• Residents' Resource
    • 1

      Assessment of Acute Respiratory Failure

      By Martin A Croce, MD, FACS; Nathan R. Manley, MD/MPH
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      Assessment of Acute Respiratory Failure

      • MARTIN A CROCE, MD, FACSProfessor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
      • NATHAN R. MANLEY, MD/MPHResident, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

      Acute respiratory failure (ARF) is fundamentally a dysfunction of gas exchange and can be due to either inadequate carbon dioxide elimination causing hypercapnia or poor oxygen exchange and delivery causing hypoxemia. A variety of etiologies exist that cause ARF in the surgical patient, including previous lung disease, such as chronic obstructive pulmonary disease or asthma, neurologic compromise of respiratory drive, nutritional and metabolic derangements that can alter respiratory metabolism and mechanics, direct lung injury, and infection. The type of surgery and the time since surgery are other key factors that influence medical decision making and that will influence priorities in the assessment and management of ARF. This review explores the full spectrum of ARF in the surgical patient, focusing particularly on its assessment and initial management. Figures illustrate algorithms in the approach to the surgical patient with ARF and show example radiographic images of acute respiratory distress syndrome (ARDS), a common complication. Tables summarize indications for emergent intubation, key etiologies of ARF, and the evolving definitions of acute lung injury and ARDS.

      Key words: acute respiratory distress syndrome, acute respiratory failure, hypercapnia, hypoxemia, mechanical ventilation 

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    • 2

      Diagnosis and Treatment of States of Shock

      By Ahmed Reda Taha, MD, FRCP, FCCP, FCCM
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      Diagnosis and Treatment of States of Shock

      • AHMED REDA TAHA, MD, FRCP, FCCP, FCCMCritical Care Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

      Shock remains a diagnosis of significant mortality and morbidity. The current definition defines shock as an acute clinical syndrome that results from inadequate tissue perfusion, which is significantly different from the previous definition of hypotension. Clinical manifestation varies broadly, and is based on the underlying etiology, degree of organ perfusion, and previous organ dysfunction. This review covers the classification, pathogenesis and organ response, evaluation, and management of shock. Figures show the balance between oxygen delivery and oxygen consumption, perfused capillary density, the Krogh Cylinder Model demonstrating the Anoxic-Hypercapnic Lethal Corner, the relation between systolic blood pressure, mean arterial pressure, and diastolic arterial pressure, glycolysis, and the approach to the patient with shock. Tables list clinical and metabolic markers of perfusion alteration to the organs, hemodynamic parameters in different types of shock, normal hemodynamic parameters, problems associated with the use of pulmonary artery catheter, clinical presentation of hypovolemic shock according to severity, causes of cardiogenic shock and cardiogenic pulmonary edema, and receptor activity of different vaspressors and clinical indication.

      This review contains 6 figures, 7 tables, and 55 references.

      Key Words: Shock; Hypovolemic shock; Cardiogenic shock; Neurogenic shock; Vasogenic shock; Septic shock; Obstructive shock

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    • 3

      Acid-base Balance and Electrolyte Management

      By Jennifer Leonard, MD, PhD; Lewis J Kaplan, MD, FACS, FCCM, FCCP
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      Acid-base Balance and Electrolyte Management

      • JENNIFER LEONARD, MD, PHD
      • LEWIS J KAPLAN, MD, FACS, FCCM, FCCPProfessor of Surgery, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, United States, Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104

      Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy.

      This review contains 12 figures, 2 tables, and 34 references.

      Key words: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

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    • 4

      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

      By Richard M Pino, MD, PhD, FCCM; Molly Paras, MD; Erica S Shenoy, MD, PhD
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      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

      • RICHARD M PINO, MD, PHD, FCCMAssociate Professor and Division Chief of Critical Care in the Department of Anesthesia, Critical Care and Pain Medicine
      • MOLLY PARAS, MDDivision of Infectious Diseases, Department of Medicine
      • ERICA S SHENOY, MD, PHDAssistant Professor of Medicine at Harvard Medical School, and the Associate Chief of the Infection Control Unit

      The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. 

      Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

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    • 5

      Shock

      By James W. Holcroft, MD, FACS; John T Anderson, MD, FACS; Matthew J. Sena, MD, FACS
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      Shock

      • JAMES W. HOLCROFT, MD, FACSProfessor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA
      • JOHN T ANDERSON, MD, FACSAssociate Professor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA
      • MATTHEW J. SENA, MD, FACSAssistant Professor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA

      Shock is defined as a tissue hypoperfusion due to an imbalance between oxygen supply and demand in the tissues of the body. Identifying the category of shock (hypovolemic, inflammatory, compressive, obstructive, neurogenic, or cardiogenic) assists in identifying the underlying pathophysiology and determining treatment options. However, in many patients there is more than one cause of shock, and the surgeon must therefore treat more than one problem. This review discusses characteristic clinical markers; management of immediately life-threatening conditions; the pathology underlying different categories of shock; treatment of hypovolemic, inflammatory, compressive/obstructive, neurogenic, and cardiogenic shock; management based on information obtained from invasive monitoring; management with the goal of increased generation and transmission of energy; and management with the goal of minimizing edema and myocardial oxygen requirements. Tables describe mechanical energy in selected components of the cardiovascular system during the cardiac cycle, clinical markers of possible shock state, and treatable conditions that can kill quickly. Figures depict pressure in the aortic root, the pressure-volume relationship for the left ventricle over an entire cardiac cycle, pressure-volume loops, the pulmonary artery catheter, the effects of ventilation, the snap test, and catheter whip. An algorithm shows the approach to a patient in apparent shock.

      This review contains 8 figures, 3 tables, and 44 references.

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    • 6

      Multiple Organ Dysfunction Syndrome

      By Vishal Bansal, MD, FACS; Jay Doucet, MD, FACS, FRCSC, RDMS
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      Multiple Organ Dysfunction Syndrome

      • VISHAL BANSAL, MD, FACSAssociate Professor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA
      • JAY DOUCET, MD, FACS, FRCSC, RDMSProfessor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA

      The concept of and approach to multiple organ dysfunction syndrome (MODS), also known as progressive systems failure, multiple organ failure, and multiple system organ failure, have evolved over the last decade. Characterized by progressive but potentially reversible tissue damage and dysfunction of two or more organ systems that arise after a significant physiologic insult and its subsequent management, MODS evolves in the wake of a profound disruption of systemic homeostasis. Pre-existing illness, nutritional status, hospital course, and genetic variation all lead to the development of organ dysfunction in patients exposed to these risk factors. The ultimate outcome from MODS is influenced not only by a patient’s genetic and biological predisposition but also by specific management principles practiced by intensivists. This review details the clinical definitions, quantification, prevention, evaluation, support, and outcomes of organ dysfunction. A figure shows the increasing severity of organ dysfunction correlated with increasing intensive care unit mortality, and an algorithm details the approach to MODS. Tables list risk factors and prognosis for MODS, the multiple organ dysfunction (MOD) score, the sequential organ failure assessment (SOFA) score, intensive care unit interventions that reduce mortality or attenuate organ dysfunction along with unproven or disproven ICU interventions, and the temporal evolution of MODS.

      This review contains 1 figure, 7 tables, and 159 references.

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    • 7

      Pulmonary Insufficiency and Respiratory Failure

      By Bruce Chung, MD; J. Jason Hoth, MD, PhD, FACS
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      Pulmonary Insufficiency and Respiratory Failure

      • BRUCE CHUNG, MD
      • J. JASON HOTH, MD, PHD, FACSAssociate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC

      Pulmonary insufficiency is the most common complication after surgical procedures. From minor atelectasis to acute respiratory distress syndrome (ARDS), postoperative pulmonary insufficiency occurs in up to 50% of surgeries. Here we discuss the anatomy, mechanics, and pathophysiology of pulmonary insufficiency; preoperative and postoperative assessment of lung function; and treatment for pulmonary insufficiency with regard to atelectasis, pulmonary edema, and ARDS. Pulmonary insufficiency secondary to cardiac disease, thromboembolism, and central nervous system depression are discussed elsewhere. Preoperative identification of risk factors for pulmonary insufficiency and understanding the physiologic changes in the perioperative period can potentially mitigate postoperative respiratory failure.

       

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    • 8

      Hepatic Failure

      By Juan R. Sanabria, MD, MSc, FACS
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      Hepatic Failure

      • JUAN R. SANABRIA, MD, MSC, FACSAdjunct Associate Professor of Surgery, Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, OH, Professor of Surgery, Roslyn Franklin School of Medicine, Chicago University, Cancer Treatment Centers of America

      Hepatic failure continues to be a frequent and major cause of morbidity and mortality in critically ill patients. Hepatic failure may be encountered as an instance of primary organ failure caused by a liver-specific disease process, caused by a liver therapeutic intervention, or as part of the multiple organ dysfunction syndrome. Advances in critical care, the increasing use of sophisticated diagnostic modalities, and the adoption of a team approach to patient care have resulted in improved overall outcomes. This review outlines clinical evaluation and investigative studies related to liver disease and the management of acute liver failure and chronic liver disease, including classification, assessment of prognosis, treatment of complications, multidisciplinary medical therapy, and liver transplantation. The mechanism of hepatic encephalopathy and bioartificial liver support systems are also discussed. Tables describe liver disease risk factors, six major components in initial management of a patient with hepatic failure, etiology of acute liver failure, King’s College Hospital prognostic criteria predicting poor outcome for patients with fulminant hepatic failure (FHF), liver transplant evaluation and workup for FHF patients, etiology of chronic liver disease, common indications for liver transplantation, differentiation of spontaneous bacterial peritonitis from secondary bacterial peritonitis through analysis of ascitic fluid, the Glasgow Coma Scale, differentiation of hepatorenal syndrome from acute tubular necrosis, complications of parenteral nutrition, contraindications to liver transplantation, and the Child-Turcotte-Pugh scoring system. Figures show a transcutaneous intrahepatic portosystemic shunt, a patient with ascites, grading of portosystemic encephalopathy, etiology of liver disease among patients waiting for liver transplantation, estimated 3-month survival as a function of the Model for End-Stage Liver Disease score, and a hypervascular hepatocellular carcinoma of the left liver. An algorithm shows the approach to the patient with liver failure.

      This review contains 6 figures, 13 tables, and 135 references.

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    • 9

      Acute Kidney Injury

      By Aileen Ebadat, MD; Eric Bui, MD; Carlos V R Brown, MD
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      Acute Kidney Injury

      • AILEEN EBADAT, MDChief Resident, Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX
      • ERIC BUI, MDSurgical Critical Care Fellow, Department of Surgery, Los Angeles County-University of Southern California, Los Angeles, CA
      • CARLOS V R BROWN, MDAssociate Professor, Department of Surgery, Dell Medical School University of Texas at Austin, Trauma Medical Director, University, Medical Center Brackenridge, Austin, TX

      Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies.

      This review contains 1 management algorithm, 2 charts, 6 tables, and 77 references.

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    • 10

      Coagulation Disorders

      By Eric M. Campion, MD; Mitchell J. Cohen, MD
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      Coagulation Disorders

      • ERIC M. CAMPION, MDTrauma and Surgical Critical Care Fellow, Department of Surgery, University of California, San Francisco, San Francisco, CA
      • MITCHELL J. COHEN, MDProfessor of Surgery in Residence, Department of Surgery, University of California, San Francisco, San Francisco, CA

      There are multiple congenital and acquired disorders of coagulation that may result in unplanned bleeding or clotting. These disorders can result in an increase in morbidity and mortality to surgical patients. Unexpected bleeding during and after surgery can be prevented by having an adequate understandings of these entities and by being aware of the available treatment options. In addition to awareness of bleeding disorders, it is important to recognize the risks associated with disorders predisposing patients to clotting, or thrombophilias. This review discusses the major inherited disorders of the coagulation cascade resulting in bleeding or clotting tendencies in relation to surgical patients. von Willebrand Disease (vWD), hemophilia A, hemophilia B, hemophilia C, acute coagulopathy of trauma, disseminated intravascular coagulation (DIC), uremic bleeding, bleeding in cirrhosis, clotting disorders, and acquired thrombophilias are covered. Tables list the classification and differentiation of vWD, correlation of factor VIII coagulant activity level with bleeding patterns in hemophilia, causes of DIC, frequency and relative risk of venous thrombosis in hypercoagulable states, inherited and acquired hypercoagulable states, clinical features that suggest thrombophilia, screening tests for patients with suspected hypercoagulable state, and pretest probability of heparin-induced thrombocytopenia. Figures depict the clinical presentation of DIC, procoagulant and anticoagulant pathways, normal factor V and factor V Leiden, and heparin-induced thrombocytopenia.

      This review contains 4 figures, 8 tables, and 51 references.

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    • 11

      Stress Response and Endocrine Deregulation During Critical Illness

      By Paul E. Marik, MD, FCCP, FCCM
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      Stress Response and Endocrine Deregulation During Critical Illness

      • PAUL E. MARIK, MD, FCCP, FCCMEastern Virginia Medical School, Norfolk, VA

      The stress system receives and integrates a diversity of cognitive, emotional, neurosensory, and peripheral somatic signals that arrive through distinct pathways. Activation of the stress system leads to behavioral and physical changes that are remarkably consistent in their qualitative presentation. The stress response is mediated largely by the hypothalamic-pituitary-adrenal (HPA) axis and the sympathoadrenal system, which includes the sympathetic nervous system and the adrenal medulla. The stress response is normally adaptive and time limited and improves the chances of the individual for survival. The time-limited nature of this process renders its accompanying antigrowth, antireproductive, catabolic, and immunosuppressive effects temporarily beneficial and/or of no adverse consequence to the individual. However, chronic activation of the stress system as occurs in critically ill patients may lead to a number of disorders, including stress hyperglycemia, dysfunction of the HPA and hypothalamic-pituitary-thyroid (HPT) axes, and hypothalamic-pituitary growth hormone (GH) dysfunction. These disorders are reviewed in this chapter. Diagnosis of adrenal insufficiency/critical illness–related corticosteroid insufficiency and who to treat with steroids are also covered in depth. The author emphasizes the controversial management of these deregulated hormonal axes with only limited data supporting an improvement in outcome with hormonal replacement therapy.

      This review contains 3 Figures, 1 Table, 39 References, 5 Board-Styled MCQs, and a Teaching Slide Set for teaching and reference purposes.

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    • 12

      Nutritional Support

      By Rindi Uhlich, MD; Parker Hu, MD; Patrick L Bosarge, MD, FACS, FCCM
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      Nutritional Support

      • RINDI UHLICH, MDResident, General Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
      • PARKER HU, MDFellow, Surgery Critical Care, Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
      • PATRICK L BOSARGE, MD, FACS, FCCMAssociate Professor of Surgery, Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL

      Nutritional optimization of the surgical patient remains a cornerstone of perioperative care. Significant effort and scrutiny are routinely directed to the field as it has the potential to improve outcomes, limit infectious complications, and decrease hospital length of stay and mortality. As such, previously identified cornerstones of care have been called into question. The timing, route, and intensity of nutritional supplementation remain the subject of controversy in an ever-evolving field. Previous methods of nutritional assessment, such as albumin and transthyretin, have proved unreliable, and their use is no longer recommended. In their place, new scoring systems are available to risk assess patients for malnutrition. We review the most pressing changes and assess the landscape of the field today.

      Key words: critical illness, enteral, glutamine, malnutrition, nutrition, outcomes, parenteral, protein

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    • 13

      Surgical Palliative Care

      By Emily B. Rivet, MD, MBA, FACS, FASCS; Zara Cooper, MD, MSc, FACS
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      Surgical Palliative Care

      • EMILY B. RIVET, MD, MBA, FACS, FASCSAssistant Professor, Department of Surgery Brigham and Women’s Hospital, Harvard Medical School
      • ZARA COOPER, MD, MSC, FACSAssistant Professor of Surgery, Harvard Medical School, Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA

      Palliative care is a multidisciplinary approach to care that includes relief of suffering and attention to the social, spiritual, physical, and psychological needs of patients and families. The intent of palliative care is to help patients live as well as possible for as long as possible, and relevant domains of palliative care include symptom relief, prognostication, communication with patients, families and clinicians, transitions of care, and end-of-life care. Palliative care is distinct from hospice in many respects including that it can be provided simultaneously with recovery-directed treatments rather than reserved for individuals at end of life. Patients with surgical disease are particularly in need of palliative care due to the common occurrence of severe symptoms such as pain and nausea, complex decision-making, and the often sudden onset of the disease or injury which precludes preparation for the new health state.

       

      This review contains 3 figures, 10 tables, and 61 references.

      Key Words: communication, end-of- life, goals of care, high-risk surgery, palliative, palliative care, palliative surgery, patient comfort, surgical decision-making, surgical prognostication

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    • 14

      Hospital Infections

      By E Patchen Dellinger, MD; Erik G. Van Eaton, MD; Heather L. Evans, MD, MS
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      Hospital Infections

      • E PATCHEN DELLINGER, MDProfessor and Vice-Chair, Department of Surgery, University of Washington, Chief, Division of General Surgery, University of Washington Medical Center, Seattle, WA
      • ERIK G. VAN EATON, MDAssistant Professor of Surgery, University of Washington, Seattle, WA
      • HEATHER L. EVANS, MD, MSDepartment of Surgery, University of Washington, Seattle, WA

      Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

      This review contains 5 figures, 1 table,1 algorithm, and 292 references.

