Surgical Intensive Care Medicine Surgical Intensive Care Medicine

SURGICAL INTENSIVE CARE MEDICINE SURGICAL INTENSIVE CARE MEDICINE

EDITORS

JOHN MERRITT O'DONNELL, M.D. Director, Surgical Intensive Care Unit Chairman, Department ofSurgical Critical Care Lahey Clinic Medical Center Burlington, MA USA

FLAVIO EDUARDO NAcUL, M.D. Senior Fellow Department ofSurgical Critical Care Lahey Clinic Medical Center Burlington, MA USA

SPRINGER SCIENCE+BUSINESS MEDIA, LLC Library of Congress Cataloging-in-Publication Data

Surgical intensive care medicine I editors, John Merritt O'Donnell, Flävio Eduardo Näcul. p. ;cm. Includes bibliographical references and index. ISBN 978-1-4757-6647-9 ISBN 978-1-4757-6645-5 (eBook) DOI 10.1007/978-1-4757-6645-5

1. Surgical intensive care. 2. Critical care medicine. I. O'Donnell, John Merritt. II. Nacul, Flävio Eduardo. [DNLM: 1. Postoperative Care--methods. 2. Intensive Care--methods. WO 183 S9614 2001] RD49 .S875 2001 617'.919--dc21 2001029713

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, mechanical, photo-copying, recording, or otherwise, without the prior written permission of the publisher, Springer Science+Business Media, LLC.

Printedon acid-free paper.

Although every effort has been made to ensure that drug doses and other information are presented accurately in this publication, the ultimate responsibility rests with the prescribing physician. Neither the publishers nor the authors can be held responsible for errors or for any consequences arising from the use of information contained herein. Products mentioned in this publication should be used in accordance with the prescribing information prepared by the manufacturers. No claims or endorsements are made for any drug or compound at present under clinical investigation. This book is dedicated to my beloved parents, Kay and Frank "Shorty" 0 'Donnell. Their time has passed, but their spirit is everlasting.

And to my wife, Rocky, and daughter, Jacquelyn, who put it all in its proper place.

JMO'D

To my parents with love

FEN TABLE OF CONTENTS

SECTION 1: RESUSCITATION

1 OXYGEN THERAPY 3 Andrew G. Villanueva 2 AIRWAY MANAGEMENT 23 Marc J Popovich 3 VASCULAR CANNULATION 37 J Esteban Varela, Albert J Varon

4 FLUID RESUSCITATION 51 Joseph R. Fontana, Thomas G. Rainey 5 SHOCK 71 Sneeta Takhar, Myer H Rosenthal 6 VASOACTIVE AMINES AND INOTROPIC AGENTS 97 Keith P. Lewis, R. Mauricio Gonzalez 7 EVALUATION OF HEMODYNAMICS AND OXYGEN DELIVERY 109 David A. Kaufman 8 ACID-BASE BALANCE AND BLOOD GAS INTERPRETATION 131 M Fareed Azam, William T. Peruzzi 9 ANALGESIAAND SEDATION 147 JeanKwo

