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PRINCIPLES OF
CRITICAL
CARE
Editors
Jesse B. Hall, MD
Director of Critical Care Services
Professor of Medicine and of Anesthesia and Critical Care
Section of Pulmonary and Critical Care
University of Chicago
Chicago, Illinois
Gregory A. Schmidt, MD
Director, Critical Care Services
Chicago, Illinois
Lawrence D. H. Wood, MD, PhD

Faculty Dean of Medical Education
University of Chicago Pritzker School of Medicine
Section of Pulmonary and Critical Care Medicine
Chicago, Illinois
Associate Editors
Jameel Ali, MD, M Med Ed, FRCS[C], FACS
Professor of Surgery, University of Toronto
Toronto, Ontario, Canada
National ATLS faculty and Educator
American College of Surgeons Committee on Trauma
Chapters 87, 88, 92, 95
Keith R. Walley, MD
Associate Professor of Medicine
University of British Columbia
Pulmonary Research Laboratory
Vancouver, British Columbia, Canada
PRINCIPLES OF
CRITICAL
CARE THIRD EDITION
Editors
JESSE B. HALL, MD
Director of Critical Care Services
Chicago, Illinois
GREGORY A. SCHMIDT, MD
Director, Critical Care Services
Chicago, Illinois
LAWRENCE D.H. WOOD, MD PHD

Faculty Dean of Medical Education
University of Chicago, Pritzker School of Medicine
Section of Pulmonary and Critical Care Medicine
Chicago, Illinois
Cora D. Taylor
Editorial Assistant
McGRAW-HILL
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Copyright © 2005, 1998, 1992 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as
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DOI: 10.1036/0071416404
We dedicate this edition to:
Larry Wood, who, through his guidance, clarity, and wisdom,

revealed to us the beauty of critical care;
Change, which excites and refreshes us;
and Karin and Barbara, who remind us of balance.

NOTICE
Medicine is an ever-changing science. As new research and
clinical experience broaden our knowledge, changes in
treatment and drug therapy are required. The authors and
the publisher of this work have checked with sources
believed to be reliable in their efforts to provide information
that is complete and generally in accord with the standards
accepted at the time of publication. However, in view of the
possibility of human error or changes in medical sciences,
neither the editors nor the publisher nor any other party
who has been involved in the preparation or publication of
this work warrants that the information contained herein is
in every respect accurate or complete, and they disclaim all
responsibility for any errors or omissions or for the results
obtained from use of the information contained in this work.
Readers are encouraged to confirm the information
contained herein with other sources. For example and in
particular, readers are advised to check the product
information sheet included in the package of each drug they
plan to administer to be certain that the information
contained in this work is accurate and that changes have not
been made in the recommended dose or in the
contraindications for administration. This recommendation
is of particular importance in connection with new or
infrequently used drugs.
CONTENTS
Contributors xi 13 CLINICAL USE OF THE PULMONARY ARTERY

Preface xxiii CATHETER 139
Introduction xxv James W. Leatherman/John J. Marini
V. Theodore Barnett 14 PAIN CONTROL, SEDATION AND USE OF
MUSCLE RELAXANTS 165
Brian Gehlbach/John P. Kress
PART I 15 CARDIOPULMONARY RESUSCITATION 181
Benjamin S. Abella/Terry L. Vanden Hoek/Jason
AN OVERVIEW OF THE APPROACH TO AND Alvarado/Lance B. Becker
ORGANIZATION OF CRITICAL CARE 16 THERAPEUTIC HYPOTHERMIA 193
Benjamin S. Abella/Terry L. Vanden Hoek/Lance
1 AN APPROACH TO CRITICAL CARE 3 B. Becker
Jesse B. Hall/Gregory A. Schmidt/Lawrence D.H. Wood 17 WITHHOLDING OR WITHDRAWING OF
2 ASSESSING COST EFFECTIVENESS IN THE LIFE-SUSTAINING THERAPY AND
INTENSIVE CARE UNIT 11 ADMINISTERING OF PALLIATIVE CARE 201
Michael T. Coughlin/Derek C. Angus John M. Luce
3 IMPROVING THE QUALITY OF CARE IN THE 18 CHRONIC CRITICAL ILLNESS 207
INTENSIVE CARE UNIT 21 Shannon S. Carson
Allan Garland 19 LONG-TERM OUTCOMES OF CRITICAL
4 INFECTION CONTROL AND SURVEILLANCE ILLNESS 217
IN THE INTENSIVE CARE UNIT 41 Margaret S. Herridge/Ramona O. Hopkins
David K. Warren/Marin H. Kollef
5 LEGAL ISSUES IN CRITICAL CARE 53
Marshall B. Kapp
PART III
6 ASSESSMENT OF SEVERITY OF ILLNESS 63
Cheryl L. Holmes/Genevieve Gregore/James A. Russell
7 TRANSPORTATION OF THE CRITICALLY ILL
PATIENT 79
Ira J. Blumen/Frank Thomas/David H. Williams
8 TELEMEDICINE 93
Michael Breslow
9 PREPAREDNESS FOR CATASTROPHE 101
Jeffrey G. Walls/J. Christopher Farmer
PART II
GENERAL MANAGEMENT OF THE PATIENT
10 PREVENTING MORBIDITY IN THE ICU 111

Deborah Cook/Graeme Rocker
11 NUTRITION IN THE CRITICALLY ILL 117
Daren K. Heyland/Steve A. McClave
12 INTRAVASCULAR DEVICES 131
John F. McConville/John P. Kress
viii CONTENTS
26 ACUTE RIGHT HEARTH SYNDROMES 335 46 SEPSIS WITH ACUTE ORGAN

Ivor S. Douglas/Gregory A. Schmidt DYSFUNCTION 699
27 PULMONARY EMBOLIC DISORDERS: E. Wesley Ely/Richert E. Goyette
THROMBUS, AIR, AND FAT 347 47 APPROACH TO INFECTION IN PATIENTS
Nuala J. Meyer/Gregory A. Schmidt RECEIVING CYTOTOXIC CHEMOTHERAPY
28 PERICARDIAL DISEASE 373 FOR MALIGNANCY 735
Israel Belenkie/John Tyberg Eric J. Bow
29 VALVULAR HEARTH DISEASE 385 48 AIDS IN THE INTENSIVE CARE UNIT 771
Matthew J. Sorrentino Peter Phillips/Julio S.G. Montaner/James A. Russell
30 AORTIC DISSECTION 401 49 ENDOCARDITIS AND OTHER
Jospeh J. Austin INTRAVASCULAR INFECTIONS 801
James M. Sizemore, Jr./C. Glenn Cobbs/Mark B. Carr
50 INFECTIOUS COMPLICATIONS OF
PART IV INTRAVASCULAR ACCESS DEVICES USED IN
PULMONARY DISORDERS CRITICAL CARE 815
John M. Conly
31 THE PATHOPHYSIOLOGY AND 51 PNEUMONIA 823
DIFFERENTIAL DIAGNOSIS OF ACUTE R. Bruce Light
RESPIRATORY FAILURE 417 52 BACTERIAL INFECTIONS OF THE CENTRAL
Lawrence D.H. Wood NERVOUS SYSTEM 845
32 VENTILATOR WAVEFORMS: CLINICAL Allan R. Tunkel/W. Michael Scheld
INTERPRETATION 427 53 ENCEPHALOMYELITIS 863
Gregory A. Schmidt John C. Galbraith/Robert Verity/D. Lorne Tyrell
33 NONINVASIVE VENTILATION 445 54 LIFE-THREATENING INFECTIONS OF THE
Laurent Brochard HEAD, NECK AND UPPER RESPIRATORY
34 UPPER AIRWAY OBSTRUCTION 455 TRACT 881
Brian Gehlbach Anthony W. Chow
35 AIRWAY MANAGEMENT 465 55 SOFT TISSUE INFECTIONS 897
Michael F. O’Connor/Andranik Ovassapian John M. Conly
36 MANAGEMENT OF THE VENTILATED 56 URINARY TRACT INFECTIONS 905
PATIENT 481 Gerard J. Sheehan/Busi Mooka
Gregory A. Schmidt/Jesse B. Hall 57 GASTROINTESTINAL INFECTIONS 913
37 VENTILATOR-INDUCED LUNG INQUIRY 499 Steven G. Weber
John T. Granton/Arthur S. Slutsky 58 SEVERE MALARIA 923
38 ACUTE LUNG INJURY AND THE David A. Warrell
RESPIRATORY DISTRESS SYNDROME 515 59 TETANUS 933
Jason Christie/Paul Lanken Perry R. Gray
39 ACUTE-ON-CHRONIC RESPIRATORY 60 VIRAL HEMORRHAGIC FEVERS 939
FAILURE 549 Susan P. Fisher-Hoch
Ivor S. Douglas/Gregory A. Schmidt/Jesse B. Hall 61 BIOWARFARE AGENTS 955
40 STATUS ASTHMATICUS 567 Manoj Karwa/Raghu S. Loganathan/Vladimir Kvetan
Thomas Corbridge/Jesse B. Hall
41 MASSIVE HEMOPTYSIS 583
Richard K. Albert
PART VI
42 RESTRICTIVE DISEASE OF THE RESPIRATORY NEUROLOGIC DISORDERS
SYSTEM AND THE ABDOMINAL
COMPARTMENT SYNDROME 587 62 DELIRIUM IN THE INTENSIVE CARE
Thomas Corbridge/Lawrence D.H. Wood UNIT 975
43 VENTILATOR-ASSOCIATED PNEUMONIA 599 E. Wesley Ely
Jean Chastre/Jean-Yves Fagon 63 CEREBROVASCULAR DISEASE 985
44 LIBERATION FROM MECHANICAL Venkatesh Aiyagari/William J. Powers/Michael N. Diringer
VENTILATION 625 64 SEIZURES IN THE INTENSIVE CARE UNIT 997
Constantine A. Manthous/Gregory A. Schmidt/Jesse B. Hall Sarice L. Bassin/Nathan B. Fountain/Thomas P. Bleck
65 INTRACRANIAL PRESSURE: MONITORING
AND MANAGEMENT 1007
PART V Axel J. Rosengart
INFECTIOUS DISORDERS 66 NEUROMUSCULAR DISEASES LEADING TO
RESPIRATORY FAILURE 1025
45 PRINCIPLES OF ANTIMICROBIAL THERAPY William M. Marinelli/James W. Leatherman
AND THE CLINICAL PHARMACOLOGY OF 67 COMA, PERSISTENT VEGETATIVE STATE,
ANTIMICROBIAL DRUGS 641 AND BRAIN DEATH 1037
Fred Y. Aoki Axel J. Rosengart and Jeffrey I. Frank
CONTENTS ix
PART VII 86 MESENTERIC ISCHEMIA 1309

Denis W. Harkin/Thomas F. Lindsay
HEMATOLOGIC AND ONCOLOGIC
DISORDERS
PART X
68 ANEMIA AND BLOOD TRANSFUSION 1055 THE SURGICAL PATIENT
Judith Luce
69 BLEEDING DISORDERS 1065 87 SPECIAL CONSIDERATIONS IN THE
Jospeph M. Baron/Beverly W. Baron SURGICAL PATIENT 1321
70 THROMBOTIC THROMOBOCYTOPENIC Jameel Ali
PURPURA, HEMOLYTIC SYNDROMES, AND 88 PREOPERATIVE ASSESSMENT OF THE
THE APPROACH TO THROMBOTIC HIGH-RISK SURGICAL PATIENT 1331
MICROANGIOPATHIES 1081 Fergus Walsh/Jameel Ali
Lawrence Tim Goodnough 89 THE ACUTE ABDOMEN AND
71 ACUTE LEUKEMIA 1089 INTRA-ABDOMINAL SEPSIS 1345
Richard A. Larson/Michael J. Hall J.M.A. Bohnen/R.A. Mustard/B.D. Schouten
72 ONCOLOGIC EMERGENCIES 1099 90 THE TRANSPLANT PATIENT 1355
Elizabeth B. Lamont/Philip C. Hoffman Damon C. Scales/John T. Granton
73 HEMATOPOIETIC STEM CELL 91 CARE OF THE MULTIORGAN DONOR 1375
TRANSPLANTATION AND Frank D’Ovidio/D. McRitchie/Shaf Keshavjie
GRAFT-VERSUS-HOST DISEASE 1111 92 PRIORITIES IN MULTISYSTEM
Stephen W. Crawford/Rodney J. Folz/Keith M. Sullivan TRAUMA 1387
74 TOXICITIES OF CHEMOTHERAPY 1123 Jameel Ali
Apurva A. Desai/Gini F. Fleming 93 HEAD INJURY AND INTRACRANIAL
HYPERTENSION 1395
PART VIII Richard J. Moulton/Lawrence H. Pitts
94 SPINE INJURIES 1409
RENAL AND METABOLIC DISORDERS Garth E. Johnson
95 TORSO TRAUMA 1421
75 ACUTE RENAL FAILURE 1139 Jameel Ali
Bharathi Reddy/Patrick Murray 96 PELVIC RING INJURIES AND EXTREMITY
76 ELECTROLYTE DISORDERS IN CRITICAL TRAUMA 1443
CARE 1161 A.S.L. Liew
Joel Michels Topf/Steve Rankin/Patrick Murray 97 ELECTRICAL TRAUMA 1451
77 ACID-BASE BALANCE 1201 Lawrence J. Gottlieb/Raphael C. Lee
David C. Kaufman/Andrew J. Kitching/John A. Kellum 98 BURNS: RESUSCITATION PHASE
78 DIABETIC KETOACIDOSIS, HYPERGLYCEMIC (0 TO 36 HOURS) 1457
HYPEROSMOLAR NONKETOTIC COMA, AND Robert H. Demling/Leslie Desanti
HYPOGLYCEMIA 1209 99 BURNS: POSTRESUSCITATION PHASE
John B. Buse/Kenneth S. Polonsky (DAYS 2 TO 6) 1467
79 ADRENOCORTICAL INSUFFICIENCY 1219 Robert H. Demling/Leslie Desanti
Paul E. Marik/Gary P. Zaloga 100 BURNS: INFLAMMATION-INFECTION PHASE
80 THYROID DISEASE 1231 (DAY 7 TO WOUND CLOSURE) 1473
Roy E. Weiss/Samuel Refetoff Robert H. Demling/Leslie Desanti
101 INTEVENTIONAL RADIOLOGY 1479
Jennifer E. Gould/Daniel Picus
PART IX
GASTRINTESTINAL DISORDERS
PART XI
81 GUT AND HEPATOBILIARY SPECIAL PROBLEMS IN CRITICAL CARE
DYSFUNCTION 1247
Eli D. Ehrenpreis/Thomas D. Schiano 102 TOXICOLOGY IN ADULTS 1499
82 GASTROINTESTINAL HEMORRHAGE 1261 Thomas Corbridge/Patrick Murray/Babak Mokhlesi
Ram M. Subramanian/Timothy M. McCashland 103 CRITICAL CARE PHARMACOLOGY 1547
83 FULMINANT HEPATIC FAILURE 1279 Vidya Krishnan/Thomas Corbridge/Patrick Murray
Sanjay Kulkarni/David C. Cronin II 104 RHEUMATOLOGY IN THE ICU 1573
84 MANAGEMENT OF THE PATIENT Walter G. Barr/John A. Robinson
WITH CIRRHOSIS 1289 105 CRITICAL ILLNESS IN PREGNANCY 1593
Gregory A. Schmidt Mary E. Strek/Michael F. O’Connor/Jesse B. Hall
85 ACUTE PANCREATITIS IN THE CRITICALLY 106 ANAPHYLACTIC AND ANAPHYLACTOID
ILL 1299 REACTIONS 1615
Bryce R. Taylor Jonathan Moss/Paul-Michel Mertes
x CONTENTS
107 DERMATOLOGIC CONDITIONS 1627 111 HYPERTHERMIA 1687

Mario E. Lacoutre/Michael J. Welsh/Anne E. Laumann Janice L. Zimmerman/Nicola A. Hanania
108 SICKLE CELL DISEASE 1655 112 DIVING MEDICINE AND NEAR
Gregory J. Kato/Mark T. Gladwin DROWNING 1693
109 THE OBESITY EPIDEMIC AND CRITICAL Claude A. Piantadosi/Steven D. Brown
CARE 1671 INDEX 1707
Brian Gehlbach/John P. Kress Color plates appear between pages 930 and 931.
110 HYPOTHERMIA 1679
Nicola A. Hanania/Janice L. Zimmerman
CONTRIBUTORS
BENJAMIN S. ABELLA, MD, MPhil FRED Y. AOKI, MD

Department of Medicine Professor of Medicine
Section of Emergency Medicine Medical Microbiology, Pharmacology
University of Chicago and Therapeutics
Chicago, Illinois University of Manitoba
Chapters 15, 16 Winnipeg, Manitoba, Canada
Chapter 45
VENKATESH AIYAGARI, MD
Assistant Professor of Neurology and
Neurological Surgery JOSEPH J. AUSTIN, MD
Washington University School of Cardiothoracic Surgery
Medicine Overlake Hospital Medical Center
St. Louis, Missouri Bellevue, Washington
Chapter 63 Chapter 30
RICHARD K. ALBERT, MD GEORGE BALTOPOULOS, MD

Professor Professor of Critical Care and
Department of Medicine Pulmonary Diseases
University of Colorado University of Athens School of Nursing
Health Sciences Center Director
Chief of Medicine Athens University School of Nursing Intensive
Denver Health Medical Center Care Unit at KAT Hospital
Denver, Colorado Athens, Greece
JAMEEL ALI, MD, M Med Ed, FRCS[C], FACS
Professor of Surgery, University of Toronto JOSEPH M. BARON, MD
Toronto, Ontario, Canada Section of Hematology/Oncology
National ATLS faculty and Educator University of Chicago
American College of Surgeons Chicago, Illinois
Committee on Trauma Chapter 69
Chapters 87, 88, 92, 95 BEVERLY W. BARON, MD
Department of Pathology
JASON ALVARADO, BA Blood Banking/Transfusion Medicine
Department of Medicine University of Chicago
Section of Emergency Medicine Chicago, Illinois
University of Chicago Chapter 69
Chicago, Illinois
Chapter 15
WALTER G. BARR, MD
DEREK C. ANGUS, MD, MPH Professor of Medicine
Professor and Vice Chair Director
Department of Critical Care Medicine Training Program
Director, The CRISMA Laboratory Division of Rheumatology
University of Pittsburgh Northwestern University Feinberg
School of Medicine School of Medicine
Pittsburgh, Pennsylvania Chicago, Illinois
Copyright © 2005, 1998, 1992 by The McGraw-Hill Companies, Inc. Click here for terms of use.
xii CONTRIBUTORS
SARICE L. BASSIN, MD MICHAEL BRESLOW, MD

Neurointensivist Executive Vice President, Research and
Neuroscience Institute Development
Critical Care Neurology and Stroke VISICU, Inc.
Queen’s Medical Center Baltimore, Maryland
Honolulu, Hawaii Chapter 8
Chapter 64
LAURENT BROCHARD
LANCE B. BECKER, MD Professor of Intensive Care Medicine
Professor of Clinical Medicine Medical Intensive Care Unit
Section of Emergency Medicine Hôpital Henri Mondor
University of Chicago Assistance Publique
Chicago, Illinois Hôpitaux de Paris
Chapters 15, 16 Université Paris
Créteil, France
ISRAEL BELENKIE, MD Chapter 33
Professor of Medicine
Departments of Medicine and Cardiac Sciences
STEVEN D. BROWN, MD
Libin Cardiovascular Institute of Alberta
Professor and Chief Medical Officer
University of Calgary
University of Texas Health Center at Tyler
Calgary, Alberta, Canada
Tyler, Texas
Chapter 28
Chapter 112
THOMAS P. BLECK, MD
The Louise Nerancy Eminent Scholar in Neurology and JOHN B. BUSE, MD, PhD
Professor of Neurology, Neurological Surgery, Associate Professor of Medicine
and Internal Medicine Chief, Division of General Medicine
Director, Neuroscience Intensive Care Unit and Clinical Epidemiology
The University of Virginia Director, Diabetes Care Center
Charlottesville, Virginia University of North Carolina
Chapter 64 School of Medicine
Chapel Hill, North Carolina
Chapter 78
IRA J. BLUMEN, MD
Professor, Section of Emergency Medicine
Department of Medicine MARK B. CARR, MD
University of Chicago Baptist Hospital
Chicago, Illinois Nashville, Tennessee
Program and Medical Director Chapter 49
University of Chicago Aeromedical
Network (UCAN)
University of Chicago Hospitals SHANNON S. CARSON, MD
Chicago, Illinois Assistant Professor
Chapter 7 Division of Pulmonary and
Critical Care Medicine
University of North Carolina
JOHN BOHNEN, MD, FRCSC, FACS Chapel Hill, North Carolina
Director Chapter 18
Postgraduate Surgical Education
Associate Professor
Department of Surgery JEAN CHASTRE, MD
University of Toronto Reanimation Medicale
Toronto, Ontario, Canada Groupe Hospitalier Pitie Salpetriere
Chapter 89 Institut de Cardiologie
Paris, France
Chapter 43
ERIC J. BOW, MD
Sections of Infectious Diseases and
Haematology/Oncology ANTHONY W. CHOW, MD
Professor and Head, Professor of Medicine
Section of Haematology/Oncology Division of Infectious Diseases
Department of Internal Medicine Department of Medicine
University of Manitoba University of British Columbia
Head, Department of Medical Oncology And Vancouver Hospital
and Haematology Health Sciences Center
Director, Infection Control Services, Cancer Care Director, MD/PhD Program, University of British
Manitoba Columbia
Winnipeg, Manitoba, Canada Vancouver, British Columbia
CONTRIBUTORS xiii
JASON D. CHRISTIE, MD, MS FRANK D’OVIDIO, MD, PhD

Assistant Professor of Medicine Thoracic Surgery and Lung Transplantation
Division of Pulmonary, Allergy, and Toronto General Hospital
Critical Care Medicine University of Toronto
Assistant Professor of Epidemiology Toronto, Ontario, Canada
Department of Biostatistics and Epidemiology Chapter 91
University of Pennsylvania
School of Medicine
ROBERT H. DEMLING, MD
Philadelphia, Pennsylvania
Burn Center
Chapter 38
Brigham and Women’s Hospital
Boston, Massachusetts
GLENN C. COBBS, MD Professor of Surgery
Professor Emeritus of Medicine Harvard Medical School
University of Alabama at Birmingham Boston, Massachusetts
Birmingham, Alabama Chapters 98, 99, 100
Chapter 49
APURVA A. DESAI, MD
Assistant Professor of Medicine
JOHN M. CONLY, MD Section of Hematology/Oncology
Head The University of Chicago Medical Center
Department of Medicine Chicago, Illinois
University of Calgary Chapter 74
Calgary Health Region
Foothills Medical Centre
Calgary, Alberta, Canada LESLIE DeSANTI, RN
Chapters 50, 55 Burn Research
Brigham & Women’s Hospital
Boston, Massachusetts
DEBORAH COOK, MD Chapter 98, 99, 100
Professor of Medicine and Clinical Epidemiology
and Biostatistics
Chair MICHAEL N. DIRINGER, MD
Critical Care Medicine Associate Professor of Neurology, Neurosurgery
McMaster University and Anesthesiology
Hamilton, Ontario, Canada Washington University School of Medicine
Chapter 10 Director, Neurology/Neurosurgery
Intensive Care Unit
Barnes-Jewish Hospital
THOMAS CORBRIDGE, MD Department of Neurology
Associate Professor of Medicine St. Louis, Missouri
Director, Medical Intensive Care Chapter 63
Northwestern Scholl of Medicine
Chicago, Illinois IVOR S. DOUGLAS, MD, MRCP (UK)
Chapters 40, 42, 102, 103 Assistant Professor
Pulmonary and Critical Care Medicine
Director
MICHAEL T. COUGHLIN, MA
Medical Intensive Care
Project Manager, The CRISMA Laboratory
Denver Health
Department of Critical Care Medicine
University of Colorado Health Sciences Center
University of Pittsburgh School of Medicine
Denver, Colorado
Pittsburgh, Pennsylvania
Chapter 39
Chapter 2
TONY T. DREMSIZOV
DAVID C. CRONIN II, MD, PhD Senior Research Specialist
Assistant Professor of Surgery CRISMA Laboratory
Section of Transplantation Department of Critical Care Medicine
University of Chicago University of Pittsburgh
Chicago, Illinois Pittsburgh, Pennsylvania
STEPHEN W. CRAWFORD, MD ELI D. EHRENPREIS, MD

United States Navy Medical Corps Assistant Professor of Medicine
Pulmonary Medicine Rush Presbyterian St. Luke’s Medical Center
Naval Medicine Center San Diego Adult Care Specialists
San Diego, California Chicago, Illinois
xiv CONTRIBUTORS
E. WESLEY ELY, MD, MPH JEFFREY I. FRANK, MD, FAAN, FAHA

Associate Professor of Medicine Director
Division of Allergy, Pulmonary, and Critical Care Neuromedical/Neurosurgical Intensive Care
Vanderbilt University Medical Center Associate Professor
Associate Director of Research Neurology and Surgery
Tennessee Valley Veterans Administration Geriatric University of Chicago
Research Education and Clinical Center Chicago, Illinois
Nashville, Tennessee Chapter 65, 67
Chapter 46, 62
JOHN C. GALBRAITH, MD
JEAN-YVES FAGON, MD, PhD Medical Director
Professor of Medicine Dynacare Kasper Medical Laboratories
Service de Réanimation Médicale Edmonton, Alberta, Canada
Hôpital Européen Georges Pompidou Chapter 53
Paris, France
Chapter 43
ALLAN GARLAND, MD
J. CHRISTOPHER FARMER, MD Case Western Reserve University School of Medicine
Professor of Medicine Director, Medical Intensive Care Unit
Division of Pulmonary and Critical Care Medicine Division of Pulmonary and Critical Care Medicine
Program in Translational Immunovirology and MetroHealth Medical Center
Biodefense Cleveland Ohio
Mayo Clinic Chapter 3
Rochester, Minnesota
Chapter 9
BRIAN GEHLBACH, MD
SUSAN FISHER-HOCH, MD Section of Pulmonary and Critical Care
Professor University of Chicago
Division of Epidemiology Chicago, Illinois
University of Texas School of Public Health at Brownsville Chapters 14, 34, 109
Brownsville, Texas
Chapter 60
ANNE M. GILLIS, MD, FRCPC
GERASIMOS S. FILIPPATOS, MD
Critical Care Unit and Heart Failure Unit
Medical Director of Pacing and Electrophysiology
Evangelismos General Hospital
Department of Cardiac Sciences
Chairman
Calgary Health
Working Group on Acute Cardiac Care
European Society of Cardiology
Calgary, Alberta, Canada
Athens, Greece
Chapter 24
Chapter 23
GINI F. FLEMING, MD MARK T. GLADWIN, MD

