrome........................... 2225
279 Deep-Venous Thrombosis and Pulmonary Rebecca M. Baron, Bruce D. Levy
Thromboembolism....................................................... 2091 302 Mechanical Ventilatory Support.................................... 2230
Samuel Z. Goldhaber Scott Schissel
280 Diseases of the Aorta.................................................... 2101
Mark A. Creager, Joseph Loscalzo SECTION 2 Shock and Cardiac Arrest
281 Arterial Diseases of the Extremities............................... 2107 303 Approach to the Patient with Shock.............................. 2235
Mark A. Creager, Joseph Loscalzo Anthony F. Massaro
282 Chronic Venous Disease and Lymphedema................... 2115 304 Sepsis and Septic Shock................................................ 2241
Mark A. Creager, Joseph Loscalzo Emily B. Brant, Christopher W. Seymour, Derek C. Angus
283 Pulmonary Hypertension.............................................. 2121 305 Cardiogenic Shock and Pulmonary Edema.................... 2250
Bradley A. Maron, Joseph Loscalzo David H. Ingbar, Holger Thiele
306 Cardiovascular Collapse, Cardiac Arrest, and
PART 7 Disorders of the Respiratory System Sudden Cardiac Death.................................................. 2257
Christine Albert, William H. Sauer
300 with
Approach to the Patient
Critical Illness
systems have been validated as tools to assess populations of critically
ill patients, their utility in predicting individual patient outcomes at
the bedside is not clear. Their utility may be more applicable toward
defining patient populations for clinical trial outcomes and broader
Rebecca M. Baron, Anthony F. Massaro epidemiologic studies. SOI scores are also useful in guiding hospital
administrative policies, directing the allocation of resources such as
nursing and ancillary care, and assisting in assessments of quality of
The care of critically ill patients requires a thorough understanding of ICU care over time. Scoring system validations are based on the prem-
pathophysiology and centers initially on the resuscitation of patients ise that age, chronic medical illnesses, and derangements from normal
at the extremes of physiologic deterioration. This resuscitation is physiology are associated with increased mortality rates. All existing
often fast-paced and occurs early, when a detailed awareness of the SOI scoring systems are derived from patients who have already been
patient’s chronic medical problems may not yet be possible. While admitted to the ICU. Nevertheless, there has been increased recent
physiologic stabilization is taking place, intensivists attempt to gather clinical use of scoring systems due to revised consensus guidelines for
important background medical information to supplement the real- definitions of sepsis, as will be detailed below.
time assessment of the patient’s current physiologic conditions. The most commonly utilized scoring systems are the SOFA (Sequen-
Numerous tools are available to assist intensivists in the assessment of tial Organ Failure Assessment) and the APACHE (Acute Physiology
pathophysiology and management of incipient organ failure, offering and Chronic Health Evaluation). There has been more recent interest
a window of opportunity for diagnosing and treating underlying dis- in the use of a “quick” or qSOFA scoring system for prognostication of
ease(s) in a stabilized patient. However, despite these tools, ongoing sepsis outcomes.
clinical bedside assessment is imperative for care of the critically ill
patient. Indeed, the use of interventions to support the patient such ■■THE SOFA SCORING SYSTEM
as mechanical ventilation and renal replacement therapy is common- The SOFA scoring system is composed of scores from six organ
place in the intensive care unit (ICU). An appreciation of the risks and systems, graded from 0 to 4 according to the degree of dysfunction
benefits of such aggressive and often invasive interventions is vital to (Table 300-1). The score accounts for clinical interventions; it can be
ensure an optimal outcome. Nonetheless, intensivists must recognize measured repeatedly (i.e., each day), and rising scores correlate well
when a patient’s chances for recovery are remote or nonexistent and with increasing mortality. The most recent sepsis consensus conference
must counsel and comfort dying patients and their significant others guidelines incorporated an increase of at least two points in the SOFA
if an initial trial of invasive supportive care is either not effective or score from baseline as diagnostic of sepsis in the setting of suspected
is not appropriate for the patient’s current condition. Critical care or documented infection. Patients with suspected infection can be
physicians often must redirect the goals of care from resuscitation predicted to have poor outcomes typical of sepsis if they have at least
and cure to comfort when the resolution of an underlying illness is two of the following clinical criteria: respiratory rate ≥22 breaths/min,
not possible. The COVID-19 pandemic has heightened the need and altered mental status, or systolic blood pressure ≤100 mmHg. Recently,
priority for effective critical care practices (Chap. 199). a new bedside clinical score using two or more of the above clinical
Updated versions of the APACHE scoring system (APACHE III and systemic vascular resistance (SVR), reductions in blood pressure can be
APACHE IV) have been published. caused by decreases in cardiac output and/or SVR. Accordingly, once
TABLE 300-2 Calculation of Acute Physiology and Chronic Health Evaluation II (APACHE II) Scorea
Critical Care Medicine
pneumothorax). The goal of aggressive resuscitation is to reestablish administration should be considered and vasopressor support peri-
adequate tissue perfusion and thus to prevent or minimize end-organ intubation may also be necessary. Figure 300-2 summarizes the diag-
injury. It is equally important not to over-resuscitate patients, as it is nosis and treatment of different types of shock. For further discussion
increasingly appreciated that excess fluid resuscitation is likely not of individual forms of shock, see Chaps. 303, 304, and 305.
Critical Care Medicine
or decrease from baseline, (4) systolic blood pressure <90 mmHg or >180 ■■RESPIRATORY SYSTEM MECHANICS
mmHg, or (5) increased anxiety or diaphoresis. If, at the end of the Respiratory system mechanics can be measured in patients during
spontaneous breathing trial, none of the above events has occurred, mechanical ventilation (Chap. 302). When volume-controlled modes
the patient can be considered for an extubation trial. Such protocol- of mechanical ventilation are used, accompanying airway pressures
Critical Care Medicine
driven approaches to patient care can have an important impact on can easily be measured as long as the patient is breathing passively.
the duration of mechanical ventilation and ICU stay. In spite of such The peak airway pressure is determined by two variables: airway resis-
a careful approach to liberation from mechanical ventilation, up to tance and respiratory system compliance. At the end of inspiration,
10% of patients develop respiratory distress after extubation and may inspiratory flow can be stopped transiently. This end-inspiratory pause
require resumption of mechanical ventilation. Many of these patients (plateau pressure) is a static measurement, affected only by respiratory
will require reintubation. The use of noninvasive ventilation in patients system compliance and not by airway resistance. Therefore, during
in whom extubation fails may be associated in some patients with worse volume-controlled ventilation, the difference between the peak (airway
outcomes than are obtained with immediate reintubation. Some studies resistance + respiratory system compliance) and plateau (respiratory
suggest that there are subgroups of patients who might benefit from system compliance only) airway pressures provides a quantitative
administration of high-flow nasal oxygen therapy postextubation, as it is assessment of airway resistance. Accordingly, during volume-controlled
believed that low levels of PEEP delivered by this device may be helpful. ventilation, patients with increases in airway resistance typically have
increased peak airway pressures as well as abnormally high gradients
MULTIORGAN SYSTEM FAILURE between peak and plateau airway pressures (typically >10–15 cmH2O)
Multiorgan system failure, which is commonly associated with critical at a constant inspiratory flow rate of 1 L/s. The compliance of the
illness, is defined by the simultaneous presence of physiologic dysfunc- respiratory system is defined by the change in volume of the respiratory
tion and/or failure of two or more organs. Typically, this syndrome system per unit change in pressure.
occurs in the setting of severe sepsis, shock of any kind, severe inflam- The respiratory system can be divided into two components: the
matory conditions such as pancreatitis, and trauma. The fact that lungs and the chest wall. Normally, respiratory system compliance is
multiorgan system failure occurs commonly in the ICU is a testament ~100 mL/cmH2O. Pathophysiologic processes such as pleural effu-
to our current ability to stabilize and support single-organ failure. The sions, pneumothorax, and increased abdominal girth all reduce chest
ability to support single-organ failure aggressively (e.g., by mechanical wall compliance. Lung compliance may be reduced by pneumonia,
ventilation or by renal replacement therapy) has reduced rates of early pulmonary edema, alveolar hemorrhage, interstitial lung disease, or
mortality in critical illness. As a result, it is less common for critically auto-PEEP. Accordingly, patients with abnormalities in compliance of
ill patients to die in the initial stages of resuscitation. Instead, many the respiratory system (lungs and/or chest wall) typically have elevated
patients succumb to critical illness later in the ICU stay, after the initial peak and plateau airway pressures but a normal gradient between these
presenting problem may have been stabilized. two pressures. Auto-PEEP occurs when there is insufficient time for
Although there is debate regarding specific definitions of organ fail- emptying of alveoli before the next inspiratory cycle. Because the alveoli
ure, several general principles governing the syndrome of multiorgan have not decompressed completely, alveolar pressure remains positive at
system failure apply. First, organ failure, no matter how it is defined, the end of exhalation (functional residual capacity). This phenomenon
must persist beyond 24 h. Second, mortality risk increases with the results most commonly from obstruction of distal airways in disease
accrual of failing organs. Third, the prognosis worsens with increased processes such as asthma and COPD. Auto-PEEP with resulting alveo-
duration of organ failure. These observations remain true across vari- lar overdistention may result in diminished lung compliance, reflected
ous critical care settings (e.g., medical vs surgical). by abnormally increased plateau airway pressures. Modern mechanical
ventilators allow breath-to-breath display of pressure and flow, permit-
MONITORING IN THE ICU ting detection of potential problems such as patient–ventilator dyssyn-
Because respiratory failure and circulatory failure are common in crit- chrony, airflow obstruction, and auto-PEEP (Fig. 300-6).
ically ill patients, monitoring of the respiratory and cardiovascular sys-
tems is undertaken frequently. Evaluation of respiratory gas exchange ■■CIRCULATORY STATUS
is routine in critical illness. The “gold standard” remains arterial blood- Oxygen delivery (Qo2) is a function of cardiac output and the content
gas analysis, in which pH, Pao2, partial pressure of carbon dioxide of O2 in the arterial blood (Cao2). The Cao2 is determined by the
(Pco2), and O2 saturation are measured directly. With arterial blood- hemoglobin concentration, the arterial hemoglobin saturation, and
gas analysis, the two main functions of the lung—oxygenation of arte- dissolved O2 not bound to hemoglobin. For normal adults:
rial blood and elimination of CO2—can be assessed directly. In fact, the
arterial blood pH, which has a profound effect on the drive to breathe, Qo2 = 50 dL/min × (1.39 × 15 g/dL [hemoglobin concentration]
can be assessed only by such sampling. Although sampling of arterial × 1.0 [hemoglobin % saturation] + 0.0031 × 100 [Pao2])
blood is generally safe and may be undertaken more frequently through = 50 dL/min (cardiac output) × 21.6 mL O2 per dL blood (Cao2)
insertion of a temporary indwelling arterial line, it may be painful and = 1058 mL O2 per min
A large multicenter study involving patients in many different ICU cedure that relieves increased intracranial pressure in the setting of
settings challenged the conventional notion that a hemoglobin level of space-occupying brain lesions or brain swelling from stroke; available
100 g/L (10 g/dL) is needed in critically ill patients, with similar out- evidence suggests that this procedure may improve survival among
comes noted in those whose transfusion trigger was 7 g/dL. Red blood select patients (e.g., ≤55 years of age), albeit at a cost of increased
cell transfusion is associated with impairment of immune function and disability for some.
increased risk of infections as well as of ARDS and volume overload, all
of which may explain the findings in this study. A conservative transfu-
sion strategy has shown similar outcomes in septic shock, postcardiac ■■SUBARACHNOID HEMORRHAGE
surgery, and post–hip surgery patients. (See also Chap. 426) Subarachnoid hemorrhage may occur secondary
to aneurysm rupture and is often complicated by cerebral vasospasm,
■■ACUTE KIDNEY FAILURE re-bleeding, and hydrocephalus. Vasospasm can be detected by either
(See also Chap. 310) Acute kidney failure occurs in a significant per- transcranial Doppler assessment or cerebral angiography; it is typically
centage of critically ill patients. The most common underlying etiology treated with the calcium channel blocker nimodipine, aggressive IV
is acute tubular necrosis, usually precipitated by hypoperfusion and/or fluid administration to avoid hypovolemia, and therapy aimed at main-
nephrotoxic agents. Currently, no pharmacologic agents are available taining adequate central perfusion pressure, typically with vasoactive
for prevention of kidney injury in critical illness. Studies have shown drugs such as phenylephrine. IV fluids and vasoactive drugs (hyper-
convincingly that low-dose dopamine, fenoldapam, and vasopressin tensive hypervolemic therapy) are used to overcome the cerebral vaso-
are not effective in protecting the kidneys from acute injury. spasm. Early surgical clipping or endovascular coiling of aneurysms
is advocated to prevent complications related to re-bleeding. Hydro-
cephalus, typically heralded by a decreased level of consciousness, may
NEUROLOGIC DYSFUNCTION IN require ventriculostomy drainage.
CRITICALLY ILL PATIENTS
■■DELIRIUM ■■STATUS EPILEPTICUS (SEE ALSO CHAP. 425)
(See also Chaps. 27 and 28) Delirium is defined by (1) an acute Recurrent or relentless seizure activity is a medical emergency. Ces-
onset of changes or fluctuations in mental status, (2) inattention, (3) sation of seizure activity is required to prevent irreversible neurologic
disorganized thinking, and (4) an altered level of consciousness (i.e., injury. Lorazepam is the most effective benzodiazepine for treating
a state other than alertness). Delirium is reported to occur in a wide status epilepticus and is the treatment of choice for controlling seizures
range of mechanically ventilated ICU patients and can be detected by acutely. Maintenance of seizure control should be effected with a load-
the Confusion Assessment Method for the ICU (CAM-ICU) or the ing dose of fosphenytoin, valproate, or levetiracetam, as these agents
Intensive Care Delirium Screening Checklist (ICDSC). These tools are have been shown to have similar efficacy and side effects.
used to ask patients to answer simple questions and perform simple
tasks and can be used readily at the bedside. The differential diagnosis ■■BRAIN DEATH
of delirium in ICU patients is broad and includes infectious etiologies (See also Chap. 307) Although deaths of critically ill patients usually
(including sepsis), medications (particularly sedatives and analgesics), are attributable to irreversible cessation of circulatory and respiratory
drug withdrawal, metabolic/electrolyte derangements, intracranial function, a diagnosis of death also may be established by irreversible
pathology (e.g., stroke, intracranial hemorrhage), seizures, hypoxia, cessation of all functions of the entire brain, including the brainstem,
hypertensive crisis, shock, and vitamin deficiencies (particularly thia- even if circulatory and respiratory functions remain intact on artificial
mine). The etiology of a patient’s ICU delirium impacts the prognosis. life support. Such a diagnosis requires demonstration of the absence of
Those with persistent ICU delirium not related to sedatives have cerebral function (no response to any external stimulus) and brainstem
increases in length of hospital stay, time on mechanical ventilation, functions (e.g., unreactive pupils, lack of ocular movement in response
cognitive impairment at hospital discharge, and 6-month mortality to head turning or ice-water irrigation of ear canals, positive apnea test
rate. Interventions to reduce ICU delirium are limited. The sedative [no drive to breathe]). Many U.S. institutions have a protocol based
dexmedetomidine has been less strongly associated with ICU delirium upon their state’s requirements for declaration of brain death. Absence
than midazolam. In addition, very early physical and occupational of brain function must have an established cause and be permanent
therapy in mechanically ventilated patients has been demonstrated to without possibility of recovery; a sedative effect, hypothermia, hypox-
reduce delirium. emia, neuromuscular paralysis, and severe hypotension must be ruled
Abbreviations: ARDS, acute respiratory distress syndrome; Fio2, inspired O2 percentage; Pao2, arterial partial pressure of O2; PCWP, pulmonary capillary wedge pressure.
in the interstitial and alveolar spaces (Fig. 301-2). Proinflammatory also reveals the presence of bilateral pulmonary infiltrates and demon-
cytokines (e.g., interleukin 1, interleukin 8, and tumor necrosis factor strates extensive heterogeneity of lung involvement (Fig. 301-4).
α [TNF-α]) and lipid mediators (e.g., leukotriene B4) are increased in Because the early features of ARDS are nonspecific, alternative
this acute phase, leading to the recruitment of leukocytes (especially diagnoses must be considered. In the differential diagnosis of ARDS,
neutrophils) into the pulmonary interstitium and alveoli. In addition, the most common disorders are cardiogenic pulmonary edema, bilat-
PART 8
condensed plasma proteins aggregate in the air spaces with cellular eral pneumonia, and alveolar hemorrhage. Less common diagnoses to
debris and dysfunctional pulmonary surfactant to form hyaline mem- consider include acute interstitial lung diseases (e.g., acute interstitial
brane whorls. Pulmonary vascular injury also occurs early in ARDS, pneumonitis; Chap. 293), acute immunologic injury (e.g., hypersensi-
with vascular obliteration by microthrombi and fibrocellular prolifer- tivity pneumonitis; Chap. 288), toxin injury (e.g., radiation pneumoni-
Critical Care Medicine
ation (Fig. 301-3). tis; Chap. 75), and neurogenic pulmonary edema (Chap. 37).
