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CHAPTER xxxiii
PREFACE
We are pleased to bring you the Seventh Edition of Textbook of Critical the gap between medical and surgical intensive care practice. Unlike
Care. We’ve listened to our readers and have retained the acclaimed many critical care references, Textbook of Critical Care includes
features that have made this book one of the top sellers in critical pediatric topics, providing a comprehensive resource for our readers
care, while also making changes to the organization and content of who see a broad range of patients. We continue to focus on the multi-
the book to best reflect the changes in the critical care specialty since disciplinary approach to the care of critically ill patients and include
the last edition. contributors trained in anesthesia, surgery, pulmonary medicine,
Our tables, boxes, algorithms, diagnostic images, and key points, and pediatrics.
which provide clear and accessible information for quick reference, will The companion online book is more interactive than ever, with 29
continue to be featured prominently throughout the book. The Seventh procedural videos and 24 e-only procedural chapters, a powerful
Edition contains a wealth of new information, including an entirely search engine, hyperlinked references, and downloadable images. The
new section on Common Approaches for Organ Support, Diagnosis, website is mobile optimized for your convenience on all portable
and Monitoring. In addition, we have added new chapters on Extra- devices. Access to the online content is included with your book pur-
corporeal Membrane Oxygenation, Biomarkers of Acute Kidney chase, so please activate your e-book to take advantage of the full scope
Injury, Antimicrobial Stewardship, Targeted Temperature Manage- of information available to you.
ment and Therapeutic Hypothermia, Telemedicine in Intensive Care,
and many more. Given the increased use of bedside ultrasonography, Jean-Louis Vincent, MD, PhD
a new chapter addressing best practices with this now ubiquitous tool Edward Abraham, MD
has been added. All chapters throughout the book have been revised Frederick A. Moore, MD, MCCM
to reflect new knowledge in the field and, thus, changes in the practice Patrick M. Kochanek, MD, MCCM
of critical care medicine. Mitchell P. Fink, MD
Textbook of Critical Care has evolved with critical care practice over
the years and is now known as the reference that successfully bridges
xxxiii
Downloaded from ClinicalKey.com at UCSI University January 11, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
CONTRIBUTORS
Basem Abdelmalak, MD Roland Amathieu, MD, PhD

Professor of Anesthesiology Associate Professor
Director of Anesthesia for Bronchoscopic Surgery Critical Care Medicine and Anesthesiology
Departments of General Anesthesiology and Outcomes Research Henri Mondor Hospital - AP-HP
Anesthesiology Institute Associate Professor
Cleveland Clinic UPEC - School of Medicine
Cleveland, Ohio Créteil, France
Yasir Abu-Omar, MB ChB, DPhil, FRCS John Leo Anderson-Dam, MD

Consultant Cardiothoracic and Transplant Surgeon Assistant Clinical Professor
Papworth Hospital Department of Anesthesiology and Perioperative Medicine
Cambridge, Great Britain University of California Los Angeles
Los Angeles, California
Felice Achilli, MD
Chief of Cardiology Rajesh K. Aneja, MD
Cardiothoracic Department Associate Professor
San Gerardo University Hospital Department of Pediatrics and Critical Care Medicine
Monza, Italy University of Pittsburgh School of Medicine
Medical Director
Hernán Aguirre-Bermeo, MD Pediatric Intensive Care Unit
Intensive Care Department Children’s Hospital of Pittsburgh of UPMC
Hospital Sant Pau Pittsburgh, Pennsylvania
Barcelona, Spain
Massimo Antonelli, MD
Ayub Akbari, MD, MSc Professor of Intensive Care and Anesthesiology
Associate Professor Department of Anesthesiology and Intensive Care
Department of Medicine Agostino Gemelli University Hospital
University of Ottawa Rome, Italy
Senior Clinical Investigator
Clinical Epidemiology Program Zarah D. Antongiorgi, MD
Ottawa Hospital Research Institute Assistant Clinical Professor
Ottawa, Ontario, Canada Department of Anesthesiology and Perioperative Medicine
Division of Critical Care
Louis H. Alarcon, MD, FACS, FCCM David Geffen School of Medicine at UCLA
Associate Professor of Surgery and Critical Care Medicine Los Angeles, California
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania Anastasia Antoniadou, MD, PhD
Associate Professor of Internal Medicine and Infectious Diseases
F. Luke Aldo, DO University General Hospital ATTIKON
Department of Anesthesiology National and Kapodistrian University of Athens Medical School
Hartford Hospital Athens, Greece
Hartford, Connecticut
Anupam Anupam, MBBS
Ali Al-Khafaji, MD, MPH, FACP, FCCP Attending Physician
Associate Professor Department of Medicine
Department of Critical Care Medicine Advocate Illinois Masonic Medical Center
Director Chicago, Illinois
Transplant Intensive Care Unit
Pittsburgh, Pennsylvania
ix
x Contributors
Lorenzo Appendini, ASLCN Arna Banerjee MD, FCCM

Presidio Ospedaliero di Saluzzo Associate Professor of Anesthesiology/Critical Care
Saluzzo (Cuneo), Italy Associate Professor of Surgery
Medical Education and Administration
Andrew C. Argent, MBBCh, MMed(Paediatrics), MD Assistant Dean for Simulation in Medical Education
(Paediatrics), DCH(SA), FCPaeds(SA) Vanderbilt University Medical Center
Professor Nashville, Tennessee
School of Child and Adolescent Health
University of Cape Town Shweta Bansal, MBBS, MD, FASN
Medical Director Professor of Medicine
Paediatric Intensive Care Division of Nephrology
Red Cross War Memorial Children’s Hospital University of Texas Health Sciences Center at San Antonio
Cape Town, South Africa San Antonio, Texas
John H. Arnold, MD Kaysie Banton, MD

Professor of Anaesthesia (Pediatrics) Assistant Professor of Surgery
Harvard Medical School University of Minnesota
Senior Associate Minneapolis, Minnesota
Department of Anesthesia and Critical Care
Medical Director Philip S. Barie, MD, MBA, FIDSA, FACS, FCCM
Respiratory Care/ECMO Professor of Surgery and Public Health
Children’s Hospital Weill Cornell Medicine of Cornell University
Boston, Massachusetts New York, New York
Stephen Ashwal, MD Igor Barjaktarevic, MD, MSc

Distinguished Professor of Pediatrics and Neurology Assistant Professor of Medicine
Chief Division of Pulmonary and Critical Care
Division of Pediatric Neurology David Geffen School of Medicine at UCLA
Department of Pediatrics Los Angeles, California
Loma Linda University School of Medicine
Loma Linda, California Barbara L. Bass, MD
John F., Jr., and Carolyn Bookout Presidential Distinguished Chair
Mark E. Astiz, MD Department of Surgery
Professor of Medicine Professor of Surgery
Hofstra Northwell School of Medicine Houston Methodist Hospital
Chairman Houston, Texas
Department of Medicine Professor of Surgery
Lenox Hill Hospital Weill Cornell Medicine of Cornell University
New York, New York New York, New York
Arnold S. Baas, MD, FACC, FACP Gianluigi Li Bassi, MD, PhD

Associate Clinical Professor of Medicine Department of Pulmonary and Critical Care Medicine
University of California Los Angeles Hospital Clinic Calle Villarroel
David Geffen School of Medicine at UCLA Barcelona, Spain
Sarice L. Bassin, MD
Marie R. Baldisseri, MD, MPH, FCCM Medical Director, Stroke Program
Professor of Critical Care Medicine PeaceHealth Southwest Medical Center
University of Pittsburgh Medical Center Vancouver, Washington
Julie A. Bastarache, MD
Zsolt J. Balogh, MD, PhD, FRACS, FACS Assistant Professor of Medicine
Professor of Traumatology Division of Allergy, Pulmonary, and Critical Care Medicine
Department of Traumatology Vanderbilt University School of Medicine
John Hunter Hospital and University of Newcastle Nashville, Tennessee
Newcastle, New South Wales, Australia

Contributors xi
Daniel G. Bausch, MD, MPH&TM Adriana Bermeo-Ovalle, MD

Professor Assistant Professor
Department of Tropical Medicine Department of Neurological Sciences
Tulane School of Public Health and Tropical Medicine Rush University Medical Center
Clinical Associate Professor Chicago, Illinois
Department of Medicine
Section of Adult Infectious Diseases Gordon R. Bernard, BS, MD
Tulane Medical Center Professor of Medicine
New Orleans, Louisiana Department of Medicine
Vanderbilt University School of Medicine
Hülya Bayır, MD Nashville, Tennessee
Professor of Critical Care Medicine
University of Pittsburgh School of Medicine Cherisse D. Berry, MD
Director of Research, Pediatric Critical Care Medicine Clinical Instructor
Associate Director, Center for Free Radical and Antioxidant Health Department of Surgery
University of Pittsburgh Medical Center University of Maryland School of Medicine
Pittsburgh, Pennsylvania Baltimore, Maryland
Yanick Beaulieu, MD, FCRPC Beth Y. Besecker, MD

Cardiologue-Échocardiographiste/Intensiviste Assistant Professor of Medicine
Hôpital du Sacré-Coeur de Montréal Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine
Professeur Adjoint de Clinique The Ohio State University Wexner Medical Center
Université de Montréal Columbus, Ohio
Montréal, Québec, Canada
Joost Bierens, MD
Thomas M. Beaver, MD, MPH Professor of Emergency Medicine
Professor of Surgery VU University Medical Centre
Chief Amsterdam, The Netherlands
Division of Thoracic and Cardiovascular Surgery
University of Florida College of Medicine Walter L. Biffl, MD
Gainesville, Florida Associate Director of Surgery
Denver Health Medical Center
Gregory Beilman, MD Denver, Colorado
Deputy Chair Professor of Surgery
Department of Surgery University of Colorado
Director of System Critical Care Program Aurora, Colorado
University of Minnesota Health System
Minneapolis, Minnesota Thomas P. Bleck, MD, MCCM
Professor
Michael J. Bell, MD Departments of Neurological Sciences, Neurosurgery, Internal
Associate Professor Medicine, and Anesthesiology
Departments of Critical Care Medicine, Neurological Surgery, Rush Medical College
and Pediatrics Director
University of Pittsburgh School of Medicine Clinical Neurophysiology
Associate Director Rush University Medical Center
Safar Center for Resuscitation Research Chicago, Illinois
Thomas A. Bledsoe, MD
Giuseppe Bello, MD Clinical Associate Professor of Medicine
Department of Anesthesia and Intensive Care Division of Critical Care
Agostino Gemelli University Hospital Pulmonary and Sleep Medicine
Università Cattolica del Sacro Cuore The Warren Alpert Medical School at Brown University
Rome, Italy Vice-Chair
Ethics Committee
Peyman Benharash, MD Rhode Island Hospital
Assistant Professor of Bioengineering Providence, Rhode Island
Division of Cardiothoracic Surgery
University of California Los Angeles
David Geffen School of Medicine at UCLA

xii Contributors
Karen C. Bloch, MD, MPH, FIDSA, FACP Sara T. Burgardt, MD, PharmD
Associate Professor Subspecialty Fellow
Departments of Medicine (Infectious Diseases) and Health Policy Adult Nephrology
Vanderbilt University Medical Center Department of Medicine
Nashville, Tennessee Division of Nephrology
University of North Carolina
Desmond Bohn, MD Chapel Hill, North Carolina
Professor of Pediatrics and Anesthesia
University of Toronto Sherilyn Gordon Burroughs, MD
Toronto, Ontario Associate Professor of Surgery
Weill Cornell Medicine of Cornell University
David Boldt, MD, MS Houston Methodist Hospital
Assistant Clinical Professor, Critical Care Medicine Sherrie and Alan Conover Center for Liver Disease and
Chief, Trauma Anesthesiology Transplantation
University of California Los Angeles Houston, Texas
Los Angeles, California Clifton W. Callaway, MD, PhD
Professor of Emergency Medicine
Geoffrey J. Bond, MD Executive Vice-Chairman of Emergency Medicine
Assistant Professor in Transplant Surgery Ronald D. Stewart Endowed Chair of Emergency Medicine Research
Thomas E. Starzl Transplantation Institute University of Pittsburgh School of Medicine
University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
Transplant Director
Pediatric Intestinal Care Center Peter M.A. Calverley, MB ChB, MD
Children’s Hospital of Pittsburgh of UPMC Professor of Respiratory Medicine
Pittsburgh, Pennsylvania Respiratory Researach Department
University of Liverpool
Michael J. Bradshaw, MD Liverpool, Great Britain
Resident Physician
Department of Neurology John Camm, QHP, MD, BsC, FMedSci, FRCP, FRCP(E),
Vanderbilt University School of Medicine FRCP(G), FACC, FESC, FAHA, FHRS, CStJ
Nashville, Tennessee Professor of Clinical Cardiology
Clinical Academic Group
Luca Brazzi, MD Cardiovascular and Cell Sciences Research Institute
Associate Professor St. George’s University of London
Department of Anesthesia and Intensive Care Medicine London, Great Britain
S. Giovanni Battista Molinette Hospital
University of Turin Andre Campbell, MD
Turin, Italy Professor of Surgery
School of Medicine
Serge Brimioulle, MD, PhD University of California San Francisco
Professor of Intensive Care San Francisco, California
Department of Intensive Care
Erasme Hospital Diane M. Cappelletty, RPh, PharmD
Université Libre de Bruxelles Associate Professor of Clinical Pharmacy
Brussels, Belgium Chair
Department of Pharmacy Practice
Itzhak Brook, MD Co-Director
Professor of Pediatrics The Infectious Disease Research Laboratory
Georgetown University School of Medicine University of Toledo College of Pharmacy and Pharmaceutical
Washington, DC Sciences
Toledo, Ohio
Richard C. Brundage, PharmD, PhD, FISoP
Distinguished University Teaching Professor Joseph A. Carcillo, MD
Professor of Experimental and Clinical Pharmacology Associate Professor
University of Minnesota College of Pharmacy Departments of Critical Care Medicine and Pediatrics
Minneapolis, Minnesota University of Pittsburgh School of Medicine

