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 Cambridge University Press
978-1-107-13163-7 — Core Topics in Cardiothoracic Critical Care
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Core Topics in Cardiothoracic

Critical Care

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Core Topics in Cardiothoracic

Critical Care
Second Edition
Edited by
Kamen Valchanov
Papworth Hospital

Nicola Jones
Papworth Hospital

Charles W Hogue
Northwestern University in Chicago

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Contents
List of Contributors page ix
Foreword xv
Nick Fletcher
Preface to the Second Edition xvii
Link between Cardiothoracic Anaesthesia and
Intensive Care: Which Patients are Admitted
to Critical Care? xix
Andrew Klein
Scoring Systems and Prognosis xxiii
Allanah Barker and Sam Nashef
List of Abbreviations xxix

Section 1 – Diagnosis 9 Chest Drainage 70

1 History and Examination 1
Lachlan Miles and Joseph E Arrowsmith
2 Electrocardiography 7
David Begley
3 Echocardiography in the Cardiothoracic
Intensive Care Unit 15
Ghislaine Douflé and Andrew Roscoe
4 Coronary Angiography 22
Unni Krishnan and Stephen P Hoole
5 Bronchoscopy in the Cardiothoracic
Intensive Care Unit 28
Sumit Chatterji and Pasupathy Sivasothy
6 Microbiology Testing 38
A Ruth M Kappeler and Margaret I Gillham
7 Radiology for Cardiothoracic
Intensivists 44
Kristian H Mortensen, Peter A Barry and
Deepa Gopalan
Section 2 – Practical Procedures
8 Airway Management in Cardiothoracic
Intensive Care: Intubation and
Tracheostomy 59
Martin John and Christiana Burt
Alia Noorani and Yasir Abu-Omar
10 Cardiac Pacing and Defibrillation 77
Sérgio Barra and Patrick Heck
11 Arterial and Venous Catheterisation and
Invasive Monitoring 86
Stuart A Gillon, Nicholas A Barrett and
Christopher IS Meadows
Section 3 – Therapeutic Intervention
12 Antibiotics in the Cardiothoracic Intensive
Care Unit 95
Oana Cole and Olly Allen
13 Blood Products and Transfusion 107
Martin Besser
14 Fluid Administration 116
Vasileios Zochios and Kamen Valchanov
15 Inotropes and Vasopressors 123
Gabriel Kleinman, Shahzad Shaefi and
Charles Shayan
16 Sedation and Analgesia 130
Lachlan Miles and Barbora Parizkova
17 Mechanical Ventilation 142
Anja Schneider and Erik Ortmann

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Contents

18 Renal Replacement Therapy 149 30 Systemic Hypertension in Cardiothoracic

Jonah Powell-Tuck, Matt Varrier and Marlies Critical Care 263
Ostermann Antonio Rubino and Susan Stevenson
19 Nutritional Support for Cardiac Surgery and 31 Pulmonary Hypertension in the
Intensive Care 157 Cardiothoracic Intensive Care Unit 272
Peter Faber Mark Toshner and Joanna Pepke-Zaba
20 Physiotherapy and Rehabilitation 164 32 The Infected Patient 278
Adam Baddeley and Allaina Eden Simon J Finney
33 Seizures 285
Ari Ercole and Lara Prisco
Section 4 – Advanced Organ Support
34 The Acute Abdomen in the Cardiac
21 Percutaneous Mechanical Circulatory
Intensive Care Unit 294
Support 173
Simon JA Buczacki and Justin Davies
Evgeny Pavlushkov and Marius Berman
35 Cardiothoracic Trauma 301
22 Ventricular Assist Devices (VAD) 180
Alia Noorani and Ravi J De Silva
Harikrishna M Doshi and Steven SL Tsui
36 The Bleeding Cardiac Surgical
23 Cardiac Extracorporeal Membrane
Patient 307
Oxygenation 193
Jerrold H Levy, Kamrouz Ghadimi and
Jason M Ali and David P Jenkins
Ian J Welsby
24 Respiratory Extracorporeal Membrane
Oxygenation in the Cardiothoracic Intensive
Care Unit 202 Section 6 – Perioperative Care:
Darryl Abrams and Daniel Brodie
The Patient Post Cardiac Surgery
37 Management after Coronary Artery
Section 5 – Acute Disorders Bypass Grafting Surgery 313
Sam Nashef and Paolo Bosco
25A Resuscitation after Adult Cardiac
Surgery 211 38 Intensive Care Unit Management
Jonathan H Mackay Following Valve Surgery 317
Yasir Abu-Omar and Shakil Farid
25B Out-of-Hospital Cardiac Arrest Patients
in the Cardiothoracic Intensive Care 39 Pulmonary Endarterectomy Patients in
Unit 220 Cardiothoracic Critical Care 324
Lisen Hockings and Sophia Fisher Choo Yen Ng
26 Airway Emergencies 231 40 Heart Transplantation 333
Tom P Sullivan and Guillermo Martinez Stephen J Pettit and Anna Kydd
27 Chest Pain as a Symptom on the 41 Lung Transplantation 340
Cardiothoracic Intensive Care Unit 241 JS Parmar
Will Davies
42 Aortic Surgical Patients in the Intensive
28 Acute Dyspnoea and Respiratory Care Unit 347
Failure 247 Pedro Catarino and Swetha Iyer
Ken Kuljit Parhar
43 Thoracic Surgical Patients 356
29 Shock in the Cardiothoracic Intensive Care J Irons and S Ghosh
Unit 256
Fabio Guarracino and Rubia Baldassarri

vi

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Contents

Section 7 – Disease Management 52 Difficult to Wean from Mechanical

Ventilation Patients in the Cardiothoracic
in the Cardiothoracic Intensive Care Intensive Care Unit 434
Unit: Incidence; Aetiology; Diagnosis; Michael G Davies

Prognosis; Treatment
44 Respiratory Disorders: Acute Respiratory Section 8 – Provision and Delivery of
Distress Syndrome 365 Cardiothoracic Intensive Care
Alastair Proudfoot and Charlotte Summers
53 Cardiothoracic Critical Care Nursing,
45 Cardiovascular Disorders: the Heart Failure Outreach and Follow-up 441
Patient in the Intensive Care Unit 372 Jo-anne Fowles
Anna Kydd and Jayan Parameshwar
54 Systems and Processes in Cardiothoracic
46 Neurological Aspects of Cardiac Surgery 380 Critical Care 445
Max S Damian James Moore and Alain Vuylsteke
47 Postoperative Delirium 392 55 Clinical Information Systems 449
Makeida B Koyi, Joseph G Hobelmann and Matthew Jones
Karin J Neufeld
56 Medical Law and Ethics in the Cardiothoracic
48 Haematological Disorders and Cardiothoracic Intensive Care Unit 456
Intensive Care 402 Oana Cole
Jerrold H Levy, Kamrouz Ghadimi and
Ian Welsby 57 Training in Cardiothoracic Intensive
Care 462
49 Pregnancy and Cardiovascular Disorders 408 Amy Needham and Chinmay Padvardthan
Kiran Salaunkey
50 Paediatric Cardiac Intensive Care 418
Ajay Desai, Lidia Casanueva and Duncan Macrae
Exercise Answers 467
51 Grown-up Congenital Heart Disease (GUCH)
Index 471
Patients in the Cardiothoracic Intensive Care
Unit 427
Colour plates are to be found between
Susanna Price and Niki Walker
pages 230 and 231.

vii

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Contributors

Darryl Abrams Peter A Barry

Department of Medicine, Columbia University Department of Surgery, Royal Marsden Hospital,
College of Physicians and Surgeons, New York, London, UK
NY, USA
David Begley
Yasir Abu-Omar Department of Cardiology, Papworth Hospital,
Department of Surgery, Papworth Hospital, Cambridge, UK
Cambridge, UK

Jason M Ali Marius Berman

Department of Surgery, Papworth Hospital, Department of Surgery, Papworth Hospital,
Cambridge, UK Cambridge, UK

Olly Allen Martin Besser

Department of Pathology, Papworth Hospital, Department of Pathology, Papworth Hospital,
Cambridge, UK Cambridge, UK

Joseph E Arrowsmith Paolo Bosco

Department of Anaesthesia and Intensive Care, Department of Surgery, Papworth Hospital,
Papworth Hospital, Cambridge, UK Cambridge, UK
Adam Baddeley
Department of Physiotherapy, Papworth Hospital, Daniel Brodie
Cambridge, UK Department of Medicine, Columbia University
College of Physicians and Surgeons, New York,
Rubia Baldassarri NY, USA
Department of Anaesthesia and Critical Care
Medicine, Azienda Ospedaliero Universitaria Pisana, Simon JA Buczacki
Pisa, Italy Department of Surgery, Addenbrooke’s Hospital,
Cambridge, UK
Allanah Barker
Department of Surgery, Papworth Hospital, Christiana Burt
Cambridge, UK Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Sérgio Barra
Department of Cardiology, Papworth Hospital, Lidia Casanueva
Cambridge, UK Great Ormond Street Hospital, London, UK

Nicholas A Barrett Pedro Catarino

Department of Intensive Care, Guy’s and St Thomas’ Department of Surgery, Papworth Hospital,
NHS Foundation Trust, London, UK Cambridge, UK

ix

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Contributors

Sumit Chatterji Simon J Finney

Department of Medicine, Addenbrooke’s Hospital, Department of Intensive Care, Barts Heart Central,
Cambridge, UK St Bartholomew’s Hospital, London, UK

Oana Cole Sophia Fisher

Department of Anaesthesia and Intensive Care, Department of Anaesthesia, Flinders Medical Centre,
Papworth Hospital, Cambridge, UK Adelaide, South Australia, Australia

Max S Damian Jo-anne Fowles

Department of Neurology, Addenbrooke’s Hospital, Department of Anaesthesia and Intensive Care,
Cambridge, UK Papworth Hospital, Cambridge, UK

Kamrouz Ghadimi
Justin Davies
Department of Anesthesiology, Duke University
Department of Surgery, Addenbrooke’s Hospital,
Hospital, Durham, NC, USA
Cambridge, UK
S Ghosh
Michael G Davies Department of Anaesthesia and Intensive Care,
Department of Respiratory Medicine, Papworth Papworth Hospital, Cambridge, UK
Hospital, Cambridge, UK
Margaret I Gillham
Will Davies Department of Pathology, Papworth Hospital,
Department of Cardiology, Papworth Hospital, Cambridge, UK
Cambridge, UK
Stuart A Gillon
Ajay Desai Department of Intensive Care, Guy’s and St Thomas’
Department of Paediatric Intensive Care, Royal NHS Foundation Trust, London, UK
Brompton and Harefield NHS Foundation Trust,
London, UK Deepa Gopalan
Department of Radiology, Imperial College,
Harikrishna M Doshi London, UK
Department of Surgery, Papworth Hospital,
Cambridge, UK Fabio Guarracino
Department of Anaesthesia and Critical Care
Ghislaine Douflé Medicine, Azienda Ospedaliero Universitaria Pisana,
University Health Network, University of Toronto, Pisa, Italy
Toronto, Ontario, Canada
Patrick Heck
Allaina Eden Department of Cardiology, Papworth Hospital,
Department of Physiotherapy, Papworth Hospital, Cambridge, UK
Cambridge, UK
Joseph G Hobelmann
Ari Ercole Department of Psychiatry, Johns Hopkins
Department of Anaesthesia, Addenbrooke’s Hospital, University School of Medicine, Baltimore,
Cambridge, UK MD, USA

Peter Faber Lisen Hockings

Department of Anaesthesia, Aberdeen Royal Department of Intensive Care, The Alfred Hospital,
Infirmary, Aberdeen, UK Melbourne, Victoria, Australia

Shakil Farid Charles W Hogue

Department of Surgery, Papworth Hospital, Department of Anesthesiology, Northwestern
Cambridge, UK University Feinberg School of Medicine, Chicago, USA