10 NEUROMUSCULAR BLOCKING AGENTS 163 Rafael A. Ortega, Ruben Azocar VIII Table ofContents

11 CARDIOPULMONARY RESUSCITATION 181 Ernest F. J. Block, Jay L. Falk

SECTION 2: NEUROLOGYINEUROSURGERY

12 HEAD INmRIES 195 Jack E. Wilberger

13 SPINAL CORD INmRIES 205 Fred H Geisler

14 ISCHEMIC STROKE 219 Jamary Oliveira-Filho, Walter J. Koroshetz

15 HEMORRHAGIC STROKE 243 Jamary Oliveira-Filho, Walter J. Koroshetz

16 INTRACRANIAL HYPERTENSION 259 Romergryko G. Geocadin, Michael A. Williams, Daniel F. Hanley

SECTION 3: CARDIOLOGY

17 POSTOPERATIVE MYOCARDIAL INFARCTION 277 Glynne D. Stanley, Sundara Rengasamy

18 POSTOPERATIVE ARRHYTHMIAS 293 Mikhail Torosoff, Ferdinand J. Venditti, Jr.

19 POSTOPERATIVE HYPERTENSION 311 Robert N Sladen Surgical Intensive Care Medicine IX

SECTION 4: PULMONARY MEDICINE

20 ACUTE RESPIRATORY FAILURE 333 Lawrence J. Caruso, T James Gallagher

21 MECHANICAL VENTILATION 345 Neil T Bennett, T James Gallagher

22 VENOUS THROMBOEMBOLISM 363 Andrew G. Villanueva

23 FAT EMBOLISM SYNDROME 385 John M 0 'Donnell

24 VENOUS AIR EMBOLISM 397 Carl J. Borromeo

SECTION 5: INFECTIOUS DISEASES

25 SEPSIS 411 Geoffrey M Clarke

26 CATHETER-RELATED INFECTION 435 Shubjeet Kaur, Stephen O. Heard

27 VENTILATOR-ASSOCIATED PNEUMONIA 451 Anthony W. Gray, Jr.

28 INTRA-ABDOMINAL SEPSIS 461 Peter W. Marcello

29 EVALUATION OF THE FEBRILE PATIENT 471 Ellen Riccobene, Richard Gleckman x Table of Contents

30 PRINCIPLES OF ANTIBIOTIC THERAPY 483 Ellen Riccobene, Richard Gleckman

SECTION 6: HEMATOLOGY

31 COAGULOPATHIC STATES 495 Charise T. Petrovitch, John C. Drummond 32 BLOOD PRODUCTS 515 William D. Hoffman

SECTION 7: METABOLISM AND NUTRITION

33 POSTOPERATIVE MANAGEMENT OF DIABETES 533 Byron Unger, Douglas B. Coursin

34 ADRENAL INSUFFICIENCY 547 Gary P. Zaloga, Paul Marik 35 ENTERAL NUTRITION 559 Susan E. Schaefer 36 PARENTERAL NUTRITION 575 James J Pomposelli

SECTION 8: NEPHROLOGY AND ELECTROLYTES

37 ACUTE RENAL FAILURE 591 Rinaldo Bellomo, Claudio Ronco 38 DIALYTIC THERAPY 601 Rinaldo Bellomo, Claudio Ronco Surgical Intensive Care Medicine Xl

39 DISORDERS OF SODIUM AND POTASSIUM 611 Flavio E. Nacui 40 DISORDERS OF MAGNESIUM, CALCIUM, AND PHOSPHORUS 621 Flavio E. Nacu/

SECTION 9: GASTROENTEROLOGY

41 ACUTE GASTROINTESTINAL HEMORRHAGE 633 Ronald F Martin

42 ACUTE PANCREATITIS 645 Ronald F. Martin

SECTION 10: SURGERY, TRAUMA, AND TRANSPLANTATION

43 BURNS 661 Larry M Jones 44 TRAUMA 675 Michael S. Rosenblatt

45 THE ABDOMINAL COMPARTMENT SYNDROME 689 James M Doly, Jun Oda, Rao R. Ivatury, Harvey J. Sugerman

46 RHABDOMYOLYSIS 699 Frank Tull, Joseph Borrelli, Jr. 47 POSTOPERATIVE CARE OF THE CARDIAC SURGICAL PATIENT 705 Ross F. DiMarco, Jr. XII Table of Contents

48 POSTOPERATIVE CARE OF THE HEART TRANSPLANT PATIENT 741 Nicholas R. Banner, Michael J. Boscoe, Asghar Khaghani

49 POSTOPERATIVE CARE OF THE LUNG TRANSPLANT PATIENT 761 Janet R. Maurer 50 POSTOPERATIVE CARE OF THE LIVER TRANSPLANT PATIENT 775 Elizabeth A. Pomfret, James J. Pomposelli 51 CARE OF THE ORGAN DONOR 795 Joseph M Darby