Associate Professor, Department of Medicine Chief
Section on Hematology, Oncology Vascular Therapeutics Section
The University of Chicago Medical Center Cardiovascular Branch
Chicago, Illinois National Heart, Lung, and Blood Institute
Chapter 74 Critical Care Medicine Department
Clinical Center
National Institutes of Health
RODNEY J. FOLZ, MD, PhD Bethesda, Maryland
Associate Professor of Medicine Chapter 108
Assistant Research Professor of Cell Biology
Division of Pulmonary, Allergy, and Critical Care
Medicine LAWRENCE TIM GOODNOUGH, MD
Duke University Medical Center Department of Pathology and Medicine
Durham, North Carolina Stanford University
Chapter 73 Stanford, California
Chapter 70
NATHAN B. FOUNTAIN, MD
Associate Professor of Neurology LAWRENCE J. GOTTLIEB, MD
Director Professor of Surgery
FE Dreifuss Comprehensive Epilepsy Program Director of Burn and Complex Wound Center
University of Virginia University of Chicago
Charlottesville, Virginia Chicago, Illinois
CONTRIBUTORS xv
JENNIFER E. GOULD, MD MARGARET S. HERRIDGE, MSc, MD, FRCPC, MPH

Assistant Professor of Radiology Pulmonary and Critical Care Medicine
Washington University School of Medicine University Health Network
St. Louis, Missouri Assistant Professor of Medicine
Chapter 101 Interdepartmental Division of Critical Care
University of Toronto
RICHERT E. GOYETTE, MD Toronto, Ontario, Canada
Consultant Chapter 19
Knoxville, Tennessee
Chapter 46
DAREN K. HEYLAND, MD, MSc, FRCPC
JOHN T. GRANTON, MD Associate Professor
Program Director Kingston General Hospital
Critical Care Medicine Kingston, Ontario, Canada
University of Toronto Chapter 11
Director, Pulmonary Hypertension Program
University Health Network
Toronto, Ontario, Canada PHILIP C. HOFFMAN, MD
Chapter 37, 90 Professor of Medicine
Section of Hematology/Oncology
PERRY R. GRAY, MD The University of Chicago
Critical Care Site Manager Chicago, Illinois
Director Chapter 72
SICU
Health Sciences Center
Winnipeg, Manitoba, Canada STEVEN M. HOLLENBERG, MD
Chapter 59 Director
Coronary Care Unit
Cooper University Hospital
GENEVIÈVE GRÉGOIRE, MD, FRCPC Professor of Medicine
Assistant Professor of Medicine Robert Wood Johnson Medical School/
University of Montreal University of Medicine and Dentistry
Intensivist of New Jersey
Department of Medicine Camden, New Jersey
Hôpital du Sacre-Couer de Montreal Chapter 25
Montreal, Quebec, Canada
Chapter 6
CHERYL L. HOLMES, MD
JESSE B. HALL, MD Clinical Instructor
Professor, Medicine, Anesthesia and Department of Medicine
Critical Care University of British Columbia
Section of Pulmonary and Critical Care Medicine Vancouver, British Columbia
Department of Medicine Director, Critical Care Medicine
University of Chicago Department of Medicine
Chicago, Illinois Kelowna General Hospital
Chapters 1, 36, 40, 44, 105 Kelowna, British Columbia, Canada
Chapter 6
MICHAEL J. HALL, MD
Section of Hematology and Oncology
Department of Medicine RAMONA O. HOPKINS, PhD
University of Chicago Psychology Department and
Chicago, Illinois Neuroscience Center
Chapter 71 Brigham Young University
Provo, Utah
NICOLA A. HANANIA, MD and Department of Medicine
Assistant Professor of Medicine Pulmonary and Critical Care Divisions
Pulmonary and Critical Care Medicine LDS Hospital
Director, Asthma Clinical Research Center Salt Lake City, Utah
Baylor College of Medicine Chapter 19
Houston, Texas
Chapter 110, 111
GARTH JOHNSON, MD
DENIS W. HARKIN, MD, FRCS Professor of Surgery
Vascular Fellow University of Ottawa
Department of Surgery Division of Orthopedic Surgery
University of Toronto Ottawa Hospital
Toronto, Ontario, Canada Ottawa, Ontario, Canada
xvi CONTRIBUTORS
MARSHALL B. KAPP, JD, MPH ANDREW J. KITCHING, MB, ChB

Arthur W. Grayson Distinguished Professor of Law Consultant Anaesthetist
and Medicine Royal Berkshire Hospital
Southern Illinois University London Road
School of Law Reading, United Kingdom
Carbondale, Illinois Chapter 77
Chapter 5
MARIN H. KOLLEFF, MD
ELIAS KARAMBATSOS, MD Washington University School of Medicine
Physician Director
Cellular and Molecular Biology Medical Intensive Care Unit
Naxos, Greece Director
Chapter 23 Respiratory Care Services
Barnes-Jewish Hospital
St. Louis, Missouri
MANOJ KARWA, MD Chapter 4
Montefiore Medical Center JOHN P. KRESS, MD
Albert Einstein College of Medicine Assistant Professor of Medicine
Bronx, New York Section of Pulmonary and Critical Care
Chapter 61 University of Chicago
Chicago, Illinois
Chapters 12, 14, 109
GREGORY J. KATO, MD
Investigator
Critical Care Medicine Department VIDYA KRISHNAN
Clinical Center Pulmonary and Critical Care Division
Vascular Therapeutics Section Johns Hopkins University School of Medicine
Cardiovascular Branch Baltimore, Maryland
National Heart, Lung, and Blood Institute Chapter 103
National Institutes of Health
Bethesda, Maryland
SANJAY KULKARNI, MD
Chapter 108
Assistant Professor
Section of Organ Transplantation and immunology
Yale University School of Medicine
DAVID C. KAUFMAN, MD New Haven, Connecticut
Associate Professor Chapter 83
Department of Surgery
Strong Memorial Hospital
University of Rochester VLADIMIR KVETAN, MD
Rochester, New York Professor of Anesthesiology and Clinical Medicine
Chapter 77 Associate Professor of Surgery
Director of Critical Care Medicine Service and Fellowship,
JOHN A. KELLUM, MD Montefiore Medical Center
Associate Professor Albert Einstein Medical Center
Departments of Critical Care Medicine Bronx, New York
and Medicine Chapter 61
University of Pittsburgh
Pittsburgh, Pennsylania
Chapter 77 MARIO E. LACOUTRE, MD
Resident, Dermatology Section University of
Chicago
SHAF KESHAVJEE, MD, MSc, FRCSC, FACS University of Chicago
Head Chicago, Illinois
Division of Thoracic Surgery Chapter 107
Director
Toronto Lung Transplant Program
Professor and Chair ELIZABETH B. LAMONT, MD, MS
Division of Thoracic Surgery Assistant Professor of Medicine
University of Toronto Massachusetts General Hospital Cancer Center
Toronto General Hospital Harvard Medical School
Toronto, Ontario, Canada Boston, Massachusetts
CONTRIBUTORS xvii
PAUL N. LANKEN, MD JOHN M. LUCE, MD

Professor of Medicine Professor of Medicine and Anesthesia
Pulmonary, Allergy, and Critical Care Division University of California–San Francisco
Hospital of the University of Pennsylvania Associate Medical Director, Medical and Surgical
Philadelphia, Pennsylvania Intensive Care Units
Chapter 38 Medical Director, Quality, Utilization, and Risk
Management
RICHARD A. LARSON, MD San Francisco General Hospital
Professor of Medicine San Francisco, California
Section of Hematology and Oncology Chapters 17, 68
Department of Medicine
Cancer Research Center JUDITH A. LUCE, MD
University of Chicago Clinical Professor of Medicine
Chicago, Illinois University of California–San Francisco
Chapter 71 Director
Oncology Services
San Francisco General Hospital
ANNE E. LAUMANN, MBChB, MRCP (UK) Chapter 68
Associate Professor of Dermatology
Northwestern University
CONSTANTINE A. MANTHOUS, MD
Chicago, Illinois
Director, Medical Intensive Care
Chapter 107
Bridgeport Hospital
Associate Clinical Professor of Medicine
JAMES W. LEATHERMAN, MD Yale University School of Medicine
Associate Professor of Medicine Bridgeport, Connecticut
University of Minnesota Chapter 44
Division of Pulmonary and
Hennepin County Medical Center, Minneapolis PAUL MARIK, MD, FCCM, FCCP
Chapters 13, 66 Director
Pulmonary and Critical Care
RAPHAEL C. LEE, MD, ScD Thomas Jefferson University
Professor of Surgery, Dermatology, Philadelphia, Pennsylvania
Molecular Medicine, and Organismal Biology Chapter 79
and Anatomy
Director, Electrical Trauma Program
Director, Program for Research in Cellular Repair WILLIAM A. MARINELLI, MD
University of Chicago Associate Professor of Medicine
Chicago, Illinois University of Minnesota
Chapter 97 Medical Director, Respiratory Care
Hennepin County Medical Center
ALLAN S. LIEW, MD, FRCSC Minneapolis, Minnesota
Division of Orthopedic Surgery Chapter 66
Ottawa Hospital
Ottawa, Ontario, Canada JOHN J. MARINI, MD
Chapter 96 Professor of Medicine
University of Minnesota
R. BRUCE LIGHT, MD Director of Translational Research
Professor of Medicine and Medical Microbiology HealthPartners Medical Group
University of Manitoba Minneapolis/St. Paul, Minnesota
Winnipeg, Manitoba, Canada Chapter 13
Chapter 51
TIMOTHY M. McCASHLAND, MD
THOMAS F. LINDSAY, MD, FRCSC, FACS Associate Professor of Medicine
Chair Section of Gastroenterology and Hepatology
Division of Vascular Surgery University of Nebraska
Associate Professor of Surgery Omaha, Nebraska
University of Toronto Chapter 82
Chapter 86
STEVE A. McCLAVE, MD
RAGHU S. LOGANATHAN, MD Professor of Medicine
Fellow in Critical Care Medicine Division of Gastroenterology/Hepatology
Montefiore Medical Center Director of Clinical Nutrition
Albert Einstein College of Medicine University of Louisville School of Medicine
Bronx, New York Louisville, Kentucky
xviii CONTRIBUTORS
JOHN F. McCONVILLE, MD RICHARD J. MOULTON, MD, FRCSC

Assistant Professor of Medicine Medical Director
University of Chicago Trauma and Neurosurgery Program
Chicago, Illinois St. Michael’s Hospital
Chapter 12 Associate Professor of Surgery
DONNA I. McRITCHIE, MD, MSc, FRCSC Chapter 93
Assistant Professor of Surgery
Medical Director PATRICK MURRAY, MD
Clinical Care Associate Professor of Anesthesia, Critical Care
North York General Hospital and Medicine
Toronto, Ontario, Canada (Nephrology)
Chicago, Illinois
Chapters 75, 76, 102, 103
PAUL MICHEL MERTES, MD, PhD
Professor and Chair ROBERT MUSTARD, MD
Service d’Anésthesie-réanimation Assistant Professor of Surgery
CHU de Nancy St. Michael’s Hospital
Hôpital Central Toronto, Ontario, Canada
Nancy, France Chapter 89
Chapter 106
MARKKU S. NIEMINEN, MD
Professor and Chief
NUALA J. MEYER, MD
Division of Cardiology
Fellow
University Central Hospital
Pulmonary and Critical Care
Chairman
Task Force on Acute Heart Failure
Chicago, Illinois
European Society of Cardiology
Chapter 27
Helsinki, Finland
Chapter 23
BABAK MOKHLESI, MD
Assistant Professor of Medicine MICHAEL F. O’CONNOR, MD
Division of Pulmonary and Critical Care Medicine Associate Professor
John H. Striger Jr. Hospital of Cook County/Rush Department of Anesthesia and Critical Care
University Medical Center Department of Medicine
Chicago, Illinois Section of Pulmonary and Critical Care
Chicago, Illinois
Chapters 35, 105
JULIO S. G. MONTANER, MD
Professor of Medicine & Chair in AIDS Research
St. Paul’s Hospital/University of British Columbia ANDRANIK OVASSAPIAN
Vancouver, British Columbia, Canada Professor
Chapter 48 Department of Anesthesia and Critical Care
The University of Chicago
Chicago, Illinois
Chapter 35
BUSI MOOKA, MD, MRCPI
Specialist Registrar
Department of Infectious Diseases JOSEPH E. PARRILLO, MD
Mater Hospital Professor of Medicine
Dublin, Ireland Robert Wood Johnson Medical School
Chapter 56 University of Medicine and Dentistry of New Jersey
Head
Division of Cardiovascular Disease and Critical Care
JONATHAN MOSS, MD, PhD Medicine
Professor and Vice Chairman for Research Director
Dept. of Anesthesia & Critical Care Cooper Heart Institute
Professor of the College Director
Chairman, Institutional Review Board Cardiovascular and Critical Care Services
University of Chicago Cooper University Hospital
Chicago, Illinois Camden, New Jersey
CONTRIBUTORS xix
CLAUDE A. PIANTADOSI, MD JOHN A. ROBINSON, MD

Professor of Medicine Professor of Medicine and Microbiology
Duke University Medical Center Director
Durham, North Carolina Therapeutic Apheresis
Chapter 112 Stritch School of Medicine
Loyola University Medical Center
Chicago, Illinois
DANIEL PICUS, MD Chapter 104
Professor of Radiology and Surgery
Department of Radiology
Washington University School of Medicine GRAEME ROCKER, MD
St. Louis, Missouri Professor of Medicine
Chapter 101 Dalhousie University
Halifax, Nova Scotia, Canada
President, Canadian Critical Care Society
LAWRENCE H. PITTS, MD Halifax, Nova Scotia, Canada
Professor of Neurosurgery Chapter 10
University of California–San Francisco
San Francisco, California
Chapter 93 AXEL J. ROSENGART, MD, PhD
Assistant Professor
Departments of Neurology and Surgery
PETER PHILLIPS, MD Assistant Director
Head, Infectious Diseases Neuromedical/Neurosurgical Intensive Care
St. Paul’s Hospital University of Chicago
Vancouver, British Columbia, Canada Chicago, Illinois
Chapter 48 Chapters 65, 67
WILLIAM J. POWERS, MD
JAMES A. RUSSELL, MD
Professor of Neurology, Neurological Surgery
Intensivist, St. Paul’s Hospital
and Radiology
Principal Investigator, James Hogg Centre
Head, Cerebrovascular Section
for Cardiovascular & Pulmonary Research
Department of Neurology
Professor of Medicine, Critical Care Medicine
Washington University School of Medicine
University of British Columbia
St. Louis, MO
Vancouver, British Columbia, Canada
Chapter 63
Chapters 6, 48
KENNETH S. POLONSKY, MD DAMON C. SCALES, MD, FRCPC

Adolphus Busch Professor Clinical Associate
Head Department of Critical Care
Department of Internal Medicine St. Michael’s Hospital
Washington University School of Medicine Toronto, Ontario, Canada
St. Louis, Missouri Chapter 90
Chapter 78
WILLIAM MICHAEL SCHELD, MD

STEVEN M. RANKIN, MD
Bayer-Gerald N. Mandell Professor of Infectious Diseases
Department of Nephrology
Professor of Internal Medicine
St. Joseph Hospital
Clinical Professor of Neurosurgery
Pontiac, Michigan
Co-Director of the Center for Global Health
Chapter 76
University of Virginia School of Medicine
Charlottesville, Virginia
BHARATHI REDDY, MD Chapter 52
Section of Nephrology
University of Chicago THOMAS D. SCHIANO, MD
Chicago, Illinois Associate Professor of Medicine
Chapter 75 Division of Liver Diseases
Mount Sinai Medical Center
New York, New York
SAMUEL REFETOFF, MD
Chapter 81
Frederick H. Rawson Professor Emeritus
Endocrinology Section
Department of Medicine and Pediatrics GREGORY A. SCHMIDT, MD
Director Section of Pulmonary and Critical Care Medicine
Endocrinology Laboratory Department of Medicine
University of Chicago University of Chicago
Chicago, Illinois Chicago, Illinois
xx CONTRIBUTORS
B.D. SCHOUTEN, MD BRYCE TAYLOR, MD, FRCSC, FACS

Sepsis Critical Care Research Office Surgeon-in-Chief
The Wellesley Hospital University Health Network
Toronto, Ontario, Canada Professor and Chair
Chapter 89 Department of Surgery
GERARD J. SHEEHAN, MB Toronto, Ontario, Canada
Consultant Physician in Infectious Diseases Chapter 85
Mater Misericordiae Hospital
Dublin, Ireland FRANK THOMAS, MD, MBA
Chapter 56 Medical Director IHC Life Flight, Adult Services
Co-Director Shock Trauma ICU, LDS Hospital
JAMES M. SIZEMORE, JR., MD, MSPH Clinical Professor of Medicine
Assistant Professor of Medicine University of Utah School of Medicine
Division of Infectious Diseases Critical Care Medicine
University of Alabama–Birmingham LDS Hospital
Birmingham, Alabama Salt Lake City, Utah
ARTHUR S. SLUTSKY, MD JOEL M. TOPF, MD

Professor of Medicine Department of Nephrology
Surgery and Biomedical Engineering Division St. John’s Hospital
Director, Interdepartmental Division of Detroit, Michigan
Critical Care Medicine Chapter 76
Vice President, Research
ALLAN R. TUNKEL, MD, PhD
St. Michael’s Hospital
Queen Wing
Associate Dean for Admissions
Drexel University College of Medicine
Chapter 37
Philadelphia, Pennsylvania
Chapter 52
MATTHEW J. SORRENTINO, MD
University of Chicago Prtizker JOHN V. TYBERG, MD, PhD
School of Medicine Professor of Medicine and Physiology & Biophysics
Department of Medicine Departments of Medicine and Cardiac Sciences
Section Cardiology Libin Cardiovascular Institute of Alberta
Chicago, Illinois University of Calgary
Chapter 29 Calgary, Alberta, Canada
Chapter 28
MARY E. STREK, MD
Associate Professor of Medicine and Clinical D. LORNE TYRRELL, MD, PhD
Pharmacology Professor
Section of Pulmonary and Critical Care Medicine Department of Medical Microbiology and Immunology
University of Chicago University of Alberta
Chicago, Illinois Edmonton, Alberta, Canada
TERRY VANDEN HOEK, MD

RAM M. SUBRAMANIAN, MD Associate Professor of Clinical Medicine
Fellow, Sections of Pulmonary & Critical Care Section of Emergency Medicine
Medicine and Gastroenterology University of Chicago
Department of Medicine Chicago, Illinois
University of Chicago Chapters 15, 16
Chicago, Illinois
Chapter 82
ROBERT VERITY, MD
Dynacare Kasper Medical Laboratories
KEITH M. SULLIVAN, MD Edmonton, Alberta, Canada
James B. Wyngaarden Professor of Medicine Chapter 53
Director, Long-Term Follow-up and
Information Research Program KEITH R. WALLEY, MD
Division of Cellular Therapy Professor of Medicine
Duke University Medical Center University of British Columbia
Durham, North Carolina Vancouver, Canada
CONTRIBUTORS xxi
JEFFREY G. WALLS, MD ROY E. WEISS, MD, PhD, FACP

Staff Physician Professor of Medicine
Pulmonary and Critical Care Director
Presbyterian Hospital Clinical Research Center
Charlotte, North Carolina Department of Medicine
Chicago, Illinois
Chapter 80
FERGUS WALSH
Consultant Anesthetist MICHAEL JUDE WELSCH, MD
Cork University Hospital Resident
Clinical Lecturer Section of Dermatology
University College Cork University of Chicago
Cork, Ireland Chicago, Illinois
DAVID WILLIAMS, MD
DAVID A. WARRELL, MA, DM, DSc Emergency Physician
Professor of Tropical Medicine and Infectious Diseases Intermountain Health Care
Founding Director of the Centre of Tropical Medicine Salt Lake City, Utah
(Emeritus) Chapter 7
University of Oxford
Oxford LAWRENCE D.H. WOOD, MD, PhD
United Kingdom Professor of Medicine
Chapter 58 Section of Pulmonary and Critical Care
Medicine
DAVID K. WARREN, MD University of Chicago
Assistant Professor Chicago, Illinois
Division of Infectious Diseases Chapters 1, 20, 42
Washington University School of Medicine GARY P. ZALOGA, MD
Hospital Epidemiologist Medical Director, Methodist Research Institute
Barnes-Jewish Hospital Clinical Professor of Medicine
Saint Louis, Missouri Indiana University
Chapter 4 Indianapolis, Indiana
Chapter 79
STEPHEN G. WEBER, MD, MS JANICE L. ZIMMERMAN, MD

Assistant Professor of Medicine Professor of Medicine
Section of Infectious Diseases Baylor College of Medicine
Hospital Epidemiologist Director, Medicine Emergency Services
Director, Infection Control Program Associate Chief, Medicine Service
The University of Chicago Ben Taub General Hospital
Chicago, Illinois Houston, Texas
PREFACE
The field of critical care has exploded since we last re- therapeutic hypothermia, interpreting ventilator waveforms,
vised this textbook in 1998. In particular, the large number adrenal dysfunction, telemedicine, biowarfare, intravascu-
of high-quality clinical trials performed to elucidate mech- lar devices, angioedema, massive hemoptysis, and evidence-
anisms of critical illness and to guide clinical care has re- based prophylactic strategies, among others. The changing
verberated through ICUs around the world and generated nature of our patients and increasing recognition of compli-
tremendous excitement. A decade ago, intensivists managed cations following critical illness by weeks, months and years
patients based largely on an in-depth understanding of car- spawned chapters on obesity in critical illness, chronic criti-
diopulmonary pathophysiology, coupled with a broad un- cal illness, long-term outcomes, delirium, and economics of
derstanding of internal medicine, surgery, and a few related critical care. We have completely revised many chapters to
fields. The last decade has added to this a wealth of evidence keep pace with changing concepts in nutrition, myocardial
revealing that there are better and worse ways to manage our ischemia, airway management, ARDS, severe sepsis, cardiac
patients. The modern intensivist must both master a complex rhythm disturbances, pericardial disease, status epilepti-
science of pathophysiology and be intimately familiar with an cus, intracranial hypertension, blood transfusion, acute renal
increasingly specialized literature. No longer can critical care failure, acid-base disorders, electrolyte disturbances, gas-
be considered the cobbling together of cardiology, nephrol- trointestinal hemorrhage, fulminant hepatic failure, cirrhosis,
ogy, trauma surgery, gastroenterology, and other organ-based mesenteric ischemia, gastrointestinal infections, coma, care of
fields of medicine. In the 21st century, the specialty of critical the organ donor, toxicology, dermatologic conditions, sickle
care has truly come of age. cell disease, hypothermia, and hyperthermia. Finally, a for-
Why have a textbook at all in the modern era? Whether at mer colleague, Dr. V. Theodore Barnett, an intensivist with
home, in the office, or on the road, we can access electronically extensive experience in the melting pot of Hawaii, has con-
our patients’ vital signs, radiographs, and test results; at the tributed an introduction that reminds all of us of the chal-
click of a mouse we can peruse the literature of the world; lenges and opportunities we face when dealing with our
consulting experts beyond our own institutions is facilitated multicultural patients and their families.
through email, listserves, and web-based discussion groups. We have collected up front many of the issues of orga-
Do we still have time to read books? nization which provide the foundation for excellent critical
We believe the answer is a resounding yes. Indeed, the tor- care as well as topics germane to almost any critically ill pa-
rent of complex—and, at times, conflicting—data can be over- tient. The remainder of the text follows an organ system ori-
whelming for even the most diligent intensivist. We have chal- entation for in-depth, up-to-date descriptions of the unique
lenged our expert contributors to deal with controversy, yet presentation, differential diagnosis, and management of spe-
provide explicit guidance to our readers. Experts can evaluate cific critical illnesses. While we have made many changes,
new information in the context of their reason and experience we have preserved the strengths of the first two editions: a
to develop balanced recommendations for the general inten- solid grounding in pathophysiology, appropriate skepticism
sivist who may have neither the time nor inclination to do it based in scholarly review of the literature, and user-friendly
all himself. chapters beginning with “Key Points.”
A definitive text of critical care must achieve two goals: the We attempted to preserve our vision and approach in the
explication of the complex pathophysiology common to all third edition of Principles of Critical Care by contributing ap-
critically ill patients, and the in-depth discussion of proce- proximately one fourth of the total chapters ourselves and
dures, diseases, and issues integral to the care of the critically recruiting associate editors and colleagues who share our vi-
ill. The exceptional response to the first two editions of Prin- sion concerning academic critical care. In general, we are con-
ciples showed us that we succeeded in meeting these goals. In vinced that clinical scholarship in critical care is conferred
this third edition, we have made numerous changes in line by balanced involvement in both management and investi-
with the tremendous evolution in our field. We have deleted gation of critical illness, so we invited two associate editors
the illustrative cases and their discussion to make room for ex- who actively deliver intensive care and publish about it. Our
citing new chapters dealing with catastrophe-preparedness, selection of associate editors having a shared spirit was
xxiv PREFACE
considerably aided by our having practiced, researched, pub- ogists, internists, and surgeons in the ICU and in the research
lished, or taught with both. laboratories. When we three began to work together at the
Dr. Jameel Ali is a Canadian trauma surgeon actively in- University of Chicago in 1982, our experience in programs
volved in providing and teaching ATLS and critical care in emphasizing clinical excellence combined with our question-
North America. His wide range of publications on critical ing, mechanistic approach to patients’ problems to help es-
care topics addresses mechanisms in basic science journals tablish a robust and active clinical critical care service with
such as the Journal of Applied Physiology and clinical investi- prominent teaching and research activities. Our teaching pro-
gations in the best surgical and medical journals. From this gram was built upon the components of: 1) an understanding
base in surgical critical care and its considerable overlap with of underlying pathophysiology; 2) a state-of-the-art knowl-
anesthesiology and medicine, Dr. Ali coordinated most of the edge of current diagnosis and management of problems in the
chapters aimed at essential surgical aspects of critical care and ICU; 3) a familiarity and experience with the tools and results
those related to the gastrointestinal system, while authoring of basic and clinical investigation in critical care; and 4) an ap-
(or co-authoring) four chapters himself. Dr. Keith Walley is preciation of the issues and methods of ICU organization and
another Canadian intensivist who combines basic and clin- management. We have attempted to make this text incorpo-
ical investigation with his practice and teaching of critical rate just these components in its explication of the principles
care. He helped organize the sections covering general man- of critical care, and hope that the text continues to be a well-
agement and cardiovascular diseases and contributed two received and valued extension of our teaching methodology
chapters himself. beyond the confines of the University of Chicago.
We have encouraged our contributors to state cautiously In addition to our associate editors and individual authors,
and with experimental support their diagnostic and thera- others too numerous to mention facilitated the completion of
peutic approaches to critical illness, and to acknowledge that this book. We are especially indebted to our own students of
each approach has adverse effects, in order to define the least critical care at the University of Chicago who motivate our
intervention required to achieve its stated therapeutic goal. teaching – our critical care fellows; residents in anesthesia,
With the help of our associate editors, our review process medicine, neurology, obstetrics and gynecology, pediatrics,
was closer to that enforced by excellent peer-reviewed jour- and surgery; and the medical students at the Pritzker School of
nals than that encountered by most contributors of invited Medicine. Our colleagues in providing critical care within the
book chapters. We hope the attendant frustrations and revi- section, Edward Naureckas, John Kress, Brian Gehlbach, John
sions of the authors provide a better learning experience for McConville, Imre Noth, and Kyle Hogarth, combine with oth-
the readers. ers in our institution such as Michael O’Connor, Avery Tung,
Our approach to patient care, teaching, and investigation of Axel Rosengart, Jeffrey Frank, Michael Woo, Patrick Murray,
critical care is energized fundamentally by our clinical prac- and Lawrence Gottlieb, to make our practice of interdisci-
tice. In turn, our practice is informed, animated, and balanced plinary critical care at the University of Chicago interesting
by the information and environment arising around learning and exciting.
and research. Clinical excellence is founded in careful history Even with all this help, we could not have completed the
taking, physical examination, and laboratory testing. These organization and editing of this book without the combined
data serve to raise questions concerning the mechanisms for efforts of many at McGraw-Hill. Our editors have guided this
the patient’s disease, upon which a complete, prioritized dif- group of academic physicians through the world of publish-
ferential diagnosis is formulated and treatment plan initiated. ing to bring our skills and ideas to a wide audience, and we
The reality, complexity, and limitations apparent in the ICU are thankful for their collaboration.
drive our search for better understanding of the pathophysi- Finally, the revision of a book such as this one is a major ad-
ology of critical care and new, effective therapies. venture that could not succeed simply through the efforts of
We enjoy teaching principles of critical care! We came to its senior authors, nor the considerable contributions of our
our affection for teaching the diagnosis and treatment of many colleagues, nor the meticulous work of its publisher.
critical illness through internal medicine, albeit by different This book would never have seen the light of day without the
tracks. Two of us (JH, GS) were educated at the University of untiring support of Cora D. Taylor, our editorial assistant, a
Chicago’s Pritzker School of Medicine and Internal Medicine remarkable colleague who guided all of our efforts through
Residency before serving as chief medical residents in 1981 the day-to-day difficulties of writing this text. To this task
and 1985, respectively. The other (LW) graduated in medicine she brought organization, persistence, and a sense of humor
from the University of Manitoba in Winnipeg, Canada, com- that delighted and aided all who were fortunate enough to
pleted a PhD program at McGill University in Montreal in the work with her. We especially acknowledge her contributions,
course of his internal medicine residency, then joined the crit- without which we would not likely have overcome the innu-
ical care faculty in Winnipeg in 1975. There, critical care had merable impediments during the three years of revising this
a long tradition of effective collaboration among anesthesiol- book.
xxvi INTRODUCTION
TABLE I-1 Communication During Critical Care
Subject Possible Issue Mechanism of Improving Care
Language Miscommunication Interpreter, translator second choice