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Contributors

Stephen P Hoole Jerrold H Levy

Department of Cardiology, Papworth Hospital, Department of Anesthesiology, Critical Care and
Cambridge, UK Surgery, Duke University School of Medicine,
Durham, NC, USA
J Irons
Department of Anaesthesia and Intensive Jonathan H Mackay
Care, Papworth Hospital, Cambridge, UK Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Swetha Iyer
Department of Surgery, Papworth Hospital, Duncan Macrae
Cambridge, UK Department of Paediatric Intensive Care, Royal
Brompton and Harefield NHS Foundation Trust,
David P Jenkins London, UK
Department of Surgery, Papworth Hospital,
Cambridge, UK Guillermo Martinez
Department of Anaesthesia and Intensive Care,
Martin John Papworth Hospital, Cambridge, UK
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK Christopher IS Meadows
Department of Intensive Care, Guy’s and St Thomas’
Matthew Jones NHS Foundation Trust, London, UK
Judge Business School, University of Cambridge,
Cambridge, UK James Moore
Department of Anaesthesia and Intensive Care,
Nicola Jones Papworth Hospital, Cambridge, UK
Deptartment of Anesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK Kristian H Mortensen
Department of Radiology, Great Ormond Street
A Ruth M Kappeler Hospital, London, UK
Department of Pathology, Papworth Hospital,
Cambridge, UK Lachlan Miles
Department of Anaesthesia and Intensive Care,
Andrew Klein Papworth Hospital, Cambridge, UK
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK Sam Nashef
Department of Surgery, Papworth Hospital,
Gabriel Kleinman Cambridge, UK
Department of Anesthesiology, Northwestern
Amy Needham
University, Chicago, IL, USA
Department of Anaesthesia and Intensive Care,
Makeida B Koyi Papworth Hospital, Cambridge, UK
Department of Psychiatry, Johns Hopkins Karin J Neufeld
University School of Medicine, Baltimore, Department of Psychiatry, Johns Hopkins University
MD, USA School of Medicine, Baltimore, MD, USA
Unni Krishnan Choo Yen Ng
Department of Cardiology, Papworth Hospital, Department of Surgery, Papworth Hospital,
Cambridge, UK Cambridge, UK

Anna Kydd Alia Noorani

Department of Transplantation, Papworth Hospital, Department of Surgery, Papworth Hospital,
Cambridge, UK Cambridge, UK

xi

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Contributors

Erik Ortmann Alastair Proudfoot

Department of Anesthesia and Intensive Care,
Kerckhoff-Klinic, Heart and Lung Centre, Bad
Nauheim, Germany
Marlies Ostermann
Department of Intensive Care, Guy’s and St Thomas’
NHS Foundation Trust, London, UK
Chinmay Padvardthan
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Jayan Parameshwar
Department of Transplantation, Papworth Hospital,
Cambridge, UK
Ken Kuljit Parhar
Department of Critical Care Medicine, University of
Calgary, Calgary, Alberta, Canada
Barbora Parizkova
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Js Parmar
Department of Transplantation, Papworth Hospital,
Cambridge, UK
Evgeny Pavlushkov
Department of Surgery, Papworth Hospital,
Cambridge, UK
Joanna Pepke-Zaba
Department of Respiratory Medicine, Papworth
Hospital, Cambridge, UK
Stephen J Pettit
Department of Transplantation, Papworth Hospital,
Cambridge, UK
Jonah Powell-Tuck
Department of Intensive Care, Guy’s and St Thomas’
NHS Foundation Trust, London, UK
Susanna Price
Department of Intensive Care, Royal Brompton and
Harefield NHS Foundation Trust, London, UK
Lara Prisco
Department of Anaesthesia, Addenbrooke’s Hospital,
Cambridge, UK
Department of Perioperative Medicine,
St. Bartholomew’s Hospital, London, UK
Andrew Roscoe
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Antonio Rubino
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Kiran Salaunkey
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Anja Schneider
Zentrum für Akute und Postakute Intensivmedizin
Kreisklinik Jugenheim, Seeheim-Jugenheim,
Germany
Shahzad Shaefi
Department of Anesthesiology, Northwestern
University, Chicago, IL, USA
Charles Shayan
Department of Anesthesiology, Northwestern
University, Chicago, IL, USA
Ravi J De Silva
Department of Surgery, Papworth Hospital,
Cambridge, UK
Pasupathy Sivasothy
Department of Medicine, Addenbrooke’s Hospital,
Cambridge, UK
Tom P Sullivan
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK
Charlotte Summers
University of Cambridge School of Clinical
Medicine, Cambridge, UK
Susan Stevenson
Department of Anaesthesia and Intensive Care,
Papworth Hospital, Cambridge, UK

xii

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Contributors

Mark Toshner Alain Vuylsteke

Department of Respiratory Medicine, Papworth Department of Anaesthesia and Intensive Care,
Hospital, Cambridge, UK Papworth Hospital, Cambridge, UK

Steven SL Tsui Niki Walker

Department of Surgery, Papworth Hospital, Department of Intensive Care, Royal Brompton and
Cambridge, UK Harefield NHS Foundation Trust, London, UK

Kamen Valchanov Ian Welsby

Deptartment of Anesthesia and Intensive Care, Department of Anesthesiology, Duke University
Papworth Hospital, Cambridge, UK Hospital, Durham, NC, USA

Matt Varrier Vasileios Zochios

Department of Intensive Care, Guy’s and St Thomas’ Department of Anaesthesia and Intensive Care,
NHS Foundation Trust, London, UK Papworth Hospital, Cambridge, UK

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Foreword
I am very pleased to be able to provide a brief intro-
duction to the owner, borrower or reader of this text.
This book is an update of the successful 2008 Core
Topics in Cardiothoracic Care text. When that book
was published, it was the first to provide a detailed
insight into the cardiothoracic critical care unit and
was widely read and appreciated. Since then other
authors have produced texts that explore this fascin-
ating area of practice, but none have quite replicated
that originality and quality. . . until now!
Cardiac critical care evolved quite separately
from general intensive care. It essentially originated
as a side room on the cardiac surgical ward in the
1950s where the patient who struggled after cardiac
surgery was ventilated and cared for by the cardiac
anaesthetist and surgeon. Today we have large mul-
tidisciplinary teams in large technology dominated
purpose-built tertiary units. This has been a rapid
and hugely successful evolution. Cardiothoracic criti-
cal care is now a full blooded and highly influential
subspecialty in the ever expanding critical care field.
Indeed I firmly believe that where cardiac intensivists
tread today, general intensivists will follow tomorrow.
This evolution has been accompanied by a vast expan-
sion in research and regulation. No branch of medi-
cine is so scrutinised and yet so open to new thinking
and new solutions. The link between cardiothoracic
anaesthesia and cardiothoracic critical care is vital in
the joined up care of these complex patients, as is the
close link with all the related specialties such as the
surgeon, the cardiologist, the echocardiographer and
so many more.
We are fortunate that the new generation of critical
care doctors and authors from Papworth have stepped
© in this web service Cambridge University Press
up and, combined with a very eminent US academic,
revisited, reorganised and rewritten the problems and
solutions in this area of practice. Kamen Valchanov
and Nicola Jones have taken over the authorship
from their mentors at the world leading Papworth
Hospital and have produced a book that retains the
vision and wisdom of the original and added the
significant advances in knowledge, technology and
practice. A significant positive change is the addi-
tion of Professor Charles Hogue of Johns-Hopkins,
Baltimore and Northwestern University, Chicago for
a North American perspective. Knowing them all, it
is not in the least surprising that they have produced
a book of such scope and such high quality. The con-
tributing authors are all experts in their fields and are
drawn from a wide international base.
This book will prove invaluable to the critical care
nurse, the trainee anaesthetist, surgeon and intensiv-
ist. It will also be of value to the new and established
consultants who are involved with patients with car-
diothoracic disease, which extends well beyond the
bounds of surgery now. I feel proud to have been
invited to write this foreword and I am proud to fully
recommend this work.
Nick Fletcher
Consultant in Cardiothoracic and Vascular Critical Care
St George’s University Hospital, London UK
Past President of the Association for Cardiothoracic
Anaesthesia and Critical Care (UK)
xv
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Preface to the Second Edition
Why the second edition of Core Topics in Cardio-
thoracic Critical Care? The first edition of Core Topics
in Cardiothoracic Critical Care was published in 2008.
It has been a great success, providing a comprehen-
sive text for the specialty and selling so many paper
copies that Cambridge University Press had to reprint
the book to meet the demands of the market. The first
editors Dr Alain Vuylsteke, Dr Andrew Klein, and Mr
Sam Nashef laid the foundation stone. However, a lot
has happened in the world of medicine since 2008,
not least in cardiothoracic critical care. Indeed prac-
tice has expanded so much that cardiothoracic critical
care has been recognised as a separate sub-specialty
by the Faculty of Intensive Care Medicine in the UK.
Therefore, the current editors were tasked with pro-
viding an updated version of this textbook, which will
hopefully offer to the reader state-of-the-art informa-
tion on the current practice in cardiothoracic critical
care.
A Few Notes from the Editors
Different sources point to different events as the birth
of our specialty of intensive care medicine. Most
revolve around mechanical ventilation with some
believing intensive care started in Boston in 1912 when
a girl suffering from poliomyelitis received mechani-
cal ventilation. Others feel that it is the organised care
for polio victims in need of invasive ventilation that
laid the foundations of the specialty. It is probably a
little easier to define the birth of cardiothoracic criti-
cal care medicine as this was born when cardiac sur-
geons needed to leave patients who had undergone
heroic operations in a place where they could recover.
Similarly to general intensive care medicine we do not
have a specific disease to treat, rather we have very
sick patients with complex disorders of the cardio-
respiratory system to care for.
© in this web service Cambridge University Press
How do we practise in this specialty? We pro-
vide organ support to patients who have undergone
cardiothoracic surgery or who have failing cardiac
or respiratory function, with the hope that they will
respond to treatment and survive. However, these
days with modern advances in life support technol-
ogy, such as extracorporeal membrane oxygenation,
death is no longer a binary phenomenon. As guard-
ians of this technology we must be ever mindful of
our patients’ quality of life and the long-term outcome
from our interventions. Importantly we must guard
against sustaining life at all costs and offer patients
and their loved ones, care which makes them happy,
or at least acts in their best interests.
In 2018 a vast amount of evidence exists to guide
this practice. However, it can be challenging to apply
evidence from trials to the heterogeneous group of
patients we treat in Cardiothoracic Critical Care each
with unique, rapidly changing derangements of car-
diorespiratory function. The world of evidence-based
medicine is also riddled with problems of spurious
evidence, and an ever-increasing number of articles
describing scientific trials are being retracted by the
publishers. In the end among a myriad of scientific
and less scientific articles, guidelines and protocols,
based on expert opinion, the patient has to be sup-
ported through their critical illness and recovery
after surgery. In most cases good doctors, nurses and
allied healthcare professionals use patient tailored
approaches in their daily work to provide patients
with the best possible care. We hope that the following
text will offer ample and unbiased information to help
us work in the best interest of each individual patient.
Kamen Valchanov
Nicola Jones
Charles W Hogue
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Link between Cardiothoracic Anaesthesia and Intensive
Care: Which Patients are Admitted to Critical Care?
Andrew Klein
Introduction
Admission to an intensive care area is undertaken
for the diagnosis, management and monitoring of
patients with conditions that require close or con-
stant attention by a group of specially trained health
professionals. Critical care encompasses all areas that
provide level 2 and/or level 3 care as defined by the
Intensive Care Society document ‘Levels of Critical
Care for Adult Patients, 2009’ (Table 1). All level 2
and level 3 areas have higher staffing levels, special-
ist monitoring and more advanced treatment options
available. Level 2 areas are commonly referred to as
High Dependency Units (HDUs), while level 3 areas
are Intensive Care Units (ICUs), and we will make
this distinction in our text. In some hospitals, the two
are separated geographically, whilst in others they co-
exist in one area.
It is extremely common for patients undergoing
cardiothoracic interventions under anaesthesia to be
admitted to an ICU or HDU afterwards and this can
often be a preplanned decision based on the poten-
tial for the patient to become more critically unwell or
unstable. However, given the current pressures placed
on the health service, in terms of both bed occupancy
and finances, each individual case should be con-
sidered and a decision made as to whether such an
admission will be necessary. These decisions can often
be very difficult and must take into consideration a
number of factors.
Patient Related Factors
A patient’s comorbidities, physiological reserve, prog-
nosis and wishes should all be taken into account
when planning their most appropriate postoperative
destination. Prioritisation of patients for critical care
beds should highlight only those patients likely to gain
from an increased level of care and thus not those that
are either too well or too sick to benefit.
It is clear that for some high-risk patients, such as
those with known chronic organ failure undergoing
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cardiac surgery, admission to an ICU will be manda-
tory after anaesthesia. It is reasonable to expect their
condition to worsen following a period of cardiopul-
monary bypass, and preparations should be made for
any necessary organ support, for example use of ino-
tropes or haemofiltration.
Consideration must also be taken as to whether
the patient is appropriate for long-term management
on an ICU. An example of this might be a palliative
thoracic oncology patient undergoing a procedure for
symptom relief; such a patient might be more appro-
priately placed in an HDU with a limit on the medical
interventions that would be appropriate. This manage-
ment plan should be discussed and formulated with
the patient and relatives prior to the procedure itself.
Diagnostic and Surgical Related
Factors
A diagnostic model can be utilised in order to pro-
vide guidelines for admission, which identifies spe-
cific conditions and diseases where it is felt a higher
level of care is always warranted. With respect to car-
diothoracic intensive care, the majority of such condi-
tions will fall under the umbrellas of the cardiac and/
or respiratory systems. However, it is also possible for
a patient to require admission on the basis of an addi-
tional diagnosis, such as sepsis or a neurological com-
plication of surgery.
All patients undergoing sternotomy will man-
date admission to either an ICU or cardiac recovery
environment after their procedure. The differentia-
tion between the two is discussed below. A number
of cardiothoracic surgical procedures will always
warrant ICU admission, due to the complex nature
of the intervention and often long procedural times.
Examples of these are repair of aortic dissection, or
multiple valve procedures.
The majority of patients undergoing thoracic
surgery will either be admitted to an HDU or dis-
charged back to the ward following a period of close
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Which Patients are Admitted to Critical Care?

