,M. 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
With 116 Figures and 21 Tables
123
,MICHAEL R. PINSKY, Prof., MD, Dr hc, FCCP, FCCM
University of Pittsburg Medical Center
Dep. of Critical Care Medicine
3550 Terrace Street
Pittsburgh, PA 15261
USA
LAURENT BROCHARD, MD JORDI MANCEBO, MD, PhD
Hôpital Henri Mondor Hospital de Sant Pau
Réanimation Médicale Servei Medicina Intensiva
51 av. Maréchal de Lattre de Tassigny Avda. S. Antonio M. Claret 167
94010 Créteil Cedex 08025 Barcelona
France Spain
The articles in this book appeared in the journal „Intensive Care Medicine“
between 2002 and 2006.
ISBN-10 3-540-37361-6 Springer-Verlag Berlin Heidelberg NewYork
ISBN-13 978-3-540-37361-2 Springer-Verlag Berlin Heidelberg NewYork
Library of Congress Control Number: 2006930741
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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, is at the limits of his or her physiologic reserve. Such patients need immediate,
aggressive but balanced life-altering interventions to minimize the detrimental aspects of
acute illness and hasten recovery. Treatment decisions and response to therapy are usually
assessed by measures of physiologic function, such as assessed by cardio-respiratory
monitoring. However, how one uses such information is often unclear and rarely
supported by prospective clinical trials. In reality, the bedside clinician is forced to rely
primarily on physiologic principles in determining the best treatments and response to
therapy. However, the physiologic foundation present in practicing physicians is uneven
and occasionally supported more by habit or prior training than science.
A series of short papers published in Intensive Care Medicine since 2002 under the
heading Physiologic Notes attempts to capture the essence of the physiologic perspectives
that underpin both our understanding of disease and response to therapy. This present
volume combines the complete list of these Physiologic Notes up until July 2006 with the
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
of applied physiology and underscore what is known and how measures and monitoring
interact with organ system function and response to therapy. This collection of physiologic
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
essential to the effective delivery of acute care medicine. Although this text can be read
from cover to cover, the reader is encouraged to use this text as a reference source reading
individual Physiologic Notes and Review articles as they pertain to specific clinical issues.
In that way the relevant information will have immediate practical meaning and hopefully
become incorporated into routine practice.
We hope that the reader finds these papers and reviews useful in their practice and enjoy
reading them as much as we enjoyed editing the original articles that it comprises.
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
Robert Naeije
1.1.1 Respiratory Mechanics
Pulmonary artery occlusion pressure . . . . . . . . . . . 49
Intrinsic (or auto-) positive end-expiratory pressure Michael R. Pinsky
during controlled mechanical ventilation . . . . . . . . . 3
Laurent Brochard Clinical significance of pulmonary artery occlusion
pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Intrinsic (or auto-) positive end-expiratory pressure Michael R. Pinsky
during spontaneous or assisted ventilation . . . . . . . . 7
Laurent Brochard Pulmonary capillary pressure . . . . . . . . . . . . . . . . 57
Jukka Takala
Work of breathing . . . . . . . . . . . . . . . . . . . . . . . . 11