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    • 15

      Electrolytes

      By Matthew R Rosengart, MD, MPH
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      Electrolytes

      • MATTHEW R ROSENGART, MD, MPHAssociate Professor, Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA

      Cell function and thus life depend on the preservation of several electrochemical gradients. Evolutionary pressures have developed several regulatory mechanisms, the penultimate goal of which is to maintain total body and distribution of each electrolyte within the intracellular and extracellular compartments at concentrations compatible with life. Ultimately, patient survival depends on this balance despite the continual changes imposed by both internal physiologic processes and external stressors. During periods of critical illness, however, these mechanisms can be overwhelmed, necessitating additional support. Indeed, disorders of electrolyte homeostasis are highly prevalent among intensive care unit patients, and severe disturbances are associated with elevated mortality. As has been previously learned, merely normalizing laboratory abnormalities without addressing the underlying pathophysiology does little to improve outcome. Thus, for those providing this care, an in-depth understanding of the biochemistry and physiology of electrolyte disorders and a systematic approach to diagnosis and therapy are complementary components essential for patient survival. This chapter discusses the major electrolytes—sodium, potassium, calcium and phosphate, and magnesium—and covers the hyper- and hypodeficiencies and disturbances for each electrolyte.

      This review contains 7 Figures, 6 Tables, 5 Etiologic Algorithms, and 106 References.

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    • 16

      Metabolic Response to Critical Illness

      By Palmer Q. Bessey, MD
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      Metabolic Response to Critical Illness

      • PALMER Q. BESSEY, MDProfessor, Department of Surgery, Weill Medical College of Cornell University, and Associate Director, William Randolph Hearst Burn Center, New York Presbyterian Hospital-Cornell Medical Center

      A wide variety of factors and processes are involved in the metabolic response to critical illness; this chapter reviews some of these factors and metabolic responses in the critically ill surgical patient to help the clinician minimize patient debility. The features of critical illness that can cause debility include wounds, pain, inflammation, infection, and iatrogenic factors. The three major features of the metabolic response are discussed: the hyperdynamic or hypermetabolic state, muscle wasting, and glucose intolerance. Other topics considered include altered temperature regulation, the role of the central nervous system, the role of the gut, manipulating the response to critical illness, altered protein metabolism, altered carbohydrate metabolism, and systemic mediators (e.g., hormones and cytokines). This review contains five figures, eight tables, and 254 references.

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    • 17

      Molecular and Cellular Mediators of the Inflammatory Response

      By Timothy A Pritts, MD, PhD, FACS; Amy T. Makley, MD; Michael D. Goodman, MD
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      Molecular and Cellular Mediators of the Inflammatory Response

      • TIMOTHY A PRITTS, MD, PHD, FACSProfessor of Surgery in the Divisions of General Surgery and Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
      • AMY T. MAKLEY, MDAssistant Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH
      • MICHAEL D. GOODMAN, MDAssistant Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH

      Inflammation is a highly complex process involving vascular, neurogenic, humoral, and cellular responses. Although the descriptive features of acute inflammation have long been known (i.e., heat, redness, pain, swelling), a single satisfactory definition of this phenomenon is still lacking. Successful therapy for inflammation rests not only on investigating the type of injury, but also on the timing of the intervention. This review focuses on humoral and cellular responses to injury, defining essential and interrelated inflammatory pathways. Systemic inflammatory response system (SIRS), in relation to sepsis syndrome, is defined by the global proinflammatory physiologic response to a stimulus. In contrast, compensatory antiinflammatory response (CARS) results from a predominant antiinflammatory response to an insult, also causing immunosuppression and increased susceptibility to infection. Also discussed are the roles of cytokines, adhesion molecules, inflammatory cells such as neutrophils, mast cells, and lymphocytes, extracellular vesicles, sphingolipids, reactive oxygen metabolites, nitric oxide, the complement cascade, and eicosanoids. Therapeutic implications and trials are examined in relation to cytokines in SIRS and CARS, activated protein C, and inflammatory bowel disease.

      This review contains 11 figures, 4 tables, and 79 references.

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    • 18

      Postoperative and Ventilator-associated Pneumonia

      By Craig M. Coopersmith, MD, FACS; Marin H. Kollef, MD
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      Postoperative and Ventilator-associated Pneumonia

      • CRAIG M. COOPERSMITH, MD, FACSProfessor of Surgery, Department of Surgery and Emory Center for Critical Care, Emory University School of Medicine, Atlanta, GA
      • MARIN H. KOLLEF, MDProfessor of Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO

      Pneumonia is the third most common postoperative infection, after urinary tract infection and surgical site infection. In critically ill patients, the respiratory tract is the most common site of nosocomial infection, and in the intensive care unit can account for up to nearly half of all nosocomial infections. This review describes the pathogenesis, incidence, and risk factors of both postoperative pneumonia and ventilator-associated pneumonia. Diagnosis and management are described, which includes antibiotic therapy and adjunct treatments. Treatment failure is also addressed. Tables include preoperative predictors of postoperative pneumonia, the Centers for Disease Control and Prevention/National Healthcare Safety Network definition for pneumonia, and diagnostic techniques used in diagnosis of ventilator-associated pneumonia. An algorithm outlines the recommended approach to antibiotic treatment of suspected pneumonia after operation. This review contains 111 references.

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    • 19

      Sepsis, Severe Sepsis, and Septic Shock

      By Sara Buckman, MD, PharmD; James Orr, MD, FACS; Suresh Agarwal, MD, FACS, FCCM
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      Sepsis, Severe Sepsis, and Septic Shock

      • SARA BUCKMAN, MD, PHARMDSurgical Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • JAMES ORR, MD, FACSAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI

      Sepsis continues to be a common and potentially lethal problem for surgical patients. This chapter describes the definitions of sepsis, severe sepsis, and septic shock. The initial assessment and evaluation is provided, including early identification of sepsis, initial assessment, initial resuscitation efforts, and various therapies to be employed such as vasopressor therapy, steroids, and empirical antimicrobial therapy. A discussion of the pathophysiology of sepsis ensues. Sepsis screening is evaluated. Implementing evidence-based guidelines, including the use of computerized clinical decision support is weighed. Modalities of treatment are discussed, including crystalloid versus colloid fluid resuscitation, the value of using steroids in septic shock, and the importance of early broad-spectrum antimicrobials. A figure reflects the protocol for early goal-directed therapy. Tables show Systemic Inflammatory Response Syndrome criteria; sepsis bundles; the Surviving Sepsis campaign guidelines regarding vasopressors, steroids, and antimicrobial therapy; and recommendations for source-specific empirical antibiotic selection.

      This review contains 3 figures, 6 tables, and 100 references.

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    • 20

      Principles of Empirical and Therapeutic Antimicrobial Therapy

      By Matthew R Rosengart, MD, MPH; Paul Waltz, MD; Brian S. Zuckerbraun, MD
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      Principles of Empirical and Therapeutic Antimicrobial Therapy

      • MATTHEW R ROSENGART, MD, MPHAssociate Professor, Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
      • PAUL WALTZ, MDGeneral Surgery Resident, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
      • BRIAN S. ZUCKERBRAUN, MDHenry T. Bahnson Professor of Surgery, Chief, Section of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Chief, General Surgery Service, VA Pittsburgh Healthcare System, Pittsburgh, PA

      The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition,  specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy,  and recommended antibiotics for necrotizing soft tissue infections.

      This review contains 6 tables and 56 references

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    • 21

      Brain Failure and Brain Death

      By Sharven Taghavi, MD, MPH; Ali Salim, MD
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      Brain Failure and Brain Death

      • SHARVEN TAGHAVI, MD, MPHClinical Fellow, Division of Trauma, Burns, and Surgical Critical Care, Brigham & Women’s Hospital, Boston, MA
      • ALI SALIM, MDChief, Division of Trauma, Burns, and Surgical Critical Care, Brigham & Women’s Hospital, Boston, MA

      Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation.


      This review contains 2 figures, 3 tables, and 69 references.

      Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation



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    • 22

      Mechanical Ventilation: Respiratory Physiology and Conventional Ventilation

      By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCP
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      Mechanical Ventilation: Respiratory Physiology and Conventional Ventilation

      • ADRIAN A. MAUNG, MD, FACS, FCCMAssociate Professor of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
      • LEWIS J KAPLAN, MD, FACS, FCCM, FCCPProfessor of Surgery, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, United States, Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104

      This three-part review is intended to enable the reader to manage the fundamentals of mechanical ventilation in both the urgent and the nonurgent setting. This first chapter provides a functional understanding of basic pulmonary physiology as a prerequisite knowledge base prior to reviewing the concepts central to basic, traditional, and cyclical ventilation that is regularly employed in the air or ground ambulance, emergency department, operating room, and intensive care unit. Subsequent chapters will review advanced ventilation modes, adjuncts, and special problems encountered in patients with respiratory failure requiring mechanical ventilation. Each segment is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion.  


      This review contains 5 Figures and 10 references

      Key Words: acute respiratory failure, acute respiratory distress syndrome, hypercapnia/therapy, hypoxia/therapy, mechanical ventilation, pulmonary gas exchange

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    • 23

      Mechanical Ventilation: Advanced Ventilation and Adjuncts

      By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCP
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      Mechanical Ventilation: Advanced Ventilation and Adjuncts

      • ADRIAN A. MAUNG, MD, FACS, FCCMAssociate Professor of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
      • LEWIS J KAPLAN, MD, FACS, FCCM, FCCPProfessor of Surgery, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, United States, Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104

      In this chapter, we continue the discussion of mechanical ventilation by reviewing advanced ventilation modes such as airway pressure release ventilation and high-frequency oscillation as well as adjuncts that can be used in patients with respiratory failure. Each segment is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion.


      This review contains 6 Figures and 69 references

      Key Words: acute respiratory failure, airway pressure–release ventilation, acute respiratory distress syndrome, high-flow nasal cannula, mechanical ventilation, non-invasive ventilation, prone positioning

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    • 24

      Mechanical Ventilation: Approaches and Special Considerations

      By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCP
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      Mechanical Ventilation: Approaches and Special Considerations

      • ADRIAN A. MAUNG, MD, FACS, FCCMAssociate Professor of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
      • LEWIS J KAPLAN, MD, FACS, FCCM, FCCPProfessor of Surgery, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, United States, Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104

      In this chapter, we complete the discussion of mechanical ventilation by examining approaches to mechanical ventilation for different patient populations and how to assess whether a patient is ready for liberation from mechanical ventilation. Each of the three chapters is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion. 

      This review contains 1 Figure, 1 Table and 31 references

      Key Words: acute respiratory failure, ARDS, mechanical ventilation liberation, spontaneous breathing trial, tracheostomy 

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  • Scientific Foundations
    • 1

      Cardiac Resuscitation

      By Konstantinos Chouliaras, MD; Kazuhide Matsushima, MD; Heidi L. Frankel, MD, FACS, FCCM
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      Cardiac Resuscitation

      • KONSTANTINOS CHOULIARAS, MDResearch Fellow, Acute Care Surgery and Surgical Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA
      • KAZUHIDE MATSUSHIMA, MDClinical Fellow, Acute Care Surgery and Surgical Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA
      • HEIDI L. FRANKEL, MD, FACS, FCCMProfessor of Surgery, Director of Surgical Critical Care Services, Keck Hospital of University of Southern California, Los Angeles, CA

      Out-of-hospital sudden cardiac arrest claims the lives of more than 300,000 persons in the United States each year, making it the leading cause of death. Although 70 to 80% of victims have underlying coronary artery disease, sudden death is the first manifestation of the disease in half of these persons. The pathophysiology that culminates in sudden cardiac death likely represents a mix of electrical abnormalities combined with acute functional triggers, such as myocardial ischemia, central and autonomic nervous system effects, electrolyte abnormalities, and pharmacologic influences. This review describes the process for resuscitating an adult victim with sudden cardiac arrest (chain of survival), which involves activation of emergency medical services, initiation of cardiopulmonary resuscitation and defibrillation, provision of advanced care, and post–cardiac arrest care. Resuscitation outcomes improve when every link in the chain of survival is quickly and sequentially available. The primary and secondary surveys of cardiac resuscitation are listed, as are cardiac resuscitation based on rhythm findings and ending a resuscitation attempt. Tables describe initial resuscitation steps in the unresponsive patient, treatment of ventricular tachycardia, using an automatic external defibrillator in patients older than 8 years, using a manual defibrillator, drugs useful in cardiac arrest, goals of post–cardiac arrest care, a revised summary of American Heart Association (AHA) recommendations, special resuscitation situations reviewed in 2010 AHA guidelines, components of optimal and suboptimal chest compressions, confirmation of endotracheal tube placements, technical problems that may prevent successful resuscitation, potentially treatable conditions that may cause or contribute to cardiac arrest, resuscitation steps in the management of pulseless electrical activity and asystole, criteria for ending a prehospital or in-hospital resuscitation attempt, and criteria for ending a resuscitation attempt for a persistently asystolic patient. Figures illustrate the foundations of cardiac resuscitation, coronary perfusion pressure as a function of time, the four phases of a capnogram, a battery-powered intraosseous drill, the sudden cardiac arrest arrhythmias, and sample capnograms. Algorithms show the approach to cardiovascular resuscitation and management of the initial treatment of cardiac arrest,

      This review contains 7 figures, 17 tables, and 104 references.

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    • 2

      Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

      By Laura Stafman, MD; Sushanth Reddy, MD, FACS
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      Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

      • LAURA STAFMAN, MDResident, Department of Surgery, University of Alabama, Birmingham, AL
      • SUSHANTH REDDY, MD, FACSAssistant Professor, Department of Surgery, University of Alabama, Birmingham, AL

      In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients.

      This review contains 5 highly rendered figures, 5 tables, and 56 references

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    • 3

      Hepatic Failure

      By Juan R. Sanabria, MD, MSc, FACS
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      Hepatic Failure

      • JUAN R. SANABRIA, MD, MSC, FACSAdjunct Associate Professor of Surgery, Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, OH, Professor of Surgery, Roslyn Franklin School of Medicine, Chicago University, Cancer Treatment Centers of America

      Hepatic failure continues to be a frequent and major cause of morbidity and mortality in critically ill patients. Hepatic failure may be encountered as an instance of primary organ failure caused by a liver-specific disease process, caused by a liver therapeutic intervention, or as part of the multiple organ dysfunction syndrome. Advances in critical care, the increasing use of sophisticated diagnostic modalities, and the adoption of a team approach to patient care have resulted in improved overall outcomes. This review outlines clinical evaluation and investigative studies related to liver disease and the management of acute liver failure and chronic liver disease, including classification, assessment of prognosis, treatment of complications, multidisciplinary medical therapy, and liver transplantation. The mechanism of hepatic encephalopathy and bioartificial liver support systems are also discussed. Tables describe liver disease risk factors, six major components in initial management of a patient with hepatic failure, etiology of acute liver failure, King’s College Hospital prognostic criteria predicting poor outcome for patients with fulminant hepatic failure (FHF), liver transplant evaluation and workup for FHF patients, etiology of chronic liver disease, common indications for liver transplantation, differentiation of spontaneous bacterial peritonitis from secondary bacterial peritonitis through analysis of ascitic fluid, the Glasgow Coma Scale, differentiation of hepatorenal syndrome from acute tubular necrosis, complications of parenteral nutrition, contraindications to liver transplantation, and the Child-Turcotte-Pugh scoring system. Figures show a transcutaneous intrahepatic portosystemic shunt, a patient with ascites, grading of portosystemic encephalopathy, etiology of liver disease among patients waiting for liver transplantation, estimated 3-month survival as a function of the Model for End-Stage Liver Disease score, and a hypervascular hepatocellular carcinoma of the left liver. An algorithm shows the approach to the patient with liver failure.

      This review contains 6 figures, 13 tables, and 135 references.

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    • 4

      Clinical Trial Design and Statistics

      By Julie Ann Sosa, MA, MD, FACS; April K.S. Salama, MD; Samantha M. Thomas, MS
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      Clinical Trial Design and Statistics

      • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT
      • APRIL K.S. SALAMA, MDAssistant Professor of Medicine, Division of Medical Oncology, Duke University School of Medicine, Durham, NC
      • SAMANTHA M. THOMAS, MSBiostatistician, Department of Biostatistics & Bioinformatics, Duke Cancer Institute, Durham, NC

      A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

      This review contains 2 highly rendered figures, 2 tables, and 38 references

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    • 5

      Acute Kidney Injury

      By Aileen Ebadat, MD; Eric Bui, MD; Carlos V R Brown, MD
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      Acute Kidney Injury

      • AILEEN EBADAT, MDChief Resident, Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX
      • ERIC BUI, MDSurgical Critical Care Fellow, Department of Surgery, Los Angeles County-University of Southern California, Los Angeles, CA
      • CARLOS V R BROWN, MDAssociate Professor, Department of Surgery, Dell Medical School University of Texas at Austin, Trauma Medical Director, University, Medical Center Brackenridge, Austin, TX

      Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies.

      This review contains 1 management algorithm, 2 charts, 6 tables, and 77 references.

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    • 6

      Coma, Cognitive Impairment, and Seizures

      By Ali Salim, MD; Melissa H Coleman, MD
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      Coma, Cognitive Impairment, and Seizures

      • ALI SALIM, MDDivision Chief, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA
      • MELISSA H COLEMAN, MDSurgical Critical Care Fellow, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA

      When a patient presents with altered mental status, it is critical to assess the patient in a systematic manner to diagnose and treat the underlying cause. A careful history, a rapid and focused neurologic examination, laboratory testing, and radiologic imaging all aid in achieving a diagnosis. Once initial stabilization of the patient has been achieved, management of coma is determined by the specific underlying etiology, precipitating condition, or acute event. It is critical to accomplish rapid assessment of coma, especially identifying reversible causes, which are in an effort to improve outcome. This review is intended to be an introductory overview of disorders of consciousness that also provides a practical and streamlined approach to the diagnosis and management of coma and seizures. To that end, an algorithmic approach to diagnosis is formulated, general treatment measures for comatose patients are outlined, specific causes of coma are reviewed, and prognostic issues are considered. Tables outline the differential diagnosis of coma, Glasgow Coma Scale, focused neurologic examination (coma examination), general physical examination, Full Outline of UnResponsiveness (FOUR) score, and questions and possible causes when considering coma history. A noncontrast head computed tomographic scan suggesting basilar artery occlusion is provided.