Table 1 Levels of critical care

Level of Criteria for admission Examples

care
0 General ward
1 Coronary care unit
2 High dependency
unit
3 Intensive care unit
• Requires hospitalisation but needs can be met
through normal ward care
• Recently discharged from higher level care
• In need of additional monitoring/intervention,
clinical input or advice
• Requiring critical care outreach service
support
• Requiring preoperative optimisation
• Requiring extended postoperative care
• Stepping down to level 2 from level 3 care
• Requiring single organ support
• Requiring basic respiratory plus basic
cardiovascular support
• Requiring advanced respiratory support alone
• Requiring a minimum of two organ systems
supported (except basic respiratory plus basic
cardiovascular – level 2, as above)
Intraveous drug administration
Observations needed less than 4 hourly
Minimal 4 hourly observations
Continuous oxygen therapy, management of
epidural, chest drain in situ
Risk of clinical deterioration, high early
warning score
Invasive monitoring to optimise fluid balance
Major elective surgery, emergency surgery in
unstable patient
Minimal hourly observations
Non-invasive ventilation, single intravenous
vasoactive drug
Continuous oxygen therapy and intra-aortic
balloon pump
Invasive mechanical ventilator support via
endotracheal tube or tracheostomy
Acute renal replacement therapy and
vasoactive medication

monitoring in recovery after surgery. An HDU bed
may often be requested to ensure vigilance in the
immediate postoperative period, and also to allow
optimisation of pain control.
Alternative Resources
Each individual institution will have slightly different
facilities available for the care of their patients and
these must be taken into consideration when plan-
ning postprocedural care. Early goal-directed ther-
apy and utilisation of a ‘fast-track’ approach has been
adopted successfully in many cardiothoracic centres
and this may allow lower risk patients to be admit-
ted to a cardiac recovery area as a temporary meas-
ure postoperatively, before being discharged back to
a ‘stepdown’ unit or ward. For such systems to work
and ensure safe patient care, there must be immedi-
ate access to critical care and adequate numbers of
trained nursing staff. This model has been proven to
be successful in some hospitals and can potentially
improve patient flow. However, for many institutions
the safest option remains to admit all cardiac surgical
patients to the ICU postoperatively. The priority in
such institutions is then to discharge out into a step-
down unit as soon as possible after extubation and a
period of stability.
Admission to an ICU may also depend on the
availability of a required specific treatment for an
individual patient. Some centres provide special-
ised advanced organ support, such as extracorporeal
membrane oxygenation. Also, cardiothoracic surgery
is a high-risk specialty fraught with potential compli-
cations, some of which might require transfer out to
an alternative centre, for example to access neurosur-
gical intervention.
Time of Admission
A well-organised cardiothoracic surgical centre
should incorporate a robust system of communica-
tion with both its ICU and HDU with respect to the
daily admission requirements and bed availability.
The majority of patients undergoing anaesthesia will
require elective admission and surgical activity will be
planned according to such requirements.
However, the ICU and HDU must also always take
into account the potential for unplanned emergency
admissions, either transferred in for surgical inter-
vention, or due to unexpected complications intraop-
eratively. Patients should be admitted to the required
higher level of care before their condition reaches a
point from which recovery may be extremely difficult.
In reality, it is often much better practice to assume

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a bed will be needed for your patient, than be left in
a situation where the availability is not there and the
patient is unstable. This could potentially lead to a
worsened patient outcome, and may also put unnec-
essary pressure on the relevant intensive care unit to
discharge prematurely.
Conclusion
It is often assumed that all patients undergoing cardi-
othoracic surgery will warrant admission to either an
ICU or HDU postoperatively and in many instances
that remains the case. Cardiothoracic anaesthesia is a
high-risk specialty and it is imperative that the post-
operative care system in place in each institution is
safe and robust.
However, variety in admission indications and
rates does exist. In recent years there have been
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Which Patients are Admitted to Critical Care?
advances in providing ‘fast-track’ surgery, and cardiac
recovery units have become increasingly popular. In
addition, thoracic surgery does not always necessitate
an HDU bed and often an adequate level of care can be
provided on general wards with critical care outreach
support. Requirements for a higher level of care are by
no means well defined and clinical practice will con-
tinue to evolve with time.
Given the current climate in the health care sys-
tem, with a constant pressure for beds and a drive to
improve patient flow, it is extremely important that
each case undergoing cardiothoracic anaesthesia is
considered individually and the safest care for that
patient determined. Such planning will take into con-
sideration patient related factors, their diagnosis and
required surgery and the resources available in the
institution.
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Scoring Systems and Prognosis
Allanah Barker and Sam Nashef
Crystal Balls
Knowing the likelihood of survival after cardiac
surgery is useful for multiple reasons including for
weighing the potential risks versus benefits of sur-
gery. Further, accurate predicting of outcome allows
for comparison with the actual outcome and thus
insight into the overall performance of the cardiac
surgical unit. Knowledge of who is likely to develop
major morbidity also has an impact on the use of valu-
able resources and may allow for sensible planning of
operating lists. In addition, some believe that being
able to predict mortality with some certitude may help
clinicians to determine when further efforts are futile.
Unfortunately, the perfect predictor – a crystal ball to
foresee the future – has not yet been fully developed.
Risk Models or Scoring Systems
Scoring systems allow reasonable prediction of out-
come after cardiac surgery. Many models have been
devised to work out the likelihood of survival, and
these and others have also been shown to predict
major morbidity, long-term survival and resource use
with some accuracy. Models can be broadly divided
into two groups:
• Preoperative models, applied before the operation,
with no knowledge of intraoperative events; and
• Postoperative models, applied immediately after
the operation on admission into the critical care
unit, taking some account of what the operation
did to the patient.
Preoperative Models
These are most useful for
• Establishing the risk of surgery as an adjunct
to surgical decision making (determining the
indication to operate on the basis of risk-to-
benefit assessment);
• Providing the patient with information, which is
helpful in obtaining consent;
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• Helping to measure the performance of the
service by comparing actual and predicted
outcomes; and
• Comparing the performance of different
institutions, surgeons and anaesthetists by
correcting for risk when outcomes are assessed.
Preoperative models take no account of what happens
in the operating theatre and are therefore less use-
ful in predicting which of a number of postoperative
patients with complications are likely to emerge intact
from the critical care unit.
There are probably more risk models in cardiac
surgery than in any other branch of medicine. Most
rely on a combination of risk factors, each of which
is given a numerical ‘weight’. Weights are added,
multiplied or otherwise mathematically processed to
come up with a percentage figure to predict mortality
or survival. In additive models, the weights given to
the risk factors are simply summed to give the pre-
dicted risk. They are easy to use and can be calculated
mentally or ‘on the back of an envelope’. They are less
accurate than more sophisticated systems and have a
tendency to overscore slightly in low-risk patients and
to underscore considerably in very high-risk patients.
Examples of such models are the Parsonnet (the pio-
neering heart surgery risk model) and the original
additive EuroSCORE for cardiac surgery overall.
Other models deal specifically with cardiac surgi-
cal subsets, like coronary surgery and valve surgery.
Sophisticated models use Bayesian analysis, logistic
regression or even computer neural networks. They
do not allow easy bedside calculation, necessitating
a computer for determining risk. They are, however,
more stable than additive models across the risk range
and slightly more accurate in exact risk prediction.
Examples of such models are the Society of Thoracic
Surgeons (STS) model, the logistic EuroSCORE and
EuroSCORE II for overall cardiac surgery.
The widespread application of scoring systems
in heart surgery has allowed robust performance
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Scoring Systems and Prognosis
measurement and probably contributed to the dra-
matic drop in cardiac surgical mortality seen in the
last 15 years.
Preoperative Model Risk Factors
Not surprisingly, several common risk factors are
included in all models (age, gender and left ventricu-
lar (LV) function). Other risk factors are included in
some models but not in others, such as hypertension,
diabetes and obesity. Models also differ depending
on whether they deal with all cardiac surgeries or a
specific subset, such as coronary surgery or valvular
surgery. They share many risk factors and it would
be repetitive to list them all here, but the models are
easily accessible and there are interactive calcula-
tors available online: www.euroscore.org and http://
riskcalc.sts.org/stswebriskcalc/. EuroSCORE II also
offers a smartphone ‘app’ for use at the bedside.
Age
There is an increased risk above the age of 60 years.
Gender
Females have a higher operative mortality than
males, possibly because of smaller coronary artery
size, smaller blood volume predisposing to risks
associated with perioperative anaemia and transfu-
sion, although the definitive reason for the difference
is unknown.
Left Ventricular Function
As estimated by echocardiography or angiography, LV
function is a good measure of cardiac status, but deter-
mination can be operator dependent and it is difficult
to produce an accurate and reproducible percentage
ejection fraction. Thus, LV function is generally classi-
fied as ‘good’, ‘moderate’ or ‘poor’; EuroSCORE II has
an additional category of ‘very poor’.
Type of Surgery
General cardiac risk models take into account patients
that undergo different surgeries – the risk for coro-
nary artery bypass graft (CABG) surgery is less than
for valve surgery, which in turn is less than that for
surgery of the thoracic aorta. Combined procedures
like valve with CABG carry a higher risk than single
procedures.
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Extent of Cardiac Disease
The severity of coronary disease is subjective and
therefore not included in surgical risk scores. The
Syntax score allows for a measure of the severity of
disease, but is time consuming and partly subjective.
Left main stem disease may be associated with more
risk. Objective measures of cardiac disease include
recent myocardial infarction (MI), unstable angina
and mechanical complications of MI such as acute
rupture of the mitral valve or ventricular septum.
Repeat Operation
Previous cardiac surgery (or previous sternotomy)
increases difficulty of access and prolongs operative
time. These patients therefore carry an increased risk of
bleeding as well as possibly having more advanced dis-
ease than those undergoing their first cardiac procedure.
Lung Disease
The presence of chronic pulmonary disease such as
chronic obstructive pulmonary disease (COPD) has a
large impact on how a patient is managed in anaes-
thetic and ventilatory terms. After cardiac surgery,
patients with concurrent lung disease are more likely
to require extended ventilation and to develop pul-
monary complications, such as chest infections. Lung
function is difficult to quantify with a single test and
severity is based partly on subjective judgements.
However, chronic pulmonary disease is taken into
account in the EuroSCORE and STS.
Renal Disease
Renal dysfunction, as evidenced by dependence on
dialysis, increases mortality by as much as 40%, but
the spectrum of renal failure is wide and difficult to
quantify. Creatinine levels are easy to measure, but are
not always an accurate measure of true kidney func-
tion. The original EuroSCORE uses grossly deranged
serum creatinine (>200 μmol/l) as a measure of sig-
nificant renal impairment. Other scores use dialysis
dependence. The best measure is probably creatinine
clearance (CC), and this now features in EuroSCORE
II, where the categories of renal dysfunction have
expanded into four: normal function (CC > 85 ml/
minute), moderate (CC 50–85 ml/minute), severe
(CC <50 ml/minute) and on dialysis (regardless of
CC). Interestingly, patients with severe dysfunction
but not on dialysis yet fare worst.
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Other Risk Factors
These include peripheral vascular disease, neurologi-
cal dysfunction, degree of urgency, diabetes, hyper-
tension and degree of pulmonary hypertension. In
addition, various scoring systems give weight to the
type of operation performed.
Postoperative Models
These models benefit from information that is only
available after the completion of the operation, such as
the physiological parameters on admission to critical
care. Many have been devised for critically ill patients
outside the cardiac surgical specialty, but have been
used and validated in cardiac surgery. The most well-
known models are the Acute Physiology and Chronic
Health Evaluation (APACHE) and the Sequential
Organ Failure Assessment (SOFA) (Table 1). The
APACHE score is used on admission to critical care to
assess the risk of in-hospital death, whereas the SOFA
was developed to quantify the severity of a patient’s ill-
ness using the degree of organ dysfunction at any one
time. The BRiSc score is specifically aimed at predicting
patients likely to bleed excessively after heart surgery.
Postoperative Model Risk Factors
Postoperative risk scores look at each organ system
systematically and score according to derangement of
function. Basically, the more organ dysfunction, the
poorer the prognosis.
Respiratory
Oxygenation and the requirement for ventilatory sup-
port are used as measures of respiratory function.
Circulatory
Most scores which are applied postoperatively use mean
arterial pressure as an easily measured and monitored
parameter. However, whereas APACHE concentrates
on derangement of normal physiology, SOFA concen-
trates on the need for (and level of) inotropic support.
Neurological
Trends are more useful than a snapshot at a particular
point in time, but the Glasgow Coma Scale is easily
measured and provides an easily reproducible meas-
ure of neurological status.
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Scoring Systems and Prognosis
Renal
As preoperatively, the mainstay of renal function is
serum creatinine level as it is easily measured and a
relatively inexpensive test; this variable can be used
to monitor changes in renal function and to compare
current with preoperative function.
Gastrointestinal/Hepatic
Both APACHE and SOFA use bilirubin levels as a
measure of liver function. APACHE is used more
widely in general critical care units and includes
many more variables, such as amylase, albumin (as a
rough measure of nutritional status) and other liver
function tests. The APACHE score also contains
variables to measure metabolic function and sep-
tic status. These criteria are less relevant in cardiac
surgery.
Thoracic Surgery
Risk modelling is not as developed in thoracic sur-
gery, although recently some attempts have been
made to produce models for predicting mortality
after lung resection. The most important risk fac-
tors associated with a poor outcome are age (older
people do less well) and how much functioning
lung remains long after the resection (the more, the
better).
Learning Points
• Many models help to predict the outcome of
cardiac surgery, and these can be applied before
or after the operation.
• Preoperative models help in the decision
making, consent and assessment of clinical
performance.
• Postoperative models can help to plan resource
use and provide information to relatives.
• Models devised specifically for mortality
have also been found to be useful in predicting
major morbidity, resource use and long-term
outcomes.
• No amount of risk modelling can predict with
certainty which patient will live and which
will die and they should be used as an adjunct
rather than as a replacement for sound clinical
judgement.
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Scoring Systems and Prognosis