Contributors xiii
Edward D. Chan, MD Staci Collins, RD, CNSC

Staff Physician Senior Dietitian
Pulmonary Section Department of Food and Nutrition Services
Denver Veterans Affairs Medical Center UC Davis Children’s Hospital
National Jewish Health Sacramento, California
Denver, Colorado
Gulnur Com, MD
Satish Chandrashekaran, MD Associate Professor of Clinical Pediatrics
Assistant Professor of Medicine University of Southern California Keck School of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine Los Angeles, California
Lung Transplantation Program
University of Florida College of Medicine Chris C. Cook, MD
Gainesville, Florida Assistant Professor of Cardiothoracic Surgery
Lakhmir S. Chawla, MD Pittsburgh, Pennsylvania
Associate Professor of Medicine
George Washington University Medical Center Robert N. Cooney, MD, FACS, FCCM
Washington, DC Professor and Chairman
Department of Surgery
David C. Chen, MD SUNY Upstate Medical University
Associate Professor of Clinical Surgery Syracuse, New York
Associate Director of Surgical Education Susan J. Corbridge, PhD, APN
David Geffen School of Medicine at UCLA Clinical Associate Professor
Los Angeles, California College of Nursing and Department of Medicine
Director of Graduate Clinical Studies
Amit Chopra, MD College of Nursing
Assistant Professor of Medicine University of Illinois at Chicago
Division of Pulmonary and Critical Care Medicine Chicago, Illinois
Albany Medical College
Albany, New York Thomas C. Corbridge, MD
Professor of Medicine
Robert S.B. Clark, MD Division of Pulmonary and Critical Care Medicine
Professor of Critical Care Medicine Department of Medicine
Chief Northwestern University Feinberg School of Medicine
Pediatric Critical Care Medicine Chicago, Illinois
Associate Director Oliver A. Cornely, MD
Safar Center for Resuscitation Research Professor of Internal Medicine
Pittsburgh, Pennsylvania Director of Translational Research
Cologne Excellence Cluster on Cellular Stress Responses in Aging-
Jonathan D. Cohen, MD, PhD Associated Diseases (CECAD)
Robert Bendheim and Lynn Bendheim Thoman Professor in Director
Neuroscience Clinical Trials Center Cologne (CTCC)
Professor of Psychology University of Cologne
Princeton University Cologne, Germany
Co-Director Princeton Neuroscience Institute
Princeton, New Jersey Marie L. Crandall, MD, MPH
Professor of Surgery
Stephen M. Cohn, MD, FACS University of Florida College of Medicine
Witten B. Russ Professor of Surgery Jacksonville, Florida
University of Texas Health Science Center
San Antonio, Texas Andrej Čretnik, MD, PhD
Professor of Traumatology
Kelli A. Cole, PharmD, BCPS University Clinical Center Maribor
Antibiotic Steward Pharmacist Maribor, Slovenia
Department of Pharmacy Services
University of Toledo Medical Center
Toledo, Ohio

xiv Contributors
David Crippen, MD, FCCM Jeffrey Dellavolpe, MD, MPH

Professor of Critical Care Medicine Critical Care Medicine
University of Pittsburgh University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Pittsburgh, Pennsylvania
Chasen Ashley Croft, MD Anne Marie G.A. De Smet, MD, PhD

Assistant Professor of Surgery Anesthesiologist-Intensivist
Department of Surgery Afdelingshoofd Intensive Care Volwassenen
University of Florida Health Science Center Head of Department of Critical Care
Gainesville, Florida University Medical Center Groningen
Groningen, The Netherlands
Elliott D. Crouser, MD
Professor of Medicine Anahat Dhillon, MD
Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine Associate Professor
The Ohio State University Wexner Medical Center Department of Anesthesiology and Perioperative Medicine
Columbus, Ohio University of California Los Angeles
Burke A. Cunha, MD, MACP
Chief Rajeev Dhupar, MD
Infectious Disease Division Resident
Winthrop-University Hospital Division of General Surgery
Mineola, New York University of Pittsburgh Medical Center
Professor of Medicine Pittsburgh, Pennsylvania
State University of New York School of Medicine
Stony Brook, New York Rochelle A. Dicker, MD
Professor
Cheston B. Cunha, MD Departments of Surgery and Anesthesia
Assistant Professor of Medicine University of California San Francisco
Division of Infectious Disease San Francisco, California
Medical Director
Antimicrobial Stewardship Program Francesca Di Muzio, MD
The Warren Alpert Medical School of Brown University Department of Anesthesiology and Intensive Care
Providence, Rhode Island Agostino Gemelli University Hospital
Università Cattolica del Sacro Cuore
J. Randall Curtis, MD, MPH Rome, Italy
Division of Pulmonary and Critical Care Medicine Michael N. Diringer, MD
University of Washington School of Medicine Professor of Neurology and Neurosurgery
Seattle, Washington Associate Professor of Anesthesiology and Occupational Therapy
Washington University School of Medicine in St. Louis
Heidi J. Dalton, MD St. Louis, Missouri
Professor of Child Health
University of Arizona College of Medicine Conrad F. Diven, MD, MS
Phoenix, Arizona Assistant Trauma Director
Trauma Research Director
Joseph M. Darby, MD Abrazo West Campus Trauma Center
Professor of Critical Care Medicine and Surgery Goodyear, Arizona
Medical Director Peter Doelken, MD
Trauma ICU Associate Professor of Medicine
UPMC-Presbyterian Hospital Division of Pulmonary and Critical Care Medicine
Pittsburgh, Pennsylvania Albany Medical College
Albany, New York
John D. Davies, MA, RRT, FAARC, FCCP
Clinical Research Coordinator Michael Donahoe, MD
Division of Pulmonary, Allergy, and Critical Care Medicine Professor of Medicine
Duke University Medical Center Division of Pulmonary, Allergy, and Critical Care Medicine
Durham, North Carolina University of Pittsburgh School of Medicine

Contributors xv
Caron L. Boyd Dover, MD Shane W. English, MD, MSc, FRCPC

Chief Associate Scientist
Cardiothoracic Imaging Clinical Epidemiology Program
Medical Director of CT Ottawa Hospital Research Institute
Assistant Professor of Radiology Assistant Professor of Medicine (Critical Care)
Department of Radiology University of Ottawa
Wake Forest School of Medicine Intensivist
Winston Salem, North Carolina Department of Critical Care
The Ottawa Hospital
Brian K. Eble, MD Ottawa, Ontario, Canada
Associate Professor of Pediatrics
University of Arkansas for Medical Sciences Brent Ershoff, MD
Little Rock, Arkansas Clinical Instructor
Department of Anesthesiology and Perioperative Medicine
Charles L. Edelstein, MD, PhD, FAHA David Geffen School of Medicine at UCLA
Professor of Medicine Los Angeles, California
Division of Renal Diseases and Hypertension
University of Colorado Denver Joel H. Ettinger, BS, MHA
Aurora, Colorado President
Category One Inc.
Randolph Edwards, MD Pittsburgh, Pennsylvania
Assistant Professor of Surgery
University of Connecticut School of Medicine Josh Ettinger, MBA
Surgical Critical Care Category One, Inc.
Department of Surgery Pittsburgh, Pennsylvania
Hartford Hospital
Hartford, Connecticut David C. Evans, MD
Assistant Professor of Surgery
Elwaleed A. Elhassan, MBBS, FACP, FASN Department of Surgery
Assistant Professor of Medicine (Nephrology) The Ohio State University
Wayne State University School of Medicine Columbus, Ohio
Detroit, Michigan
Gregory T. Everson, MD
E. Wesley Ely, MD, MPH Professor of Medicine
Professor of Medicine Division of Gastroenterology and Hepatology
Department of Allergy, Pulmonary, and Criticial Care Medicine University of Colorado Denver
Vanderbilt University Medical Center Director of Hepatology
Nashville, Tennessee Hepatology and Transplant Center
University of Colorado Hospital
Lillian L. Emlet, MD, MS, FACEP, FCCM Aurora, Colorado
Assistant Professor
Departments of Critical Care Medicine and Emergency Medicine Chiara Faggiano, MD
Associate Program Director Department of Anesthesia and Critical Care Medicine
IM-CCM Fellowship of the MCCTP S. Giovanni Battista Mollinette Hospital
University of Pittsburgh Medical Center University of Turin
Pittsburgh, Pennsylvania Turin, Italy
Amir Emtiazjoo, MD, MSc Jeff Fair, MD

Assistant Professor of Medicine Professor
Division of Pulmonary, Critical Care, and Sleep Medicine Department of Surgery
Lung Transplantation Program University of Texas Medical Branch
University of Florida College of Medicine Galveston, Texas
Gainesville, Florida
Ronald J. Falk, MD
Allen Brewster Distinguished Professor of Medicine
Director
UNC Kidney Center
Chairman
Chapel Hill, North Carolina

xvi Contributors
Brenna Farmer, MD Ericka L. Fink, MD, MS

Assistant Professor of Medicine Associate Professor of Critical Care Medicine
Department of Emergency Medicine University of Pittsburgh School of Medicine
Weill Cornell Medicine of Cornell University Children’s Hospital of Pittsburgh of UPMC
Assistant Residency Director Associate Director
Department of Emergency Medicine Safar Center for Resuscitation Research
New York Presbyterian Hospital Pittsburgh, Pennsylvania
New York, New York
Mitchell P. Fink, MD†
Rory Farnan, MB, BCh, BAO Professor of Surgery and Anesthesiology
Division of Cardiology Vice Chair for Critical Care
Cooper University Hospital Department of Surgery
Camden, New Jersey David Geffen School of Medicine at UCLA
Alan P. Farwell, MD
Associate Professor of Medicine Brett E. Fortune, MD
Chair Assistant Professor of Medicine (Digestive Diseases) and of Surgery
Division of Endocrinology, Diabetes, and Nutrition (Transplant)
Boston University School of Medicine Associate Program Director
Director Gastroenterology Fellowship
Endocrine Clinics Yale School of Medicine
Boston Medical Center New Haven, Connecticut
Boston, Massachusetts
Barry I. Freedman, MD
Carinda Feild, PharmD, FCCM Professor and Chief
Assistant Dean and Associate Professor Department of Internal Medicine
Department of Pharmacotherapy and Translational Research Section on Nephrology
University of Florida College of Pharmacy Wake Forest School of Medicine
Seminole, Florida Winston-Salem, North Carolina
David Feller-Kopman, MD, FACP Elchanan Fried, MD

Associate Professor of Medicine, Otolaryngology - Head and Neck Senior Physician
Surgery Department of Medicine
Department of Pulmonary and Critical Care Medicine Hadassah Medical Centers
The Johns Hopkins University Jerusalem, Israel
Director
Bronchoscopy and Interventional Pulmonology Kwame Frimpong, MD
Johns Hopkins University Medical Institutions Clinical Research Coordinator
Baltimore, Maryland Vanderbilt University Medical Center
Nashville, Tennessee
Kathryn Felmet, MD
Assistant Professor Rajeev K. Garg, MD, MS
Departments of of Critical Care Medicine and Pediatrics Assistant Professor of Neurological Sciences and Neurosurgery
University of Pittsburgh School of Medicine Rush University Medical Center
Pittsburgh, Pennsylvania Chicago, Illinois
Miguel Ferrer, MD, PhD Raúl J. Gazmuri, MD, PhD, FCCM

Department of Pneumology Professor of Medicine
Respiratory Institute Professor of Physiology and Biophysics
Hospital Clinic Director
IDIBAPS Resuscitation Institute
CibeRes Rosalind Franklin University of Medicine and Science
Associate Professor Director of Critical Care Medicine
Department of Medicine Captain James A. Lovell Federal Health Care Center
University of Barcelona North Chicago, Illinois
Barcelona, Spain
†Deceased.