      This review contains 1 management algorithm, 1 computed tomographic scan, 6 tables, and 23 references

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    • 7

      Coagulation Disorders

      By Eric M. Campion, MD; Mitchell J. Cohen, MD
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      Coagulation Disorders

      • ERIC M. CAMPION, MDTrauma and Surgical Critical Care Fellow, Department of Surgery, University of California, San Francisco, San Francisco, CA
      • MITCHELL J. COHEN, MDProfessor of Surgery in Residence, Department of Surgery, University of California, San Francisco, San Francisco, CA

      There are multiple congenital and acquired disorders of coagulation that may result in unplanned bleeding or clotting. These disorders can result in an increase in morbidity and mortality to surgical patients. Unexpected bleeding during and after surgery can be prevented by having an adequate understandings of these entities and by being aware of the available treatment options. In addition to awareness of bleeding disorders, it is important to recognize the risks associated with disorders predisposing patients to clotting, or thrombophilias. This review discusses the major inherited disorders of the coagulation cascade resulting in bleeding or clotting tendencies in relation to surgical patients. von Willebrand Disease (vWD), hemophilia A, hemophilia B, hemophilia C, acute coagulopathy of trauma, disseminated intravascular coagulation (DIC), uremic bleeding, bleeding in cirrhosis, clotting disorders, and acquired thrombophilias are covered. Tables list the classification and differentiation of vWD, correlation of factor VIII coagulant activity level with bleeding patterns in hemophilia, causes of DIC, frequency and relative risk of venous thrombosis in hypercoagulable states, inherited and acquired hypercoagulable states, clinical features that suggest thrombophilia, screening tests for patients with suspected hypercoagulable state, and pretest probability of heparin-induced thrombocytopenia. Figures depict the clinical presentation of DIC, procoagulant and anticoagulant pathways, normal factor V and factor V Leiden, and heparin-induced thrombocytopenia.

      This review contains 4 figures, 8 tables, and 51 references.

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    • 8

      Severity of Illness Scoring Systems in Critical Care

      By Mark T. Keegan, MD
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      Severity of Illness Scoring Systems in Critical Care

      • MARK T. KEEGAN, MDAssociate Professor, Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN

      Critical care consumes about 4% of national health expenditure and 0.65% of United States gross domestic product. There are approximately 94,000 critical care beds in the United States, and provision of critical care services costs approximately $80 billion per year. The enormous costs and the heterogeneity of critical care have led to scrutiny of patient outcomes and cost-effectiveness by a variety of governmental and nongovernmental organizations; furthermore, individual critical care practitioners and their hospitals should evaluate the care delivered. This review discusses scoring systems in medicine, critical care systems, development, validation, performance, and customization of the models, adult intensive care unit (ICU) prognostic models, model use, limitations, prognostic models in trauma care, perioperative scoring systems, assessment of organ failure, severity of illness and organ dysfunction scoring in children, and future directions. Figures show the distribution of predicted risk of death using two different prediction models among a population of patients who ultimately are observed to either live or die, a comparison of  “expected” deaths (based on the expectation that the predicted probability from the model is correct) to observed deaths within each of the 10 deciles of predicted risk, the importance of disease in the risk of death equation,  and the revised Rapaport-Teres graph for ICUs in the Project IMPACT validation set. Tables list three main ICU prognostic models, study characteristics and performance of the fourth-generation prognostic models, variables included in the fourth-generation prognostic models, potential uses of adult ICU prognostic models, variables included in the calculation of the organ failure scores, and sequential organ failure assessment.

      This review contains 4 highly rendered figures, 6 tables, and 293 references

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    • 9

      Principles of Empirical and Therapeutic Antimicrobial Therapy

      By Paul Waltz, MD; Matthew R Rosengart, MD, MPH; Brian S. Zuckerbraun, MD
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      Principles of Empirical and Therapeutic Antimicrobial Therapy

      • PAUL WALTZ, MDGeneral Surgery Resident, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
      • MATTHEW R ROSENGART, MD, MPHAssociate Professor, Department of Surgery, Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
      • BRIAN S. ZUCKERBRAUN, MDHenry T. Bahnson Professor of Surgery, Chief, Section of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Chief, General Surgery Service, VA Pittsburgh Healthcare System, Pittsburgh, PA

      The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition,  specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy,  and recommended antibiotics for necrotizing soft tissue infections.

      This review contains 6 tables and 56 references

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    • 10

      Preoperative Evaluation of the Elderly Surgical Patient

      By Tracy S. Wang, MD, MPH, FACS; Jennifer Roberts, MD
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      Preoperative Evaluation of the Elderly Surgical Patient

      • TRACY S. WANG, MD, MPH, FACSAssistant Professor, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
      • JENNIFER ROBERTS, MDDepartment of Surgery, Medical College of Wisconsin, Milwaukee, WI

      The following is a detailed approach to the preoperative evaluation of the elderly surgical patient. A focus is placed on physiologic changes in the elderly that predispose them to complications and a systems-based approach to appropriate perioperative evaluation. Specifically, recommendations on the workup of cardiovascular, pulmonary, and renal systems are discussed. We also introduce the concept of frailty as a measure of an elderly patient's overall physiologic reserve. Finally, a diagnostic approach to common elderly-specific disease processes such as decreased functional status, malnutrition, and delirium is outlined. Throughout, an emphasis is placed on how to carefully assess this specific patient population and optimize preoperative functional status to improve surgical outcomes in the elderly. This review has 1 figure, 4 tables, and 62 references.

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    • 11

      Sepsis, Severe Sepsis, and Septic Shock

      By Sara Buckman, MD, PharmD; James Orr, MD, FACS; Suresh Agarwal, MD, FACS, FCCM
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      Sepsis, Severe Sepsis, and Septic Shock

      • SARA BUCKMAN, MD, PHARMDSurgical Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • JAMES ORR, MD, FACSAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI

      Sepsis continues to be a common and potentially lethal problem for surgical patients. This chapter describes the definitions of sepsis, severe sepsis, and septic shock. The initial assessment and evaluation is provided, including early identification of sepsis, initial assessment, initial resuscitation efforts, and various therapies to be employed such as vasopressor therapy, steroids, and empirical antimicrobial therapy. A discussion of the pathophysiology of sepsis ensues. Sepsis screening is evaluated. Implementing evidence-based guidelines, including the use of computerized clinical decision support is weighed. Modalities of treatment are discussed, including crystalloid versus colloid fluid resuscitation, the value of using steroids in septic shock, and the importance of early broad-spectrum antimicrobials. A figure reflects the protocol for early goal-directed therapy. Tables show Systemic Inflammatory Response Syndrome criteria; sepsis bundles; the Surviving Sepsis campaign guidelines regarding vasopressors, steroids, and antimicrobial therapy; and recommendations for source-specific empirical antibiotic selection.

      This review contains 3 figures, 6 tables, and 100 references.

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    • 12

      Infection Control in Surgical Practice

      By Elizabeth A Bailey, MD, MEd; Caroline E. Reinke, MD, MSHP; Rachel R. Kelz, MD, MSCE, FACS
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      Infection Control in Surgical Practice

      • ELIZABETH A BAILEY, MD, MED
      • CAROLINE E. REINKE, MD, MSHPInstructor of Surgery, Department of Surgery Education, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
      • RACHEL R. KELZ, MD, MSCE, FACSAssistant Professor of Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

      Health care–associated infections (HAIs) are those that are acquired while patients are being treated for another condition in the health care setting. HAIs are associated with substantial morbidity and mortality, with 75,000 deaths attributable to HAIs each year. This review outlines the evolution of HAI as a quality metric and introduces key governmental and professional organization stakeholders. The role of the local infection control program is also discussed. Using the example of surgical site infection, we detail the multitude of factors that contribute to the occurrence of an HAI, evidence-based preventive strategies, and systems-based programs to reduce preventable infections. Specific diagnostic criteria and preventive strategies are also introduced for catheter-associated urinary tract infection, central line–associated bloodstream infection, ventilator-associated pneumonia, Clostridium difficile infection, and various multidrug-resistant organisms.

      This review contains 3 figures, 9 tables, and 74 references.

      Key words: catheter-associated urinary tract infection, central line–associated bloodstream infection, Clostridium difficile, hospital-acquired infection, infection, quality, surgical site infection, ventilator-associated pneumonia 

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    • 13

      Clinical Immunology and Innate Immunity

      By Lung-Yi Lee, MD; David P Foley, MD
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      Clinical Immunology and Innate Immunity

      • LUNG-YI LEE, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • DAVID P FOLEY, MDDivision of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Our body encounters a multitude of microorganisms in our daily lives. Due to surveillance of our robust immune system, these microbial encounters remain largely benign and only become pathologic at times. The majority of these pathogens are cleared rapidly by our innate immune system. The innate immune system is our body’s first line of defense that mounts a nonspecific response against pathogens. In this review, a contemporary summary of this complex system and its relevance to disease processes that are commonly seen in the surgical setting are presented, including components and activation of innate immunity, and relevant clinical scenarios. Figures show hematopoiesis, the complement system, leukocyte extravasation, pattern recognition receptors, pattern recognition receptor signaling pathways, phagocytosis, neutrophil extracellular traps, wound healing, ischemia-reperfusion injury, and innate immunity and deep vein thrombosis formation. Tables list tissue-resident macrophages, toll-like receptors, cytokines, and chemokines.

      This review contains 10 highly rendered figures, 4 tables, and 39 references

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    • 14

      Bleeding and Transfusion

      By Garth H. Utter, MD, MSc, FACS; Robert C. Gosselin, MT; John T. Owings, MD, FACS
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      Bleeding and Transfusion

      • GARTH H. UTTER, MD, MSC, FACSAssistant Professor, Department of Surgery, University of California Davis Medical Center, Sacramento, CA
      • ROBERT C. GOSSELIN, MTCoagulation Specialist, Department of Clinical Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA
      • JOHN T. OWINGS, MD, FACS Professor, Department of Surgery, University of California Davis Medical Center, Sacramento, CA

      This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function. This review contains 83 references.

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    • 15

      Brain Failure and Brain Death

      By Sharven Taghavi, MD, MPH; Ali Salim, MD
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      Brain Failure and Brain Death

      • SHARVEN TAGHAVI, MD, MPHClinical Fellow, Division of Trauma, Burns, and Surgical Critical Care, Brigham & Women’s Hospital, Boston, MA
      • ALI SALIM, MDChief, Division of Trauma, Burns, and Surgical Critical Care, Brigham & Women’s Hospital, Boston, MA

      Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation.


      This review contains 2 figures, 3 tables, and 69 references.

      Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation



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  • Organ Systems: Anatomy & Physiology
    • 1

      Cardiac System

      By David C Mauchley, MD
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      Cardiac System

      • DAVID C MAUCHLEY, MD

      The circulatory system, which consists of the heart, arterial system, venous system, and lymphatics, constitutes a complicated network of vessels and ducts that are responsible for the delivery of oxygenated blood to the body and return of deoxygenated blood to the heart and lungs. The heart is at the center of the circulatory system, and its pumping mechanism provides energy and nutrition to all organs in the body. This review focuses on the anatomy and physiology of the heart and describes anatomic details that are important to the planning of many common cardiac operations.   

      This review contains 28 figures, and 25 references.

      Key words: aortic root, aortic valve, atrial septum, atrioventricular node, coronary artery, fibrous skeleton of heart, mitral valve, myocardium, pericardium, pulmonic valve, sinoatrial node, tricuspid valve, ventricular septum 

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    • 2

      The Respiratory System

      By Hee Soo Jung, MD; Walker Julliard, MD; Suresh Agarwal, MD, FACS, FCCM
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      The Respiratory System

      • HEE SOO JUNG, MDAssistant Professor, Department of Surgery, University of Wisconsin, Madison, WI
      • WALKER JULLIARD, MDResident, Department of Surgery, University of Wisconsin, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI

      This review discusses gas exchange and transport processes in the lungs; anatomic considerations; impact on the circulatory system (airway pressure, lung volume, regional pleural pressures); normal ventilation, including the mechanics of breathing; and pulmonary function assessment, including pulse oximetry, capnometry, pulmonary function testing, physiologic variations in respiration, perioperative physiologic changes, risk factors for and strategies to prevent postoperative pulmonary complications, initial airway/respiratory evaluation and management, mechanical ventilator strategies, oxygenation, ventilation, adjuncts and rescue therapies, and weaning from mechanical ventilation. Tables describe patient-specific risk factors for noncardiothoracic postoperative pulmonary complication, chronic obstructive lung disease optimization strategies, the Glasgow Coma Scale, and the LEMON mnemonic. Figures show gas exchange at the alveolar capillary membrane, factors affecting the oxygen dissociation curve, uneven distribution of air and blood in different zones of the lung, carbon dioxide metabolism in the lungs and periphery, the lateral wall of the right nasal cavity, sagittal section of the upper aerodigestive tract, tracheobronchial tree, diaphragmatic motion during respiration, schematic diagram of normal filtration and resorption of fluid in the pleural space, respiratory tree, neurologic control of respiration, pressure gradient between the pleural space and the airway, pressure-volume curve, the four phases of a capnogram, lung volumes and capacities, the 3-3-2 rule, evaluation of the oropharynx, transnasal introduction of a flexible bronchoscope, ventilator waveforms, and the therapeutic ladder in the management of acute respiratory distress syndrome.

      This review contains 20 figures, 4 tables, and 113 references.

       

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    • 3

      The Renal System

      By John T Killian Jr, MD; Jayme E. Locke, MD, MPH, FACS
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      The Renal System

      • JOHN T KILLIAN JR, MDResident, General Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
      • JAYME E. LOCKE, MD, MPH, FACSAssistant Professor of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL

      This updated review on the renal system provides a concise overview of the topics most important to the general surgeon. Anatomic topics have been expanded to also include variant anatomy and surgical approaches. There is a new focus on the accuracy and utility of equations for estimating the glomerular filtration rate, as well as supplementation and pharmacology for the general surgeon with discussions of vitamin D and erythropoietin. Acute kidney injury is defined; its pathophysiology is discussed; and its management is outlined, highlighting evidence-based practice. Finally, urologic surgery is addressed with a focus on donor nephrectomy and its consequences, as well as the management of iatrogenic ureteral injuries.

      Key words: acute kidney injury; contrast nephropathy; erythropoiesis-stimulating agents; estimated glomerular filtration rate; iatrogenic ureteral injury; laparoscopic donor nephrectomy; renal surgical anatomy; vitamin D supplementation

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    • 4

      The Endocrine System: Pituitary and Adrenal Glands

      By Haggi Mazeh, MD; Herbert Chen, MD, FACS; Iddo Paldor, MD
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      The Endocrine System: Pituitary and Adrenal Glands

      • HAGGI MAZEH, MDClinical Instructor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI
      • IDDO PALDOR, MDClinical Instructor, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

      This review presents the pituitary gland--where the neural and endocrine systems function in continuity, maintaining homeostasis of many functional elements of the human body and the adrenal glands with their two hormone-secreting organs: the cortex and the medulla. The embryology and development, anatomy, normal physiology of each gland is presented. Figures show a midsagittal view of the brain; the pituitary blood supply, venous drainage, and portal system; a summary of pituitary hormones and their main acions; the adrenal layers and hormones; the adrenal blood supply and venous drainage; synthetic pathways for adrenal steroid synthesis; and major steps in catecholamine synthesis and degradation. This review contains 61 references.

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    • 5

      The Endocrine System: Adrenal Glands

      By Abbas Al-Kurd, MD; Haggi Mazeh, MD, FACS
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      The Endocrine System: Adrenal Glands

      • ABBAS AL-KURD, MDClinical Instructor, Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
      • HAGGI MAZEH, MD, FACSAssociate Professor, Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel

      The adrenal glands represent an essential component of the endocrine system, and their failure can have catastrophic consequences to several aspects of bodily homeostasis. Each adrenal gland can be divided into two different endocrine components, the cortex and the medulla, each with distinct functions. This in-depth review of normal adrenal embryology, anatomy, and physiology also emphasizes the clinical relevance of various irregularities in adrenal functioning. Every surgeon attempting to manage adrenal diseases is expected to be familiar with the detailed pathophysiology of these conditions because such an understanding is essential for sound preoperative evaluation and perioperative management of this potentially complicated patient group. 

      This review contains 4 figures, 1 table, and 70 references.

      Key words: adrenal, adrenal glands, adrenal pathophysiology, adrenal physiology, anatomy of adrenal glands, cortex, embryology, endocrine system, medulla

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  • Competency-based Surgical Care
    • 1

      Bedside Procedures for General Surgeons: Part 1

      By Thomas H. Cogbill, MD; Basem S Marcos, MD
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      Bedside Procedures for General Surgeons: Part 1

      • THOMAS H. COGBILL, MDProgram Director Emeritus, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI
      • BASEM S MARCOS, MD

      This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged.

      This review contains 19 figures, 7 tables, and 33 references.

      Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown

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    • 2

      Ethical Issues in Surgery

      By Jason D. Keune, MD, MBA; Ira J. Kodner, MD, FACS; Mary E. Klingensmith, MD, FACS
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      Ethical Issues in Surgery

      • JASON D. KEUNE, MD, MBAChief Resident in General Surgery, Washington University School of Medicine, St. Louis, MO
      • IRA J. KODNER, MD, FACSEmeritus Professor of Surgery, Washington University School of Medicine, St. Louis, MO
      • MARY E. KLINGENSMITH, MD, FACSChief Resident in General Surgery, Washington University School of Medicine, St. Louis, MO

      To be a good surgeon, one must be technically good and scientifically sound, but also ethical to the degree that has traditionally been demanded by our profession. In this chapter, the authors discuss what ethical problems in surgery are and how they might be approached. Respect for autonomy, nonmaleficence, beneficence, and justice define Principlism that forms the backbone of most discourse in clinical medical ethics. Consequentialism/utilitarianism, deontology, virtue ethics, “ethics of care”, and casuistry are all covered. The authors then scrutinize several contemporary problems in surgical ethics. Described and discussed in depth are issues associated with the ‘end of life’; surrogate decision making, futility, “do not resuscitate” orders in the operating room, conflicts of interest, industry payments, and surgical innovation, informed consent, and refusal of care. This review is not meant to be an exhaustive treatment of surgical ethics but a survey highlighting the most common ethical problems.

      This review contains 2 figures, 3 tables, and 61 references.

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    • 3

      Value-driven Nonemergent Surgical Care

      By Peter A Najjar, MD, MBA; Julie Ann Sosa, MA, MD, FACS
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      Value-driven Nonemergent Surgical Care

      • PETER A NAJJAR, MD, MBAResident in Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
      • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT

      As healthcare expenditures rise, payers and providers have increasingly recognized the importance of measuring and improving value. Surgical care accounts for a significant percentage of total healthcare expenditures in the United States, and efforts to improve value globally must take into account the unique challenges and opportunities specific to elective surgical care. This situation makes it essential that surgeons have a thorough understanding of surgical value, its measurement, improvement, and incentivization efforts predicated on it. Toward that end, this review (1) explores the fundamental concept of value in healthcare, particularly as applied to surgery, (2) surveys the challenges in measuring surgical cost and quality, (3) describes the framework of value improvement, (4) identifies selected tools to help surgeons improve the value of care provided, and (5) discusses the increasing role that value-based competition is likely to play in the American healthcare industry.

      This review contains 5 figures, 3 tables, and 56 references.

      Key Words: healthcare costs, quality improvement, surgery, surgical value, value, value-based competition, value improvement

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    • 4

      Evidence-based Surgery

      By Samuel R. G. Finlayson, MD, MPH; Karl Y. Bilimoria, MD, MS
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      Evidence-based Surgery

      • SAMUEL R. G. FINLAYSON, MD, MPHChair, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
      • KARL Y. BILIMORIA, MD, MSAssistant Professor of Surgery, Director, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL

      Evidence-based surgery describes the consistent and judicious use of the best available scientific evidence in making decisions about the care of surgical patients. In this chapter, guidelines and secondary sources of scientific evidence are provided. Examples include Clinical Evidence, the Cochrane Database of Systematic Reviews, and the Institute for Healthcare Improvement. Levels of evidence are defined. Appraising scientific evidence via specific study designs is described, including studies’ internal and external validity (generalizability). In evaluating the quality of a study, the properties of chance (Type I and Type II errors); bias (selection bias and measurement bias); and confounding (along with randomization, restriction and matching, instrumental variable analysis, stratification, and propensity score risk adjustment) are defined. Interpreting and applying evidence to practice (external validity) are discussed. A discussion of evidence-based surgery and quality of care is provided and focuses on how efforts to assess quality on evidence-based processes of care or clinical outcomes are as much practical as philosophical. A figure shows processes that affect the internal and external validity of a clinical study. Tables show levels of evidence, as stratified by the U.S. Preventive Services Task Force, and methods observed in published clinical studies that demonstrate efforts to minimize the effects of chance, bias, and confounding.

      This review contains 1 figure, 3 tables, and 42 references.

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    • 5

      Minimizing Vulnerability to Malpractice Claims

      By William R Berry, MD, MPH, FACS
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      Minimizing Vulnerability to Malpractice Claims

      • WILLIAM R BERRY, MD, MPH, FACSResearch Associate, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

      This review provides strategies for avoiding lawsuits and advice for dealing with a lawsuit if one is ever filed. Medical malpractice is explained as are the personal issues for the defendant physician. Strategies for preventing malpractice suits are presented, including those relative to communication and interpersonal skills, the informed consent process, and documentation. Advice is provided for what surgeons should do if sued or if threatened with a lawsuit, including measures for assisting in the defense and settling claims versus trying a case. Preparing for a deposition is discussed. How a surgeon should act when a defendants or witness in a courtroom trial is presented. This review contains 13 references.

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    • 6

      Nontechnical Skills in Surgery

      By Douglas S. Smink, MD, MPH; Steven Yule, MA, MSc, PhD
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      Nontechnical Skills in Surgery

      • DOUGLAS S. SMINK, MD, MPHProgram Director, General Surgery Residency, Associate Medical Director, Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham and Women’s Hospital, Department of Surgery, Harvard Medical School, Boston, MA
      • STEVEN YULE, MA, MSC, PHDDirector of Education and Research, Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham & Women’s Hospital, Assistant Professor, Department of Surgery, Harvard Medical School, Boston, MA

      Nontechnical skills are the cognitive and social skills that underpin knowledge and expertise in high-demand workplaces. In the operating room (OR), surgeons with good nontechnical skills can effectively share information about their perceptions of ongoing situations with other team members, elicit critical information from others regarding the task and patient safety, and allow the formation of better shared mental representations about the operation in real time. In rare OR crises, surgeons use their nontechnical skills to delegate tasks and effectively manage challenging operations under time pressure. This review covers approaches in high-risk industry; the development, testing, and usage of the non-technical skills for surgeons (NOTSS) system; and the underpinning theory of nontechnical skills. Tables outline the NOTSS skills taxonomy, behavioral rating tools in surgery, and the skills taxonomy used in the aviation industry.

      This review contains 3 tables, and 62 references.

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    • 7

      Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS; Caprice C. Greenberg, MD, MPH, FACS
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      Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssociate Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor, MI, United States; Associate Professor of Management and Organizations, University of Michigan Stephen M. Ross School of Business, Ann Arbor, MI, United States; Director, Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, United States; Surgical Director, University Hospital, Michigan Medicine, Ann Arbor, MI, United States
      • CAPRICE C. GREENBERG, MD, MPH, FACSProfessor of Surgical Research, Associate Professor of Surgery, Director, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI

      The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries.

      This review contains 4 figures, 7 tables, and 165 references.

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    • 8

      Performance Measurement in Surgery

      By Justin B. Dimick, MD, MPH
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      Performance Measurement in Surgery

      • JUSTIN B. DIMICK, MD, MPHUniversity of Michigan Medical School, Ann Arbor, MI

      With growing recognition that the quality of surgical care varies widely, good measures of performance are in high demand. An ever-broadening array of performance measures is being developed to meet these different needs; however, considerable uncertainty remains about which measures are most useful for measuring surgical quality. Current measures encompass different elements of health care structure, process of care, and patient outcomes. This review covers overview of surgical quality measures, categories of quality measures, structural measures of quality, process of care measures, direct outcome measures, matching the measure to the purpose, improving existing performance measures, and the future of performance measurement. Figures show relative ability of historical (2005-2006) measures of hospital volume and risk-adjusted mortality to predict subsequent (2007-2008) risk-adjusted mortality in US Medicare patients,  risk-adjusted mortality and morbidity for colon resection at individual hospitals before and after adjustment for reliability, variation in surgeon technical skill for 20 bariatric surgeons performing laparoscopic gastric bypass in the Michigan Bariatric Surgery Collaborative (MBSC), and relationship of surgeon technical skill and risk-adjusted complications and resource use after laparoscopic gastric bypass in the MBSC. The table lists primary strengths and limitations of structure, process, and outcome measures.

       

      This review contains 4 highly rendered figures, 1 table, and 34 references

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    • 9

      Preoperative Testing and Planning for Safer Surgery

      By Valerie Ng, MD, PhD; Sarah Markham, MD; Jill Antoine, MD; Alden H. Harken, MD, FACS
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      Preoperative Testing and Planning for Safer Surgery

      • VALERIE NG, MD, PHDProfessor Emeritus, Department of Laboratory Medicine, University of California, San Francisco-East Bay; and Chair Laboratory Medicine and Pathology, Alameda County Medical Center, Oakland, CA
      • SARAH MARKHAM, MDSurgical Resident, University of California, San Francisco-East Bay Surgical Residency Program, Department of Surgery, Alameda County Medical Center, Oakland, CA
      • JILL ANTOINE, MDMedical Director, Anesthesiology, Pre-Operative Clinic, Department of Anesthesia, Highland Hospital, Alameda Health Systems, Oakland, CA
      • ALDEN H. HARKEN, MD, FACSProfessor and Chair, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA

      Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).

       

      This review contains 4 highly rendered figures, 3 tables, and 111 references

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    • 10

      Process Improvement in Surgery

      By Frederick H Millham, MD, MBA
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      Process Improvement in Surgery

      • FREDERICK H MILLHAM, MD, MBAAssociate Clinical Professor of Surgery, Harvard Medical School, Chair of Surgery, South Shore Hospital, Weymouth, MA

      Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps.

      This review contains 10 figures, 2 tables, and 22 references.

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    • 11

      Professionalism in Surgery

      By K. Christopher McMains, MD, PhD, MS; Jo Shapiro, MD, FACS
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      Professionalism in Surgery

      • K. CHRISTOPHER MCMAINS, MD, PHD, MS
      • JO SHAPIRO, MD, FACSAssociate Professor, Otolaryngology, Harvard Medical School, Boston, MA

      The medical profession continues to be challenged along the entire range of its cultural values and its traditional roles and responsibilities. This review explores the meaning of professionalism, translating the theory of professionalism into practice, and the future of surgical professionalism. A table offers the elements of the American College of Surgeons’ Code of Professional Conduct. This review contains 22 references.

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    • 12

      Strategies for Improving Surgical Quality

      By Mark A. Healy, MD; Nancy J. O. Birkmeyer, PhD
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      Strategies for Improving Surgical Quality

      • MARK A. HEALY, MDFellow, Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
      • NANCY J. O. BIRKMEYER, PHDAssociate Professor, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI

      Surgical morbidity and mortality are major public health concerns. The outcomes of surgery have been shown to differ among providers; this variability in the outcomes of surgical procedures has long suggested opportunities to improve the quality of surgical care. Payers, health care policy makers, and surgeons’ professional organizations have implemented a range of strategies to effect large-scale quality improvement efforts targeted toward patients undergoing surgery. This review examines outcomes measurement and feedback, regional collaborative quality improvement, selective referral, pay for performance strategies, and new strategies for surgical quality improvement. Figures show example of provider desktop user interface for a regional quality collaborative; mortality after (30-day) bariatric surgery: Michigan hospitals versus non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) based on data from the 2007 to 2009 Michigan Bariatric Surgery Collaborative and national ACS-NSQIP registries; and percentage of mortality decline for esophagectomy, pancreatectomy, cystectomy, and lung resection attributable to increases in market concentration, based on 2001 to 2008 national Medicare data. Tables list characteristics of different strategies for improving surgical quality; components of the Institute for Healthcare improvement ventilator and central catheter insertion bundle checklists; evidence regarding the relationship between compliance with Surgical Care Improvement Project (SCIP) measures and clinical outcomes; SCIP measures retired as of January 15, 2015; and SCIP measures remaining.

      This review contains 3 highly rendered figures, 5 tables and 74 references.

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    • 13

      Surgical Practice Management

      By Valentine N. Nfonsam, MD, MS; Leigh A. Neumayer, MD, MS
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      Surgical Practice Management

      • VALENTINE N. NFONSAM, MD, MSAssistant Professor of Surgery, General Surgery Residency Program Director, Department of Surgery, University of Arizona, Tucson, AZ
      • LEIGH A. NEUMAYER, MD, MSProfessor and Chair, Department of Surgery, University of Arizona, Tucson, AZ

      As individuals complete their surgical residencies and fellowships, their attention must soon turn toward choosing their career path. This review aims to help those individuals in making informed choices that will properly prepare a successful future in surgical practice. Included here is a survey of some principles that will help guide individuals to proper decision making, an analysis of several different practice settings, sections on negotiations, benefits, and contracts, and a guide to making a smooth transition and developing a successful practice. Helpful tips and possible pitfalls, such as general dos and don’ts for applying and interviewing, are also presented to ensure that the trainee is well prepared and well aware. Figures show a template for curriculum vitae format, a sample resume, a sample executive summary, a contract worksheet, an onboarding timeline, and screenshots of Surgeon Specific Registry. Tables list types of surgical practice, a summary of a personnel file, benefits packages, and lessons learned in kindergarten. Also included are suggested readings related to the topic of surgical practice management.

      This review contains 6 figures, 4 tables, 13 references, and 8 additional readings.

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    • 14

      Bedside Procedures for General Surgeons: Part 2

      By Thomas H. Cogbill, MD; Basem S Marcos, MD
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      Bedside Procedures for General Surgeons: Part 2

      • THOMAS H. COGBILL, MDProgram Director Emeritus, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI
      • BASEM S MARCOS, MD

      This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures and pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on a careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged.

      This review contains 24 figures, 9 tables, and 33 references.

      Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy

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    • 15

      Surgical Palliative Care

      By Emily B. Rivet, MD, MBA, FACS, FASCS; Zara Cooper, MD, MSc, FACS
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      Surgical Palliative Care

      • EMILY B. RIVET, MD, MBA, FACS, FASCSAssistant Professor, Department of Surgery Brigham and Women’s Hospital, Harvard Medical School
      • ZARA COOPER, MD, MSC, FACSAssistant Professor of Surgery, Harvard Medical School, Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA

      Palliative care is a multidisciplinary approach to care that includes relief of suffering and attention to the social, spiritual, physical, and psychological needs of patients and families. The intent of palliative care is to help patients live as well as possible for as long as possible, and relevant domains of palliative care include symptom relief, prognostication, communication with patients, families and clinicians, transitions of care, and end-of-life care. Palliative care is distinct from hospice in many respects including that it can be provided simultaneously with recovery-directed treatments rather than reserved for individuals at end of life. Patients with surgical disease are particularly in need of palliative care due to the common occurrence of severe symptoms such as pain and nausea, complex decision-making, and the often sudden onset of the disease or injury which precludes preparation for the new health state.

       

      Key Words: communication, end-of- life, goals of care, high-risk surgery, palliative, palliative care, palliative surgery, patient comfort, surgical decision-making, surgical prognostication

      This review contains 3 figures, 10 tables, and 61 references.

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    • 16

      Health Economics: National Health Expenditures

      By Bruce L Hall, MD, PhD, MBA, FACS
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      Health Economics: National Health Expenditures

      • BRUCE L HALL, MD, PHD, MBA, FACSProfessor of Surgery, School of Medicine, Professor of Healthcare Management, Olin Business School, Washington University, Saint Louis, MO, United States, Vice President and Chief Quality Officer, BJC Healthcare, Saint Louis MO, United States

      A picture of the overall structure of the US health care industry can be garnered by examining national health expenditures. In 2015, US national health expenditures grew to $3.2 trillion (US), outpacing growth in gross domestic product. Valuable insights are found by examining categories of spending, sources of funds, and target areas of spending, raising questions about the logic and performance of the US system. These perspectives can inform deeper consideration of healthcare policy and reform.

      This review contains 3 tables and 20 references.

      Key Words: health economics, health policy, Medicaid, Medicare, national health expenditures, opportunity cost, projections

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    • 17

      Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance

      By Bruce L Hall, MD, PhD, MBA, FACS
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      Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance

      • BRUCE L HALL, MD, PHD, MBA, FACSProfessor of Surgery, School of Medicine, Professor of Healthcare Management, Olin Business School, Washington University, Saint Louis, MO, United States, Vice President and Chief Quality Officer, BJC Healthcare, Saint Louis MO, United States

      The production of health as an output of various inputs is a key concept of health care economics and a key influence on health care policy. Similarly, the notion of risk—that an outcome might not turn out as expected or hoped—underpins the entire theory of insurance. Insurance, and the benefits it can provide, cannot be understood without understanding risk, or without understanding how the features of an insurance contract transform risk for the individual, the payer, or society. The health economist, policy maker, leader, expert operator, financier, insurer, clinician of any stripe, patient or family or advocate, or other interested stakeholder must always consider the structural, clinical, and economic anatomy of health care in the context of the underlying physiology of these economic concepts.

      This review contains 2 figures, 1 table, and 14 references.

      Key Words: health economics, health policy, health production, marginal return (diminishing), utility, inputs, QALY, risk (aversion or tolerance), insurance (contract features)

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    • 18

      Understanding Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS
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      Understanding Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssociate Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor, MI, United States; Associate Professor of Management and Organizations, University of Michigan Stephen M. Ross School of Business, Ann Arbor, MI, United States; Director, Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, United States; Surgical Director, University Hospital, Michigan Medicine, Ann Arbor, MI, United States

      This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety.

      This review contains 3 figures, 3 tables, and 78 references

      Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations


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    • 19

      Improving Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS
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      Improving Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssociate Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Ann Arbor, MI, United States; Associate Professor of Management and Organizations, University of Michigan Stephen M. Ross School of Business, Ann Arbor, MI, United States; Director, Michigan Bariatric Surgery Collaborative, Ann Arbor, MI, United States; Surgical Director, University Hospital, Michigan Medicine, Ann Arbor, MI, United States

      This chapter outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries.