Table 1 Postoperative cardiac surgery risk assessment scores

Organ system SOFA APACHE

Respiratory Oxygenation (PaO2/FiO2) Respiratory rate non-ventilated
Respiratory support PaO2 with FiO2 1.0
PaCO2
Coagulation/haematological WCC WCC
Haematocrit
Platelet count
Prothrombin time
Circulatory Mean arterial pressure Mean arterial pressure
Dopamine dose Heart rate ventricular response
Adrenaline dose Central venous pressure
Norepinephrine dose Evidence of acute MI
Dobutamine use Arrhythmia
Serum lactate
Arterial pH
Neurological Glasgow Coma Scale Glasgow Coma Scale
Renal Creatinine Creatinine
Urine ouput/24 hour Urine output/24 hour
Blood urea nitrogen
Gastrointestinal/hepatic Bilirubin Amylase
Albumin
Bilirubin
Alkaline phosphatase
Liver enzymes
Anergy by skin testing
Septic Cerebrospinal fluid positive culture
Blood culture positive
Fungal culture positive
Rectal temperature
Metabolic Calcium level
Glucose
Sodium
Potassium
Bicarbonate
Serum osmolarity
Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation; FiO2, fraction of inspired oxygen; MI, myocardial infarction;
PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood; SOFA, Sequential Organ
Failure Assessment; WCC, white cell count.

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Further Reading
Arts D, de Keizer NF, Vroom MB, et al. Reliability and
accuracy of sequential organ failure assessment.
Critical Care Medicine. 2005; 33: 1988–1993.
Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a
severity of disease classification system. Critical Care
Medicine. 1985; 13: 818–829.
Nashef S. The Naked Surgeon. The Power and Peril of
Transparency in Medicine. London: Scribe, 2015.
Nashef SAM, Roques F, Michel PR, et al. European system
for cardiac operative risk evaluation (EuroSCORE).
European Journal of Cardio-Thoracic Surgery. 1999;
16: 9–13.
© in this web service Cambridge University Press
Scoring Systems and Prognosis
Nashef, SAM, Roques F, Sharples LD, et al. EuroSCORE
II. European Journal of Cardio-Thoracic Surgery. 2012;
41: 1–12.
Parsonnet V, Dean D, Bernstein AD. A method of uniform
stratification of risk for evaluating the results of
surgery in acquired adult heart disease. Circulation.
1989; 79: 3–12.
Vuylsteke A, Pagel C, Gerrard C, et al. The Papworth
Bleeding Risk Score: a stratification scheme for
identifying cardiac surgery patients at risk of
excessive early postoperative bleeding. European
Journal of Cardio-Thoracic Surgery. 2011; 39:
924–930.
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Abbreviations

AC Assist-Control ventilation BLUE Bedside Lung Ultrasound in

ACBT Active Cycle of Breathing Technique Emergency
ACEI Angiotensin Converting Enzyme BNP B-type Natriuretic Peptide
Inhibitor BPF Bronchopleural Fistula
ACLS Advanced Cardiac Life Support BPS Behavioural Pain Scale
ACT Activated Clotting Time BTC Bridge to Candidacy
AD Advanced Directive BTS British Thoracic Society
AEDs Automated External Defibrillators BTT Bridge to Transplant
AEG Atrial Electrocardiogram BURP Backwards, Upwards and Rightward
AEP Auditory Evoked Potentials Pressure on the thyroid cartilage
AF Atrial Fibrillation CABG Coronary Artery Bypass Grafting
AFE Amniotic Fluid Embolism CAM-ICU Confusion Assessment Method for the
AKI Acute Kidney Injury ICU
ALG Anti-human Lymphocyte Globulin CAP Community Acquired Pneumonia
ALS Advanced Life Support CC Creatinine Clearance
AMP Adenosine Monophosphate CCA Critical Care Area
APACHE Acute Physiology and Chronic Health CCS Canadian Cardiovascular Society
Evaluation ccTGA Congenitally Corrected Transposition
APRV Airway Pressure Release Ventilation of the Great Arteries
aPTT Activated Partial Thromboplastin CCU Coronary Care Unit
Time CDC Centers for Disease Control
AR Aortic Regurgitation cEEG Continuous Electroencephalography
ARB Angiotensin Receptor Blockers CF Cystic Fibrosis
ARDS Acute Respiratory Distress CHD Congenital Heart Disease
Syndrome CHF Congestive Heart Failure
ARF Acute Respiratory Failure CICO ‘Can’t Intubate, Can’t Oxygenate’
ASD Atrial Septal Defect CIN Contrast Induced Nephropathy
ATG Anti-human Thymocyte Globulin CI Cardiac Index
ATLS Advanced Trauma Life Support CIS Clinical Information Systems
AVNRT Atrioventricular Node Re-entrant CK Creatinine Kinase
Tachycardia CKD Chronic Kidney Disease
AVSD Atrioventricular Septal Defect CLABSI Central Line Associated Bloodstream
BAL Bronchoalveolar Lavage Infections
BALF Bronchoalveolar Lavage Fluid CLAD Chronic Lung Allograft Dysfunction
BIPAP Biphasic or Bilevel Positive Airway CMR Cardiac Magnetic Resonance
Pressure CMV Continuous Mandatory Ventilation
BIPDs Bilateral Independent PDs CMV Cytomegalovirus
BIS Bispectral Index CNI Calcineurin Inhibitors
BiVAD Bilateral Ventricular Assist Device CO Cardiac Output
BLS Basic Life Support

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Abbreviations

COAD Chronic Obstructive Airways Disease, ELSO Extracorporeal Life Support

same as COPD Organisation
COPD Chronic Obstructive Pulmonary EMR Electronic Medical Records
Disease ERP Enhanced Recovery Programmes
CP Constrictive Pericarditis ESBL Extended Spectrum Beta-Lactamases
CPAP Constant Positive Airway Pressure ESG Endovascular stent graft
CPAx Chelsea Critical Care Physical ETT Endotracheal Tube
Assessment Tool EVLWI Extravascular Lung Water Index
CPB Cardiopulmonary Bypass EWMA Exponentially Weighted Moving
CPE Carbapenemase Producing Average
Enterobacteriaceae EWS Early Warning Scores
CPOT Critical Care Pain Observation Tool FAC Fractional Area Change
CPP Cerebral Perfusion Pressure FALLS Fluid Administration Limited by Lung
CRP C-Reactive Protein Sonography
CT Computerised Tomography FAM Functional Assessment Measure
CTCA Computerised Tomography Coronary FB Flexible Bronchoscopy
Angiogram FBC Full Blood Count
CTEPH Chronic Thromboembolic Pulmonary FDO2 Fraction of Oxygen Delivered
Hypertension FEV1 Forced Expiratory Volume for 1
CV Stroke Volume second
CVC Central Venous Catheter FFP Fresh Frozen Plasma
CVD Cardiovascular Disease FIM Functional Independence Measure
CVP Central Venous Pressure FIRDA Frontal IRDA
CXR Chest X-Ray FOUR Full Outline of Unresponsiveness
DAG 1,2-Diacylglycerol FRC Function of Residual Capacity
DBD Donation after Brain Death FS Fraction of Shortening
DBexs Deep Breathing Exercises FVC Forced Vital Capacity
DCD Donation after Circulatory Death GBS Guillain–Barré Syndrome
DD Diastolic Dysfunction GCS Glasgow Coma Score
DNAR Do Not Attempt Resuscitation Order GEDVI Global End-Diastolic Volume Index
DOLS Deprivation of Liberty Safeguards GICS Gastrointestinal Complication Score
DSI Daily Sedation Interruption GPCR G Protein Coupled Receptors
DT Destination Therapy GUCH Grown-Up Congenital Heart disease
DTI Direct Thrombin Inhibitor HD Haemodialysis
DVT Deep Venous Thrombosis HDF Haemodiafiltration
EACA Epsilon Aminocaproic Acid HDU High Dependency Unit
ECC Emergency Cardiovascular Care HES Hydroxyethil Starch
ECCO2R Extracorporeal Carbon Dioxide HF Haemofiltration
Removal HFV High Frequency Ventilation
ECG Electrocardiography HIT Heparin Induced Thrombocytopenia
ECLS Extracorporeal Life Support HIV Human Immunodeficiency Virus
ECMO Extracorporeal Membrane HLHS Hypoplastic Left Heart Syndrome
Oxygenation HOCM Hypertrophic Obstructive
ECPR Extracorporeal Cardiopulmonary Cardiomyopathy
Resuscitation HSV Herpes Simplex Virus
EDA End-Diastolic Area HTEA High Thoracic Epidural Analgesia
EEG Electroencephalography IABP Intra-aortic Balloon Pump
EF Ejection Fraction ICD Implantable
ELISA Enzyme-Linked Immunosorbent Cardioverter-Defibrillators
Assay ICP Intracranial Pressure