Decision-Making Alternate models Clear delineation of decision maker early
Religion Need for rituals Trained chaplains, connections with sectarian clergy
Autonomy No desire for autonomy Clarify decision making with patient and family on admission
Visitation Entire family with children Allow maximal family interactions as possible including children
desire for care on each side of the physician/patient relation- without input from those larger entities would simply be un-
ship. Unfortunately, cultural interpreters are uncommon and acceptable. Therefore, it is important to identify the mode of
difficult–if not impossible–to obtain for all cultures that an family communication and the decision-making processes of
intensivist may come into contact with. Many persons who the family, as much as possible. Simply asking the family who
act as interpreters can, although not trained, act as a valuable will make the decisions and how is important. Truth-telling
cultural resource. This, however, requires the practitioner to enters into the autonomy equation. Many cultures consider it
understand their limitations and the potential problems, and potentially harmful to tell a patient they have a terminal ill-
to ask the interpreter the proper questions about approach to ness, because telling a person they are dying may make that
the family and patient, and manner of dealing with them. A likelihood a certainty.
true interpreter, as opposed to a translator, will perform some What is therefore needed at times is a hybrid. We are un-
of these tasks. They may say, for example, that in a particular willing to give up our ethics as we feel we must practice them,
culture the phrase “we’ll think about it” generally means “we and yet we are ethically obliged to respect the wishes of the
have decided to proceed but must wait a respectable period patient. At times we have to respect the autonomy of a patient
of time.” That is the difference between a strict translator of to make the decision to not be autonomous. Discussions with
words and an interpreter of meaning. An interpreter is the the patient regarding whom they feel should make the deci-
least that is required for true understanding; but again, this sions, whether it should be them or another member of the
is not possible in many hospitals and in many situations, e.g., family, are necessary in many cultural contexts. In addition,
in the middle of the night where decisions are crucial and the along with that discussion, a discussion concerning whether
abilities and resources at hand must be used. All too often the patient wants to know their diagnosis and prognosis is im-
a family member is recruited to translate. To make matters portant. It would seem, if autonomy is to be respected fully,
worse this is often a minor who knows English by virtue of that a patient should have the right to say “I do not want to
school. Only under extreme circumstances should a family know and please give my family the medical information and
member be used to translate. Conscious and unconscious fil- allow them to make the decisions.” It is sometimes helpful
tering are common in this situation. Almost as bad, a person to have a discussion with patients who are ambiguous about
who is available but untrained in either communication skills full knowledge in a third person way. “What would you think
or medical interpreting is drafted into service. Hospitals have about a person who had this diagnosis or who had this hap-
lists of translators but these persons have generally received pening to them or was going to have this happen to them?”
little or no formal training. If these persons must be used (and “How do you feel this type of situation should be handled?”
realistically it cannot be avoided), training should be manda- Those kinds of discussions with some degree of individual
tory. It should not be forgotten, however, as with any other dissociation can be helpful in allowing a patient of any culture
tool in the ICU, that using a strict translator is not using the to discuss subjects that would otherwise not be acceptable, or
optimal resource and obtaining the optimal information, and emotionally or intellectually possible, topics of discussion.
that inaccurate information may well be transmitted.
FAMILY AND VISITATION
ETHICS
Intensive care units have traditionally had very restrictive vis-
Many of the precepts of western biomedical ethics which are itation policies. These have, in general, become less stringent
taken as undeniable truths in much of American medicine are in recent years. They still clash with the feeling of many fami-
simply cultural constructs which are subject to the same in- lies regarding family presence at a sick bed. In many cultures
tercultural variability as all other cultural constructs. Three of it is regarded as a familial obligation for at least one mem-
these of primary importance in the ICU are autonomy, truth- ber of the family to be present at the sick bed of a gravely ill
telling, and beneficence. person at all times. Although this is at times inconvenient for
Autonomy, as it regards decision making, becomes an issue the medical staff, it is only rarely contraindicated and at these
as patients are admitted to the ICU and end-of-life discussions times having a family member wait outside the room is gener-
are begun. They often become a moot point by the time de- ally acceptable for all. Visitation by children and the presence
cisions occur concerning the pursuit of very aggressive care of children in the rooms of the gravely ill also varies. Whether
or withdrawal of care, as the patient is no longer capacitated children are capable of handling visitation in the ICU is a deci-
for medical decision making. However, it must be noted from sion best left to those family members who know them best.
the beginning of the patient’s admission that multiple models Their presence should be allowed unless there is a signif-
of decision making are possible. In many cultures, the con- icant contraindication, particularly in end-of-life situations.
cept that a patient would have the autonomy to bankrupt In many cultures it is seen as quite normal to expose children
their family and put enormous strains on their community to all aspects of life and death, and their exclusion leads to
INTRODUCTION
“An elderly Hindu in a British hospital was found lying on the scribed in many ways, but for purposes of simplicity can be
floor, so, thinking that he had fallen out of bed, the nurses placed defined as a system of beliefs and a learned and ingrained
him back. Shortly afterwards he was found on the floor again. worldview that goes beyond surface belief to patterns of core
He could not speak English to explain that he thought he was values and meaning.
dying and wanted to die on the floor where he would be near Culture should not be confused with either ethnicity or
Mother Earth, so that his soul could leave more freely than in a
race. Race is a term which has no biological validity. The con-
bed. Like many Hindus, he had a clear model of how he should
die, yet he died alone, before his family could be summoned to
cept of race as a valid biological categorization has been re-
perform the final rituals.’’ futed by the American Anthropological Association, and in
Shirley Firth, Dying, Death and Bereavement in a British Hindu general the term has no scientific meaning. Ethnicity refers
Community to the ethnic background into which a person was born. It is
generally similar to culture but can be very different (as in
cross-ethnic adoption); although often used as a marker for
Caring For Critically Ill Patients and culture, “ethnicity” and “culture” are not synonymous and
cannot simply be used as such.
Their Families: Culture Matters Acculturation modifies the effects of culture. This has long
been recognized by immigrants themselves. The Japanese in
The probability of any two random persons in America America classify themselves as Issei, Nisei, Sansei, and Yonsei
being of the same ethnicity is 0.49; 58% of medical critical care for successive generations after immigration. This is a tacit
fellows are graduates of foreign medical schools. These two recognition that worldview and interaction with the domi-
facts are enough to explain why a discussion of cross-cultural nant culture changes with increasing exposure to, and assimi-
medicine should be placed at the front of a critical care text. Di- lation of pieces of, that culture. The rate of acculturation varies
versity and cultural sensitivity are concepts which are much tremendously among immigrants, in part due to the degree
in the forefront of recent conversations regarding medicine. to which cultural continuity is maintained in a specific locale
However, much of what is done with these concepts and re- as opposed to integration into the larger community.
alties is simplistic, and many of the tools purporting to help A textbook discussion of specific issues and table of pos-
cultural sensitivity do little more than reinforce prejudgment sible solutions does not remove the complexity of cultural
and stereotypes. diversity. What must be appreciated is the enormous vari-
Practitioners struggling to deal with the bewildering array ation in human belief and desires regarding health, illness,
of ethnicities, religions and cultures with which they are con- and dying. A realization and admission of lack of knowledge
fronted and must interact could be forgiven for being over- and beliefs is the first step. The one specific piece of informa-
whelmed. Learning the nuances of even one culture takes tion regarding your patient from whatever culture, ethnicity,
years of study. When that culture is confronted with an en- nationality and religion that can be given is this: You do not
trenched biomedical culture the complications multiply. It is know what they believe until you ask them, and that asking
therefore not possible to state in detail the proper way to ap- opens a dialogue of extraordinary value to all concerned.
proach any particular type of patient or family. The best that
can be done is to learn what some of the fundamental issues
are, and how to sensibly and practically approach them in
the daily care of patients in the intensive care unit. Although
Specific Considerations
there is some evidence of higher satisfaction when the patient
COMMUNICATION
and provider are similar in demographics, matching patients
and physicians by demographics is neither reasonable nor The ideal person to act as an interpreter in these situations is
desirable. a cultural interpreter. This person can not only translate the
A look at the basic language and terms involved can illus- words and conversation but interpret the appropriate social
trate the complexity of the situation and begin a process of customs and mores and help in dealing with areas of cul-
coming to terms with this challenge. Culture has been de- tural incongruity by interpreting the worldview and resultant
INTRODUCTION xxvii
a sense of lacking a full family presence. This is particularly ceased. The full import of this change in a definition of death
true in withdrawal of care situations. which has existed for the entire history of mankind can be
felt at times when dealing with families who have not kept
up with the pace of our changing medical beliefs, or whose
PAIN CONTROL faith does not allow them to acknowledge brain death. There
The question of pain control has been addressed in several are places in America and throughout the world where reli-
recent discussions regarding end-of-life care. It is generally gion determines whether a person is deemed dead or not–a
taken as a tenet of end-of-life care that pain should be abol- remarkable example of the influence of culture and religion
ished if possible and maximally controlled if removal of pain on what we often believe are definitive medical concepts.
is not possible. There are beliefs, particularly religious beliefs, The events surrounding end-of-life are of particular inter-
regarding the redemptive value of pain. This exists in several est to clinicians and researchers today. We should in no way
religious traditions including the Catholic and Islamic tradi- believe, however, that we have created the concepts of the
tions. It should not, however, be presumed that a member dying, the near-dead, and persons who are for most pur-
of these religions wishes to suffer, or that members of other poses dead although physiologically alive. Each of those con-
religions do not. The presence of multiple meanings of pain cepts exists in multiple cultures throughout the world and
simply needs to be realized. Our beliefs must be checked with has for millennia. It would be extreme hubris on our part
the those of the patient, and their wishes followed. to believe that we have somehow discovered dying and can
now somehow manage it. We must learn from the billions of
human beings who have already faced this situation with
RELIGION their families and communities. To do otherwise would be a
disservice to our humanity.
Religion is often closely tied to culture and ethnicity. In many
tribal societies, prior to western contact, religion was not TRUST
defined as separate from the rest of life. Most commonly,
Patients and families from traditionally underprivileged eth-
however, we are dealing with patients with specific religious
nicities and poorer socioeconomic classes may have issues
beliefs. Virtually all hospitals have chaplains or ministers of
with trust in the dominant biomedical structure. The legacy of
specific denominations. It is best to make an institutional re-
grievous breaches of ethics, and even currently documented
lationship with religious leaders of any denomination with
inequality in care, leave a cloud of suspicion over recommen-
which significant contact is likely given the population of in-
dations to withdraw care in some patients. Families, with
tensive care patients. In general, a chaplain trained in hospi-
some historical justification, have suspicions of the medical
tal chaplaincy can deal with most contingencies in helping
establishment and the motives for recommendations which
the family cope. There are, however, specific rites and rituals
are made. It is also a concern among some minority patients
which do require the presence of a practitioner with knowl-
and families that recommendations, particularly regarding
edge and credentials of the religion in question.
limitation of expensive technology or withdrawal of care, are
Treatises on specific religious beliefs regarding health and
potentially being made for economic and not medical rea-
end-of-life issues can be found, but given the extraordinary
sons. These are very difficult situations to resolve once mis-
proliferation of subgroups within any religion, generalities
trust has arisen. Clear communication from the beginning can
should be avoided and specific guidance sought from the
help avoid such situations. Once a situation arises, involve-
family and their spiritual counselor.
ment of medical personal of similar cultural background and
the involvement of community resources in the dialogue can
END-OF-LIFE AND WITHDRAWAL OF CARE be helpful.
Death is where the effects of culture impact most strongly in

the ICU. Biomedicine often views death as a simple physio- Recommendations
logic concept which all staff know can be confirmed by a rapid
exam. It is, in reality, a complex and mutable concept. As ill- Several articles have examined some of the specific issues ad-
ness is culturally defined, even death is subject to cultural dressed here in more depth and have resources and additional
definition. There are persons in the mainstream of American suggestions for approaches to cross-cultural care.
culture who believe death is the final event of a physical body What we must focus on when faced with a culture and
with nothing further. There are those who know with equal belief system different than our own is attempting to under-
assurance that there is a soul which lives on after the body stand how that person or persons knows the world. We must
and goes to one of a number of different fates. To the indi- ask and listen to their answers regarding how they know dis-
viduals involved these are less beliefs than truths and ways ease, life and death. We must learn how to discern what is
of defining existence. It is important to realize that this same important to our patients and families, not try to focus on
tremendous diversity of ethical certainty and potential in- any specific belief of any group. It is impossible to know all
compatibility of beliefs occurs in many situations. Regarding of the answers. The best we can hope for is knowing what
death, there has also been a long tradition in several cultures questions to ask.
of regarding persons as being in the category of the dead
before what we would consider physiologic death. Lest this V. Theodore Barnett, MD
seem ridiculous, it is worth remembering that within the last Division of Pulmonary and Critical Care Medicine
few decades biomedicine has changed the definition of death Medical College of Wisconsin
to now include persons whose brain function has irreversibly Milwaukee, Wisconsin
PRINCIPLES OF
CRITICAL
CARE
PART I
AN OVERVIEW OF
THE APPROACH TO
AND
ORGANIZATION OF
CRITICAL CARE
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CHAPTER 1 AN APPROACH TO CRITICAL CARE 3
Chapter 1 programs. Yet the vast majority of critical care is delivered in

community-based ICUs not affiliated with universities, where
AN APPROACH TO critical care physicians rely on their penchant for lifelong
learning to update their knowledge and skills through in-
CRITICAL CARE formed reading and attending continuing medical education
critical care conferences. These activities in providing, teach-
JESSE B. HALL
GREGORY A. SCHMIDT ing, and investigating critical care contribute to a unique per-
LAWRENCE D. H. WOOD spective on and approach to medicine among critical care
physicians.
Providing Exemplary Care

KEY POINTS DEVELOP AND TRUST YOUR CLINICAL SKILLS
t Thoughtful clinical decision making often contributes more to
the patient’s outcome than dramatic and innovative Clinical excellence is founded in careful history taking, phys-
interventions or cutting-edge technology. ical examination, and laboratory testing. These data serve to
t Formulate clinical hypotheses, then test them. raise questions concerning the mechanisms for the patient’s
t Define therapeutic goals and seek the least intensive
disease, on which a complete prioritized differential diagno-
sis is formulated and treatment plan initiated. The reality,
intervention that achieves each. complexity, and limitations apparent daily in the ICU present
t Novel treatments require objective clinical trials before they are
several pitfalls on the path to exemplary practice. By its very
implemented, and traditional therapies require clarification of nature, critical care is exciting and attracts physicians hav-
goals and adverse effects in each patient before their use can be ing an inclination toward action. Despite its obvious utility
optimized. in urgent circumstances, this proclivity can replace effective
t Determine daily whether the appropriate therapeutic goal is clinical discipline with excessive unfocused ICU procedures.
treatment for cure or treatment for palliation. This common approach inverts the stable pyramid of bedside
t Critical care is invigorated by a scholarly approach, involving skills, placing most attention on the least informative source
teaching, learning, and performing research. of data, while losing the rational foundation for diagnosis and
treatment.
Intensive care has its roots in the resuscitation of dying pa-

FORMULATE CLINICAL HYPOTHESES
tients. Exemplary critical care provides rapid therapeutic
AND TEST THEM
responses to failure of vital organ systems, utilizing stan-
dardized and effective protocols such as advanced cardiac An associated problem is that ICU procedures become an end
life support and advanced trauma life support. Other criti- in themselves rather than a means to answer thoughtful clini-
cally ill patients in less urgent need of resuscitation are vul- cal questions. Too often these procedures are implemented to
nerable to multiple organ system failure, and benefit from provide monitoring, ignoring the fact that the only alarm re-
prevention or titrated care of each organ system dysfunction sides in the intensivist’s intellect. Students of critical care ben-
according to principles for reestablishing normal physiology. efit from the dictum: “Don’t just do something, stand there.’’
This critical care tempo differs from the time-honored round- Take the time to process the gathered data to formulate a
ing and prescription practiced by most internists and primary working hypothesis concerning the mechanisms responsible
care physicians. Furthermore, the critical care physicians pro- for each patient’s main problems, so that the next diagnostic
viding resuscitation and titrated care often have little first- or treatment intervention can best test that possibility. With-
hand familiarity with their patients’ chronic health history, out this thoughtful clinical decision making, students of crit-
but extraordinary tools for noninvasive and invasive descrip- ical care are swept away by the burgeoning armamentarium
tion and correction of their current pathophysiology. Though of the ICU toward the unproductive subspecialty of critical
well prepared for providing cure of the acute life-threatening care technology. So often in the ICU thoughtful compilation
problems, the intensivist is frequently disappointed to be the of the patient’s health evaluation preceding the acute event
bearer of bad news when recovery is impossible, and increas- is more helpful than acquiring new data defining the current
ingly must develop and use compassionate pastoral skills pathophysiologic state. Accordingly, attention to this search
to help comfort dying patients and their significant others, for meaningful collateral history and the retrieval of prior
using clinical judgment to help them decide to forego fur- radiologic studies and laboratory values often should pre-
ther life-sustaining treatment. Accordingly, experienced in- cede the next invasive ICU procedure. The next intervention
tensivists develop ways to curb their inclination toward ac- should be chosen to test a diagnostic hypothesis formulated
tion in order to minimize complications of critical care, while by thoughtful processing of the available data.
organizing the delivery of critical care to integrate and coor- Testing a therapeutic hypothesis requires knowing the goal
dinate the efforts of many team members to help minimize of the intervention and titrating the therapy toward that end
the intrinsic tendency toward fragmented care. In academic point. Too often students of initial care employ too little too
critical care units, teaching and investigation of critical care late during resuscitation. For example, the patient with hy-
are energized by the clinical practice; in turn, the practice is povolemic shock receives a bolus of 250 mL of crystalloid so-
informed, animated, and balanced by the information and lution followed by 200 mL/h infused through two 18-gauge
environment arising from and around teaching and research needles in peripheral veins, while the mean blood pressure
4 PART I AN OVERVIEW OF THE APPROACH TO AND ORGANIZATION OF CRITICAL CARE
(bp) rises from 50 to 60 mm Hg over 2 hours. A far better and volume resuscitation were achieved. Once a stable blood
volume resuscitation protocol targets urgent restoration of a pressure and hemostasis are achieved, what is the time course
normal bp and perfusion, so it establishes central venous ac- for discontinuing the β-agonist therapy?
cess for a bolus of 3 L of warmed crystalloid and colloid in One answer is to wean the vasoconstrictor slowly (e.g., de-
20 minutes, to continue at that rate until the bp exceeds 90 mm crease the norepinephrine infusion rate from 30 µg per minute
Hg without inducing pulmonary edema. As another exam- by 5 µg per minute each hour). Another approach is to liber-
ple, a patient requires intubation and ventilation with 100% ate the patient from the vasoconstrictor by reducing the nore-
oxygen for acute hypoxemic respiratory failure. Positive end- pinephrine infusion rate by half every 15 minutes. The dif-
expiratory pressure (PEEP) is increased from 0 to 5 to 10 cm ference between these two approaches is more than the time
H2 O overnight, while arterial O2 saturation (SaO2 ) increases taken to discontinue the agent, for if in the second approach
from 70% to 80% to 90% and bp remains at 95 mm Hg. A the bp were to fall after reducing the norepinephrine to 15 µg
better PEEP resuscitation protocol targets an SaO2 of >90% on per minute, the critical care physician learns that the patient
an inspired O2 fraction (FiO2 ) of <0.6, so it increases PEEP by remains hypovolemic and needs more volume infusion; the
5-cm-H2 O increments from 0 to 20 cm H2 O at 5-minute inter- first approach would mask the hypovolemic hypoperfused
vals, dropping FiO2 as tolerated until the end point is achieved state by the prolonged use of vasoconstrictor agents, leading
unless bp falls. If bp does fall unacceptably, positive inotropic to the adverse consequences of multiple organ hypoperfu-
therapy or volume infusion corrects the hypotension, allow- sion. Words convey meaning, and to wean connotes the re-
ing further PEEP increments toward the end point. In each moval of a nurturing, even friendly life-support system from a
of the better protocols, a clinical hypothesis about the mech- dependent, deprived infant, a process that should proceed
anism of the critical illness—(1) the patient is hypovolemic, slowly; by contrast, liberation is the removal of an unneces-
so rapid volume infusion will correct the hypotension, or (2) sary and potentially toxic intervention from an otherwise in-
the hypoxemia is due to airspace flooding, so PEEP will cor- dependent adult, a process that should proceed urgently.1
rect the shunt—can be tested by titration of therapy toward
a thoughtful end point without causing common adverse ef-
fects (Fig. 1-1). The results are more timely correction of life- DEFINE THERAPEUTIC GOALS AND SEEK THE LEAST
threatening conditions. INTENSIVE INTERVENTION THAT ACHIEVES EACH
The principle from this example applies to many other criti-
LIBERATE FROM INTERVENTIONS SO THERE ARE cal care therapies, such as liberation from the ventilator, va-
NOT MORE TREATMENTS THAN DIAGNOSES soactive drugs, and sedative and muscle-relaxing agents. Of
course, the difficulty in all these examples is that the thera-
One of the consequences of protocol-driven resuscitations is peutic intervention is initially life-saving, but how long the
that the recovered patient now has more treatments than di- intervention needs to continue for the patient’s benefit versus
agnoses. An effective approach to the adverse outcome of the patient’s harm depends on a critical evaluation of the goal
excess therapeutic interventions is the mindset that liberates of therapy.
the patient from these potentially harmful interventions as Figure 1-1 indicates the intensity-benefit relationship of
rapidly as their removal is tolerated. For example, the patient many of these interventions (e.g., the continued use of high-
with hemorrhagic shock treated with volume resuscitation dose norepinephrine in the hypotensive patient with hemor-
and blood products also received intravenous vasoconstrict- rhagic shock discussed earlier). During the initial resuscita-
ing agents to maintain perfusion pressure while hemostasis tion, the benefit of increasing the norepinephrine dose along
the x axis (intensity) was demonstrated by the rising bp dur-
FIGURE 1-1 A schematic diagram relating therapeutic intensity ing hemostasis, volume resuscitation, and norepinephrine in-
(abscissa) to the benefit of therapy (ordinate). For many fusion. Yet bp is not the appropriate benefit sought in the
interventions in critical illness, there is a monotonic increase in hypoperfused patient, but rather adequate perfusion of all
benefit as treatment intensity increases (solid line), but organs. Even without measuring cardiac output, an adequate
concomitant adverse effects of the intervention cause harm at perfusion state could be inferred from an adequate bp when
higher intensity (interrupted line) (for examples, see text). This the vasoconstrictor agent is diminished. However, with con-
leads to an approach to critical care that defines the overall goal of tinued infusion of the vasoconstrictor, the adverse effect of a
each intervention and seeks the least intense means of achieving it.
prolonged hypoperfusion state, even with an adequate bp, is
indicated by the interrupted line, which illustrates a decreas-
ing benefit as the intensity of the intervention and the shock
it masks continues. Armed with this rationale, the intensivist
should progressively reduce the intensity of norepinephrine
infusion over a relatively short period to determine whether
the volume resuscitation is adequate.
A second example is the use of fluid restriction and diuresis
in the treatment of pulmonary edema. In Fig. 1-1 the intensity
of the intervention is the reduction of the pulmonary capil-
lary wedge pressure (PCWP), while the benefit would be the
reduction of pulmonary edema. Considerable data suggest
a monotonic relationship between the intensity of these
therapeutic interventions and the benefit of reduced pul-
monary edema.2 Yet, if the PCWP is reduced too much, there
is a consequent reduction in the cardiac output, so the benefit
to the patient is more than offset by the attendant hypoperfu- ers and students of critical care are frequently called on to
sion state. The thoughtful intensivist recognizes that the goal guide patients and their families through this new, complex
of reducing PCWP and pulmonary edema should not induce decision-making process without much prior personal expe-
a hypoperfusion state, so the targeted intensity is the low- rience or literature on which to rely. Accordingly, we discuss
est PCWP associated with an adequate cardiac output and an approach to managing death and dying in the ICU meant
oxygen delivery to the peripheral tissues. Similarly, for PEEP to minimize one current adverse outcome of modern criti-
therapy, considerable data suggest that the higher the PEEP cal care—our patients die alone in pain and distress because
intensity, the greater will be the reduction in intrapulmonary maximal care aimed at cure proceeds despite little chance of
shunt as the benefit to the patient. Yet the thoughtful inten- success.
sivist recognizes that PEEP has adverse effects, as indicated
by the interrupted line in Fig. 1-1 showing decreasing ben- DECIDE WHETHER THE PATIENT IS DYING
efit as the intensity increases due to pulmonary barotrauma
In a recent analysis of 6110 deaths in 126 ICUs between Jan-
and decreased cardiac output. Accordingly, the goals of PEEP
uary and July of 1996, approximately half were associated
therapy should be the least PEEP that provides the end points
with the decision to withhold or to withdraw ICU care, as dis-
of PEEP therapy—90% saturation of an adequate circulating
tinguished from deaths after CPR or with full ICU care but
hemoglobin on a nontoxic FiO2 . Of course, the adverse effects
no CPR.4 One interesting feature of this study was the het-
of PEEP can be diminished by concomitant decreases in tidal
erogeneity among different units, with some units reporting
volume, as currently practiced in “lung-protective ventila-
90% of deaths associated with withholding and withdrawing
tion’’ (see Chaps. 37 and 38).2
ICU care, and others reporting less than 10% associated with
this decision. Considerable discussion in the recent literature
FIRST DO NO HARM focuses on the definition of medical futility, and many inten-
Beyond enhancing the clinical scholarship of critical care, this sive care physicians are perplexed regarding how to utilize
approach maximizes another hallowed principle of patient the vagaries of survivorship data to be confident that contin-
care—“First do no harm.’’Despite excited opinions to the con- uing therapy would be futile.5
trary, effective critical care is rarely based on brilliant, incisive, Yet many of these same physicians have a clear answer to
dramatic, and innovative interventions, but most often de- another formulation of the question “Is this patient dying?’’6
rives from meticulously identifying and titrating each of the An increasing number of critical care physicians are answer-
patient’s multiple problems toward improvements at an ur- ing “yes’’ to this question based on their evaluation of the
gent but continuous pace. This conservative approach breeds patient’s chronic health history, the trajectory of the acute
skepticism toward innovative strategies: Novel treatments re- illness, and the number of organ systems currently failing.
quire objective clinical trials before they are implemented, When the physician concludes that the patient is dying, this
and traditional therapies require clarification of goals and ad- information needs to be communicated to the patient, or as
verse effects in each patient before their use can be optimized. so often happens in the ICU, to the significant other of the
Accordingly, intensivists should carefully consider the exper- dying patient who is unable to communicate and has not left
imental support for each diagnostic and therapeutic approach advance directives. This communication involves two com-
to critical illness and acknowledge that each approach has ad- plex processes: 1. helping the patient or the significant oth-
verse effects in order to define the least intensive intervention ers with the decision to withhold or withdraw life-sustaining
required to achieve its stated therapeutic goal. therapy, and 2. helping them process the grief this decision
entails (Table 1-1).
ORGANIZE THE CRITICAL CARE TEAM
CHANGE THE GOAL OF THERAPY FROM CURE
The ICU is no longer simply a room in which ventilators are TO COMFORT
used. Instead, in a well-functioning ICU, the physical plant
and technology are planned to facilitate the delivery of care, In our view, this decision is best aided by a clear, brief explana-
while also responding to new opportunities in this rapidly tion of the patient’s condition and why the physician believes
evolving field. The physician director, the nurse manager, the patient is dying. When the patient or significant other has
and the respiratory therapist must build a mutually support- had the opportunity to challenge or clarify that explanation,
ive environment conducive to teaching, learning, and care. the physician needs to make a clear recommendation that con-
Intensivists must be aware of the economic and legal continued treatment for cure is most unlikely to be successful, so
cerns as ICUs capture the interest of politicians, ethicists, and therapeutic goals should be shifted to treatment for comfort
the courts. Furthermore, the managers of ICUs should build for this dying patient. In our experience, about 90% of such
on experience. Quality assurance, triage and severity scor- patients or their families understand and agree with the rec-
ing, and infection surveillance are essential to the continued ommendation, most expressing considerable relief that they
smooth running of ICUs and indeed to their improvement
over time.3 TABLE 1-1 The Intensivist’s Roles in Deciding to Forego
Life-Sustaining Treatment
Managing Death and Dying in the Guiding the Decision Managing the Grief
Intensive Care Unit
Explanation Patient’s advocate
Recommendation Empathic listening
Perhaps no critical care issue is more emotionally charged
Patient’s response Assemble support
and time-consuming than the decision to withhold and/or Implementation Acknowledge the loss
withdraw life-sustaining therapy (see Chap. 17). Practition-
TABLE 1-2 Reconsdering the Goals of Therapy toral skills such as empathic listening, assembling the family
and other support systems, and acknowledging and sharing
Cure Comfort
in the pain while introducing the vocabulary of grief pro-
Ventilation Treat pain cessing are constructive ways to help the patient and fam-
Perfusion Relieve dyspnea ily reconsider the goals of therapy. This is not an easy task
Dialysis Allay anxiety when the physician knows the patient and family well, but
Nutrition Minimize interventions it is even more difficult in the modern intensive care envi-
Treat infection Family access ronment, when the physician may have met the patient for
Surgery Support the first time within hours to days preceding the reconsid-
Differential diagnosis Grieving eration of therapeutic goals. Yet the critical care physician
needs to establish his or her position as a credible advocate
for the patient by being a source of helpful information, by
do not have to make a decision, but rather follow the recom- providing direction, and by listening empathically. Because
mendation of the physician. It is important to provide time the critical care physician is often a stranger, all efforts should
and support for the other 10% while they process their rea- be made at the time of reconsidering the goals of therapy
sons for disagreement with the physician’s recommendation, to assemble support helpful to the patient, including family
but this remains a front-burner issue to be discussed again friends, the primary physician, the bedside nurse, house staff
within 24 hours in most cases. and students caring for the patient, appropriate clergy, ethics
At this point, patients or their significant others who agree specialists, and social services.
with the recommendation to shift goals from cure to com-
fort benefit from understanding that comfort care in the ICU COMBINE EXCELLENCE AND COMPASSION
constitutes a systematic removal of the causes of patient dis-
Since up to 90% of patients who die in modern ICUs do so with
comfort, together with the incorporation of comforting in-
the decision to withhold and withdraw life-sustaining ther-
terventions of the patient’s choice (Table 1-2). For example,
apy, exemplary critical care should include a commitment to
treatment for cure often consists of positive-pressure ventila-
make this transition to treatment for comfort a humane and
tion associated with posturing, chest pummeling and tracheal
compassionate process, conducted with the same expertise
suctioning, the infusion of vasoactive drugs to enhance circu-
and excellence sought during treatment for cure. In our view,
lation, dialysis for renal failure, aggressive intravenous or ali-
the physician’s conclusion that the patient is dying is the start-
mentary nutrition, antibiotics for multiple infections, surgery
ing point. Thereafter, the physician’s recommendation to shift
where indicated, and daily interruption of sedative infusions
treatment goals from cure to comfort is essential so that the
to allow ongoing confirmation of CNS status. Each of these
patient and the family have no illusions that full ICU care will
components of treatment for cure includes uncomfortable in-
produce a cure. Third, understanding that comfort care is ex-
terventions that need to be explicitly described so that pa-
tensive and effective allows the ICU to become a safe place
tients or their significant others do not maintain the miscon-
for grieving and dying. This is a distinctly different approach
ception that continued ICU care is a harmless, comfortable
from that of many physicians who feel they have failed their
course of action. By contrast, treatment for comfort consists
dying patients by not providing cure; all too often this fear of
of intravenous medication effective at relieving pain, dysp-
failure leads to abandoning dying patients without provid-
nea, and anxiety. It also consists of withholding interventions
ing effective comfort care. Since death is not an option but an
that cause the patient pain or irritation, and of replacing both
inevitability for all of us, critical care physicians can bring
interventions and electronic monitoring of vital signs with
their expertise and understanding to help patients decide
free access of the family and friends to allow the intensive
when to forego life-sustaining therapy and to replace it with
care cubicle to become a safe place for grieving and dying
effective comfort care, making the ICU a safe and supporting
with psychospiritual support systems maximized. Once an
space for the dying patient and his or her significant oth-
orderly transition from treatment for cure to treatment for
ers. Note that the ministerial skills and attitudes required to
comfort has been effected in the ICU, timely transfer out of
implement this approach are more in the province and cur-
the unit to an environment that permits death and grieving
riculum of social workers, psychologists, and clerical pastoral
with privacy and dignity is often appropriate. Whenever pos-
associates than critical care physicians. To the extent that ex-
sible, continuity of care for the dying patient outside the ICU
perienced intensivists find this approach helpful, teaching it
should be effected by the ICU physician-house staff team to
to students of critical care becomes an important contribution
minimize fragmentation of comfort measures and to keep the
to a curriculum of critical care.
patient from feeling abandoned.
MANAGE GRIEF The Scholarship of Teaching and