      This review contains 1 figures, 4 tables, and 84 references


      Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork


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    • 20

      The Impaired Surgeon

      By David B. Hoyt, MD, FACS; Krista L. Kaups, MD, MSc, FACS
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      The Impaired Surgeon

      • DAVID B. HOYT, MD, FACSExecutive Director, American College of Surgeons, Chicago, IL
      • KRISTA L. KAUPS, MD, MSC, FACSProfessor of Clinical Surgery, UCSF Fresno, Department of Surgery

      Among the obligations and responsibilities of a surgeon is to practice in a competent manner. From a professional standpoint, competence is widely defined as the ability to practice with reasonable skill and safety, and a surgeon is impaired when she or he is not able to do so. There are a number of potential reasons leading to impairment, which may be temporary or a limitation throughout a surgeon’s professional career. Impairment may range from mild degradation of skills to complete incapacitation. The consequences of surgical practice with impairment are wide ranging and include patient-related harm and failure to provide exemplary care; personal consequences to the surgeon’s health and well-being; interpersonal issues with family, colleagues, and staff; and disciplinary and legal issues. This review covers substance abuse, personality issues (character impairment), medical school, residency, the practicing surgeon, the faculty member, boundary issues, aging, the individual surgeon, the department/hospital, burnout, prevention and recognition, individual/personal, organizational, the unprepared or "out-of-date" surgeon, prevention, and dealing with the unprepared surgeon. The figure shows an algorithm outlining the approach to the impaired surgeon. Tables list signs of substance abuse–related impairment, signs of character impairment, and signs of age-related impairment.

      This review contains 1 highly rendered figure, 3 tables, and 123 references

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  • Administration and Quality
    • 1

      Coding and Billing

      By Samuel A Tisherman, MD, FACS, FCCM; Daniel Herr, MD, FCCM
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      Coding and Billing

      • SAMUEL A TISHERMAN, MD, FACS, FCCM
      • DANIEL HERR, MD, FCCM

      Appropriate documentation and coding are critical for billing in the intensive care unit (ICU). Diagnoses are based on the International Statistical Classification of Diseases and Related Health Problems (e.g., ICD-9 or ICD-10). Procedures are coded based on the Current Procedural Terminology (CPT) system. Evaluation and management (E/M) services make up the vast majority of non–procedure-based care provided by physicians in the ICU environment. Critical care services (codes 99291 and 99292) represent a specific subset of the CPT codes for E/M with different requirements. Three criteria must be met to justify a critical care code. First, the physician must document that the patient is critically ill (i.e., the patient has impairment in one or more vital organ systems with a high probability of imminent or life-threatening deterioration). Second, critical care requires high-complexity medical decision making to support vital organ function and/or prevent further deterioration. Third, critical care codes are time based. The physician must document the time spent in “full attention” to the patient. Critical care can also be provided via telemedicine technologies. Reimbursement for these services requires appropriate credentialing and contracts with the hospital, as well as appropriate documentation. Hospital reimbursement is based on Medical Severity-Diagnosis Related Groups (MS-DRGs), as documented in the medical record. Based on performance, a portion of hospital reimbursement may be withheld if the rates for certain hospital-acquired conditions are too high. Accurate documentation serves to (1) provide good communication between providers, (2) justify billing, and (3) legally document what was done for the patient and why.

      This review contains 4 tables, and 13 references.

      Key words: critical care codes, evaluation and management codes, global surgical package, pay for performance

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  • Cardiovascular
    • 1

      Inotropes and Vasopressors for Shock

      By Amour B U Patel, MBBS, BSc; Gareth L Ackland, PhD, FRCA, FFICM
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      Inotropes and Vasopressors for Shock

      • AMOUR B U PATEL, MBBS, BSCAnaesthetist, Department of Anaesthesia, University College London Hospital, University College London Hospitals NHS Trust, London, UK
      • GARETH L ACKLAND, PHD, FRCA, FFICMConsultant Anaesthetist, William Harvey Research Institute, QMUL Queen Mary, University of London, Department of Anaesthesia, Royal London Hospital, BartsHealth NHS Trust, London, UK

      Inotropes and vasopressors play a key role in the management of shock. The goal of therapy is to restore end-organ perfusion by augmenting cardiac output and vascular tone. Despite their frequent use, randomized controlled trials have failed to identify optimal inotropes and/or vasopressors for shock. The pathophysiology underlying various types of shock and the prognostic importance of various biomarkers are required to refine the use of these agents. In the absence of such evidence, the aims of treatment are exemplified by the PROCESS/ARISE/PROMISE trials in septic shock. Shock is a medical emergency requiring experienced, vigilant practitioners who use fluids in combination with inotropes/vasopressors at the lowest dose to maintain end-organ perfusion without causing adverse effects. The increasing recognition that prolonged treatment with fluid and/or vasoactive drugs promotes deleterious, off-target effects highlights the need to focus on systemic physiology rather than pursuing isolated hemodynamic targets.

      Key words: biomarkers, clinical vigilance, fluid resuscitation, inotropes/vasopressors, systemic physiology

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    • 2

      Cardiac Support Devices

      By Charles C. Hill, MD; Lindsay Raleigh, MD
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      Cardiac Support Devices

      • CHARLES C. HILL, MD
      • LINDSAY RALEIGH, MD

      Mechanical circulatory support (MCS) involves the use of intra-aortic balloon pump (IABP), short-term percutaneous ventricular assist devices, long-term surgically implanted continuous-flow ventricular assist devices (cf-LVADs), and extracorporeal membrane oxygenation (ECMO) for the treatment of acute and chronic heart failure and cardiogenic shock. IABP is increasingly recognized as an important adjunct in the postoperative treatment arsenal for those patients with severely reduced left ventricular systolic function. Short-term percutaneous options for the treatment of acute right and left heart failure include both the Impella and Tandem Heart, whereas the Centrimag is often used in the surgical setting for acute cardiogenic shock and heart failure. Long-term surgical MCS options include the total artificial heart and the cf-LVADs HeartWare and Heartmate II. ECMO is frequently used for the treatment of acute cardiogenic shock and may be placed peripherally via a percutaneous approach or with central cannulation. ECMO is also increasingly used in the setting of acute cardiac life support, known as extracorporeal life support.

      Key words: cardiac critical care, extracorporeal membrane oxygenation, long-term ventricular assist device, mechanical circulatory support, short-term ventricular assist device 

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    • 3

      Diagnosis and Treatment of States of Shock

      By Ahmed Reda Taha, MD, FRCP, FCCP, FCCM
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      Diagnosis and Treatment of States of Shock

      • AHMED REDA TAHA, MD, FRCP, FCCP, FCCMCritical Care Department, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

      Shock remains a diagnosis of significant mortality and morbidity. The current definition defines shock as an acute clinical syndrome that results from inadequate tissue perfusion, which is significantly different from the previous definition of hypotension. Clinical manifestation varies broadly, and is based on the underlying etiology, degree of organ perfusion, and previous organ dysfunction. This review covers the classification, pathogenesis and organ response, evaluation, and management of shock. Figures show the balance between oxygen delivery and oxygen consumption, perfused capillary density, the Krogh Cylinder Model demonstrating the Anoxic-Hypercapnic Lethal Corner, the relation between systolic blood pressure, mean arterial pressure, and diastolic arterial pressure, glycolysis, and the approach to the patient with shock. Tables list clinical and metabolic markers of perfusion alteration to the organs, hemodynamic parameters in different types of shock, normal hemodynamic parameters, problems associated with the use of pulmonary artery catheter, clinical presentation of hypovolemic shock according to severity, causes of cardiogenic shock and cardiogenic pulmonary edema, and receptor activity of different vaspressors and clinical indication.

      This review contains 6 figures, 7 tables, and 55 references.

      Key Words: Shock; Hypovolemic shock; Cardiogenic shock; Neurogenic shock; Vasogenic shock; Septic shock; Obstructive shock

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    • 4

      Diagnosis and Acute Management of Cardiac Tamponade

      By Kristi A Lorenzen, MD; Daniel W Johnson, MD
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      Diagnosis and Acute Management of Cardiac Tamponade

      • KRISTI A LORENZEN, MDResident Physician, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, [email protected]
      • DANIEL W JOHNSON, MD Division Chief and Fellowship Director, Critical Care, Medical Director, Cardiovascular ICU,Assistant Professor, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE, [email protected]

      Cardiac tamponade is a medical and surgical emergency that requires quick recognition and treatment by the critical care provider. Tamponade results from accumulation of fluid in the pericardial space leading to equalization of pressures between the pericardial space, atria, and ventricles. This alteration in physiology causes hemodynamic changes that can range from tachycardia and hypotension to cardiovascular collapse. Diagnosis relies on a high index of suspicion and accurate interpretation and use of multiple diagnostic modalities. One of the most important tools, echocardiography, plays a vital role in the diagnosis, monitoring, and treatment of tamponade. Treatment depends on the hemodynamic stability of the patient and may include advanced cardiac life support, emergent pericardiocentesis, emergent sternotomy, or medical management. This review discusses the acute diagnosis and management of cardiac tamponade specifically related to surgical patients cared for by the critical care provider.

      This review contains 2 figures, 2 tables, 5 videos, and 55 references.

      Key words: atrial and ventricular collapse, cardiac tamponade, cardiogenic shock, critical care echocardiography, equalization of pressures, hemopericardium, pericardial effusion, pericardiocentesis, pulsus paradoxus, ventricular interdependence

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    • 5

      Interpretation of Noninvasive and Invasive Information

      By Erik P Anderson, MD; Mark P Hamlin, MD, MS, FCCM; Borzoo Farhang, DO, MS
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      Interpretation of Noninvasive and Invasive Information

      • ERIK P ANDERSON, MD
      • MARK P HAMLIN, MD, MS, FCCM
      • BORZOO FARHANG, DO, MS

      Traditional, static measures of resuscitation, such as vital signs, central venous pressure, and pulmonary arterial pressure, provide momentary glimpses evolving hemodynamic states. In patients with shock, these measures of resuscitation are poor indicators of response to therapy.As a result, dynamic assessments of cardiovascular status are now used in critically ill patients to facilitate resuscitation. Some of these approaches focus on fluid responsiveness. These assessments allow care to be tailored to each patient’s response to interventions. An evolving aspect of hemodynamic monitoring is evaluation of the adequacy of tissue perfusion and oxygen delivery. In this review, we consider the use of arterial, central venous, and pulmonary arterial blood pressure monitoring; echocardiography; transesophageal Doppler technology; pulse contour analysis; bioimpedance and bioreactance; and partial rebreathing monitoring modalities to assess hemodynamic status in critically ill patients. 

      This review contains 22 figures, 5 tables, and 38 references.

      Key words: echocardiography, esophageal Doppler technology, invasive and noninvasive hemodynamic monitoring, pulse contour analysis, shock 

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    • 6

      Ventilator Weaning

      By Brian Brajcich, MD; Ann Hwalek, DO; Joseph Posluszny, MD
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      Ventilator Weaning

      • BRIAN BRAJCICH, MDGeneral Surgery Resident, Northwestern University
      • ANN HWALEK, DOGeneral Surgery Resident, Loyola University, Stritch School of Medicine,
      • JOSEPH POSLUSZNY, MDAssistant Professor of Surgery, Northwestern University

      Ventilator weaning/liberation is a complex process that requires focus on a patient’s respiratory mechanics, strength, awareness, airway patency, and secretions while also keeping in mind a patient’s overall clinical status and critical illness. The recommendations in the chapter are based on evidence-based medicine when available. When no clear data can definitively guide patient management, clinical guidelines and accepted practices are described.  Our hope is that the reader finds this chapter as a reliable and safe way to approach ventilator liberation.

      This review contains 4 figures, 6 tables and 77 references

      Key Words: ABCDE bundle, diaphragm dysfunction, negative inspiratory force, reintubation, RSBI, sedation, spontaneous breathing trial, tracheostomy, ventilator liberation, ventilator weaning

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    • 7

      Extracorporeal Membrane Oxygenation

      By Julian Villar, MD, MPH; Stephen Ruoss, MD; Richard HA , MD; Joe Hsu, MD, MPH
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      Extracorporeal Membrane Oxygenation

      • JULIAN VILLAR, MD, MPHClinical Fellow, Critical Care Medicine, Department of Medicine, Stanford University Medical School
      • STEPHEN RUOSS, MDProfessor, Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University Medical School
      • RICHARD HA , MDAssociate Physician, Cardiothoracic Surgery Surgical Directory of Mechanical Circulatory Support, Department of Cardiothoracic Surgery, The Permanente Medical Group,
      • JOE HSU, MD, MPHAssistant Professor, Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University Medical School

      Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is the practice of using circulatory assist devices and a gas exchange system to maintain sufficient tissue oxygen delivery, supplementing pulmonary and/or cardiac function in patients whose native physiology is too severely altered to be successfully supported solely by conventional life support techniques (eg, mechanical ventilation and inotropic and vasopressor drugs). ECMO should be considered in patients who are at a high risk of death due to a potentially reversible etiology of cardiopulmonary collapse. Indications for ECMO can be broadly divided into profound respiratory failure and/or cardiogenic shock. The indications include acute respiratory distress syndrome, heart failure, postoperative cardiogenic shock, and as an adjunct to cardiopulmonary resuscitation in patients with cardiac arrest. ECMO is currently experiencing a renaissance, and familiarity with its concepts is important for all critical care practitioners.

      This review contains 8 figures, 8 tables and 34 references

      Key Words: complications, equipment, indications, management basics, outcomes

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    • 8

      Cardiac Arrhythmias, Acute Coronary Syndromes, and Heart Failure in the Surgical Patient

      By Glen Franklin, MD; Amirreza Motameni, MD; Johnson Walker, MD
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      Cardiac Arrhythmias, Acute Coronary Syndromes, and Heart Failure in the Surgical Patient

      • GLEN FRANKLIN, MDProfessor of Surgery, Program Director, Surgical Critical Care Fellowship, University of Louisville Department of Surgery, Louisville, KY, United States,
      • AMIRREZA MOTAMENI, MDFellow, Surgical Critical Care, University of Louisville Department of Surgery, Louisville, KY, United States
      • JOHNSON WALKER, MDFellow, Surgical Critical Care, University of Louisville Department of Surgery, Louisville, KY, United States

      Cardiac arrhythmias and events, such as acute coronary syndrome and acute decompensated heart failure, are becoming increasingly common with an aging population. Much is written regarding the evaluation and management of these conditions in the cardiac and vascular patient populations; however, there is less literature to discuss the management strategies in the critically ill noncardiac postoperative and polytrauma patients. Factors such as physiologic stress, electrolyte imbalances, neurologic derangement, infection, and massive fluid shifts create an environment that promotes cardiopulmonary instability. Appropriate recognition of cardiac arrhythmias, acute coronary syndromes, and heart failure coupled with accurate and timely intervention can reduce morbidity and mortality in these patients. This review discusses the assessment and management of cardiac tachy- and brady-arrhythmias, acute coronary syndromes, and acute decompensated heart failure in the surgical patient.

      This review contains 4 figures, 5 tables and 45 references

      Key Words: acute coronary syndrome, angina, arrhythmia, bradycardia, cardiac ischemia, dieresis, fluid overload, heart failure, infarction, tachycardia

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    • 9

      Trauma to the Thoracic Aorta

      By Thurston M. Bauer, MD; Mark A. Farber, MD
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      Trauma to the Thoracic Aorta

      • THURSTON M. BAUER, MDResident, Cardiothoracic Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
      • MARK A. FARBER, MDProfessor of Surgery and Radiology, Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC

      Blunt thoracic aortic injury (BTAI) is predominantly a phenomenon of the 20th century secondary to high-energy deceleration injuries. Prior to the widespread adoption of automobiles, midway through the 20th century, 85% of injuries to the aorta were attributed to penetrating trauma, with 57% caused by gunshots and 25% by stab wounds.1–4 However, BTAI has become more prevalent, with an estimated incidence of 7,500 to 8,000 cases per year in the United States. BTAI is the second most common cause of trauma-related death after head injury and accounts for 15% of all motor vehicle collision (MVC)-related deaths.5 The incidence of thoracic aortic injury among MVC victims is 1.5%.6 Prehospital mortality is 85% secondary to complete aortic transection.7 Approximately 8% of patients survive more than 4 hours, and most of those who survive to reach the hospital have small or partial-thickness tears with pseudoaneurysm formation. Up to 50% of patients who reach the hospital die prior to definitive surgery.8,9 Therefore, expeditious collaborative evaluation by trauma and aortic surgeons at a level I trauma center is necessary to provide appropriate care to these patients who may have multiple life-threatening injuries.

      This review contains 13 figures, 8 tables, 1 video and 56 references.

      Keywords: Blunt Aortic Traumatic Injury, Thoracic Transection, Aortic Transection, Aortic Injury, Blunt Traumatic Aortic Injury, Blunt Thoracic Aortic Injury, Aortic Tear, Aortic pseudoaneurysm, TEVAR for BTAI, Endovascular repair (TEVAR) of BTAI, Endovascular repair (TEVAR) for transection

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  • Endocrine/metabolic
    • 1

      Acid-base Disorders

      By James Orr, MD, FACS; Suresh Agarwal, MD, FACS, FCCM; Ann P. O'Rourke, MD, MPH
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      Acid-base Disorders

      • JAMES ORR, MD, FACSAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI
      • ANN P. O'ROURKE, MD, MPHAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Anticipation and early identification of conditions that alter the body's ability to compensate for acid-base disorders are vital in managing surgical patients. This review describes the general principles and classification of acid-base disorders. Metabolic acid-base disorders are presented, including metabolic acidosis and alkalosis. Respiratory acid-base disorders are also presented, including respiratory acidosis and alkalosis. Tables show the differentiation of acid-base disorders, causes of positive–anion gap acidosis, the differential diagnosis for normal–anion gap metabolic acidosis, the mechanisms associated with increased serum lactate concentration, and the differential diagnosis for metabolic alkalosis.