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Edited by Kamen Valchanov , Nicola Jones , Charles W. Hogue
Frontmatter
More Information
xxxi

Abbreviations

ICSD Intensive Care Delirium Screening MDT Multidisciplinary Team

Checklist MET Medical Emergency Teams
ICU-AW Intensive Care Unit Acquired MHI Manual Hyperinflation
Weakness MI Myocardial Infarction
IE Infective Endocarditis MIC Minimum Inhibitory Concentration
IJV Internal Jugular Vein MMF Mycophenolate Mofetil
IMCA Independent Mental Capacity MMV Mandatory Minute Ventilation
Advocate mPAP Mean Pulmonary Arterial Pressure
IMV Invasive Mechanical Ventilation MR Mitral Regurgitation
INR International Normalised Ratio MRSA Methicillin Resistant Staphylococcus
INTERMACS Interagency Registry for Mechanically aureus
Assisted Circulatory Support MSE Myoclonic Status Epilepticus
IPF Idiopathic Pulmonary Fibrosis MSSA Methicillin-Sensitive Staphylococcus
IR Interventional Radiology aureus
IRDA Intermittent Rhythmic Delta Activity mTOR Mammalian Target of Rapamicin
IRV Inversed Ratio Ventilation Inhibitors
IS Incentive Spirometry MUST Malnutrition Universal Screening Tool
ISHLT International Society for Heart and MV Mitral Valve
Lung Transplantation NAAT Nucleic Acid-Based Amplification
ITBVI Intrathoracic Blood Volume Index Technologies
IUGR Intrauterine Growth Retardation NAP4 Fourth National Audit Project
IVC Inferior Vena Cava NAVA Neurally Adjusted Ventilatory Assist
IVS Interventricular Septum NCS Non-convulsive Seizures
JET Junctional Ectopic Tachycardia NCSE Non-convulsive Status Epilepticus
LAD Left Anterior Descending artery NHSBT National Health Service Blood and
LAS Lateral Amiotrophic Sclerosis Transfusion
LBBB Left Bundle Branch Block NI Narcotrend Index
LCx Left Circumflex Artery NICE National Institute for Clinical
LMA Laryngeal Mask Airway Excellence
LMCA Left Main Coronary Artery NIPPV Non-invasive Positive Pressure
LMWH Low Molecular Weight Heparin Ventilation
LTACH Long-Term Acute Care Hospitals NIRS Near Infrared Spectroscopy
LV Left Ventricle NIV Non-invasive Ventilation
LVAD Left Ventricular Assist Device NMDA N-Acetyl-D-Aspartate receptor
LVEDV Left Ventricular End-Diastolic Volume NOAC Newer Oral Anticoagulants
LVESV Left Ventricular End-Systolic Volume NRS Nutritional Risk Screening
LVOT Left Ventricular Outflow Tract NVE Native Valve Endocarditis
LVOTO Left Ventricular Outflow Tract NYHA New York Heart Association
Obstruction OD Optical Density
LVSF Left Ventricular Systolic Function OHCA Out-of-Hospital Cardiac Arrest
MACE Major Adverse Cardiac Events OIRDA Occipital IRDA
MALDI Matrix Assisted Laser Desorption/ OpCAB Off pump Coronary Artery Bypass
TOF MS Ionisation Time-of-Flight Mass PAC Pulmonary Artery Catheter
Spectrometry PAH Pulmonary Arterial Hypertension
MAO Monoamine Oxydase PAP Pulmonary Arterial Pressure
MAP Mean Arterial Pressure PAWP Pulmonary Arterial Wedge Pressure
MCCD Mechanical Chest Compression PBM Patient Blood Management
Devices PBW Predicted Body Weight
MCFP Mean Circulatory Filling Pressure PCAS Post-Cardiac Arrest Syndrome
MDR Multidrug Resistance PCI Percutaneous Coronary Intervention

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Edited by Kamen Valchanov , Nicola Jones , Charles W. Hogue
Frontmatter
More Information
xxxi

Abbreviations

PCP Pneumocystis jirovecii Carinii ROTEM Rotational Thromboelastometry

Pneumonia RRT Renal Replacement Therapy
PCR Polymerase Chain Reaction RV Right Ventricle
PCT Procalcitonin RVP Right Ventricular Pressure
PCWP Pulmonary Capillary Wedge Pressure RVAD Right Ventricular Assist Device
PD Peritoneal Dialysis RWMA Regional Wall Motion Abnormalities
PDA Posterior Descending Artery SACP Selective Antegrade Cerebral
PDE Phosphodiesterase Inhibitors Perfusion
PDR Posterior Dominant Rhythm SAH Subarachnoid Haemorrhage
PDs Periodic Discharges SAM Systolic Anterior Motion
PE Pulmonary Embolism SAS Sedation Agitation Scale
PEA Pulmonary Endarterectomy SDD Selective Digestive Decontamination
PEEP Positive End Expiratory Pressure SE Status Epilepticus
PF Pulmonary Fibrosis SGA Subjective Global Assessment
PF4 Platelet Factor 4 SIMV Synchronised Intermittent Mandatory
PFIT Physical Functional Intensive Care Ventilation
Test SLED Slow Low-Efficiency Dialysis
PGD Primary Graft Dysfunction SMR Standardised Mortality Ratio
PH Pulmonary Hypertension, same as SOFA Sepsis Related Organ Failure
PAH Assessment
PKC Protein Kinase C SR Sarcoplasmic Reticulum
PLC Phospholipase C SRA Serotonin Release Assay
PPCs Postoperative Pulmonary SSEP Somatosensory Evoked Potentials
Complications SSRI Selective Serotonin Reuptake Inhibitor
PPCI Primary Percutaneous Coronary SVC Superior Vena Cava
Intervention SVCS Superior Vena Cava Syndrome
PPCM Peripartum Cardiomyopathy SVR Systemic Vascular Resistance
PPHN Persistent Pulmonary Hypertension of TAA Thoracic Aortic Aneurysm
the Newborn TAH Total Artificial Heart
PPV Pulse Pressure Variation TAPSE Tricuspid Annular Plane Systolic
PRC Post-resuscitation Care Excursion
PRES Posterior Reversible Encephalopathy TAPVD Total Anomalous Pulmonary Venous
Syndrome Drainage
PRVC Pressure Regulated Volume TCPC Total Cavopulmonary Connection
Controlled Ventilation TEG Thromboelastography
PSI Patient State Index TETS Transcutaneous Energy Transfer
PT Prothrombin Time Systems
PTE Pulmonary Thromboendarterectomy, TEVAR Thoracic Endovascular Aortic Repair
same as PEA TGA Transposition of the Great Arteries
PTLD Post-transplantation TnC Troponin C
Lymphoproliferative Disorder TNF Tumour Necrosis Factor
PVE Prosthetic Valve Endocarditis TOE Transoesophageal Echocardiography
PVR Pulmonary Vascular Resistance TOF Tetralogy of Fallot
RAP Right Atrial Pressure TPG Transpulmonary Gradient
RASS Richmond Agitation Sedation Scale TR Tricuspid Regurgitation
RBBB Right Bundle Branch Block TRALI Transfusion Related Lung Injury
RCM Restrictive Cardiomyopathy TTE Transthoracic Echocardiography or
RCT Randomised Controlled Trial Thoracic Expansion Exercises as TTEs
ROC Receiver Operating Characteristic TTM Targeted Temperature Management
ROSC Return of Spontaneous Circulation TXA Tranexamic Acid

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978-1-107-13163-7 — Core Topics in Cardiothoracic Critical Care
Edited by Kamen Valchanov , Nicola Jones , Charles W. Hogue
Frontmatter
More Information
xxxi

Abbreviations

URR Urea Reduction Ratio VT Ventricular Tachycardia

VALI Ventilator Associated Lung Injury VTI Velocity-Time Integral
VAP Ventilator Associated Pneumonia VTM Viral Transport Media
VATS Video Assisted Thoracic Surgery vWF von Willebrand Factor
VF Ventricular Fibrillation WCRS Withdrawal of Cardiorespiratory
VHI Ventilator Hyperinflation Supports
VRE Vancomycin Resistant Enterococci WOB Work of Breathing
VSD Ventricular Septal Defect WPW Wolff–Parkinson–White syndrome

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1
Section 1 Diagnosis
History and Examination
Chapter
1 Lachlan Miles and Joseph E Arrowsmith
The first rule of diagnosis, gentlemen!
Eyes: first and most; hands: next and least; tongue:
not at all!
Sir Lancelot Spratt –​as played by James Robertson
Justice
In: Doctor in the House (1954, The J. Arthur Rank
Organisation)
Introduction
Patients may be admitted to the specialist cardio-
thoracic critical care unit from a variety of sources
(Figure 1.1). In all elective admissions, and in the
majority of emergency admissions, a clinical his-
tory will already have been elicited and a physical
examination performed –​often more than once.
Most patients will already have undergone exten-
sive investigation or therapeutic intervention, and
the underlying diagnosis or diagnoses will have
been established. Despite this seemingly ideal situ-
ation, the cardiothoracic intensivist should adopt an
inquisitive attitude and use the so-​called ‘history and
physical examination’ to confirm previous findings,
assess disease progression and exclude new path-
ology. Contrary to popular belief, this is often the
most efficient and effective means of predicting and
detecting significant comorbid conditions. Clinical
investigations should therefore be considered an
adjunct to, rather than a substitute for, basic medical
assessment.
In the critical care setting, particularly when a
patient is physiologically unstable or has reduced con-
sciousness, the conventional stepwise approach to the
history and physical examination will usually require
modification (Table 1.1). Indeed it may have to be
conducted during or after initial resuscitation.
.003
History
The Conscious Patient
All available sources of information should be drawn
upon to construct as detailed a history as possible.
Where the patient is conscious and able to respond
to direct questioning, this important primary source
of information should not be overlooked. Rather
than using ‘open’ questions and expecting them to
recount their entire current and past medical history
in a concise fashion and in chronological order, it is
often easier to ask the patient to confirm previously
documented information and append newly acquired
information as necessary. When faced with an acutely
unwell and possibly deteriorating patient, the skilled
intensivist needs to be able to quickly gather sufficient
information to aid diagnosis and guide management.
Of particular importance is the patient’s understand-
ing of their medical condition, their insight into treat-
ment options and prognosis, and their expectations.
Corroborative history from family and carers is also
invaluable, especially in the setting of acute delirium
or dementia, where the patient’s own account may be
unreliable. This information should be solicited and
documented whenever possible.
Symptoms of cardiorespiratory disease (e.g.
angina pectoris, dyspnoea, orthopnoea, syncope, pal-
pitations, ankle swelling, etc.) (Table 1.2) should be
actively sought, as should any recent progression in
symptom severity. Symptoms should be described in
terms of their nature (using the patient’s own words),
onset, duration, progression, modifying factors and
associations. The impact of symptoms on functional
status should be documented using the New York
Heart Association (NYHA) classification and the
Canadian Cardiovascular Society (CCS) angina scale.
13:36:26 1
2

Section 1: Diagnosis

Table 1.1 Modification of conventional history and physical for use in critical care

Conventional Critical care

History of presenting complaint Handover information
Past medical history Review of medical notes
Past surgical/​anaesthetic history Information from family members
Drug history, allergies, sensitivities
Recreational substance (mis)use
Educational level/​native language
History
Social/​employment history
Religious/​cultural beliefs
Family history
Systematic enquiry
Sensory impairments
Review of medical notes
Patient supine –​reclining at 45° Patient supine, lateral or prone
Cardiovascular ABC (Airway, Breathing, Circulation)
Respiratory Lines, tubes, drains and catheters
Physical Gastrointestinal Drug and fluid infusions
Genitourinary Ongoing physiological monitoring
Neurological Anatomical examination
Integument

Airway Intervention Operating Room Emergency

(Bronchoscopy) Suite Department

Critical
External Care High Dependency Unit
Community Unit /Stepdown Unit
Other hospital

Radiology Department Ward/Floor

(Coronary, structural,
electrophysiological)

Figure 1.1 Cardiothoracic critical care admission sources.