The second process that is ongoing during this decision mak- Discovery in Critical Care
ing allows the dying patient or the family and friends to begin
to express their grief (see Table 1-1). The very best care of the The process of providing exemplary critical care is magnified
patient is care for the patient, and the critical care physician’s and refined by learning interactions with students of critical
demeanor during the decision making process goes a long care at all levels—from freshmen to senior medical students
way toward demonstrating that he or she is acting as the pa- through residents in anesthesia, medicine, and surgery, to crit-
tient’s advocate. The urgent pursuit of an agenda that care ical care fellows and practicing intensivists seeking continu-
should be withdrawn does not help the patient or family to ing medical education. In such teaching sessions, these stu-
trust in the physician’s desire to help the patient. Instead, pas- dents always question the principles of critical care and how
best to impart them, thereby helping direct a search for better TABLE 1-3 Critical Care Curriculum: The Pathophysiology of
teaching methods. Of course, any active ICU is a classroom Critical Illness
for learning the principles of critical care. Yet teachers of crit-
1. O2 delivery and the management of life-threatening hypoxia
ical care need to avoid the pitfalls to learning when there is 2. Pulmonary exchange of CO2 , Vd/Vt and ventilatory (type II)
little time for the student to process the reasons for the for- failure
mulations of differential diagnostic and treatment plans in 3. Pulmonary exchange of O2 , shunt, and acute hypoxemic (type I)
each patient. There can develop a “shoot from the hip’’ pat- respiratory failure
tern recognition of critical illness that often misses the mark 4. Respiratory mechanics and ventilator-lung model demonstration
and perpetuates a habit of erroneous interventions that delay 5. Perioperative (type III) respiratory failure and liberation of the
a more rational, mechanistic, questioning approach to each patient from mechanical ventilation
patient’s problem. 6. Right heart catheter, central hemodynamics, and lung liquid flux
7. Cardiovascular management of acute hypoxemic respiratory
failure
IMPLEMENT A CRITICAL CARE CURRICULUM IN 8. Ventilatory management of acute hypoxemic respiratory failure,
THE INTENSIVE CARE UNIT including ventilator-induced lung injury
One helpful teaching technique is to implement a sched- 9. Ventilator waveforms to guide clinical management
ule providing students of critical care with the luxury of 10. Status asthmaticus and acute-on-chronic respiratory failure
11. Control of the cardiac output and bedside differential diagnosis
time to think. This priority provides a counterpoint to the
of shock
work rounds and clinical problem-solving activities that un- 12. Volume and vasoactive drug therapy for septic, hypovolemic,
fettered, tend to dominate the daily activities of the unit. A and cardiogenic shock
good start is to ritualize a curriculum for critical care learn- 13. Left ventricular mechanics and dysfunction in critical illness—
ing. In many academic centers, house staff and fellows ro- systolic versus diastolic
tate through the ICU on monthly intervals. Accordingly, a 14. Acute right heart syndromes and pulmonary embolism
monthly series of well-planned seminars addressing the es- 15. Acid-base abnormalities
sential topics that house staff and fellows need to know can 16. Severe electrolyte abnormalities
incorporate medical students and nursing staff, and lay the 17. Nutrition in critical illness
foundations of conceptual understanding necessary to ap- 18. Sedation, analgesia, and muscle relaxation in critical illness
19. Evaluation and management of CNS dysfunction in critical illness
proach the critically ill patient effectively. In our teaching
20. The physician on the other end of the ET tube—audiotape and
program, we emphasize a conceptual framework based on discussion
the pathophysiology of organ system dysfunction shared by 21. Managing death and dying in the ICU—videotape and discussion
most types of critical illness (Table 1-3). 22. Miscellaneous additional topics: noninvasive ventilation, heat
This approach complements the specific etiology and ther- shock, rhabdomyolysis, acute renal failure, hypothermia, and
apy of individual illnesses, because the opportunity for favor- critical illness in pregnancy
ably treating many concurrent organ system failures in each
Vd/Vt, dead space/tidal volume ratio.
patient occurs early in the critical illness, when the specific
diagnosis and focused therapy are less important than re-
suscitation and stabilization according to principles of organ 24 hours on each of our patients, including computer-assisted
system pathophysiology. Critically ill patients present many tomograms, magnetic resonance images, and ultrasonogra-
diagnostic and therapeutic problems to their attending physi- phy. This formal review allows faculty and fellows to teach
cians and so to the students of critical care. Recent advances medical students and house staff a systematic review of the
in intensive care management and monitoring technology fa- chest radiograph and special features of ICU radiology, in-
cilitate early detection of pathophysiology of vital functions, cluding identification and positioning of diverse diagnostic
allowing the potential for prevention and early treatment. and therapeutic instruments (e.g., the endotracheal tube, in-
However, this greater volume of diagnostic data and possible travascular catheters, feeding tubes, pacemakers, and others).
therapeutic interventions occasionally can create “informa- We also set aside one day per week to review the echocar-
tion overload’’for students of critical care, confounding rather diographic studies performed during the previous week. Of
than complementing clinical skills. The purpose of a syllabus course, these have been reviewed online when the procedures
addressing the pathophysiology of critical illness is to provide were done, but this forum allows students of critical care to
students with an informed practical approach to integrating become more comfortable with the types of diagnostic infor-
established concepts of organ system dysfunction with con- mation we seek from these imaging techniques. Encouraging
ventional clinical skills. New duty hour regulations for U.S. students of critical care to be active participants in bedside di-
house officers have made it difficult to include all members agnostic and therapeutic procedures such as endoscopy, and
of the team in these teaching sessions, an issue we have not to follow-up on all biopsy specimens by direct observation
been able to fully solve. A syllabus of reading material that with the pathologist are other ways to encourage active learn-
follows the seminar topics closely is helpful to students.7 ing concerning the interpretation of ICU procedures and their
integration with the patient’s clinical evaluation in a timely
ENCOURAGE INDEPENDENT INTERPRETING OF manner.
IMAGING TECHNIQUES, BIOPSIES, AND OTHER
INTERVENTIONS TEACH HOW TO TEACH
A second forum for teaching critical care is to review essential An essential component of the critical care fellowship is
imaging procedures. Accordingly, we set aside about 45 min- learning how to teach. It is common in academic medical en-
utes at 11:00 am each day to systematically review the di- vironments to assume that completing medical school and
agnostic radiology imaging procedures conducted in the last residency confers the ability to teach,8 but most critical care
fellows value the opportunity for supervised and guided en- thoughtful, focused, and timely care. Teachers of critical care
hancement of their teaching abilities by effective teaching fac- can diffuse the angst among students by appropriate, well-
ulty. The critical care syllabus outlined earlier gives the op- placed affirmation of the care being delivered. For example,
portunity for fellows to observe faculty teaching during their exemplary case presentations, thoughtful and complete dif-
first rotation through the unit and during subsequent months ferential diagnoses, focused and insightful treatment plans,
to organize and present selected topics from the syllabus with and well-formulated questions appropriately researched in
the help of their faculty preceptor. Our target is that our fel- the available literature are all targets for faculty approbation.
lows have mastery of the complete syllabus by the time they When praised appropriately and without flattery, students of
complete their fellowship, an exercise that confers confidence critical care respond with energy and enthusiasm, allowing
and credibility on their teaching skills, and undoubtedly en- them to learn to the limit of their potential.
hances their learning of the concepts they teach. Just as bench
researchers go elsewhere and establish their laboratories, our
TEACH CRITICAL CARE IN THE CURRICULA OF
clinical scholars have created the same learning programs
MEDICAL SCHOOLS AND RESIDENCY PROGRAMS
elsewhere, exporting this approach and content rather than
evolving it over years. A second forum is our daily morn- In many academic institutions, critical care faculty are well
ing report, where three to five new pulmonary and critical known among medical students and house staff as outstand-
care patients are presented in a half-hour conference. One ing teachers. This can allow diverse outlets for teaching
fellow provides a brief analysis and solution to each clinical scholarship in the medical school curriculum and in resi-
problem, and suggestions or affirmations of the analysis by dency training programs. In our medical school, freshmen
faculty and other fellows help develop the skill of processing students learn the physiology of the cardiovascular and res-
and presenting complex patients. piratory systems during the winter quarter and have time for
elective courses during the spring quarter. This created the
LEARN AND USE A QUESTIONING APPROACH opportunity for a freshman spring elective entitled “An In-
troduction to the Pathophysiology of Critical Illness,’’ which
Another important forum for encouraging active learning of
attracts about a quarter of the freshman class each year. Dur-
critical care is the daily teaching round led by the intensive
ing two 21/2 -hour sessions each week for the 10-week quar-
care faculty and critical care fellows. The format we have
ter, we review in detail with the students extensions of their
found most useful is to encourage the most junior member
cardiopulmonary physiology as it is deranged in critical ill-
of the team responsible for the patient to provide a complete,
ness, utilizing a core curriculum similar to the topics shown in
systematic review of the patient, concluding with a differen-
Table 1-3. These students are stimulated by finding that their
tial diagnosis and treatment plan, while the attending faculty
hard work in learning physiology has practical applications
member provides an active listening presence. When the pre-
in treating critically ill patients, and are enthusiastic to apply
sentation is complete, the faculty member questions or con-
this new knowledge of pathophysiology during preceptored
firms directly the essential points from the history, physical
visits on four occasions to patients with respiratory failure or
examination, and laboratory results, and provides any clari-
hypoperfusion states. Utilizing clinically real teaching aids
fication helpful to the rest of the team on generic or specific
like a ventilator-lung model, an echocardiography teaching
teaching issues, integrating the input of more senior members
tape, and a heart sound simulator provides freshmen students
of the team to encourage participation in the bedside decision
with a vision of patient care at an early stage in their clinical
making as a learning exercise.
exposure. During sophomore year, focused topics related to
Often the case discussions can be led to formulate questions
critical care are taught during our clinical pathophysiology
not yet answered concerning the patient’s problems. It is less
course, including asthma and acute respiratory distress syn-
important to provide answers to the questions formed than
drome. In the junior year, students rotate twice through the
to point the students of critical care in the direction of how to
ICU for 2-hour preceptored visits to patients illustrating man-
find the answers, beginning with their reading of appropriate
ifestations of respiratory failure or hypoperfusion states. As
topics in a critical care text available in the ICU. This contin-
described earlier, most senior medical students in our school
ues to the appropriate use of medical informatics to search the
spend a month as members of the critical care teams in our
critical care literature electronically for answers expected in a
medical or surgical ICU.
short interval. Whenever the answer is not available, it is the
In the medical ICU, medical residents and interns rotate for
teaching responsibility of the faculty and critical care fellows
a least three 1-month periods during their 3-year residency
to help students of critical care formulate the clinical investi-
program. To refresh and maintain the knowledge base ac-
gation that could answer the question. In this way, the rounds
quired during these rotations, our critical care faculty leads
in the ICU become intellectually charged, and active partici-
two medicine morning reports per month, during which they
pation of all members of the team is encouraged. A spin-off
review a syllabus of critical care meant to allow residents not
of this questioning approach to active learning in the ICU
on the ICU to utilize their critical care knowledge to process
is much more informed cross-coverage between critical care
cases representing a specific aspect of critical care. Our fac-
teams. In units with active clinical investigation programs,
ulty members are also regular participants in the house staff
this questioning approach stimulates interaction between the
teaching conferences conducted by the departments of anes-
personnel delivering care and those conducting the research.
thesia and critical care, pediatrics, obstetrics and gynecology,
and surgery, and this interaction fosters a collegial approach
AFFIRM LEARNING
to critically ill patients among these different departments. Fi-
Students of critical care learn in a charged environment where nally, the participation of academic critical care faculty in city,
some patients do not improve or actually deteriorate despite regional, national, and international critical care conferences
helps to fine-tune and update teaching approaches that can their critical illness. Some would say that such studies sim-
then enhance the scholarship of teaching critical care at one’s ply cannot be done without consent, but we find this an un-
home institution. desirable acceptance of the current state of our ignorance.
We believe that true equipoise exists in the interface between
INVESTIGATE MECHANISMS AND MANAGEMENT many clinical problems and their potential treatments (i.e.,
OF CRITICAL ILLNESS a realization on the one hand that our understanding of an
Clinical investigation of critical illness is essential for the con- existing treatment for a disease process is inadequate, yet no
tinued growth of effective critical care. Indeed, one of the secure knowledge that a new approach or therapy is com-
hallmarks of critical care in the last decade has been the large pletely safe and efficacious).10 In this circumstance we believe
number of high-quality clinical studies leading to better care. that prospective, randomized trials offer the only hope of in-
Yet the practice of critical care is often so demanding that forming our practice of medicine, and that studies in the ICU,
the intensivist’s time is consumed with providing state-of- even if conducted with proxy or under some circumstances
the-art care. Accordingly, clinical investigation in the ICU re- waived consent, are justified. The function of the institutional
quires an organized program that is parallel to and integrated review board is to foster careful deliberation of the merits of
with the practice and teaching of exemplary critical care. Such each situation and proposed study to ensure that these bal-
a program allows an outlet for the creative formulation of ances are struck.
hypotheses arising at the bedside of critically ill patients. It
also enhances the morale of the critical care physician–nurse–
respiratory therapist team by developing shared confidence
References
that new concepts are being regularly learned during delivery
1. Hall JB, Wood LDH: Liberation of the patient from mechanical
of critical care.
ventilation. JAMA 257:1621, 1987.
An effective critical care research team consists of a re- 2. Acute Respiratory Distress Syndrome (ARDS) Network: Ventila-
search director, critical care nurse research coordinator, and tion with lower tidal volumes as compared with traditional tidal
several critical care fellows. Regular scheduled communica- volumes for acute lung injury and the acute respiratory distress
tions about ongoing research protocols, their significance, and syndrome. N Engl J Med 342:1301, 2000.
their need for patient recruitment need to be maintained be- 3. Ralph DB, Gleason DH: Staffing and management of the intensive
tween the research team and the critical care team. The re- care unit, in Hall JB, Schmidt GA, Wood LDH (eds): Principles of
search team needs to meet on a regular basis to interpret and Critical Care. New York, McGraw-Hill, 1992, p 465.
update data in each of its protocols, and to consider and dis- 4. Prendergast TJ, Claessens MT, Luce JM: A national survey of
cuss new hypotheses for testing. Ideally, the clinical investi- end-of-life care for critically ill patients. Am J Respir Crit Care Med
158:1163, 1998.
gation of critical illness should interface with a basic science
5. Fine RL, Mayo TW: Resolution of futility by due process: Early
research program to allow bench or animal extensions of hy- experience with the Texas Advance Directives Act. Ann Intern
potheses that are difficult to test in the intensive care envi- Med 138:743, 2003.
ronment. Together the basic and clinical investigative teams 6. Karlawish JHT, Hall JB: Managing death and dying in the inten-
implement the essential steps in clinical research in critically sive care unit. Am J Respir Crit Care Med 155:1, 1997.
ill patients: formulate a hypothesis, prepare a protocol, obtain 7. Wood LDH, Schmidt GA, Hall JB: The pathophysiology of critical
institutional review board approval, obtain funding, perform illness, in Hall JB, Schmidt GA, Wood LDH (eds): Principles of
the study, and communicate the results.9 Critical Care. New York, McGraw-Hill, 1992, p 3.
Many challenges exist in conducting studies in the envi- 8. Wipf JE, Pinsky LE, Burke W: Turning interns into senior resi-
ronment of the ICU. These include the unpredictable and un- dents: Preparing residents for their teaching and leadership roles.
Acad Med 70:591, 1995.
scheduled nature of events, the need to maintain complex
9. Murray JF, Rodriguez-Roisin R: Clinical investigation in critically
schedules related to routine care in parallel with schedules ill patients, in Hall JB, Schmidt GA, Wood LDH (eds): Principles
for study protocols, and the very heterogeneous nature of pa- of Critical Care. New York, McGraw-Hill, 1992, p 2269.
tient populations. In the view of many, the greatest challenge 10. Karlawish JT, Hall J: Clinical commentary: The controversy
is conducting studies of promising therapies for which the over emergency research: A review of the issues and sug-
precise risks and benefits are unknown, yet doing so in pa- gestions for a resolution. Am J Respir Crit Care Med 153:499,
tients in whom informed consent is not possible because of 1996.
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CHAPTER 2 ASSESSING COST EFFECTIVENESS IN THE INTENSIVE CARE UNIT 11
Chapter 2 specific guidelines for the conduct of cost-effectiveness analy-