Contributors xvii
Robert H. Geelkerken, Prof Dr Diana J. Goodman, MD

Medisch Spectrum Twente Assistant Professor
and Faculty of Science and Technology and Experimental Center of Department of Neurological Sciences
Technical Medicine Rush University Medical Center
University of Twente Chicago, Illinois
Enschede, The Netherlands
Shankar Gopinath, MD
Todd W.B. Gehr, MD Associate Professor of Neurosurgery
Sir Hans A. Krebs Chair of Nephrology Baylor College of Medicine
Department of Internal Medicine Houston, Texas
Division of Nephrology
Virginia Commonwealth University School of Medicine John Gorcsan, III, MD
Richmond, Virginia Professor of Medicine
Division of Cardiology
Michael A. Gentile, RRT, FAARC, FCCM University of Pittsburgh
Associate in Research Pittsburgh, Pennsylvania
Division of Pulmonary and Critical Care Medicine
Duke University Medical Center Yaacov Gozal, MD
Durham, North Carolina Associate Professor of Anesthesiology
Hebrew University
M. Patricia George, MD Chair
Assistant Professor of Medicine Department of Anesthesiology, Perioperative Medicine and Pain
University of Pittsburgh School of Medicine Treatment
UPMC Montefiore Hospital Shaare Zedek Medical Center
Pittsburgh, Pennsylvania Jerusalem, Israel
Herwig Gerlach, MD, PhD, MBA Jeremy D. Gradon, MD, FACP, FIDSA
Professor and Chairman Attending Physician
Department of Anesthesia, Intensive Care, and Pain Management Department of Medicine
Vivantes-Klinikum Neukölln Sinai Hospital of Baltimore
Berlin, Germany Associate Professor of Medicine
The Johns Hopkins University School of Medicine
Helen Giamarellou, MD, PhD Baltimore, Maryland
Professor of Internal Medicine and Infectious Diseases
Hygeia Hospital Cornelia R. Graves, MD
Athens, Greece Professor of Obstetrics and Gynecology
University of Tennessee College of Medicine
Fredric Ginsberg, MD Clinial Professor of Obstetrics and Gynecology
Associate Professor of Medicine Vanderbilt University School of Medicine
Division of Cardiovascular Disease Director of Perinatal Services
Cooper Medical School of Rowan University St. Thomas Health System
Camden, New Jersey Medical Director
Tennessee Maternal Fetal Medicine
Thomas G. Gleason, MD Nashville, Tennessee
Ronald V. Pellegrini Endowed Professor of Cardiothoracic Surgery
University of Pittsburgh School of Medicine Cesare Gregoretti, MD
Chief Department of Biopathology and Medical Biotechnologies
Division of Cardiac Surgery (DIBIMED)
Heart and Vascular Institute Section of Anesthesia, Analgesia, Intensive Care, and Emergency
Director Policlinico P. Giaccone University of Palermo
Center for Thoracic Aortic Disease Palermo, Italy
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Andreas Greinacher, MD
Institute for Immunology and Transfusion Medicine
Corbin E. Goerlich, MD University Medicine Greifswald
The University of Texas Medical School at Houston Department of Anesthesiology and Intensive Care Medicine
Houston, Texas Greifswald, Germany

xviii Contributors
Michael A. Gropper, MD, PhD Jonathan R. Hiatt, MD

Professor and Chair Professor of Surgery
Department of Anesthesia and Perioperative Care Vice Dean for Faculty
University of California San Francisco David Geffen School of Medicine at UCLA
San Francisco, California Los Angeles, California
Paul O. Gubbins, PharmD Robert W. Hickey, MD FAAP, FAHA

Associate Dean Associate Professor of Pediatrics
Vice Chair and Professor University of Pittsburgh School of Medicine
Division of Pharmacy Practice and Administration Department of Emergency Medicine
UMKC School of Pharmacy at Missouri State University Children’s Hospital of Pittsburgh of UPMC
Springfield, Missouri Pittsburgh, Pennsylvania
Vadim Gudzenko, MD Thomas L. Higgins, MD, MBA

Assistant Clinical Professor Professor
Departments of Anesthesiology and Perioperative Medicine Departments of Medicine, Anesthesia, and Surgery
David Geffen School of Medicine at UCLA Chief Medical Officer
Los Angeles, California Baystate Franklin Medical Center and BH Northern Region
Baystate Noble Hospital and BH Western Region
Kyle J. Gunnerson, MD Westfield, Massachusetts
Associate Professor of Emergency Medicine
Chief, Division of Emergency Critical Care Nicholas S. Hill, MD, FPVRI
University of Michigan Medical School Professor of Medicine
Ann Arbor, Michigan Chief
Division of Pulmonary, Critical Care, and Sleep Medicine
Fahim A. Habib, MD, MPH, FACS Tufts University Medical Center
Assistant Professor of Surgery Boston, Massachusetts
DeWitt Daughtry Department of Surgery
University of Miami Miller School of Medicine Swapnil Hiremath, MD, MPH
Director Assistant Professor
Department of Critical Care Department of Medicine
University of Miami Hospital University of Ottawa
Attending Trauma Surgeon Senior Clinical Investigator
Ryder Trauma Center Clinical Epidemiology Program
Jackson Memorial Hospital Ottawa Hospital Research Institute
Miami, Florida Ottawa, Ontario, Canada
Brian G. Harbrecht, MD Gerald A. Hladik, MD

Professor of Surgery Doc J Thurston Distinguished Professor of Medicine
University of Louisville School of Medicine Interim Chief
Louisville, Kentucky Division of Nephrology and Hypertension
UNC Kidney Center
Yenal I.J. Harper, MD, ABIM University of North Carolina
Cardiovascular Disease Fellow Chapel Hill, North Carolina
University of Tennessee Health Science Center
Memphis, Tennessee Steven M. Hollenberg, MD
Moustafa Hassan, MD Cooper Medical School of Rowan University
Associate Professor Director
Departments of Surgery and Anesthesiology Coronary Care Unit
State University of New York Cooper University Hospital
SUNY Upstate Medical University Camden, New Jersey
Syracuse, New York
Eric Hoste, MD, PhD
Jan A. Hazelzet, MD, PhD Associate Professor
Professor in Healthcare Quality and Outcome Department of Intensive Care Medicine
Chief Medical Information Officer Ghent University Faculty of Medicine and Health Sciences
Vice Director Ghent University Hospital
Strategy and Policy IT Ghent, Belgium
Erasmus Medical Center Senior Clinical Investigator
Rotterdam, The Netherlands Research Fund-Flanders (FWO)
Brussels, Belgium

Contributors xix
Albert T. Hsu, MD Ashutosh P. Jadhav, MD, PhD

Assistant Professor of Surgery Assistant Professor
University of Florida College of Medicine Departments of Neurology and Neurological Surgery
Jacksonville, Florida University of Pittsburgh
David T. Huang, MD, MPH
Associate Professor David Jiménez, MD, PhD
Departments of Critical Care Medicine and Emergency Medicine Associate Professor of Medicine (Respiratory Medicine)
Director Alcalá de Henares University
Multidisciplinary Acute Care Research Organization Chief, Venous Thromboembolism Programme
University of Pittsburgh School of Medicine Hospital Ramón y Cajal
Pittsburgh, Pennsylvania Madrid, Spain
J. Terrill Huggins, MD Jimmy Johannes, MD

Associate Professor of Medicine Fellow, Department of Pulmonary and Critical Care Medicine
Pulmonary, Critical Care, Allergy, and Sleep Medicine David Geffen School of Medicine at UCLA
Medical University of South Carolina Los Angeles, California
Charleston, South Carolina
Janeen Rene Jordan, MD
Russell D. Hull, MBBS, MSc, FRCPC, FACP, FCCP Department of Surgery
Professor of Medicine University of Florida
University of Calgary Faculty of Medicine Gainesville, Florida
Calgary, Alberta, Canada
Philippe G. Jorens, MD, PhD
Joseph Abdellatif Ibrahim, MD Professor and Chair
Associate Program Director Department of Critical Care Medicine
Department of General Surgery Professor of Clinical Pharmacology and Toxicology
Orlando Health University of Antwerp and Antwerp University Hospital
Orlando, Florida Antwerp, Belgium
Angie Ingraham, MD Mathieu Jozwiak, MD

Assistant Professor of Surgery Medical Intensive Care Unit
University of Wisconsin Bicêtre University Hospital
Madison, Wisconsin Paris-South University
Le Kremlin-Bicêtre, France
Margaret L. Isaac, MD
Assistant Professor of Medicine Rose Jung, PharmD, MPH, BCPS
University of Washington School of Medicine Clinical Associate Professor
Seattle, Washington Department of Pharmacy Practice
University of Toledo College of Pharmacy and Pharmaceutical
James P. Isbister, BSc(Med), MB, BS, FRACP, FRCPA Sciences
Consultant in Haematology and Transfusion Medicine Toledo, Ohio
Clinical Professor of Medicine
Sydney Medical School Aanchal Kapoor, MD
Royal North Shore Hospital of Sydney Associate Program Director
Conjoint Professor of Medicine Department of Critical Care Medicine
University of New South Wales Cleveland Clinic
Sydney, Australia Cleveland, Ohio
Adjunct Professor of Medicine
Monash University David C. Kaufman, MD, FCCM
Melbourne, Australia Professor of Surgery, Anesthesia, Internal Medicine, Medical
Humanities and Bioethics, and Urology
Frederique A. Jacquerioz, MD, MPH, CTropMed University of Rochester
Clinical Assistant Professor Rochester, New York
Department of Tropical Medicine
Tulane School of Public Health and Tropical Medicine A. Murat Kaynar, MD, MPH
New Orleans, Louisiana Associate Professor
Department of Tropical and Humanitarian Medicine Departments of Critical Care Medicine and Anesthesiology
Geneva University Hospitals University of Pittsburgh School of Medicine
Geneva, Switzerland The Clinical Research, Investigation, and Systems Modeling of Acute
Illness (CRISMA) Center

xx Contributors
John A. Kellum, MD Robert L. Kormos, MD, FRCS(C), FAHA

Professor of Critical Care Medicine Professor
University of Pittsburgh Department of Surgery
Pittsburgh, Pennsylvania University of Pittsburgh School of Medicine
Director
Orlando Kirton, MD Artificial Heart Program
Ludwig J. Pyrtek, MD, Chair of Surgery Co-Director
Department of Surgery Heart Transplantation
Hartford Hospital Medical Director
Hartford, Connecticut Vital Engineering
Professor and Vice Chairman University of Pittsburgh Medical Center
University of Connecticut School of Medicine
Farmington, Connecticut Lucy Z. Kornblith, MD
Fellow
Jason Knight, MD Trauma and Critical Care
Emergency Department Medical Director University of California San Francisco
Maricopa Medical Center San Francisco, California
Phoenix, Arizona
Roman Košir, MD, PhD
Patrick M. Kochanek, MD, MCCM Chief
Ake N. Grenvik Professor in Critical Care Medicine Emergency Center
Professor and Vice Chairman Attending Physician
Department of Critical Care Medicine Trauma Department
Professor of Anesthesiology, Pediatrics, Bioengineering, and Clinical University Clinical Center Maribor
and Translational Science Maribor, Slovenia
Director Robert M. Kotloff, MD
Safar Center for Resuscitation Research Chairman
Pittsburgh, Pennsylvania Department of Pulmonary Medicine
Respiratory Institute
Philipp Koehler, MD Cleveland Clinic
Resident Physician Cleveland, Ohio
Department of Internal Medicine
University Hospital Cologne Rosemary A. Kozar, MD, PhD
Cologne Excellence Cluster on Cellular Stress Responses in Aging- Professor of Surgery
Associated Diseases (CECAD) University of Maryland
Faculty of Medicine Baltimore, Maryland
University of Cologne
Cologne, Germany Wolf Benjamin Kratzert, MD, PhD
Assistant Clinical Professor
Jeroen J. Kolkman, Prof Dr Department of Anesthesiology and Perioperative Medicine
Department of Gastroenterology University of California Los Angeles
Medische Spectrum Twente Los Angeles, California
Enschede, The Netherlands
Department of Gastroenterology Anand Kumar, MD
University Medical Center Groningen Associate Professor
Groningen, The Netherlands Sections of Critical Care Medicine and Infectious Diseases
University of Manitoba
Marin H. Kollef, MD Winnipeg, Manitoba, Canada
Division of Pulmonary and Critical Care Medicine Associate Professor
Washington University School of Medicine in St. Louis Sections of Critical Care Medicine and Infectious Diseases
St. Louis, Missouri Robert Wood Johnson Medical School, UMDNJ
Camden, New Jersey
Cecilia Korb, MD, MSc
Research Fellow
Department of Paediatric Intensive Care
Royal Brompton Hospital
London, United Kingdom

Contributors xxi
Vladimir Kvetan, MD Jerrold H. Levy, MD, FAHA, FCCM

Director Professor of Anesthesiology
Jay B. Langner Critical Care System Director Associate Professor of Surgery
Division of Critical Care Medicine Co-Director
Montefiore Medical Center Cardiothoracic ICU
Albert Einstein College of Medicine Anesthesiology, Critical Care, and Surgery
Bronx, New York Duke University Hospital
Durham, North Carolina
Shawn D. Larson, MD, FACS
Assistant Professor of Surgery Mitchell M. Levy, MD
Division of Pediatric Surgery Professor of Medicine
University of Florida College of Medicine The Warren Alpert Medical School of Brown University
Gainesville, Florida Chief
Division of Critical Care, Pulmonary and Sleep Medicine
Gilles Lebuffe, MD Rhode Island Hospital
Professor of of Anaesthesiology and Intensive Care Medicine Providence, Rhode Island
Lille University School of Medicine
Lille University Hospital Anthony J. Lewis, MD
Lille, France General Surgery Resident
Constance Lee, MD University of Pittsburgh
Fellow Pittsburgh, Pennsylvania
Surgical Critical Care
Department of Surgery Catherine E. Lewis, MD
University of Florida College of Medicine Assistant Professor of Surgery
Gainesville, Florida Trauma, Emergency General Surgery, and Surgical Critical Care
Hans J. Lee, MD Los Angeles, California
Assistant Professor of Medicine
Director of Pleural Disease Service Susan J. Lewis, PharmD, BCPS
Fellowship Director Assistant Professor
Kopen Wang Interventional Pulmonary Fellowship Department of Pharmacy Practice
Division of Pulmonary/Critical Care Medicine University of Findlay College of Pharmacy
The Johns Hopkins University Findlay, Ohio
Baltimore, Maryland
Scott Liebman, MD, MPH
Angela M. Leung, MD, MSc Associate Professor
Assistant Clinical Professor of Medicine Department of Medicine
Division of Endocrinology University of Rochester Medical Center
David Geffen School of Medicine at UCLA Rochester, New York
VA Greater Los Angeles Healthcare System
Los Angeles, California Stuart L. Linas, MD
Rocky Mountain Professor of Renal Research
Allan D. Levi, MD, PhD, FACS Department of Internal Medicine
Chair University of Colorado School of Medicine
Department of Neurological Surgery Aurora, Colorado
Professor of Neurological Surgery, Orthopedics, and Rehabilitation Chief of Nephrology
Medicine Denver Health Medical Center
University of Miami Miller School of Medicine Denver, Colorado
Chief of Neurosurgery
Jackson Memorial Hospital Jason P. Linefsky, MD, MS
Miami, Florida Assistant Professor of Medicine
Division of Cardiology
Phillip D. Levin, MA, MB, BCHIR Emory University School of Medicine
Director Decatur, Georgia
Senior Lecturer
Department of Anesthesia Kerry Michael Link, MD, MBA
Hebrew University Professor of Radiology
Director Cardiology, Regenerative Medicine, and Translational Sciences
General Intensive Care Unit Department of Radiology
Shaare Zedek Medical Center Wake Forest School of Medicine
Jerusalem, Israel Winston-Salem, North Carolina

xxii Contributors
Pamela Lipsett, MD, MHPE Bernhard Maisch, MD, FESC, FACC

Warfield M. Firor Endowed Professorship Professor and Director
Department of Surgery Department of Cardiology
The Johns Hopkins University School of Medicine Marburg Heart Center
Baltimore, Maryland Marburg, Germany
Angela K.M. Lipshutz, MD, MPH Jordi Mancebo, MD