Enquiry into the patient’s past medical history
should include coexisting conditions, previous hospital
admissions, surgical procedures and complications,
prolonged hospitalisation and unplanned admissions
to a critical care unit. It is important to note the indi-
cation for any surgical procedure or therapeutic inter-
vention (e.g. splenectomy, permanent pacemaker,
angioplasty), the outcome of the procedure and any
anaesthetic related morbidity. A history of difficult
tracheal intubation is of particular note, both with
respect to the unintubated patient who may require
intervention during their stay, and the patient who is
already intubated who will require extubation before
discharge to the ward. Factors known to be associated
with increased mortality and morbidity (e.g. con-
gestive cardiac failure, peripheral vascular disease,
renal insufficiency, arterial hypertension, pulmonary
hypertension, diabetes mellitus, chronic pulmonary
disease, neurological disease and previous cardiovas-
cular surgery) should be documented.

13:36:26
.003
3

Chapter 1: History and Examination

Table 1.2 Common symptoms associated with Where adherence to a particular cultural or reli-
cardiorespiratory conditions gious belief system (e.g. Jehovah’s Witnesses) has
Cardiovascular Respiratory the potential to influence any aspect of critical care
Syncope Recent overseas travel
management, this should be comprehensively docu-
mented. In some instances it may be appropriate to
Chest pain Fever and/​or rigors
explore and document a patient’s specific wishes in a
Fatigue or exercise Facial or sinus pain
number of hypothetical clinical scenarios, including
intolerance
limits of care. It is often preferable that limits of care
Exertional dyspnoea Chest pain
be discussed with the patient and family early on in the
Paroxysmal nocturnal Cough
critical care stay, rather than late in the course of the
dyspnoea
illness when the patient is in extremis. It is important
Orthopnoea Sputum production (volume,
that both the patient and the family have a realistic
time course, purulence)
understanding of what intensive care can offer, rather
Palpitations Haemoptysis
than relying on preconceived ideas.
Intermittent claudication or Dyspnoea
ischaemic rest pain
Stroke or transient Exercise intolerance
The Unconscious Patient
ischaemic attack The unconscious, critically unwell patient represents a
Cough or sputum History of bird keeping, special challenge for any clinician. From a cardiothor-
production asbestos exposure, or other acic point of view, such patients cover a wide range of
sources of occupational lung potential presentations, including, but not limited to
disease
the following:
Peripheral oedema
• A patient transferred from the operating theatre
or catheter laboratory following an invasive
procedure;
Where the patient has been admitted following a
diagnostic or therapeutic intervention (e.g. coronary • A patient admitted following out-​of-​hospital
angiography or angioplasty), a comprehensive medical cardiac arrest, via either the catheter laboratory or
and nursing ‘handover’ is essential. This is particularly the emergency department;
important when the patient has been brought to hospital • A patient requiring ongoing organ support
by emergency ambulance and taken directly to the angi- following an interventional cardiology or
ography suite. Similarly, when a patient is transferred bronchoscopic intervention; and
from another hospital for specialist cardiothoracic care • A ward patient who has physiologically
(e.g. surgical repair of acute type A aortic dissection), deteriorated and requires more advanced
a formal handover of clinical information and docu- treatment modalities or resuscitation.
mentation is an absolute prerequisite for the transfer of When reviewing an obtunded patient the clinician
clinical responsibility and for safe ongoing care. In many is deprived of many of the usual visual and auditory
areas a formal handover document or aide memoire is clues that guide patient assessment, forcing the use of
used both to guide and to document the comprehensive alternative sources of information. Family members
handover of clinically relevant information. and carers are often the key source of information
It is essential to record current and recent pre- regarding recent symptoms, and it is often possible to
scription drug administration, including formula- establish the temporal course of the presenting com-
tion, dosage and route of administration. In addition, plaint with thorough questioning. In many respects,
the medication history should include drugs taken it is often possible to obtain a full history, provided
‘as required’, proprietary or ‘over-​the-​counter’ medi- that the right questions are asked, and an open mind
cines, complimentary or alternative therapies, and maintained.
recreational drugs. This latter category should include A thorough review of the medical record is also
alcohol and tobacco products. A history of allergic invaluable when the patient is not able to speak for
or other idiosyncratic reaction to a specific drug (e.g. him or herself. Written correspondence from other
suxamethonium) or class of drugs (e.g. penicillins) clinicians (e.g. surgeons, cardiologists, respiratory
should be sought and documented. physicians, general practitioners) will answer many

13:36:26 3
.003
Another random document with
no related content on Scribd:
escape, he took the pet from the basket, and placed him in Lady
Jane’s arms.
“See here,” he said, “I’ve sewed this band of leather around his
leg, and you can fasten a strong string to it. If your mama allows you
to have him, you can always tie him to something when you go out,
and leave him alone, and he will be there quite safe when you come
back.”
“I should never leave him alone. I should keep him with me
always,” said the child.
“But, if you should lose him,” continued the boy, spreading one of
the pretty wings over Lady Jane’s plump little arm, “I’ll tell you how
you can always know him. He’s marked. It’s as good as a brand. See
those three black crosses on his wing feathers. As he grows larger
they will grow too, and no matter how long a time should pass
without your seeing him, you’d always know him by these three little
crosses.”
“If mama says I can have him, I can take him with me, can’t I?”
“Certainly, this basket is very light. You can carry it yourself.”
“You know,” she whispered, glancing at her mother, who had
leaned her head on the back of the seat in front of her, and appeared
to be sleeping, “I want to see Carlo and kitty, and the ranch, and all
the lambs; but I mustn’t let mama know, because it’ll make her cry.”
“You’re a good little girl to think of your mother,” said the boy, who
was anxious to cultivate her confidence, but too well-bred to question
her.
“She has no one now but me to love her,” she continued, lowering
her voice. “They took papa from us, and carried him away, and
mama says he’ll never come back. He’s not gone to San Antonio,
he’s gone to heaven; and we can’t go there now. We’re going to New
York; but I’d rather go to heaven where papa is, only mama says
there are no trains or ships to take us there, now, but by-and-by
we’re going if we’re very good.”
 The boy listened to her innocent prattle with a sad smile, glancing
uneasily now and then at the mother, fearful lest the plaintive little
voice might reach her ear; but she seemed to be sleeping, sleeping
uneasily, and with that hot flush still burning on her cheeks.
“Have you ever been in New York?” he asked, looking tenderly at
the little head nestled against his arm. She had taken off her hat, and
was very comfortably curled up on the seat with Tony in her lap. The
bird also seemed perfectly satisfied with his position.
“Oh, no; I’ve never been anywhere only on the ranch. That’s
where Carlo, and kitty, and the lambs were, and my pony, Sunflower;
he was named Sunflower, because he was yellow. I used to ride on
him, and papa lifted me on, and took me off; and Sunflower was so
gentle. Dear papa—I—loved him best of all and now he’s gone
away, and I can’t see him again.”
Here the rosy little face was buried in Tony’s feathers, and
something like a sob made the listener’s heart ache.
“Come, come,” he said softly, “you mustn’t cry, or I shall think you
don’t care for the blue heron.”
In a moment, her little head was raised, and a smile shone through
her tears. “Oh, I do, I do. And if I can have him I won’t cry for the
others.”
“I’m quite sure your mama will consent. Now, let me tell you about
my home. I live in New Orleans, and I have lots of pets,” and the boy
went on to describe so many delightful things that the child forgot her
grief in listening; and soon, very soon the weary little head drooped,
and she was sleeping with her rosy cheek pressed against his
shoulder, and Tony clasped close in her arms.
And so the long, hot afternoon passed away, and the train sped on
toward its destination, while the mother and the child slept, happily
unconscious of the strange fate that awaited them in that city, of
which the spires and walls were even now visible, bathed in the red
light of the evening sun.
 CHAPTER II
TONY GOES WITH LADY JANE

A ND now that the end of the journey was so near, the drowsy
passengers began to bestir themselves. In order to look a little
more presentable, dusty faces and hands were hastily wiped, frowsy
heads were smoothed, tumbled hats and bonnets were arranged,
and even the fretful babies, pulled and coaxed into shape, looked
less miserable in their soiled garments, while their mothers wore an
expression of mingled relief and expectation.
Lady Jane did not open her eyes until her companion gently tried
to disengage Tony from her clasp in order to consign him to his
basket; then she looked up with a smile of surprise at her mother,
who was bending over her. “Why, mama,” she said brightly, “I’ve
been asleep, and I had such a lovely dream; I thought I was at the
ranch, and the blue heron was there too. Oh, I’m sorry it was only a
dream!”
“My dear, you must thank this kind young gentleman for his care of
you. We are near New Orleans now, and the bird must go to his
basket. Come, let me smooth your hair and put on your hat.”
“But, mama, am I to have Tony?”
The boy was tying the cover over the basket, and, at the child’s
question, he looked at the mother entreatingly. “It will amuse her,” he
said, “and it’ll be no trouble. May she have it?”
“I suppose I must consent; she has set her heart on it.”
The boy held out the little basket, and Lady Jane grasped it
rapturously.
“Oh, how good you are!” she cried. “I’ll never, never forget you,
and I’ll love Tony always.”
 At that moment the young fellow, although he was smiling brightly,
was smothering a pang of regret, not at parting with the blue heron,
which he really prized, but because his heart had gone out to the
charming child, and she was about to leave him, without any
certainty of their ever meeting again. While this thought was vaguely
passing through his mind, the lady turned and said to him:
“I am going to Jackson Street, which I believe is uptown. Is there
not a nearer station for that part of the city, than the lower one?”
“Certainly, you can stop at Gretna; the train will be there in a few
minutes. You cross the river there, and the ferry-landing is at the foot
of Jackson Street, where you will find carriages and horse-cars to
take you where you wish to go, and you will save an hour.”
“I’m very glad of that; my friends are not expecting me, and I
should like to reach them before dark. Is it far to the ferry?”
“Only a few blocks; you’ll have no trouble finding it,” and he was
about to add, “Can’t I go with you and show you the way?” when the
conductor flung open the door and bawled, “Grate-na! Grate-na!
passengers for Grate-na!”
Before he could give expression to the request, the conductor had
seized the lady’s satchel, and was hurrying them toward the door.
When he reached the platform, the train had stopped, and they had
already stepped off. For a moment, he saw them standing on the
dusty road, the river and the setting sun behind them—the black-
robed, graceful figure of the woman, and the fair-haired child with her
violet eyes raised to his, while she clasped the little basket and
smiled.
He touched his hat and waved his hand in farewell; the mother
lifted her veil and sent him a sad good-by smile, and the child
pressed her rosy fingers to her lips, and gracefully and gravely threw
him a kiss. Then the train moved on; and the last he saw of them,
they were walking hand in hand toward the river.
 As the boy went back to his seat, he was reproaching himself for
his neglect and stupidity. “Why didn’t I find out her name?—or the
name of the people to whom she was going?—or why didn’t I go with
her? It was too bad to leave her to cross alone, and she a stranger
and looking so ill. She seemed hardly able to walk and carry her bag.
I don’t see how I could have been so stupid. It wouldn’t have been
much out of my way, and, if I’d crossed with them, I should have
found out who they were. I didn’t want to seem too presuming, and
especially after I gave the child the heron; but I wish I’d gone with
them. Oh, she’s left something,” and in an instant he was reaching
under the seat lately occupied by the object of his solicitude.
“It’s a book, ‘Daily Devotions,’ bound in russia, silver clasp,
monogram ‘J. C.,’” he said, as he opened it; “and here’s a name.”
On the fly-leaf was written
Jane Chetwynd.
From Papa,
New York, Christmas, 18—.
“‘Jane Chetwynd,’ that must be the mother. It can’t be the child,
because the date is ten years ago. ‘New York.’ They’re from the
North then; I thought they were. Hello! here’s a photograph.”
It was a group, a family group—the father, the mother, and the
child; the father’s a bright, handsome, almost boyish face, the
mother’s not pale and tear-stained, but fresh and winsome, with
smiling lips and merry eyes, and the child, the little “Lady Jane,”
clinging to her father’s neck, two years younger, perhaps, but the
same lovely, golden-haired child.
The boy’s heart bounded with pleasure as he looked at the sweet
little face that had such a fascination for him.
“I wish I could keep it,” he thought, “but it’s not mine, and I must try
to return to it the owner. Poor woman! she will be miserable when
she misses it. I’ll advertise it to-morrow, and through it I’m likely to
find out all about them.”
Next morning some of the readers of the principal New Orleans
journals noticed an odd little advertisement among the personals:
 Found, “Daily Devotions”; bound in red russia-leather, silver clasp,
with monogram, “J. C.” Address,
Blue Heron, P. O. Box 1121.