Belen Cabello, Jordi Mancebo Ventricular interdependence: how does it impact
on hemodynamic evaluation in clinical practice? . . . 61
Interpretation of airway pressure waveforms . . . . . . 15 François Jardin
Evans R. Fernandez-Perez, Rolf D. Hubmayr
Cyclic changes in arterial pressure during
1.1.2 Gas exchange mechanical ventilation . . . . . . . . . . . . . . . . . . . . . 65
François Jardin
Dead space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Umberto Lucangelo, luis Blanch
1.3. Metabolism and Renal Function
Alveolar ventilation and pulmonary blood flow: Lactic acidosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
The VA/QT concept . . . . . . . . . . . . . . . . . . . . . . . . . 21 Daniel De Backer
Enrico Calzia, Peter Radermacher
Defining renal failure: Physiological principles . . . . . 73
Mechanisms of hypoxemia . . . . . . . . . . . . . . . . . . 25 Rinaldo Bellomo, John A. Kellum,
Robert Rodríguez-Roisin, Josep Roca Claudio Ronco
Pulse oximetry . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Hypotension during intermittent hemodialysis:
Amal Jubran new insights into an old problem . . . . . . . . . . . . . . 79
Frédérique Schortgen
Effects of body temperature on blood gases . . . . . . 33
Andreas Bacher
1.4. Cerebral Function
Venous oximetry . . . . . . . . . . . . . . . . . . . . . . . . . 37 Intracranial pressure: Part one: Historical overview
Frank Bloos, Konrad Reinhart and basic concepts . . . . . . . . . . . . . . . . . . . . . . . . 85
Peter J. D. Andrews, Giuseppe Citerio
Influence of FIO2 on the PaO2/FIO2 ratio . . . . . . . . . . 41
Jerome Aboab, Bruno Louis, Intracranial pressure: Part two: Clinical applications
Björn Jonson, Laurent Brochard and technology . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Peter J. D. Andrews, Giuseppe Citerio
,VIII Contents
2. Physiological Reviews Acute right ventricular failure – from
pathophysiology to new treatments . . . . . . . . . . . . 217
Alexandre Mebazaa, Peter Karpati,
2.1. Measurement techniques
Estelle Renaud, Lars Algotsson
Fluid responsiveness in mechanically ventilated
patients: a review of indices used in intensive care . . 95 Red blood cell rheology in sepsis . . . . . . . . . . . . . 229
Karim Bendjelid, Jacques-André Romand Michael Piagnerelli,
Karim Zouaoui-Boudjeltia,
Different techniques to measure intra-abdominal Michel Vanhaeverbeek, Jean-Louis Vincent
pressure (IAP): time for a critical re-appraisal . . . . . 105
Manu L. N. G. Malbrain Stress-hyperglycemia, insulin and
immunomodulation in sepsis . . . . . . . . . . . . . . . 239
Tissue capnometry: does the answer lie Paul E. Marik, Murugan Ragavanh
under the tongue? . . . . . . . . . . . . . . . . . . . . . . . . 121
Alexandre Toledo Maciel, Hypothalamic-pituitary dysfunction in critically
Jacques Creteur, Jean-Louis Vincent ill patients with traumatic and nontraumatic brain
injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Noninvasive monitoring of peripheral perfusion . . . 131 Ioanna Dimopoulou, Stylianos Tsagarakis
Alexandre Lima, Jan Bakker
Matching total body oxygen consumption and
Ultrasonographic examination of the venae cavae . . 143 delivery: a crucial objective? . . . . . . . . . . . . . . . . 259
Antoine Vieillard-Baron, François Jardin Pierre Squara
Normalizing physiological variables in acute illness:
2.2. Physiological processes
five reasons for caution . . . . . . . . . . . . . . . . . . . . 269
Sleep in the intensive care unit . . . . . . . . . . . . . . . 147 Brian P. Kavanagh, L. Joanne Meyer
SAiram Parthasarathy, Martin J. Tobin
Magnesium in critical illness: metabolism, 3. Seminal Studies in Intensive Care