SECTION 11: ADDITIONAL TOPICS

52 HYPERSENSITIVITY REACTIONS 807 Maged S. Mikhail, Delbert R. Black

53 DISORDERS OF THERMOREGULATION 825 Michael H Entrup, Sana Ata

54 SCORING SYSTEMS AND OUTCOME PREDICTION 853 Keith L. Stein 55 TRANSPORT 867 Marc J. Shapiro

APPENDIX WORLD WIDE WEB (WWW) CRITICAL CARE INTERNET SITES 881

INDEX 883 CONTRIBUTORS

SANAATA, M.D. ERNEST F. J. BWCK, M.D., F.A.C.S., Assistant Clinical Professor F.C.C.M of Anesthesiology Clinical Assistant Professor of Surgery Tufts University School of Medicine University of Florida College of Medicine Director, Liver Transplant Anesthesia Assistant Director of Trauma Services Lahey Clinic Medical Center Director, Trauma Quality Services Burlington, MA USA Orlando Regional Medical Center Orlando, FL USA M. FAREED AZAM, M.D. Assistant Professor JOSEPH BORRELLI, Jr., M.D. Department of Anesthesiology Assistant Professor University of Colorado Health Department of Orthopedic Surgery Science Center Washington University School of Medicine Denver, CO USA Saint Louis, MO USA

RUBEN AZOCAR, M.D. CARL J. BORROMEO, M.D. Chief Resident Assistant Clinical Professor of Anesthesiology Department of Anesthesiology Tufts University School of Medicine Boston University Medical Center Staff Anesthesiologist Boston, MA USA Department of Anesthesiology Lahey Clinic Medical Center NICHOLAS R. BANNER, F.R.C.P. Burlington, MA USA Consultant Cardiologist and Transplant Physician MICHAEL J. BOSCOE, F.R.C.A. Royal Brompton and Harefield NHS Trust Consultant Anaesthesist Harefield, Middlesrx, UK Royal Brompton and Harefield NHS Trust Harefield, Middlesex, UK RINALDO BELLOMO, M.D. Associate Professor of Medicine LAWRENCE J. CARUSO, M.D. University of Melbourne Assistant Professor of Anesthesiology Director of Intensive Care Research Staff Anesthesiologist Austin & Repatriation Medical Centre College of Medicine Melbourne, Australia University of Florida Gainesville, FL USA NEIL T. BENNETT, M.D. Staff Anesthesiologist GEOFFREY M. CLARKE, M.D., M.B.B.S. Medical Director of Respiratory Services Head, Intensive Care Unit Assistant Professor of Anesthesiology Director, Division of Critical Care College of Medicine Royal Perth Hospital University of Florida Perth, Western Australia Gainesville, FL USA DOUGLAS B. COURSIN, M.D. DELBERT R. BLACK, M.S., M.D. Professor of Anesthesiology and Internal Medicine Resident in Anesthesia Associate Director of the Trauma and Life Department of Anesthesia Support Center and Critical Care University of Wisconsin Hospitals and School Massachusetts General Hospital of Medicine Boston, MA USA Madison, WI USA XIV Contributors

JOSEPH M. DARBY, M.D. T. JAMES GALLAGHER, M.D. Associate Professor of Anesthesiologyl Professor of Anesthesiology and Surgery Critical Care Chief, Critical Care Medicine University of Pittsburgh School of Medicine College of Medicine Medical Director, Trauma/Surgical Intensive University of Florida Care Unit Gainesville, FL USA UPMC - Presbyterian University Hospital Pittsburgh, PA USA FRED H. GEISLER, M.D. Assistant Professor of Surgery ROSS F. DiMARCO, Jr., M.D. Rush University Chief, Cardiovascular Surgery Director of Complex Spine Surgery Mercy Hospital of Pittsburgh Chicago Institute of Neurosurgery and Pittsburgh, PA USA Neuroresearch Chicago, lL USA JAMES M. DOTY, M.D. Generalffrauma Surgery Division ROMERGRYKO G. GEOCADlN, M.D. Department of Surgery Instructor of Neurology Medical College of Virginia Neurosciences Critical Care Division Virginia Commonwealth University Johns Hopkins University School of Medicine Richmond, VA USA Baltimore, MD USA