2015-2016 Severinghaus Assistant Professor Director
Department of Anesthesia and Perioperative Care Intensive Care Department
University of California San Francisco Hospital Sant Pau
San Francisco, California Barcelona, Spain
Alejandro J. Lopez-Magallon, MD Henry J. Mann, PharmD, FCCM, FCCP, FASHP

Assistant Professor of Medicine Dean and Professor
Division of Critical Care Medicine The Ohio State University College of Pharmacy
University of Pittsburgh School of Medicine Columbus, Ohio
Sanjay Manocha, MD, FRCPC
Andrew I.R. Maas, MD, PhD Medical Director
Professor and Chair Critical Care Unit
Department of Neurosurgery Division of Critical Care Medicine
University Hospital Antwerp and University of Antwerp Department of Medicine
Antwerp, Belgium Humber River Hospital
Toronto, Ontario, Canada
Neil R. MacIntyre, MD Assistant Professor
Professor of Medicine Department of Medicine
Duke University School of Medicine Queen’s University
Clinical Chief Kingston, Ontario, Canada
Pulmonary and Critical Care Division
Medical Director Daniel R. Margulies, MD, FACS
Respiratory Care Services Professor of Surgery
Duke University Medical Center Director
Durham, North Carolina Trauma Services and Acute Care Surgery
Associate Director, General Surgery
Duncan Macrae, MB, ChB, FRCA Cedars-Sinai Medical Center
Consultant Los Angeles, California
Department of Paediatric Intensive Care
Royal Brompton Hospital Paul E. Marik, MD, FCCP, FCCM
Senior Lecturer and Adjunct Reader Chief
Imperial College School of Medicine Division of Pulmonary and Critical Care Medicine
London, United Kingdom Department of Internal Medicine
Eastern Virginia Medical School
Michael C. Madigan, MD Norfolk, Virginia
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Donald W. Marion, MD, MSc
Senior Clinical Consultant
Stefano Maggiolini, MD Division of Clinical Affairs
Chief of Cardiology The Defense and Veterans Brain Injury Center
Cardiovascular Department Silver Spring, Maryland
ASST-Lecco
San Leopoldo Mandic Hospital Merate Stephanie Markle, DO, MPH
Lecco, Italy Acute Care Surgery Fellow
Clinical Instructor
Aman Mahajan, MD, PhD University of Florida College of Medicine
Professor of Anesthesiology and Bioengineering Gainesville, Florida
Chair
Department of Anesthesiology Alvaro Martinez-Camacho, MD
David Geffen School of Medicine at UCLA Assistant Professor of Gastroenterology and Hepatology
Los Angeles, California University of Colorado Denver
Division of Digestive and Liver Health
Denver Health Hospital and Authority
Denver, Colorado

Contributors xxiii
Florian B. Mayr, MD, MPH Daniel R. Meldrum, MD

Assistant Professor of Critical Care Medicine Professor of Surgery
University of Pittsburgh School of Medicine Michigan State University College of Human Medicine
Pittsburgh, Pennsylvania Grand Rapids, Michigan
George V. Mazariegos, MD Joseph S. Meltzer, MD

Professor of Surgery and Critical Care Associate Clinical Professor
University of Pittsburgh School of Medicine Department of Anesthesiology and Perioperative Medicine
Director, Pediatric Transplantation University of California Los Angeles
Hillman Center for Pediatric Transplantation David Geffen School of Medicine at UCLA
Children’s Hospital of Pittsburgh of UPMC Los Angeles, California
Dieter Mesotten, MD, PhD
Joanne Mazzarelli, MD, FACC Associate Professor of Medicine
Division of Cardiovascular Disease Division of Intensive Care Medicine
Women’s Heart Program Katholieke Universiteit Leuven
Cooper University Hospital Leuven, Belgium
Cooper Medical School of Rowan University Kimberly S. Meyer, MSN, ACNP-BC
Camden, New Jersey Neurosurgery Nurse Practitioner
Trauma Institute
Steven A. McGloughlin, FCICM, FRACP, MPH&TM, University of Louisville Hospital
PGDipEcho Instructor in Nursing
Department of Intensive Care and Hyperbaric Medicine University of Louisville
The Alfred Hospital Louisville, Kentucky
Melbourne, Australia
Scott T. Micek, PharmD
Lauralyn McIntyre, MD, MSc Associate Professor of Pharmacy Practice
Senior Scientist St. Louis College of Pharmacy
Clinical Epidemiology Program St. Louis, Missouri
Ottawa Hospital Research Institute
Associate Professor of Medicine (Critical Care) David J. Michelson, MD
University of Ottawa Assistant Professor
Intensivist Departments of Pediatrics and Neurology
Department of Critical Care Loma Linda University Health
The Ottawa Hospital Loma Linda, California
Ottawa, Ontario, Canada
Dianne Mills, RD, CNSC
Anna W. McLean, MD Senior Dietitian
Department of Internal Medicine Department of Food and Nutrition Services
George Washington University School of Medicine UC Davis Children’s Hospital
VA Medical Center UC Davis Medical Center
Washington, DC Sacramento, California
John F. McNamara, BDSc, MDS (Adel), FICD, FADI, FPFA, Bartley Mitchell, MD
MRACDS (ENDO) Endovascular Neurosurgeon
Registrar—Associate Lecturer Baptist Medical Center
Center for Clinical Research Jacksonville, Florida
University of Queensland
Brisbane, Australia Aaron M. Mittel, MD
Clinical Fellow in Anaesthesia
Michelle K. McNutt, MD Department of Anesthesia, Critical Care, and Pain Medicine
Assistant Professor of Surgery Harvard Medical School
University of Texas Health Science Center at Houston Beth Israel Deaconess Medical Center
Houston, Texas Boston, Massachusetts
Lucido L. Ponce Mejia, MD Xavier Monnet, MD, PhD

Resident Physician Medical Intensive Care Unit
Department of Neurosurgery Paris-South University
Baylor College of Medicine Bicêtre Hospital
Houston, Texas Le Kremlin-Bicêtre, France

xxiv Contributors
John Montford, MD Bruno Mourvillier, MD

Assistant Professor of Medicine Assistant
University of Colorado School of Medicine Medical and Infectious Diseases Intensive Care
Aurora, Colorado Bichat-Claude Bernard Hospital
Paris 7 University
Frederick A. Moore, MD, MCCM Paris, France
Head Ricardo Muñoz, MD, FAAP, FCCM, FACC
Acute Care Surgery Professor
Department of Surgery Departments of Critical Care Medicine, Pediatrics, and Surgery
University of Florida College of Medicine University of Pittsburgh School of Medicine
Gainesville, Florida Chief
Pediatric Cardiac Critical Care
Laura J. Moore, MD Medical Director
Associate Professor of Surgery Global Business and Telemedicine
Chief of Surgical Critical Care Children’s Hospital of Pittsburgh of UPMC
The University of Texas Health Science Center Houston
Medical Director Kurt G. Naber, MD, PhD
Shock Trauma Intensive Care Unit Associate Professor of Urology
Texas Trauma Institute Technical University of Munich
Memorial Hermann Hospital Munich, Germany
Texas Medical Center
Houston, Texas Girish B. Nair, MD, FACP, FCCP
Director
Lisa K. Moores, MD Interstitial Lung Disease Program and Pulmonary Rehabilitation
Associate Dean for Student Affairs Internal Medicine
Office of the Dean Winthrop University Hospital
Professor of Medicine Mineola, New York
F. Edward Hebert School of Medicine Assistant Professor of Clinical Medicine
The Uniformed Services University of the Health Sciences Internal Medicine
Bethesda, Maryland SUNY Stony Brook
Stony Brook, New York
Colleen M. Moran, MD
Assistant Professor Jovany Cruz Navarro, MD
Departments of Anesthesiology and Critical Care Resident Physician
University of Pittsburgh School of Medicine Department of Anesthesiology
Pittsburgh, Pennsylvania Baylor College of Medicine
Houston, Texas
Alison Morris, MD, MS
Associate Professor of Medicine and Immunology Melissa L. New, MD
Division of Pulmonary, Allergy, and Critical Care Medicine Pulmonary and Critical Care Fellow
Vice Chair of Clinical Research Department of Medicine
Department of Medicine University of Colorado Denver
University of Pittsburgh School of Medicine Anschutz Medical Campus
Pittsburgh, Pennsylvania Aurora, Colorado
Thomas C. Mort, MD Jennifer Nguyen-Lee, MD

Assistant Professor of Surgery Assistant Clinical Instructor
University of Connecticut School of Medicine Department of Anesthesiology and Perioperative Medicine
Farmington, Connecticut Liver Transplant Anesthesia
Associate Director David Geffen School of Medicine at UCLA
Surgical Intensive Care Unit Los Angeles, California
Hartford Hospital
Hartford, Connecticut Michael S. Niederman, MD, MACP, FCCP, FCCM, FERS
Clinical Director
Michele Moss, MD Division of Pulmonary and Critical Care
Professor and Vice Chair New York Hospital
Department of Pediatrics Weill Cornell Medicine of Cornell University
University of Arkansas for Medical Sciences New York, New York
Little Rock, Arkansas

Contributors xxv
Alexander S. Niven, MD Joseph E. Parrillo, MD

Professor of Medicine Chairman
Uniformed Services University of the Health Sciences Heart and Vascular Hospital
Bethesda, Maryland Hackensack University Medical Center
Director of Medical Education and DIO Hackensack, New Jersey
Educational Resources Division Professor of Medicine
Madigan Army Medical Center Rutgers New Jersey Medical School
Tacoma, Washington Newark, New Jersey
Juan B. Ochoa, MD Rohit Pravin Patel, MD

Department of Surgery and Critical Care Medicine Assistant Professor
University of Pittsburgh School of Medicine Departments of Emergency Medicine, Anesthesiology, and Surgery
Pittsburgh, Pennsylvania Co-Director
Emergency Medicine Critical Care Fellowship
Mauro Oddo, MD Director of Critical Care Ultrasound
Staff Physician Surgical ICU
Head University of Florida Health Shands Hospital
Clinical Research Unit Gainesville, Florida
Department of Intensive Care Medicine
Centre Hospitalier Universitaire Vaudois (CHUV) – University David L. Paterson, MBBS (Hons), PhD, FRACP, FRCPA,
Hospital GDCE
Faculty of Biology Medicine Professor of Medicine
University of Lausanne Centre for Clinical Research (UQCCR)
Lausanne, Switzerland The University of Queensland
Consultant Infectious Diseases Physician
Patrick J. O’Neill, MD, PhD Department of Infectious Diseases
Clinical Associate Professor of Surgery Royal Brisbane and Women’s Hospital
University of Arizona College of Medicine Brisbane, Australia
Phoenix, Arizona
Trauma Medical Director Andrew B. Peitzman, MD
Abrazo West Campus Trauma Center Distinguished Professor of Surgery
Goodyear, Arizona Mark M. Ravitch Professor and Vice-Chair
University of Pittsburgh Vice President for Trauma and Surgical
Steven M. Opal, MD Services
Professor of Medicine Pittsburgh, Pennsylvania
Infectious Disease Division
The Warren Alpert Medical School of Brown University Daleen Aragon Penoyer, PhD, RN, CCRP, FCCM
Providence, Rhode Island Director
Center for Nursing Research and Advanced Nursing Practice
James P. Orlowski, MD Orlando Health
Division of Pediatric Critical Care Orlando, Florida
Community Hospital
Tampa, Florida Judith L. Pepe, MD
Senior Associate Director, Surgical Critical Care
Catherine M. Otto, MD Department of Surgery
J. Ward Kennedy-Hamilton Endowed Chair in Cardiology Hartford Hospital
Professor of Medicine Hartford, Connecticut
University of Washington School of Medicine Associate Professor of Surgery
Seattle, Washington University of Connecticut Medical Center
Farmington, Connecticut
Aravinda Page, MA, MB BChir, MRCS
Specialist Registrar Steve G. Peters, MD
Cardiothoracic Surgery Professor of Medicine
Papworth Hospital NHS Foundation Trust Division of Pulmonary and Critical Care Medicine
Cambridge, Great Britain Mayo Clinic
Rochester, Minnesota
Adrian Pilatz, MD, PhD