      This review contains 7 highly rendered figures, 5 tables, and 135 references.

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    • 2

      Disorders of Water and Sodium Balance

      By Micah Katz; Herbert Chen, MD, FACS
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      Disorders of Water and Sodium Balance

      • MICAH KATZUniversity of Wisconsin School of Medicine and Public Health, Madison, WI
      • HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI

      Water is vital to life. Cells, the blood bringing nutrients and oxygen to them, and the interstitial fluid bathing them are all mostly water. Each day, water and salt are lost and replaced. To maintain stability of the internal milieu, body fluids are processed by the kidney, guided by intricate physiologic control systems that regulate fluid volume and composition. When regulatory pathways are disrupted or overwhelmed by medical interventions, irreversible deficits may be caused. Factors affecting the fluid homeostasis include osmolality, fluid movement between compartments, renal processing, and cell volume regulation in hypotonicity and hypertonicity. This review presents the diagnosis and management of disorders of water excess (hyponatremia), water deficiency (hypernatremia), saltwater excess (edematous states), and saltwater deficiency (volume depletion). Tables present the causes of acute hyponatremia (water intoxication), the syndrome of inappropriate antidiuretic hormone (SIADH), and hypernatremia. Figures depict the mechanisms of sodium resorption, the normal relation between plasma vasopressin levels/urine osmolality and sodium concentration, and dose-response curves for a loop diuretic in patients with normal and reduced renal function.

      This review contains 5 figures, 7 tables, and 66 references.

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    • 3

      Glucose Control

      By Timothy P. Graham, MD; Erich N. Marks, MD; Joshua J. Sebranek, MD; Douglas B. Coursin, MD
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      Glucose Control

      • TIMOTHY P. GRAHAM, MDIntensivist, Aurora Critical Care Service, Aurora St. Luke’s Medical Center, Milwaukee, WI
      • ERICH N. MARKS, MDStaff Anesthesiologist, Colorado Permanente Medical Group, Denver, CO
      • JOSHUA J. SEBRANEK, MDAssociate Professor of Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • DOUGLAS B. COURSIN, MDProfessor of Anesthesiology and Medicine, Departments of Anesthesiology and Internal Medi¬cine, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Patients with diabetes mellitus routinely require management in the adult intensive care unit (ICU). These patients have increased morbidity, mortality, hospital length of stay, cost of care, and frequency of hospital and ICU admission. Glucose control in these patients presents challenges for the clinician. In the critically ill, hyperglycemia does not occur exclusively in patients with diabetes or prediabetes but may be related to stress-induced hyperglycemia or iatrogenic causes. Hyperglycemia can contribute to decreased wound healing and immune function and a host of cellular and molecular dysfunctions and has been linked to increased hospital mortality. Hypoglycemia in the ICU is associated with patients with preexisting diabetes, those receiving insulin and other medications, and septic individuals, among others. Insulin therapy is the mainstay of glucose management in the critically ill. ICU practitioners should be aware that point-of-care glucose meters are not as accurate as core laboratory results. Finally, both hypoglycemia and wide fluctuations in blood glucose during critical illness are also associated with increased mortality, although clear cause-and-effect relationships have not been established.

      Key words: diabetes mellitus, glucose measurement, glucose targets, hyperglycemia, hypoglycemia, insulin

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    • 4

      Steroid Replacement in Critical Care

      By Djillali Annane, MD, PhD; Nicholas Heming, MD, PhD
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      Steroid Replacement in Critical Care

      • DJILLALI ANNANE, MD, PHDProfessor of medicine at University of Versailles SQY, Versailles, France, director of the General ICU at Raymond Poincaré Hospital, and director of Team 1 of the Laboratory Inflammation and Infection, U1173, INSERM, Garches, France
      • NICHOLAS HEMING, MD, PHDAssociate professor at the General ICU at Raymond Poincaré Hospital, Garches, France.

      Corticosteroids, mainly produced by the adrenal glands, regulate the response to acute and chronic stress. Acute inflammation associated with critical illness may counteract the hypothalamic-pituitary-adrenal response, resulting in a condition called critical illness–related corticosteroid insufficiency. This condition may benefit from corticosteroid replacement. As it translates into a broad variety of clinical and biological syndromes, although there is still no gold standard, critical illness–related corticosteroid insufficiency may be best recognized by a blunted cortisol response to 250 µg of corticotropin given as an intravenous bolus. Corticosteroid replacement should rely on prolonged treatment with low to moderate doses. In practice, the type and duration of corticosteroid dose may vary with the cause of critical illness (e.g., sepsis, acute respiratory distress syndrome, trauma). Finally, optimal corticosteroid replacement should also include minimization of the risk of serious adverse events mainly by careful prevention of superinfection and avoidance of drugs that may potentiate corticosteroids’ deleterious effects on body metabolism or the nervous system.

      Key words: Adrenals – hypothalamic pituitary adrenal axis – sepsis – inflammation – cytokines – hydrocortisone

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    • 5

      Critical Care Implications of Adrenal Disease States

      By Shaun Thompson, MD; Erin Etoll, MD
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      Critical Care Implications of Adrenal Disease States

      • SHAUN THOMPSON, MDCritical Care Anesthesiology fellow, Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
      • ERIN ETOLL, MDAssistant Professor, Division of Critical Care, Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE

      Adrenal disease in the critically ill patient can present many challenges for the intensivist. Besides primary, secondary, and tertiary adrenal insufficiency, a state known as critical care–related corticosteroid insufficiency (CIRCI) has been described. Adrenal insufficiency can pose many issues to the critically ill patient as it can decrease the patient’s ability to respond to the stress that critical illness presents to the human body. Proper recognition and diagnosis of adrenal insufficiency in the critically ill patient can be extremely important in the treatment of these patients and could be a lifesaving intervention if CIRCI is discovered. A less commonly encountered issue of adrenal disease lies in the area of adrenal hormone excess caused by a pheochromocytoma or extra-adrenal paragangliomas. These tumors can release large amounts of endogenous catecholamines that cause significant patient morbidity and mortality if not recognized early and treated appropriately. Although adrenal insufficiency and adrenal excess are less commonly encountered problems in critically ill patients, the recognition and treatment of these disease states can prevent the morbidity and mortality of critically ill patients that suffer from these disease states.

      Key words: adrenal insufficiency, hypothalamic-pituitary axis, critical illness–related corticosteroid insufficiency, pheochromocytoma, steroid replacement therapy

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    • 6

      The Role of Hemoglobin A1c in Operative Patients

      By Gurwinder Gill, MD; Vivek K Moitra, MD
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      The Role of Hemoglobin A1c in Operative Patients

      • GURWINDER GILL, MDAssistant Professor, Department of Anesthesiology and Critical Care Medicine, George Washington Uni¬versity, Washington, DC
      • VIVEK K MOITRA, MDAssociate Professor, Department of Anesthesiology, College of Physicians & Surgeons, Columbia Univer¬sity, New York, NY

      Patients with diabetes mellitus have abnormal carbohydrate metabolism and systemic complications. Up to 10% of patients who undergo surgery present with occult diabetes mellitus. With poor glucose control, serum and tissue proteins are glycosylated to produce advanced glycosylated end products (AGEs) that contribute to the development of rapidly progressive atherosclerosis and plaque progression. AGEs block nitric oxide activity and have been implicated in the vascular complications of diabetes. The glycosylated fraction of hemoglobin (HbA1c) is formed from the nonenzymatic glycation of hemoglobin residues and reflects long-term (3 months) glucose control and may be a useful screening tool to identify patients with undiagnosed diabetes. An elevated HbA1c is associated with an increased risk of postoperative infectious complications and risk of acute kidney injury, cerebrovascular accidents, and myocardial infarction during the perioperative period.

      This review contains 1 figure, 2 tables, and 42 references.

      Key words: HbA1c, perioperative hyperglycemia, glycosylated hemoglobin, surgical infection, Diabetes Mellitus, perioperative complications

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    • 7

      Critical Care Implications of Thyroid Disease States

      By James Sullivan, MD; Daniel Kalin, MD
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      Critical Care Implications of Thyroid Disease States

      • JAMES SULLIVAN, MD
      • DANIEL KALIN, MD

      Thyroid dysfunction in the critically ill has many causes. In this review, primary and acquired thyroid disease states are discussed. The anatomy, physiology, and pathophysiology of thyroid disorders are addressed, as well as surgical and medical treatment options. Nonthyroidal illness syndrome (sick euthyroid) is also considered.

      This review contains 3 figures, 7 tables, and 31 references.

      Key words: agranulocytosis, brain death, hyperthyroidism, hypothyroidism, sick euthyroid

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    • 8

      Postoperative Complications of Thyroid and Parathyroid Disease

      By David F Schneider, MD, MS; Joseph R Imbus, MD
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      Postoperative Complications of Thyroid and Parathyroid Disease

      • DAVID F SCHNEIDER, MD, MS
      • JOSEPH R IMBUS, MD

      Although thyroid and parathyroid surgery is considered very safe, with rare morbidity and mortality, serious complications can occur. These include bilateral recurrent laryngeal nerve injury, life-threatening hematoma, and severe hypoparathyroidism. Although infrequent, these complications require timely identification and intensive care. Critical care physicians should understand the clinical presentations and management of affected patients. This review provides a critical care–focused review of endocrine surgery complications, including relevant background information, definitions, risk factors, identification, and management. Special clinical situations and treatment considerations are included. Figures show the vocal fold anatomy in recurrent laryngeal nerve paralysis, the regulation of calcium homeostasis, and electrocardiogram changes seen in the setting of severe hypocalcemia.

      This review contains 3 figures, and 58 references.

      Key words: hypocalcemia, hypoparathyroidism, neck hematoma, parathyroid, recurrent laryngeal nerve injury, thyroid

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  • Palliative Care/ethics
    • 1

      End of Life Care and Withdrawal of Life Support

      By Craig Chen, MD
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      End of Life Care and Withdrawal of Life Support

      • CRAIG CHEN, MDClinical Anesthesiologist and Critical Care Intensivist, Private Practice, Mountain View, CA, Clinical Ethics Committee, Stanford Health Care, Stanford, CA

      Despite advances in critical care medicine and resuscitation, many patients who are admitted to the intensive care unit (ICU) will ultimately die. Even those who survive the ICU are at risk for readmission. Although outcomes may be better for surgical rather than medical ICU patients, addressing the end of life is a fundamental and necessary aspect of critical care for all patients. Over the last few years, we have increasingly recognized the role of palliative care in the surgical and trauma ICU. Palliative medicine in the surgical ICU setting results in decreased length of stay, improved communication with family and patients, and earlier identification of goals of care. This review covers indications for palliative care consultation, approaching the end of life, withdrawal of artificial nutrition and hydration, withdrawal of mechanical ventilation, practical considerations at the end of life, symptoms and symptom management at the end of life, and time of death. Tables list the American College of Surgeons statement on the principles guiding care at the end of life, guidelines for palliative care consultation in the surgical ICU, ABCDs of dignity-conserving care, palliative care principles on transitioning a patient to comfort measures only, and process of withdrawing ventilatory support.

      Key words: comfort measures; end of life; intensive care unit end-of-life care; palliation; palliative care; palliative care consultation; palliative medicine; quality of dying; withdrawal of life support

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    • 2

      Brain Death

      By Anupamaa Seshadri, MD; Ali Salim, MD, FACS
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      Brain Death

      • ANUPAMAA SESHADRI, MD
      • ALI SALIM, MD, FACS

      The concept of “brain death” is one that has been controversial over time, requiring the development of clear guidelines to diagnose and give prognoses for patients after devastating neurologic injury. This review discusses the history of the definition of brain death, as well as the most recent guidelines and practice parameters on the determination of brain death in both the adult and pediatric populations. We provide specific and detailed instructions on the various clinical tests required, including the brain death neurologic examination and the apnea test, and discuss pitfalls in the diagnosis of brain death. This review also considers the most recent literature and guidelines as to the role of confirmatory tests making this diagnosis. 

      Key Words: apnea test, brain death, brainstem reflex, death examination

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    • 3

      Disclosure of Error in the Intensive Care Unit

      By Leslie Hale, MD; Katrina Kirksey Harper, MD; Anna Bovill Shapiro, MD
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      Disclosure of Error in the Intensive Care Unit

      • LESLIE HALE, MDClinical Instructor in the Department of Anesthesiology, Weill Cornell Medical College, New York, NY.
      • KATRINA KIRKSEY HARPER, MDAssistant Clinical professor, emergency medicine and critical care medicine, in the Departments of Emergency Medicine and Pulmonary Critical Care Medicine, NYU Langone and NYU Lutheran Medical Centers, Brooklyn, NY.
      • ANNA BOVILL SHAPIRO, MDAnesthesiologist and Intensivist at Guam Regional Medical City, Guam.

      Each year, as many as 98,000 hospital deaths in the United States can be attributed to medical error. Considering that at least half of all medical errors go unreported, the impact they have on mortality, morbidity, prolonged hospital stay, rising hospital costs, and the doctor-patient relationship cannot be overemphasized. At the heart of the dilemma are patients and their family members, who rely on clinicians to provide optimal medical care, devoid of mistakes and error, and want an apology if an error has taken place. In this review, we discuss the moral obligation of hospitals to disclose medical error, no matter what the impact. Whereas in the past, a paternalistic approach to medicine viewed this acknowledgment as weakness, there is now a consensus to advocate for full disclosure, apology, and discussions that facilitate early disclosure of error using teams representing administration, patient care liaisons, and treatment providers. Many institutions now recognize that medical errors are commonly the result of a breakdown of checks and balances, and an increasing number are implementing protocols that target system errors to prevent similar future occurrences. We examine institutions across the United Statesthat take a proactive approach by assembling “communication and resolution” programs to address the concerns of patients and their families through the process of disclosure. We also explore barriers to disclosure, which are attributed to lack of training, fear of litigation, and the “shame and blame culture.” We discuss the benefit, to both patient and provider, of disclosure of accountability as we move toward a culture of strengthening systems and improving patient care and patient-provider relationships.

      Key words: apology, culture, disclosure, error, resolution

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    • 4

      Pain in the Intensive Care Setting

      By Beverly Chang, MD
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      Pain in the Intensive Care Setting

      • BEVERLY CHANG, MDAssistant Professor, Department of Anesthesiology, Perioperative and Pain Medicine, New York University Langone Medical Center, New York, NY

      Pain occurs frequently in the intensive care setting even among nonprocedural patients. Pain in the critical care setting creates significant downstream burdens in the recovery and psychological health of patients. Moderate to severe pain is reported in a significant number of intensive care unit (ICU) patients without significant differences in pain scores between trauma/surgical patients and medical ICU patients. However comparatively, medical ICU patients were found to experience higher pain intensity. Many of these patients reported a lack of pain relief from their analgesics, and 90% described experiencing the highest levels of distress due to difficulty in communicating their pain. This review covers the physiology of pain, physiologic effects of pain, challenges of pain management in the ICU, preemptive analgesia, multimodal analgesia, and treatment of pain. Figures show classification of chronic pain syndromes, the major neural pathways involved in nociception, pain transmission pathway and treatment interventions, and the analgesic pain ladder. Tables list incidence of chronic postoperative pain, risk factors for developing persistent postoperative pain, basic principles of the World Health Organization pain ladder, side effects of opioids, opioid medications, effects of ketamine, comparison of ester and amide local anesthetics, and characteristics of commonly used local anesthetics.

      This review contains 4 figures, 8 tables, and 60 references.

      Key words: Pain in the ICU; Pain management; Postoperative pain; Preemptive analgesia; Analgesic pain ladder

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    • 5

      Brain Death and Resuscitation of the Organ Donor

      By Kasra Khatibi, MD; Chitra Venkatasubramanian, MBBS, MD, MSc,
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      Brain Death and Resuscitation of the Organ Donor

      • KASRA KHATIBI, MDFellow, Neurocritical care, Department of Neurology, UCLA, CA.
      • CHITRA VENKATASUBRAMANIAN, MBBS, MD, MSC, Clinical Associate Professor, Department of Neurology and (by courtesy) Neurological Surgery, Stanford University, Stanford, CA

      When is a patient brain dead? Under what scenarios in the surgical intensive care unit is brain death a possibility? Who can declare brain death and how? What are the steps after brain death declaration? You will find answers to all of these and more in this review. We will walk you through the principles, prerequisites, and techniques of clinical brain death evaluation using checklists and videos. The role and interpretation of ancillary testing and pitfalls are also discussed. New in this section is a description of the techniques that can be adapted when a patient is on extracorporeal membrane oxygenation. In addition, we have included a section on how to communicate effectively (i.e., what phrases to use) with families while discussing brain death and thereby avoid conflicts. We conclude with a detailed section on the physiology and critical care of the potential organ donor after brain death.

      This review contains 2 videos, 8 figures, 3 tables and 21 references

      Key words: Brain death, Apnea testing, ECMO, Organ donation

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    • 6

      Medical Futility

      By Jacob A Blythe, MA, MD; Stephanie Harman, MD
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      Medical Futility

      • JACOB A BLYTHE, MA, MDCandidate, Stanford University School of Medicine, Stanford, CA
      • STEPHANIE HARMAN, MDClinical Associate Professor, Department of Medicine, Stanford University School of Medicine, Stanford, CA

      Since its infancy in the 1980s, the concept of medical futility has represented the challenge between increasing technological advancements in medicine and how to approach their limits. Given the nature of the debate, this is likely to continue to be the case; however, in recent years, the concept of medical futility has softened as many have realized that determinations of futile care do not fall solely under the purview of medical experts. Although some jurisdictions continue to enshrine the concept of futility, many professional societies and states have begun to transition away from strong invocations of medical futility toward more robust methods of shared decision making and more equitable procedures for resolving intractable disputes. This review attempts to trace the history of medical futility from its rise in the 1980s to its fall over the past few years, to grasp medical futility as a conceptual model, and, finally, to provide a template for invoking futility in an age when most admit that patient desires are integral to understanding both the goals of care and potentially inappropriate treatments.