JOHN C. DRUMMOND, M.D. RICHARD GLECKMAN, M.D., F.A.C.P. Professor and Chair Clinical Professor of Medicine Department of Anesthesiology Mt. Sinai School of Medicine UCSD Medical Center Chairman, Department of Medicine San Diego, CA USA Residency Program Director Chief, Infectious Disease MICHAEL H. ENTRUP, M.D. St. Joseph's Hospital & Medical Center Assistant Clinical Professor of Paterson, NJ USA Anesthesiology Tufts University School of Medicine RAFAEL MAURICIO GONZALEZ, M.D. Director, Cardiac Anesthesia Fellow, Cardiothoracic and Vice-Chairman, Department Vascular Anesthesia of Anesthesiology Department of Anesthesia Lahey Clinic Medical Center Boston University Medical Center Burlington, MA USA Boston, MA USA

JAY L. FALl(, M.D., F.A.C.E.P., ANTHONY W. GRAY, Jr., M.D. F.C.C.M. Assistant Professor of Medicine Clinical Professor, Tufts University Medical School Department of Medicine Associate Director, Surgical Intensive Care Unit and Emergency Medicine Department of Surgical Critical Care University of Florida College of Medicine Staff Physician Academic Chairman, Department of Department of Pulmonary and Critical Care Emergency Medicine Lahey Clinic Medical Center Orlando Regional Healthcare Burlington, MA USA Orlando, FL USA DANIEL F. HANLEY, M.D. JOSEPH R. FONTANA, M.D. Jeffrey and Harriet Legum Professor of Acute Staff Intensivist Care Neurology Clinical Coordinator, Fellowship Program Department of Neurology Critical Care Medicine Johns Hopkins University School Suburban Hospital of Medicine Bethesda, MD USA Baltimore, MD USA Surgical Intensive Care Medicine xv

STEPHEN O. HEARD, M.D. WALTER KOROSHETZ. M.D. Professor of Anesthesiology and Surgery Associate Professor of Neurology University of Massachusetts Harvard Medical School Medical School Associate Director Co-Director, Surgical Intensive Care Units Stroke and Clinical Neurology Services University of Massachusetts Medical Center Medical Director Worcester, MA USA Stroke and Neurointensive Care Massachusetts General Hospital WILLIAM D. HOFFMAN, M.D. Boston, MA USA Associate Professor of Surgery Harvard Medical School JEAN KWO, M.D. Director, Cardiothoracic Instructor of Anesthesia Intensive Care Unit Harvard Medical School Massachusetts General Hospital Assistant in Anesthesia Boston, MA USA Department of Anesthesia and Critical Care Massachusetts General Hospital RAO R. IVATURY, M.D. Boston, MA USA Professor of Surgery & Emergency Medicine Virginia Commonwealth University KEITH P. LEWIS, M.D., R.Ph. Director of Trauma and Critical Care Associate Professor and Chairman Medical College of Virginia Hospitals Department of Anesthesiology Richmond, VA USA Boston University Medical Center Boston, MA USA LARRY M. JONES. M.D.• F.A.C.S. Director, Trauma Services PETER W. MARCELLO, M.D. and Burn Center Assistant Professor of Surgery Chief, Division of Multisystem Trauma Tufts University School of Medicine Department of Surgery Staff Surgeon The Mercy Hospital of Pittsburgh Department of Colorectal Surgery Pittsburgh, PA USA Lahey Clinic Medical Center Burlington, MA USA DAVID A. KAUFMAN, M.D. Associate Professor of Medicine PAUL MARIK, M.D. University of Massachusetts Director, Medical Intensive Care Unit Medical School Department of Medicine Chief, Department of Critical Care Medicine Washington Hospital Center st. Vincent Hospital Washington, DC USA Worcester, MA USA JANET R. MAURER, M.D. SHUBJEET KAUR, M.D. Head, Section of Advanced Lung Disease and Assistant Professor of Anesthesiology Lung Transplantation University of Massachusetts Department of Pulmonary and Critical Care Medical School Medicine Vice-Chair, Clinical Affairs Medical Director, Transplant Center Co-Medical Director, Operative Services The Cleveland Clinic Foundation University of Massachusetts Memorial Cleveland, OH USA Medical Center Worcester, MA USA RONALD F. MARTIN, M.D. Clinical Associate Professor of Surgery ASGHANI KHAGHANI, F.R.e.S. University of Vermont Consultant Cardiac and Staff Surgeon Transplant Surgeon Department of Surgery Royal Brompton and Harefield NHS Trust Maine Medical Center and Mercy Hospital Harefield, Middlesex, UK Portland, ME USA XVI Contributors