Clinic for Urology, Pediatric Urology, and Andrology
Justus-Liebig-University
Geissen, Germany

xxvi Contributors
Giovanni Piovesana, MD Davinder Ramsingh, MD

Fellow in Cardiothoracic Surgery Director of Clinical Research and Perioperative Ultrasound
Department of Surgery Associate Professor
University of Florida College of Medicine Department of Anesthesiology
Gainesville, Florida Loma Linda Medical Center
Loma Linda, California
Fred Plum, MD†
Department of Neurology Sarangarajan Ranganathan, MD
Weill Cornell Medicine of Cornell University Professor of Pathology
New York, New York University of Pittsburgh School of Medicine
Director of Anatomic Pathology
Kees H. Polderman, MD, PhD Division of Pediatric Pathology
Professor of Critical Care Medicine Children’s Hospital of Pittsburgh of UPMC
University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
V. Marco Ranieri, MD
Murray M. Pollack, MD, MBA Policlinico Umberto I
Professor of Pediatrics Anesthesia and Critical Care Medicine
George Washington University School of Medicine and Health Sapienza Università di Roma
Sciences Rome, Italy
Director
Clinical Outcomes Research Sepehr Rejai, MD
Department of Critical Care Resident
Children’s National Medical Center Department of Anesthesiology and Perioperative Medicine
Washington, DC David Geffen School of Medicine at UCLA
Sebastian Pollandt, MD
Assistant Professor Jorge Reyes, MD
Department of Neurological Sciences Professor of Surgery
Rush University Medical Center Chief
Chicago, Illinois Division of Transplant Surgery
University of Washington School of Medicine
Peter J. Pronovost, MD Seattle, Washington
Professor
Departments of Anesthesiology/Critical Care Medicine and Surgery Joshua C. Reynolds, MD, MS
The Johns Hopkins University School of Medicine Assistant Professor
Baltimore, Maryland Department of Emergency Medicine
Michigan State University College of Human Medicine
Juan Carlos Puyana, MD, FACS, FACCP Grand Rapids, Michigan
Professor of Surgery, Critical Care Medicine, and Translational
Science Arsen D. Ristic, MD, PhD, FESC
Director Associate Professor of Internal Medicine (Cardiology)
Global Health Surgery Belgrade University School of Medicine
University of Pittsburgh School of Medicine Deputy Director
Pittsburgh, Pennsylvania Polyclinic of the Clinical Center of Serbia
Chief
Jin H. Ra, MD, FACS Interventional Pericardiology and Diseases of Pulmonary Circulation
Assistant Professor of Surgery Department of Cardiology
Medical Director, SICU Clinical Center of Serbia
Program Director, SCC Fellowship Belgrade, Serbia
University of Florida College of Medicine
Jacksonville, Florida Claudia S. Robertson, MD
Professor
Thomas G. Rainey, MD Department of Neurosurgery
President Baylor College of Medicine
Critical Medicine Houston, Texas
Bethesda, Maryland
Emmanuel Robin, MD, PhD
Head, Anesthesia—Cardiothoracic Intensive Care
Lille University Hospital
†Deceased. Lille, France

Contributors xxvii
Todd W. Robinson, MD Santhosh Sadasivan, MD

Assistant Professor Senior Research Assistant
Department of Internal Medicine Department of Neurosurgery
Section on Nephrology Baylor College of Medicine
Wake Forest School of Medicine Houston, Texas
Winston-Salem, North Carolina
Howard L. Saft, MD, MSHS
Ferran Roche-Campo, MD Assistant Professor
Intensive Care Department Department of Medicine
Hospital Verge de la Cinta David Geffen School of Medicine at UCLA
Tortosa, Tarragona, Spain VA Greater Los Angeles Healthcare System
Bryan Romito, MD National Jewish Health
Assistant Professor of Anesthesiology and Pain Management Denver, Colorado
University of Texas Southwestern Medical Center
Dallas, Texas Rajan Saggar, MD
Matthew R. Rosengart, MD, MPH David Geffen School of Medicine at UCLA
Associate Professor Los Angeles, California
Departments of Surgery and Critical Care Medicine
University of Pittsburgh Manish K. Saha, MBBS
Pittsburgh, Pennsylvania Postdoctoral Fellow
Department of Internal Medicine
Gordon D. Rubenfeld, MD, MSc Division of Nephrology
Professor of Medicine University of Alabama Birmingham
Interdepartmental Division of Critical Care Medicine Birmingam, Alabama
University of Toronto
Chief Juan C. Salgado, MD
Program in Trauma, Emergency, and Critical Care Assistant Professor of Medicine
Sunnybrook Health Sciences Center Division of Pulmonary, Critical Care, Sleep, and Occupational
Toronto, Ontario, Canada Medicine
Lung Transplantation Program
Lewis J. Rubin, MD Indiana University School of Medicine
Emeritus Professor Indianapolis, Indiana
University of California San Diego Joan Sanchez-de-Toledo, MD, PhD
La Jolla, California Assistant Professor of Medicine
Division of Critical Care
Jeffrey A. Rudolph, MD University of Pittsburgh School of Medicine
Assistant Professor of Pediatrics Clinical Director
University of Pittsburgh School of Medicine Cardiac Intensive Care Unit
Director, Intestinal Care and Rehabilitation Center Children’s Hospital of Pittsburgh of UPMC
Children’s Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania
Vivek R. Sanghani, MD
Mario Rueda, MD Subspecialty Fellow
Assistant Professor of Surgery Adult Nephrology
The Johns Hopkins University School of Medicine Department of Medicine
Baltimore, Maryland Division of Nephrology
Randall A. Ruppel, MD Chapel Hill, North Carolina
Assistant Professor of Pediatrics
Virginia Tech Carilion School of Medicine Cristina Santonocito, MD
Medical Director Department of Anesthesia and Intensive Care
Neonatal/Pediatric Transport Team IRCSS-ISMETT-UPMC
Carilion Clinic Children’s Hospital Palermo, Italy
Roanoke, Virginia

xxviii Contributors
Penny Lynn Sappington, MD Donna L. Seger, MD

Assistant Professor of Critical Care Medicine Associate Professor of Medicine and Emergency Medicine
University of Pittsburgh School of Medicine Vanderbilt University Medical Center
Medical Director Medical Director and Executive Director
Surgical Intensive Care Unit Tennessee Poison Center
University of Pittsburgh Medical Center Nashville, Tennessee
Sixten Selleng, MD
John Sarko, MD Senior Physician
Clinical Attending Physician Department of Anaesthesiology and Intensive Care
Department of Emergency Medicine University Medicine Greifswald
Maricopa Medical Center Greifswald, Germany
University of Arizona—Phoenix School of Medicine
Phoenix, Arizona Frank W. Sellke, MD
Karlson and Karlson Professor of Surgery
Richard H. Savel, MD, FCCM Chief of Cardiothoracic Surgery
Associate Professor The Warren Alpert Medical School of Brown University
Departments of Clinical Medicine and Neurology Providence, Rhode Island
Albert Einstein College of Medicine
Medical Co-Director Kinjal N. Sethuraman, MD, MPH
Surgical Intensive Care Unit Assistant Professor
Montefiore Medical Center Department of Emergency Medicine
New York, New York University of Maryland School of Medicine
Baltimore, Maryland
Irina Savelieva, MD, PhD
Lecturer in Cardiology Robert L. Sheridan, MD
Division of Cardiac and Vascular Sciences Medical Director, Burn Service
St. Georges University of London Shriners Hospital for Children
London, United Kingdom Boston, Massachusetts
Anton C. Schoolwerth, MD Ariel L. Shiloh, MD

Professor of Medicine Assistant Professor of Clinical Medicine and Neurology
Dartmouth University Geisel School of Medicine Director
Lebanon, New Hampshire Critical Care Medicine Consult Service
Albert Einstein College of Medicine
Christopher K. Schott, MD, MS, RDMS Montefiore Medical Center
Assistant Professor New York, New York
Department of Critical Care Medicine
Department of Emergency Medicine Pierre Singer, MD
Director of Critical Care Ultrasonography Department of General Intensive Care
VA Pittsburgh Healthcare Systems and University of Pittsburgh/ Rabin Medical Center
UPMC Petah Tikva and the Sackler School of Medicine
Pittsburgh, Pennsylvania Tel Aviv, Israel
Robert W. Schrier, MD Sumit P. Singh, MBBS, MD

Professor Emeritus Assistant Professor of Anesthesiology and Intensive Care
Department of Medicine David Geffen School of Medicine at UCLA
University of Colorado VA Greater Los Angeles
Aurora, Colorado Los Angeles, California
Carl Schulman, MD Anthony D. Slonim, MD, DrPH

Director Professor of Medicine and Pediatrics
Department of Critical Care University of Nevada School of Medicine
University of Miami Miller School of Medicine President and CEO
Miami, Florida Renown Health
Reno, Nevada

Contributors xxix
Neel R. Sodha, MD Jean-Louis Teboul, MD, PhD

Assistant Professor of Surgery Professor of Medicine
Division of Cardiothoracic Surgery Medical Intensive Care Unit
Director Paris-South University
Lifespan Thoracic Aortic Center Bicêtre University Hospital
The Warren Alpert Medical School of Brown University Le Kremlin-Bicêtre, France
Providence, Rhode Island
Isaac Teitelbaum, MD
Vincenzo Squadrone, MD Professor of Medicine
Department of Anesthesia University of Colorado School of Medicine
Città della Salute e della Scienza Aurora, Colorado
Torino, Italy
Pierpaolo Terragni, MD
Roshni Sreedharan, MD Associate Professor
Clinical Assistant Professor Department of Surgical Sciences
Department of Anesthesiology and Center for Critical Care University of Sassari
Cleveland Clinic Lerner College of Medicine Sassari, Italy
Cleveland, Ohio
Stephen R. Thom, MD, PhD
Steven M. Steinberg, MD Professor
Professor of Surgery Department of Emergency Medicine
The Ohio State University University of Maryland School of Medicine
Columbus, Ohio Baltimore, Maryland
David M. Steinhorn, MD Elizabeth Thomas, DO

Professor of Pediatrics Assistant Professor
Department of Critical Care Department of Surgery
Children’s National Medical Center University of Florida
Washington, DC Gainesville, Florida
Nino Stocchetti, MD Jean-Francois Timsit, MD, PhD

Professor of Anesthesia Intensive Care Decision Sciences in Infectious Disease Prevention
Department of Physiopathology and Transplantation Paris Diderot University
Milan University Paris, France
Director
Neurosurgical Intensive Care Samuel A. Tisherman, MD, FACS, FCCM
Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Professor
Milan, Italy Department of Surgery
R. A. Cowley Shock Trauma Center
Joerg-Patrick Stübgen, MB ChB, MD University of Maryland School of Medicine
Professor of Clinical Neurology Baltimore, Maryland
Weill Cornell Medicine of Cornell University
New York, New York S. Robert Todd, MD, FACS, FCCM
Associate Professor of Surgery
Joseph F. Sucher, MD Baylor College of Medicine
Vice Chairman of Surgery Chief
HonorHealth John C. Lincoln North Mountain Hospital General Surgery and Trauma
Director of Trauma Ben Taub Hospital
John C. Lincoln Deer Valley Hospital Houston, Texas
Phoenix, Arizona
Ashita J. Tolwani, MD, MSc
David Szpilman, MD Professor of Medicine
Medical Director Department of Medicine
Sociedade Brasileira de Salvamento Aquatico Division of Nephrology
Rio de Janeiro Civil Defense University of Alabama at Birmingham
Retired Director Birmingham, Alabama
Drowning Resuscitation Center
Retired Colonel
Fire Department of Rio de Janeiro—Lifeguard
Rio de Janeiro, Brazil

xxx Contributors
Antoni Torres, MD, FCCP Paul M. Vespa, MD, FCCM, FAAN, FANA, FNCS
Professor of Medicine (Pulmonology) Assistant Dean for Research in Critical Care Medicine
Universidad de Barcelona Gary L. Brinderson Family Chair in Neurocritical Care
Director Director of Neurocritical Care
Institut Clínic de Pneumologia i Cirurgia Toràcica Professor of Neurology and Neurosurgery
Hospital Clínic de Barcelona David Geffen School of Medicine at UCLA
Barcelona, Spain University of California Los Angeles
Cody D. Turner, MD
Department of Medicine Jean-Louis Vincent, MD, PhD
Division of Critical Care Professor of Intensive Care
Summa Akron City Hospital Université Libre de Bruxelles
Akron, Ohio Department of Intensive Care
Erasme Hospital
Krista Turner, MD Brussels, Belgium
Medical Director of Trauma
Department of Surgery Florian M.E. Wagenlehner, MD, PhD
The Medical Center of Aurora Professor of Urology
Aurora, Colorado Clinic for Urology, Pediatric Urology, and Andrology
Justus-Liebig-University
Edith Tzeng, MD Giessen, Germany
University of Pittsburgh Justin P. Wagner, MD
Chief of Vascular Surgery Resident
VA Pittsburgh Healthcare System Department of Surgery
Pittsburgh, Pennsylvania David Geffen School of Medicine at UCLA
Benoît Vallet, PhD
Professor of Anesthesiology and Critical Care Paul Phillip Walker, BMedSci (Hons), BM BS, MD
Lille University School of Medicine Consultant Physician
Lille University Hospital Respiratory Medicine
Lille, France University Hospital Aintree
Honorary Senior Lecturer
Greet Van den Berghe, MD, PhD Respiratory Research Department
Professor of Medicine University of Liverpool
Division of Intensive Care Medicine Liverpool, Great Britain
Katholieke Universiteit Leuven
Leuven, Belgium Keith R. Walley, MD
Professor
Arthur R.H. van Zanten, MD, PhD Department of Medicine
Hospital Medical Director University of British Columbia
Department of Intensive Care Vancouver, British Columbia, Canada
Gelderse Vallei Hospital
Ede, The Netherlands Robert J. Walter, MD
Brandywine Pediatrics
Floris Vanommeslaeghe, MD Wilmington, Delaware
Renal Division
Ghent University Hospital Kevin K.W. Wang, PhD
Ghent, Belgium Executive Director
Center for Neuroproteomics and Biomarker Research
Ramesh Venkataraman, AB Associate Professor
Consultant in Critical Care Medicine Department of Psychiatry
Academic Coordinator McKnight Brain Institute
Department of Critical Care University of Florida
Apollo Hospitals Gainesville, Florida
Chennai, India
Tisha Wang, MD
Kathleen M. Ventre, MD Associate Clinical Professor
Assistant Professor of Pediatrics Division of Pulmonary and Critical Care
University of Colorado School of Medicine David Geffen School of Medicine at UCLA
Children’s Hospital Colorado Los Angeles, California
Aurora, Colorado