For more than a week this advertisement remained in the columns

of the paper, but it was never answered, nor was the book ever
claimed.
 CHAPTER III
MADAME JOZAIN

M ADAME JOZAIN was a creole of mixed French and Spanish

ancestry. She was a tall, thin woman with great, soft black
eyes, a nose of the hawk type, and lips that made a narrow line
when closed. In spite of her forbidding features, the upper part of her
face was rather pleasing, her mild eyes had a gently appealing
expression when she lifted them upward, as she often did, and no
one would have believed that the owner of those innocent, candid
eyes could have a sordid, avaricious nature, unless he glanced at
the lower part of her face, which was decidedly mean and
disagreeable. Her nose and mouth had a wily and ensnaring
expression, which was at the same time cruel and rapacious. Her
friends, and she had but few, endowed her with many good qualities,
while her enemies, and they were numerous, declared that she was
but little better than a fiend incarnate; but Father Ducros, her
confessor, knew that she was a combination of good and evil, the
evil largely predominating.
With this strange and complex character, she had but two
passions in life. One was for her worthless son, Adraste, and the
other was a keen desire for the good opinion of those who knew her.
She always wished to be considered something that she was not,—
young, handsome, amiable, pious, and the best blanchisseuse de fin
in whatever neighborhood she hung out her sign.
And perhaps it is not to be wondered at, that she felt a desire to
compensate herself by duplicity for what fate had honestly deprived
her of, for no one living had greater cause to complain of a cruel
destiny than had Madame Jozain. Early in life she had great
expectations. An only child of a well-to-do baker, she inherited quite
a little fortune, and when she married the débonnair and handsome
André Jozain, she intended, by virtue of his renown and her
competency, to live like a lady. He was a politician, and a power in
his ward, which might eventually have led him to some prominence;
but instead, this same agency had conducted him, by dark and
devious ways, to life-long detention in the penitentiary of his State—
not, however, until he had squandered her fortune, and lamed her for
life by pushing her down-stairs in a quarrel. This accident, had it
disabled her arms, might have incapacitated her from becoming a
blanchisseuse de fin, which occupation she was obliged to adopt
when she found herself deprived of her husband’s support by the too
exacting laws of his country.
In her times of despondency it was not her husband’s disgrace,
her poverty, her lameness, her undutiful son, her lost illusions, over
which she mourned, as much as it was the utter futility of trying to
make things seem better than they were. In spite of all her painting,
and varnishing, and idealizing, the truth remained horribly apparent:
She was the wife of a convict, she was plain, and old, and lame; she
was poor, miserably poor, and she was but an indifferent
blanchisseuse de fin, while Adraste, or Raste, as he was always
called, was the worst boy in the State. If she had ever studied the
interesting subject of heredity, she would have found in Raste the
strongest confirmation in its favor, for he had inherited all his father’s
bad qualities in a greater degree.
On account of Raste’s unsavory reputation and her own
incompetency, she was constantly moving from one neighborhood to
another, and, by a natural descent in the scale of misfortune, at last
found herself in a narrow little street, in the little village of Gretna,
one of the most unlovely suburbs of New Orleans.
The small one-story house she occupied contained but two rooms,
and a shed, which served as a kitchen. It stood close to the narrow
sidewalk, and its green door was reached by two small steps.
Madame Jozain, dressed in a black skirt and a white sack, sat upon
these steps in the evening and gossiped with her neighbor. The
house was on the corner of the street that led to the ferry, and her
greatest amusement (for, on account of her lameness, she could not
run with the others to see the train arrive) was to sit on her doorstep
and watch the passengers walking by on their way to the river.
 On this particular hot July evening, she felt very tired, and very
cross. Her affairs had gone badly all day. She had not succeeded
with some lace she had been doing for Madame Joubert, the wife of
the grocer, on the levee, and Madame Joubert had treated her
crossly—in fact had condemned her work, and refused to take it until
made up again; and Madame Jozain needed the money sorely. She
had expected to be paid for the work, but instead of paying her that
“little cat of a Madame Joubert” had fairly insulted her. She, Madame
Jozain, née Bergeron. The Bergerons were better than the Jouberts.
Her father had been one of the City Council, and had died rich, and
her husband—well, her husband had been unfortunate, but he was a
gentleman, while the Jouberts were common and always had been.
She would get even with that proud little fool; she would punish her
in some way. Yes, she would do her lace over, but she would soak it
in soda, so that it would drop to pieces the first time it was worn.
Meantime she was tired and hungry, and she had nothing in the
house but some coffee and cold rice. She had given Raste her last
dime, and he had quarreled with her and gone off to play “craps” with
his chums on the levee. Besides, she was very lonesome, for there
was but one house on her left, and beyond it was a wide stretch of
pasture, and opposite there was nothing but the blank walls of a row
of warehouses belonging to the railroad, and her only neighbor, the
occupant of the next cottage, had gone away to spend a month with
a daughter who lived “down town,” on the other side of the river.
So, as she sat there alone, she looked around her with an
expression of great dissatisfaction, yawning wearily, and wishing that
she was not so lame, so that she could run out to the station, and
see what was going on: and that boy, Raste, she wondered if he was
throwing away her last dime. He often brought a little money home. If
he did not bring some now, they would have no breakfast in the
morning.
Then the arriving train whistled, and she straightened up and her
face took on a look of expectancy.
“Not many passengers to-night,” she said to herself, as a few men
hurried by with bags and bundles. “They nearly all go to the lower
ferry, now.”
In a moment they had all passed, and the event of the evening
was over. But no!—and she leaned forward and peered up the street
with fresh curiosity. “Why, here come a lady and a little girl and
they’re not hurrying at all. She’ll lose the ferry if she doesn’t mind. I
wonder what ails her?—she walks as if she couldn’t see.”
Presently the two reached her corner, a lady in mourning, and a
little yellow-haired girl carefully holding a small basket in one hand,
while she clung to her mother’s gown with the other.
Madame Jozain noticed, before the lady reached her, that she
tottered several times, as if about to fall, and put out her hand, as if
seeking for some support. She seemed dizzy and confused, and was
passing on by the corner, when the child said entreatingly, “Stop
here a minute, mama, and rest.”
Then the woman lifted her veil and saw Madame Jozain looking up
at her, her soft eyes full of compassion.
“Will you allow me to rest here a moment? I’m ill and a little faint,—
perhaps you will give me a glass of water?”
“Why, certainly, my dear,” said madame, getting up alertly, in spite
of her lameness. “Come in and sit down in my rocking-chair. You’re
too late for the ferry. It’ll be gone before you get there, and you may
as well be comfortable while you wait—come right in.”
The exhausted woman entered willingly. The room was neat and
cool, and a large white bed, which was beautifully clean, for madame
prided herself upon it, looked very inviting.
The mother sank into a chair, and dropped her head on the bed;
the child set down the basket and clung to her mother caressingly,
while she looked around with timid, anxious eyes.
Madame Jozain hobbled off for a glass of water and a bottle of
ammonia, which she kept for her laces; then, with gentle, deft hands,
she removed the bonnet and heavy veil, and bathed the poor
woman’s hot forehead and burning hands, while the child clung to
her mother murmuring, “Mama, dear mama, does your head ache
now?”
“I’m better now, darling,” the mother replied after a few moments;
then turning to madame, she said in her sweet, soft tones, “Thank
you so much. I feel quite refreshed. The heat and fatigue exhausted
my strength. I should have fallen in the street had it not been for
you.”
“Have you traveled far?” asked madame, gently sympathetic.
“From San Antonio, and I was ill when I started”; and again she
closed her eyes and leaned her head against the back of the chair.
At the first glance, madame understood the situation. She saw
from the appearance of mother and child, that they were not poor. In
this accidental encounter was a possible opportunity, but how far she
could use it she could not yet determine; so she said only, “That’s a
long way to come alone”; then she added, in a casual tone,
“especially when one’s ill.”
The lady did not reply, and madame went on tentatively, “Perhaps
some one’s waiting for you on the other side, and’ll come back on
the ferry to see what’s become of you.”
“No. No one expects me; I’m on my way to New York. I have a
friend living on Jackson Street. I thought I would go there and rest a
day or so; but I did wrong to get off the train here. I was not able to
walk to the ferry. I should have gone on to the lower station, and
saved myself the exertion of walking.”
“Well, don’t mind now, dear,” returned madame, soothingly. “Just
rest a little, and when it’s time for the boat to be back, I’ll go on down
to the ferry with you. It’s only a few steps, and I can hobble that far.
I’ll see you safe on board, and when you get across, you’ll find a
carriage.”
“Thank you, you’re very good. I should like to get there as soon as
possible, for I feel dreadfully ill,” and again the weary eyes closed,
and the heavy head fell back against its resting-place.
 Madame Jozain looked at her for a moment, seriously and silently;
then she turned, smiling sweetly on the child. “Come here, my dear,
and let me take off your hat and cool your head while you’re waiting.”
“No, thank you, I’m going with mama.”
“Oh, yes, certainly; but won’t you tell me your name?”
“My name is Lady Jane,” she replied gravely.
“Lady Jane? Well, I declare, that just suits you, for you are a little
lady, and no mistake. Aren’t you tired, and warm?”
“I’m very hungry; I want my supper,” said the child frankly.
Madame winced, remembering her empty cupboard, but went on
chatting cheerfully to pass away the time.
Presently the whistle of the approaching ferryboat sounded; the
mother put on her bonnet, and the child took the bag in one hand,
and the basket in the other. “Come, mama, let us go,” she cried
eagerly.
“Dear, dear,” said madame, solicitously, “but you look so white and
sick. I’m afraid you can’t get to the ferry even with me to help you. I
wish my Raste was here; he’s so strong, he could carry you if you
gave out.”
“I think I can walk; I’ll try,” and the poor woman staggered to her
feet, only to fall back into Madame Jozain’s arms in a dead faint.
 CHAPTER IV
AN INTERRUPTED JOURNEY