ses based on the USPHS recommendations.6 These standards
ASSESSING COST have the potential to greatly improve the quality of future
cost-effectiveness studies. However, if clinicians do not un-
EFFECTIVENESS IN THE derstand and embrace the principles of cost effectiveness, it
is likely that such studies will continue to be viewed simply
INTENSIVE CARE UNIT as ammunition for nonclinician administrators in the battle
to restrict physician freedom of choice and to control clinical
MICHAEL T. COUGHLIN
DEREK C. ANGUS decision making.
In this chapter, we will cover many of the principal as-
pects of cost-effectiveness analyses and consider how such
studies ought to be conducted on potential new therapies.
We will use drotrecogin alfa (activated) as a working exam-
ple of the type of therapy often utilized in the modern ICU
KEY POINTS that is expensive, but has potentially life-saving effects. The
t The care of critically ill patients in the modern ICU results in a
overall goal of this chapter is to encourage all of us to fa-
large societal burden in terms of both manpower and monetary miliarize ourselves with cost analyses and to consider cost-
cost. effectiveness analysis as simply another tool in our evaluation
t The high cost of critical care can largely be attributed to high
toolkit, along with case reports, animal studies, and random-
overhead costs (e.g., need for experienced staff and expensive ized clinical trials of potential new therapies. We have pre-
equipment), high resource utilization (e.g., drugs, lab tests, and viously reviewed this topic,7 and here will further describe
complex imaging procedures), and an ever-growing demand for the utility of economic analyses in critical care. For a more
ICU services. detailed in-depth discussion of economic analysis in health
t Complex economic analysis of health care decision making can care, the reader is referred to the excellent text by Gold and
be reduced to two fundamental questions that need to be associates.8
answered: First, “Is a therapy worth using when compared with
the alternatives?” The second question is broader and asks
“Should a portion of available health care resources be allocated Economic Evaluations in Health Care
to a given therapy or program?”
t Routine incorporation of Cost Effectiveness studies is important One can compress all of health economics down to two main
to the conduct of high quality clinical trials research in the questions. First, “Is a therapy worth using when compared
intensive care unit. Inclusion of cost effectiveness gives the with alternatives?’’ For example, what is the worth of a new
clinician the opportunity to fully assess the effect of a new antisepsis agent like drotrecogin alfa (activated) that has re-
therapy in the ICU. cently demonstrated a beneficial effect in a large randomized
clinical trial? We can consider that worth represents some
trade-off of cost and benefit (or effect). The second question is
The care of critically ill patients in the modern ICU results in broader and asks “Should a portion of available health care
a large societal burden in terms of both manpower and mone- resources be allocated to a given therapy or program?’’ This
tary cost. The high cost of critical care can largely be attributed is principally a social policy issue and requires considering
to: high overhead costs (e.g., need for experienced staff and the worth of new therapies not only within a given disease,
expensive equipment), high resource utilization (e.g., drugs, but also in comparison to other therapies in other diseases.
lab tests, and complex imaging procedures), and an ever- For example, although drotrecogin alfa (activated) might be
growing demand for ICU services. With the continuing rise in deemed worthwhile in the treatment of sepsis, a state Med-
health care costs, there is an ever-increasing need to establish icaid agency might be forced to compare its value to that
whether new therapies are not only efficacious, but also cost of a hepatitis B vaccination program for newborns, or to in-
effective. The need for cost-effectiveness evaluations is spread fluenza vaccinations for the elderly. These types of choices are
throughout medicine, but the issue of cost effectiveness is es- becoming increasingly common in situations in which health
pecially important in critical care medicine. While ICU beds care resources are limited and must be equitably distributed
account for only about 10% of all inpatient hospital beds, ICU among multiple programs. In other words, we would wish
costs in the U.S. exceed $60 billion annually, and consume up to know if drotrecogin alfa (activated) is not only cost effec-
to one third of all hospital costs.1 Furthermore, attempts to tive with respect to standard management for sepsis, but also
reduce ICU costs by other mechanisms, such as reduction in whether we can afford it as a society.
length of stay, have proved to be difficult.2 While access to There are a variety of different analytic approaches that ad-
new therapies is being tied increasingly to cost, physicians dress all or some part of these two questions. Though the ap-
continue to be skeptical and suspicious of cost analyses. In proaches appear similar, and have similar names, there are
large part, this skepticism is prompted by the variable qual- key differences. In order to understand the strengths and
ity of earlier cost analyses. However, skepticism is also due to weaknesses of each approach, we must first describe the
the lack of familiarity many physicians have with the general various methodologies used to evaluate health care costs.
principles of health economics. The U.S. Public Health Service There are essentially four types of cost analyses: cost min-
(USPHS) attempted to set standards for the conduct of rigor- imization, cost benefit, cost effectiveness, and cost utility.
ous cost-effectiveness analyses in medicine.3–5 In critical care The fourth, cost utility, is best viewed as a special case of
medicine, the American Thoracic Society (ATS) established cost effectiveness. In addition, there are situations in which a
cost-effectiveness analysis can produce a cost-minimization the gain in health. Since the units used are different for the
statement. numerator and denominator, the typical cost-effectiveness ex-
pression will take a form such as cost (dollars) per year of
COST-MINIMIZATION ANALYSIS life saved. Cost-effectiveness analyses are the current domi-
nant form of cost evaluation, and were endorsed by both the
The cost studies that are most familiar to clinicians are cost USPHS Panel on Cost-Effectiveness in Health and Medicine
minimization studies, and these consider only how much (PCEHM), and more recently by the ATS as the primary
a drug costs to stock in the pharmacy. They are essentially method by which to measure the costs and effects of health
studies of drug acquisition cost, and are most frequently con- care programs and medical therapies.4,6
ducted by hospital pharmacy departments. When compar- Deciding whether a therapy is cost effective is a subjective
ing different products (e.g., two sulfonamides), each product evaluation of the cost-effectiveness ratio. If $100,000 per year
is assumed to have equal efficacy and to equally impact all of life gained is deemed the threshold for effectiveness, then a
other aspects of treatment (although this may or may not be new therapy with a cost-effectiveness ratio of $82,000 per year
true). Drug effects such as shortened length of stay, reduced of life gained is viewed as cost effective. Though there is no
need for other therapies, and improved quality of life after absolute cut-off, there is general consensus that a level some-
illness are not considered in cost-minimization analyses. The where between $50,000 and $100,000 per year of life gained is
preferred therapy is simply the one that costs the hospital less acceptable in the U.S. today. However, the way in which both
money per unit of treatment (e.g., per day of therapy, or per costs and effects are calculated can have profound effects on
dose). the resulting ratio, and therein lies much of the controversy
Additionally, a cost-minimization analysis can result when over CEA.
a formal cost-effectiveness analysis (CEA, see below) with so- The typical CEA requires the collection of a significant
phisticated assessment of all potential changes in costs and amount of information on costs and effects, much of which
effects between two programs demonstrates no difference in may be gathered from widely varying sources. Interpretation
effect. However, in the situation in which there is no dif- of this information is often difficult, and a decision analysis
ference in effect, there may be significant differences in cost model is usually constructed that mimics the key clinical de-
between the programs. This result does not produce a cost- cisions and events. This model can most easily be represented
effectiveness ratio (since one would be dividing the change by a tree in which each branch point is calibrated with a prob-
in costs by zero), but does allow accurate assessment of the ability of occurrence and a cost. At its simplest, the tree will
true differences in cost between two programs with compara- contain only branches for treatment allocation (e.g., drotreco-
ble treatment effects. This explicit evaluation of costs and ef- gin alfa [activated] or standard therapy) and outcome (e.g.,
fects, as opposed to an assumption of no difference in effect, is alive or dead). To calibrate such a tree, we would need to
in contrast to traditional cost-minimization studies done in know only the probability of living or dying, depending on
the past. whether a given patient received the new therapy or not, and
the average cost of care for survivors and nonsurvivors in the
COST-BENEFIT ANALYSIS two treatment arms (Fig. 2-1).
The term “cost benefit’’ is frequently confused with cost Alternatively, we may be interested in understanding the
effectiveness.9 In fact, a cost-benefit analysis is a very spe- key events that drive either morbidity or cost (e.g., mechani-
cific analysis, rarely conducted today, that expresses all costs cal ventilation or hemodialysis). This could be important for a
and effects in monetary units. This means that a dollar value variety of reasons; there may be evidence that the study pop-
must be placed on all effects. For example, a life saved must ulation has a far lower rate of mechanical ventilation than is
be converted into a monetary value. This conversion of life expected for septic patients in general. Therefore, the extent
into economic terms can be problematic and very nonintu- to which differences in cost are the result of the number of
itive. After conversion of all effects into monetary units, one
then adds up all the costs (expressed in dollars) and subtracts
FIGURE 2-1 Simple decision tree comparing outcome for patients
them from all the benefits (effects, expressed in dollars). If
treated with drotrecogin alfa (activated) versus standard care. In
the final total is negative, the costs outweigh the benefits,
order to calibrate the tree, we must estimate: (1) the probability
and vice versa. Although the final output is attractive in its for a given patient to live or die, given whether they received the
simplicity, the manipulations required to convert all effects new therapy or not; and (2) the average costs associated with each
into dollar values are often very controversial. Because of of the four branches.
this controversy concerning the “value’’ of effects, this type
of analysis has largely fallen out of favor for health economic
evaluations.
COST-EFFECTIVENESS ANALYSIS
Cost effectiveness is simply a ratio of the net change in costs
(dollars) associated with two different programs or therapies
divided by the net change in effects (health outcome). The
denominator represents the gain in health (life-years gained,
number of additional survivors, or cases of disease averted),
while the numerator reflects the cost (in dollars) of affecting
FIGURE 2-2 Decision tree comparing outcomes for patients receive hemodialysis. In order to calibrate the tree, we must
treated with drotrecogin alfa (activated) versus standard care that estimate the probabilities and average costs for 16 separate trees.
incorporates the potential to undergo mechanical ventilation and MV, mechanical ventilation; HD, hemodialysis.
patients undergoing mechanical ventilation may be impor- compare drotrecogin alfa (activated) for critically ill adults to
tant when estimating the cost effectiveness of the new therapy a hepatitis B vaccination program in newborns.
in the real world. Similarly, need for hemodialysis can be a
significant cost driver. A new therapy that reduces the need
for mechanical ventilation or hemodialysis may be expensive,
Methodologic Considerations in
but the cost of the therapy can be offset by the reduced need Cost-Effectiveness Analysis
for supportive care, and hence deemed cost effective by CEA.
In contrast, cost-benefit analysis would take into account only Good cost-effectiveness analysis design requires considera-
the expense of the new therapy, without considering the re- tion of multiple elements in order to both adequately explore
duction in supportive care. However, considering changes the relationship between costs and effects, and to determine
in other care modalities leads to the addition of branch the robustness of the conclusions and the comparability of the
points for mechanical ventilation and hemodialysis, and results to those of other studies. Each of these elements is out-
thereby expands the model dramatically, creating 16 branches lined in Table 2-1 with reference to both the PCEHM and ATS
to consider. For each branch, we must know a patient’s guidelines, and discussed individually in more detail below.
likelihood of entering such an arm and the average costs
(Fig. 2-2). PERSPECTIVE
The costs considered in a CEA can vary depending on whose
perspective is considered. As an example, consider the issue
COST-UTILITY ANALYSIS
of early discharge from the hospital after childbirth. From the
A cost-utility analysis is a form of CEA in which the effects hospital’s or managed care organization’s perspective, cost
are converted into common units of utility. Typically, this ap- may be reduced by early discharge. In contrast, from a societal
proach involves adjusting the number of years of survival for perspective, the cost savings for the health care system may
the “quality’’ of that survival, in which a person living for one be offset by additional costs to the patient, such as extra time
year with a quality-of-life score of 80% would be “awarded’’ off work for the husband who must stay home to care for the
0.8 years of quality-adjusted survival. The advantage of this new mother. Cost studies conducted to date have often been
approach is that it allows comparison of different programs hampered by a lack of consistent perspective either within or
across different diseases. In this way we can compare the among studies. Failure to maintain a consistent perspective
number of quality-adjusted life years (as opposed simply to hampers comparison of results across studies and threatens
the number of lives saved), and perhaps can more equitably the validity of the study itself. Both the PCEHM and ATS
TABLE 2-1 Methodologic Considerations in Cost-Effectiveness Analysis
METHODOLOGIC PROBLEMS
SECOND ATS WORKSHOP ON OUTCOMES RESEARCH
Individual Comparing PCEHM
Aspect CEA CEAs ICU-Specific Recommendations (Rationale) Position Comment
Perspective Not defined Different Societal (ethical, pragmatic) Agree t May be instances when provider
perspective is useful
Outcomes Data are Different Long-term follow-up is QALYs (pragmatic, conventional) Agree t Require better natural history of ICU
(effects) inadequate or outcomes rare conditions and modeling or longer
difficult to follow-up; other outcomes may be useful
evaluate depending on perspective
Best-designed, least biased source (pragmatic) Agree t Consider modeling reduced efficacy in
sensitivity analysis
Costs Data are Different costs Only hospital costs are Costs to include: health care services; patient Agree t Standard approach to measuring these costs
inadequate or usually measured; no time; caregiving; nonhealth impacts not yet developed; estimating units of
difficult to international standard (theoretical) resource use and multiplying by standard
evaluate Include or exclude other disease costs and test Include costs of costs probably most practical approach
in sensitivity analysis (theoretical, pragmatic, other diseases currently; detail with which resource use is
user needs and accounting) (too hard to tracked should be tailored to nature of
disentangle) intervention and likely effects on costs
Comparators Choice distorts — Determining standard Existing practice (conventional) Agree

(standard results often difficult
care)
If existing practice is suspect, consider Agree t Many existing ICU practices may be
best-available, viable low-cost, or “do ineffective or cost-ineffective; therefore,
nothing’’ (conventional) consider comparison to “best practice’’
rather than standard practice
Discounting Inadequate Different rates Not usually done Discount costs and effects to present value Agree
representation of (theoretical)
the effect of time
Use a 3% discount rate (theoretical, pragmatic) Agree
Uncertainty Inadequate — Not usually done Sensitivity analysis essential; multi-way Agree t Multi-way sensitivity analyses probably
representation of sensitivity analysis preferred (user needs) essential given high likelihood that several
uncertainty on key assumptions will be necessary to
results generate reference case from critical care
trials
Reporting — Not standard Reference case (user needs) Agree t But, also present “data-rich’’ case
Compare to available ratios (user needs) Agree
Journal and technical report (user needs) Agree t Also file (e.g., on internet) intended analysis
plan prior to unblinding when concurrent
with randomized clinical trial
Abbreviations: CEA, cost-effectiveness analysis; ICU, intensive care unit; PCEHM, Panel on Cost-effectiveness in Health and Medicine; ATS, American Thoracic Society, QALY, quality-adjusted life years.
Reproduced with permission from Angus et al.6
recommend adoption of the societal perspective when con- mended that day 28 mortality was an appropriate primary
ducting cost-effectiveness studies. end point, but recommended follow-up to ≥90 days, and
whenever possible to ≥6 months.14 Recent successful trials
in sepsis reported mortality at widely varying time points:
OUTCOMES (EFFECTS)
28 days (drotrecogin alfa [activated]),15 28 days and one year
This is an exceedingly difficult problem for CEA for a vari- (steroids),16 60 days (early-goal directed therapy),17 and a re-
ety of reasons. First, information on outcomes usually comes cent study of ARDS (Low Tidal Volume)18 reported mortality
from randomized clinical trials (RCTs), which often do not re- to 180 days.
flect the actual clinical practice of medicine. Conversely, the Proponents of short-term outcome state that longer follow-
implications of a CEA are intended for real-world practice. A up is too expensive and not necessarily related to the therapy
cost-effectiveness ratio is intended to capture the expected re- being studied. Advocates of longer follow-up state that short-
lationship between the costs incurred and the effects gained term survival, of indeterminate quality of life, and possibly
in actual practice. Conversely, an RCT is usually designed with death a short time thereafter, is of little utility to society.8
to maximize the likelihood of finding an effect. As such, an They further argue that the ability to prioritize health care
RCT can represent a rather idealized situation, which is quite spending on the basis of value requires that we compare the
distinctly different from the real world. For example, only long-term value of alternative programs for alternative dis-
specific patients may be selected, the dosage and timing of ease processes. Many health care programs are administered,
therapy will likely be optimized, and other aspects of care and/or have effects lasting, over a long period of time, mak-
may be protocolized and carefully controlled. The effect size ing long term follow-up of patients enrolled in these programs
generated under such rigorous situations is termed a ther- essential.
apy’s efficacy (or maximal effect). In the real world, the effect There is currently relatively little long-term follow-up in-
of a new therapy is likely diluted by less appropriate patient formation on ICU patients. However, the available evidence
selection, changes in dosing and timing, and increased vari- does suggest that there is considerable mortality and mor-
ability in other aspects of patient care. The effect of a new bidity beyond hospital discharge, supporting the notion that
therapy under these real-world conditions is termed a ther- we should consider longer follow-up.19–21 Quartin and col-
apy’s effectiveness. The more RCTs are refined, the further re- leagues showed that continuing mortality occurs in sepsis
moved they are from the reality of using a therapy in clinical patients for many months after discharge from the hospital.19
practice.10 Thus, the relationship between cost and effect in Studies exploring quality of life after ICU care have yielded
some RCTs becomes increasingly distorted. conflicting results, but certainly several suggest considerable
A cost analysis conducted using efficacy from an RCT might diminution of quality of life that appears to be sustained over
better be termed a cost-efficacy study, rather than a cost- time.22
effectiveness study. However, there are no clear guidelines Thus, until more evidence is available, studies of new ICU
on how to reduce the bias introduced by using efficacy data therapies upon which CEAs are to be performed should have
instead of effectiveness data. One possibility is to consider some mechanism (e.g., a subset study or parallel cohort) to
adding an open-label, open-enrollment arm to clinical trials incorporate mortality follow-up for 6 to 12 months with an
in which a CEA is being conducted.11 However, this presents accompanying quality-of-life assessment.
both many logistic and ethical problems. The more accepted
alternative is to expose the cost model to varying estimates of
COSTS
reduced effect from those seen in the RCT during sensitivity
analysis (see below). Which costs should be included? Debates over this subject can
Another problem encountered when determining effect or be very contentious and can resemble debates over whether
outcome is that the outcome measure evaluated in the RCT to give colloids or crystalloids to hypotensive patients. The
may not be directly relevant in the cost analysis. The PCEHM subject is further complicated by economic terms such as di-
recommends, and the ATS agrees, that quality-adjusted life rect versus indirect costs and tangible versus intangible costs.
years (QALYs) be used as the units of effect, or utility. How- We will attempt to avoid using too many accounting terms
ever, most RCTs in critical care use short-term (day 28 or and to suggest alternative ways to understand this issue.
hospital) mortality as the primary end point, and still oth- Let us reconsider the cost-effectiveness ratio. It is a ratio of
ers use indices such as “organ failure–free days’’ as outcome net costs divided by net effects. Thereby, regardless of whether
measures.12 Although short-term survival likely correlates the costs of any given element seem important, if they are dis-
with long-term quality-adjusted survival, the relationship is tributed equally in both comparison groups, the net difference
not explicitly clear. Whether there is any relationship between will be zero and we therefore need not worry about them. In
organ failure–free days and long-term quality of life is even other words, we need consider only those costs we believe to
less clear. A recent study by Clermont and associates showed be relevant and likely to differ between the treatment groups.
that patients who develop acute organ dysfunction are at risk As an example, the PCEHM believed that the intangible costs
for poor long-term quality of life (QOL), but that the risk is of pain and suffering were relevant costs that should be mea-
largely due to poor baseline health status, and not directly to sured in CEAs, but we have never measured these costs in
organ failure in the ICU.13 any critical care CEA. Therefore, if a new therapy is unlikely
This problem is only slowly evolving. While the PCEHM to cause either more or less pain, then we can continue to ig-
recommends long-term outcome, a National Institutes of nore such intangible costs, even though they are considered
Health (NIH)–sponsored workshop on sepsis studies rec- relevant. The caveat here is that we have now made the im-
ommended day 28 mortality.12 More recently, the United portant assumption of no difference in pain, which may or
Kingdom Medical Research Council workshop still recom- may not be true.
We have of course glossed over the term “relevant.’’ Which HOW SHOULD COSTS BE MEASURED?
costs are relevant? All costs to society could be considered rel- For those costs that we choose to measure, we must decide
evant from the societal perspective. Utilizing this perspective, what represents true cost. When we consider hospital costs,
one could argue that the costs of lost wages while a patient true costs are generally assumed to be those generated by
is sick are relevant. In response to this issue, the PCEHM formal cost-accounting mechanisms. For example, the cost
recognized there are no correct answers. However, in order of a complete blood count includes the wage rate for and
to promote standardization of CEA methodologies, they rec- time spent by the employee who drew the blood, the cost
ommend inclusion of all health-related costs, and the ATS of the tube, and some tiny amortized fraction of the cost
concurs that this is the current best approach. They also rec- of the equipment upon which the test is run. However, de-
ommended including opportunity costs, and suggested that tailed information such as this is rarely available as part of a
lost wages, not only as a postdischarge consequence of the ill- CEA. Another frequently used approach is to collect hospi-
ness but also during hospitalization, represents an example tal charges and adjust them by the hospital- or department-
of an opportunity cost. Direct application of these guidelines specific cost-to-charge ratios. The relationship between hospi-
to critical care is not easy. But one way to consider them is tal charges and costs has long been a source of skepticism for
to think about a health care system without drotrecogin alfa physicians. However, recent work by Shwartz and associates
(activated) and a health care system with the new therapy. comparing department-specific cost-to-charge ratio-adjusted
We then need to include all possible cost elements that could charges to estimates generated from a formal cost-accounting
differ between these two health care worlds. system, found good correlation when assessing patients in
groups.23 Agreement was much worse when comparing
individual patients and when using hospital-specific ratios.
ESTIMATING, MEASURING, OR GUESSING COSTS
However, CEAs rely on average grouped estimates of costs,
Not all costs included in a CEA are necessarily measured
and therefore department-specific cost-to-charge ratios ap-
empirically. The CEA is a model that is often calibrated using
pear adequate for estimating hospital costs.
estimates. Some of these estimates come from measurements.
Other proxy measures of cost, such as the Therapeutic In-
For example, the estimate of differences in the mortality rate
tervention Scoring System (TISS) or length of stay, can also
between a drug and placebo often is derived from the effect of
be used.24,25 As stated above, their value will depend on how
size in an RCT. Other estimates can be based on expert opin-
sensitive the conclusions are to variations in the relationship
ion, or some combination of measurement and opinion. For
between these measures and true costs.
example, the cost of the actual therapy is usually unknown
since the therapy is often not yet approved, and no price has
been set by the company that manufactures the therapy. One DEFINING STANDARD CARE (COMPARATORS)
is therefore forced to estimate on the basis of an educated
When comparing a new therapy, the choice of comparator,
“best guess,’’ perhaps with some knowledge of preliminary
or standard therapy, is also critical. For example, the cost-
pricing from the company. While one might be alarmed at this
effectiveness ratio of a 1-year cervical cancer screening pro-
notion of educated guesswork, it is important to appreciate
gram is quite different than that of 2-year or 3-year programs.
that such estimates can be wildly erroneous, yet have min-
Similarly, a tissue thromboplastin activator has a different
imal impact on the cost-effectiveness ratio. In order to test
cost-effectiveness ratio when compared to standard acute my-
how sensitive a CEA ratio is to various estimates in the cost
ocardial infarction therapy with no thrombolytic therapy as
model, the completed CEA model is exposed to a rigorous
opposed to standard therapy with streptokinase. The PCEHM
sensitivity analysis (see below). In this way, we can decide to
recommended that the control therapy used for comparative
include many costs in a CEA, yet only measure specifically
purposes be the least expensive available standard therapy.
some portion of that total. As long as the estimated costs have
However, in the field of critical care this view is currently
little impact on the overall final CEA conclusions, the strategy
changing. In the treatment of sepsis, should standard care in-
regarding which costs to measure and which to estimate can
clude early goal-directed therapy, steroids, and/or drotreco-
be considered robust.
gin alfa (activated), even though these may be expensive? If
so, do we consider all treatments to be standard therapy, or
FOR HOW LONG DO WE MEASURE COSTS? just one or two? The ATS Guidelines recommend that stan-
When the cost of therapy is computed, the duration of the dard care isn’t always “best practice,’’ and that best practice
costs attributed to the therapy must also be considered. For should be the comparator of choice in critical care.
example, if our new therapy allows more people to leave the
ICU, but causes a higher incidence of renal failure requiring
DISCOUNTING (TIME)
long-term dialysis, shouldn’t all the costs of dialysis be at-
tributed to that therapy? The answer is yes. Discounting costs due to time is another important factor to
Although most intensivists do not accept this concept of consider when conducting a CEA. When we borrow money,
blaming therapy received in the ICU for incurred long-term we must pay it back with interest. This is because money is
costs, it is difficult to argue to the contrary. In producing a sur- worth more now than it will be in the future. Therefore, $10
vivor, one must also take responsibility for the cost of main- is more valuable now than $10 delivered at a rate of $1 per
taining survival, which means following the cost streams for year for the next ten years. Thus, to pay back $10 that we just
a significant length of time. Furthermore, if chronic renal fail- received over the next 10 years, we would be required to pay
ure leads to a lower quality of life, the new therapy will be back more than $1 per year. Worldwide economic growth is
doubly penalized, both for the cost of the dialysis and for the occurring at approximately 3% per year, and therefore the
reduced quality-adjusted survival. PCEHM has recommended that all costs be discounted at a
3% rate per annum, and the ATS has agreed with this recom- can in fact often be considered more powerful than a p-value,
mendation. because it can be used to graphically show all of the uncer-
But what about effects; should they also be discounted? Are tainties inherent in the underlying assumptions of the CEA
ten people living for one year more valuable than one person model.
living for ten years? Although this issue may seem inhumane, Figure 2-3 shows the base case cost effectiveness and ref-
consideration of this point is vital. Discounting costs without erence case cost-effectiveness ratio estimates for drotrecogin
discounting effects will incur the Keeler-Cretin procrastina- alfa (activated) generated by running 1000 simulations.27 This
tion paradox wherein we would forever favor health care is a common graphic representation of the output from a rig-
programs that take place some time in the future.26 This situ- orously conducted CEA. The x axis shows incremental effects
ation would have us forever putting off until tomorrow that and the y axis incremental costs. Quadrants to the right of the
which could be done today, and therefore we also discount y axis represent where treatment with drotrecogin alfa (ac-
effects at 3%, the same rate as costs. tivated) was associated with a net gain in effect. Quadrants
above the x axis represent a net increase in cost. The majority
of the simulation estimates fall within the upper right hand
ROBUSTNESS AND UNCERTAINTY
quadrant, indicating a net gain in effect with an associated in-
When we perform an RCT, our primary conclusion is a state- crease in cost (more costly, more effective). The dashed lines
ment of effect: did the new therapy change the outcome of represent thresholds of cost, with regions below and to the
interest? While it is highly likely that the outcome rates will right of the thresholds being more cost effective than regions
be different (rarely would the mortality rates in both trial above and to the left.
arms be identical), we rely on statistical significance to tell us
whether the observed difference is due to a true effect of the
therapy and not chance alone. We traditionally infer statisti-
Reporting and the PCEHM Reference Case
cal significance when the p-value is <0.05. In this instance, we
The PCEHM also recommended that all future CEAs pro-
are 95% certain that the observed difference did not occur by
duce a reference case. This is accomplished by generation of
chance alone. If we are interested only in effect, then we care
the CE ratio by a standardized approach to estimating and
only about which therapy arm is better, not how much better.
measuring each of the important elements of the CEA (see
It is important to appreciate, however, that the p-value does
Table 2-1). This includes the perspective chosen, determina-
not confirm the magnitude of effect. Consider the case of
tion of costs and effects, study time horizon, and measurement
drotrecogin, for which a recent large RCT found a mortal-
of uncertainty and sensitivity analyses. Use of this standard-
ity rate in the treatment arm of 25%, as opposed to a placebo
ized approach allows for comparison of CEA results across
rate of 31%, with a p = 0.006.15 This does not mean that six
studies. Comparison of reference cases between CEAs allows
lives are saved per 100 persons treated. Rather, it tells us that
us to make inferences about the cost effectiveness of a new
our best estimate is that six lives are saved. If we presume a
sepsis therapy like drotrecogin alfa (activated) vs. a therapy
binomial distribution around the mortality rates, we can gen-
used to fight breast cancer. It allows us to compare apples to
erate confidence intervals around the two estimates. These
oranges and bananas and not just apples to apples. Figure
confidence intervals might now tell us that new therapy saves
2-4 shows comparisons of costs for a variety of treatments in
between 2 and 10 lives per 100 persons treated, but cannot tell
different diseases. These include both interventions against
us where the true value falls within that range. The p-value
specific disease states (e.g., myocardial infarction, stroke),28,29
simply confirms the likelihood that there are lives saved by
and interventions designed to prevent injury or illness (e.g.,
the new therapy, not how many lives.
airbags).30 The ATS Guidelines also recommend the genera-
In CEAs, however, we must quantify the magnitude of ef-
tion of a reference case, and further recommend the presen-
fect (and cost) so that we can generate a ratio. The general
tation of a data-rich case from the results of the randomized
principle is to first take our best point estimates of cost and
trial. This case would be generated using a minimal number
effect to generate a base case. Thereafter, we vary all our mea-
of model assumptions and the maximum amount of available
sures and estimates across their range of probabilities (e.g.,
data from the clinical trial.
95% CI) in order to determine the extent to which the cost-
effectiveness ratio varies. This is a sensitivity analysis and can
be done either with one or multiple variables simultaneously. Policy Implications
In one respect, the sensitivity analysis can be considered anal-
ogous to the p-value in that it allows us to explore the robust- Decision making based on the results of a CEA is founded
ness of our conclusions. In other words, if, despite varying on the idea of social utilitarianism. This valuation is in turn
several or all variables across their stochastic distributions, based on the assumptions that: (1) good is determined by con-
there is minimal change in the final ratio, then one can have sequences at the community level, these consequences being
considerable confidence in the CE ratio estimate. the sum of individual utilities (health and happiness); (2) all
Another aspect of the sensitivity analysis is that it can be utilities are equal within the metric used to measure them;
used to determine which model estimates must be the most and (3) loss of benefit to some individuals is balanced by ben-
accurate. For example, the CE ratio may be exquisitely sen- efit to others. As a simple example, consider the decision to
sitive to the estimate of ICU costs, but relatively insensitive fund a childhood immunization program rather than a rad-
to the expected costs of postdischarge health care resource ical chemotherapy program to treat a rare cancer. This deci-
use. In this situation, one might need to measure ICU costs sion assumes that spending resources on immunizations will
very carefully, yet rely only on approximate estimates of post- maximize the community’s utility (health) more than money
discharge resource use. A comprehensive sensitivity analysis spent on treating a rare cancer. Social utilitarianism acts to
FIGURE 2-3 Cost effectiveness of drotrecogin alfa (activated) in The dotted lines are illustrative thresholds. Regions below and to
severe sepsis. The figure shows the CEbase (left panel) and the right of the thresholds are more cost effective than regions
CEreference (right panel) distributions of cost-effectiveness ratios of above and to the left of the thresholds. The ellipses are the
the 1000 simulations with the corresponding 95% confidence smallest areas containing the average incremental costs and
ellipses generated by Fieller’s method.31 Incremental effects are effects, with 95% confidence. Both distributions are
shown on the x axes and incremental costs are shown on the predominantly in the “more costly, more effective’’ upper right
y axes. Quadrants to the right of the y axes represent regions quadrant, with the majority of simulations falling below the
where treatment with drotrecogin alfa (activated) is associated $500,000 per life saved and $100,000 per quality-adjusted life year
with a net gain in effects. Quadrants above the x axes represent thresholds. (Reproduced with permission from Angus et al.27 )
regions where treatment is associated with a net increase in costs.
FIGURE 2-4 League table showing the range of cost-effectiveness 20,000/quality-adjusted life year and 100,000/quality-adjusted life
ratios for a variety of medical or preventive year levels. The range of values within an intervention indicates
interventions.27,28,30,32–36 The vertical lines show the differences in conditions or assumptions included in the model.
maximize the health and happiness (utility) of the commu- 7. Coughlin MT, Angus DC: Pharmacoeconomics of new therapies
nity, and consequently leads to maximum efficiency in use of in critical illness. Crit Care Med 31(Suppl):S7, 2003.
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to result in a ranked list of community benefits resulting from and Medicine. New York, Oxford University Press, 1996.
9. Doubilet P, Weinstein MC, McNeil BJ: Use and misuse of the term
given cost outlays. While CEAs can inform us about where
“cost effective’’ in medicine. N Engl J Med 314:253, 1986.
to spend money to improve utility, they cannot inform about
10. Linden PK, Angus DC, Chelluri L, et al: The influence of clinical
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overall. of gram-negative sepsis with human anti-endotoxin antibody. J
The overall goal of CEAs is to provide decision makers Crit Care 10:154, 1995.
with information that can be used to choose between medical 11. Freemantle N, Drummond M: Should clinical trials with concur-
care options when all options are not financially feasible. If rent economic analyses be blinded? JAMA 277:63, 1997.
monies are unlimited, the relevant question becomes “what 12. Dellinger RP: From the bench to the bedside: The future of sepsis
treatment options minimize patient morbidity and mortal- research. Executive summary of an American College of Chest
ity?’’and CEAs are unnecessary. If funds are limited, the ques- Physicians, National Institute of Allergy and Infectious Disease,
and National Heart, Lung, and Blood Institute Workshop. Chest
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111:744, 1997.
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sion of the ATS and the workshop further recommended that organ dysfunction predict patient-centered outcomes? Chest
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conduct reference case cost-effectiveness analyses as part of 14. Cohen J, Guyatt G, Bernard GR, et al: New strategies for clinical
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16. Annane D, Sebille V, Charpentier C, et al: Effect of treatment with
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patients with septic shock. JAMA 288:862, 2002.
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terol reduction in adults, in Gold MR, Siegel JE, Russell LB, et al for prevention of sudden cardiac death. Ann Intern Med 126:1,
(eds): Cost-Effectiveness in Health and Medicine. New York, Oxford 1997.
University Press, 1996, p 349. 36. Ramsey SD, Patrick DL, Albert RK, et al: The cost-effectiveness of
33. Boyle MH, Torrance GW, Sinclair JC, et al: Economic evaluation of lung transplantation. A pilot study. Chest 108:1594, 1995.
CHAPTER 3 IMPROVING THE QUALITY OF CARE IN THE INTENSIVE CARE UNIT 21
Chapter 3 alized countries, but still represent an important segment of