Alveolar edema predominantly involves dependent portions of the
lung with diminished aeration. Collapse of large sections of dependent Proliferative Phase This phase of ARDS usually lasts from
lung can contribute to decreased lung compliance. Consequently, approximately day 7 to day 21. Many patients recover rapidly and are
intrapulmonary shunting and hypoxemia develop and the work of liberated from mechanical ventilation during this phase. Despite this
breathing increases, leading to dyspnea. The pathophysiologic altera- improvement, many patients still experience dyspnea, tachypnea, and
tions in alveolar spaces are exacerbated by microvascular occlusion hypoxemia. Some patients develop progressive lung injury and early
that results in reductions in pulmonary arterial blood flow to ventilated changes of pulmonary fibrosis during the proliferative phase. Histolog-
portions of the lung (and thus in increased dead space) and in pulmo- ically, the first signs of resolution are often evident in this phase, with
nary hypertension. Thus, in addition to severe hypoxemia, hypercapnia the initiation of lung repair, the organization of alveolar exudates, and
secondary to an increase in pulmonary dead space can be prominent a shift from neutrophil- to lymphocyte-predominant pulmonary infil-
in early ARDS. trates. As part of the reparative process, type II pneumocytes proliferate
The exudative phase encompasses the first 7 days of illness after expo- along alveolar basement membranes. These specialized epithelial cells
sure to a precipitating ARDS risk factor, with the patient experiencing synthesize new pulmonary surfactant and differentiate into type I
the onset of respiratory symptoms. Although usually presenting within pneumocytes.
12–36 h after the initial insult, symptoms can be delayed by 5–7 days.
Dyspnea develops, with a sensation of rapid shallow breathing and an Fibrotic Phase While many patients with ARDS recover lung func-
inability to get enough air. Tachypnea and increased work of breathing tion 3–4 weeks after the initial pulmonary injury, some enter a fibrotic
result frequently in respiratory fatigue and ultimately in respiratory phase that may require long-term support on mechanical ventilators
failure. Laboratory values are generally nonspecific and are primar- and/or supplemental oxygen. Histologically, the alveolar edema and
ily indicative of underlying clinical disorders. The chest radiograph inflammatory exudates of earlier phases convert to extensive alveolar-
usually reveals opacities consistent with pulmonary edema and often duct and interstitial fibrosis. Marked disruption of acinar architecture
involves at least three-quarters of the lung fields (Fig. 301-2). While leads to emphysema-like changes, with large bullae. Intimal fibroprolif-
characteristic for ARDS, these radiographic findings are not specific eration in the pulmonary microcirculation causes progressive vascular
and can be indistinguishable from cardiogenic pulmonary edema
(Chap. 305). Unlike the latter, however, the chest x-ray in ARDS may
not demonstrate cardiomegaly, pleural effusions, or pulmonary vas-
cular redistribution as is often present in pure cardiogenic pulmonary
edema. If no ARDS risk factor is present, then some objective evalua-
tion is required (e.g., echocardiography) to exclude a cardiac etiology
for hydrostatic edema. Chest computed tomography (CT) in ARDS
Hyaline
Edema Membranes Interstitial Inflammation Fibrosis
Day: 0 2 7 14 21 . . .
FIGURE 301-1 Diagram illustrating the time course for the development and
resolution of acute respiratory distress syndrome (ARDS). The exudative phase
is notable for early alveolar edema and neutrophil-rich leukocytic infiltration of
the lungs, with subsequent formation of hyaline membranes from diffuse alveolar
damage. Within 7 days, a proliferative phase ensues with prominent interstitial
inflammation and early fibrotic changes. Approximately 3 weeks after the initial FIGURE 301-2 A representative anteroposterior chest x-ray in the exudative phase
pulmonary injury, most patients recover. However, some patients enter the fibrotic of acute respiratory distress syndrome (ARDS) shows bilateral opacities consistent
phase, with substantial fibrosis and bullae formation. with pulmonary edema that can be difficult to distinguish from left ventricular failure.
Sloughing of
bronchial epithelium
Inactivated
Surfactant
surfactant
layer
Necrotic or apoptotic
Epithelial type I cell
basement
membrane Red blood cell
Alveolar Protein-rich
air space edema fluid
Type I cell Denuded basement
Activated membrane
Interstitium neutrophil
Leukotrienes Intact type II cell
PAF
Type II cell Oxidants
Proteases Hyaline membrane
Alveolar
IL-6, IL-8
MIF Migrating
TNF-α
neutrophil
Red blood
cell Procollagen
Platelets
Endothelial
cell IL-8
IL-8 Swollen, injured
Capillary endothelial cell
Endothelial
basement Neutrophils
membrane
Fibrob
Fibrobl
rob
blas
lasts
lasts
Fibroblasts Gap formation
FIGURE 301-3 The normal alveolus (left) and the injured alveolus in the acute phase of acute lung injury and the acute respiratory distress syndrome (right). In the acute
phase of the syndrome (right), there is sloughing of both the bronchial and alveolar epithelial cells, with the formation of protein-rich hyaline membranes on the denuded
basement membrane. Neutrophils are shown adhering to the injured capillary endothelium and transmigrating through the interstitium into the air space, which is filled
with protein-rich edema fluid. In the air space, an alveolar macrophage is secreting proinflammatory cytokines—i.e., interleukins 1, 6, 8 (IL-1, 6, 8) and tumor necrosis factor
α (TNF-α)—that act locally to stimulate chemotaxis and activate neutrophils. IL-1 can also stimulate the production of extracellular matrix by fibroblasts. Neutrophils can
release oxidants, proteases, leukotrienes, and other proinflammatory molecules, such as platelet-activating factor (PAF). A number of anti-inflammatory mediators are also
present in the alveolar milieu, including the IL-1 receptor antagonist, soluble TNF-α receptor, autoantibodies to IL-8, and cytokines such as IL-10 and IL-11 (not shown).
The influx of protein-rich edema fluid into the alveolus can lead to the inactivation of surfactant. MIF, macrophage inhibitory factor. (From LB Ware, MA Matthay. The acute
respiratory distress syndrome. N Engl J Med 342:1334, 2000. Copyright © 2000 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.)
pause after inspiration), with pressures targeted at ≤30 cm H2O with increasing left atrial pressure. Maintaining a low left atrial
in the low-tidal-volume group versus ≤50 cm H2O in the high- filling pressure minimizes pulmonary edema and prevents further
tidal-volume group. The mortality rate was significantly lower in decrements in arterial oxygenation and lung compliance; improves
the low VT patients (31%) than in the conventional VT patients pulmonary mechanics; and shortens ICU stay and the duration of
mechanical ventilation. Thus, aggressive attempts to reduce left atrial
Critical Care Medicine
Acknowledgment
Goals and Limits:
Initiate
The authors acknowledge the contributions to this chapter by the previous
volume/pressure-limited
Tidal volume ≤6 mL/kg PBW authors, Drs. Augustine Choi and Steven D. Shapiro.
Plateau pressure ≤30 cmH2O
ventilation
RR ≤35 bpm
■■FURTHER READING
ARDS Definition Task Force: Acute respiratory distress syndrome:
FIO2 ≤0.6
The Berlin definition. JAMA 307:2526, 2012.
Oxygenate SpO2 88–95% ARDS Network: Ventilation with lower tidal volumes as compared
with traditional tidal volumes for acute lung injury and the acute
respiratory distress syndrome. N Engl J Med 342:1301, 2000.
Beitler JR et al: Effect of titrating positive end-expiratory pressure
pH ≥7.30 (PEEP) with an esophageal pressure-guided strategy vs an empirical
Minimize acidosis RR ≤35 bpm high PEEP-FiO2 strategy on death and days free from mechanical
ventilation among patients with acute respiratory distress syndrome.
JAMA 321:846, 2019.
MAP ≥65 mmHg
Bellani G et al: Epidemiology, patterns of care, and mortality for
Diuresis Avoid hypoperfusion patients with acute respiratory distress syndrome in intensive care
units in 50 countries. JAMA 315:788, 2016.
Combes A et al: Extracorporeal membrane oxygenation for severe
FIGURE 301-5 Algorithm for the initial management of acute respiratory distress acute respiratory distress syndrome. N Engl J Med 378:1965, 2018.
syndrome (ARDS). Clinical trials have provided evidence-based therapeutic goals The National Heart, Lung, and Blood Institute Petal Clinical
for a stepwise approach to the early mechanical ventilation, oxygenation, and Trials Network: Early neuromuscular blockade in the acute respi-
correction of acidosis and diuresis of critically ill patients with ARDS. Fio2, inspired
O2 percentage; MAP, mean arterial pressure; PBW, predicted body weight; RR, ratory distress syndrome. N Engl J Med 380:1996, 2019.
respiratory rate; Spo2, arterial oxyhemoglobin saturation measured by pulse Ware LB, Matthay MA: The acute respiratory distress syndrome.
oximetry. N Engl J Med 342:1334, 2000.
20
0
Scott Schissel –30 –20 –10 0 10 20 30 40 50
Pressure (cmH2O)
FIGURE 302-1 Hypothetical pressure-volume curves of patients with normal lung
Critical Care Medicine
Mechanical ventilation refers to devices that deliver positive-pressure function (normal) and acute respiratory distress syndrome (ARDS). A tidal volume
gas, of varying oxygen content, to patients with acute or chronic breath of 0.5 L in the normal lung requires 8 cmH2O of pressure (open box), but in
ARDS requires 28 cmH2O (shaded box).
respiratory failure. Hypoxemic respiratory failure refractory to sup-
plemental oxygen and requiring mechanical ventilation is most often
due to ventilation-perfusion mismatch or shunt caused by processes
such as pneumonia, pulmonary edema, alveolar hemorrhage, acute greatest, or where the smallest change in applied pressure leads to the
respiratory distress syndrome (ARDS), and sequelae of trauma or greatest increase in lung volume (Fig. 302-2, shaded box). To prevent
surgery. Hypercapnic respiratory failure is most frequently caused by too low lung volumes at end exhalation, where alveolar collapse occurs,
severe exacerbations of obstructive lung disease, including asthma and the ventilator can be set to maintain a specified positive pressure at end
chronic obstructive pulmonary disease (COPD); loss of central respi- exhalation, or positive end-expiratory pressure (PEEP) (Fig. 302-2, B.
ratory drive from acute neurologic events, such as stroke, intracranial Optimal PEEP). Lower tidal volume ventilation (goal 6 mL/kg of ideal
hemorrhage, or drug overdose; and respiratory muscle weakness from body weight) can help prevent the end-inhalation, or “plateau,” pres-
diseases such as Guillain-Barré syndrome. Mechanical ventilation may sure (measured just after flow stops at end inhalation) from exceed-
also be necessary if patients have an artificial airway placed (an endo- ing 30 cmH2O; this approach minimizes barotrauma- and volume
tracheal tube) due to poor airway protection, such as in coma or in the trauma–induced lung injury, especially in ARDS patients (Fig. 302-2,
context of a large upper gastrointestinal hemorrhage and vomiting, or C. Protective ventilation).
due to processes leading to large airway obstruction, such as laryngeal
edema. Finally, since mechanical ventilation can lower the work of
breathing compared to spontaneous ventilation, it is a useful adjunct
therapy for shock and multiorgan system failure.
5 L 100
PRINCIPLES OF MECHANICAL 90
Volume (liters and % total lung capacity)
VENTILATION 80
Although contemporary mechanical ventilators use positive pressure
to inflate the lungs, a patient’s response to pressure applied across the 70
lung (transpulmonary pressure) depends on the elastic properties of
their lungs and chest wall; the amount of pressure needed to inflate a 60
B. D.
lung is the same, therefore, whether applied positively via mechanical Optimal PEEP: Alveolar
2.5 L 50
ventilation or negatively using the diaphragm and chest wall muscles. 20 cmH2O overdistension
In ARDS, for example, lungs are “stiff ” or poorly compliant and often 40
require much more pressure to achieve a physiologic tidal volume ARDS
(Fig. 302-1), which, over time, may lead to respiratory muscle fatigue. 30
If a patient with ARDS is on mechanical ventilation and makes no C.
spontaneous respiratory effort, using sedation and neuromuscular 20 A. Protective
Alveolar ventilation
blockade, the amount of positive pressure needed to inflate the lung
is equal to the negative inflation pressure required if the patient were 0.5 L 10 collapse
spontaneously breathing; however, the work of breathing is removed 0
on a ventilator, allowing for sustainable ventilation. –30 –20 –10 0 10 20 30 40 50
Mechanical ventilation can be lifesaving by restoring adequate oxy- Pressure (cmH2O)
genation and correcting hypercapnia. Optimal application of positive-
pressure ventilation, however, requires avoiding underinflation, which FIGURE 302-2 Hypothetical pressure-volume curve of a patients with acute
can cause cycles of alveolar recruitment and then collapse, and at the respiratory distress syndrome (ARDS), demonstrating optimal positive end-
expiratory pressure (PEEP) and protective ventilation. A tidal volume breath of
other extreme, alveolar overinflation (Fig. 302-2); collectively, these 0.5 L initiated at a PEEP of 20 cmH2O (B), after the area of greatest alveolar collapse
processes can cause ventilator-induced lung injury by barotrauma and (A). End inhalation occurs within the most compliant portion of the pressure-volume
volume trauma. Optimal tidal volume ventilation occurs along the curve (C) and at a pressure <30 cmH2O, before the area where lung over distention
lung pressure-volume curve where respiratory system compliance is occurs (D), minimizing lung injury.
Pressure-regulated VT Peak inspiratory airway Patient effort can vary inspiratory Variable patient effort can lead to VT
volume control Respiratory rate pressure flow, increasing comfort, and larger than set VT; monitor to prevent
End-inhalation (plateau) ventilator synchrony volume trauma
PEEP
pressure Guarantee minimum VT and VE
Fio2
VE
Pressure support Inspiratory pressure VT Patient effort preserved and Apnea and hypoventilation possible;
PEEP Respiratory rate controls VT, inspiratory flow, and must monitor respiratory rate, VT, and VE
respiratory rate, allowing for closely
Fio2 VE ventilator synchrony
Abbreviations: Fio2, fraction of inspired oxygen; PEEP, positive end-expiratory pressure; VE, minute ventilation; VT, tidal volume.
40
B
30 COPD-related hospital admissions. Despite the technical innovations
A in NIV and expanding clinical applications, several important con-
20 traindications to using mechanical ventilation without a secure airway,
such as an endotracheal tube or tracheostomy tube, include delirium,
0.5 L 10
difficulty managing respiratory secretions, and hemodynamic instabil-
PART 8
ventilation, paralyzed (A) and breathing spontaneously (B). A. Paralyzed patient ■■ARTERIAL OXYGENATION
(light shaded box): positive end-expiratory pressure (PEEP), 10 cmH2O; inspiratory The optimal partial pressure of arterial oxygen (Pao2) and oxygen
(driving) pressure: 15 cmH2O; end-inhalation (plateau) pressure, 25 cmH2O; tidal
volume (VT), 300 mL. B. Breathing patient (dark shaded box): PEEP, 10 cmH2O;
saturation measured by pulse oximetry (SpO2) during mechanical
inspiratory (driving) pressure, 15 cmH2O; patient effort (negative “pulling” pressure), ventilation remain uncertain. Although tissue hyperoxia can cause
10 cmH2O; end-inhalation (plateau) pressure displayed on ventilator, 25 cmH2O; net oxidative injury, with some clinical studies of mechanically ventilated
end-inhalation (transalveolar) pressure, 35 cmH2O; VT, 700 mL. patients suggesting worse clinical outcomes with higher Fio2 and when
Pao2 frequently reaches supraphysiologic levels, randomized studies
comparing conservative oxygen delivery to a more liberal oxygen strat-
on PSV, and ventilator support is entirely patient triggered and con- egy have not demonstrated a clear advantage to conservative oxygen
trolled. The clinician sets the Fio2, PEEP, and maximum inspiratory delivery. In ARDS, targeting a lower Pao2 of 55–70 mmHg (or SpO2 of
pressure. When patients make a negative-pressure inspiratory effort on 88–92%) versus a higher, but more physiologic, Pao2 of 90–105 mmHg
PSV, the ventilator senses this pressure change and increases positive (or SpO2 >96%) did not lower mortality, with adverse events being
pressure to the set inspiratory pressure level, maintaining it until flow more frequent in the lower Pao2 group, including mesenteric ischemia.
decreases below a set threshold (often ~20% of peak inspiratory flow); Pao2 and SpO2 targets, therefore, should be individualized to patients
at this point, inhalation ends and pressure drops back to the set PEEP. considering circumstances where even mild hyperoxia may be harm-
The tidal volume on PSV is monitored but not assured, is determined ful, such as in recovery from ischemic brain injury and, conversely,
by lung compliance, and depends on the patient’s sustaining an inspi- where lower Pao2 levels (<55–70 mmHg) may be less optimal, such as
ratory effort. Tidal volume, minute ventilation, and respiratory rate, in patients with ARDS and evidence of bowel dysfunction. Regardless
therefore, must be closely monitored on PSV to detect hypopnea/apnea of the approach, there is no evidence that a supraphysiologic Pao2
and hypoventilation. PSV is often used when patients are less sedated (>100 mmHg) has clinical benefit; thus, sustained hyperoxia should
and able to participate in respiratory work, such as when transitioning be avoided.
off mechanical ventilation or on a ventilator only for airway support. Arterial hypoxemia refractory to standard mechanical ventilation
techniques is common in severe acute lung disease, especially ARDS.
