Table Of ContentM. R.Pinsky·L.Brochard·J.Mancebo
Applied Physiology in Intensive Care Medicine
M. R. Pinsky · L. Brochard · J. Mancebo
Applied Physiology
in Intensive
Care Medicine
With116Figuresand21Tables
123
MICHAEL R. PINSKY, Prof., MD, Dr hc, FCCP, FCCM
UniversityofPittsburgMedical Center
Dep.of Critical CareMedicine
3550Terrace Street
Pittsburgh,PA15261
USA
LAURENT BROCHARD, MD JORDI MANCEBO, MD, PhD
Hôpital HenriMondor Hospitalde SantPau
RéanimationMédicale ServeiMedicina Intensiva
51av.MaréchaldeLattredeTassigny Avda. S. AntonioM. Claret167
94010 Créteil Cedex 08025Barcelona
France Spain
Thearticlesinthisbookappearedinthejournal„Intensive CareMedicine“
between2002and2006.
ISBN-103-540-37361-6 Springer-VerlagBerlin Heidelberg NewYork
ISBN-13978-3-540-37361-2 Springer-VerlagBerlin Heidelberg NewYork
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Introduction
The practice of intensive care medicine is at the very forefront of titration of treatment
and monitoring response. The substrate of this care is the critically ill patient who, by
definition,isatthelimitsofhisorherphysiologicreserve. Suchpatientsneedimmediate,
aggressivebutbalancedlife-alteringinterventionstominimizethedetrimentalaspectsof
acuteillnessandhastenrecovery. Treatmentdecisionsandresponsetotherapyareusually
assessed by measures of physiologic function, such as assessed by cardio-respiratory
monitoring. However, how one uses such information is often unclear and rarely
supportedby prospectiveclinicaltrials. Inreality,the bedsideclinicianisforcedtorely
primarily on physiologic principles in determining the best treatments and response to
therapy. However,thephysiologicfoundationpresentinpracticingphysiciansisuneven
andoccasionallysupportedmorebyhabitorpriortrainingthanscience.
A series of short papers published in Intensive Care Medicine since 2002 under the
headingPhysiologic Notesattemptstocapturetheessenceofthephysiologicperspectives
thatunderpinbothourunderstandingofdiseaseandresponsetotherapy. Thispresent
volumecombinesthecompletelistofthesePhysiologic NotesupuntilJuly2006withthe
associated review articles over the same interval that also addressed these central issues.
This volume was created to address this fundamental unevenness in our understanding
ofappliedphysiologyandunderscorewhatisknownandhowmeasuresandmonitoring
interactwithorgansystemfunctionandresponsetotherapy. Thiscollectionofphysiologic
perspectives and reviews, written by some of the most respected experts in the field,
represent an up-to-date and invaluable compendium of practical bedside knowledge
essentialtotheeffectivedeliveryofacutecaremedicine. Althoughthistextcanberead
fromcovertocover,thereaderisencouragedtousethistextasareferencesourcereading
individualPhysiologic NotesandReviewarticlesastheypertaintospecificclinicalissues.
Inthatwaytherelevantinformationwillhaveimmediatepracticalmeaningandhopefully
becomeincorporatedintoroutinepractice.
Wehopethatthereaderfindsthesepapersandreviewsusefulintheirpracticeandenjoy
readingthemasmuchasweenjoyededitingtheoriginalarticlesthatitcomprises.