medical care and its costs.16,19–23
IMPROVING THE A necessary starting point for improving ICUs is to rec-
ognize that problems of quality are common and serious. A
QUALITY OF CARE recent Institute of Medicine Roundtable24 stated that:
IN THE INTENSIVE Serious and widespread quality problems exist throughout

American medicine. These . . . occur in small and large communi-
CARE UNIT ties alike, in all parts of the country and with approximately equal
frequency in managed care and fee-for-service systems of care.
ALLAN GARLAND
Millions of Americans are not reached by proven effective inter-
ventions that can save lives and prevent disability. Perhaps an
equal number suffer needlessly because they are exposed to the
harms of unnecessary health services. Large numbers are injured
because preventable complications are not averted. . . . Quality of
KEY POINTS care is the problem, not managed care.
t Improving ICU performance demands a systems-oriented
approach embodied in total quality management (TQM). The U.S. health care system is by far the most expensive in the
t In most ICUs this requires a major paradigm shift away from
world, while ranking thirty-seventh in overall performance,
the discredited notion that most omissions, errors, and other and seventy-second in population health.25 Canadian health
problems are the fault of individuals, and embraces the idea that care is the tenth most expensive, ranking thirtieth and thirty-
meaningful and sustained improvement comes from fifth on these measures, respectively. This poor performance
transforming structures and processes into those that make it is not explained by society’s violence, poor health habits, or
hard for people to make mistakes. high cholesterol levels.26
t Creating an effective program of TQM is much easier in an ICU There are many factors contributing to this poor perfor-
having the resources to hire personnel and purchase information mance. Inappropriate use of medical interventions is com-
systems. mon throughout the health care system,26–29 with nonadher-
t The most difficult, labor-intensive, and expensive part of TQM ence to established standards of care being related to poor
is data collection, but there are ways to make this less outcomes.30,31 Medical errors are prevalent, often leading to
burdensome. disability and resulting in 27,000 to 98,000 deaths/year.26,32,33
t Every ICU should implement a system of TQM that is A study in Veterans Administration hospitals found that 6%
to 34% of deaths there may be preventable.34 A study limited
multidisciplinary and inclusive, has the vigorous support of
to certain subsets of patients with iatrogenic complications
hospital and ICU leadership, and has sufficient personnel and
in ICUs observed them to occur in 31% of patients, and to be
economic support to succeed.
severe in 13%.35 Errors were observed to occur in 1% of all the
interventions done each day to patients in an Israeli ICU.36
Another problem is variation in practice and outcomes
Intensive care units (ICUs) are an important component of not explained by patient or illness characteristics. Since wide
modern health care. This importance derives from large costs and widespread variation could not exist if most practi-
that are both human and economic. Approximately one third tioners practiced optimally, and such variation is evidence
of adult deaths in the U.S. occur in acute care hospitals,1 and as that suboptimal care is common. Variation has been found
many as half of these occur in ICUs.2,3 An even greater fraction for many outcomes in a broad range of settings, with im-
of people spend time in an ICU during the final 6 months of portant differences by geographic region,3,37,38 hospital,39–41
life.3 Among patients admitted to ICUs, 8% to 17% die there, physician,40,42–48 and insurance status or payer system.42,49–53
though for some diagnoses the ICU mortality rate is much Such variation occurs in ICUs as well.45,49,51,54–56 Lest one
higher.4–6 think otherwise, such variation is not just an American
Beyond death rates, suffering is common among ICU phenomenon.48,57–62
patients. Half or more of ICU patients endure substantial Given the primary function of ICUs, it is particularly trou-
pain.7–9 Bergbom-Engberg and Haljamae found that 30% of bling that they suffer from serious deficiencies regarding pal-
patients surviving mechanical ventilation recall agony, panic, liative and end-of-life care. In addition to the high preva-
or both.10 Among oncology patients in an ICU, 30% to 75% ex- lence of suffering discussed above, caregivers often don’t ask
perienced dyspnea, hunger, anxiety, insomnia, or thirst, with about their patients’ end-of-life preferences, with consequent
increased suffering during even such innocuous procedures discordance between the care desired and that received.7,63
as turning.9 Substantial dissatisfaction among relatives and The conversations that do occur are often much delayed.63–66
friends of ICU patients11–13 indicates that suffering in critical Communication between caregivers and ICU patients or their
illness is not limited to the patients themselves. surrogates is frequently poor. Azoulay and associates found
To go along with these human costs, the economic costs that 20% to 43% of surrogates did not understand what they
of ICU care are staggering. Comprising just 8% of acute had been told about diagnosis, prognosis, and therapeutic op-
hospital beds,14,15 ICU care consumes 20% of total inpatient tions, and that these problems correlated with family-doctor
expenditures,15–17 equivalent to 0.9% of the gross domestic meetings that were too brief.67 In other studies families ex-
product of the United States, or $91 billion in 2001.18 ICUs are pressed dissatisfaction with the amount and nature of com-
a smaller portion of the health care systems in other industri- munication, and many experienced actual conflict with the
caregivers.12,68 Even more worrisome was that 24% of pa- TABLE 3-1 Domains and Measures of Intensive
tients said they were not aware of the current approach to Care Unit Performance
care, and 47% of those who preferred a palliative approach
Medical outcomes
felt the care they were receiving was inconsistent with that
t
wish.63 In addition, the variation in practice present in other Survival rates: ICU, hospital, and long-term
t
aspects of ICU care is also present in end-of-life and palliative Complication rates related to care
t
Medical errors
care.3,4,62,64,65,69,70 t
Adequacy of symptom control
The data above demonstrate that ICUs are an important,
expensive, and problematic component of health care. There- Economic outcomes
fore, vigorous efforts are needed to critically examine and im- t
Resource consumption: ICU, hospital, and posthospital
prove every aspect of how well and how efficiently they per- t
Cost effectiveness of care
form their functions. Because “quality’’ is an extremely vague
Psychosocial and ethical outcomes
term often used to encompass various, often equally vague,
t
concepts, this chapter will instead refer to the more tangible Patient satisfaction
t
concept of ICU performance, and use the term performance Family satisfaction
t
improvement (PI) in place of the various alternatives. Concordance of desired and actual end-of-life decisions
t
Appropriateness of medical interventions provided
Since it would require us to believe that ICU care is differ- t
Long-term functioning and quality of life among survivors
ent than every other area of human endeavor, it is implausible
that all ICUs perform equally well, or even that any given ICU Institutional outcomes
is performing optimally. To identify how well a given ICU t
Staff satisfaction and turnover rate
performs requires quantitation of relevant indices of perfor- t
Effectiveness of ICU bed utilization
mance. However, ICUs are complex organizations, and it is t
Satisfaction of others in the hospital with the care and services
difficult to clearly define or measure such indices. In fact, the supplied by the ICU
t
meaning, scope, and measurement of performance in health Efficiency of the processes, procedures, and functions involved in
care have evolved and broadened over the past two decades. ICU care
Some of the most widely used approaches to improving per-
formance in health care have proved inadequate. This chapter
will discuss both the conceptual basis and practical aspects of altered drug labeling or direct communication with nurses,
a superior method of evaluating and improving ICU perfor- represent surrogates for the relevant index. While address-
mance. ing such processes is in fact the necessary means to the end,
changing a given process may or may not result in improve-
ment in the rate of such errors, and does not obviate the need
Defining Intensive Care Unit Performance to measure it.
The ICU readmission rate is not listed in Table 3-1 because
Defining ICU performance is a difficult exercise that em- it is at best a questionable indicator of ICU performance. Its
braces diverse elements such as medical knowledge, ethics, potential value derives from observations that readmitted pa-
economics, systems engineering, sociology, and philosophy. tients have a higher mortality rate and longer length of stay.71
Efforts to measure ICU performance should follow two es- However, for it to be a meaningful surrogate requires that:
sential principles: (1) evaluate a variety of measures that span (1) premature ICU discharge was the cause of a subsequent
the dimensions of ICU performance; and (2) use performance detrimental outcome due to a problem that was already
measures that are directly relevant, or have an unequivocal present in the ICU, and (2) it would not have occurred if
relationship to measures that possess such relevance. the patient had remained longer in the ICU. There are no
There are a number of domains within which an ICU should data that have demonstrated this.71,72 The optimal readmis-
be judged (Table 3-1). While ultimately an ICU exists to serve sion rate is unknown, and a low one could indicate that on
the medical needs of critically ill patients, it also provides average, patients are inappropriately remaining in the ICU
important services for families and friends of patients, health too long, when they could be adequately cared for in less
care workers in the ICU, the hospital, and society. Rating ICUs expensive venues.
only on narrowly defined measures of health outcomes fails All of the performance parameters listed in Table 3-1 have
to recognize the larger social value associated with expert care limitations. ICU or hospital mortality rates are commonly
of these patients. In addition, no single metric is adequate to used measures of ICU performance that are relatively simple
address all of the categories of outcomes listed in Table 3-1. to collect. While some data indicate that hospitals with higher
Assessing performance requires direct measurement of end death rates have more preventable deaths,30 short-term sur-
points that are relevant—to patients, society, and the hospital. vival tells us nothing about the things that are much more
Table 3-1 lists relevant measures of ICU performance. Because important to people, long-term survival and quality of life
they are usually easier to measure, surrogate parameters are (QOL).73–75 Also, certain attitudes about death and dying can
often used in PI efforts. While assessing surrogate end points mean that higher short-term mortality represents superior
is often a component of PI, this should not substitute for mea- care by virtue of being more concordant with patients’ end-
suring and addressing the truly important parameters. For of-life wishes.76,77
example, errors in drug administration have a proven associ- The laborious nature of collecting data on posthospital sur-
ation with detrimental outcomes,32 and therefore the rate of vival and QOL undoubtedly contributes to low usage of these
such errors is a relevant performance measure. Processes in- important measures.78 It is even more work to combine these
stituted within the pharmacy to try and reduce errors, such as into a quality-adjusted measure of long-term survival, such as
Another random document with
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limpide. Devant une toile d’araignée tendue dans un rosier, et où des
gouttes de rosée semblaient des perles prises dans le filet d’une fée,
on s’arrêtait longtemps. On ne parlait presque pas. C’était un muet
émerveillement, que tout était joli !… « Regarde, ma Fine »,
murmurait-il. « Regarde, Mimi », murmurait-elle.
Quelquefois, dans leur grand lit, ils se réveillaient en même
temps. « Bonjour toi ! » disait Fine. — « Bonjour, bonjour ! » disait
Mimi. Il l’embrassait. Puis, sous prétexte que les cheveux de Fine
l’avaient frôlé, et qu’ils l’avaient fait exprès, il la chatouillait. Alors,
elle riait, mais bientôt elle se défendait, elle criait « Laissez-moi !
Voulez-vous !… mais je vous défends ! Horreur !… » Quand il se
réveillait avant elle, il ne bougeait pas : il la regardait dormir. Il
arrivait qu’elle faisait semblant, et à travers ses cils baissés, elle le
regardait qui la contemplait.
Ils allaient se promener dans les champs. Au village, tout le
monde les voyait passer en souriant, on les trouvait si gentils… Ils
longeaient souvent le bord de l’eau. Ils aimaient les nuées blanches
des beaux matins, les légères nuées qui roulent sur le fleuve et
s’accrochent aux roseaux des rives, et qui, tout à coup, comme un
rideau qu’on a tiré, se dispersent pour découvrir la splendeur
renouvelée des choses. Ils suivaient du regard le vol des libellules, ils
s’amusaient du saut des poissons ; et des oiseaux qui boivent d’un
plongeon soudain, à ras d’eau… Ils connaissaient un terrain semé de
pierres, couvert de broussailles, où abondaient les lézards. Sophie
s’exclamait à leurs fuites instantanées, au bruissement subit et au
court frisson des feuilles. On marchait dans les labours, au milieu
des grands paysages, et le soleil vous entrait dans le cœur, et s’y
étalait, éblouissant comme à la surface d’un lac.
Et puis, le déjeuner. C’était toujours la dînette. Ils étaient à côté
l’un de l’autre, ils s’embrassaient, ils ne savaient pas ce qu’ils
mangeaient. Déjeuner, c’était plutôt jouer. « Veux-tu des fraises,
monsieur Mimi ? disait Fine… Ah ! oui ! bien sûr ! vous êtes un vieux
gourmand ! »
Après, ils retournaient au jardin. Sophie paraissait travailler à
quelque broderie, Scholch paraissait lire. Leur repos n’était troublé
par rien. Le soleil, filtré par les feuilles, tombait en petite pluie sur le
gazon, et l’inondait de gouttes d’or. Un merle sautillait dans l’allée.
La voix fraîche d’une fontaine voisine qui bavardait dans le silence,
faisait sentir toute la joie et le calme du village assoupi. Quelquefois,
un bruit de grelots passait sur la route, ou la trompe d’un marchand ;
Sophie levait la tête et disait entre haut et bas : « Tiens ! voilà
Cagny ! »
Cette vie-là dura un an. Ce fut un bonheur délicieux, le bonheur
d’êtres très jeunes, très purs, qui s’aiment sans soucis et sans
arrière-pensées, qui ont des âmes d’enfant, et qui entrent dans le
monde en chantant la plus jolie de toutes les chansons.
Mais Scholch n’étudiait plus. Par les Allemands, ses camarades à

Grenoble, son père sut la vie qu’il menait et lui coupa les vivres. Il
fallut revenir à Mulhouse.
La catastrophe éclata soudainement. Ce fut pour Sophie comme
si, marchant paisiblement au milieu d’une plaine verdoyante, la terre
tout à coup, devant ses pieds, s’était ouverte. Elle se sentit prise
d’un vertige, l’abîme l’attirait, le malheur l’appelait… Elle n’était
surprise qu’à demi ; vraiment, elle était trop heureuse, ce n’était pas
naturel d’être si heureux. Malgré tout, et jusque dans le ciel où elle
planait, elle avait une appréhension sourde ; elle s’était étourdie, elle
avait fermé l’oreille aux voix qui lui disaient que ce bonheur ne
durerait pas toujours, mais maintenant elle se répétait : je le savais
bien, il fallait un jour que tout s’écroulât… Scholch, en pleurant, lui
avait dit qu’il reviendrait ; elle le sentait, elle en était sûre, elle ne le
reverrait jamais.
Elle quitta la gare, le cœur en lambeaux… Elle se retrouvait
seule ! Il était parti ! Elle pensa à se tuer… Elle errait dans la ville
comme une bête perdue. Solitude ! visages durs. Elle marchait,
marchait, pour se fuir !… Elle se disait tout à coup : mais non !
croyait qu’elle avait rêvé, et pour le retrouver rentrait en courant
dans la chambre qu’il avait louée, et où il avait mis ses meubles… Si !
c’était vrai ! elle était bien toute seule ! Sur cette chaise il ne
s’assiérait plus, ces rideaux-là jamais plus il ne les verrait ! Tout cela
était abandonné… Elle aurait voulu, alors, ne toucher à rien, pour
conserver aux choses tout ce qui restait de son amant sur elles.
Ah ! s’il lui avait laissé quelque chose de lui ! une chose vivante à
regarder, à embrasser, en se rappelant tout !… Un petit !… Si elle
avait eu un enfant de Scholch !… Elle rêvait à cela en pleurant.
Le soir, elle allait au jardin public. C’était, l’été, la musique jouait.
Elle s’accoudait au balcon qui domine l’orchestre, et elle écoutait,
devenue absente. Elle ne voyait pas la foule qui passait devant elle,
sous les arbres. La musique avait pris son âme, la musique lui faisait
revivre toute sa vie d’amour. Là, accoudée, immobile, elle était toute
en elle-même… Et quand la musique était finie, elle continuait à
écouter…
PREMIÈRE PARTIE
Il y en avait trois sur le trottoir, place Clichy, à côté du bureau

d’omnibus. Il faisait nuit, et il pleuvait. Elles étaient arrêtées sous le
renfoncement d’une porte, devant un réverbère, et attendaient. De
temps en temps, un tramway arrivait, le contrôleur sortait du
bureau, suivi d’un groupe noir, puis le tramway repartait, et l’homme
au capuchon regagnait son bureau en courant. On voyait en face
l’éclairage du café Wepler, et au fond du boulevard, la lumière
changeante des enseignes de Bostock.
Une femme avait tourné le coin de la rue de Douai, et suivait le
trottoir, se dirigeant vers la rue de Clichy. Elle fut rouge, puis verte,
devant la pharmacie de la place. Elle arrivait à la hauteur des trois :
« Tiens ! dit l’une, tiens, la v’là la bath ! Ils ne vont donc pas
l’emballer ! »
La passante ne fit aucun geste, mais elle pressa le pas ; elle
courbait son dos étroit sous la pluie, on la sentait toute mouillée,
frissonnante et lasse ; les trois filles la suivaient du regard. « Penses-
tu qu’elle va faire quelqu’un ce soir !… Mais elle est enragée c’te
môme-là ! On peut pas remuer sans se buter dans elle. Avec son air
de pas vous regarder… »
La femme avait pris maintenant la rue de Clichy, elle descendait
dans le noir. Il n’était pas tard, dix heures, mais avec cette pluie le
trottoir était vide. Elle ne croisait, de loin en loin, qu’une ouvrière
attardée, qui, la longue journée finie, rentrait, impatiente de sa
chambre.
Elle longeait les boutiques fermées, le bas de sa jupe trempée
battait ses jambes, une gêne vague lui serrait l’estomac. Le patron
d’hôtel l’avait dit : si demain elle n’avait pas d’argent, il la mettrait
dehors en gardant sa malle… Mon Dieu ! depuis qu’elle faisait ça, elle
ne rencontrait que des hommes qui partaient sans rien lui donner !
Est-ce qu’elle était plus bête que les autres ? Demander, elle ne
pouvait pas…
D’abord, elle avait eu de la chance — toujours la même chose :
quand elle ne cherchait pas… — une fois, elle sortait d’une maison
où l’on venait encore de lui répondre qu’on ne pouvait pas
l’employer, un monsieur lui avait parlé, elle l’avait suivi, et il lui avait
laissé vingt francs… Elle avait eu d’autres occasions… Toujours pas
de travail… Et, lasse à la fin de monter des étages avec espoir pour
les redescendre découragée, lasse de s’entendre faire la même
réponse partout, elle n’avait plus cherché de travail ; maintenant elle
ne sortait que pour trouver des occasions. Seulement, à présent
qu’elle les désirait… Les hommes, auparavant, la regardaient, lui
souriaient, ils la suivaient ; maintenant ils la regardaient rapidement
et passaient. Et Sophie comprenait : avant, ils la voulaient, parce
qu’elle ne les recherchait pas ; ils ne la voulaient plus, à présent,
parce qu’elle les recherchait ; c’était à séduire qu’ils aimaient, c’était
à vaincre. Devenue quelque chose à acheter, elle avait perdu pour
eux son attrait… Et quand faire ça devient un métier pour une
femme, c’est bien plus difficile. Alors, il faut savoir : elle, elle ne
savait pas, elle n’avait pas la routine. Et puis elle avait peur ;
s’arrêter, elle n’osait pas : les femmes lui en voulaient, elles
l’auraient fait emballer. On dit aux mœurs : Et elle ! Pourquoi que
vous n’y touchez pas ?… Et après il paraît qu’on écrit au maire chez
vous, et c’est fini, tout le monde le sait…
Cependant il y avait une femme qui était bonne, P’tit-Jy, elle lui
donnait bien des conseils.
P’tit-Jy faisait les boulevards et la Chaussée-d’Antin depuis cinq
ou six ans, jamais on ne l’avait chauffée. Ce soir-là, Sophie la
retrouva sous une porte, rue de Provence : « Eh bien ! dit P’tit-Jy, ça
va ? » Sophie ne répondit pas. « Et hier soir ? » Sophie baissa la tête.
« Je parie que tu t’es encore fait poser un lapin. — Oui, fit tout bas
Sophie. — Ah ! ben vrai ! j’te cause pus, t’es trop gourde ! — Oh !
P’tit-Jy !… — C’est vrai, tu te dessaleras jamais alors ! »
P’tit-Jy avait un parapluie, elles remontèrent ensemble jusqu’au
boulevard, et là, P’tit-Jy quitta Sophie : « Quand je te le dis, Fifi !
Fais-les payer d’avance… »
Le boulevard était presque désert. Quelques passants se
hâtaient. Sous la marquise d’un café, deux agents et des camelots
s’abritaient. Le trottoir mouillé, plein de reflets, indéfiniment
s’allongeait sous les pas des filles. De temps en temps, au trot lourd
de ses trois chevaux qui flaquaient dans les mares, un omnibus
passait.
Sophie marchait, les bottines gonflées d’eau, elle avait froid.
Devant elle, une femme posait sa main sur le bras d’un passant. « Tu
viens, mon loup ? » Il ne répondait pas… Ah ! ce soir, c’était sûr ! elle
ne trouverait rien — et demain : à la rue ! Que ferait-elle alors ?…
Mais un homme l’a regardée, au prochain réverbère, sous la
lumière, il l’examine… « Eh bien ! oui, venez, venez donc ! »… Il s’en
va ! Ce n’est pas ainsi alors qu’il fallait s’y prendre avec celui-là ; oui,
il y a des hommes qui n’aiment pas qu’on soit trop hardie, oui, mais
comment le savoir ? Il serait peut-être venu… Ah ! dire qu’il y a si
peu d’hommes, et en rater un par bêtise ! Que je suis fatiguée, mon
Dieu ! ah ! je suis malheureuse !… Tiens ! Mais cet homme-là qui me
regardait, c’était peut-être un mœurs ? S’il me regardait pour me
reconnaître un jour ? Un peut-être à qui une aura parlé !… Bon ! une
voiture ! De la boue sur la joue !… Comme il pleut ! j’ai les cheveux
mouillés et des gouttes dans le cou… froid… Celui-là, avec son
mégot, qu’est-ce qu’il veut ? il rit. « Ça irait bien mieux, Fifi, si tu
prenais un petit homme. » Laissez-moi tranquille !… Et celle-là qui
vient, elle va me dire quoi ? — Elle ne m’a rien dit…
… Ah, quelqu’un ! oui, il me dépasse, il me regarde. — Mais il a
l’air bien cet homme-là ! Il se retourne. Attention de ne pas le
manquer celui-là, pas le regarder trop, je le laisse venir… Qu’est-ce
qu’il fait ? Il ralentit : il va me parler. Non. Alors il veut que je le
dépasse ?… Mais j’ai peut-être eu tort de ne pas lui parler, peut-être
un pas comme l’autre, un avec qui il faut être hardie. Non : il est
derrière moi. Quoi faire ?… Mais pourquoi me suit-il sans parler ? Un
mœurs ! Dieu ! un mœurs ! Oh non ! il a l’air bien ; oui, mais les airs,
on ne sait jamais, faut pas s’y fier… Je vais prendre à gauche, il aime
peut-être les petites rues… On dirait qu’il hésite. Est-ce qu’il me
laisserait là, oh ! pourvu qu’il ne s’en aille pas ! Non, ça y est ! il
vient !
L’homme a rejoint Sophie. Maintenant c’est un couple, un homme
et une femme qui marchent l’un à côté de l’autre, dans la rue
ténébreuse. Il lui demande si elle rentre, si c’est bien loin, et Sophie
ne sent plus qu’elle a l’estomac vide et qu’elle est trempée, la joie
chante en elle, tout l’espoir. Elle est sauvée. Ah ! cette fois-ci ! je ferai
comme dit P’tit-Jy, je lui demanderai d’avance ! « C’est trop loin,
disait l’homme, si tu veux, nous irons par ici, dans un hôtel que je
connais. » — « Je veux bien, mon chat. » Cependant elle pensait que
s’il payait l’hôtel, il lui donnerait moins. C’est vrai que chez elle, ce
n’était pas assez bien pour lui…
Arrivé sous la lanterne, il entrait le premier, cognait à la vitre de
la loge, et le garçon ensommeillé sortait, prenait une bougie au
râtelier et montait, les précédant dans l’escalier tournant au tapis
café au lait. « Au premier, Monsieur, Dame », disait le garçon qui
pénétrait dans une chambre, découvrait le lit, puis attendait. « C’est
trois francs », faisait-il au bout d’un moment, l’air discret, et payé, il
sortait. Le client mettait le verrou derrière lui.
Sophie pensait : Il faut que je lui dise… Elle n’osait pas. — Il faut,
il faut que je lui dise… Impossible ! — Alors elle se donnait des
raisons ; il était très bien cet homme-là, ça le fâcherait de lui
demander avant, on dirait qu’on n’a pas confiance. Il était très bien,
il n’était pas comme celui d’hier, qui n’avait pas l’air franc, et qui,
après, était parti si précipitamment qu’il avait laissé ses bretelles.
« Qu’est-ce que tu attends pour te déshabiller ? » disait le
Monsieur. — « Rien », faisait Sophie. — Puis elle s’étendait sur le lit
froid… Oh ! comme elle avait froid !… Oh ! ses pieds glacés dans ses
bas mouillés !… Oui, il avait de l’argent cet homme-là : le joli caleçon
de couleur, et des bottines neuves… C’est un homme du grand
monde. Sûr, il la paierait en la quittant… Et, après, il ne se dépêchait
pas de se rhabiller pour être prêt avant elle, il l’attendait, il n’allait
pas ouvrir la porte et descendre très vite, ayant bredouillé qu’il
l’attendait en bas. Non, il l’aidait à passer son corsage. Il était très
comme il faut vraiment. « Là ! tu es prête, tu n’oublies rien ; va, je
prends la bougie. » Il descendait derrière elle. Il demandait le
cordon, mais, aussitôt la porte ouverte, d’un mouvement brusque il
poussait Sophie dehors, et la porte se refermait sur elle, sur elle
toute seule dans la rue, dans la nuit.
II
Elle se réveillait. Elle voyait la fenêtre étroite et le mur sale de la