      This review contains 3 figures and 30 references

      Key words: end-of-life care, futile care, ineffective care, medical futility, potentially inappropriate care

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    • 7

      Communication of Bad News

      By Paul K Mohabir, MD; Preethi Balakrishnan, MD
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      Communication of Bad News

      • PAUL K MOHABIR, MDClinical Professor, Pulmonary and Critical Care Medicine
      • PREETHI BALAKRISHNAN, MDCritical Care Medicine Fellow, Stanford Hospital, Stanford, CA

      Delivering bad news is a critical part of the patient-physician relationship. Historically, physicians have withheld or incompletely related the diagnosis and prognosis of a patient’s disease. However, the trajectory of medical practice and patient expectations mandates a change in communicating bad news. Poor communication of bad news also affects physician job satisfaction and increases burnout. Empathy is crucial to communicating bad news well. It is a very complex emotion that requires the physician to identify the patient’s reaction to the news being delivered and to react to the patient in a supportive manner. Patients do not find it helpful when the physician underplays the bad part of the news. Emerging research shows that patients prefer pairing of bad news with hope to provide anchors in the overwhelming conversation but not to take away from the gravity of the news. Family and friends can help ameliorate or, unfortunately, augment patient anxiety. Physicians have to be cognizant of the dynamics family and friends bring to the interaction as well. A patient-centered approach—a combination of evidence-based medicine and patient goal-oriented medicine—to delivering bad news is most likely to benefit the patient-physician relationship and decision-making process. The SPIKES and the Expanded Four Habits Model can be used as guidelines for communicating bad news.

      This review contains 1 figure and 38 references.

      Key words: communicating bad news, empathy, Expanded Four Habits Model, patient-centered care, SPIKES

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  • Acute Renal Events
    • 1

      Rhabdomyolysis

      By Anthony Baldea, MD
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      Rhabdomyolysis

      • ANTHONY BALDEA, MD

      Rhabdomyolysis is a condition that results from the breakdown of skeletal muscle. The etiologies can be broken down into three main categories of causes: traumatic, atraumatic exertional, and atraumatic nonexertional. Patients with rhabdomyolysis often present with myalgia and are found to have myoglobinuria with elevations in serum creatine kinase levels. The mainstay in therapy is focused on restoration of intravascular volume with large-volume fluid resuscitation using isotonic fluids. Adequate hydration is necessary to prevent the potential complications of rhabdomyolysis, including the development of acute kidney injury. Practitioners should maintain a high level of suspicion of compartment syndrome in patients with rhabdomyolysis. If extremity compartment syndrome is diagnosed, prompt decompressive fasciotomies should be performed to preserve muscle and nerve viability. The early use of renal replacement therapy in patients with rhabdomyolysis has been described in the literature and may represent another modality of therapy to prevent the adverse sequelae of rhabdomyolysis.

      Key words: acute kidney injury, compartment syndrome, creatine kinase, disseminated intravascular coagulation, rhabdomyolysis

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    • 2

      Renal Support Therapy

      By Samuel M Galvagno Jr, DO, PhD, FCCM; Anthony E Tannous, MD
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      Renal Support Therapy

      • SAMUEL M GALVAGNO JR, DO, PHD, FCCMAssociate Professor, Department of Anesthesiology and Chief, Division of Critical Care Medicine, Associate Medical Director, Surgical Intensive Care Unit, University of Maryland School of Medicine, Baltimore, MD
      • ANTHONY E TANNOUS, MDSurgical Critical Care Fellow, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD

      Knowledge regarding the practical aspects of managing continuous renal replacement therapy (CRRT) in the surgical intensive care unit is a prerequisite for achieving desired physiologic end points. Familiarity with the initiation, dosing, adjustment, and termination of CRRT is a core skill for surgical intensivists. Modalities, terminology, and components of CRRT are discussed in this review, with an emphasis on the practical aspects of dosing, adjustments, and termination. Filter selection and management of electrolyte and acid-base derangements are emphasized.

      Key words: continuous renal replacement therapy, continuous venovenous hemofiltration, continuous venovenous hemofiltration dialysis, dialysis, intensive care unit

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    • 3

      Acid-base Balance and Electrolyte Management

      By Jennifer Leonard, MD, PhD; Lewis J Kaplan, MD, FACS, FCCM, FCCP
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      Acid-base Balance and Electrolyte Management

      • JENNIFER LEONARD, MD, PHD
      • LEWIS J KAPLAN, MD, FACS, FCCM, FCCPProfessor of Surgery, Department of Surgery, Division of Trauma, Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, 1MOB, Suite 120, Philadelphia, PA 19104, United States, Section Chief, Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA 19104

      Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy.

      This review contains 12 figures, 2 tables, and 34 references.

      Key words: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

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    • 4

      Acute Kidney Injury in Critically Ill Patients

      By Monica G Valero, MD; Zara Cooper, MD, MSc, FACS
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      Acute Kidney Injury in Critically Ill Patients

      • MONICA G VALERO, MD
      • ZARA COOPER, MD, MSC, FACS

      Acute kidney injury is a common disease that affects critically ill patients and increases morbidity and mortality. Even though there have been extensive efforts to prevent this disease, the incidence has steadily increased over the last decade. This could be attributed to better recognition or to overestimation of the disease based on the most recent consensus criteria. Complications of acute kidney injury have a significant effect on quality of life, morbidity, and mortality. Despite advances in the field, this disease continues to be a challenge, and decreasing the mortality associated with it remains difficult. Plenty of literature has been published about the appropriate definition, diagnosis, and treatment of the disease. One of the topics of ongoing discussion deals with the lack of consensus about the exact timing for initiation of renal replacement therapy (RRT). Even though RRT adds more complexity to the treatment, recent publications suggest that early versus late initiation of RRT is related to reduced mortality in critically ill patients. Further high-level studies of this intervention are warranted to standardize treatment.

      This review contains 5 figures, 7 tables, and 77 references.              

      Key words:Acute Kidney Injury Network (AKIN), acute kidney injury, chronic kidney disease, Kidney Disease: Improving Global Outcomes (KDIGO), renal biomarkers, replacement therapy, Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE)

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  • Gastrointestinal
    • 1

      Pancreatitis

      By Lisa M. Kodadek, MD; Pamela A. Lipsett, MD, MHPE, MCCM
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      Pancreatitis

      • LISA M. KODADEK, MDFellow, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
      • PAMELA A. LIPSETT, MD, MHPE, MCCMWarfield M. Firor Endowed Professorship in Surgery, Professor, Departments of Surgery and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD

      Pancreatitis is a complex spectrum of disease including chronic pancreatitis, acute pancreatitis, and manifestations of severe acute pancreatitis such as sterile and infected necrotizing pancreatitis. Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. Pancreatitis is a dynamic condition, and severity may change and evolve during the course of the disease. Although most patients with acute pancreatitis have mild disease, 10 to 15% will run a fulminant course, leading to severe acute pancreatitis, pancreatic necrosis, and multisystem organ injury. The mortality for severe acute pancreatitis is 15 to 30%; however, the overall mortality for all patients with acute pancreatitis is less than 5%. Early management of acute pancreatitis includes fluid resuscitation, pain control, and enteral nutrition. There are no specific directed therapies proven to be effective for the early treatment of acute necrotizing pancreatitis; therapy is entirely supportive. Chronic pancreatitis is a challenging disease often marked by chronic pain. Surgical intervention may help improve quality of life and relieve pain in selected patients. International consensus guidelines provide definitions and classifications to aid clinicians with diagnosis and management of pancreatitis. This review covers advances related to pancreatitis, including literature pertaining to the step-up approach for necrotizing pancreatitis first published in 2010, discussion of the revised Atlanta Classification System for severity of acute pancreatitis published in 2013, review of the current spectrum of microbial pathogens implicated in infected necrotizing pancreatitis, and the international draft consensus proposal for a new mechanistic definition for chronic pancreatitis published in 2016.

      Key words: acute pancreatitis, antibiotic prophylaxis, Atlanta Classification System, biliary pancreatitis, chronic pancreatitis, necrosectomy, pancreatic necrosis, pancreatitis, step-up approach, video-assisted retroperitoneal drainage (VARD)

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    • 2

      Acute Liver Failure

      By Jeffrey DellaVolpe, MD, MPH; Ali Al Khafaji, MD, MPH
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      Acute Liver Failure

      • JEFFREY DELLAVOLPE, MD, MPH
      • ALI AL KHAFAJI, MD, MPH

      Acute liver failure (ALF) can be challenging to manage due to the effect of liver failure on other organs and the severity of illness that ensues. Both the practicing surgeon and the intensivist should be aware of the manifestations, workup, and management implications as ALF is not uncommon to many intensive care settings. ALF precipitates a severe multiorgan dysfunction syndrome in a majority of cases, with high rates of complications and an elevated risk of death. Management requires a systemic approach in addition to the collaboration of a multidisciplinary team with an emphasis on early recognition, prompt management of complications, and timely transfer to a transplant center. In the absence of spontaneous recovery, transplantation is the only definitive management option and may not always be feasible or immediately available. The continuing search to develop alternatives is essential.

      Key words: acetaminophen, acute liver failure, cerebral edema, coagulopathy, hepatitis, jaundice, N-acetylcysteine, transplantation

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    • 3

      Ileus and Obstruction in the Surgical Critical Care Patient

      By Eric Benoit, MD; Charles A Adams Jr, MD
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      Ileus and Obstruction in the Surgical Critical Care Patient

      • ERIC BENOIT, MD
      • CHARLES A ADAMS JR, MD

      Gastrointestinal dysfunction is a common occurrence in the critically ill surgical patient as both a contributor to disease progression and a consequence of critical illness. Failure of motility may ultimately progress to obstruction, either functional (e.g., paralytic ileus) or mechanical (e.g., small bowel obstruction). Obstruction leads to bowel distention, fluid sequestration in the lumen and wall of the bowel, alterations in mucosal integrity, and bacterial overgrowth, which results in not only local bowel ischemia but also distant organ damage due to the release of inflammatory cytokines. Although postoperative ileus is a common condition, in the critically ill patient, it may signify a serious complication such as anastomotic leak or sepsis; therefore, management is directed toward identification and treatment of the underlying cause. Regarding small bowel obstruction (SBO), management hinges on whether or not the bowel is strangulated, and the need for operation should be addressed at every step of the evaluation. Although most patients are successfully treated without operation, SBO is a surgical disease, a fact underscored by the improved outcomes seen in patients admitted to a surgical service. Large bowel obstruction is a surgical emergency that requires prompt decompression either by colonoscopy or surgery. Regardless of the etiology of gastrointestinal dysfunction, emergency surgery is required in patients with signs of bowel strangulation or perforation such as tachycardia, peritonitis, fever, or leukocytosis.

      Key words: acute colonic pseudo-obstruction, adhesive small bowel disease, ileus, large bowel obstruction, Ogilvie syndrome, small bowel obstruction bowel perforation, volvulus

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    • 4

      Biliary Disease: Calculous and Acalculous Cholecystitis

      By Kevin Y Pei, MD, FACS; Kimberly A Davis, MD, MBA, FACS, FCCM
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      Biliary Disease: Calculous and Acalculous Cholecystitis

      • KEVIN Y PEI, MD, FACSAssistant Professor of Surgery, Section of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, CT
      • KIMBERLY A DAVIS, MD, MBA, FACS, FCCMProfessor of Surgery, Vice Chairman of Clinical Affairs, Chief of the Section of General Surgery, Trauma, and Surgical Critical Care, Yale School of Medicine, New Haven, CT

      Cholelithiasis is extremely common in the United States, affecting approximately 10 to 15% of the population. The vast majority of patients remain asymptomatic. Elective cholecystectomy for symptomatic cholelithiasis is a well-established procedure with excellent outcomes. The diagnosis in critically ill patients may not be straightforward. Inflammation and infection of the gallbladder can lead to significant morbidity and mortality. Whether the gallbladder is the primary etiology of hemodynamic compromise (as in emphysematous or gangrenous cholecystitis) or is the victim of secondary insult (as in ischemia-related acalculous cholecystitis), the intensivist must consider cholecystitis in the differential of clinical deterioration.

      This review contains 6 figures, 5 tables, and 53 references.

      Key words: acalculous, biliary disease, cholangitis, cholecystitis, emphysematous cholecystitis

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    • 5

      Upper Gastrointestinal Bleeding

      By Chasen A Croft, MD, FACS; Frederick Moore, MD, FACS, MCCM
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      Upper Gastrointestinal Bleeding

      • CHASEN A CROFT, MD, FACSAssistant Professor of Surgery, Department of Surgery, University of Florida, Gainesville, FL
      • FREDERICK MOORE, MD, FACS, MCCMProfessor and Chief of Acute Care Surgery, Department of Surgery, University of Florida, Gainesville, FL

      Acute upper gastrointestinal bleeding (UGIB) is a common and potentially life-threatening emergency. Despite significant advances in intensive care resuscitation, medical treatment of gastric acid hypersecretion, and progress in endoscopic and surgical management, mortality from upper gastrointestinal hemorrhage has remained steady over the past four decades. One of the major challenges of managing UGIB involves identifying patients who are at high risk for rebleeding and death and who require admission to the intensive care unit. Regardless of the cause, initial evaluation of patients with UGIB is based on the degree of hemodynamic instability and the presumed rate of bleeding. Those patients with evidence of active bleeding and hemodynamic instability require aggressive resuscitation and hospitalization. Although diagnostic imaging may be useful in identifying the source of bleeding, endoscopy remains the “gold standard” diagnostic and therapeutic modality. Recent advances in transcatheter angiographic embolization have made this modality an attractive alternative to surgical intervention in patients who fail endoscopic management. However, in the hemodynamically unstable patient, surgical intervention is often necessary. In this review, we describe the most common causes of acute UGIB and detail the initial workup and management of each cause. 

      This review contains 6 figures, 3 tables, and 71 references.

      Key words: acute upper gastrointestinal bleeding, angiographic embolization, Billroth, Dieulafoy, esophagogastroduodenoscopy, peptic ulcer disease, scintigraphy, varices

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    • 6

      Lower Gastrointestinal Bleeding

      By Chasen A Croft, MD, FACS; Frederick Moore, MD, FACS, MCCM
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      Lower Gastrointestinal Bleeding

      • CHASEN A CROFT, MD, FACSAssistant Professor of Surgery, Department of Surgery, University of Florida, Gainesville, FL
      • FREDERICK MOORE, MD, FACS, MCCMProfessor and Chief of Acute Care Surgery, Department of Surgery, University of Florida, Gainesville, FL

      Lower gastrointestinal (GI) hemorrhage is a common clinical condition often encountered by the acute care surgeon. Lower GI bleeding, defined as bleeding distal to the ligament of Treitz, may present with diverse manifestations, from occult bleeding as evidenced only by anemia to massive hemorrhage and exsanguination. Severe, life-threatening hemorrhage may present precipitously with few initial symptoms. As such, the astute surgeon must be able to expeditiously identify patients with acute, massive lower GI bleeding and initiate the appropriate therapeutic algorithm to reduce the high morbidity and mortality associated with this condition. After initial resuscitation, the cause of the hemorrhage must be identified. Identification of the bleeding site often includes a multidisciplinary approach, including practitioners from critical care, gastroenterology, radiology, and surgery. In general, the primary methods to locate the site of hemorrhage include CT and endoscopy. Advances in endoscopic localization have increased both the diagnostic and therapeutic yields of such therapy. Surgical intervention is generally reserved for those patients in whom hemodynamic instability precludes further diagnostic workup or those in whom the source of bleeding cannot be controlled with other modalities. In this review, we discuss the diagnostic workup and therapeutic management of life-threatening lower GI hemorrhage.

      This review contains 10 figures, 3 tables and 93 references

      Key words: BLEED criteria, colonic ischemia, colonoscopy, CT angiography, diverticular disease, lower gastrointestinal bleeding, mesenteric arteriography, nuclear scintigraphy, push enteroscopy, video capsule endoscopy

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  • Hematology
    • 1

      Assessment of Hemostasis

      By Martin A Schreiber, MD; Phillip M. Kemp Bohan, BA
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      Assessment of Hemostasis

      • MARTIN A SCHREIBER, MDProfessor of Surgery, Chief, Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
      • PHILLIP M. KEMP BOHAN, BAMedical Student, Duke University School of Medicine, Durham, NC

      Hemostasis is the collection of biological mechanisms responsible for bleeding cessation following surgical procedures or trauma. Congenital and acquired disorders affecting any element of the hemostatic system can result in a spectrum of bleeding pathologies ranging from inability to form stable blood clot to the pathologic propagation of blood clot outside the area of injury. Assessing the hemostatic system in an accurate and timely fashion is critical for detection of these disorders. This review briefly covers the mechanisms of primary and secondary hemostasis before comprehensively exploring the approach to preoperative evaluation of hemostasis, the strengths and weaknesses of commonly used laboratory tests of coagulation, the interpretation of test results, and the management of patients found to have abnormal hemostatic systems. Figures detail the mechanisms of hemostasis and the important features of viscoelastic testing. Tables explain the parameters frequently measured in viscoelastic testing and propose potential treatment plans based on test findings.  