Contributors xxxi
Nicholas S. Ward, MD Richard G. Wunderink, MD

Associate Professor of Medicine Professor of Medicine
Division of Critical Care, Pulmonary and Sleep Medicine Division of Pulmonary and Critical Care
The Warren Alpert Medical School at Brown University Northwestern University Feinberg School of Medicine
Providence, Rhode Island Medical Director, Medical ICU
Northwestern Memorial Hospital
Lorraine B. Ware, MD Chicago, Illinois
Professor of Medicine and Pathology, Microbiology, and
Immunology Christopher Wybourn, MD
Division of Allergy, Pulmonary, and Critical Care Medicine Trauma/Critical Care Fellow
Vanderbilt University School of Medicine Department of Surgery
Nashville, Tennessee University of California San Francisco
San Francisco General Hospital
Gregory A. Watson, MD, FACS San Francisco, California
Assistant Professor of Surgery and Critical Care
University of Pittsburgh School of Medicine Zhihui Yang, PhD
Pittsburgh, Pennsylvania Associate Scientific Director and Senior Scientist
Center for Neuroproteomics and Biomarkers Research
Lawrence R. Wechsler, MD Department of Psychiatry and Neuroscience
Henry B. Higman Professor and Chair University of Florida College of Medicine
Department of Neurology Gainesville, Florida
Pittsburgh, Pennsylvania Lonny Yarmus, DO
Wolfgang Weidner, MD, PhD Clinical Chief
Professor of Urology Division of Pulmonary and Critical Care
Clinic for Urology, Pediatric Urology, and Andrology Johns Hopkins University School of Medicine
Justus-Liebig-University Baltimore, Maryland
Giessen, Germany
Sachin Yende, MD, MS
Charles Weissman, MD Associate Professor
Professor and Chair Departments of Critical Care Medicine and Clinical and
Department of Anesthesiology and Critical Care Medicine Translational Sciences
Hadassah-Hebrew University Medical Center Director
Hebrew University—Hadassah School of Medicine Clinical Epidemiology Program
Jerusalem, Israel CRISMA Center
Mark H. Wilcox, MD Vice President
Professor and Head of Medical Microbiology Critical Care
University of Leeds Faculty of Medicine and Health VA Hospital Pittsburgh
Leeds General Infirmary NHS Trust Pittsburgh, Pennsylvania
Leeds, United Kingdom
Stephanie Grace Yi, MD
Keith M. Wille, MD, MSPH Abdominal Transplant Surgery Fellow
Associate Professor of Medicine Houston Methodist Hospital
Department of Internal Medicine Houston, Texas
Division of Pulmonary and Critical Care
University of Alabama Birmingham Dongnan Yu, MD
Birmingham, Alabama Attending Physician
Department of Anesthesiology
Michel Wolff, MD Guangdong General Hospital
Head Guangdong Academy of Medical Sciences
Medical and Infectious Diseases Intensive Care Guangzhou, Guangdong, China
Bichat-Claude Bernard Hospital
Paris, France Felix Yu, MD
Division of Pulmonary, Critical Care and Sleep Medicine
Tufts Medical Center
Boston, Massachusetts

xxxii Contributors
Roger D. Yusen, MD, MPH Allyson R. Zazulia, MD

Associate Professor of Medicine Associate Professor
Division of Pulmonary and Critical Care Medicine Departments of Neurology and Radiology
Washington University School of Medicine in St. Louis Associate Dean
St. Louis, Missouri Continuing Medical Education
Washington University
St. Louis, Missouri

IN MEMORIAM
MITCHELL P. FINK, MD
This edition of the Textbook of Critical Care is dedicated to the revising the textbook that served as the backbone for the Sixth
late Mitchell P. Fink, MD. Dr. Fink was Professor of Surgery and and this new Seventh Edition, which he also importantly helped
Vice Chair for Critical Care at the University of California Los to formulate. Mitch was a great friend and colleague to each of
Angeles and an international leader and giant in the field of us, and he will be dearly missed by us and by the entire field.
critical care medicine. He was the lead author of the Fifth We are confident that his visionary work on this book will serve,
Edition of this textbook. In the Fifth Edition, Dr. Fink inspired through its users, to improve the care and outcomes of critically
a novel, informative, user-friendly, and exciting approach to ill adults and children worldwide for many years into the future.

To my family and friends and all who can contribute to make a better world
— Jean-Louis Vincent
To Norma-May, my true love. To Claire and Erin, who bring me the greatest joy,
and to my mother, Dale Abraham, for her support throughout my life
— Edward Abraham
To my father, Ernest E. Moore, who was a family practitioner for 50 years in Butler,
Pennsylvania. He inspired me by his dedication to self-education, humility,
and service to his community
— Frederick A. Moore
To my family, friends, colleagues, and staff for their sacrifices, support, and
dedication, and to the late Dr. Peter Safar for inspiring each of us to bring promising
new therapies to the bedside of the critically ill
— Patrick M. Kochanek

1 Sudden Deterioration in Neurologic Status
Joseph M. Darby and Anupam Anupam
P
atients admitted to the intensive care unit (ICU) with critical stupor to coma) frequently represents the development of brain edema,
illness or injury are at risk for neurologic complications.1-5 A increasing intracranial pressure, new or worsening intracranial hemor-
sudden or unexpected change in the neurologic condition of a rhage, hydrocephalus, CNS infection, or cerebral vasospasm. In
critically ill patient often heralds a complication that may cause direct patients without a primary CNS diagnosis, an acute change in con-
injury to the central nervous system (CNS). Alternatively, such changes sciousness is often due to the development of infectious complications
may simply be neurologic manifestations of the underlying critical (i.e., sepsis-associated encephalopathy), drug toxicities, or the develop-
illness or treatment that necessitated ICU admission (e.g., sepsis). These ment or exacerbation of organ system failure. Nonconvulsive status
complications can occur in patients admitted to the ICU without neu- epilepticus is increasingly being recognized as a cause of impaired
rologic disease and in those admitted for management of primary CNS consciousness in critically ill patients (Box 1-1).44-53
problems (e.g., stroke). Neurologic complications can also occur as a States of altered consciousness manifesting as impairment in wake-
result of invasive procedures and therapeutic interventions performed. fulness or arousal (i.e., coma and stupor) and their causes are well
Commonly, recognition of neurologic complications is delayed or defined.42,43,54,55 Much confusion remains, however, regarding the diag-
missed entirely because ICU treatments (e.g., intubation, drugs) inter- nosis and management of delirium, perhaps the most common state
fere with the physical examination or confound the clinical picture. In of impaired CNS functioning in critically ill patients at large. When
other cases, neurologic complications are not recognized because of a dedicated instruments are used, delirium can be diagnosed in more
lack of sensitive methods to detect the problem (e.g., delirium). Mor- than 80% of critically ill patients, making this condition the most
bidity and mortality are increased among patients who develop neu- common neurologic complication of critical illness.56-58 Much of the
rologic complications; therefore, the intensivist must be vigilant in difficulty in establishing the diagnosis of delirium stems from the belief
evaluating all critically ill patients for changes in neurologic status. that delirium is a state characterized mainly by confusion and agitation
Despite the importance of neurologic complications of critical and that such states are expected consequences of the unique environ-
illness, few studies have specifically assessed their incidence and impact mental factors and sleep deprivation that characterize the ICU experi-
on outcome among ICU patients. Available data are limited to medical ence. Terms previously used to describe delirium in critically ill
ICU patients; data regarding neurologic complications in general sur- patients include ICU psychosis, acute confusional state, encephalopathy,
gical and other specialty ICU populations must be extracted from and postoperative psychosis. It is now recognized that ICU psychosis is
other sources. In studies of medical ICU patients, the incidence of a misnomer; delirium is a more accurate term.59
neurologic complications is 12.3% to 33%.1,2 Patients who develop Currently accepted criteria for the diagnosis of delirium include
neurologic complications have increased morbidity, mortality, and abrupt onset of impaired consciousness, disturbed cognitive func-
ICU length of stay. Sepsis is the most common problem associated with tion, fluctuating course, and presence of a medical condition that
development of neurologic complications (sepsis-associated encepha- could impair brain function.60 Subtypes of delirium include hyperac-
lopathy). In addition to encephalopathy, other common neurologic tive (agitated) delirium and the more common hypoactive or quiet
complications associated with critical illness include seizures and delirium.58 Impaired consciousness may be apparent as a reduction
stroke. As the complexity of ICU care has increased, so has the risk of in awareness, psychomotor retardation, agitation, or impairment in
neurologic complications. Neuromuscular disorders are now recog- attention (increased distractibility or vigilance). Cognitive impairment
nized as a major source of morbidity in severely ill patients.6 Recog- can include disorientation, impaired memory, and perceptual aber-
nized neurologic complications occurring in selected medical, surgical, rations (hallucinations or illusions).61 Autonomic hyperactivity and
and neurologic ICU populations are shown in Table 1-1.7-41 sleep disturbances may be features of delirium in some patients (e.g.,
those with drug withdrawal syndromes, delirium tremens). Delirium
in critically ill patients is associated with increased morbidity, mor-
IMPAIRMENT IN CONSCIOUSNESS tality, and ICU length of stay.62-64 In general, sepsis and medications
Global changes in CNS function, best described in terms of impair- should be the primary etiologic considerations in critically ill patients
ment in consciousness, are generally referred to as encephalopathy or who develop delirium.
altered mental status. An acute change in the level of consciousness, As has been noted, nonconvulsive status epilepticus is increasingly
undoubtedly, is the most common neurologic complication that occurs recognized as an important cause of impaired consciousness in criti-
after ICU admission. Consciousness is defined as a state of awareness cally ill patients. Although the general term can encompass other enti-
(arousal or wakefulness) and the ability to respond appropriately to ties, such as absence and partial complex seizures, in critically ill
changes in environment.42 For consciousness to be impaired, global patients, nonconvulsive status epilepticus is often referred to as status
hemispheric dysfunction or dysfunction of the brainstem reticular epilepticus of epileptic encephalopathy.53 It is characterized by alteration
activating system must be present.43 Altered consciousness may result in consciousness or behavior associated with electroencephalographic
in a sleeplike state (coma) or a state characterized by confusion and evidence of continuous or periodic epileptiform activity without overt
agitation (delirium). States of acutely altered consciousness seen in the motor manifestations of seizures. In a study of comatose patients
critically ill are listed in Table 1-2. without overt seizure activity, nonconvulsive status epilepticus was
When an acute change in consciousness is noted, the patient should evident in 8% of subjects.51 Nonconvulsive status epilepticus can
be evaluated, keeping in mind the patient’s age, presence or absence of precede or follow an episode of generalized convulsive status epilepti-
coexisting organ system dysfunction, metabolic status and medication cus; it can also occur in patients with traumatic brain injury, subarach-
list, and presence or absence of infection. In patients with a primary noid hemorrhage, global brain ischemia or anoxia, sepsis, and multiple
CNS disorder, deterioration in the level of consciousness (e.g., from organ failure. Despite the general consensus that nonconvulsive status
2 Downloaded from ClinicalKey.com By Mahmoud El Morsy January 11, 2017.