petite cour, sur laquelle ouvrait sa chambre. Enfoncée dans son lit, la
tête seule découverte et ses jolis yeux fripés, elle restait là, ne
bougeant pas. Elle repassait sa soirée.
Quand la porte s’était refermée, elle avait eu un saisissement,
puis elle avait voulu appeler, crier, dénoncer l’injustice dont elle
venait d’être victime, mais elle s’était écroulée près de la porte et
s’était mise à pleurer. Appeler !… Qui ?… Elle était là, couverte de
boue, la tête dans les mains, échouée, et comme une épave
lamentable. La pluie tombait, sombrement. Quelquefois un fiacre
survenait, le cocher jetait un vague regard sur cette chose noire,
inerte, et passait. Elle pleurait, pleurait, dans un désespoir infini.
Une main, tout à coup, lui toucha l’épaule, elle leva la tête ; au
milieu de ses larmes, elle vit alors, éclairée par la lanterne de l’hôtel,
une vieille barbe grise penchée sur elle. C’était une sorte de camelot
misérable. « Reste pas là, petite, dit-il, ils t’emballeraient. » Et le
vieux mit entre ses doigts une pièce de cinq sous, puis il s’éloigna
d’un pas fatigué… Quand Sophie comprit, il était loin déjà. Oh ! elle
aurait voulu courir après ! elle aurait voulu s’attacher à lui, ne pas le
quitter, pareille au chien perdu qu’on a caressé. Il était loin. Elle se
leva et rentra, machinalement, la tête vidée par les larmes. Elle
s’était endormie tout de suite.
Sophie entendait la pluie qui dégouttait sur le rebord de zinc de
sa fenêtre, elle voyait ses vêtements couverts de boue sur la chaise,
et, par terre, ses chaussures informes… Elle se trouvait dans une
courte chambre, un cabinet. La logeuse la lui louait vingt francs par
mois, et chaque fois que Sophie amenait quelqu’un, réclamait deux
francs. Elle la volait. Sophie devait trente et un francs. Il n’y avait là
pour meuble et ornement qu’une mince descente de lit tachée
d’huile et usée, une table couverte de toile cirée, garnie d’une
cuvette, et sur la commode deux ou trois fioles de pharmacie, un
éventail réclame, le portrait de Scholch, et un bout de bougie.
Sophie pensait à Scholch. Elle n’y comprenait rien. Le lendemain
de son arrivée là-bas, il avait écrit, puis, après, jamais plus. Elle avait
attendu tous les jours une lettre, de plus en plus inquiète, de plus en
plus anxieuse… Mais les journées s’étaient écoulées, rien n’était
venu. Rien ! Scholch avait disparu comme s’il était mort… Que
s’était-il passé ? Était-il malade ? L’avait-il oubliée ? Sa famille le
forçait-elle au silence ?… Mais s’il avait voulu… Non, il fallait que, de
lui-même, il se fût laissé vaincre, il fallait qu’il en fût arrivé à ne plus
aimer Sophie, — davantage : à se reprocher de l’avoir aimée… Sans
doute que son milieu l’avait ressaisi ; repris par une vie régulière,
une vie de bourgeois, il avait détesté son existence passée. Il devait
penser qu’avec sa maîtresse il avait couru un péril, et se montrer
pour elle plus dur d’autant qu’il se sentait au fond moins fort contre
elle…
Mais ne pas avoir pitié !… Il fallait donc qu’il ne l’eût jamais
aimée !… Car il savait bien qu’elle n’avait que lui au monde, il savait
que son abandon la tuerait… Hélas ! il ne l’avait pas aimée !… Non,
Sophie s’était trompée : il n’y avait rien eu. Tandis qu’elle se donnait,
lui se gardait, — ainsi pensait-elle… Et tous les délicieux souvenirs
de l’amoureuse étaient gâtés, son rêve était ruiné par l’idée que
Scholch ne l’avait pas partagé avec elle comme elle l’avait cru. Ah !
c’était affreux ! Cela ouvrait au centre d’elle-même une profonde
blessure ! Elle ne pouvait plus croire à rien, aimer rien ; le monde
n’était que mensonge et que méchanceté…
Rester à Grenoble, où tout lui parlait de Scholch… Elle était
venue à Paris… On dit que dans ce grand Paris chacun trouve sa vie,
cependant elle n’avait point trouvé la sienne. Et puis elle n’avait plus
de courage. Alors, peu à peu, elle était tombée, elle s’était laissée
aller… D’abord cela lui avait fait très mal, elle pensait que si Scholch
la voyait !… En même temps, c’était comme une vengeance. Ah !
salir ce qu’elle lui avait donné de pur, ce qu’elle lui avait donné de
bon ! Oui, perdre ça à jamais, n’être plus rien de la femme de
Scholch !… D’ailleurs elle ne croyait plus à rien. Ah ! qu’importait !…
Elle se serait tuée si, par une obscure contradiction, elle n’avait
conservé au fond d’elle-même l’espoir vague et inavoué de le
retrouver un jour.
Mais maintenant, ce matin, dans son lit, elle revoyait sa vie, sa
vie lamentable depuis qu’elle était à Paris, sa vie de faim, de honte
et de misère. Marcher, marcher, toujours ! Et les hommes qui ne la
regardent point, parce qu’elle est mal habillée, et parce qu’elle ne
sait pas les provoquer ! Quand un homme venait avec elle, il la
volait ! Et combien de soirs elle avait marché, marché sans trouver
personne, se sentant devenir folle, finissant par s’arrêter au coin
d’une porte, attendant obstinément, comme une mendiante,
étourdie, prête à tomber…
Ah ! non ! C’était fini ! Pour les pauvres la vie n’est qu’un supplice
interminable. Quelle joie avait-elle eue ? Elle avait bien souffert aussi
à Grenoble… Scholch seulement, — et c’était mensonge ! — Il valait
mieux en finir. D’ailleurs on allait la jeter à la rue. Le sort décidait, on
ne voulait plus d’elle nulle part : c’est la vie qui ne voulait plus d’elle.
Dans ce grand Paris, il y a une rivière : voilà ce qu’on y trouve.
Sophie, sans bouger, réfléchissait. On faisait du bruit dans l’hôtel,
des gens passaient dans le couloir, descendaient l’escalier, mais elle
n’entendait pas. Cependant, à côté, il y eut un homme et une
femme qui se disputèrent. — « Tu n’es qu’un mac ! » disait une voix
plaintive. Une grosse voix éclata : « Veux-tu te taire, saleté ! j’te vas
réveiller les sangs ! » — Puis un bruit de chaises qui tombent, un
vacarme de coups. Sophie entendit cela, écouta… Ah ! elle enviait la
femme dans la chambre voisine, la femme battue, celle-là, elle
n’était pas seule ! Elle restait avec un homme qui la battait, c’est
qu’elle l’aimait ; elle aimait, elle croyait ! Sophie l’entendait pleurer,
des gros sanglots d’enfant ; l’homme s’était tu, et ne bougeait plus.
Ça doit être bon de pleurer ainsi, près d’un homme violent qui vous
prendra dans ses bras, tout à l’heure, et vous consolera. Jamais elle
n’avait été battue par un homme, elle, — mais elle, elle serait
toujours seule… Elle ressentait une immense fatigue de la vie… Elle
allait donc enfin mourir !…
La porte s’ouvrit, et un homme roux, très haut, en pantalon de
toile et chemise de flanelle, s’y encadra. C’était le garçon. Il avait à
trimer dur, et on le voyait dans le même costume toute la journée. Il
était le maître ici, on disait qu’il couchait avec la patronne. Il entra,
l’air oblique et louche des hommes qui, le matin, au petit jour,
pénètrent dans la cellule du condamné. Puis il se planta devant le lit
de Sophie : « Ben quoi ! n’y a pus d’amour ? A quelle heure que vous
allez vous en aller ?… »
Sophie le regarda, et docilement, sans rien dire, elle sortit un
bras de son lit et tira à elle les bas qui se trouvaient sur la
couverture.
L’homme parut étonné, il reprit un peu plus doucement : « Vous
n’avez pas d’argent hein ? pas du tout ? Vous savez bien ce que la
patronne a dit hier ? » Sophie fit signe de la tête que oui, et elle
retourna ses bas.
Le garçon sortit, et Sophie se leva. Elle était en jupon, quand, à
son tour, la logeuse entra. C’était une petite grosse, ronde comme
une boule. Elle cria tout de suite : « Ah ! elle s’habille ! N’emportez
rien, vous savez. Où qu’est la malle ?… Malheur ! Y en a pas
seulement pour dix balles !… Trente et un francs qu’elle me doit !…
Est-ce que vous pensiez que j’allais vous garder sans payer ? Dites
donc, vous ne savez pas travailler, alors c’est moi qui dois pâtir ? » —
Sophie ne répondait rien, et mettait son chapeau encore tout mouillé
de la pluie d’hier. Son silence et cet air indifférent inquiétaient la
logeuse. « Vous savez, quand vous me donnerez mon argent, je vous
rendrai votre malle. Je ne veux rien vous prendre. » — « Sûrement »,
ajouta le garçon qui était revenu, et qui dépassait la patronne de
tout le buste, « sûrement, mais on ne peut pas vous loger pour rien,
pas ? »
Sophie prit sur la commode le portrait de Scholch. Puis elle
descendit l’escalier sombre et gras.
III
« Fifi, où vas-tu ? cria P’tit-Jy. Comme t’es pâle ! Je vois ce que

c’est, ils t’ont fichue dehors. T’as encore rien fait hier, hein, ma
gosse ? Et où que t’allais à présent ?… Bien, me le dis pas, mais je
veux pas que tu me quittes, t’entends ! D’abord, tu vas venir manger
avec moi, y a combien de temps que t’as pas bouffé ?… Ah ! comme
c’est bête ces mômes-là !… Allons, fais pas ta figure. J’te prends
avec moi, tu ne t’en iras pas, ou j’te colle un jeton. Comme elle est
mouillée ! Si c’est pas malheureux !… »
P’tit-Jy conduisait Fifi chez un marchand de vin, Chaussée-
d’Antin : « Qu’est-ce que c’est pour ces dames ? » Elle lisait la carte :
« Tu mangeras bien une gibelotte, Fifi, — avec une chopine de
blanc… T’entends, Alfred ? »
Autour, c’était de bonnes gens, des cochers qui cassaient la
croûte, au comptoir trois maçons qui prenaient un verre. Il faisait
chaud, ça sentait bon la cuisine. Du gros tube en cuivre tout brillant,
avec des robinets, où chauffe le café, une vapeur s’échappe. La
patronne tricote un fichu. Fifi regardait P’tit-Jy, sa gueule de bon
chien et de bonne fille, avec des grosses lèvres, un gros nez et des
beaux yeux. Elle se sentait pénétrée de douceur, elle n’avait plus
envie de mourir, elle aurait voulu embrasser P’tit-Jy, là, devant tout
le monde. Elle lui prenait la main. « Eh bien ! qu’est ce que c’était ?
demandait P’tit-Jy. On voulait se laisser glisser ? En v’là des
bêtises !… » La pluie avait cessé ; dehors, le trottoir étincelait,
couvert de soleil.
P’tit-Jy emmena Sophie chez elle, elle la coucha dans son lit.
Sophie murmurait : « Oh ! P’tit-Jy ! Oh ! P’tit-Jy ! »
P’tit-Jy dit : « Bouge pas. Reste là. Roupille, ma gosse. Je
rentrerai ce soir, t’entends. T’occupe pas… »
Un calme délicieux. L’aube… Une clarté pâle s’étend sur la
campagne ; un champ de marguerites s’éveille, et, dans un buisson
frais, du chèvrefeuille et des liserons. D’ailleurs des ramiers blancs
s’envolent, et ils font un grand bruit d’ailes ; ils vont se poser près
d’un rossignol qui songe, et le rossignol commence à chanter… Il
chante si fort que Sophie ouvre les yeux : Comme il fait sombre ici !
Oh ! c’est qu’il y a des rideaux à la fenêtre, de beaux rideaux !… Et
sur la cheminée ces machins en bronze. Et un grand lit. Et un
couvre-pied de soie… Un tapis…
Où était-elle donc ? On l’avait enlevée, ou bien elle dormait
encore ?… Dans la chambre, elle entendit respirer, et regarda du côté
d’où cela venait. Il y avait sur la chaise longue une forme de femme
enveloppée dans une couverture. Mais c’était P’tit-Jy. Oh ! P’tit-Jy !
Sophie se leva en chemise et alla embrasser P’tit-Jy. P’tit-Jy fit un
mouvement, elle grommela : « Ah ! zut ! la barbe ! laisse-moi
dormir. » Mais elle dit, tout de suite après, joyeusement : « Ah ! c’est
toi, Fifi ? Bonjour, ma gosse ! T’as bien dormi ? »
— Oui, P’tit-Jy ! Oh ! oui ! Mais toi, pourquoi tu t’es mise là ?
Pourquoi que tu ne t’es pas couchée dans le lit ?
P’tit-Jy avait eu peur de lui faire froid et de la réveiller. Elle qui
était si fatiguée hier !…
— Tu ne vas pas rester là ?
P’tit-Jy alla se coucher près de Fifi. Elle la prit dans ses bras avec
des petits mots : « Bonjour, bonjour, ma jolie gosse ; bonjour, ma
choute… » Puis elle dit : « Je ne veux plus que tu pleures, Fifi. Quand
on te fera des misères, tu viendras me le dire… »
Sophie se serrait contre P’tit-Jy :
— Comme c’est gentil ici !
— C’est un bath meublé, fit P’tit-Jy. Mais cher. Faut pas être
manchote pour rester là. J’y ai pas toujours été, tu sais. J’ai couché
sur les bancs. Tiens ! les commencements !
— T’as été bien malheureuse aussi ?
— Naturellement. On peut bien dire d’abord que je suis venue au
monde dans les gifles, et ça se comprend. Pour une femme, c’est
pas drôle de se voir enceinte. L’ouvrière qui se dit un matin : bon
dieu, je suis pincée ! qui de mois en mois grossit, qui se serre pour
qu’on ne s’aperçoive de rien, qu’est malade, et continue — faut bien
— à turbiner, elle ne peut guère aimer le gosse qui lui arrive là,
comme ça, en vrai malheur… j’ai été bien reçue !
— Et ton père ?
— Ton père ! Est-ce qu’on a un père, nous autres ? Tu ne connais
donc pas encore les hommes !… Il n’y a rien de lâche et de cochon
comme un homme, Fifi ! Ils vous plantent là, avec votre môme sur
les bras, et ils se défilent. C’est toujours la même histoire.
— Pauvre P’tit-Jy !… Alors ta mère à toi t’aimait pas ?
— Pas des tas ! Quelquefois elle disait : j’aurais mieux fait de
t’étrangler quand tu es venue au monde. Elle était comme ça, ma
maman à moi.
— Y a-t-il des gens méchants quand même ! dit Sophie.
— Alors, dis donc, il y avait un jeune homme très gentil qui me
faisait la cour. Je le rencontrais tous les jours, et il me répétait
tellement que nous serions si heureux tous les deux, et qu’il
m’aimait tant, un jour que maman avait encore été très méchante
avec moi, je suis partie.
— Quel âge t’avais ?
— Seize ans ! J’avais seize ans, t’entends ! Pendant huit jours, ah !
une vie charmante ! théâtres, restaurants, promenades en voitures,
et des toilettes et des chapeaux… P’tit-Jy, qui n’avait jamais rien vu,
ouvrait de grands yeux, croyait rêver, et elle était en train de se
répéter qu’elle était joliment bien tombée, qu’elle en avait une
chance, quand un beau matin mon ami me dit : « Ma petite chérie,
je n’ai plus d’argent, tu vas aller faire la petite fille aux Champs-
Élysées. »
Sophie, étendue sur le ventre, la tête appuyée sur ses mains,
écoutait P’tit-Jy. Elle était reposée. P’tit-Jy sourit à ses cheveux
blonds, à ses jolis yeux… Sophie ne se sentait plus malheureuse. Ses
yeux flânaient par la chambre, rencontrant sur le fauteuil la dépouille
de P’tit-Jy, le jupon de soie rose, maniéré et provocant, la chemise,
le pantalon, le corset qui, dans son étoffe à ramages et
l’emmêlement de ses lacets, paraît toujours tiède ; un peu plus loin,
il y avait une petite table, garnie de mousseline, sur laquelle les
brosses, les peignes, les tubes, les boîtes à poudres et les flacons
était alignés soigneusement. Par la porte entr’ouverte de l’armoire,
apparaissaient des piles de linge frais. Le chapeau de P’tit-Jy coiffait
tout le buste du chanteur florentin debout sur une console. Au-
dessus de la chaise longue, sur une gravure très noire, Mazeppa,
ficelé sur un cheval sauvage, subissait son affreux supplice, avec un
visage sombre et deux yeux lançant des éclairs…
Sophie se retourna vers P’tit-Jy. P’tit-Jy bâillait et s’étirait
paresseusement ; Fifi bâilla, elle aussi, et se sentit l’âme molle. On
gratta à la porte ; une petite femme noiraude et maigre entra. Elle
apportait le café au lait. « Bonjour, madame P’tit-Jy », dit-elle, elle
tira les rideaux de la fenêtre, le grand jour envahit la chambre. Une
boule de fourrure blanche, qui l’avait suivie, sauta silencieusement
sur le lit, et vint se blottir en ronronnant contre l’épaule de P’tit-Jy :
« Moute, fit P’tit-Jy, bouzou, gôsse bête » et elle souffla chaudement
dans le ventre du chat.
Là-dessus, ayant déjeuné, P’tit-Jy allongea son bras brun vers la
table de nuit, et y prit un jeu de cartes. Elle cueillit de même une
cigarette, l’alluma, et elle en tira plusieurs bouffées, pendant qu’elle
disposait les cartes sur le lit entre elle et Sophie. « Tous les jours, je
me les fais pour savoir ma chance », dit-elle. Elle regarda le jeu d’un
air de réflexion. « Me voilà, moi, la femme de cœur, pas mal
entourée : trèfle et cœur. Valet de carreau : une lettre ; de qui donc ?
Ah ! peut-être le type de l’autre jour, il a dit qu’il m’écrirait… Mais pas
beaucoup d’hommes dans tout ça : y aura pas grand’chose à faire
aujourd’hui, Fifi !… »
Elle détacha de l’ongle un léger brin de tabac collé à sa lèvre…
Puis, les yeux clignés, à cause de la fumée de sa cigarette, elle prit
le gros chat blanc et se mit à jouer avec lui. Sophie la regardait en
rêvant.
— Tu veux que je te les fasse, Fin ? demanda tout à coup P’tit-Jy.
— Je veux bien.
— On ne te les a pas encore faites ?
— Jamais, dit Sophie.
P’tit-Jy, tout à fait grave, jeta sa cigarette. Elle demeura
silencieuse un instant ; puis, subitement, elle éclata de rire et
embrassa son amie. Elle s’écriait : « Quand je te le dis, Fifi, que tu
réussiras !… Roi de cœur, dix de cœur, dix de trèfle. Et pas un
carreau, ni un pique ! Quelles cartes ! Eh bien, tu en as une veine,
ma choute !… » Cependant Sophie restait impassible. Elle murmura :
— Mais… il n’y a pas un jeune homme, là-dedans, P’tit-Jy ?
— Un jeune homme !
— Oui… à l’étranger ?
— Non, fit P’tit-Jy. Qu’est-ce que c’est que ce jeune homme-là ?
— Oh ! Une idée que j’avais…
Il y eut un silence ; puis P’tit-Jy dit, d’un ton sérieux. « Ne
t’occupe pas des jeunes gens, va, Fifi. Le meilleur d’eux tous ne vaut
rien, t’entends… J’espère bien que t’es chipée pour personne, Fifi ? »
Sophie fit non de la tête. Ses yeux étaient tristes. Elle pensait à
Scholch. Elle venait de décider qu’elle ne parlerait pas de lui à P’tit-
Jy.
D’ailleurs, P’tit-Jy n’insistait pas. Mais, après avoir allumé une
autre cigarette, elle reprit :
— Bien sûr ! rester toute seule, c’est pas drôle. C’est bon d’avoir
un petit homme. Seulement, quoi ! C’est la misère un homme. Il te
sucera les moelles. Et il se fiche de toi par derrière. Et mets qu’il te
trompe, tu souffres et tu fais des bêtises ! Faut rester seule, Fifi !
— Oh ! murmura Sophie involontairement, c’est dur quand on a
goûté au ménage !
Alors P’tit-Jy se mit sur son séant, regarda Sophie, et dit :
— Raconte-moi donc un peu ta vie, ma choute.
Sophie, pour avoir repensé à Scholch, était triste, en outre elle
était dominée à présent par une sorte d’étonnement, de stupeur…
P’tit-Jy… Ce changement de vie… Elle ne s’était pas encore
ressaisie : elle rêvait. Elle commença, pour plaire à son amie, à dire
son histoire, mais elle parlait mollement. Pourtant, comme elle
rapportait la mort de ses parents, elle s’anima… Puis, bientôt, elle ne
sut plus où elle était — P’tit-Jy ne fut plus là — elle revivait dans le
passé, et par toutes leurs pointes, ses malchances, ses désillusions,
ses efforts stériles vers le plus honnête, de nouveau lui perçaient le
cœur… Elle revoyait entière sa misérable existence de fille pauvre, le
fils du patron à Lyon, Genève, la vie chez M. Bourdit, Grenoble, ses
dimanches découragés dans sa petite chambre froide, et ses
inquiétudes parce qu’elle n’avait plus de chaussures et pas d’argent,
et la mère Rançon, et M. Pampelin…
Là, elle s’arrêta. Quelque chose l’étouffait, la serrait dans la
poitrine. Ah ! avoir été toujours si seule et si abandonnée, toujours
un tel objet d’indifférence ! elle revoyait la réalité, elle était reprise
par son désespoir, elle regrettait de ne pas être morte hier… Cachant
sa figure dans le traversin, elle se mit à sangloter ; tout son menu
corps était secoué, en reprenant sa respiration, elle faisait le bruit de
gorge désolé des petits enfants qui ont un gros chagrin. P’tit-Jy
l’avait prise dans ses bras, elle baisait ses joues mouillées, sa bouche
crispée : « Pauv’Fifi ! Pleure pas, pleure pas comme ça, mon mignon.
Là ! là ! petit, petite choute… » Elle se sentait vers Sophie comme un
élan maternel, elle avait envie de la protéger… Quelle jeunesse,
quelle douceur ! un petit agneau ! Et en la voyant pleurer là, si
malheureuse, voilà qu’elle pleurait aussi… Mais elle l’embrassait,
disant d’une voix troublée : « Là ! là ! C’est fini, Fifi ! c’est fini !… »
Sophie, maintenant, rendait avec attendrissement ses baisers à
P’tit-Jy. Sa peine perdait son âcreté. Elle éprouvait pour son amie
une reconnaissance infinie, elle l’aimait de tout son cœur, elle n’osait
pas croire à tant de bonté. Jamais personne, excepté Scholch —
Scholch ! — ne s’était encore penché sur elle avec un pareil
sentiment, jamais personne ainsi ne s’était intéressé à elle. Elle
n’avait encore jamais raconté son histoire : nul n’avait désiré la
connaître. Et P’tit-Jy l’écoutait, P’tit-Jy s’attristait avec elle et la
réconfortait. Sophie prit la main de P’tit-Jy et la baisa.
— Tu vois, tu as été plus malheureuse que moi, Fifi… dit P’tit-Jy.
On entendait dans la rue un grand bruit de voitures ; les
marchands des quatre saisons ne criaient plus, ils étaient passés
depuis longtemps : il était midi. P’tit-Jy se leva. Et comme Sophie
était à genoux sur le lit, ainsi qu’une petite qui fait sa prière, mince
et frêle dans sa chemise blanche, toute blonde, pareille à une enfant
de quinze ans, avec ses clairs jolis yeux bleus, elle la regarda avec
attendrissement :
— Ce que t’es môme, Fifi !… dit-elle.
Elle avait ouvert l’armoire à glace, elle en sortait des bas de soie,
une chemise fine avec un joli ruban rose, un cache-corset bleu ciel,
elle avait tiré de la commode un jupon de soie et un corsage clair.
— En v’là des jolies affaires !… dit Sophie.
Tu vas te frusquer avec ça, Fifi… répondit P’tit-Jy.
IV
Le repas tirait à sa fin. Trempant dans son verre un biscuit, P’tit-

Jy le mangeait avec gourmandise. Elle venait de commander au
garçon deux cafés filtre et de la fine ; elle se sentait dans le bien-
être.
Le restaurant, à cette heure un peu avancée, s’était tout à fait
vidé. Mais, à travers les rideaux de la baie, on voyait tout le
mouvement de la rue, les voitures et les passants, le trottoir qui
vivait, avec ses chances et ses hasards. P’tit-Jy considérait en face
d’elle Fifi, gentille, discrète, et remplie du désir de bien faire.
Vraiment elle était charmante Fifi ! elle devait réussir… Elles prirent
leur café tranquillement.
Cependant le garçon, ayant demandé si ces dames désireraient
une voiture, P’tit-Jy, magnifique, répondit oui, puis, laissant un bon
pourboire, se leva.
— Tiens, Fifi ! s’écria-t-elle dans le fiacre, aujourd’hui, en dépit
des cartes, on ferait quelque chose. C’est quand on est comme ça,
quand on s’en fiche, qu’on a la veine. Mais zut ! on ferme !
Aujourd’hui, vacances en l’honneur de Fifi !
L’été, on serait allé au Bois. Mais c’était novembre. P’tit-Jy avait
pris une voiture, pour le seul plaisir de se croire riche et de mener
grand train. Dans la voiture elle s’étala, elle lançait aux passants des
regards de triomphe, elle trouvait qu’on n’allait pas assez vite.
Sophie, à côté d’elle, n’osait pas bouger de peur de se salir. On
gagna les Champs-Élysées. Au milieu des beaux équipages insolents,
Cocotte allait son petit train. P’tit-Jy regardait à droite, regardait à
gauche, et réfléchissait tout haut à ces types du grand monde qui
dépensent mille francs par jour, et qui ne connaissent pas leur
fortune. Sophie n’écoutait pas, elle ouvrait ses yeux, admirait la
mêlée des voitures, était étourdie, et se rappelait que, pendant
quinze jours, à son arrivée à Paris, elle n’avait pas pu dormir, un rien
l’éveillait, tout ce bruit, tout ce tohu-bohu, il fallait venir ici pour
s’imaginer ça !
Mais bientôt P’tit-Jy s’ennuya… D’ailleurs il faisait beau, c’était
une de ces jolies journées d’automne qui ressemblent aux tristes
sourires des poitrinaires qui se voient. Tout dans le ciel et sur les
choses est regret, tout sent l’adieu. On est enveloppée d’une
mélancolie dorée… Elles descendirent et revinrent à pied vers la
Concorde.
P’tit-Jy tout à coup montra un fiacre :
— Tu l’as vue ? Chichinette !… Depuis un mois elle ne se balade
qu’en sapin !… T’as remarqué le beau garçon qui est avec elle ? Un
caprice : elle a le moyen…
Et P’tit-Jy raconta que Chichinette, au mois de septembre, avait
rencontré un Américain ; ils étaient partis ensemble rigoler à
Londres, chez les Englishes. Après, le type voulait emmener
Chichinette en République Argentine. Mais elle avait eu peur du mal
de mer, et elle était restée. L’Américain lui avait laissé trois mille
balles… Depuis, elle était en bombe. Un jour elle avait voulu louer
une auto : le chauffeur lui avait plu, maintenant elle faisait la noce
avec lui. C’était le beau brun qui était dans le fiacre.
— Mais, dit Sophie, son argent ne durera pas toujours. Elle aurait
mieux fait de le mettre de côté pour si elle tombait malade.
La nuit était venue très vite. Sur la chaussée, ce ne fut plus
qu’une course de lumières dans un bruit de sonnettes, au milieu de
deux lignes de réverbères.
On traversa la place de la Concorde, suivit la rue Royale, et l’on
arriva aux boulevards.
Il semblait à Sophie qu’elle voyait Paris pour la première fois.