■■NONINVASIVE POSITIVE-PRESSURE In general, if the Fio2 requirement is >0.6 or the Pao2:Fio2 ratio is <150
VENTILATION mmHg, additional interventions should be considered to improve
Noninvasive ventilation (NIV) is historically referred to as positive- arterial oxygenation. The application of adequate PEEP to prevent
pressure ventilation and is delivered via a nasal or full-face mask at a alveolar
. .
collapse during exhalation improves oxygenation by decreas-
continuous pressure (continuous positive airway pressure [CPAP]) or ing V/Q mismatch and shunt in areas of atelectatic lung. PEEP should
at different inspiratory and expiratory pressures (bilevel positive airway ideally be set at the lower inflection point of the most compliant region
pressure [BiPAP]). Most current noninvasive ventilators, however, can of the lung pressure-volume curve (Fig. 302-2B). Although optimal
function in full support modes, including volume control ventilation. PEEP may improve arterial oxygenation, achieving best PEEP has
NIV is particularly beneficial for acute respiratory failure where the not been shown to improve clinical outcomes definitively and may
underlying cause responds quickly to treatment, minimizing the need have deleterious effects, including barotrauma with pneumothorax
for prolonged mechanical ventilatory support. For example, in moder- and hypotension from decreasing venous return to the right ventricle.
ate acute hypercarbia (blood pH between 7.25 and 7.35) due to exac- Patients with refractory hypoxemia are often dyspneic on mechanical
erbations of COPD, NIV reduces the need for endotracheal intubation ventilation and make significant respiratory efforts dyssynchronous
and shortens hospital length of stay; more severe acute respiratory with the ventilator despite. .
deep sedation, leading to poor ventilation
acidosis from COPD exacerbations (blood pH <7.2) generally requires and preventing optimal V/Q matching. In this context, neuromuscular
mechanical ventilation with an endotracheal tube. NIV can also be an blockade can be very effective at restoring effective mechanical venti-
important adjunct treatment for respiratory failure from acute cardio- lation and optimizing gas exchange. Although a necessary intervention
genic pulmonary edema, where interventions, such as diuresis and at times, neuromuscular blockade does not improve overall outcomes
vasodilator therapy, can rapidly improve gas exchange and respiratory in ARDS, can contribute to critical illness myopathy, and requires ade-
mechanics. NIV, particularly with volume support modes, is effective quately deep sedation to prevent conscious paralysis; thus, it should
in managing chronic respiratory failure from restrictive lung diseases, be used only when necessary to treat refractory hypoxemia. In ARDS,
such as severe scoliosis and respiratory muscle weakness, and in COPD diseased lung is predominantly dependent, and placing the patient in a
complicated by chronic hypercapnia, where nocturnal NIV reduces prone position for extended periods can significantly improve arterial
Discontinuing mechanical ventilation and transitioning a patient back fail an SBT or require reintubation and continued mechanical ventila-
to spontaneous breathing is often referred to as ventilator “weaning,” tion, common processes perpetuating mechanical ventilation include
implying dependency on positive-pressure ventilation once started. critical illness myopathy and polyneuropathy, myocardial ischemia,
Although patients on prolonged mechanical ventilation can develop congestive heart failure, vascular and extravascular volume overload,
respiratory muscle weakness, this occurs is a minority of patients. delirium, malnutrition, and electrolyte abnormalities (hypophosphate-
Approaching removal of ventilator support as a “wean” extends unnec- mia, hypokalemia, and hypomagnesemia). These processes should
essary mechanical ventilation time up to 40%. Liberating a patient from be evaluated and treated, as necessary, in patients failing attempts to
mechanical ventilation, therefore, should be more active by frequently discontinue mechanical ventilation.
assessing a patient’s readiness for spontaneous breathing, determined
largely by resolution of the underlying process causing respiratory EXTRACORPOREAL GAS EXCHANGE
failure (Fig. 302-4). Important criteria indicating a patient may be Despite interventions to optimize oxygenation and alveolar ventila-
ready for extubation include the following: underlying disease process tion on mechanical ventilation, some patients suffer life-threatening
has improved, patient is awake and largely off sedative medications, hypoxemia, refractory respiratory acidosis, and barotrauma and may
Fio2 ≤0.5, PEEP <8 cmH2O, SaO2 >88%, stable hemodynamics, and be candidates for salvage therapy with extracorporeal gas exchange—a
manageable respiratory secretions with adequate cough. These criteria procedure whereby blood continuously circulates outside the body
should be assessed daily, and if achieved, patients should have a spon- through a device that oxygenates it, removes CO2, and then returns
taneous breathing trial (SBT)—a maneuver wherein positive pressure blood to the patient’s circulation. Although often referred to as
is set to a minimum to compensate for endotracheal tube resistance ECMO, modern gas exchange membranes both deliver oxygen and
(usually 5–7 cmH2O) and the patient breathes spontaneously from remove CO2, replacing the gas exchange function of the lung. The
30–120 min. A patient “passes” the SBT if they appear comfortable main components of an ECMO “circuit” include vascular cannulas to
overall (no marked anxiety or diaphoresis) and have a respiratory rate remove and return blood to the patient, a pump to circulate blood,
<35, SaO2 >90%, systolic blood pressure between 90 and 180 mmHg, and a gas exchange membrane. ECMO can provide varying levels of
FIGURE 302-4 Algorithm for discontinuing mechanical ventilation. APACHE-II, Acute Physiology and Chronic Health Enquiry II; BMI, body mass index; COPD, chronic
obstructive pulmonary disease; PEEP, positive end-expiratory pressure; NIV, noninvasive ventilation.
303
return oxygenated blood at relatively high flow rates (up to 6 L/min),
providing mechanical circulatory support, so-called VA-ECMO. In Approach to the Patient
the absence of shock, both the draining and return vascular cannulas
can be central venous, or VV-ECMO, but blood flow is still relatively
with Shock
high (2–5 L/min) to provide adequate oxygen delivery to tissues. In Anthony F. Massaro
situations where a patient’s lungs can provide adequate oxygenation but
insufficient CO2 removal, such as severe obstructive lung disease exac-
erbations, a venovenous circuit with low blood flows (0.25–2 L/min) is
often adequate to remove CO2 and treat refractory respiratory acidosis, Shock is the clinical condition of organ dysfunction resulting from
a process called extracorporeal CO2 removal (ECCO2R). an imbalance between cellular oxygen supply and demand. This
Although technologic advances in the ECMO pumps, gas exchange life-threatening condition is common in the intensive care unit (ICU).
membranes, and even vascular catheters have reduced ECMO-related A multitude of heterogeneous disease processes can lead to shock. The
complications, the procedure is resource-intensive and still associated organ dysfunction seen in early shock is reversible with restoration of
with several adverse events, including cannula site hemorrhage and adequate oxygen supply. Left untreated, shock transitions from this
vascular injury, catheter-related infection, pneumothorax, pulmonary reversible phase to an irreversible phase and death from multisystem
and gastrointestinal hemorrhage, limb ischemia, intracranial hemor- organ dysfunction (MSOF). The clinician is required to identify the
rhage, and disseminated intravascular coagulation. Moreover, despite patient with shock promptly, make a preliminary assessment of the
some promising clinical outcomes data, the mortality benefit from type of shock present, and initiate therapy to prevent irreversible organ
ECMO, especially in ARDS, remains unclear. Selecting patients most dysfunction and death. In this chapter, we review a commonly used
likely to benefit from ECMO, therefore, is very important, and in addi- classification system that organizes shock into four major types based
tion to exhausting traditional mechanical ventilatory support, patients on the underlying physiologic derangement. We discuss the initial
being considered for ECMO should have a reversible underlying illness assessment utilizing the history, physical examination, and initial diag-
or be eligible for organ transplant (heart and/or lung), have no chronic nostic testing to confirm the presence of shock and determine the type
severe end-organ disease (e.g., severe kidney disease), have no con- of shock causing the organ dysfunction. Finally, we will discuss key
traindication to systemic anticoagulation, have a good functional status principles of initial therapy with the aim of reducing the high morbid-
before the acute illness requiring ECMO, and have a good neurologic ity and mortality associated with shock.
prognosis.
■■PATHOPHYSIOLOGY OF SHOCK
The cellular oxygen imbalance of shock is most commonly related to
■■FURTHER READING impaired oxygen delivery in the setting of circulatory failure. Shock
Acute Respiratory Distress Syndrome Network et al: Ventilation can also develop during states of increased oxygen consumption or
with lower tidal volumes as compared with traditional tidal volumes impaired oxygen utilization. An example of impaired oxygen utiliza-
for acute lung injury and the acute respiratory distress syndrome. N tion is cyanide poisoning, which causes uncoupling of oxidative phos-
Engl J Med 342:1301, 2000. phorylation. This chapter will focus on the approach to the patient with
Barrot L et al: Liberal or conservative oxygen therapy for acute respi- shock related to inadequate oxygen delivery.
ratory distress syndrome. N Engl J Med 328:999, 2020. In the setting of insufficient oxygen supply, the cell is no longer able
Girard T et al: An official American Thoracic Society clinical practice to support aerobic metabolism. With adequate oxygen, the cell metab-
guideline: Liberation from mechanical ventilation in critically ill olizes glucose to pyruvate, which then enters the mitochondria where
adults. Rehabilitation protocols, ventilator liberation protocols, and ATP is generated via oxidative phosphorylation. Without sufficient
cuff leak tests. Am J Respir Crit Care Med 195:120, 2017. oxygen supply, the cell is forced into anaerobic metabolism, in which
Hernandez G et al: Effect of post extubation high-flow nasal cannula pyruvate is metabolized to lactate with much less ATP generation (per
vs non-invasive ventilation on reintubation and post extubation mole of glucose). Maintenance of the homeostatic environment of the
respiratory failure in high risk patients. A randomized clinical trial. cell is dependent on an adequate supply of ATP. ATP-dependent ion
JAMA 316:1565, 2016. pumping systems, such as the Na+/K+ ATPase, consume 20–80% of the
Moss M et al: Early neuromuscular blockade in the acute respiratory cell’s energy. Inadequate oxygen delivery and subsequent decreased ATP
distress syndrome. N Engl J Med 380:1997, 2019. disrupt the cell’s ability to maintain osmotic, ionic, and intracellular
Murphy PB et al: Effect of home noninvasive ventilation with oxygen pH homeostasis. Influx of calcium can lead to activation of calcium-
therapy vs oxygen therapy alone on hospital readmission or death dependent phospholipases and proteases, causing cellular swelling
after an acute COPD exacerbation. A randomized clinical trial. and death. In addition to direct cell death, cellular hypoxia can cause
JAMA 317:2177, 2017. damage at the organ system level via leakage of the intracellular con-
Tramm R et al: Extracorporeal membrane oxygenation for critically ill tents into the extracellular space activating inflammatory cascades and
adults. Cochrane Database Syst Rev 1:CD010381, 2015. altering the microvascular circulation.
be represented as 3. Obstructive
SV α (Preload × Contractility)/SVR a. Tension pneumothorax
b. Cardiac tamponade
In this equation, preload refers to the myocardial fiber length before
c. Constrictive pericarditis
contraction (the ventricular end-diastolic volume). Contractility refers
Critical Care Medicine
d. Pulmonary embolism
to the ability of the ventricle to contract independent of preload and
afterload. The SVR represents the afterload, or the force against which e. Aortic dissection
the ventricle must contract. 4. Hypovolemic
The CaO2 is composed of oxygen carried by convection with hemo- a. Hemorrhagic
globin and oxygen dissolved in blood, given as i. Trauma
ii. GI bleeding
CaO2 = (Hb × 1.39 × SaO2) + (PaO2 × 0.03) iii. Ruptured ectopic pregnancy
A disease process that affects these variables (HR, preload, contrac- b. GI losses
tility, SVR, SaO2, or Hb) has the potential to reduce oxygen delivery c. Burns
and cause cellular hypoxia. Each of the shock types described below d. Polyuria
has a distinctive physiologic hemodynamic profile corresponding with i. Diabetic ketoacidosis
alterations in one of the variables affecting oxygen delivery described ii. Diabetes insipidus
above.
Abbreviation: GI, gastrointestinal.
■■CLASSIFICATION OF SHOCK
While there is a heterogeneous list of specific conditions that can cause
shock, it is helpful to categorize these processes into four major shock the circulating blood volume within 10 min. Patients with severe brain
types based on the primary physiologic derangement leading to reduced or spinal cord injury may have a reduction of SVR related to disrup-
oxygen delivery and cellular hypoxia. The four major shock types are tion of the autonomic pathways that regulate vascular tone. In these
distributive, cardiogenic, hypovolemic, and obstructive. Table 303-1 patients, there is pooling of blood in the venous system with a resulting
outlines these major shock types as well as specific disease processes decreased venous return and decreased CO. A final category of patients
that can result in that physiologic derangement. Each shock type has who present with distributive shock consists of those with adrenal
a distinct hemodynamic profile (Table 303-2). Familiarity with the insufficiency. Adrenal insufficiency may be related to chronic steroid
major shock types and their unique hemodynamic profile is essential use, medications (immune checkpoint inhibitor-associated primary
so that when evaluating a patient presenting with shock, the clinician adrenal insufficiency), metastatic malignancy, adrenal hemorrhage,
can use the history, physical examination, and diagnostic testing to infection (tuberculosis, HIV), autoimmune adrenalitis, or amyloido-
determine the type of shock present and promptly begin appropriate sis. In conditions of stress (such as infection or surgery), the deficit
initial therapy to restore oxygen delivery. may become apparent with an inability to increase cortisol leading to
vasodilation as well as aldosterone deficiency-mediated hypovolemia.
Distributive Shock Distributive shock is the condition of reduced
oxygen delivery where the primary physiologic disturbance is a Cardiogenic Shock Cardiogenic shock is characterized by reduced
reduction in SVR. It is unique among the types of shock in that there oxygen delivery related to a reduction in CO owing to a primary cardiac
is a compensatory increase in CO (Table 303-2). The central venous problem. There is usually a compensatory increase in SVR in cardio-
pressure (CVP) and pulmonary capillary wedge pressure (PCWP) genic shock. When the cardiac process (e.g., myocardial infarction)
are usually reduced. The most common cause of distributive shock
is sepsis. Sepsis has recently been redefined as the dysregulated host
response to infection resulting in life-threatening organ dysfunction. TABLE 303-2 Hemodynamic Characteristics of the Major Types of
When this process is accompanied by persistent hypotension requir- Shock
ing vasopressor support (despite adequate volume resuscitation), it is CARDIAC SYSTEMIC VASCULAR
classified as septic shock. Other processes that are manifest as cellular TYPE OF SHOCK CVP PCWP OUTPUT RESISTANCE
hypoxia related to a primary reduction of SVR include pancreatitis, Distributive ↓ ↓ ↑ ↓
severe burns, and liver failure. Anaphylaxis is predominantly an IgE- Cardiogenic ↑ ↑ ↓ ↑
mediated allergic reaction that can rapidly develop after exposure to
an allergen (food, medication, or insect bite), in which there is a pro- Obstructive ↑ ↓↑ ↓ ↑
found distributive type of shock possibly mediated through histamine Hypovolemic ↓ ↓ ↓ ↑
release. In this setting, there is evidence of both venous and arterial Abbreviations: CVP, central venous pressure; PCWP, pulmonary capillary wedge
vasodilation. Studies have demonstrated extravasation of up to 35% of pressure.
and new organ dysfunction, in which the clinician must have a high Elevation of jugular venous pressure (JVP) and presence of peripheral
suspicion for septic shock. Similarly, a patient with extensive cardiac edema are seen with high right-sided cardiac pressures. The JVP
disease requires a higher suspicion for cardiogenic shock. may be elevated in cardiogenic shock (with right-sided failure) and
obstructive shock (pulmonary embolism) but reduced (JVP <8 cm)
Critical Care Medicine
Physical Examination The physical examination can assist in in hypovolemic shock. Similarly, patients with cardiogenic shock and
the identification of shock (in both the compensated stage prior to right-sided cardiac dysfunction may have peripheral edema, but this
overt evidence of organ dysfunction and decompensated stage). The is not an examination finding present in acute hypovolemic shock.
examination also can add insight into what type of shock is present Distinguishing cardiogenic from obstructive shock can also be aided
(distributive, cardiogenic, hypovolemic, or obstructive). by physical examination. Rales on pulmonary auscultation may be
Shock is most commonly seen in the setting of circulatory failure. related to left-sided cardiac dysfunction. The presence of cardiogenic
Vital signs are frequently abnormal. In most cases, this is manifest shock would be further supported by an S3 gallop. One must remem-
as hypotension (a systolic blood pressure [SBP] <90 mmHg or mean ber, however, that it is well established that patients with chronic
arterial pressure [MAP] <65 mmHg), but isolated blood pressure heart failure do not present with the classical findings of acute heart
measurements below these values do not define shock. Many patients failure.
may have underlying conditions such as peripheral vascular disease or At times, the physical examination may identify the specific etiol-
autonomic dysfunction or are on medications that cause longstanding ogy of shock. This is particularly helpful in the patient who cannot
low blood pressure without any evidence of organ dysfunction. Alter- provide a detailed history. The examination may demonstrate the site
natively, patients with underlying hypertension may develop shock and of an untreated infection (cellulitis, abscess, infected pressure injury, or
organ dysfunction at higher blood pressures. Evaluating the patient’s focal). The examination may reveal a brady- or tachyarrhythmia lead-
current blood pressure in relation to the patient’s baseline blood pres- ing to development of shock. Similarly, large ecchymosis may indicate
sure and observing hemodynamic trends over short time intervals are a significant bleed related to trauma or spontaneous retroperitoneal
more useful than an absolute SBP or MAP value. Tachycardia is a com- bleeding. The rectal examination may reveal GI hemorrhage. Pulsus
mon compensatory mechanism in shock. The absence of an elevated paradox and elevated JVP may suggest the presence of cardiac tampon-
heart rate does not exclude shock as patients with underlying cardiac ade. Patients with a tension PTX may have a paucity of breath sounds
conduction system disease or on home nodal blocking medications over the affected side, deviation of the trachea away from the affected
may have a diminished or absent tachycardic response. Alternatively, side, or subcutaneous emphysema.
one cannot be reassured by an elevated heart rate without hypotension, Combinations of easily assessed examination components have been
as many younger patients can compensate an extended period of time organized into a scoring system to identify high-risk patient popula-
before developing hypotension. Tachypnea is another vital sign abnor- tions. The shock index (SI) is defined as the HR/systolic blood pressure
mality seen early in shock as the body compensates for a developing (SBP) with a normal SI being 0.5–0.7. An elevated SI (>0.9) has been
metabolic acidosis. While these early compensatory responses are proposed to be a more sensitive indicator of transfusion requirement
nonspecific, the clinician should recognize these findings early as they and of patients with critical bleeding among those with hypovolemic
may herald the development of end-organ dysfunction if perfusion and (hemorrhagic) shock than either HR or BP alone. The SI may also
oxygen delivery are not restored. identify patients at risk for postintubation hypotension. This concept
The physical examination can confirm the presence of shock of use of a clinical score to identify at-risk patients has been extended
prior to the return of laboratory testing. The central nervous system to patients with distributive shock from sepsis. The quick Sequential
(CNS), kidney, and skin are the organ systems most easily assessed for Organ Failure Assessment (qSOFA) score is a rapid assessment scale
evidence of organ dysfunction. These organ systems are considered that assigns a point for SBP <100, respiratory rate >22, or altered men-
the “windows” through which we can identify organ dysfunction. tal status (Glasgow Coma Scale <15). A qSOFA ≥2 (with a concern
Decreased oxygen delivery to the brain is manifest as confusion and for infection) is associated with a significantly greater risk of death or
encephalopathy. In the early stage of shock, the body will redirect prolonged ICU stay. The Third International Consensus Definition of
blood flow to the CNS to maintain adequate perfusion. In the patient Sepsis has recommended the use of the qSOFA to identify the most
with shock and altered mental status, all the usual compensatory acutely ill subset of patients with sepsis (longer length of stay, increased
mechanisms have been outstripped by the magnitude of shock patho- need for ICU admission, and higher in-hospital mortality).
physiology. New encephalopathy represents decompensated shock.
