The Surgical clinics of North America
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Surg. Clin. North Am. · Dec 2006
ReviewCritical care issues in the early management of severe trauma.
Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year, for a combined mortality of 48 deaths per 100,000 population per year. Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals. ⋯ The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions. A systematic approach to the trauma patient in the critical care unit would avoid errors and preventable deaths.
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Surg. Clin. North Am. · Dec 2006
Review Biography Historical ArticleCritical care medicine: landmarks and legends.
Critical care medicine was born from the selective pressures of human disease, and with the perseverance and foresight of a select few pioneers, has become an independent field of medicine. This introduction travels back in time to evaluate those visionaries and their landmark contributions. Advancements in caring for the critically ill and organ failure occurred during the wars of the twentieth century. ⋯ It was during this era that the world's first ICU was developed. Contemporary critical care differs considerably from that which marked its birth. Much of the technology we currently employ is assumed: invasive hemodynamic monitoring, mechanical ventilation, antisepsis, and antibiotics.
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The hemodynamic monitoring of a surgical patient acquires a major relevance in high-risk patients and those suffering from surgical diseases associated with hemodynamic instability, such as hemorrhagic or septic shock. This article reviews the fundamental physiologic principles needed to understand hemodynamic monitoring at the bedside. ⋯ The major hemodynamic parameters measured and derived from invasive hemodynamic monitoring, such as arterial, central venous, and pulmonary catheterization, are discussed, as are its clinical indications, benefits, and complications. The current clinical data relevant to hemodynamic monitoring are reviewed and discussed.
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Severe sepsis remains a common cause of death in surgical patients. Eradication of the septic source and supportive care has long been the mainstay of treatment. In recent years, however, early goal-directed therapy, tighter glucose control, administration of drotrecogin alfa (activated), and steroid replacement have produced improved morbidity and mortality. In the future, a better understanding of the pathophysiology of sepsis and clinical studies may further improve outcomes from severe sepsis.
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Sepsis and septic shock are not uncommon conditions in the surgical intensive care unit. Sepsis is a generalized activation of the immune system in the presence of clinically suspected or culture-proven infection. Severe sepsis is sepsis with organ system dysfunction. ⋯ Although the incidence of sepsis is increasing, the case fatality rate is falling. This improvement in outcome is in part due to bold initiatives like the Surviving Sepsis Campaign from the Institute for Health Care Improvement. In this article the authors present the epidemiology of severe sepsis and evidence-based campaigns for its treatment, with a focus on the surgical patient.