Jusqu’à ce jour, tout lui était resté vague et brumeux ; perdue dans
un dédale de rues, pressée par une foule sans nom, elle éprouvait
de l’angoisse, était enveloppée de misère. Aujourd’hui, à côté de
P’tit-Jy si belle et elle-même si bien habillée, elle ne se sentait plus
toute humilité et crainte ; elle était redevenue une personne.
— Tu vois, Fifi, par ici c’est bon, dit P’tit-Jy devant le café de la
Paix. C’est par ici les Américains. Ça vaut la peine.
Et P’tit-Jy raconta :
— Je m’en rappelle toujours, c’est là que j’ai trouvé mon meilleur
micheton, ça m’a donné du cœur. C’était comme toi, à présent,
c’était dans les commencements… Il pleuvait à verse… Comme je
passais devant le café, le gérant — il avait le béguin pour moi, il me
parlait chaque fois (il aurait été d’un autre café, j’aurais peut-être
marché, mais c’était pas un café pour moi ce café-là) — le gérant
me dit : « Abritez-vous un peu là, les femmes doivent pas s’asseoir à
la terrasse, mais mettez-vous dans le coin. » Il y avait un Américain,
il m’offre quelque chose. Et il fait : « Volez-vô venir prendre un
bouteille champêgne hôtel Continental ? » Et le chasseur va chercher
un sapin. On nous regardait. J’entendais les femmes : elle en fait un
chopin ! L’Américain donne dix francs au cocher. « Oh !!! » que je me
dis. A l’hôtel, dans une chambre superbe, il fait monter du
champagne, des cigarettes. On boit, il commence à m’embrasser ; il
me mordait, il me pinçait, je ne disais rien, je me cramponnais :
c’était son plaisir à c’t’homme-là. Après, je me rhabille, et j’allais
m’en aller, tellement saoule que je ne pensais plus à rien demander.
Il m’arrête « le petit cado », qu’il dit — il savait dire ça — et il me
met deux cents francs dans la main, du papier, et des francs, un tas
de pièces, pour la voiture. En fiacre, j’étais malade. Mais je n’ai
rendu que chez moi. Puis je me suis couchée. Mais c’est le
lendemain que j’ai été contente en voyant mes billets et toute ma
monnaie ! Deux cents balles !
— Ce qu’il fallait qu’il soit riche ! fit Sophie.
— Tiens, dit P’tit-Jy, tiens, on les voit tout de suite celles qui ne
savent pas travailler… Celle-là, elle devait tourner rue Taitbout. Le
bonhomme qui la suit va pas l’accoster sur le boulevard, ça se voit
ça : c’est un homme marié.
Elle ajouta :
« C’est pas une mauvaise heure avant le dîner : on a les hommes
mariés… Tu vois, par ici, c’est toujours assez bon. Y a du boursier.
Ça a de l’argent et ça ne flâne pas. Seulement ils sont à passions.
Ah ! dame ! y a le pour et le contre ! C’est comme les juifs. Le
fameux Drumont qu’est antisémite !… C’est pourtant des bons
clients, les juifs ; tout ronds : c’est ça, c’est ça. T’as pas à discuter :
c’est agréable. »
On arrivait rue Drouot, et P’tit-Jy fit demi-tour en disant : « Oh !
on ne va pas plus loin, par là, c’est le pays du gigolo ! »
Elle avait souri à une grande femme qui passait :
— C’est Tartine… En v’là une qui connaît le truc ! Elle suivra pas
tout droit quand il faut tourner, Tartine… Dame ! les boulevards, c’est
comme autre chose, c’est bon et c’est pas bon : faut savoir faire.
Elle réfléchit :
— Au fond, voilà. Le client ose pas. D’abord il croit toujours un
peu que tu lui as fait de l’œil parce qu’il est beau. Ça le flatte, il tient
à ça. Il voit bien que tu ne marches pas pour la rigolade, il t’a
numérotée, eh ben ! tout de même !… Alors il ose pas t’aborder, —
ah ! c’est tordant ! — tu comprends, ça l’embêterait que tu le
rembarres, là, devant le monde… Il te suit, mais il attend la petite
rue.
Sophie écoutait en regardant de loin les étalages flamboyants.
P’tit-Jy lui donnait le bras… Le temps était sec, on n’était pas encore
aux grands froids, et les terrasses des cafés restaient peuplées. P’tit-
Jy mena Sophie dans un endroit du boulevard qui tenait le milieu
entre le caboulot et la brasserie, on voyait à l’intérieur un comptoir
comme chez les marchands de vins, mais dehors c’était une terrasse
comme devant un café. P’tit-Jy commanda un vermouth fraisette, et
conseilla la même chose à Fifi. Puis, bien posées, les jupes étalées,
toutes les deux regardèrent la vie qui défilait sous leurs yeux…
C’était tout un mouvement qui surgissait, éclairé soudain, dans un
rectangle lumineux pour retomber quelques pas plus loin, dans la
nuit ; foule qui se faisait et se défaisait sans cesse : des couples… un
passant seul… tout à coup un groupe compact… puis rien… puis
beaucoup de monde… et encore… et encore… Cela n’arrêtait jamais.
Sophie, étourdie, suivait distraitement tout ce brouhaha, elle
entendait le tumulte des gros attelages courant sur le pavé de bois,
accompagné de toutes les voix mutines des petites sonnettes. Et le
long du trottoir, comme au bord d’une berge, un fleuve de voitures
dévalait, roulement et galopade… Sophie ne disait rien. Ses yeux
étaient tirés par une annonce lumineuse, qui, en face, à la hauteur
d’un deuxième étage, par intervalles réguliers, mécaniquement
s’allumait, peu à peu, lettre à lettre, pour, complète, s’éteindre
subitement. Elle avait mal à la tête… Elle se sentait toute petite, elle
se sentait faible, le découragement qui vous abat devant les choses
immenses ou magnifiques la prenait. Et maintenant tout ce que
disait P’tit-Jy ajoutait à sa fatigue ; tant de conseils et de réflexions
nouvelles lui montraient difficile et compliquée la vie où elle allait
entrer. Toutes les femmes qui passaient lui semblaient supérieures à
elle : tout ce qu’elles savaient celles-là ! à combien de choses elles
avaient pensé !
Elle dit, d’une voix triste :
— Ah ! P’tit-Jy, je ne saurai jamais ! J’ai pas assez de présence
d’esprit.
— Laisse donc, ça viendra. On travaillera ensemble, répondit P’tit-
Jy.
V
Sophie eut chez Mme Giberton une jolie chambre ; pas si jolie
que celle de P’tit-Jy, pas si grande, on n’y voyait ni chaise longue, ni
armoire à glace, mais il y avait un beau tapis, des rideaux épais à la
fenêtre, un lit de milieu, et, à la place de la gravure qui représentait
chez P’tit-Jy le malheureux Mazeppa, on trouvait chez Fifi un tableau
en tapisserie, figurant un bouquet de roses, avec, en exergue, cette
inscription, tracée d’une laine appliquée et naïve :
Offert à la plus tendre des mères.

Elisa Iridon,
âgée de onze ans.
Jamais Sophie n’avait été si bien logée. Elle se rappelait son triste
trou de Grenoble, puis le sale cabinet qu’elle avait habité jusqu’ici à
Paris, et son cœur se fondait de reconnaissance pour P’tit-Jy.
Elle passa une heure à admirer le dessin compliqué de son tapis,
et le motif en cuivre de la pendule posée sur la cheminée et qui
représentait Mars et Vénus. Elle ouvrit et referma cinq ou six fois
chaque tiroir de la grande commode qui était à côté de la fenêtre.
Elle se regarda dans la glace.
P’tit-Jy, dès qu’elle s’était sentie éveillée, était entrée, en peignoir,
dans la chambre de Fifi, et jouissait de son bonheur. Sophie lui avait
sauté au cou. Mais pour couper court aux émotions, P’tit-Jy, qui avait
apporté son Petit Parisien, commençait à Fifi la lecture du feuilleton,
quand Mme Giberton entra pour savoir si sa nouvelle locataire était
satisfaite.
La mère Giberton dit les nouvelles : « La femme du fruitier qui
faisait le coin avait accouché cette nuit. Un garçon. C’était son
huitième. Avoir tant d’enfants ! Quand on n’est pas riche, c’est la
misère ! En v’là un avec un sabot, l’autre avec un soulier… Le dix-huit
avait ramené quelqu’un qui n’était pas encore parti… Il y avait un
grand enterrement à la Trinité, on posait des tentures noires dans
tout l’intérieur, ça allait être superbe, on disait dans le quartier que
c’était un général… »
P’tit-Jy et Sophie déjeunèrent de bonne heure, et à une heure et
demie, elles étaient devant la Trinité au milieu de la foule. Des
soldats occupaient la place ; tout rouge ; des lieutenants passaient
d’un air affairé ; quand le cercueil sortit, porté par quatre hommes,
avec un bruit de grandes orgues venant du fond de l’église, que des
commandements furent jetés, que des éclairs de sabre tiré jaillirent,
que des chevaux d’officiers se cabrèrent… un petit monsieur barbu,
derrière Sophie, qui déjà l’avait regardée beaucoup, dit :
« Mademoiselle, pardon, le nom du militaire ? » P’tit-Jy poussa le
coude de Sophie. Sophie sourit gentiment et répondit : « Je ne sais
pas, monsieur… » — « Ah ! ah ! dommage ! dommage ! » répéta
plusieurs fois le petit monsieur barbu avec un sourire nerveux… On
le sentait timide et un peu bizarre. Il avait des yeux bleus clairs de
rêveur dans un visage encore jeune, mais creusé de rides, hâlé,
tanné et bruni. Il était vêtu d’une redingote démodée, mais
parfaitement propre ; le col qui bordait son cou était très blanc.
« Province, souffla P’tit-Jy dans l’oreille de Sophie. Très bon. » Puis
P’tit-Jy dit tout haut avec cérémonie : « Ah ! mais ! voilà l’heure ! Au
revoir, je ne dois pas faire attendre mon amie Marguerite… » et,
avant salué le petit homme timide, elle s’en alla. Elle ne voulait pas
gêner Sophie, elle était contente qu’elle eût déjà trouvé quelqu’un…
« Mademoiselle, si vous permettez, voulez-vous que nous nous
promenions, voulez-vous que nous allions au Bois de Boulogne ? » dit
le petit homme avec hésitation. Ils restaient là tous les deux en face
l’un de l’autre. Enfin il se décida et fit signe à un cocher.
Dans la voiture, il s’épongeait le front. Le silence de Sophie le
gênait, et il était troublé par son parfum. Tout à coup il s’approcha
d’elle et la baisa dans le cou, puis il se recula d’un air craintif. Sophie
aurait voulu parler pour être aimable, mais les manières de son
compagnon la déroutaient. Maintenant il regardait par la portière. Il
dit : Bon sang ! que de voitures !… Sophie approuva, elle remarqua
que c’était incroyable le mouvement qu’il y avait à Paris. Puis elle lui
demanda s’il venait de loin. — « Oh oui ! fit-il, de loin ! » Il garda le
silence un instant, puis ajouta : « Je suis marin. »… Alors il raconta
qu’il était toujours en mer, qu’il commandait un cargo-boat : La Ville
de Cette, qui faisait le service entre Marseille et Tunis, et qu’il avait
un congé d’un mois, et qu’il était venu à Paris pour prendre un peu
de bon temps. Puis il se mit à rire, et il embrassa Sophie.
Le fiacre entrait dans le bois, on ne croisait plus que, de temps
en temps, une voiture au pas, quelque cycliste, ou bien une troupe
de jeunes anglaises coiffées de casquettes-bérets et vêtues d’amples
manteaux verts. Quand on fut au bord de la Seine, le capitaine
voulut marcher ; la vue de l’eau l’animait. Sophie descendit. Le fiacre
suivait. Il y avait du vent, des feuilles tournoyaient sur la chaussée,
on en écrasait d’autres qui étaient collées dans la boue, les arbres
étaient jaunes et le ciel gris. Le petit homme en redingote marchait
à côté de Sophie en la tenant par la taille. Maintenant il était
apprivoisé, un bon sourire nichait dans son collier de barbe. « Tu ne
ressembles pas aux autres femmes. » — « Pourquoi donc ? »
demanda Sophie. — « Tu n’as pas encore dit miel », dit le capitaine,
et il réfléchit.
Il était surpris de la douceur de Sophie, il n’avait pas envie d’être
brutal avec elle, comme avec celles qu’il rencontrait dans les
brasseries, dans ses bombes, après ses jours de solitude et de
silence, quand il avait envie de vin, de bruit et de violence. Çà, elle
était bonne ! Il la raconterait à son second. Il n’y a qu’à Paris qu’on
trouve des femmes comme ça. — Sophie s’intéressait à son
compagnon. Elle lui demanda s’il avait fait de grands voyages. —
Ah ! pour sûr ! il avait navigué dix ans dans l’Océan Indien et dans
les mers d’Orient. C’est là qu’il y en avait des sales coups de temps
et qu’on reconnaissait les matelots ! Il avait vu des hommes et des
poissons de toutes les couleurs, les Chinois qui sont mous comme
des chiques et qu’on fait travailler à coups de pied. Il avait fumé
l’opium. Il avait roulé dans les sales rues de Canton, et s’était battu
avec des Anglais et des Allemands saouls, pour de toutes petites
femmes jaunes aux yeux bridés. Et puis il avait vu tous les nègres de
l’Afrique, des forêts vierges, des grands déserts et des grands lacs. Il
avait entendu chanter des oiseaux gros comme le petit doigt. Il avait
vu sur la Fille des Indes (un trois-mâts barque, capitaine Ploumach)
un singe grand comme un homme, qui servait à table, et qui frappait
avant d’entrer, et qui comprenait tout ce qu’on lui disait.
Sophie songeait à ces pays auxquels jamais elle n’avait pensé.
Elle marchait à côté du capitaine, sans mot dire, et tout étonnée
comme un petit enfant.
Le capitaine voulut remonter en voiture, il était grisé par
l’évocation de tous ces souvenirs étonnants, il prit Sophie dans ses
bras et l’embrassa goulûment. Elle se laissait faire, sans révolte et
sans dégoût, reprochant seulement à cette barbe rude de la gratter
un peu fort. On descendit à la Cascade et on commença à boire. Le
capitaine tapait sur la table criait : « Eh ! le mousse ! un verre de
schnick ! » Il fit boire le cocher. Il était gai et embrassait Sophie sans
vergogne. Le garçon raide et solennel le dévisageait d’un air
méprisant. Mais le capitaine lui donna deux francs de pourboire, et le
garçon le reconduisit jusqu’à la voiture, en le saluant au moins dix
fois.
Maintenant le capitaine se taisait. Il avait pris dans sa grosse
patte la main de Sophie, et touchait chacun de ses doigts avec
précaution : comme elle avait une petite main ! Il considérait cela
avec étonnement. Ça lui rappelait une nuit à Buenos-Ayres, où il
avait été chez une femme, et, dans un coin de la chambre, il y avait
un petit lit où dormait un bébé… Il demanda : « Comment vous
appelez-vous ? » Elle dit : « Sophie »… Ah ! quel joli nom ! Et il dit
que, d’ailleurs, de toutes les choses qu’il avait vues, il n’avait jamais
rien vu d’aussi joli que Sophie. Puis il lui baisa la main
maladroitement et avec émotion. Sophie était flattée, elle était
contente. A ce moment, le capitaine pensa qu’il avait une vie bête,
que c’était bête d’être toujours sans femme, comme un vieux loup.
Mais il voyait un café, on descendit et on but. Il entrait le premier
d’un pas balancé, comme s’il s’était promené sur un quai, les mains
dans ses poches sur le ventre, et coiffé de sa casquette de capitaine
marchand… On reprit la voiture, on repartit, et on s’arrêta sur le
boulevard dans un café à musique ; on resta là une heure, le
capitaine fredonnait avec l’orchestre ; le fiacre attendait à la porte…
Il faisait nuit depuis longtemps, on alla donc dans une brasserie pour
dîner. Il y avait pour treize francs de voiture, le capitaine donna un
louis au cocher, et l’on s’installa devant une belle nappe blanche
parée de fleurs…
Quand il sortit du restaurant, le capitaine était gai comme un

pinson, il avait acheté un gros cigare à bague, et il en tirait de larges
bouffées. Il avait envie de courir sur l’avenue de l’Opéra. Il avait pris
Sophie par le bras et l’entraînait. D’habitude quand il partait en
bombe, il passait toute la nuit dans les brasseries, à boire, et il
échouait à la fin, saoul et misérable, dans le lit de n’importe quelle
sale fille où il s’endormait d’un sommeil de plomb. Mais, ce soir, ce
n’était pas cela du tout, il ne désirait plus boire. Il se sentait plein de
tendresse, il voulait se trouver tout seul avec son amie. Il était
d’ailleurs, assez gris. Il racontait maintenant les bonnes blagues de
la dernière guerre de Chine, quand les Français, mal chaussés,
s’embusquaient le soir dans des coins à Pékin, pour attendre les
cipayes, qui portaient de bons godillots anglais. On leur fichait un
coup de fusil dans les jambes, ils tombaient, on sautait dessus et on
leur barbottait leurs godasses. Ah ! elle était bonne, il riait fort et il
pinçait Sophie. Mais Sophie sentait qu’il n’était pas méchant, il avait
un peu bu, voilà tout.
D’ailleurs, chez elle, il redevint subitement silencieux. Il regardait
autour de lui. C’est là qu’elle vivait… Que c’était charmant ! Et il
rêvait, comme la nuit, à bord, sur la passerelle, dans son fauteuil de
toile. Il la prit dans ses bras : « Petite Sophie ! Petite Sophie ! » et il
osait à peine l’embrasser, il avait peur de la chiffonner. Elle se
déshabillait. Il la regardait, il était attendri. Oh ! son corsage !… et
son corset !… il aurait voulu les tenir dans ses mains, et appuyer son
oreille, et puis ses lèvres, là où ce petit cœur avait battu. Elle était
en chemise, et il voyait sa jeune chair et ses seins naïfs et gracieux
comme des fleurs de printemps. Mon Dieu !… Il dépouilla ses
vêtements, dans un coin, sans bruit, tout doucement. Puis il se
glissa timidement entre les draps, à côté de Sophie, et il se mit à
pleurer quand il la sentit dans ses bras.
… Alors il raconta sa vie, mais maintenant c’était de sa vraie vie
qu’il parlait. Il se décrivait, tout seul toujours, au milieu de la mer, il
rapportait ses grandes rêveries pendant les longs jours, quand il
réfléchissait aux femmes, aux arbres, aux fleurs, à toutes les belles
choses bonnes qu’ils ont à terre, et dont il était si loin, errant
gravement, avec austérité, parmi le désert océan. Il disait tout ce
dont il était privé, il n’avait jamais eu une femme, lui, une femme
pour lui murmurer des paroles douces et délicieuses, pour mener
autour de lui sa petite existence adorable ! Il respirait le parfum de
Sophie et se grisait, car il n’avait dans la mémoire que les fortes
odeurs marines, il écoutait parler Sophie, cette petite voix
l’enchantait : il n’avait dans les oreilles que le grand mugissement
des vagues. Ah ! c’était exquis une femme ! Elle, comme elle avait
une jolie bouche, et un joli nez, et des jolis yeux, des jolis yeux ! Ses
cheveux ! et sa peau ! ah ! quelle peau douce ! Oh ! si elle voulait
parler encore, dire n’importe quoi !… Et puis qu’elle le regarde en
souriant, comme ça, oui comme ça, petit colibri !
Sophie l’écoutait, elle était attendrie. C’est vrai qu’il était gentil,
cet homme-là, et il lui disait des choses touchantes. C’est
malheureux qu’il n’était plus jeune. Certainement elle pourrait bien
l’aimer, oui, mais pas l’aimer d’amour. Cependant le capitaine avait
une idée. Il n’osait pas la dire. Tout à coup il se lança : « Voilà ! Eh
bien voilà !… Vous devriez venir avec moi… »
Sophie répondit tout doucement :
— Je ne peux pas…
Elle pensait : S’il est gentil avec moi… Mais s’il n’est pas gentil,
qu’est-ce que je ferais là-bas dans tous ses pays ?… Et elle se disait
surtout : Je ne veux pas quitter P’tit-Jy.

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Core Topics in Endocrinology in Anaesthesia and

Historical Aspects of Critical Illness and Critical

The F Word 3rd Edition Jesse Sheidlower

Oxford handbook of critical care nursing Second Edition

Macroeconomics Principles and Applications 6th Edition

Critical Care Focus 9 Gut 1st Edition Intensive Care

Atlas of EEG in Critical Care 1st Edition Lawrence

Lawrence D. H. Wood, MD, PhD

LAWRENCE D.H. WOOD, MD PHD

Larry Wood, who, through his guidance, clarity, and wisdom,

Change, which excites and refreshes us;

and Karin and Barbara, who remind us of balance.

Contributors xi 13 CLINICAL USE OF THE PULMONARY ARTERY

10 PREVENTING MORBIDITY IN THE ICU 111

26 ACUTE RIGHT HEARTH SYNDROMES 335 46 SEPSIS WITH ACUTE ORGAN

PART VII 86 MESENTERIC ISCHEMIA 1309

107 DERMATOLOGIC CONDITIONS 1627 111 HYPERTHERMIA 1687

BENJAMIN S. ABELLA, MD, MPhil FRED Y. AOKI, MD

RICHARD K. ALBERT, MD GEORGE BALTOPOULOS, MD

SARICE L. BASSIN, MD MICHAEL BRESLOW, MD

JASON D. CHRISTIE, MD, MS FRANK D’OVIDIO, MD, PhD

STEPHEN W. CRAWFORD, MD ELI D. EHRENPREIS, MD

E. WESLEY ELY, MD, MPH JEFFREY I. FRANK, MD, FAAN, FAHA

GINI F. FLEMING, MD MARK T. GLADWIN, MD

JENNIFER E. GOULD, MD MARGARET S. HERRIDGE, MSc, MD, FRCPC, MPH

MARSHALL B. KAPP, JD, MPH ANDREW J. KITCHING, MB, ChB

PAUL N. LANKEN, MD JOHN M. LUCE, MD

JOHN F. McCONVILLE, MD RICHARD J. MOULTON, MD, FRCSC

CLAUDE A. PIANTADOSI, MD JOHN A. ROBINSON, MD

KENNETH S. POLONSKY, MD DAMON C. SCALES, MD, FRCPC

WILLIAM MICHAEL SCHELD, MD

B.D. SCHOUTEN, MD BRYCE TAYLOR, MD, FRCSC, FACS

ARTHUR S. SLUTSKY, MD JOEL M. TOPF, MD

TERRY VANDEN HOEK, MD

JEFFREY G. WALLS, MD ROY E. WEISS, MD, PhD, FACP

STEPHEN G. WEBER, MD, MS JANICE L. ZIMMERMAN, MD

TABLE I-1 Communication During Critical Care

Subject Possible Issue Mechanism of Improving Care

Language Miscommunication Interpreter, translator second choice

Death is where the effects of culture impact most strongly in

Chapter 1 programs. Yet the vast majority of critical care is delivered in

Providing Exemplary Care

Intensive care has its roots in the resuscitation of dying pa-

MANAGE GRIEF The Scholarship of Teaching and

Chapter 2 specific guidelines for the conduct of cost-effectiveness analy-

Comparators Choice distorts — Determining standard Existing practice (conventional) Agree

Chapter 3 alized countries, but still represent an important segment of

IN THE INTENSIVE Serious and widespread quality problems exist throughout

Mais Scholch n’étudiait plus. Par les Allemands, ses camarades à

Il y en avait trois sur le trottoir, place Clichy, à côté du bureau

Elle se réveillait. Elle voyait la fenêtre étroite et le mur sale de la

« Fifi, où vas-tu ? cria P’tit-Jy. Comme t’es pâle ! Je vois ce que

Le repas tirait à sa fin. Trempant dans son verre un biscuit, P’tit-

Il semblait à Sophie qu’elle voyait Paris pour la première fois.

Offert à la plus tendre des mères.