To assess renal function during the physical examination, one should Diagnostic Testing Laboratory evaluation should be initiated
evaluate the patient’s urine output since the time of presentation. If promptly in all patients with suspected shock. The laboratory evalu-
not already present, a urinary catheter should be placed for accurate ation is directed toward the dual aim of assessing the extent of end-
hourly assessment of urine output. In patients with normal baseline organ dysfunction and of gaining insight into the possible etiology of
renal function, oliguria (<0.5 mL/kg per h) may indicate shock. Finally, shock. Table 303-4 outlines the recommended initial laboratory evalu-
cold and clammy skin is a sign of hypoperfusion with compensatory ation of the patient with undifferentiated shock.
that require initiation of lifesaving specific therapy. volume resuscitation) begins with the physical examination (described
The development of shock is a medical emergency, and optimal above). The passive leg raise (PLR) test can predict responsiveness to
therapy involves the involvement of a multidisciplinary team to allow additional intravenous fluid (IVF) by providing the patient with an
the evaluation and initiation of therapy to begin simultaneously. endogenous volume bolus. While the patient is resting in a semire-
Patients must be treated in a setting where adequate resources are avail-
Critical Care Medicine
organ dysfunction. This definition distinguishes sepsis from uncompli- data, prospective cohorts with manual case identification, and large
cated infection that does not lead to organ dysfunction, a poor course, electronic health record databases. Organ dysfunction is often defined
or death. In light of the wide variation in the ways that septic shock is by the provision of supportive therapy, in which case epidemiologic
identified in research, clinical, or surveillance settings, the Third Inter- studies count the “treated,” rather than the actual, incidence. In the
Critical Care Medicine
national Consensus Definitions further specified that septic shock be United States, cohort studies using administrative data suggest that
defined as a subset of sepsis cases in which underlying circulatory and upwards of 2 million cases of sepsis occur annually. Shock is present in
cellular/metabolic abnormalities are profound enough to substantially ~30% of cases, resulting in an estimated 230,000 cases in a recent sys-
increase mortality risk. tematic review. An analysis of data (both clinical and administrative)
To aid clinicians in identifying sepsis and septic shock at the from 300 hospitals in the United Healthcare Consortium estimated
bedside, “Sepsis-3” clinical criteria for sepsis include (1) a suspected that septic shock occurred in 19 per 1000 hospitalized encounters. The
infection and (2) acute organ dysfunction, defined as an increase by incidences of sepsis and septic shock are also reported to be increasing
two or more points from baseline (if known) on the sequential (or (according to International Classification of Diseases, Ninth Edition,
sepsis-related) organ failure assessment (SOFA) score (Table 304-1). Clinical Modification [ICD-9-CM] diagnosis and procedure codes),
Criteria for septic shock include sepsis plus the need for vasopressor with a rise of almost 50% in the past decade. However, the stability of
therapy to elevate mean arterial pressure to ≥65 mmHg with a serum objective clinical markers (e.g., provision of organ support, detection
lactate concentration >2.0 mmol/L despite adequate fluid resuscitation. of bacteremia) over this period in a two-center validation study sug-
gests that coding rules, confusion over semantics (e.g., septicemia vs
■■ETIOLOGY severe sepsis), rising capacity to provide intensive care, and increased
Sepsis can arise from both community-acquired and hospital-acquired case-finding confound the interpretation of serial trends. Studies from
infections. Of these infections, pneumonia is the most common source, other high-income countries report rates of sepsis in the ICU similar
accounting for about half of cases; next most common are intraabdom- to those in the United States.
inal and genitourinary infections. Blood cultures are typically positive Until now, although data demonstrated that sepsis is a significant
in only one-third of cases, while many cases are culture negative at public health burden in high-income countries, its impact on the pop-
all sites. Staphylococcus aureus and Streptococcus pneumoniae are the ulations of low- and middle-income countries was largely unknown.
most common gram-positive isolates, while Escherichia coli, Klebsiella A recent analysis of the Global Burden of Disease Study revealed that
species, and Pseudomonas aeruginosa are the most common gram- the global impact of sepsis is twice that of previous estimates, with
negative isolates. In recent years, gram-positive infections have been an estimated 48.9 million (95% confidence interval [CI], 38.9–62.9
reported more often than gram-negative infections, yet a 75-country million) incident cases reported worldwide. Sepsis-related deaths rep-
point-prevalence study of 14,000 patients on intensive care units resent 19.7% (95% CI, 18.2–21.4%) of all global deaths, of which 85%
(ICUs) found that 62% of positive isolates were gram-negative bacteria, occur in low- and middle-income countries. Among all age groups,
47% were gram-positive bacteria, and 19% were fungi. both sexes, and all locations, diarrheal disease represented the most
The many risk factors for sepsis are related to both the predisposi- common underlying cause of sepsis. Sepsis related to underlying injury
tion to develop an infection and, once infection develops, the likeli- and maternal disorders were the most common noncommunicable
hood of developing acute organ dysfunction. Common risk factors for causes of sepsis.
increased risk of infection include chronic diseases (e.g., HIV infection,
chronic obstructive pulmonary disease, cancers) and immunosuppres- ■■PATHOGENESIS
sion. Risk factors for progression from infection to organ dysfunction For many years, the clinical features of sepsis were considered the result
are less well understood but may include underlying health status, of an excessive inflammatory host response (SIRS). More recently, it
preexisting organ function, and timeliness of treatment. Age, sex, and has become apparent that infection triggers a much more complex,
race/ethnicity all influence the incidence of sepsis, which is highest variable, and prolonged host response than was previously thought.
at the extremes of age, higher in males than in females, and higher in The specific response of each patient depends on the pathogen (load
blacks than in whites. The differences in risk of sepsis by race are not and virulence) and the host (genetic composition and comorbidity), with
fully explained by socioeconomic factors or access to care, raising the different responses at local and systemic levels. The host response evolves
possibility that other factors, such as genetic differences in suscepti- over time with the patient’s clinical course. Generally, proinflammatory
bility to infection or in the expression of proteins critical to the host reactions (directed at eliminating pathogens) are responsible for “collat-
response, may play a role. eral” tissue damage in sepsis, whereas anti-inflammatory responses are
implicated in the enhanced susceptibility to secondary infections that
■■EPIDEMIOLOGY occurs later in the course. These mechanisms can be characterized as
The incidences of sepsis and septic shock depend on how acute an interplay between two “fitness costs”: direct damage to organs by the
organ dysfunction and infection are defined as well as on which data pathogen and damage to organs stemming from the host’s immune
sources are studied. Disparate estimates come from administrative response. The host’s ability to resist as well as tolerate both direct and
CELL
Increased ATP
O2 diffusion Lactate/H+
distance
Activated Mitochondrial
leukocyte Tissue edema dysfunction DO2 Tissue
oxygenation
INTERSTITIUM
Endothelial
leak/dysfunction Barrier function
Cytokines DO2
Inflammation Thrombus/
Platelets
DAMPs
MICROCIRCULATION
Antithrombin
Tissue Tissue factor
Protein C
Inflammatory damage pathway inhibitor
Activated Lactate/H+
mediators Tissue factor Altered
protein C Hypotension
Fibrinolysis Hypovolemia microvascular
PAMPs Vasodilation flow
TLR,
NLR, or
CLR
Adhesion
Transmigration
FIGURE 304-1 Select mechanisms implicated in the pathogenesis of sepsis-induced organ and cellular dysfunction. The host response to sepsis involves multiple
mechanisms that lead to decreased oxygen delivery (DO2) at the tissue level. The duration, extent, and direction of these interactions are modified by the organ under threat,
host factors (e.g., age, genetic characteristics, medications), and pathogen factors (e.g., microbial load and virulence). The inflammatory response is typically initiated by
an interaction between pathogen-associated molecular patterns (PAMPs) expressed by pathogens and pattern recognition receptors expressed by innate immune cells
on the cell surface (Toll-like receptors [TLRs] and C-type lectin receptors [CLRs]), in the endosome (TLRs), or in the cytoplasm (retinoic acid inducible gene 1–like receptors
and nucleotide-binding oligomerization domain–like receptors [NLRs]). The resulting tissue damage and necrotic cell death lead to release of damage-associated molecular
patterns (DAMPs) such as uric acid, high-mobility group protein B1, S100 proteins, and extracellular RNA, DNA, and histones. These molecules promote the activation
of leukocytes, leading to greater endothelial dysfunction, expression of intercellular adhesion molecule (ICAM) and vascular cell adhesion molecule 1 (VCAM-1) on the
activated endothelium, coagulation activation, and complement activation. This cascade is compounded by macrovascular changes such as vasodilation and hypotension,
which are exacerbated by greater endothelial leak tissue edema, and relative intravascular hypovolemia. Subsequent alterations in cellular bioenergetics lead to greater
glycolysis (e.g., lactate production), mitochondrial injury, release of reactive oxygen species, and greater organ dysfunction.
and other mechanisms impairs cellular oxygen utilization. The slowing those sepsis patients who have hyperinflamed rather than immuno-
of oxidative metabolism, in parallel with impaired oxygen delivery, suppressed phenotypes. Improved identification and monitoring of
reduces cellular O2 extraction. Yet energy (i.e., ATP) is still needed to host immune response could be helpful for guiding immunologic
support basal, vital cellular function, which derives from glycolysis and therapies. The dynamic nature of the immune response (i.e., response
fermentation and thus yields H+ and lactate. With severe or prolonged
Critical Care Medicine
can vary at different stages of sepsis and change rapidly) and unclear
insult, ATP levels fall beneath a critical threshold, bioenergetic failure understanding of whether the dysfunctional immune system is driving
ensues, toxic reactive oxygen species are released, and apoptosis leads organ dysfunction or whether the immune system itself is just another
to irreversible cell death and organ failure. Endothelial dysfunction is dysfunctional organ, remain challenges.
also critical to the pathogenesis of multiple organ failure common to
sepsis. Cell-cell connections in the vascular endothelium are disrupted
in sepsis due to a number of factors, resulting in loss of barrier integ- APPROACH TO THE PATIENT
rity, giving rise to subcutaneous and body-cavity edema. Endothelial
glycocalyx disruption also contributes to endothelial permeability and Sepsis and Septic Shock
edema formation. Circulatory dysfunction, both at the systemic and At the bedside, a clinician begins by asking, “Is this patient sep-
microcirculatory level, is also common in sepsis and contributes to the tic?” Consensus criteria for sepsis and septic shock agree on core
development of organ failure. Uncontrolled release of nitric oxide from diagnostic elements, including suspected or documented infection
cellular damage causes vasomotor collapse, opening of arteriovenous accompanied by acute, life-threatening organ dysfunction. If infec-
shunts, and pathologic shunting of oxygenated blood from susceptible tion is documented, the clinician must determine the inciting cause
tissues. Microcirculatory complications, including microthrombosis and the severity of organ dysfunction, usually by asking: “What
and decreased capillary density, also impair tissue oxygen delivery, just happened?” Severe infection can be evident, but it is often
resulting in the development of organ dysfunction. quite difficult to recognize. Many infection-specific biomarkers
Emerging evidence suggests the gut may also play an independent and molecular diagnostics are under study to help discriminate
role in the development of sepsis-associated organ dysfunction. Pro- sterile inflammation from infection, but these tools are not com-
posed hypotheses include bacterial translocation through impaired monly used. The clinician’s acumen is still crucial to the diagnosis
mucosal integrity, release of toxic mediators by injured gut mucosa, of infection. Next, the primary physiologic manifestations of organ
and even alteration in gut microbiome due to critical illness. The dysfunction can be assessed quickly at the bedside with a six-
resulting morphologic changes in sepsis-induced organ failure are also organ framework, yielding the SOFA score. Particular focus should
complex. Generally, organs such as the lung undergo extensive micro- then be placed on the presence or absence of shock, which con-
scopic changes, while other organs may undergo rather few histologic stitutes a clinical emergency. The general manifestations of shock
changes. In fact, some organs (e.g., the kidney) may lack significant include arterial hypotension with evidence of tissue hypoperfusion
structural damage while still having significant tubular-cell changes (e.g., oliguria, altered mental status, poor peripheral perfusion, or
that impair function. hyperlactemia).
Anti-inflammatory Mechanisms The immune system harbors
humoral, cellular, and neural mechanisms that may exacerbate the ■■CLINICAL MANIFESTATIONS
potentially harmful effects of the proinflammatory response. Phago- The specific clinical manifestations of sepsis are quite variable, depend-
cytes can switch to an anti-inflammatory phenotype that promotes ing on the initial site of infection, the offending pathogen, the pattern
tissue repair, while regulatory T cells and myeloid-derived suppressor of acute organ dysfunction, the underlying health of the patient, and
cells further reduce inflammation. The so-called neuroinflamma- the delay before initiation of treatment. The signs of both infection
tory reflex may also contribute: sensory input is relayed through the and organ dysfunction may be subtle. Guidelines provide a long list of
afferent vagus nerve to the brainstem, from which the efferent vagus potential warning signs of incipient sepsis (Table 304-1). Once sepsis
nerve activates the splenic nerve in the celiac plexus, with consequent has been established and the inciting infection is assumed to be under
norepinephrine release in the spleen and acetylcholine secretion by a control, the temperature and white blood cell (WBC) count often
subset of CD4+ T cells. The acetylcholine release targets α7 cholinergic return to normal. However, organ dysfunction typically persists.
receptors on macrophages, reducing proinflammatory cytokine release.
Disruption of this neural-based system by vagotomy renders animals Cardiorespiratory Failure Two of the most commonly affected
more vulnerable to endotoxin shock, while stimulation of the efferent organ systems in sepsis are the respiratory and cardiovascular systems.
vagus nerve or α7 cholinergic receptors attenuates systemic inflamma- Respiratory compromise classically manifests as acute respiratory
tion in experimental sepsis. distress syndrome (ARDS), defined as hypoxemia and bilateral infil-
trates of noncardiac origin that arise within 7 days of the suspected
Immune Suppression Patients who survive early sepsis but infection. ARDS can be classified by Berlin criteria as mild (Pao2/Fio2,
remain dependent on intensive care occasionally demonstrate evidence 201–300 mmHg), moderate (101–200 mmHg), or severe (≤100 mmHg).
Uncomplicated Uncomplicated
infection Organ infection
Organ
dysfunction
dysfunction
Sepsis Sepsis
FIGURE 304-3 Schematic of the importance of accurate, easy-to-use criteria for sepsis and its components, infection and organ dysfunction. In the ideal case (left), criteria
PART 8
clearly distinguish sepsis patients from other patients with uncomplicated infection or organ dysfunction. The reality (right), however, is that existing criteria fail to make
clear distinctions, leaving a significant proportion of patients in areas of uncertainty. (Reproduced with permission from DC Angus et al: A framework for the development
and interpretation of different sepsis definitions and clinical criteria. Crit Care Med 44:e113, 2016.)
Critical Care Medicine
and—ideally—the mechanism by which the host response to an infec- lactate concentration may simply be the manifestation of impaired
tion causes organ dysfunction. clearance. These factors may confound the use of lactate as a stand-
In order to sort through these complex details, clinicians need sim- alone biomarker for the diagnosis of sepsis; thus, it should be used in
ple bedside criteria to operationalize the logic statement (Fig. 304-3). the context of other markers of infection and organ dysfunction.
The Sepsis Definitions Task Force, with the introduction of Sepsis-3,
has recommended that, once infection is suspected, clinicians consider TREATMENT
whether it has caused organ dysfunction by determining a SOFA score.