MAGED S. MIKHAIL, M.D. ELIZABETH A. POMFRET, M.D., Ph.D. Professor of Clinical Anesthesiology and Assistant Professor of Surgery Surgery Tufts University School of Medicine Keck School of Medicine Director, Adult Living Donor Liver University of Southern California Transplantation Los Angeles, CA USA Department ofHepatobiliary and Liver Transplantation FLAVIO E. NAcUL, M.D. Lahey Clinic Medical Center Senior Fellow Burlington, MA USA Department of Surgical Critical Care Division of Surgery JAMES J. POMPOSELLI, M.D., Ph.D. Lahey Clinic Medical Center Assistant Professor of Surgery Burlington, MA USA Tufts University School of Medicine Staff Surgeon JUN ODA, M.D., Ph.D. Co-Director, Nutrition Support Service Research Fellow Department ofHepatobiliary and Liver Generalffrauma Surgery Division Transplantation Department of Surgery Lahey Clinic Medical Center Medical College of Virginia Burlington, MA USA Virginia Commonwealth University Richmond, VA USA MARC J. POPOVICH, M.D. Staff AnesthesiologistlTntensivist JOHN M. O'DONNELL, M.D. Surgical Intensive Care Unit Director, Surgical Intensive Care Unit Division of Anesthesiology and Critical Chairman, Department of Surgical Care Medicine Critical Care The Cleveland Clinic Foundation Division of Surgery Cleveland, OH USA Lahey Clinic Medical Center Burlington, MA USA THOMAS G. RAINEY, M.D., F.C.C.M. President, Critical Med Incorporated JAMARY OLIVEIRA-FILHO, M.D. Director, Critical Care Medicine Senior Fellow Suburban Hospital Stroke and Neurointensive Care Bethesda, MD USA Massachusetts General Hospital Boston, MA USA SUNDARA RENGASAMY, M.D. Research Resident RAFAEL A. ORTEGA, M.D. Department of Anesthesiology Associate Professor of Anesthesiology Boston University Medical Center Vice-Chairman, Department of Anesthesiology Boston, MA USA Boston University Medical Center Boston, MA USA ELLEN RICCOBENE, M.D. Associate Program Director for Internal WILLIAM T. PERUZZI, M.D. Medicine Associate Professor of Anesthesiology St. Joseph's Hospital & Medical Center Chief, Section of Critical Care Medicine Paterson, NJ USA Department of Anesthesiology Northwestern University Medical School CLAUDIO RONCO, M.D. Chicago, IL USA Visiting Professor of Medicine Renal Research Institute and CHARISE T. PETROVITCH, M.D. Renal Research Laboratory Director Chairman and Director Division of Nephrology and Hypertension Department of Anesthesiology Beth Israel Medical Center Providence Hospital Albert Einstein College of Medicine Washington, D.C. USA New York, NY USA Surgical Intensive Care Medicine XVI!