Michael R. Pinsky, Prof., MD, Dr hc
Laurent Brochard, MD, PhD
Jordi Mancebo, MD, PhD
Contents
1.2. Cardiovascular:
1. Physiological Notes
Pulmonary vascular resistance: A meaningless
variable? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
1.1 Pulmonary
RobertNaeije
1.1.1 Respiratory Mechanics
Pulmonary artery occlusion pressure . . . . . . . . . . . 49
Intrinsic (or auto-) positive end-expiratory pressure MichaelR.Pinsky
during controlled mechanical ventilation . . . . . . . . . 3
LaurentBrochard Clinical significance of pulmonary artery occlusion
pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Intrinsic (or auto-) positive end-expiratory pressure MichaelR.Pinsky
during spontaneous or assisted ventilation . . . . . . . . 7
LaurentBrochard Pulmonary capillary pressure . . . . . . . . . . . . . . . . 57
JukkaTakala
Work of breathing . . . . . . . . . . . . . . . . . . . . . . . . 11
BelenCabello,JordiMancebo Ventricular interdependence: how does it impact
on hemodynamic evaluation in clinical practice? . . . 61
Interpretation of airway pressure waveforms . . . . . . 15 FrançoisJardin
EvansR.Fernandez-Perez,RolfD.Hubmayr
Cyclic changes in arterial pressure during
1.1.2 Gas exchange mechanical ventilation . . . . . . . . . . . . . . . . . . . . . 65
FrançoisJardin
Dead space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
UmbertoLucangelo,luisBlanch
1.3. Metabolism and Renal Function
Alveolar ventilation and pulmonary blood flow: Lactic acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
The V/Q concept . . . . . . . . . . . . . . . . . . . . . . . . . 21 DanielDeBacker
A T
EnricoCalzia,PeterRadermacher
Defining renal failure: Physiological principles . . . . . 73
Mechanisms of hypoxemia . . . . . . . . . . . . . . . . . . 25 RinaldoBellomo,JohnA.Kellum,
RobertRodríguez-Roisin,JosepRoca ClaudioRonco
Pulse oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Hypotension during intermittent hemodialysis:
AmalJubran new insights into an old problem . . . . . . . . . . . . . . 79
FrédériqueSchortgen
Effects of body temperature on blood gases . . . . . . 33
AndreasBacher
1.4. Cerebral Function
Venous oximetry . . . . . . . . . . . . . . . . . . . . . . . . . 37 Intracranial pressure: Part one: Historical overview
FrankBloos,KonradReinhart and basic concepts . . . . . . . . . . . . . . . . . . . . . . . . 85
PeterJ.D.Andrews,GiuseppeCiterio
Influence of FO on the PO/FO ratio . . . . . . . . . . 41
I 2 a 2 I 2
JeromeAboab,BrunoLouis, Intracranial pressure: Part two: Clinical applications
BjörnJonson,LaurentBrochard and technology . . . . . . . . . . . . . . . . . . . . . . . . . . 89
PeterJ.D.Andrews,GiuseppeCiterio
VIII Contents
2. Physiological Reviews Acute right ventricular failure – from
pathophysiology to new treatments . . . . . . . . . . . . 217
AlexandreMebazaa,PeterKarpati,
2.1. Measurement techniques
EstelleRenaud,LarsAlgotsson
Fluid responsiveness in mechanically ventilated
patients: a review of indices used in intensive care . . 95 Red blood cell rheology in sepsis . . . . . . . . . . . . . 229
KarimBendjelid,Jacques-AndréRomand MichaelPiagnerelli,
KarimZouaoui-Boudjeltia,
Different techniques to measure intra-abdominal MichelVanhaeverbeek,Jean-LouisVincent
pressure (IAP): time for a critical re-appraisal . . . . . 105
ManuL.N.G.Malbrain Stress-hyperglycemia, insulin and
immunomodulation in sepsis . . . . . . . . . . . . . . . 239
Tissue capnometry: does the answer lie PaulE.Marik,MuruganRagavanh
under the tongue? . . . . . . . . . . . . . . . . . . . . . . . . 121
AlexandreToledoMaciel, Hypothalamic-pituitary dysfunction in critically
JacquesCreteur,Jean-LouisVincent ill patients with traumatic and nontraumatic brain
injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Noninvasive monitoring of peripheral perfusion . . . 131 IoannaDimopoulou,StylianosTsagarakis
AlexandreLima,JanBakker
Matching total body oxygen consumption and
Ultrasonographic examination of the venae cavae . . 143 delivery: a crucial objective? . . . . . . . . . . . . . . . . 259
AntoineVieillard-Baron,FrançoisJardin PierreSquara
Normalizing physiological variables in acute illness:
2.2. Physiological processes
five reasons for caution . . . . . . . . . . . . . . . . . . . . 269
Sleep in the intensive care unit . . . . . . . . . . . . . . . 147 BrianP.Kavanagh,L.JoanneMeyer
SAiramParthasarathy,MartinJ.Tobin
Magnesium in critical illness: metabolism, 3. Seminal Studies in Intensive Care
assessment, and treatment . . . . . . . . . . . . . . . . . . 157
LuisJ.Noronha,GeorgeM.Matuschak Manipulating afterload for the treatment of acute
heart failure: a historical summary . . . . . . . . . . . . 279
Pulmonary endothelium in acute lung injury: ClaudePerret,Jean-FrançoisEnrico
from basic science to the critically ill . . . . . . . . . . . . 171
stylianosEOrfanos,IreneMavrommati, Nosocomial pneumonia . . . . . . . . . . . . . . . . . . . 283
IonnaKorovesi,CharisRoussos WaldemarGJohanson,LisaL.Dever
Pulmonary and cardiac sequelae of subarachnoid The introduction of positive end-expiratory
haemorrhage: time for active management? . . . . . 185 pressure into mechanical ventilation:
CarolS. A.Macmillan, a retrospective . . . . . . . . . . . . . . . . . . . . . . . . . . 291
IanS.Grant,PeterAndrews KonradJ.Falke
Permissive hypercapnia-role in protective lung Elastic pressure-volume curves in acute lung injury
ventilatory strategies . . . . . . . . . . . . . . . . . . . . . . 197 and acute respiratory distress syndrome . . . . . . . . 295
JohnG.Laffey,DonalO’Croinin, BjörnJonson
PaulMcLoughlin,BrianP.Kavanagh
The concept of “baby lung” . . . . . . . . . . . . . . . . . 303
Right ventricular function and positive pressure LucianoGattinoni,AntonioPesenti
ventilation in clinical practice: from hemodynamic
subsets to respirator settings . . . . . . . . . . . . . . . . . 207 The effects of anesthesia and muscle paralysis on
AntoineVieillard-Baron,FrançoisJardin the respiratory system . . . . . . . . . . . . . . . . . . . . 313
GöranHedenstierna,LennartEdmark
Contents IX
Diaphragmatic fatigue during sepsis Organ dysfunction during sepsis . . . . . . . . . . . . . 345
and septic shock . . . . . . . . . . . . . . . . . . . . . . . . 323 SuveerSingh,TimothyW.Evans
SophieLanone,CamilleTaillé,
JorgeBoczkowski,MichelAubier Ventilator-induced lung injury: from the bench
to the bedside . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
The use of severity scores in the intensive care . . . . . 331 LorraineN.Tremblay,ArthurS.Slutsky
Jean-RogerLeGall
Remembrance of Weaning Past:
Oxygen transport-the oxygen delivery the Seminal Studies . . . . . . . . . . . . . . . . . . . . . . . 367
controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 MartinJ.Tobin
jean-LouisVincent,DanielDeBacker
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Contributors
Jérôme Aboab Karim Bendjelid
RéanimationMédicale Surgical Intensive CareDivision,
Hôpital HenriMondor GenevaUniversity Hospitals
Créteil,France 1211Geneva14, Switzerland
Lars Algotsson Lluis Blanch
Departmentof Anaesthesiology– Critical Care Center
Heart-LungDivision Hospitalde Sabadell
University HospitalofLund, ParcTaulis/n,08208 Sabadell, Spain
22185Lund, Sweden
Frank Bloos
Peter J.D. Andrews Klinikfür Anästhesiologieund Intensivtherapie
Departmentof Anaesthetics, Intensive KlinikumderFriedrich-Schiller-Universität
CareandPainMedicine Erlanger Allee101,07747Jena,Germany
Universityof Edinburgh,WesternGeneral Hospital
CreweRoad, EH42XU Edinburgh, Scotland,UK Jorge Boczkowski
INSERMU700and IFR02,Facult XavierBichat