The SOFA score ranges from 0 to 24 points, with up to 4 points accrued Sepsis and Septic Shock
across six organ systems. The SOFA score is widely studied in the ICU
among patients with infection, sepsis, and shock. With ≥2 new SOFA EARLY TREATMENT OF SEPSIS AND SEPTIC SHOCK
points, the infected patient is considered septic and may be at ≥10% Recommendations for sepsis care begin with prompt diagnosis.
risk of in-hospital death. Recognition of septic shock by a clinician constitutes an emer-
To aid in early identification of infected patients, the quick SOFA gency in which immediate treatment can be life-saving. Up-to-date
(qSOFA) and the National Early Warning Score (NEWS) scores are pro- guidelines for treatment are derived from international clinical
posed as clinical prompts to identify patients at high risk of sepsis outside practice guidelines provided by the Surviving Sepsis Campaign.
the ICU, whether on the medical ward or in the emergency department. This consortium of critical care, infectious disease, and emergency
The qSOFA score ranges from 0 to 3 points, with 1 point each for systolic medicine professional societies has issued three iterations of clinical
hypotension (≤100 mmHg), tachypnea (≥22 breaths/min), or altered guidelines for the management of patients with sepsis and septic
mentation. A qSOFA score of ≥2 points has a predictive value for sepsis shock (Table 304-2).
similar to that of more complicated measures of organ dysfunction. The The initial management of infection requires several steps: form-
National Early Warning Score (NEWS) is an aggregate scoring system ing a probable diagnosis, obtaining samples for culture, initiating
derived from six physiologic parameters, including respiratory rate, oxy- empirical antimicrobial therapy, and achieving source control. More
gen saturation, systolic blood pressure, heart rate, altered mentation, and than 30% of patients with sepsis require source control, mainly for
temperature. Recent work has also shown that, although SIRS criteria may abdominal, urinary, and soft-tissue infections. The mortality rate is
be fulfilled in sepsis, they sometimes are not and do not meaningfully lower among patients with source control than among those with-
contribute to the identification of patients with suspected infection who out, although the timing of intervention is debated. Antibiotic delay
are at greater risk of a poor course, ICU admission, or death—outcomes may be deadly. For every 1-h delay among septic patients, a 3−7%
more common among patients with sepsis than among those without. increase in the odds of in-hospital death is reported. Thus, interna-
Septic shock is a subset of sepsis in which circulatory and cellular/ tional clinical practice guidelines recommend the administration of
metabolic abnormalities are profound enough to substantially increase appropriate broad-spectrum antibiotics within 1 h of recognition of
mortality risk, but the application of this definition as a criterion for sepsis or septic shock. For empirical therapy, the appropriate choice
enrollment of patients varies significantly in clinical trials, observa- depends on the suspected site of infection, the location of infection
tional studies, and quality improvement work. For clarity, criteria are onset (i.e., the community, a nursing home, or a hospital), the
proposed for septic shock that include (1) sepsis plus (2) the need for patient’s medical history, and local microbial susceptibility patterns
vasopressor therapy to elevate mean arterial pressure to ≥65 mmHg, (Table 304-3). In a single-center study of >2000 patients with bac-
with (3) a serum lactate concentration >2.0 mmol/L after adequate teremia, the number of patients who needed to receive appropriate
fluid resuscitation. antimicrobial therapy in order to prevent one patient death was 4.0
Arterial lactate is a long-studied marker of tissue hypoperfusion, (95% CI, 3.7–4.3). Empirical antifungal therapy should be admin-
and hyperlactemia and delayed lactate clearance are associated with istered only to septic patients at high risk for invasive candidiasis.
a greater incidence of organ failure and death in sepsis. In a study of The treatment elements listed above form the basis for a 1-h
>1200 patients with suspected infection, 262 (24%) of 1081 patients bundle of care, replacing the previous guidelines recommend-
exhibited an elevated lactate concentration (≥2.5 mmol/L) even in the ing treatment initiation within 3−6 h. This management bundle
setting of normal systolic blood pressure (>90 mmHg) and were at ele- includes five components: (1) measurement of serum lactate levels,
vated risk of 28-day in-hospital mortality. However, lactic acidosis may (2) collection of blood for culture before antibiotic administration,
occur in the presence of alcohol intoxication, liver disease, diabetes (3) administration of appropriate broad-spectrum antibiotics, (4)
mellitus, administration of total parenteral nutrition, or antiretroviral initiation of a 30 mL/kg crystalloid bolus for hypotension or lactate
treatment, among other conditions. Furthermore, in sepsis, an elevated ≥4 mmol/L, and (5) treatment with vasopressors for persistent
hypotension or shock. Serum lactate levels should be remeasured if thresholds for fluid administration, blood transfusion, and use
initial level ≥2 mmol/L. of inotropes. Given the many controversial features of this older
Other elements of the management bundle are cardiorespiratory single-center trial, subsequent trials, including ProCESS, ARISE,
resuscitation and mitigation of the immediate threats of uncon- and ProMISe, compared protocol-based standard care with proto-
trolled infection. Early resuscitation requires a structured approach col-based EGDT and usual care. Each found that EGDT offered no
including the administration of IV fluids and vasopressors, with mortality benefit in early septic shock but did increase treatment
oxygen therapy and mechanical ventilation to support injured intensity and cost. Multiple subsequent meta-analyses of these trials
organs. The exact components required to optimize resuscitation, confirmed that EGDT offers no mortality benefit while increas-
such as choice and amount of fluid, appropriate type and intensity ing health care utilization and ICU admission in well-resourced
of hemodynamic monitoring, and role of adjunctive vasoactive countries. Modified versions of EGDT were also tested in lower-
agents, all remain controversial. resourced settings, with no change in outcome. Thus, EGDT is no
Evidence suggests that protocolized treatment bundles may con- longer recommended as the primary strategy for early resuscitation
fer a greater survival advantage than clinical assessments of organ in septic shock. More contemporary treatment bundles recom-
perfusion and management without a protocol. Though the corner- mended initiating treatment within 3−6 h, but these management
stone of all sepsis treatment bundles is early antibiotic administra- protocols were replaced with the “hour-1” treatment bundle to
tion and rapid restoration of perfusion, bundle timing and intensity enforce the necessity of beginning resuscitation and management
remain controversial. Arguably the first protocol-based sepsis treat- immediately. Met with controversy about feasibility and safety,
ment strategy—early, goal-directed therapy (EGDT)—included the “hour-1 bundle” continues to be the focus of investigation and
an aggressive resuscitation protocol with specific hemodynamic debate.
plus caspofungin (one dose of 70 mg, then 50 mg q24h) if (RR, 0.83; 95% CI, 0.65–1.04 [moderate confidence]) or gelatin (RR,
the patient has severe sepsis/septic shock.
1.24; 95% CI, 0.61–2.55 [very low confidence]) and crystalloids. In
Splenectomy Use ceftriaxone (2 g q24h, or—in meningitis—2 g q12h). general, crystalloids are recommended on the basis of strong evi-
If the local prevalence of cephalosporin-resistant
pneumococci is high, add vancomycin (as above). If the dence as first-line fluids for sepsis resuscitation, with specific cave-
Critical Care Medicine
patient is allergic to β-lactam antibiotics, use levofloxacin ats; their use is guided by resolution of hypotension, oliguria, altered
(750 mg q24h) or moxifloxacin (400 mg q24h) plus mentation, and hyperlactemia. Inconsistent evidence supports the
vancomycin (as above). use of balanced crystalloids, and guidelines recommend against
a
All agents are administered by the intravenous route. Beta-lactam antibiotics may using hydroxyethyl starches for intravascular volume replacement.
exhibit unpredictable pharmacodynamics in sepsis; therefore, continuous infusions When circulating fluid volume is adequate, vasopressors are
are often used. recommended to maintain perfusion of vital organs. Vasopressors
Source: Adapted in part from DN Gilbert et al: The Sanford Guide to Antimicrobial such as norepinephrine, epinephrine, dopamine, and phenylephrine
Therapy, 47th ed, 2017; and from RS Munford: Sepsis and septic shock, in DL Kasper
et al (eds). Harrison’s Principles of Internal Medicine, 19th ed. New York,
differ in terms of half-life, β- and α-adrenergic stimulation, and
McGraw-Hill, 2015, p. 1757. dosing regimens. Recent evidence comes from the SOAP II trial,
a double-blind randomized clinical trial at eight centers compar-
ing norepinephrine with dopamine in 1679 undifferentiated ICU
patients with shock, of whom 63% were septic. Although no differ-
Nonetheless, some form of resuscitation is considered essential, ence was observed in 28-day mortality or in predefined septic shock
and a standardized approach, akin to the use of “trauma teams,” subgroup, arrhythmias were significantly greater with dopamine.
has been advocated to ensure prompt care. The patient should be These findings were confirmed in a subsequent meta-analysis. As
moved to an appropriate setting, such as the ICU, for ongoing care. a result, expert opinion and consensus guidelines recommend nor-
SUBSEQUENT TREATMENT OF SEPSIS AND SEPTIC SHOCK epinephrine as the first-choice vasopressor in septic shock. Levels of
After initial resuscitation, attention is focused on monitoring and the endogenous hormone vasopressin may be low in septic shock,
support of organ function, avoidance of complications, and de- and the administration of vasopressin can reduce the norepineph-
escalation of care when possible. rine dose. Consensus guidelines suggest adding vasopressin (up to
0.03 U/min) in patients without a contraindication to norepineph-
Monitoring Hemodynamic monitoring devices may clarify the rine, with the intent of raising mean arterial pressure or decreasing
primary physiologic manifestations in sepsis and septic shock. The the norepinephrine dose. There may be select indications for use of
clinical usefulness of these monitoring devices can be attributable alternative vasopressors—e.g., when tachyarrhythmias from dopa-
to the device itself, the algorithm linked to the device, or the static/ mine or norepinephrine, limb ischemia from vasopressin, or other
dynamic target of the algorithm. Decades ago, the standard care of adverse effects dictate.
shock patients included invasive devices like the pulmonary artery The transfusion of red blood cells to high thresholds (>10 g/
catheter (PAC), also known as the continuous ScvO2 catheter. The dL) had been suggested as part of EGDT in septic shock. However,
PAC can estimate cardiac output and measure mixed venous oxygen the Scandinavian TRISS trial in 1005 septic shock patients demon-
saturation, among other parameters, to refine the etiology of shock strated that a lower threshold (7 g/dL) resulted in 90-day mortality
and potentially influence patient outcomes. Recently, a Cochrane rates similar to those with a higher threshold (9 g/dL) and reduced
review of 2923 general-ICU patients (among whom the proportion transfusions by almost 50%. Thus, red blood cell transfusion should
of patients in shock was not reported) found no difference in mortal- be reserved for patients with a hemoglobin level ≤7 g/dL.
ity with or without PAC management, and therefore, the PAC is no Significant hypoxemia (Pao2, <60 mmHg or SaO2, <90%), hypoven-
longer recommended for routine use. Instead, a variety of noninva- tilation (rising Paco2), increased work of breathing, and inadequate
sive monitoring tools, such as arterial pulse contour analysis (PCA) or unsustainable compensation for metabolic acidosis (pH <7.20) are
or focused echocardiography, can provide continuous estimates of common indications for mechanical ventilatory support. Endotra-
parameters such as cardiac output, beat-to-beat stroke volume, and cheal intubation protects the airway, and positive-pressure breathing
pulse pressure variation. These tools, along with passive leg-raise allows oxygen delivery to metabolically active organs in favor of
maneuvers or inferior vena cava collapsibility on ultrasound, can help inspiratory muscles of breathing and the diaphragm. An experiment
determine a patient’s volume responsiveness but require that a variety in dogs showed that the relative proportion of cardiac output deliv-
of clinical conditions be met (e.g., patient on mechanical ventilation, ered to respiratory muscles in endotoxic shock decreased by fourfold
sinus rhythm); in addition, more evidence from larger randomized with spontaneous ventilation over that with mechanical ventilation.
trials on the impact of these tools in daily management is needed. During intubation, patients in shock should be closely monitored for
Support of Organ Function The primary goal of organ support is vasodilatory effects of sedating medications or compromised car-
to improve delivery of oxygen to the tissues as quickly as possible. diac output due to increased intrathoracic pressure, both of which
Depending on the underlying physiologic disturbance, this step may cause hemodynamic collapse. With hemodynamic instability,
arterial pressure unresponsive to volume replacement or by the use of uncommon cause of transient CS is the takotsubo syndrome.
vasopressors needed to maintain adequate BP (systolic >90 mmHg) and
is accompanied by clinical features of peripheral hypoperfusion, such as Pathophysiology The understanding of the complex pathophysi-
elevated arterial lactate (>2 mmol/L). Objective hemodynamic param- ology of CS has evolved over the past decades. In general, a profound
eters such as cardiac index or pulmonary capillary wedge pressure can depression of myocardial contractility results in a deleterious spiral of
help confirm a cardiogenic cause of shock but are not mandatory. The reduced cardiac output, low BP, and ongoing myocardial ischemia, fol-
in-hospital mortality rates range from 40 to 60%, depending on shock lowed by further contractility reduction (Fig. 305-1). This vicious cycle
severity and the associated underlying cause. Recently, the new Society usually leads to death if not interrupted. CS can result in both acute and
for Cardiovascular Angiography and Interventions (SCAI) classification subacute derangements to the entire circulatory system. Hypoperfusion
Ventilation
LVEDP ↑
Lung edema ↑
Fluids + + SIRS Cardiac output ↓
inotropes/ Stroke volume ↓
vasopressors
Mechanical
+ Hypotension
support Hypoxia
device eNOS
iNOS Peripheral perfusion ↓
Bleeding/
transfusion Coronary
perfusion ↓
Ischemia
+
Reperfusion:
PCI/CABG
NO ↑ Vasoconstriction
Peroxynitrite ↑ Fluid retention
Interleukins ↑ Progressive
TNF-α ↑ left ventricular
dysfunction
SVR ↓
Pro-inflammation
Catecholamine sensitivity ↓
Contractility ↓ Death
FIGURE 305-1 Pathophysiology of cardiogenic shock and potential treatment targets. The pathophysiologic concept of the expanded cardiogenic shock spiral and treatment
targets. CABG, coronary artery bypass grafting; eNOS, endothelial nitric oxide synthase; iNOS, inducible nitric oxide synthase; LVEDP, left ventricular end-diastolic pressure;
NO, nitric oxide; PCI, percutaneous coronary intervention; SIRS, systemic inflammatory response syndrome; SVR, systemic vascular resistance; TNF, tumor necrosis factor.
(Reproduced with permission from H Thiele et al: Shock in acute myocardial infarction: The Cape Horn for trials? Eur Heat J 31:1828, 2010.)
FIGURE 305-2 Shock severity definition. Five categories of cardiogenic shock (CS). Stage A: At risk: Patients “at risk” for cardiogenic shock development but not currently
experiencing signs/symptoms of cardiogenic shock. Stage B: Patients with clinical evidence of relative hypotension or tachycardia without hypoperfusion being at
“beginning” of cardiogenic shock. Stage C: Patients in the state of “classic” cardiogenic shock. Stage D: Cardiogenic shock signals deteriorating or “doom.” Stage E:
Patients in “extremis,” such as those experiencing cardiac arrest with ongoing cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation (ECMO)
cardiopulmonary resuscitation. MCS, mechanical circulatory support. (Reproduced with permission from H Thiele et al: Management of cardiogenic shock complicating
myocardial infarction: An update 2019. Eur Heart J 40:2671, 2019.)
of vital organs and extremities remains a clinical hallmark. Although to high-grade heart block may be present. Systolic BP is typically
ineffective stroke volume is the inciting event, inadequate circulatory reduced (<90 mmHg, or catecholamines are required to maintain BP
compensation also may contribute to shock. Initial peripheral vasocon- >90 mmHg), but occasionally, BP may be maintained by very high
striction may improve coronary and peripheral perfusion at the cost systemic vascular resistance. Tachypnea and jugular venous distention
of increased afterload. However, over the course of CS, the systemic may be present. Typically, there is a weak apical pulse and a soft S1, and
inflammation response triggered by acute cardiac injury often induces an S3 gallop may be audible. Acute, severe MR and VSR usually are
pathologic vasodilatation. Inflammatory cytokines and endothelial and associated with characteristic systolic murmurs (Chap. 275). Crackles
inducible nitric oxide (NO) synthase may augment production of NO are audible in most patients with LV failure. Oliguria/anuria is com-
and its by-product, peroxynitrite, which has a negative inotropic effect mon. CS patients often require early mechanical ventilation (~80%)
and is cardiotoxic. Lactic acidosis and hypoxemia contribute to the for management of acute hypoxemia, increased work of breathing, and
vicious circle, as severe acidosis reduces the efficacy of endogenous and hemodynamic instability; vasopressors often are required to maintain
exogenous catecholamines. During ICU or CICU support, bleeding adequate BP.
and/or transfusions may trigger inflammation and are usually associ-
LABORATORY FINDINGS The white blood cell count and C-reactive
ated with higher mortality (Fig. 305-1).
protein typically are elevated. Renal function often is progressively
Patient Profile In patients with MI, older age, prior MI, diabetes impaired. Newer renal function markers such as cystatin C or neu-
mellitus, anterior MI location, and multivessel coronary artery dis- trophil gelatinase–associated lipocalin (NGAL) do not add prognostic
ease with extensive coronary artery stenoses are associated with an information over creatinine. Hepatic transaminases are elevated due
increased risk of CS. Shock associated with a first inferior MI should to liver hypoperfusion in ~20% of patients and may be very high. The
prompt a search for a mechanical cause or RV involvement. CS may arterial lactate level is usually elevated to >2 mmol/L; if higher, it indi-
rarely occur in the absence of significant stenosis, as seen in takotsubo cates worse prognosis. ABGs usually demonstrate hypoxemia and an
syndrome or fulminant myocarditis. anion gap metabolic acidosis. Glucose levels at admission are often ele-
vated, a strong independent predictor for mortality. Cardiac markers,
Timing Shock is present on admission in approximately one-quarter creatine kinase and its MB fraction, and troponins I and T are typically
of MI patients who develop CS; of these patients, one-quarter develop markedly elevated in acute MI.
it rapidly thereafter, within 6 h of MI onset, and another quarter ELECTROCARDIOGRAM In acute MI with CS, Q waves and/or ST ele-
develop shock later on the first day. Later onset of CS may be due to vation in multiple leads or left bundle branch block are usually present.
reinfarction, marked infarct expansion, or mechanical complications. Approximately one-half of MIs with CS are anterior infarctions. Global
Diagnosis For these unstable patients, supportive therapy must be ischemia due to severe left main stenosis usually is accompanied by
initiated simultaneously with diagnostic evaluation (Fig. 305-3). A ST-segment elevation in lead aVR and ST depressions in multiple leads.
focused history and physical examination should be performed along CHEST ROENTGENOGRAM The chest x-ray typically shows pulmo-
with an electrocardiogram (ECG), chest x-ray, arterial blood gas (ABG) nary vascular congestion and often pulmonary edema but may be
analysis, lactate measurement, and blood specimens for laboratory normal in up to a third of patients. The heart size is usually normal
analysis. Initial echocardiography is an invaluable tool to elucidate the when CS results from a first MI but may be enlarged when it occurs in
underlying cause of CS. a patient with a previous MI.