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Arad was undeniably frightened. Although he might explain the fact
of his opening Don’s letter as eminently proper, to himself, he well
knew that he could not make these friends of his nephew see it in
the same light.
“I—I—it came arter Brandon went away,” he gasped in excuse.
“It did, hey?” exclaimed Caleb suspiciously.
Mr. Pepper took the envelope again and examined the postmark
critically.
“Hum—um,” he said slowly, “postmarked in New York on the third;
received on the afternoon of the fourth at the Chopmist post office.
I’m afraid, my dear sir, that that yarn won’t wash.”
Uncle Arad was speechless, and looked from one to the other of the
stern faced men in doubt.
“He—he was my nevvy; didn’t I hev a right ter see what he had
written ter him?”
“You can bet ye didn’t,” Caleb declared with confidence, and with a
slight wink at Adoniram. “Let me tell ye, Mr. Tarr, that openin’ other
folks’ correspondence is actionable, as the lawyers say. I reckon that
you’ve laid yourself li’ble to gettin’ arrested yourself, old man.”
“Ye—ye can’t do it,” sputtered Arad.
“If that monkey of a sheriff finds Brandon (w’ich same I reckon he
won’t), we’ll see if we can’t give you a taste of the same medicine.”
The old man was undeniably frightened and edged towards the door.
“I guess I better go,” he remarked hesitatingly. “I dunno as that
officer’ll be able ter ketch thet reskil.”
“No, I don’t b’lieve he will myself,” Caleb declared. “And if you want
to keep your own skin whole, you’d best see that he doesn’t touch
the lad.”
Old Arad slunk out without another word, and the two friends allowed
him to depart in contemptuous silence.
When he had disappeared Adoniram turned to the sailor at once.
“Where has Don gone, Caleb?” he asked anxiously.
“You’ve got me. He told me he was goin’ to skip, and for us to go
ahead with the preparations for getting off next week, just the same.
He’d lay low till the old scamp had given it up, and then slip aboard
the steamer. Oh, the boy’s all right.”
“He is, if that sheriff doesn’t find him,” said the merchant doubtfully.
“I’ll risk that,” responded Caleb, who had vast confidence in
Brandon’s ability to take care of himself.
But Adoniram shook his head.
“New York is a bad place for a boy to be alone in. Where will he go?”
“Down to the pier, I reckon, and hide aboard the steamer. I’ll agree to
put him away there so that no measly faced sheriff like that fellow
can find him.”
“It’s a bad business,” declared Mr. Pepper, shaking his head slowly.
“If he hadn’t run off there might have been some way of fixing it up
so that he wouldn’t have had to go back to Rhode Island, and thus
delay the sailing of the steamer. We might have scared the uncle out
of prosecuting him. He was badly frightened as it was.”
Caleb gazed at his friend for several moments with a quizzical smile
upon his face.
“Do you know, Adoniram,” he said at length, “I b’lieve you’re too
innocent for this wicked world.”
“How do you mean?” asked the merchant, flushing a little, yet
smiling.
“Well, you don’t seem to see anything fishy in all this.”
“Fishy?”
“Yes, fishy,” returned Caleb, sitting down and speaking confidentially.
“Several things make me believe that you (and me, too) haven’t
been half awake in this business.”
“I certainly do not understand you,” declared Adoniram.
“Well, give me a chance to explain, will you?” said the sailor
impatiently. “You seem to think that this old land shark of an uncle of
the boy’s is just trying to get him back on the farm, and has hatched
up this robbery business for that purpose? I don’t suppose you think
Don stole any money from him, do you?” he added.
“Not for an instant!” the merchant replied emphatically.
“That’s what I thought. Well, as I say, you suppose he wants
Brandon back on the farm—wants his work, in fact?”
“Ye—es.”
“Well, did it ever strike you, ’Doniram,” Caleb pursued, with a smile
of superiority on his face—“did it ever strike you that if he was
successful in proving Brandon guilty, the boy would be locked up and
then nobody would get his valuable services—nobody except the
State?”
“Why, that’s so.”
“Of course it’s so.”
“Then, what is his object in persecuting the poor lad? Is he doing it
just out of spite?”
“Now, see here; does that look reasonable? Do you think for a
moment that an old codger like him—stingy as they make ’em—d’ye
think he’d go ter the expense o’ comin ’way down here to New York
out of revenge simply? Well, I guess not!”
“Then, what is he up to?” demanded Adoniram, in bewilderment.
“Well, of that I’m not sure, of course; but,” said Caleb, with
vehemence, “I’m willing to risk my hull advance that he’s onter this
di’mond business.
“Why, Pepper, how could he help being? Didn’t he get that letter of
mine, an’ didn’t I give the hull thing away in it, like the blamed idiot I
was? Man alive, a sharper like that feller would sell his immortal soul
for a silver dollar. What wouldn’t he for a big stake like this?”
“But—” began Adoniram.
“Hold on a minute and let me finish,” urged Caleb. “That scoundrel
Leroyd was up to Chopmist, mind ye. Who knows but what he an’
old Arad Tarr have hitched hosses and gone inter this together? I
haven’t told either you or Brandon, for I didn’t want to worry you, but
I learned yesterday that Jim is tryin’ ter charter a craft of some kind—
you an’ I know what for.
“He’s got no money; what rascal of a sailor ever has? He must have
backing, then. And who is more likely to be the backer than the old
sharper who’s just gone out of here! I tell ye, ’Doniram, they’re after
them di’monds, and it behooves us ter git up an’ dust if we want ter
beat ’em.”
The ship owner shook his head unconvinced.
“You may be right, of course, Caleb; I don’t say it is an impossibility.
But it strikes me that your conclusions are rather far fetched. They
are not reasonable.”
“Well, we’ll see,” responded the old seaman, pursing up his lips. “I
shall miss Brandon’s help—a handier lad I never see—but he will
have to lay low till after the whaleback sails.”
He went back to the work of getting the steamer ready for departure,
expecting every hour that Brandon would appear. But the captain’s
son did not show up that day, nor the next.
Monday came and Number Three was all ready for sailing. Her crew
of twenty men, beside the officers, were aboard.
The first and third mates were likewise present, the former, Mr.
Coffin, being a tall, shrewd looking, pleasant faced man, who
eternally chewed on the end of a cigar (except when eating or
sleeping) although he was never seen to light one; and Mr. Bolin, the
third, a keen, alert little man who looked hardly older than Brandon
himself.
But Brandon did not come. The new captain of the whaleback, and
the owner himself, were greatly worried by the boy’s continued
absence.
They had already set on foot inquiry for the youth’s whereabouts, but
nothing had come of it.
They did discover that Uncle Arad had gone back to Rhode Island,
and gone back alone. The “scaly” ward politician who held the
onerous position of deputy sheriff, and who had sought to arrest the
boy, had not been successful, Brandon’s friends knew, for the man
haunted the pier at which the whaleback lay, day and night.
“If he don’t come tonight, Adoniram,” Caleb declared, “we shall sail in
the morning, just the same—and that by the first streak of light, too.
You will be here, and I can trust you to look out for the lad. I must be
away after those di’monds. Don’ll turn up all right, I know right well;
and we mustn’t let them swabs get ahead of us, and reach the brig
first.”
He had taken the precaution ere this to have his own and Brandon’s
effects brought down to the boat. He was ready, in fact, to cast off
and steam away from the dock at a moment’s notice.
As the evening approached Caleb ordered the fires built under the
boilers, and everything to be made ready for instant departure.
Adoniram Pepper came down after dinner and remained in the
whaleback’s cabin, hoping to see Brandon once again before the
steamer sailed.
Caleb was too anxious to keep still at all, but tramped back and forth,
occasionally making trips to the wheelman’s turret in which he had
stationed Mr. Coffin and one of the sailors, so as to have no delay in
starting, no matter what should happen.
“By Jove, this beats blockade running at Savannah in the sixties,”
muttered the first mate, after one of his commander’s anxious trips to
the forward turret to see that all was right. “This youngster they’re
taking all this trouble for must be a most remarkable boy.”
“There’s two fellows watching the steamer from the wharf,” Caleb
declared, entering the cabin again.
Just then there was a sound outside, and a heavy knock sounded at
the cabin door. Caleb pulled it open in an instant.
Without stood three burly police officers.
“Well, well!” exclaimed Mr. Pepper, in wonder.
“What do you want?” Caleb demanded, inclined to be a little
combative.
“Beg pardon, sir,” said the spokesman of the two, nodding
respectfully to Mr. Pepper, “but we’ve been sent to search the
steamer for a boy against whom this man holds a warrant,” and the
officer motioned to a third individual who stood without. It was the
deputy sheriff.
“Very well,” said Mr. Pepper quietly.
“Search and be hanged,” growled Caleb, glowering at the man with
the warrant. “If you can find him you’ll have better luck than we.”
He refused to assist them in any way, however, and Mr. Bolin politely
showed the party over the whole steamer. But of course, they found
not a sign of Brandon.
After nearly an hour’s search the officers gave it up and departed,
Caleb hurling after them several sarcastic remarks about their
supposed intellectual accomplishments—or rather, their lack of such
accomplishments.
The deputy sheriff, whose name was Snaggs, by the way, would not
give it up, however, but still remained on the wharf.
Mr. Coffin, who had begun to take a lively interest in the
proceedings, was pacing the inclined deck of the whaleback on the
side furtherest from the pier, a few minutes past midnight (everybody
on board was still awake at even this late hour) when his ear caught
the sound of a gentle splash in the black waters just below him.
He stopped instantly and leaned over the rail.
“Hist!” whispered a voice out of the darkness. “Toss me a rope. I
want to come aboard.”
Mr. Coffin was not a man to show his emotions, and therefore,
without a word, he dropped the end of a bit of cable into the water,
just where he could see the faint outlines of the owner of the voice.
Hidden by the wheelhouse from the view of anybody who might be
on the wharf, he assisted the person aboard, and in a minute the
mysterious visitor stood upon the iron plates at Mr. Coffin’s side.
CHAPTER XXVIII
THE DEPARTURE OF THE WHALEBACK,
NUMBER THREE
No emergency was ever too great for Lawrence Coffin. The