MICHAEL S. ROSENBLATT, M.D., HARVEY J. SUGERMAN, M.D. F.A.C.S. Professor of Surgery Associate Clinical Professor of Surgery Department of Surgery Tufts University School of Medicine General!frauma Surgery Division Associate Director, Surgical Intensive Medical College of Vitginia Care Unit Virginia Commonwealth University Director, Trauma Service Richmond, VA USA Lahey Clinic Medical Center Burlington, MA USA SNEETA TAKHAR, M.D. Fellow MYER ROSENTHAL, M.D. Critical Care Medicine Professor of Anesthesia. Medicine, Stanford University School of Medicine and Surgery Stanford, CA USA Stanford University School of Medicine Stanford, CA USA MIKHAIL TOROSOFF, M.D. Senior Fellow SUSAN E. SCHAEFER, M.S., R.D., Department of Cardiology C.N.S.D. Albany Medical College Clinical Dietitian Albany, NY USA Lahey Clinic Medical Center Burlington, MA USA FRANK TULL, M.D. Resident MARC J. SHAPIRO, M.D. Department of Orthopedic Surgery Professor of Surgery and Trauma Washington University School Director, Trauma Services of Medicine Department of Surgery Saint Louis, MO USA Division of General Surgery Section of Trauma BYRON UNGER, M.D., F.R.c.P.c. Saint Louis University Clinical Assistant Professor Saint Louis, MO USA Department of Anesthesiology and Pain Medicine ROBERT N. SLADEN, M.D. University of Alberta Professor and Vice-Chair Edmonton, Alberta. Canada Department of Anesthesiology Director, Cardiothoracic Intensive J. ESTEBAN VARELA, M.D. Care Unit Resident College of Physicians and Surgeons General Surgery Columbia University Department of Surgery New York, NY USA University of Illinois at Chicago Hospital Chicago, IL USA GLYNNE D. STANLEY, M.B, ChB., F.R.C.A. ALBERT J. VARON, M.D. Assistant Professor of Anesthesiology Professor and Director Boston University School of Medicine Division of Trauma Anesthesia & Program Director Critical Care Anesthesiology Residency Program Department of Anesthesiology Boston Medical Center University of Miami School of Medicine Boston, MA USA Miami, FL USA

KEITH L. STEIN, M.D. F.C.C.M., FERDINAND J. VENDITTI, Jr., M.D. F.c.c.P. Richard T. Beebe, Professor and Chairman Vice President, Clinical Effectiveness Department of Medicine Baptist Medical Center and Health System Albany Medical Center Jacksonville, FL USA Albany, NY USA XVIII Contributors

ANDREW G. VILLANUEVA, M.D. Assistant Clinical Professor of Medicine Tufts University School of Medicine Director, Medical Intensive Care Unit Department of Pulmonary and Critical Care Medicine Lahey Clinic Medical Center Burlington, MA USA

JACK E. WILBERGER, M.D. Professor and Acting Chairman of Neurosurgery Vice Dean, Medical College of Pennsylvania Hahnemann School of Medicine Director of Neurotrauma Allegheny General Hospital Pittsburgh, PA USA

MICHAEL A. WILLIAMS, M.D. Assistant Professor of Neurology and Neurosurgery Neurosciences Critical Care Division Johns Hopkins University School of Medicine Baltimore, MD USA

GARY P. ZALOGA, M.D. Director, Critical Care Medicine Department of Medicine Washington Hospital Center Washington, DC USA FOREWORD

An internist/anesthesiologist editing a textbook on Surgical Critical Care? Another textbook on Critical Care? While some might think these are valid questions, I believe that this book fills an important void. Surgeons in the past were both capable of and had the time to manage their patients after surgery, but the increasing complexity of technical procedures performed in elderly patients with many co• morbidities in some ways has limited the surgeon's ability to continue this tradition. In addition, we are all well aware of the increasing demands on everyone's time, so that the prolonged management of the complicated postoperative surgical patient is just not feasible for the busy surgeon. There are only a limited number of physicians trained in Critical Care and, of that number, only approximately 20% have a background of surgical training. Thus, many patients' care will be largely or completely provided by nonintensivists, and internists and anesthesiologists will make up a large percentage of these physicians.