CLINICAL FINDINGS Most patients initially are dyspneic, pale, appre- ECHOCARDIOGRAM An echocardiogram (Chap. 241) should be
hensive, and diaphoretic, and mental status may be altered. The pulse obtained promptly in patients with suspected/confirmed CS to help
is typically weak and rapid, or occasionally, severe bradycardia due define its etiology. Echocardiography is able to delineate the extent of
Heart team
clearance
Stabilization?
Mechanical
Yes No
Weaning Short-term percutaneous MCS in selected patients/refractory cardiogenic shock (IIB/C)
FIGURE 305-3 Emergency management of patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). Treatment algorithm for patients with
CS. The class of recommendation and level of evidence according to European Society of Cardiology guidelines are provided (see “Further Reading”). CABG, coronary
artery bypass grafting; ECG, electrocardiogram; IABP, intraaortic balloon pump; IRA, infarct-related artery; MCS, mechanical circulatory support; NSTEMI, non–ST-segment
elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; VSD, ventricular septal defect. (Reproduced
with permission from H Thiele et al: Management of cardiogenic shock complicating myocardial infarction: An update 2019. Eur Heart J 40:2671, 2019.)
VASOPRESSORS AND INOTROPES doses, there is stimulation of first β-adrenergic receptors and then
Inotropic agents are theoretically appealing in CS treatment. How- α-adrenergic receptors. Dopamine should be avoided as first-line
ever, current evidence is scarce. Vasoactive medications are often therapy for MI with CS based on hemodynamic and proarrhyth-
used in the management of patients with CS, and all have important mogenic effects.
disadvantages, including increases in myocardial oxygen consump- Dobutamine is a synthetic sympathomimetic amine with posi-
tion, afterload, lethal arrhythmias, and possible myocardial cell tive inotropic action and minimal positive chronotropic activity at
death. As a consequence, catecholamines should be used in the low doses (2.5 μg/kg per min) but moderate chronotropic activity at
lowest possible doses for the shortest possible time. Despite their higher doses. Its vasodilating activity often precludes its use when
frequent use, little clinical outcome data prove their benefit or are a vasoconstrictor effect is required. Levosimendan may also be
available to guide the initial selection of vasoactive therapies in appealing despite a lack of randomized data but was not beneficial
patients with CS. No vasopressor has been demonstrated to change for organ dysfunction in sepsis and also in high-risk patients under-
outcome in large clinical trials. Norepinephrine is reasonable as going cardiovascular surgery.
the first-line vasopressor based on randomized trials compared to
dopamine and also epinephrine. Norepinephrine was associated MECHANICAL CIRCULATORY SUPPORT
with fewer adverse events, including arrhythmias, compared to The most commonly used mechanical circulatory support (MCS)
dopamine in a randomized trial of patients with several etiologies device has been the intraaortic balloon pump (IABP), which is
of circulatory shock and with improved survival in a prespecified inserted into the aorta via the femoral artery and provides passive
subgroup of CS patients. Norepinephrine dosing is usually begun at hemodynamic support. However, routine IABP use in conjunction
2–4 μg/min and titrated upward based on BP. Norepinephrine was with early revascularization (predominantly with PCI) did not reduce
associated with lower lactate levels and less refractory CS compared 30-day, 12-month, or 6-year mortality in the IABP-SHOCK II trial.
to epinephrine. Dopamine’s hemodynamic effects vary depending IABP also had no benefit on secondary endpoints (arterial lactate, cat-
on dose, and there is interpatient variability in responses. Low echolamine doses, renal function, or intensive care severity of illness
doses stimulate renal dopaminergic receptors, and with increasing unit scores). IABP is no longer recommended for CS with LV failure.
Cardiac Tamponade
• Circumferential versus localized effusion therapy (Chap. 260). Assist devices should be used selectively in
• Route of pericardiocentesis if indicated suitable patients based on decisions by a multidisciplinary team
Acute Pulmonary Embolism with expertise in the selection, implantation, and management of
• Right ventricular function
MCS devices (Fig. 305-3).
Critical Care Medicine
IV nitroprusside (0.1–5 μg/kg per min) is a potent venous and arte- SPECIAL CONSIDERATIONS
rial vasodilator. It is useful for patients with pulmonary edema and
hypertension but is not recommended in states of reduced coronary Risk of Iatrogenic Cardiogenic Shock In the treatment of pul-
artery perfusion. It requires close monitoring and titration using an monary edema, vasodilators lower BP, and their use, particularly in
arterial catheter for continuous BP measurement. combination, may lead to hypotension, coronary artery hypoperfu-
Critical Care Medicine
CHAPTER 306 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death
Should we emergently revascularize occluded coronaries for cardio- association with a witnessed rapid collapse or within 1 h of symptom
genic shock. N Engl J Med 341:625, 1999. onset. This definition is based on the presumption that rapid deaths
Ingbar DH: Cardiogenic pulmonary edema: Mechanisms and are often due to an arrhythmia, an assumption that cannot always be
treatment—An intensivists view. Curr Opin Crit Care 25:371, 2019. validated. Approximately half of all SCDs are not witnessed. In the
Thiele H et al: Intraaortic balloon support for myocardial infarction United States, few deaths undergo autopsies, and noncardiac condi-
with cardiogenic shock. N Engl J Med 367:1287, 2012. tions that evolve rapidly such as acute cerebral hemorrhage, aortic
Thiele H et al: PCI strategies in patients with acute myocardial infarc- rupture, and pulmonary embolism cannot be excluded without an
tion and cardiogenic shock. N Engl J Med 377:2419, 2017. autopsy. Therefore, definitive information necessary to establish the
Thiele H et al: Percutaneous short-term active mechanical support cause of death is usually not available. In unwitnessed cases, the defi-
devices in cardiogenic shock: A systematic review and collaborative nition is often further expanded to include unexpected deaths where
meta-analysis of randomized trials. Eur Heart J 38:3523, 2017. the subject was documented to be well when last observed within
Thiele H et al: One-year outcomes after PCI strategies in cardiogenic the preceding 24 h. This expanded definition further decreases the
shock. N Engl J Med 379:1699, 2018. certainty that the death was due to an arrhythmia or other cardiac
Thiele H et al: Management of cardiogenic shock complicating myo- causes, and recent data suggest that noncardiac causes may comprise a
cardial infarction: An update 2019. Eur Heart J 40:2671, 2019. larger than expected percentage of these unwitnessed sudden deaths.
van Diepen S et al: Contemporary management of cardiogenic shock: Most countries, including the United States, do not have national
A scientific statement. Circulation 136:e232, 2017. surveillance systems or reporting requirements for SCD; thus the true
incidence and frequency of SCD and its different mechanisms can only
be estimated.
EPIDEMIOLOGY
■■DEMOGRAPHICS
19th ed, DL Kasper et al (eds). New York, McGraw-Hill Education, 2015, pp. 1764–1771, Table 327-1.
low-income neighborhoods, is likely a contributing factor but does not ■■RISK FACTORS (SEE FIG. 306-1)
Critical Care Medicine
appear to account for the entirety of the elevated SCD rate in blacks. The presence of overt structural heart disease and/or certain types
Alternatively, individuals of Hispanic ethnicity appear to have lower of inherited arrhythmia syndromes markedly elevates SCD risk (see
rates of SCD, despite having a higher prevalence of cardiac risk factors. Chaps. 254 and 255). Preexisting CHD and HF are the most prevalent
It appears that the incidence of SCD may be relatively low among Asian predisposing cardiac conditions and are associated with a four- to
populations as well, both within the United States and globally. These tenfold increase in SCD risk. Correspondingly, SCD shares many
gender and racial differences in SCD/SCA incidence and survival are of the same risk factors with CHD and HF, including hypertension,
poorly understood and warrant further research. diabetes, hypercholesterolemia, obesity, and smoking. Diabetes is a
Idiopathic
Valvular heart disease
VF/Others Coronary heart disease ~ 40–70%
1–5%
White Men: 70%
Women and Black Men 40–50%
Inherited arrhythmia Asians < 40%
syndrome
(LQTS, BrS, CPVT, ERS, etc.)
1–2% in Western countries Myocardial Substrates:
10% in Asia Myocardial scar
Sudden Cardiac Death Hypertrophy
Causes Fibrosis
Myocardial stretch
Cardiomyopathies
Electrical heterogeneity
(NIDCM, HCM, ARVC, etc.)
Ion channel functional modification
10–15% in Western countries
Abnormal calcium handling
30–35% in Asia
Triggers
Population‐Based Risk Factors Heart failure/Stretch
Male sex Family history of SCD (genetics) Ischemia
Black race Diet low in N-3 PUFA Myocardial inflammation
Diabetes Atrial fibrillation Vigorous exertion
Current smoking Obstructive sleep apnea Electrolyte abnormality
Hypertension Heavy alcohol intake Environmental stress
Chronic kidney disease Low magnesium levels Psychological stress/Depression
ECG features (QT, QRS prolongation, early repolarization, LVH)
CHAPTER 306 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death
Obstructive sleep apnea and seizure disorders are also associated channelopathies accounting for a significant number of these deaths.
with increased SCD risk; the underlying mechanism is not clear but
may be due to hypoxia-induced cardiac arrest. Atrial fibrillation also ■■CARDIAC RHYTHMS AND SUDDEN DEATH
appears to be associated with an increased risk of SCD, which is partly, The initial rhythm found when EMS arrive at the scene of an out-
but not entirely, accounted for by its association with underlying heart of-hospital cardiac arrest is an important indication of the potential
disease. Patients with chronic kidney disease are also at higher SCD cause of the arrest and of the prognosis. In the early days of EMS sys-
risk with annualized SCD rates approaching 5.5% in patients under- tems, over half of victims were found in VF, giving rise to the hypoth-
going dialysis. Electrolyte shifts and LVH, which are common in this esis that ischemic VF or ventricular tachycardia (VT) degenerating to
population, have been suggested to play a role. There are also poten- VF was the most common event. The proportion of cardiac arrests
tial dietary influences on SCD risk. Individuals with higher intakes found in VF has decreased markedly since the 1970s, to only 20–25%
of polyunsaturated fatty acids, particularly n-3 fatty acids, and other in more recent studies, and PEA or asystole are now the most common
components of a Mediterranean-style diet have lower SCD risks in scenarios (Fig. 306-2B). However, the vast majority of cardiac arrests
observational studies, possibly due to antiarrhythmic effects of dietary are not monitored at the time of collapse, and since arrhythmias are
components. Low levels of alcohol intake may be beneficial, but heavy inherently unstable once hemodynamic collapse occurs, the rhythm
intake (>3 drinks/day) appears to elevate risk. at the time of EMS arrival may not reflect the rhythm that initially
precipitated the SCA as VF and primary bradycardias can degenerate
■■PRECIPITATING FACTORS into asystole. Nonetheless, VF as an initial rhythm still predominates
SCD/SCA occurs with higher frequency at certain times, locations, in public locations or in other situations when there is a short time
and in association with certain activities and exposures. Although not frame between witnessed arrest and arrival of EMS, suggesting that
consistently observed across all studies, there does appear to be circa- VF remains a common initial precipitating rhythm. However, there
dian variations in the incidence of SCD and cardiac arrest, with peaks are also data to support an absolute decrease in VF incidence. Pro-
in incidence in the morning hours and again in the later afternoon. posed explanations include decreases in underlying CHD incidence,
There is also seasonal variability in SCD rates, which may be related to increased used of beta blockers in CHD, and implantable cardioverter
temperature and light exposure. Rates are highest during winter in the defibrillators (ICD) in high-risk patients. There also appears to be an
northern hemisphere and summer in the southern hemisphere. SCD increase of PEA incidence over the past several years, suggesting that
rates also acutely peak during disasters such as earthquakes and terror- the proportion of SCD due to abrupt hemodynamic collapse in the
ist attacks. SCA arrests are more likely to occur in certain locations as absence of preceding fatal arrhythmia may be increasing. Proposed
well, with notable clustering around train stations, airports, and other explanations for these proportional changes in PEA versus VF include
public places where there is significant population transit. SCD rates the aging of the population and the increased prevalence of end-stage
tend to be higher in urban areas and individuals that live near major cardiovascular disease and other severe comorbidities. These older,
roadways are at elevated SCD risk. There is also a well-recognized sicker patients may be more likely to have arrests in the home and to
acute elevation in SCD risk that occurs during or shortly after bouts have acute precipitants leading to PEA (i.e., respiratory, metabolic, vas-
of vigorous exertion, and men appear to be more susceptible. Habit- cular), and/or be less likely to sustain VF up to the point of EMS arrival.
ual exercise and training lower this acute risk but do not eliminate it
entirely. Exertion-associated SCDs are particularly tragic and highly ■■DISEASE-SPECIFIC MECHANISMS
publicized when they occur in highly trained athletes; however, the CAD can cause SCD through several mechanisms (Table 306-2). The
majority of such deaths actually occur in the general population. The most common cause is acute MI or transient myocardial ischemia that
common thread amongst these precipitating factors is likely height- leads to polymorphic VT and VF (see Chap. 255). Other primary
ened autonomic tone, which can promote ischemia and has direct mechanisms include severe bradyarrhythmias such as heart block
proarrhythmia and electrophysiologic actions that lower the threshold with a slow escape rhythm, or PEA due to a massive MI or associated
for sustained VF. myocardial rupture. Areas of ventricular scar from prior infarcts
increase the predisposition to reentrant VT, which often degenerates
CAUSES OF SUDDEN CARDIAC DEATH to VF. Once patients have suffered an MI, their risk of SCD elevates
up to tenfold, with the highest absolute rates in the first 30 days after
■■UNDERLYING HEART DISEASE (FIG. 306-1) MI. The mechanisms underlying SCD vary at different time points
Our understanding regarding the diseases that contribute to SCD is after MI, with nonarrhythmic causes such as myocardial rupture
derived primarily from autopsy series and cardiac evaluations in car- and/or extensive reinfarction predominating early, within the first
diac arrest survivors, which are highly variable in level of detail. Despite 1–2 months, and ischemic polymorphic VT and/or scar-related ven-
the limitations of these data, it is generally accepted that sudden death tricular arrhythmias prevailing later. VT and sudden death can, and
due to cardiac causes is most commonly due to CAD, although the often do, occur years after an initial MI.
proportion with CAD varies markedly by age, race, and sex. It is esti-
mated that ~70% of SCDs in white men are due to CAD, as compared Cardiomyopathies and Other Forms of Structural Heart
with only 40–50% in women and blacks. The proportion of SCDs with Disease Scar-mediated reentrant VT can also occur in a host of
35%
Overall VT or VF Asystole or PEA Proportion of Acute MI Patients with Low
PART 8
25% 17%
20% 15%
Critical Care Medicine
15%
10% 8.3%
10%
5%
5% 5%
2.5%
0%
2005–06 2007 2008 2009 2010 2011 2012 0%
Jordaens EHJ 2001 Avezum AJC 2008 Bauer EHJ 2009 Voller H Europace
C D 2011
FIGURE 306-2 Changing epidemiology of sudden cardiac death/arrest. A. The proportion of sudden cardiac deaths attributable to coronary artery disease among individuals
without a history of heart disease in Finland over time. Postmortem examinations are mandatory in Finland, which has the highest autopsy rate in the Western world.
(J Junttila et al: Circ Arrhythm Electrophysiol 2016). B. Proportion of treated cardiac arrest with ventricular fibrillation as first recorded rhythm in Seattle, Washington,
United States, over time. (Data from L Cobb et al: JAMA 288:3008, 2002, and G Nichol et al: JAMA 300:1423, 2008.) C. Rates of overall survival and survival from shockable and
nonshockable rhythms to hospital discharge among 70,027 out-of-hospital cardiac arrests across the United States from 2005 to 2012 (Cardiac Arrest to Enhance Survival
Registry). (Reproduced with permission from P Chan et al: Recent trends in survival from out-of-hospital cardiac attacks in United States. Circulation 130:1876, 2014.)
