Based upon the Dr. Avedis Donabedian’s model for quality in health care, the outcome of care can be considered the result of the processes of by which that care was delivered and the specific health care structure in which it was delivered. This model proposes the assessment of the performance of a health care system in six domains: death, adverse events, readmissions, resource use, quality of…
Overview In 2010, the number of deaths in the United States associated with unintentional injury was 120,859. The leading cause of death in 2010 in age group 1 to 44 continues to be unintentional injury. It was the third leading cause of death for males of all ages, after heart disease and cancer. For females, it is the sixth leading cause of death. In 2010, unintentional…
Despite recent advances in trauma resuscitation and surgery, surgeons continue to care for critically injured patients who will succumb to their injuries. The mortality rate for trauma patients who require admission to the intensive care unit (ICU) remains at 10% to 20%, and an additional percentage of those who survive will be significantly disabled or functionally impaired. Appropriate and compassionate care for the dying trauma patient…
Some neurologic injuries are so severe that they are initially deemed to be nonsurvivable and are termed “catastrophic brain injuries.” In such cases, the primary goal of critical care is to maintain hemodynamic stability and end-organ perfusion. The primary reason for maintaining normal physiologic parameters is that some initial prognostications are incorrect and maintenance of optimal critical care and perfusion of the brain may allow for…
Pandemic disease is the spread of an illness across a vast geographic area, with a prevalence that transcends a singular country or continent, but extends across the entire globe. By comparison, an epidemic is the spread of an illness across a particular locality, region, or community. Human history features a well-documented record of pandemics; some of the most notable examples include the plague of Athens (430–427…
Extracorporeal membrane oxygenation (ECMO), otherwise known as extracorporeal life support, is a rapidly evolving technology that allows for the oxygenation and ventilation functions of the lungs and, depending on the configuration, the perfusion functions of the heart to be replaced during times of acute organ injury. As will be discussed in depth later in this chapter, the fundamental purpose of ECMO is to drain the oxygenated…
The advent of Advanced Trauma Life Support (ATLS) brought great improvements to the care of the trauma patient. Standardized methods for assessment and resuscitation of trauma patients have resulted in increased survival and improved outcomes. While recognition of injuries and resuscitative efforts have improved and are the priority in injured patients, there remain outstanding areas where care of the trauma patient can be improved. One such…
Critically ill patients in the intensive care unit (ICU) present with increased levels of anxiety, agitation, and pain. This often requires intense support and invasive monitoring. To ensure the comfort and safety of these patients, the use of sedative, analgesic, and paralytic therapies may be essential. In the ICU, however, options may be limited by several patient-specific contraindications such as the management of comorbidities, electrolyte abnormalities,…
This chapter is not intended to provide a comprehensive review of all the bedside procedures that can be performed in the ICU. Rather, it will illustrate the indications, management, and complications of common surgical procedures that can be performed outside of the OR and propose an algorithm with basic principles to follow for bedside procedures ( Fig. 1 ). Open full size image FIGURE 1 Algorithm:…
Human beings, as homeotherms, maintain their temperature within a narrow range around a core temperature of 37° C. Hypothermia can be classified as accidental/spontaneous or induced Classical definition for hypothermia is a body core temperature less than or equal to 35° C. For trauma patients, however, Advanced Trauma Life Support (ATLS) defines hypothermia as any core temperature below 36° C (96.8° F). Hypothermia causes significant dysfunction…
Venous thromboembolism (VTE) is a challenge in the management of injured patients. The mainstay of management requires thoughtful decision making regarding prevention, diagnosis, and appropriate therapy both while hospitalized and post discharge. Concomitant injuries frequently delay initiating VTE prophylaxis or interrupts chemoprophylactic therapy. The trauma population has a varied risk tolerance (e.g., immobility, spinal injury, hemorrhage, intracranial hemorrhage), which makes general algorithms difficult to apply. In…
Metabolic stress and malnutrition Patients who are injured or undergo extensive and complicated surgery manifest a profound acute phase reaction in response to tissue injury, reperfusion, and hemodynamic disturbances. A metabolic environment of increased catecholamines and cortisol orchestrates an increase in energy expenditure and protein turnover, leading to a state of heightened catabolism. The resultant insulin resistance from this increased catabolic response is responsible for the…
Key points ■ Fungal infections are a leading cause of nosocomial infections in patients, in particular those residing in the intensive care unit (ICU). ■ Risk factors for developing fungal infections include diabetes mellitus, immunosuppression, previous antibiotic use, prolonged ICU length of stay, malignancy, parenteral nutrition, neutropenia, and prolonged central line catheterization. ■ Although Candida albicans is the most common fungus infection seen, other mycoses including…
Surgeons manage infections that require invasive intervention (e.g., complicated intra-abdominal infections [cIAIs] and skin/soft tissue infections [cSSTIs]), but also surgical patients afflicted by nosocomial infections. Therefore, the surgeon must be concerned with the prevention and treatment of all infections that affect surgical patients, including surgical site infections (SSIs), central line–associated bloodstream infections (CLABSIs), complicated urinary tract infections (cUTIs), and hospital-acquired or ventilator-associated bacterial pneumonia (HABP/VABP). Trauma…
Two broad classes of pneumonia are community-acquired pneumonia (CAP) and nosocomial pneumonia. Nosocomial pneumonia includes patients with hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP). HAP is defined as pneumonia occurring more than 48 hours after hospital admission that was not incubating at the time of admission. If the infection develops after the patient has undergone intubation and mechanical ventilation for longer than 48 hours, the condition…
Infection is the major threat to recovery among most trauma patients that survive the successful resuscitation and intervention of the initial 24 hours following severe injury. The infectious risk may occur from environmental contamination that attended the injury process or from endogenous microflora of disrupted organ structures within the patient. Infection may complicate the surgical site employed for injury repair. Similarly, the trauma patient receives a…
The immune system is complex, with numerous mechanisms to confront a myriad of both foreign pathogens and even nonforeign neoplasms. The immune response to injury is mediated by the innate and adaptive arms of the immune system. The innate response is nonspecific and includes cellular components such as polymorphonuclear leukocytes (PMNLs), eosinophils, natural killer cells, and noncellular components such as complement, lysozyme, coagulation proteins, and neutrophil…
Since the publication of the last edition of Current Therapy in Trauma and Surgical Critical Care , there have been many changes regarding the diagnosis of sepsis, the most accurate definition to capture its true incidence, and its overall burden in the United States. Additional issues concern whether there is an increasing incidence associated with a lower mortality rate and the evolution of the treatment strategy…
Multiple organ failure (MOF) has plagued surgical intensive care units (ICUs) for nearly 5 decades. MOF was first described as a syndrome of progressive organ failure leading to early death that most often occurred after sepsis (principally from intra-abdominal infections [IAIs]). With ongoing research, it was recognized that MOF could also occur soon after noninfectious insults (principally blunt trauma). Over the ensuing decades with fundamental advances…
Since the advent of the mechanical ventilator and the modern era of critical care medicine, many topics have been the subject of intense debate and investigation. The acute respiratory distress syndrome (ARDS), first described over half a century ago by Asbaugh, a surgeon, has been such a subject. Despite multiple trials and attempted strategies, high mortality rates are still attributed to this disease process. ARDS is…