appearance of the stranger whom he had lifted over the rail to the
steamer’s deck may have surprised him; but he gave no visible sign.
The instant the fellow was on his feet, Mr. Coffin slid open the door
of the wheelhouse and pushed the newcomer in.
“Jackson,” he said sharply, to the man inside, “go for Captain
Wetherbee.”
Then he turned to the dripping figure that stood just within the door
of the turret.
The stranger was a youth of fifteen or sixteen, with a sharp,
intelligent face, and his saturated clothing was little more than rags.
“Hullo!” said the mate, “you’re not Brandon Tarr, I take it.”
“You kin bet on that, mister,” responded the youth grinning. “An’ you,
I reckon, ain’t Cale Wetherbee. He’s got a wooden leg.”
“I’ve sent for Mr. Wetherbee,” replied Mr. Coffin. “What do you want?”
“I’ll tell th’ boss, wot I was told ter see,” declared the fellow shrewdly.
The youth was evidently of that great class of individuals known as
“street gamins” who, in New York City, are numbered by the
thousand.
He was thin and muscular, quick in his movements, and his eyes
were shifty and uneasy, not from any lack of frankness or honesty,
perhaps, but because his mode of life forced him to be ever on the
watch for what might “happen next.”
Mr. Coffin had hardly made this mental inventory of the fellow, when
Caleb, accompanied by Mr. Pepper, came forward. The strange
youth evidently recognized the captain of the whaleback at once as
the individual he wished to see.
“You’re Captain Wetherbee,” he said quickly fumbling in the inside of
his coarse flannel shirt (the shirt and trousers were all he had on) “I
got somethin’ fur you from Brandon Tarr.”
“Where is he?” cried Mr. Pepper, in great excitement.
“He’s gone to sea, boss,” responded the boy calmly.
“Hey!” roared Caleb, and then the messenger brought forth that
which he was fumbling for—a little waterproof matchbox.
“Gone to sea?” repeated Adoniram, in bewilderment.
“Dat’s it,” said the boy. “He went day ’fore yest’day mornin’ in de
Success.”
But Caleb had opened the matchbox and drawn forth the folded
paper it contained.
“It’s a letter—the young rascal! Why didn’t he come himself?”
“Didn’t I tell ye he’d gone ter sea?” demanded the youth in disgust.
“Listen to this,” exclaimed Caleb, paying not the least attention to the
messenger’s words, and he read the closely written page aloud:
“Dear Caleb—Swivel is going to make a break with this
letter for me, although the Success sails, we understand,
in an hour or two. He can tell you how I came aboard
here, so I won’t stop to do that.
“What I want to say is, that Leroyd is aboard and that the
brig will touch at Savannah for Mr. Pepper’s old clerk, Mr.
Weeks, who is in the plot to find the Silver Swan, too. I
shall leave her at Savannah if it is a possibility.
“If you get into Savannah while she is there, however, and
I don’t appear, try to find some way of getting me out. I’m
afraid of Leroyd—or, that is, I should be if he knew I was
here.
“I’ve got enough to eat and drink to last me a long time
and am comfortable. I can make another raid on the
pantry, too, if I run short.
“Look out for Swivel; he’s a good fellow. He can tell you all
that I would like to, if space and time did not forbid.
“Yours sincerely,
“Brandon Tarr.
“P. S. We’ll beat these scamps and get the Silver Swan
yet.”
“Well, well!” commented Mr. Pepper, in amazement. “What will that
boy do next?”
“The young rascal!” Caleb exclaimed in vexation. “What does he
mean by cutting up such didoes as this? Aboard the very vessel the
scoundrels have chartered, hey?”
“But how did he get there?” cried Adoniram wonderingly.
“This young man ought to be able to tell that,” suggested Mr. Coffin,
referring to the dripping youth.
Caleb looked from the open letter to the boy.
“So you’re Swivel, eh?” he demanded.
The lad grinned and nodded.
“Well, suppose you explain this mystery.”
But here Adoniram interposed.
“Let us take him to the cabin, and give him something dry to put on.
He’ll catch his death of cold here.”
“’Nough said. Come on,” said Caleb leading the way.
Fifteen minutes later the youth who rejoiced in the name of Swivel
was inside of warm and dry garments, several sizes too large for
him, and was telling his story to a most appreciative audience.
I will not give it in detail, and in Swivel’s bad grammar; a less
rambling account will suffice.
When Brandon Tarr had made his rapid retreat from the office of
Adoniram Pepper and Co. he had run across the street, dodged
around the first corner, and then walked hastily up town. He
determined to keep away from the office for the remainder of the day,
hoping to tire out both Uncle Arad and the deputy sheriff.
Finally he took a car and rode over to Brooklyn, and it was there that
he fell in with Swivel, who was a veritable street gamin—a “wharf-rat”
even—though a good hearted and not an altogether bad principled
one.
It being a time in the day when there were no papers to sell, Swivel
(wherever the boy got the name he didn’t know, and it would have
been hard to trace its origin) was blacking boots, and while he
shined Brandon’s the two boys scraped up an acquaintance.
Fearing that Uncle Arad or the officer, or perhaps both, would be on
the watch about the shipping merchant’s office, or the steamer dock,
Brandon decided that Swivel would be a good one to have along
with him to send ahead as “scout,” and for a small sum the gamin
agreed.
Brandon was a country boy, and was unfamiliar with city ways or city
conveniences. It never crossed his mind to use the telephone
communicating with his friends, and Swivel knew very little about
telephones, any way.
So they waited until toward evening and then came back to New
York.
Water Street and its vicinity, and the docks, were as familiar to
Swivel as were the lanes and woods of Chopmist to Brandon. By
devious ways the gamin led the captain’s son to the ship owner’s
office, but it was quite dark by that time and the place was closed.
So they went to the pier at which the whaleback lay, and here Swivel
showed that he was of great use to Brandon, for had it not been for
him, his employer would have run straight into a trap. The deputy
sheriff, Snaggs, was watching the steamer, and no less a person
than Mr. Alfred Weeks himself, was talking with him.
By careful maneuvering the two boys got into a position from which
they could hear some of the conversation of the two rascals; but the
way to the steamer was right under Snaggs’ eye, and Brandon dared
not attempt it.
By intently listening, the captain’s son heard several important items
of news, and, greatly to his astonishment, discovered that Uncle
Arad, Leroyd, and Mr. Weeks himself were playing right into each
other’s hands, and that their object was to keep Brandon from
getting back to his friends, and thus delay the sailing of the
whaleback so that the craft on which the plotters expected to sail
might get away first.
Snaggs was to keep a sharp lookout from the shoreward side of the
whaleback and there was already a man in a boat patroling the
riverside that Brandon might not return from that direction, and a
third person was “shadowing” Adoniram Pepper’s residence. The
ship owner’s office would be watched during the day.
As soon as Brandon made his appearance he was to be seized at
once on the strength of the Rhode Island warrant and sent back to
Chopmist. This, the conspirators hoped, would keep Caleb
Wetherbee from sailing for several weeks, and by that time Leroyd
and the ex-clerk expected to overhaul the Silver Swan—that is, this
is what Weeks and Leroyd themselves were planning to do; but the
former took care to say nothing about the Silver Swan to the deputy
sheriff.
Finding that there was no chance to get aboard the whaleback just
then, and having heard Weeks say that he was going to meet Leroyd
and that they two were to go that night and see the vessel and her
commander, Brandon decided to follow them, and find out the name
of the craft and where she lay, believing that the information would
be of value to himself and to his friends.
Piloted by Swivel, Brandon followed “Sneaky Al” to the New England
Hotel and while the ex-clerk went inside for Leroyd the two boys
waited without, and then took up the trail again when the two
conspirators appeared.
The sailor and Weeks went over to Brooklyn and after two hours’
dodging and running and hiding, they tracked the rascals to the brig
Success, lying at a Brooklyn wharf.
Brandon decided that it would never do to be so near and not hear
the plans the villains made with the captain of the Success, so he
rashly crept aboard and listened to the conversation at the cabin
skylight. And this was when he got into trouble.
He heard the two plotters agree with the captain of the vessel (who
was not in the scheme at all) to pay two hundred dollars for six
week’s use of the brig, providing the Success put to sea at once.
She already had a very fair cargo for Savannah, and the agreement
was that she should put in at that port for the time necessary for the
cargo to be landed.
Thus, of course, the captain, who was the owner as well, was going
to make a very good thing out of it, indeed. He asked no questions
as to what use the brig was to be put to; and he agreed to allow
Leroyd to accompany him to Savannah, where Weeks would meet
them.
Brandon made a shrewd guess that the ex-clerk was to remain in
New York until he was certain of his capture and incarceration; then
he would reach Savannah by steamer.
It was quite evident that the two rascals had managed to “boil” more
money out of old Arad Tarr than they had first expected, and could
afford to be more lavish with their funds.
But, as I said, the boys, by venturing aboard the Success, got into
trouble. Somebody came aft while they were listening to the
conference below, and to escape discovery, they dodged down the
after hatch.
The crew of the Success were already aboard, and the two men who
constituted the “anchor watch” remained near the open hatchway
(the other hatches were battened down), and the two boys were
unable to leave the hold.
Morning came, and found them still there. The cargo was nearly all
in, and the crew went to work to finish the lading by daylight.
Brandon and Swivel retreated into the bows of the vessel, and
managed to remain hidden all day.
They did not dare leave the hold, although they suffered extremely
from lack of food and water, for Leroyd had come aboard to
superintend the work, and would have seen them.
At evening the hatches were battened down, and the unintentional
stowaways were left in darkness. But Swivel, who a shrewd and
sharp eyed lad, had noticed a small door in the cabin bulkhead by
which the cook doubtless entered the hold for provisions from time to
time.
With their pocket knives they forced the fastenings of this door and
Swivel made a raid into the pantry, which was left unguarded, and
returned laden with provisions enough to last them a week if need
be. He secured a big “beaker” of water, too.
Brandon also discovered the ship’s provisions stored near the bows,
and was sure that he could stand a siege.
Leroyd, they ascertained, hardly ever left the cabin or deck of the
Success, and Brandon dared not venture out. At last, after talking the
whole matter over, Swivel agreed to take the risk of giving himself up
as a stowaway, and thus get put ashore before the brig started.
Then he was to make his way to the whaleback and explain
Brandon’s situation to Caleb.
The captain’s son wrote his letter and placed it in the matchbox,
which Swivel in turn had hidden in the breast of his shirt. Then the
gamin pounded on the hatch until the crew heard him and let him
out.
Naturally the captain of the Success was angry enough, for the brig
was already to sail, and they were getting the lines cast off, so he
summoned a night watchman from the dock, who took the unlucky
Swivel in charge and handed him over to a policeman.
This was a phase of the situation which neither of the boys had
considered. But there was no way out of it, and the gamin spent the
day in the police station, for it was Sunday.
He was brought before the magistrate the next morning, but of
course there was nobody to appear against him, so he was
discharged with a reprimand. The police captain, however, kept him
busy about the station until late in the afternoon, before he would let
him go.
“He kep’ me jugglin’ wid er mop er wipin’ up de floor,” as the gamin
expressed it to his hearers.
As soon as he was free he had hurried to the New York side; but
upon reaching the vicinity of the whaleback he discovered that the
“patrol line” was drawn even closer than before.
Snaggs and two of his friends were on duty, for as the time
approached for the sailing, they decided that if Brandon came back
he would do so very soon.
Swivel had seen the raid the policemen made under the deputy’s
instigation, and after the bluecoats were safely out of the way, he
had slipped into the water and made for the steamer.
“An’ here I is,” he said, in conclusion. “Dey didn’t ketch me, nor dat
Brandon Tarr, nuther. We’s too fly for ’em.”
“Of all the scrapes I ever heard of, this is the worst,” Adoniram
exclaimed in comment.
But Caleb, now that his fears for Don’s safety were somewhat
allayed, seemed rather to enjoy the situation.
“Oh, that boy’s smart,” he declared, with a chuckle. “I’ll risk him even
if he is in that vessel’s hold. Leroyd won’t get the best of him.
Probably, too, the captain of the Success is not a bad sort of a fellow,
an’ he won’t see the boy maltreated.
“I feel better, ’Doniram, and with your permission we’ll get under way
at once.”
“But what shall we do with this lad?” asked the little merchant,
nodding and smiling at Swivel. “He’s deserving of much praise for his
honesty and faithfulness.”
“Oh, take me along, will yer?” exclaimed the gamin, with eagerness.
“I’ll work hard ef ye will! I jest wanter see dis thing out, I do! I like dat
Brandon Tarr, an’ I wanter see him git the di’monts wot he said was
on dat wreck yer arter. Say, lemme go, will yer?”
Caleb looked at the ship owner in perplexity.
“Oh, take him, Caleb,” said Adoniram quickly. “It may be the making
of the lad to get him off the city streets. He deserves it.”
“So be it then,” said Caleb, rising. “Now, Mr. Coffin and Mr. Bolin—to
work! You’ll have to go ashore at once, Adoniram. I shall have
Number Three out of her berth in half an hour.”
Steam was got up, the crew flew about their several duties under the
energetic commands of the officers, and within a short time the
whaleback, to the manifest disappointment of Mr. Snaggs, who
watched proceedings from the shadow of the wharf, cast off her lines
and steamed down the bay into the darkness of the night.
Thus did she begin the voyage whose object was the finding of the
wreck of the Silver Swan.
CHAPTER XXIX
THE STOWAWAY ABOARD THE SUCCESS
As we know, Brandon Tarr had no intention of remaining long away

from his friends when he slipped out of Adoniram Pepper’s office to
escape arrest on the fraudulent charge of robbery, concocted by
Uncle Arad.
The events which followed, however, made it necessary for him to
remain away, and, finally, to go to sea as a stowaway in the hold of
the Success, the vessel chartered by the conspirators to make
search for the Silver Swan.
After the friendly street gamin, Swivel, left him in the hold, in the
early hours of Sunday morning, Brandon of course had no means of
knowing what had become of him—whether he had accomplished
his purpose of getting away from the brig before she sailed, or
whether, because she was short handed, the captain of the Success
had retained him.
After Swivel was let up on deck, and the hatch closed, however,
Brandon heard nothing further, except the heavy tramping of the
sailors, the creaking of the ropes, and the hoarse roars of command
from the officers.
The work of getting the Success away from the dock went rapidly on.
Quite fortunately for the stowaway, the hold of the Success was little
more than two thirds filled with Savannah goods. In the bows, beside
a great many bags and boxes and barrels of provisions for the use of
the crew, there were likewise spare sails, cordage, etc.
It would be a very easy matter indeed for him to hide among the stuff
if any one came into the hold.
The scent of bilge water was not at all strong, for the Success was a
comparatively new vessel and had evidently been recently pumped
out.
Brandon judged her to be about the size of the Silver Swan, much
the same sort of craft in fact, and, like his father’s vessel, the
Success was a “tramp.”
It was night—or at least a gloomy twilight—at all times in the hold;
but Brandon thought that it was surely daylight by the time the brig
was under way.
She was taken down the river by a fussy little steam tug and then,
meeting the swells of the Atlantic, and a brisk gale springing up, she
shook out her sails and dropped the tug astern.
Brandon was fearful that he might be sick, for he had never really
been to sea and the brig pitched not a little in the waves of the
ocean.
To reduce the possibility of this misfortune to a minimum, he ate but
sparingly the first day or two out, and by that time all “squeamish”
feelings passed away.
It was dreadfully dull in the dark hold, however. Of food and water he
had a sufficiency, although the latter was warm and brackish; but
there was absolutely nothing for him to do to pass away the time.
There was not even the spice of danger about his situation, for
nobody came into the hold.
He dared not explore much at first, for he was afraid that he might be
heard from the cabin or forecastle.
During a slight blow which came up the fourth day, however, while
the spars and cordage were creaking so that all other sounds were
drowned, he felt perfectly safe in moving about. If he could not hear
what went on outside, nobody outside would be likely to hear him.
On this day, however, he received several tumbles, for the ship
occasionally pitched so suddenly that he was carried completely off
his feet. Nothing worse happened to him, though, than the barking of
his elbows and knees.
Gaining confidence in his ability to get around without being
discovered, he changed his position more frequently after this. The
weather remained fair for some time following this small blow, and
Brandon hung about the cabin bulkhead, striving to hear more of
Leroyd’s plans, if possible.
It was plain that the captain of the brig knew nothing of the real plans
of the conspirators. They had told him what they pleased, and he
was to ask no questions.
It was not long, however, before the stowaway discovered something
which was quite a surprise to him. There was a woman on board the
brig; he heard the rustle of her garments, and occasionally the tones
of a female voice.
At first he thought her to be the captain’s wife, but because of the
youthfulness of her tones and some words which the captain
addressed to her, he changed this opinion, and decided that she was
his daughter.
Brandon was quite interested in her, for a girl on a sailing vessel was
certainly a novelty. He was sure she must be a “jolly one,” as he
expressed it, to sail with her father on a merchantman. Not many
girls would have the pluck to do that.
As the days passed by, and the Success fled on before the favoring
gales, drawing nearer and nearer to Savannah, Brandon became
correspondingly worried over the obstructions to a safe escape from
the brig, which were presented to his mind.
Once the brig reached port and the hatches were opened, it would
be “all day” with him. Nothing but a miracle would save him from
falling into the hands of Jim Leroyd, and he didn’t like to think of that.
He had good reason to believe that the rascally sailor would not
hesitate to injure him in any way possible.
Naturally his mind reverted to the trap in the cabin bulkhead by
which Swivel had gained access to the cook’s galley, as a possible
means of escape before the hatches were removed. If the brig
reached Savannah late in the day, doubtless the hatches would
remain battened down till the next morning. In that case the trap
might be his salvation.
Several times during the voyage the steward, sometimes with a
seaman with him, entered the hold by this door, for something
among the stores. At such times Brandon “laid low” and his presence
was not discovered.
What little food he had purloined from the stores was not noticed
either.
Therefore, as the brig drew nearer to her destination Brandon set
about studying the topography of the cabin—its entrances and exits
—and how he could best pass through it and reach the deck without
attracting the attention of anybody on board.
All this scouting had to be done at night, of course, and many were
his narrow escapes while engaged in this most perilous undertaking.
“Nothing ventured, nothing gained,” was the motto of the Tarrs,
father and son. In Captain Tarr’s case, and in that of his brother
Anson, it had been, as a usual thing, a good deal of venture and little
gain.
The same motive, however, was predominant in Brandon’s nature,
and he took many risks in thus scouting about the brig’s cabin that
almost any other boy would not have taken.
One night he had cautiously set the narrow door leading into the
steward’s pantry ajar, and sat just under it in the darkness of the
hold, trying to discover if all but the officers, excepting the one in
command of the watch, had turned in.
There was a light in the outer cabin, but he could not see into the
room from where he sat, and he dared not enter the pantry until he
was sure that the cabin was unoccupied. Occasionally a sound of
low conversation would reach his ears from the deck, but otherwise
all was still.

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