assessment, and treatment . . . . . . . . . . . . . . . . . . 157
Luis J. Noronha, George M. Matuschak Manipulating afterload for the treatment of acute
heart failure: a historical summary . . . . . . . . . . . . 279
Pulmonary endothelium in acute lung injury: Claude Perret, Jean-François Enrico
from basic science to the critically ill . . . . . . . . . . . . 171
stylianos E Orfanos, Irene Mavrommati, Nosocomial pneumonia . . . . . . . . . . . . . . . . . . . 283
Ionna Korovesi, Charis Roussos Waldemar G Johanson, Lisa L. Dever
Pulmonary and cardiac sequelae of subarachnoid The introduction of positive end-expiratory
haemorrhage: time for active management? . . . . . 185 pressure into mechanical ventilation:
Carol S. A. Macmillan, a retrospective . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Ian S. Grant, Peter Andrews Konrad J. Falke
Permissive hypercapnia-role in protective lung Elastic pressure-volume curves in acute lung injury
ventilatory strategies . . . . . . . . . . . . . . . . . . . . . . 197 and acute respiratory distress syndrome . . . . . . . . 295
John G. Laffey, Donal O’Croinin, Björn Jonson
Paul McLoughlin, Brian P. Kavanagh
The concept of “baby lung” . . . . . . . . . . . . . . . . . 303
Right ventricular function and positive pressure Luciano Gattinoni, Antonio Pesenti
ventilation in clinical practice: from hemodynamic
subsets to respirator settings . . . . . . . . . . . . . . . . . 207 The effects of anesthesia and muscle paralysis on
Antoine Vieillard-Baron, François Jardin the respiratory system . . . . . . . . . . . . . . . . . . . . 313
Göran Hedenstierna, Lennart Edmark
, Contents IX
Diaphragmatic fatigue during sepsis Organ dysfunction during sepsis . . . . . . . . . . . . . 345
and septic shock . . . . . . . . . . . . . . . . . . . . . . . . 323 Suveer Singh, Timothy W. Evans
Sophie Lanone, Camille Taillé,
Jorge Boczkowski, Michel Aubier Ventilator-induced lung injury: from the bench
to the bedside . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
The use of severity scores in the intensive care . . . . . 331 Lorraine N. Tremblay, Arthur S. Slutsky
Jean-Roger Le Gall
Remembrance of Weaning Past:
Oxygen transport-the oxygen delivery the Seminal Studies . . . . . . . . . . . . . . . . . . . . . . . 367
controversy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 Martin J. Tobin
jean-Louis Vincent, Daniel De Backer
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
,Contributors
Jérôme Aboab Karim Bendjelid
Réanimation Médicale Surgical Intensive Care Division,
Hôpital Henri Mondor Geneva University Hospitals
Créteil, France 1211 Geneva 14, Switzerland
Lars Algotsson Lluis Blanch
Department of Anaesthesiology– Critical Care Center
Heart-Lung Division Hospital de Sabadell
University Hospital of Lund, Parc Taulis/n, 08208 Sabadell, Spain
22185 Lund, Sweden
Frank Bloos
Peter J. D. Andrews Klinik für Anästhesiologie und Intensivtherapie
Department of Anaesthetics, Intensive Klinikum der Friedrich-Schiller-Universität
Care and Pain Medicine Erlanger Allee 101, 07747 Jena, Germany
University of Edinburgh, Western General Hospital
Crewe Road, EH4 2XU Edinburgh, Scotland, UK Jorge Boczkowski
INSERM U 700 and IFR 02, Facult Xavier Bichat
Michel Aubier 16 rue Henri Huchard, 75018 Paris, France
INSERM U 700 and IFR 02, Facult Xavier Bichat
16 rue Henri Huchard, 75018 Paris, France Laurent Brochard
Réanimation Médicale
Andreas Bacher Hôpital Henri Mondor,
Department of Anesthesiology Université Paris 12, INSERM
and General Intensive Care U651, 94010 Créteil, France
Medical University of Vienna, AKH