Michel Aubier 16rue Henri Huchard,75018Paris,France
INSERMU700and IFR02,FacultXavierBichat
16rue Henri Huchard,75018Paris,France Laurent Brochard
RéanimationMédicale
Andreas Bacher Hôpital HenriMondor,
Departmentof Anesthesiology UniversitéParis12, INSERM
andGeneral Intensive Care U651,94010 Créteil,France
MedicalUniversityofVienna, AKH
WähringerGürtel18–20,1090Vienna, Austria Belen Cabello
Hospital Santa Creui SantPau,
Daniel De Backer ServiciodeMedicina Intensiva
Departmentof Intensive Care, Av/ Sant AntoniMaria Claret167,
ErasmeUniversity Hospital CP08025Barcelona, Spain
FreeUniversityofBrussels
RoutedeLennik808,1070Brussels,Belgium Enrico Calzia
Sektion AnästhesiologischePathophysiologie
Jan Bakker undVerfahrensentwicklungUniversitätsklinik
Departmentof Intensive Care, ErasmusMC für Anästhesiologie,UniversitätUlm
UniversityMedical CenterRotterdam Parkstrasse11,89070Ulm,Germany
P.O.Box2040,3000 CA
Rotterdam,The Netherlands Giuseppe Citerio
Neurorianimazione,Dipartimento
Rinaldo Bellomo di AnestesiaeRianimazione
Departmentof Intensive Care Nuovo Ospedale SanGerardo
andDivisionof Surgery ViaDonizetti106,20052Monza, Italy
Austin&RepatriationMedical Centre
3084 Heidelberg,Melbourne,Victoria, Australia Jacques Creteur
Departmentof Intensive Care,
ErasmeUniversity Hospital,Free
UniversityofBrussels
RoutedeLennik808,1070Brussels,Belgium
XII Contributors
Lisa L. Dever Göran Hedenstierna
UMDNJ-NewJerseyMedical School, ClinicalPhysiology,Departmentof
VA NewJersey Health Care System Medical Sciences,University Hospital
385Tremont, East Orange, NJ07018,USA 75185Uppsala, Sweden
Ioanna Dimopoulou Rolf D. Hubmayr
SecondDepartmentof Critical CareMedicine, Mayo Clinic CollegeofMedicine
Attikon Hospital,Medical School National Rochester55905,MN,USA
and KapodistrianUniversityof Athens
2Pesmazoglou Street,14561 François Jardin
Kifissia, Athens,Greece Hôpital AmbroiseParé,
ServicedeRéanimationMédicale,
Lennart Edmark 9avenue CharlesdeGaulle,
Departmentof Anesthesiaand Intensive Care 92104Boulogne,France
Central Hospital
72335Vasteras, Sweden Waldemar G. Johanson†
UMDNJ-NewJerseyMedical School
Jean-François Enrico 185 South Orange, Newark, NJ07018,USA
Former Chiefof Intensive CareUnit
Hôpitaldes Cadolles, Björn Jonson
Neuchâtel, Switzerland Departmentof ClinicalPhysiology
University HospitalofLund
Timothy W. Evans 22185Lund, Sweden
Imperial College SchoolofMedicine
Departmentof Intensive CareMedicine Amal Jubran
RoyalBrompton Hospital,London,UK DivisionofPulmonaryand Critical CareMedicine
Edward HinesJr.Veterans Affairs Hospital
Konrad J. Falke Route111 N, Hines, IL,60141,USA
Klinikfür Anaesthesiologyund
operative IntensivmedizinBerlin Peter Karpati
CampusVirchow Klinikum,Charite, Departmentof Anaesthesiology
Berlin,Germany and Critical CareMedicine
HopitalLariboisie`re,2Rue AmbroisePare
Evans R. Fernández Pérez 75475Paris Cedex10,France
Mayo Clinic CollegeofMedicine
Rochester55905,MN,USA Brian P. Kavanagh
Departmentof Critical CareMedicine,
Jean-Roger Le Gall Hospitalfor Sick Children
Departmentof Intensive CareMedicine 555University Avenue,Toronto,
Saint-LouisUniversity Hospital,Paris,France ONT,M5G1X8, Canada
Luciano Gattinoni John A. Kellum
Istitutodi AnestesiaeRianimazione Divisionof Critical CareMedicine, Scaife Hall
Fondazione IRCCS OspedaleMaggiorePoliclinico UniversityofPittsburghMedial Centre,
Mangiagalli,Regina Elenadi Terrace Street,Pittsburgh,PA 15260,USA
Milano,Universitàdegli Studi
ViaFrancesco Sforza35,20122Milan, Italy Ioanna Korovesi
Departmentof Critical Care&Pulmonary
Ian S. Grant Medicineand“M. Simou”Laboratory
Departmentof Anaesthesia, Medical School,Universityof
Universityof Edinburgh, Athens, Evangelismos Hospital
WesternGeneral Hospital, Edinburgh, 45–47 Ipsilandou St.,10675 Athens,Greece
Scotland,UK