D. Proportion of myocardial infarction patients with left ventricular ejection fractions <30–35% in myocardial infarction registries over time.
nonischemic cardiomyopathies in which replacement fibrosis and/or compressions. The approach is codified in the “out-of-hospital chain
inflammatory ventricular infiltrates occur (Chap. 254). In congenital of survival,” which includes: (1) initial evaluation and recognition of
heart disease, surgical scars created during corrective surgery, such as the SCA; (2) rapid initiation of cardiopulmonary resuscitation (CPR)
those performed to correct ventricular septal defects in tetralogy of with an emphasis on chest compressions; (3) defibrillation as quickly
Fallot, can also serve as the substrate for ventricular reentry. Other as possible usually with an automatic external defibrillation applied
common predisposing processes such as LVH, ventricular stretch due by the lay rescuer or EMT; (4) advanced life support and postcardiac
to fluid overload, and cardiomyocyte dysfunction can result in electri- arrest care. There have been major advances in each of these areas
cal heterogeneity and other electrophysiologic changes that predispose and survival rates to hospital discharge for out-of-hospital cardiac
to ventricular arrhythmias, including ion channel alterations that arrest have increased, particularly for patients found in VT or VF,
prolong action potential duration, impair cellular calcium handling, where survival rates can approach 30% in some regions (Fig. 306-2C).
and diminish cellular coupling. These processes occur in a wide vari- Overall survival rates for out-of-hospital cardiac arrest are also higher
ety of diseases associated with depressed ventricular function and/or for patients receiving CPR, with recent studies in Europe reporting
hypertrophy, including CAD, valvular heart disease, myocarditis, and survival rates of 16%. Multiple studies have pointed to socioeconomic
nonischemic cardiomyopathies. disparities in the administration of CPR and application of automatic
external defibrillators (AEDs) contributing to reduced survival rates
Absence of Structural Heart Disease In the absence of struc- from out-of-hospital cardiac arrest in black and Hispanic populations
tural heart disease, VF can be due to an inherited ion channel abnor- in the United States.
mality, as in long QT and Brugada syndromes (Chap. 255), rapid atrial The initial goal of resuscitation is to achieve the return of spon-
fibrillation associated with Wolff-Parkinson-White syndrome (Chap. taneous circulation (ROSC). Success is strongly related to the time
249), or drug toxicities, such as polymorphic VT due to drugs that between collapse and initiation of resuscitation, decreasing markedly
prolong the QT interval (Chap. 255). PEA can result from pulmonary after 5 min, and the rhythm at the time of EMT arrival, being best for
emboli, exsanguination, or the terminal phase of respiratory arrest. VT, worse for VF, and poor for PEA and asystole. Outcomes are also
determined by the age, clinical state, and comorbidities of the victim
MANAGEMENT OF CARDIAC ARREST prior to the arrest.
As the ability to predict SCA in the population is very limited, com-
munity approaches to reduce death focus on the rapid identification ■■INITIAL EVALUATION AND INITIATION OF CPR
of victims and implementation of resuscitation measures by those The rescuer should check for a response from the victim, shout for
who first encounter the victim, most likely the lay public, who ideally help, and call or ask someone else to call their local emergency number
summon EMS and initiate basic life-support measures with chest (e.g., 911), ideally on a cell phone that can be placed on speaker mode
CHAPTER 306 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death
Polymorphic VT/VF
Aortic stenosis Obstruction to outflow Bradyarrhythmia
Ventricular hypertrophy Pulseless electrical activity
Bradyarrhythmia
Polymorphic VT/VF
Mitral valve prolapse/mitral regurgitation Pump failure VT
Ventricular scar Polymorphic VT/VF
Arrhythmia syndromes without structural heart disease: Abnormal cellular electrophysiology Polymorphic VT/VF
Genetic:
Long QT
Brugada
CPVT
Idiopathic VF, early repolarization
Drug toxicities (acquired long QT, others)
Electrolyte abnormalities (severe hypokalemia)
Wolff-Parkinson-White syndrome Accessory atrioventricular connection Preexcited AF/VF
Noncardiac Causes of Cardiovascular Collapse
Pulmonary embolism PEA
Stroke PEA, bradyarrhythmia
Aortic dissection PEA, VF
Exsanguination PEA
Tension pneumothorax PEA
Sepsis PEA
Neurogenic PEA, bradyarrhythmia
Drug overdose PEA, bradyarrhythmia
Abbreviations: AF, atrial fibrillation; ARVC, arrhythmogenic right ventricular cardiomyopathy; CPVT, catecholaminergic polymorphic ventricular tachycardia; LV, left ventricle;
PEA, pulseless electrical activity; VF, ventricular fibrillation; VSD, ventricular septal defect; VT, ventricular tachycardia.
at the patient’s side such that the responding dispatcher can provide ■■RHYTHM-BASED MANAGEMENT (SEE FIG. 306-3)
instructions and queries to the rescuer. Consideration of aspiration or The rapidity with which defibrillation/cardioversion is achieved is an
airway obstruction is important and if suspected a Heimlich maneuver important predictor of outcome. A defibrillator, most often an AED,
may dislodge the obstructing body. A trained health care provider should be applied as soon as available. AEDs are easily used by lay res-
would also check for a pulse (taking no longer than 10 s so as not to cuers and trained first responders, such as police officers and trained
delay initiation of chest compressions) and assess breathing. Gasping security guards. When the arrest is witnessed, the use of AEDs by lay
respirations and brief seizure activity are common during SCA and responders can improve cardiac arrest survival rates. Once patches are
may be misinterpreted as breathing and responsiveness. Chest com- applied to the chest, a brief pause in chest compressions is required to
pressions should be initiated without delay and administered at a rate allow the AED to record the rhythm. An AED will advise delivery of a
of 100–120/min depressing the sternum by 5 cm (2 in.) and allowing shock if the recorded rhythm meets criteria for VF or VT. Chest com-
full chest recoil between compressions. Chest compressions generate pressions are continued while the defibrillator is being charged. As soon
forward cardiac output with sequential filling and emptying of the car- as a diagnosis of VF or VT is established, a 200 joule biphasic waveform
diac chambers, with competent valves maintaining forward direction shock should be delivered. Chest compressions are resumed immedi-
of flow. Interruption of chest compressions should be minimized to ately and continue for 2 min until the next rhythm check. If VT/VF is
reduce end organ ischemia. Ventilation may be administered with two still present, a second maximal energy shock is delivered. This sequence
breaths for every 30 compressions if a trained rescuer is present, but for is continued until personnel to administer advanced life support are
lay rescuers without training, chest compressions alone (“hands only available or ROSC is achieved. Electrocardiogram (ECG) rhythm strips
CPR”) are more likely to be effectively applied and of similar benefit. produced by the AED should be retrieved, as the initial rhythm can be
If a second rescuer is present, they should be sent to seek out an AED, an important consideration in determining the cause of the arrest and
which are now widely available in many public areas. to guide further therapy and evaluation if resuscitation is successful.
Specific therapies
PART 8
For Bradycardia:
Atropine 1 mg I.V.
Pacing — external or pacing wire
B
FIGURE 306-3 Algorithm for approach to cardiac arrest due to VT or VF (shockable rhythm). A. Chest compressions with ventilation and defibrillation or cardioversion
should be initiated as soon as possible. Defibrillation should be repeated with minimal interruption of chest compressions. Once an intravenous or intraosseous access is
established, administration of epinephrine defibrillation and amiodarone and defibrillation are performed. Further therapy can be guided by possible causes as suggested
by the initial or recurrent cardiac rhythm as shown. CPR, cardiopulmonary resuscitation; I.O., intraosseous; I.V., intravenous; PCI, percutaneous coronary intervention;
ROSC, return of spontaneous circulation. B. Algorithm for approach to cardiac arrest due to bradyarrhythmias/asystole and pulseless electrical activity. Chest compressions
with ventilation (and intubation) should be initiated as soon as possible, and IV access should be obtained. Once an intravenous or intraosseous access is established,
administration of epinephrine is performed. At the same time, an investigation for potential reversible causes should be made and any such causes should be treated if
present. For bradycardic rhythms, atropine 1 mg IV and external subcutaneous or transvenous pacing are also performed. Defibrillation should be repeated with minimal
interruption of chest compressions. Further therapy can be guided by possible causes. CPR, cardiopulmonary resuscitation; I.O., intraosseous; I.V., intravenous; M.I.,
myocardial infarction.
CHAPTER 306 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death
followed by a 150-mg bolus if the arrhythmia recurs. If amiodarone been shown to be beneficial, including administration of corticosteroids,
fails, lidocaine can be administered. hemofiltration, and efforts to tightly control blood glucose.
Consideration of etiology should also guide therapy (Chaps. 254 Hypothermia and sedation preclude reliable prognostication for
and 255). Commonly encountered causes of recurrent VT/VF may be neurologic recovery. Functional neurologic assessment for neurologic
due to ongoing myocardial ischemia or infarction that would benefit recovery is generally deferred for at least 72 h after return to normoth-
from emergent coronary angiography and revascularization, or QT ermia, typically 4–5 days after the cardiac arrest. Features that predict
prolongation causing the polymorphic VT torsades des pointes that poor outcome include absence of pupillary reflex to light, status myo-
may respond to administration of magnesium. Hyperkalemia should clonus, absence of EEG reactivity to external stimuli, and persistent
respond to administration of calcium, while other measures are imple- burst suppression on EEG.
mented to reduce serum potassium.
PEA/asystole should be managed with CPR, ventilation, and admin- ■■LONG-TERM MANAGEMENT AFTER SURVIVAL OF
istration of epinephrine. Causes of PEA/asystole that require specific OUT-OF-HOSPITAL CARDIAC ARREST
therapy should be considered including airway obstruction, hypoxia, For patients who survive cardiac arrest and have neurologic recovery,
hypovolemia, acidosis, hyperkalemia, hypothermia, toxins, cardiac the likely underlying cause of the arrest guides further treatment. For
tamponade, tension pneumothorax, pulmonary embolism, and MI. arrests not due to an obvious noncardiac cause, a full evaluation for the
Naloxone should be administered if opiate overdose is suspected. forms of structural heart disease outlined in Fig. 306-1 and Table 306-2
should be performed including an assessment for underlying CAD and
■■POSTCARDIAC ARREST ACUTE MANAGEMENT ischemia as well as echocardiography and/or cardiac MRI to look for
Following restoration of effective circulation, the possibility of acute evidence of prior MI, valvular disease, nonischemic cardiomyopathies,
MI should be immediately assessed. The majority of patients who have and to provide an assessment of left ventricular ejection fraction (LVEF).
ST elevation consistent with acute MI will be found to have a culprit If the initial evaluation is not definitive or is suggestive of an inflamma-
coronary stenosis/occlusion and emergent coronary angiography with tory cardiomyopathy (i.e., sarcoidosis, myocarditis), a cardiac PET scan
percutaneous angioplasty, and stenting is recommended. Angiography and/or endomyocardial biopsy may also be performed. Patients without
should also be considered if an acute coronary syndrome is suspected, obvious structural abnormalities should undergo an evaluation for pri-
even if ST segment elevation is absent, as approximately half of selected mary electrical disease (long QT syndrome [LQTS], Brugada syndrome,
patients undergoing angiography for this concern are found to have a early repolarization syndrome, or Wolff-Parkinson-White syndrome).
coronary lesion as a potential cause of sudden cardiac arrest (SCA). In cases where a heritable syndrome is suspected, further genetic eval-
However, immediate angiography has not been found to result in better uation should be considered. Diagnostic electrophysiology studies are
outcomes compared to delayed angiography in patients presenting with warranted in selected patients to assess inducible arrhythmias, or pro-
out-of-hospital cardiac arrest due to a VT/VF with no ECG evidence vocative testing, such as with epinephrine challenge for LQTS, or sodium
of ST-segment elevation. Thus, decisions regarding which patients channel blocker (e.g., procainamide) challenge for Brugada syndrome.
without ST segment elevation should undergo urgent angiography are Patients with shockable rhythms at arrest (VF and VT) that are not
complex and factors such as hemodynamic or electrical instability and deemed to have been due to a transient reversible cause and have rea-
evidence of ongoing ischemia are taken into consideration. sonable life expectancy should undergo insertion of an implantable car-
Hemodynamic instability is often present following resuscitation diac defibrillator (ICD) for secondary prevention of SCA/SCD. Most of
and further ischemic end organ damage is a major consideration. these patients will be found to have CAD. Patients with a VF arrest that
Optimizing ventilation with consideration of acidosis, hypoxemia, occurs within the first 48 h of a documented acute MI generally do not
and electrolyte abnormalities is important. Maintaining systolic BP at require an ICD because they have a similar risk of sudden death over
>90 mmHg and mean BP >65 mmHg is desirable and may require the next 5 years as infarct survivors who did not have a cardiac arrest.
administration of vasopressors and adjustment of volume status. However, patients who have a large infarction with acutely depressed
Potentially treatable reversible causes including hyperkalemia, severe LV ejection fraction (e.g., <35%) have an increased risk for future devel-
hypokalemia, and drug toxicity with QT prolongation causing torsades opment of life-threatening ventricular arrhythmias related to reentry in
des pointes should be identified and treated (Chap. 255). the infarct scar (Chap. 252). The percentage of patients with such large
After stable spontaneous circulation is achieved, brain injury due infarcts has been declining due to improved revascularization strate-
to ischemia and reperfusion is a major determinant of survival and gies for acute MI (Fig. 306-2D). Implantation of an ICD early after MI
accounts for over two-thirds of deaths. The probability of successful in these patients does not, however, improve overall survival, in part
neurologic recovery decreases rapidly with time from collapse to ROSC because a significant number of sudden deaths in the first 3 months
and is <30% at 5 min in the absence of bystander CPR. The time between are due to recurrent myocardial ischemia or myocardial rupture, rather
collapse and restoration of circulation is generally imprecise, and some than cardiac arrhythmias. For patients with large infarcts, a wearable
patients have a period of hypotensive VT prior to complete collapse, such defibrillator that will treat VT/VF if it occurs may be used while left
that a reported long period prior to arrival of rescuers does not always ventricular remodeling is taking place, followed by reevaluation of
preclude good neurologic recovery. Therapeutic hypothermia (targeted arrhythmia risk after the infarct is healed to determine if an ICD is
temperature management) has been shown to improve the likelihood of warranted. Patients who experience VF in-hospital >48 h after MI or
opathy, cardiac sarcoidosis, or a cardiac syndrome associated with sud- warrant an ICD. In general, these criteria are not applied to patients
den death, including Brugada syndrome, or LQTS is present (Chaps. who are within 90 days of myocardial revascularization, since some will
254 and 255). In patients with structural heart disease, it is important experience improvement in ventricular function and older trial data
to recognize that life-threatening arrhythmias can be an indication of suggested there was no benefit with ICDs in these patents. High-risk
Critical Care Medicine
terminal, end-stage heart disease with minimal prospect for meaning- patients with low LVEFs may be considered for a wearable defibrillator
ful survival despite successful resuscitation, and ICDs will not alter the with later reassessment of ventricular function and ICD placement.
course of these patients and should not be implanted in this situation, ICDs for primary prevention of sudden death are also recom-
unless there is a prospect for cardiac replacement therapy with future mended for patients with diseases other than CAD that put them at
cardiac transplantation or a ventricular assist device. risk for SCD. Primary prevention ICDs are currently indicated in select
high-risk patients with HCM, arrhythmogenic right ventricular dys-
PREVENTION OF SCD plasia, cardiac sarcoidosis, and Brugada syndrome, as well, and some
Although advances in CPR and postresuscitation care have improved patients with congenital LQTS with high-risk features or who have
survival rates after cardiac arrest, 90% of patients will not survive to be failed therapy with beta-adrenergic blocking agents. ICDs are currently
discharged from the hospital. Of those that do survive, a proportion also recommended for those with nonischemic DCM who have an
(~20%) are left with severe neurologic and/or physical disability. The LVEF ≤35% and who have NYHA functional Class II or III symptoms
majority of cardiac arrests do not occur in public places where AEDs on guideline-directed medical therapy.
and rapid defibrillation have the greatest impact. Patients who suffer Data from a recent randomized trial, the Danish Study to Assess the
an arrest at home also have longer EMS response times and are much Efficacy of ICDs in Patients with Non-ischemic Systolic Heart Failure
less likely to be found in VF. Finally, 50% of cardiac arrests are not on Mortality (DANISH), performed in patients with nonischemic
witnessed precluding effective resuscitation efforts. Thus, preventive DCM and LVEF ≤35%, who also had elevated NT-proBNP levels and
efforts are critical to reducing mortality from cardiac arrest. NYHA Class II–IV HF, have resulted in some debate regarding these
latter guidelines. This trial did not demonstrate an overall mortality
■■SCD RISK STRATIFICATION
benefit of the ICD despite a reduction in the incidence of SCD. In sub-
The presence of overt structural heart disease and/or primary electrical
group analyses, mortality benefits were observed in younger patients
heart disease is associated with an increased risk of SCD that varies with
in whom the competing risk of dying from other causes of death was
the severity and type of disease. For patients with structural heart disease,
lower. These data underscore the importance of considering competing
depressed left ventricular function is the best validated marker for risk, and
risks for other causes of mortality when deciding to implant a primary
clinical HF elevates risk further. After MI, SCD risk increases gradually as
prevention ICD. Patients who are likely to die from other causes are
the LVEF decreases to 40% and then exponentially thereafter. In addition
unlikely to benefit from an ICD. Patients who do not have a reasonable
to LVEF and CHF, other potential markers of increased SCD risk in the
expectation of survival with an acceptable functional status for at least
setting of structural heart disease include unexplained syncope, sustained
1 year, should not undergo ICD placement. There are also other cir-
VT induced at electrophysiology study (EP study), left ventricular scar
cumstances where an ICD is not indicated even if there is a significant
size and heterogeneity on cardiac magnetic resonance, markers of altered
sudden death risk (Table 306-4).
autonomic function and altered repolarization, and QRS prolongation.