Having known Dr. O'Donnell since his Fellowship in Surgical Critical Care in 1980 at the University of Miami Jackson Memorial Medical Center, I can attest that he indeed followed the adage he quoted, "You've gotta learn to walk before you can run." He therefore understands from the perception of an internist what supplemental information is necessary in order to enable the intensivist to provide excellent care to the critically ill surgical patient. By presenting the "bottom line" information and referencing botp the journal articles and other critical care textbooks, this book should be a valuable resource for all entry level providers and particularly for physicians at all levels who decide to venture into collaborative management of the surgical critical care patient. I believe that this book will help the new practitioner find solid initial footing in this new environment and also provide a bridge to other works necessary to develop a deeper understanding of this complex field.

It is a pleasure to see limited and clearly defined objectives attained as I review this book. It is also personally quite special to see a friend, to quote a newer adage, not only ''talk the talk," but also, as he has amply demonstrated for over 20 years, "walk the walk."

Joseph M. Civetta, M.D. Professor and Chairman Department ofSurgery, University of Connecticut School ofMedicine Director ofSurgery, Hartford Hospital Hartford, Connecticut PREFACE

Surgical Intensive Care Medicine has been specifically designed to be a practical reference for medical students and house officers to help manage the critically ill surgical patient. The structure of this textbook is based on the old adage, "you've gotta learn to walk before you can run." The first section is titled "Resuscitation" and exposes the reader to a condensed version of generic topics in primary intensive care medicine. The sections that follow have been categorized according to medical and surgical sub specialties and cover the most germane of problems encountered in a tertiary surgical intensive care unit.

Sections of certain chapters, while repetitive, have been left intact in an attempt to maintain the authors' messages and provide the reader with some contradictory but referenced views. The technical chapters describe a very introductory approach to various exercises such as airway management and vascular cannulation. It is the opinion of the editors that written or spoken instructions can never replace personal observation and supervised "hands-on" experience when learning to perform procedures. Organizational, fmancial, and ethical dilemmas surrounding intensive care medicine are of enormous proportions, and space constraints make it impossible to introduce the young reader to the complexity of the issues at hand. Readers are referred to the numerous textbooks on these SUbjects.

It is the sincere hope of the editors that this manuscript will provide physicians, medical students, nurses, and paramedical personnel with the information necessary to confidently initiate and maintain care of the critically ill surgical patient. The editors further hope that by becoming familiar with the contents of this textbook, the reader's curiosity will be stimulated to pursue the ever-changing knowledge base of surgical intensive care medicine.

John Merritt O'Donnell, M.D. Fhivio Eduardo Nacul, M.D. ACKNOWLEDGEMENTS

We would first and foremost like to thank Barbara Murphy and Kluwer Academic Publishing Company for giving us the opportunity to publish this textbook. We are indebted to Lynda Charters of Medical International for copy editing and organizing the text and for her relentless encouragement during the course of this project. We are forever grateful to Maria Fernanda Gamba for formatting the entire manuscript. We thank Carol Spencer, the Lahey Clinic Librarian, for reviewing and editing over 2,500 references. We thank Betsy M. Dempsey for her meticulous attention to detail while reviewing and editing over 800 pages of text. We thank Jim Millerick and Mike Mahoney from the Lahey Clinic Art Department. We are indebted to Robert E. Wise, M.D., of the Eleanor Dana Research Fund and Ortho Biotec for their educational grants. We thank Stephen R. Freidberg, M.D. and John A. Libertino, M.D. of the Division of Surgery and Sanford R. Kurtz, M.D. and David M. Barrett, M.D. of the Lahey Clinic for their support. We thank all of the authors and publishers who granted us permission to incorporate their work into our text. We especially thank Luis Nacul, M.D., Andrew Villanueva, M.D., and Anthony Gray, M.D., for reviewing the subject material and sharing their suggestions. And finally, we wish to thank the following physicians for dedicating their time to help us review the contents of this textbook: Sidney Alexander, M.D., Sabino Arias, M.D., Eugene P. Clerkin, M.D., Peter K. Dempsey, M.D., Peter W. Marcello, M.D., Bruce E. Mirbach, M.D., David M. Shahian, M.D., Lars G. Svennson, PhD, M.D., John J. Smith, M.D., Robert A. Roth, M.D., Dan R. Thompson, M.D., and Christopher Y. Ymg, M.D.