Währinger Gürtel 18–20, 1090 Vienna, Austria Belen Cabello
Hospital Santa Creu i Sant Pau,
Daniel De Backer Servicio de Medicina Intensiva
Department of Intensive Care, Av/ Sant Antoni Maria Claret 167,
Erasme University Hospital CP 08025 Barcelona, Spain
Free University of Brussels
Route de Lennik 808, 1070 Brussels, Belgium Enrico Calzia
Sektion Anästhesiologische Pathophysiologie
Jan Bakker und Verfahrensentwicklung Universitätsklinik
Department of Intensive Care, Erasmus MC für Anästhesiologie, Universität Ulm
University Medical Center Rotterdam Parkstrasse 11, 89070 Ulm, Germany
P.O. Box 2040, 3000 CA
Rotterdam, The Netherlands Giuseppe Citerio
Neurorianimazione, Dipartimento
Rinaldo Bellomo di Anestesia e Rianimazione
Department of Intensive Care Nuovo Ospedale San Gerardo
and Division of Surgery Via Donizetti 106, 20052 Monza, Italy
Austin & Repatriation Medical Centre
3084 Heidelberg, Melbourne, Victoria, Australia Jacques Creteur
Department of Intensive Care,
Erasme University Hospital, Free
University of Brussels
Route de Lennik 808, 1070 Brussels, Belgium
, XII Contributors
Lisa L. Dever Göran Hedenstierna
UMDNJ-New Jersey Medical School, Clinical Physiology, Department of
VA New Jersey Health Care System Medical Sciences, University Hospital
385 Tremont, East Orange, NJ 07018, USA 75185 Uppsala, Sweden
Ioanna Dimopoulou Rolf D. Hubmayr
Second Department of Critical Care Medicine, Mayo Clinic College of Medicine
Attikon Hospital, Medical School National Rochester 55905, MN, USA
and Kapodistrian University of Athens
2 Pesmazoglou Street, 14561 François Jardin
Kifissia, Athens, Greece Hôpital Ambroise Paré,
Service de Réanimation Médicale,
Lennart Edmark 9 avenue Charles de Gaulle,
Department of Anesthesia and Intensive Care 92104 Boulogne, France
Central Hospital
72335 Vasteras, Sweden Waldemar G. Johanson †
UMDNJ-New Jersey Medical School
Jean-François Enrico 185 South Orange, Newark, NJ 07018, USA
Former Chief of Intensive Care Unit
Hôpital des Cadolles, Björn Jonson
Neuchâtel, Switzerland Department of Clinical Physiology
University Hospital of Lund
Timothy W. Evans 22185 Lund, Sweden
Imperial College School of Medicine
Department of Intensive Care Medicine Amal Jubran
Royal Brompton Hospital, London, UK Division of Pulmonary and Critical Care Medicine
Edward Hines Jr. Veterans Affairs Hospital
Konrad J. Falke Route 111 N, Hines, IL, 60141, USA
Klinik für Anaesthesiology und
operative Intensivmedizin Berlin Peter Karpati
Campus Virchow Klinikum,Charite, Department of Anaesthesiology
Berlin, Germany and Critical Care Medicine
Hopital Lariboisie`re, 2 Rue Ambroise Pare
Evans R. Fernández Pérez 75475 Paris Cedex 10, France
Mayo Clinic College of Medicine
Rochester 55905, MN, USA Brian P. Kavanagh
Department of Critical Care Medicine,
Jean-Roger Le Gall Hospital for Sick Children
Department of Intensive Care Medicine 555 University Avenue, Toronto,
Saint-Louis University Hospital, Paris, France ONT, M5G 1X8, Canada
Luciano Gattinoni John A. Kellum
Istituto di Anestesia e Rianimazione Division of Critical Care Medicine, Scaife Hall
Fondazione IRCCS Ospedale Maggiore Policlinico University of Pittsburgh Medial Centre,
Mangiagalli, Regina Elena di Terrace Street, Pittsburgh, PA 15260, USA
Milano, Università degli Studi
Via Francesco Sforza 35, 20122 Milan, Italy Ioanna Korovesi
Department of Critical Care & Pulmonary
Ian S. Grant Medicine and “M. Simou” Laboratory
Department of Anaesthesia, Medical School, University of
University of Edinburgh, Athens, Evangelismos Hospital
Western General Hospital, Edinburgh, 45–47 Ipsilandou St., 10675 Athens, Greece
Scotland, UK