The majority of these tests, with the exception of the EP study in post-MI ■■THE CHALLENGE OF SCD PREVENTION
patients, broadly predict death from cardiovascular causes and are not (FIG. 306-4)
able to discriminate patients who will die suddenly from an arrhythmia
and those who will die of other cardiac causes. For instance, patients with The Greatest Number of Sudden Deaths Occur in “Low-
the greatest degree of systolic HF and/or lowest LVEF, although at elevated Risk” Patients While patients with reduced left ventricular func-
risk for SCD, are more likely to die from HF. Although sustained VT at EP tion and HF are at substantially elevated SCD risk, only ~20% of all
study does identify individuals at a higher risk of SCA versus non-SCA in SCDs occur in patients with poor left ventricular function. Most SCDs
certain subsets of patients, the sensitivity of the test is generally inadequate occur in individuals with preserved ventricular function who would
when LV function is significantly reduced. not qualify for a primary prevention ICD. Although SCD rates are
elevated compared to the general population, the absolute SCD risk in
■■PREVENTIVE THERAPIES FOR SCD IN HIGH-RISK patients with CHD or HF who have an LVEF >35% is not high enough
POPULATIONS to warrant consideration of ICD therapy. While the incidence of SCD is
Therapy with beta-adrenergic blockers has been demonstrated to lower in patients with preserved LVEF, SCD accounts for a greater pro-
reduce SCD risk in a multitude of settings including after MI, among portion of cardiac deaths, and active efforts are being made to advance
patients with ischemic and nonischemic cardiomyopathy, and in SCD risk stratification in this segment of the population. However,
LQTS. Angiotensin-converting enzyme inhibitors, aldosterone antag- at the present time, SCD prevention primarily involves cardiac risk
onists, and most recently angiotensin-receptor/neprilysin inhibitors factor modification and standard medical therapy for the underlying
have been associated with reductions in SCD in subsets of patients condition.
CHAPTER 306 Cardiovascular Collapse, Cardiac Arrest, and Sudden Cardiac Death
determine a cause.
Primary Prevention
Ischemic cardiomyopathy ICD therapy is indicated in patients with LVEF ≤35% due to prior MI who are at least Class I B
40 days post-MI and are in NYHA functional Class II or III.
ICD therapy is indicated in patients with LV dysfunction due to prior MI who are at Class I A
least 40 days post-MI, have an LVEF ≤30%, and are in NYHA functional Class I.
ICD therapy is indicated in patients with nonsustained VT due to prior MI, LVEF ≤40%, Class I B
and inducible VF or sustained VT at electrophysiological study.
Nonischemic ICD therapy is indicated in patients with nonischemic DCM who have an LVEF ≤35% Class I B
cardiomyopathy and who are in NYHA functional Class II or III.
ICD implantation is reasonable for patients with unexplained syncope, significant LV Class IIa C
dysfunction, and nonischemic DCM.
ICD therapy can be considered in patients with nonischemic heart disease and NYHA Class IIb C
functional Class I.
Hypertrophic ICD implantation is reasonable for patients with HCM who have one or more major Class IIa C
cardiomyopathy risk factors for SCD.
Arrhythmogenic right ICD implantation is reasonable for the prevention of SCD in patients with ARVC who Class IIa C
ventricular dysplasia have one or more risk factors for SCD.
Cardiac sarcoidosis ICD implantation is reasonable for the prevention of SCD in patients with cardiac Class IIa C
sarcoidosis who have one or more risk factors for SCD.
Brugada syndrome ICD implantation is reasonable for patients with Brugada syndrome who have had Class IIa C
syncope.
ICD implantation is reasonable for patients with Brugada syndrome who have Class IIa C
documented VT that has not resulted in cardiac arrest.
Long-QT syndrome ICD implantation is reasonable to reduce SCD in patients with long QT syndrome who Class IIa B
are experiencing syncope and/or VT while receiving beta blockers.
ICD may be considered as primary therapy in patients with long QT syndrome who Class IIb B
are deemed to be at very high risk, especially those with a contraindication to beta
blocker therapy.
Catecholaminergic ICD implantation is reasonable for patients with catecholaminergic polymorphic VT Class IIa C
polymorphic VT (CPVT) who have syncope and/or documented sustained VT while receiving beta blockers.
Familial cardiomyopathy ICD therapy may be considered in patients with a familial cardiomyopathy associated Class IIa C
with SCD.
LV noncompaction ICD therapy may be considered. Class IIa C
CLASS OF RECOMMENDATION* LEVEL OF EVIDENCE**
Class I Class IIa Level A Level B Level C
Procedure/treatment Additional studies with focused Multiple populations evaluated. Limited populations Very limited
SHOULD be performed/ objectives needed. Data derived from multiple randomized clinical trials evaluated. populations
administered IT IS REASONABLE to or meta-analyses. Data derived from a evaluated.
perform procedure/administer single randomized trial or Only consensus
treatment. nonrandomized studies. opinion of experts,
case studies, or
standard of care.
Abbreviations: VF, ventricular fibrillation; VT, ventricular tachycardia.
Preventing Sudden Death in the General Population Only recently been developed with the intent to stratify SCD risk in low-risk
about one-half of men and one-third of women who suffer SCA are populations, the clinical utility to date is limited by the low absolute
recognized to have heart disease prior to the event, and only half incidence of SCD, which is estimated to be only 50–90 per 100,000 in
have warning symptoms prior to the event. SCD often occurs without the general adult population. Therefore, current efforts aimed at pre-
warning as the first manifestation of cardiac disease. In order to pre- venting SCD in general populations primarily focus on modification
vent these SCDs, preventive interventions would need to be employed of the SCD risk factors outlined previously. Individuals who adhere
broadly to the general population. Although several risk scores have to a low-risk, healthy lifestyle that includes avoidance of smoking,
Post-MI, CHD,
Su CM, or HF with
sta LVEF>35%
ine
dV
T/V
F5
Patients %
treated Other
LVEF <30–35%
with ICDs 15%
80%
No known heart
disease
50%
A
PART 8
6.0%
Critical Care Medicine
3% Year:
Threshold for
ICD 3.0%
Demonstrate
benefit
1.5% 1.5%
1.0%
0.8%
0.08%
Sustained Ischemic CM, Ischemic + Non-Ischemic Heart Failure POST-MI, Multiple General
VT/VF LVEF<30% Non-Ischemic CM, LVEF with LVEF>35% Cardiac Population
Arrest (MADIT) CM, LVEF ≤35% NYHA Preserved Risk Factors
≤35%, NYHA HF Class II- Ejection
HF Class II-III IV, NT- Fraction
(SCD-HEFT) proBNP>200 (HFPEF)
(DANISH Trial)
B
FIGURE 306-4 A. Proportion of sudden cardiac deaths that occur in clinical subgroups of the population treated and not treated with ICDs. B. Absolute risk of sudden cardiac
death within clinical subgroups in comparison to the threshold of risk where ICDs demonstrated benefit.
TABLE 306-4 Implantable Cardioverter Defibrillator (ICD) Not maintaining a healthy body weight, participating in moderate exercise,
Indicated and a Mediterranean-type dietary pattern have markedly lower rates
Patients who do not have a reasonable expectation of survival with an of SCD. A substantial number of SCDs are likely to be preventable
acceptable functional status for at least 1 year, even if they meet ICD through lifestyle modifications and treatment of risk factors.
implantation criteria. Acknowledgment
Patients with incessant VT or VF. William G. Stevenson contributed to this chapter in the 20th edition and
Patients with significant psychiatric illnesses that may be aggravated by device some material from that chapter has been retained here.
implantation or that may preclude systematic follow-up.
Patients with drug-refractory New York Heart Association Class IV congestive ■■FURTHER READING
heart failure who are not candidates for cardiac transplantation or cardiac Al-Khatib SM et al: 2017 AHA/ACC/HRS Guideline for Management
resynchronization therapy. of Patients With Ventricular Arrhythmias and the Prevention of Sud-
Syncope of undetermined cause in a patient without inducible ventricular den Cardiac Death. A Report of the American College of Cardiology/
tachyarrhythmias and without structural heart disease. American Heart Association Task Force on Clinical Practice Guide-
VF or VT is amenable to surgical or catheter ablation in patients without other lines and the Heart Rhythm Society. 72:e91, 2018.
disease predisposing to SCA (e.g., atrial arrhythmias associated with Wolff- Callaway CW et al: Part 8: Post-Cardiac Arrest Care: 2015 American
Parkinson-White syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular Heart Association Guidelines Update for Cardiopulmonary Resuscita-
VT in the absence of structural heart disease). tion and Emergency Cardiovascular Care. Circulation 132:S465, 2015.
Patients with ventricular tachyarrhythmias due to a completely reversible Dankiewicz J et al: Hypothermia versus normothermia after out-of-
disorder in the absence of structural heart disease (e.g., electrolyte imbalance, hospital cardiac arrest. N Engl J Med 384:2283, 2021.
drugs, or trauma). Deo R, Albert CM: Epidemiology and genetics of sudden cardiac
Abbreviations: LV, left ventricular; RV, right ventricular; VF, ventricular fibrillation; VT, death. Circulation 125:620, 2012.
ventricular tachycardia. Fishman GI et al: Sudden cardiac death prediction and prevention
Source: Adapted from AE Epstein et al: 2012 ACCF/AHA/HRS focused update report from a National Heart, Lung, and Blood Institute and Heart
incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy Rhythm Society workshop. Circulation 122:2335, 2010.
of cardiac rhythm abnormalities: A report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines and the Hayashi M et al: The spectrum of epidemiology underlying sudden
Heart Rhythm Society. Circulation 127:e283, 2013. cardiac death. Circ Res 116:1887, 2015.
exacerbate ischemic brain injury include systemic hypotension and over wide physiologic changes such as neuronal activation or changes
hypoxia, which further reduce substrate delivery to vulnerable brain in hemodynamic function. If systemic blood pressure drops, cerebral
tissue, and fever, seizures, and hyperglycemia, which can increase perfusion is preserved through vasodilation of arterioles in the brain;
cellular metabolism, outstripping compensatory processes. Clinically, likewise, arteriolar vasoconstriction occurs at high systemic pressures
these events are known as secondary brain insults because they lead to to prevent hyperperfusion, resulting in fairly constant perfusion across
Critical Care Medicine
exacerbation of the primary brain injury. Prevention, identification, a wide range of systemic blood pressures (Fig. 307-1). At the extreme
and treatment of secondary brain insults are fundamental goals of limits of MAP or CPP (high or low), flow becomes directly related to
management. perfusion pressure. These autoregulatory changes occur in the micro-
An alternative pathway of cellular injury is apoptosis. This process circulation and are mediated by vessels below the resolution of those
implies programmed cell death, which may occur in the setting of seen on angiography. CBF is also strongly influenced by pH and Paco2.
Cerebral Blood Flow (CBF),
F), mL/100
), m g/min
L/100 g/
g min
55
0
50 150
A Mean Arterial Pressure (MAP), mmHg
), mL/100 g/min
Cerebral Blood Flow (CBF), g
55
50 150
B Mean Arterial Pressure (MAP), mmHg
FIGURE 307-1 Pressure autoregulation of cerebral blood flow. In the normal state where autoregulation is intact A, cerebral perfusion is constant over a wide range
of systemic blood pressures (BP). This is mediated by dilation and constriction of small cerebral arterioles (round circles). Below the BP threshold for maximal dilation,
cerebral blood flow becomes pressure-dependent and decreases, whereas above the threshold for maximum constriction, cerebral blood flow increases with increasing
systemic BP. In severe brain injury, autoregulatory mechanisms may be impaired and cerebral blood flow becomes pressure-dependent throughout (B). At the extremes of
BP, there may be vascular collapse (very low BP) or forced vasodilation (very high BP).
FIGURE 307-2 Intracranial pressure (ICP) and brain tissue oxygen monitoring. A
ventriculostomy allows for drainage of cerebrospinal fluid to treat elevated ICP.
tilation on ICP are short-lived, often lasting only for several hours
Fiberoptic ICP and brain tissue oxygen monitors are usually secured using a screw- because of the buffering capacity of the cerebral interstitium, and
like skull bolt. Cerebral blood flow and microdialysis probes (not shown) may be rebound elevations of ICP may accompany abrupt discontinuation
placed in a manner similar to the brain tissue oxygen probe. of hyperventilation. As the level of consciousness declines to coma,
the ability to follow the neurologic status of the patient by examina-
Critical Care Medicine
FIGURE 307-3 Electroencephalography (EEG) after cardiac arrest. A burst-suppression pattern is seen in a comatose patient with severe hypoxic-ischemic encephalopathy
after cardiac arrest. In this patient, each burst on EEG was associated with a whole-body jerking movement leading to the clinical and electrophysiologic diagnosis of
myoclonic status epilepticus.
to affect the posterior rather than anterior portions of the brain may
be due to a lower threshold for autoregulatory breakthrough in the
posterior circulation or a vasculopathy that is more common in these
blood vessels.
FIGURE 307-6 Wernicke’s disease. Coronal T1-weighted postcontrast magnetic
These disorders of hyperperfusion can be divided into those caused
Critical Care Medicine
orders including myasthenia gravis (Chap. 448) and botulism (Chap. ation in weak ICU patients; however, persistent weakness secondary
153), and primary muscle disorders such as polymyositis (Chap. 365). to impaired neuromuscular junction transmission is almost always
The latter result either from the systemic disease itself or as a conse- due to administration of drugs. A number of medications impair neu-
quence of interventions and as a group are often referred to as ICU- romuscular transmission; these include antibiotics, especially amino-
Critical Care Medicine
acquired weakness (ICUAW). glycosides, and beta-blocking agents. In the ICU, the nondepolarizing
General principles of respiratory evaluation in patients with PNS neuromuscular blocking agents (nd-NMBAs), also known as muscle
involvement, regardless of cause, include assessment of pulmonary relaxants, are most commonly responsible. Included in this group of
mechanics, such as maximal inspiratory force (MIF) and vital capacity drugs are such agents as pancuronium, vecuronium, rocuronium, and
(VC), and evaluation of strength of bulbar muscles. Regardless of the cisatracurium. They are often used to facilitate mechanical ventilation
cause of weakness, endotracheal intubation should be considered when or other critical care procedures, but with prolonged use, persistent
the MIF falls to below –25 cmH2O or the VC is <1 L. Also, patients neuromuscular blockade may result in weakness even after discon-
with severe palatal weakness may require endotracheal intubation in tinuation of these agents hours or days earlier. Risk factors for this
order to prevent acute upper airway obstruction or recurrent aspira- prolonged action of neuromuscular blocking agents include female sex,
tion. Arterial blood gases and oxygen saturation from pulse oximetry metabolic acidosis, and renal failure.
are used to follow patients with potential respiratory compromise Prolonged neuromuscular blockade does not appear to produce
from PNS dysfunction. However, intubation and mechanical ventila- permanent damage to the PNS. Once the offending medications are
tion should be undertaken based on clinical assessment rather than discontinued, full strength is restored, although this may take days.
waiting until oxygen saturation drops or CO2 retention develops from In general, the lowest dose of neuromuscular blocking agent should
hypoventilation. Noninvasive mechanical ventilation may be consid- be used to achieve the desired result, and when these agents are used
ered initially in lieu of endotracheal intubation in myasthenia gravis in the ICU, a peripheral nerve stimulator should be used to monitor
but is generally insufficient in patients with severe bulbar weakness or neuromuscular junction function.
ventilatory failure with hypercarbia. Principles of mechanical ventila-
tion are discussed in Chap. 302. ■■MYOPATHY
Critically ill patients, especially those with sepsis, frequently develop
■■NEUROPATHY muscle weakness and wasting, often in the face of seemingly adequate
Although encephalopathy may be the most obvious neurologic dys- nutritional support. Critical illness myopathy is an overall term that
function in critically ill patients, dysfunction of the PNS is also quite describes several different discrete muscle disorders that may occur in
common. It is typically present in patients with prolonged critical critically ill patients. The assumption has been that a catabolic myopa-
illnesses lasting several weeks and involving sepsis; clinical suspicion thy may develop as a result of multiple factors, including elevated corti-
is aroused when there is failure to wean from mechanical ventilation sol and catecholamine release and other circulating factors induced by
despite improvement of the underlying sepsis and critical illness. the SIRS. In this syndrome, known as cachectic myopathy, serum cre-
Critical illness polyneuropathy refers to the most common PNS com- atine kinase levels and electromyography (EMG) are normal. Muscle
plication related to critical illness; it is seen in the setting of prolonged biopsy shows type II fiber atrophy. Panfascicular muscle fiber necrosis
critical illness, sepsis, and multisystem organ failure. Neurologic find- may also occur in the setting of profound sepsis. This less common
ings include diffuse weakness, decreased reflexes, and distal sensory acute necrotizing intensive care myopathy is characterized clinically by
loss. Electrophysiologic studies demonstrate a diffuse, symmetric, weakness progressing to a profound level over just a few days. There
distal axonal sensorimotor neuropathy, and pathologic studies have may be associated elevations in serum creatine kinase and urine myo-
confirmed axonal degeneration. The precise mechanism of critical globin. Both EMG and muscle biopsy may be normal initially but even-
illness polyneuropathy remains unclear, but circulating factors such tually show abnormal spontaneous activity and panfascicular necrosis
as cytokines, which are associated with sepsis and SIRS, are thought with an accompanying inflammatory reaction. Acute rhabdomyolysis
to play a role. It has been reported that up to 70% of patients with the can occur from alcohol ingestion or from compartment syndromes.
sepsis syndrome have some degree of neuropathy, although far fewer A thick-filament myopathy may occur in the setting of glucocorti-
have a clinical syndrome profound enough to cause severe respira- coid and nd-NMBA use. The most frequent scenario in which this is
tory muscle weakness requiring prolonged mechanical ventilation or encountered is the asthmatic patient who requires high-dose glucocor-
resulting in failure to wean. Aggressive glycemic control with insulin ticoids and nd-NMBA to facilitate mechanical ventilation. This muscle
infusions appears to decrease the risk of critical illness polyneuropathy. disorder is not due to prolonged action of nd-NMBAs at the neuromus-
Treatment is otherwise supportive, with specific intervention directed cular junction but, rather, is an actual myopathy with muscle damage; it
at treating the underlying illness. Although spontaneous recovery is has occasionally been described with high-dose glucocorticoid use or
usually seen, the time course may extend over weeks to months and sepsis alone. Clinically this syndrome is most often recognized when
necessitate long-term ventilatory support and care even after the a patient fails to wean from mechanical ventilation despite resolution
underlying critical illness has resolved. of the primary pulmonary process. Pathologically, there may be loss of