F OR a moment, madame debated on what was best to be done;

then, finding herself equal to the emergency, she gently laid the
unconscious woman on the bed, unfastened her dress, and slowly
and softly removed her clothing. Although madame was lame, she
was very strong, and in a few moments the sufferer was resting
between the clean, cool sheets, while her child clung to her cold
hands and sobbed piteously.
“Don’t cry, my little dear, don’t cry. Help me to bathe your mama’s
face; help me like a good child, and she’ll be better soon, now she’s
comfortable and can rest.”
With the thought that she could be of some assistance, Lady Jane
struggled bravely to swallow her sobs, took off her hat with womanly
gravity, and prepared herself to assist as nurse.
“Here’s smelling salts, and cologne-water,” she said, opening her
mother’s bag. “Mama likes this; let me wet her handkerchief.”
Madame Jozain, watching the child’s movements, caught a
glimpse of the silver fittings of the bag, and of a bulging pocket-book
within it, and, while the little girl was hanging over her mother, she
quietly removed the valuables to the drawer of her armoire, which
she locked, and put the key in her bosom.
“I must keep these things away from Raste,” she said to herself;
“he’s so thoughtless and impulsive, he might take them without
considering the consequences.”
For some time madame bent over the stranger, using every
remedy she knew to restore her to consciousness, while the child
assisted her with thoughtfulness and self-control, really surprising in
one of her age. Sometimes her hot tears fell on her mother’s white
face, but no sob or cry escaped her little quivering lips, while she
bathed the pale forehead, smoothed the beautiful hair, and rubbed
the soft, cold hands.
At length, with a shiver and a convulsive groan, the mother partly
opened her eyes, but there was no recognition in their dull gaze.
“Mama, dear, dear mama, are you better?” implored the child, as
she hung over her and kissed her passionately.
“You see she’s opened her eyes, so she must be better; but she’s
sleepy,” said madame gently. “Now, my little dear, all she needs is
rest, and you mustn’t disturb her. You must be very quiet, and let her
sleep. Here’s some nice, fresh milk the milkman has just brought.
Won’t you eat some rice and milk, and then let me take off your
clothes, and bathe you, and you can slip on your little nightgown
that’s in your mother’s bag; and then you can lie down beside her
and sleep till morning, and in the morning you’ll both be well and
nicely rested.”
Lady Jane agreed to madame’s arrangements with perfect docility,
but she would not leave her mother, who had fallen into a heavy
stupor, and appeared to be resting comfortably.
“If you’ll please to let me sit by the bed close to mama and eat the
rice and milk, I’ll take it, for I’m very hungry.”
“Certainly, my dear; you can sit there and hold her hand all the
time; I’ll put your supper on this little table close by you.”
And madame bustled about, apparently overflowing with kindly
attentions. She watched the child eat the rice and milk, smiling
benevolently the while; then she bathed her, and put on the fine little
nightgown, braided the thick silken hair, and was about to lift her up
beside her mother, when Lady Jane exclaimed in a shocked voice:
“You mustn’t put me to bed yet; I haven’t said my prayers.” Her
large eyes were full of solemn reproach as she slipped from
madame’s arms down to the side of the bed. “Mama can’t hear them,
because she’s asleep, but God can, for he never sleeps.” Then she
repeated the touching little formula that all pious mothers teach their
children, adding fervently several times, “and please make dear
mama well, so that we can leave this place early to-morrow
morning.”
Madame smiled grimly at the last clause of the petition, and a
great many curious thoughts whirled through her brain.
As the child rose from her knees her eyes fell on the basket
containing the blue heron, which stood quite neglected, just where
she placed it when her mother fainted.
“Oh, oh!” she cried, springing toward it. “Why, I forgot it! My Tony,
my dear Tony!”
“What is it?” asked madame, starting back in surprise at the
rustling sound within the basket. “Why, it’s something alive!”
“Yes, it’s alive,” said Lady Jane, with a faint smile. “It’s a bird, a
blue heron. Such a nice boy gave it to me on the cars.”
“Ah,” ejaculated madame, “a boy gave it to you; some one you
knew?”
“No, I never saw him before.”
“Don’t you know his name?”
“That’s funny,” and the child laughed softly to herself. “No, I don’t
know his name. I never thought to ask; besides he was a stranger,
and it wouldn’t have been polite, you know.”
“No, it wouldn’t have been polite,” repeated madame. “But what
are you going to do with this long-legged thing?”
“It’s not a thing. It’s a blue heron, and they’re very rare,” returned
the child stoutly.
She had untied the cover and taken the bird out of the basket, and
now stood in her nightgown and little bare feet, holding it in her arms,
and stroking the feathers softly, while she glanced every moment
toward the bed.
“I’m sure I don’t know what to do with him to-night. I know he’s
hungry and thirsty, and I’m afraid to let him out for fear he’ll get
away”; and she raised her little anxious face to madame inquiringly,
for she felt overburdened with her numerous responsibilities.
“Oh, I know what we’ll do with him,” said madame, alertly—she
was prepared for every emergency. “I’ve a fine large cage. It was my
parrot’s cage; he was too clever to live, so he died a while ago, and
his empty cage is hanging in the kitchen. I’ll get it, and you can put
your bird in it for to-night, and we’ll feed him and give him water; he’ll
be quite safe, so you needn’t worry about him.”
“Thank you very much,” said Lady Jane, with more politeness than
warmth. “My mama will thank you, too, when she wakes.”
After seeing Tony safely put in the cage, with a saucer of rice for
his supper, and a cup of water to wash it down, Lady Jane climbed
up on the high bed, and not daring to kiss her mother good-night lest
she might disturb her, she nestled close to her. Worn out with
fatigue, she was soon sleeping soundly and peacefully.
For some time Madame Jozain sat by the bed, watching the sick
stranger, and wondering who she was, and whether her sudden
illness was likely to be long and serious. “If I could keep her here,
and nurse her,” she thought, “no doubt she would pay me well. I’d
rather nurse than do lace; and if she’s very bad she’d better not be
moved. I’d take good care of her, and make her comfortable; and if
she’s no friends about here to look after her, she’d be better off with
me than in the hospital. Yes, it would be cruel to send her to the
hospital. Ladies don’t like to go there. It looks to me as if she’s going
to have a fever,” and madame laid her fingers on the burning hand
and fluttering pulse of the sleeper. “This isn’t healthy, natural sleep.
I’ve nursed too many with fever, not to know. I doubt if she’ll come to
her senses again. If she doesn’t no one will ever know who she is,
and I may as well have the benefit of nursing her as any one else;
but I must be careful, I mustn’t let her lie here and die without a
doctor. That would never do. If she’s not better in the morning I’ll
send for Doctor Debrot; I know he’ll be glad to come, for he never
has any practice to speak of now, he’s so old and stupid; he’s a good
doctor, and I’d feel safe to have him.”
 After a while she got up and went out on the doorstep to wait for
Raste. The night was very quiet, a fresh breeze cooled the burning
heat, the stars shone brightly and softly, and as she sat there alone
and lifted her mild eyes toward the sky no one would have dreamed
of the strange thoughts that were passing through her mind. Now
she was neither hungry nor lonesome; a sudden excitement thrilled
her through and through. She was about to engage in a project that
might compensate her for all her misfortunes. The glimpse she had
of money, of valuables, of possible gain, awakened all her cupidity.
The only thing she cared for now was money. She hated work, she
hated to be at the beck and call of those she considered beneath
her. What a gratification it would be to her to refuse to do Madame
Joubert’s lace, to fling it at her, and tell her to take it elsewhere! With
a little ready money, she could be so independent and so
comfortable. Raste had a knack of getting together a great deal in
one way and another. He was lucky; if he had a little to begin with he
could, perhaps, make a fortune. Then she started, and looked
around as one might who suddenly found himself on the brink of an
awful chasm. From within she heard the sick stranger moan and toss
restlessly; then, in a moment, all was quiet again. Presently, she
began to debate in her mind how far she should admit Raste to her
confidence. Should she let him know about the money and valuables
she had hidden? The key in her bosom seemed to burn like a coal of
fire. No, she would not tell him about the money. While taking the
child’s nightgown from the bag, she had discovered the railroad
tickets, two baggage checks, and a roll of notes and loose change in
a little compartment of the bag. He would think that was all; and she
would never tell him of the other.
At that moment, she heard him coming down the street, singing a
rollicking song. So she got up, and hobbled toward him, for she
feared he might waken the sleepers. He was a great overgrown, red-
faced, black-eyed fellow, coarse and strong, with a loud, dashing
kind of beauty, and he was very observing, and very shrewd. She
often said he had all his father’s cunning and penetration, therefore
she must disguise her plans carefully.
 “Hallo, mum,” he said, as he saw her limping toward him, her
manner eager, her face rather pale and excited; “what’s up now?” It
was unusual for her to meet him in that way.
“Hush, hush, Raste. Don’t make a noise. Such a strange thing has
happened since you went out!” said madame, in a low voice. “Sit
down here on the steps, and I’ll tell you.”
Then briefly, and without much show of interest, she told him of
the arrival of the strangers, and of the young woman’s sudden
illness.
“And they’re in there asleep,” he said, pointing with his thumb in
the direction of the room.
“That’s a fine thing for you to do—to saddle yourself with a sick
woman and a child.”
“What could I do?” asked madame indignantly. “You wouldn’t have
me turn a fainting woman into the street? It won’t cost anything for
her to sleep in my bed to-night.”
“What is she like? Is she one of the poor sort? Did you look over
her traps? Has she got any money?” he asked eagerly.
“Oh, Raste, Raste; as if I searched her pockets! She’s beautifully
dressed, and so is the child. She’s got a fine watch and chain, and
when I opened her bag to get the child’s nightgown, I saw that it was
fitted up with silver.”
“What luck!” exclaimed Raste brightly. “Then she’s a swell, and to-
morrow when she goes away she’ll give you as much as a ‘fiver.’”
“I don’t believe she’ll be able to go to-morrow. I think she’s down
for a long sickness. If she’s no better in the morning, I want you to
cross and find Dr. Debrot”
“Old Debrot? That’s fun! Why, he’s no good—he’ll kill her.”
“Nonsense; you know he’s one of the best doctors in the city.”
“Sometimes, yes. But you can’t keep the woman here, if she’s
sick; you’ll have to send her to the hospital. And you didn’t find out
her name, nor where she belongs? Suppose she dies on your
hands? What then?”
“If I take care of her and she dies, I can’t help it; and I may as well
have her things as any one else.”
“But has she got anything worth having? Enough to pay you for
trouble and expense?” he asked. Then he whistled softly, and added,
“Oh, mum, you’re a deep one, but I see through you.”
“I don’t know what you mean, boy,” said madame, indignantly. “Of
course, if I nurse the woman, and give up my bed to her, I expect to
be paid. I hate to send her to the hospital, and I don’t know her
name, nor the name of her friends. So what can I do?”
“Do just what you’ve planned to do, mum. Go right ahead, but be
careful and cover up your tracks. Do you understand?”
Madame made no reply to this disinterested piece of advice, but
sat silently thinking for some time. At last she said in a persuasive
tone, “Didn’t you bring some money from the levee? I’ve had no
supper, and I intend to sit up all night with that poor woman. Can’t
you go to Joubert’s and get me some bread and cheese?”
“Money, money—look here!” and the young scapegrace pulled out
a handful of silver. “That’s what I’ve brought.”
An hour later madame and Raste sat in the little kitchen, chatting
over their supper in the most friendly way; while the sick woman and
the child still slept profoundly in the small front room.
 CHAPTER V
LAST DAYS AT GRETNA

T HE next morning, Madame Jozain sent Raste across the river for
Dr. Debrot, for the sick woman still lay in a heavy stupor, her dull
eyes partly closed, her lips parched and dry, and the crimson flush of
fever burning on cheek and brow.
Before Raste went, Madame Jozain took the traveling bag into the
kitchen, and together they examined its contents. There were the
two baggage-checks, the tickets and money, besides the usual
articles of clothing, and odds and ends; but there was no letter, nor
card, nor name, except the monogram, J. C., on the silver fittings, to
assist in establishing the stranger’s identity.
“Hadn’t I better take these,” said Raste, slipping the baggage-
checks into his pocket, “and have her baggage sent over? When she
comes to, you can tell her that she and the young one needed
clothes, and you thought it was best to get them. You can make that
all right when she gets well,” and Raste smiled knowingly at
madame, whose face wore an expression of grave solicitude as she
said:
“Hurry, my son, and bring the doctor back with you. I’m so anxious
about the poor thing, and I dread to have the child wake and find her
mother no better.”
When Doctor Debrot entered Madame Jozain’s front room, his
head was not as clear as it ought to have been, and he did not
observe anything peculiar in the situation. He had known madame,
more or less, for a number of years, and he might be considered one
of the friends who thought well of her. Therefore, he never suspected
that the young woman lying there in a stupor was any other than the
relative from Texas madame represented her to be. And she was
very ill, of that there could be no doubt; so ill as to awaken all the
doctor’s long dormant professional ambition. There were new