      Key words: coagulation; conventional coagulation tests; hemostasis; thromboelastography; thromboelastometry 

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    • 2

      Deep Vein Thrombosis and Venous Thromboembolism in the Critically Ill

      By Kathryn L. Butler, MD; George Velmahos, MD, PhD, MSEd
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      Deep Vein Thrombosis and Venous Thromboembolism in the Critically Ill

      • KATHRYN L. BUTLER, MDConsultant in Surgery, Massachusetts General Hospital, Lecturer, Harvard Medical School, Boston, MA
      • GEORGE VELMAHOS, MD, PHD, MSEDJohn F. Burke Professor of Surgery, Harvard Medical School, Chief, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA

      Venous thromboembolism (VTE) poses unique diagnostic and therapeutic dilemmas in the intensive care unit (ICU). Immobility, inflammatory states, and trauma uniquely predispose surgical ICU patients to deep vein thrombosis and pulmonary embolism. Concurrently, the risks of perioperative and traumatic bleeding complicate management of VTE, with anticoagulation contraindicated in many scenarios. This review surveys the latest evidence in the diagnosis and management of VTE among critically ill surgical patients. It discusses evidence-based guidelines regarding diagnostic imaging, anticoagulation, prophylaxis, inferior vena cava filters, non–vitamin K oral anticoagulants, and surgical and catheter-based therapies. The review also examines the special challenges encountered when treating multisystem trauma patients. 

      Key words: anticoagulation therapy, deep vein thrombosis, pharmacoprophylaxis, pulmonary embolism, venous thromboembolism  

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    • 3

      Transfusion Therapy

      By Ronald Chang, MD; John B. Holcomb, MD
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      Transfusion Therapy

      • RONALD CHANG, MD
      • JOHN B. HOLCOMB, MD

      Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking.

      Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

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    • 4

      Heparin-induced Thrombocytopenia With Thrombosis

      By Young Kim, MD, MS; Brent T Xia, MD; Christopher A Droege, PharmD; Kristen E Carter, PharmD, BCPS; Timothy A Pritts, MD, PhD, FACS
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      Heparin-induced Thrombocytopenia With Thrombosis

      • YOUNG KIM, MD, MSClinical Instructors in Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.
      • BRENT T XIA, MDClinical Instructors in Surgery, Department of Surgery, University of Cincinnati. Cincinnati, OH.
      • CHRISTOPHER A DROEGE, PHARMDClinical Pharmacy Specialist Specializing in critical care, UC Health, University of Cincinnati Medical Center
      • KRISTEN E CARTER, PHARMD, BCPSClinical Pharmacy Specialist Specializing in Critical Care, UC Health, University of Cincinnati Medical Center
      • TIMOTHY A PRITTS, MD, PHD, FACSProfessor of Surgery in the Divisions of General Surgery and Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH.

      Heparin-induced thrombocytopenia type II (HIT II) is an immune-mediated adverse drug reaction to heparin and heparinoid compounds. Unlike other etiologies of thrombocytopenia, HIT II frequently manifests with arterial or venous thromboemboli, leading to significant morbidity and mortality. Diagnosis of HIT II requires a high clinical suspicion, pretest probability scoring, and laboratory confirmation through immunologic and functional assays. Moderate probability for HIT II should be met with discontinuation of the offending agent and initiation of an alternative anticoagulant.

      Key words: heparin-induced thrombocytopenia, heparin-induced thrombocytopenia with thrombosis, HIT II, HITT

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    • 5

      Direct Oral Anticoagulants

      By Michael G Mount, DO; Panna A. Codner, MD, FACS
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      Direct Oral Anticoagulants

      • MICHAEL G MOUNT, DOClinical assistant professor of surgery at North East Ohio Medical University, Assistant Program Director of General Surgery Residency, and clerkship director at Saint Elizabeth Hospital, Youngstown, OH.
      • PANNA A. CODNER, MD, FACSAssistant Professor of Surgery, Department of Surgery. Division of Trauma/Critical Care, Medical College of Wisconsin, Milwaukee, WI

      Non–vitamin K antagonist oral anticoagulants, also known as direct oral anticoagulants, are a relatively recent class of medications introduced into clinical practice. Due to their safety profiles, fixed dosing, and lack of need for frequent laboratory monitoring, they are becoming preferred to traditional anticoagulation with warfarin in many cases of nonvalvular atrial fibrillation and venous thromboembolism. Currently, four drugs are available: dabigatran, a direct thrombin inhibitor, and rivaroxaban, apixaban, and edoxaban, factor Xa inhibitors. This review covers the pharmacology, monitoring, and reversal agents currently available for these medications. The indications for their use are covered through a review of the major clinical trials that led to their US and European approvals for clinical use. Perioperative management of these medications is discussed. Tables list indications, dosing, and monitoring, as well as bleeding risks and efficacy compared with warfarin. 

      This review contains 1 figure, 11 tables, and 70 references.

      Key words: apixaban, dabigatran, direct oral anticoagulant, edoxaban, rivaroxaban

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  • Infectious Diseases
    • 1

      Central Nervous System Infections

      By Anna Finley Caulfield, MD; Brian G. Blackburn, MD
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      Central Nervous System Infections

      • ANNA FINLEY CAULFIELD, MDClinical Associate Professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA
      • BRIAN G. BLACKBURN, MDClinical Associate Professor, Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Stanford University School of Medicine, Stanford, CA

      Central nervous system (CNS) infections are associated with a high morbidity and mortality. Fortunately, the incidence of acute community-acquired bacterial meningitis has declined with the advancement and implementation of vaccination programs over the past 30 years. Treatment with corticosteroids, along with initial antimicrobial therapy, has also decreased the morbidity and mortality of patients with acute Streptococcus pneumoniae meningitis in developed countries. Molecular diagnostic testing may become a helpful tool to identify bacterial pathogens for targeted treatments. This review covers common CNS infections with a focus on the diagnosis and initial management of the adult patient suspected of having acute meningitis and encephalitis. 

      Key words: acute meningitis, brain abscess, chronic meningitis, encephalitis, ventriculitis 

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    • 2

      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part II: Factors Influencing Therapeutic Levels, Toxicity, and Allergic Reactions

      By Richard M Pino, MD, PhD, FCCM; Molly Paras, MD; Erica S Shenoy, MD, PhD
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      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part II: Factors Influencing Therapeutic Levels, Toxicity, and Allergic Reactions

      • RICHARD M PINO, MD, PHD, FCCMAssociate Professor and Division Chief of Critical Care in the Department of Anesthesia, Critical Care and Pain Medicine
      • MOLLY PARAS, MDDivision of Infectious Diseases, Department of Medicine
      • ERICA S SHENOY, MD, PHDAssistant Professor of Medicine at Harvard Medical School, and the Associate Chief of the Infection Control Unit

      The effective dose of an antibiotic administered to a patient in an intensive care unit is based on multiple factors. The antibiotic dose for each patient must be tailored based on pharmacokinetic and pharmacodynamic principles. Antibiotic levels can vary during the course of therapy with changes in organ function that may affect the volume of distribution. Antibiotic dose adjustments are necessary to ensure that the appropriate tissue levels are reached to achieve bacterial killing while side effects are minimized. This review discusses the factors that may affect antibiotic levels and the rationales for dosing, barriers to effective treatment, and common side effects.

      Key words: antibiotics, antibiotic toxicity, intensive care unit, pharmacodynamics, pharmacokinetics

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    • 3

      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

      By Richard M Pino, MD, PhD, FCCM; Molly Paras, MD; Erica S Shenoy, MD, PhD
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      Appropriate Antibiotic Selection and Use for Intensive Care Unit Patients, Part I: Rationale for Antibiotic Choices

      • RICHARD M PINO, MD, PHD, FCCMAssociate Professor and Division Chief of Critical Care in the Department of Anesthesia, Critical Care and Pain Medicine
      • MOLLY PARAS, MDDivision of Infectious Diseases, Department of Medicine
      • ERICA S SHENOY, MD, PHDAssistant Professor of Medicine at Harvard Medical School, and the Associate Chief of the Infection Control Unit

      The aim of this review is to help clinicians optimize treatment of infections and reduce adverse events. With that goal in mind, we discuss the basis for the selection of antibiotics for the surgical patient in the intensive care unit (ICU), the mechanism of antibiotic action, and resistance of pathogens to antibiotic therapy—factors that may affect antibiotic levels, the rationales for dosing, and the role of antimicrobial stewardship programs. The evaluation and management of infections in critically ill patients are uniquely different from those of the general patient population. Age, medical comorbidities, alterations in anatomy, changes in vascular supply, insertion of vascular conduits, and orthopedic hardware are some factors that increase the risk of infection and influence antibiotic choice in the surgical ICU patient. 

      Key words: antibiotics, antibiotic resistance, antibiotic stewardship, intensive care unit

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    • 4

      The Immunocompromised Surgical Patient and Opportunistic Infections

      By Kiran Gajurel, MD; Aruna K Subramanian, MD
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      The Immunocompromised Surgical Patient and Opportunistic Infections

      • KIRAN GAJUREL, MDClinical Assistant Professor of Medicine, Division of Infectious Disease, Carver College of Medicine, University of Iowa, Iowa City, IA
      • ARUNA K SUBRAMANIAN, MDClinical Associate Professor of Medicine, Division of Infectious Disease and Geographic Medicine, Stan¬ford University, Stanford, CA

      Immunosuppressive medications used to prevent allograft rejection render solid-organ transplant recipients vulnerable to various opportunistic infections. These infections include bacteria, viruses, fungi, and parasites and occur either via reactivation of previously acquired latent infection or de novo acquisition from the donor organ itself or the environment after the transplantation. The type and clinical course of the infection depend on various factors, including the transplanted organ, nature of immunosuppressive regimens, timing of infection relative to the organ transplant, and type and duration of prophylaxis. Proper donor and recipient screening for preventable infections and posttransplantation prophylaxis are instrumental in preventing morbid infections. Posttransplantation infections may present with subtle findings and thus may cause a delay in diagnosis and treatment, resulting in a poor outcome. Appropriate pathogen-specific tests should be requested promptly for early diagnosis. Since these infections may have overlapping clinical and radiologic features, tissue biopsy, if feasible, should be done to establish a definitive diagnosis. Surgical excision or débridement should be attempted in patients presenting with abscesses or invasive fungal sinusitis along with antimicrobial therapy. After the completion of treatment, suppressive therapy may be required in certain infections to prevent a relapse as long as the patient remains immunosuppressed.

      This review contains 3 tables, and 82 references.

      Key words: allograft, donor, immunocompromised, infection, opportunistic, organ, transplant 

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    • 5

      Viral, Fungal, and Atypical Infections

      By Daniel Caroff, MD; Chanu Rhee, MD, MPH
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      Viral, Fungal, and Atypical Infections

      • DANIEL CAROFF, MD
      • CHANU RHEE, MD, MPH

      Viral, fungal, and “atypical” bacterial pathogens are important causes of infections in critically ill patients. Many of these pathogens predominantly cause disease in immunosuppressed patients, but immunocompetent patients can also face serious illness or death. Understanding the risk factors and clinical syndromes caused by these pathogens is necessary to quickly identify patients who may need specialized diagnostics and treatment and is an essential component of training for any provider who practices in the intensive care unit. In this review, we discuss the most relevant aspects of clinical presentation, epidemiology, diagnosis, and management of these infectious agents, with a particular focus on respiratory tract infections. New advances in the diagnosis and treatment of influenza, invasive Candida infections, aspergillosis, and Legionella are highlighted.

      This review contains 3 figures, 5 tables, and 94 references.

      Key words: Candida, influenza, invasive pulmonary aspergillosis, Legionella pneumophilia, viral pneumonia

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    • 6

      Septic Shock

      By Allison Dalton, MD ; Mark Nunnally, MD, FCCM
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      Septic Shock

      • ALLISON DALTON, MD
      • MARK NUNNALLY, MD, FCCM

      Sepsis is a leading cause of morbidity and mortality worldwide. Infectious injury leads to inflammation, which leads to additional injury. This cyclical pattern leads to tissue dysfunction, resulting in hypovolemic and vasodilatory shock, hyperdynamic circulatory shock, mitochondrial dysfunction, cellular apoptosis, and immunosuppression. Septic patients are unable to use oxygen effectively, leading to organ dysfunction. The key to management of sepsis is early recognition and treatment. Prompt administration of appropriate antibiotics (preferably but not necessarily following culture) is vital to avoiding the morbidity and mortality associated with sepsis. Aggressive fluid resuscitation resulting in improved blood flow to tissues is the mainstay of initial therapy for septic shock. Balancing the needs for improved preload against the consequences of excessive intravascular volume is paramount. There are many methods (e.g., central venous pressure, mixed/central venous saturation, pulse pressure variation, ultrasonography) to determine when a septic shock patient may no longer respond to fluids and requires vasoconstrictors or inotropes for blood pressure control. Early recognition of sepsis, treatment with appropriate antibiotics, and limiting end-organ damage have led to decreased in-hospital mortality associated with septic shock.

      This review contains 5 figures, 5 tables, and 105 references.

      Key Words: antibiotic therapy, fluid therapy, resuscitation, sepsis, shock

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  • Monitoring/bioengineering
    • 1

      Invasive Hemodynamic Monitoring in the Intensive Care Unit

      By Mary Garland, MD; Michael C Chang, MD
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      Invasive Hemodynamic Monitoring in the Intensive Care Unit

      • MARY GARLAND, MDChief Surgical Resident, Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC
      • MICHAEL C CHANG, MDProfessor of Surgery, Executive Director, Trauma/Acute Care Surgery Service Line, Department of Sur¬gery, Wake Forest Baptist Medical Center, Winston-Salem, NC

      Optimal support of critically ill surgical patients with cardiovascular dysfunction requires that the bedside clinician have both a clear understanding of basic cardiovascular physiology and thorough knowledge of the information available from invasive hemodynamic monitors, including the advantages and pitfalls of each system. Assessment of hemodynamic function in underperfused patients should start with a quantitative assessment of global cardiovascular function. Global variables can be flow derived (e.g., cardiac output), pressure derived (e.g., systolic blood pressure), or both (e.g., ventricular stroke work and power). Any assessment consistent with inadequate global hemodynamic performance should be followed by analysis of the independent determinants of cardiovascular function. These independent determinants include heart rate, preload, afterload, and myocardial contractility. Invasive hemodynamic monitors allow the bedside clinician to measure and quantitate various combinations of global performance and the determinants of cardiac function depending on the monitoring system employed. Central venous lines enable measurement of central venous pressure but limited measure of right ventricular preload. Pulmonary artery catheters offer information pertaining to several global measures and independent determinants. Devices that depend on pulse contour wave analysis, when coupled with a central venous catheter, can measure cardiac output and preload in the context of measurements of stroke volume. However, being invasive, each device carries some degree of risk to the patient, and each monitoring technique employed via these devices carries pitfalls in both measurement and interpretation. It is incumbent upon the bedside clinician to understand the physiologic derangements affecting the patient and the utility and pitfalls of the information available from each device when selecting monitoring systems to be used in any given patient and the supportive therapy that ensues.

      This review contains 3 figures, 1 table, and 28 references.

      Key words: afterload, cardiac output, central venous catheter, hemodynamic monitor, myocardial contractility, perfusion, preload, pulmonary artery catheter, pulse contour analysis, stroke volume, stroke volume variability, stroke work, ventricular power 

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  • Acute Neurological Events
    • 1

      Blunt Cerebrovascular Injuries

      By Clay Cothren Burlew, MD, FACS
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      Blunt Cerebrovascular Injuries

      • CLAY COTHREN BURLEW, MD, FACSProgram Director, Trauma and Acute Care Surgery Fellowship, Department of Surgery, Denver Health Medical Center, Associate Professor of Surgery, University of Colorado, Denver, CO

      Blunt cerebrovascular injuries (BCVIs) are increasingly recognized in trauma patients, with 1 to 3% of all blunt trauma patients being diagnosed with a carotid artery injury or a vertebral artery injury. Specific injury patterns are associated with BCVI and serve as the trigger for injury screening in asymptomatic patients. Multislice (> 64-slice) computed tomographic angiography is the routine imaging test performed to identify BCVI. Once an injury is identified, antithrombotic treatment almost universally prevents BCVI-related stroke. Endovascular therapy for BCVI is reserved for those patients who are markedly symptomatic or have an enlarging pseudoaneurysm on repeat imaging.

      Key Words: blunt cerebrovascular injuries, blunt trauma, carotid artery injury, stroke, vertebral artery injury

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  • Nutrition
    • 1

      Enteral and Parenteral Nutritional Support

      By Cherisse Berry, MD; Jose J Diaz, MD, CNS, FACS, FCCM
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      Enteral and Parenteral Nutritional Support

      • CHERISSE BERRY, MDClinical Instructor in Surgery, R Adams Cowley Shock Trauma, University of Maryland Medical Center, Baltimore, MD
      • JOSE J DIAZ, MD, CNS, FACS, FCCMProfessor of Surgery, Chief, Division of Acute Care Surgery, Program Director, Acute Care Surgery Fellowship, Program in Trauma, R Adams Cowley Shock Trauma, University of Maryland Medical Center, Baltimore, MD

      Malnutrition among the critically ill is widely prevalent, resulting in impaired ventilator drive, prolonged ventilator dependence, impaired immunologic function, and increased risk of infection. The initiation of early nutrition therapy, specifically enteral nutrition, decreases the early loss of lean mass, provides calories, and improves patients’ immunity and healing, which is critical for improving morbidity and mortality in patients suffering from critical illness.  Determining nutritional risk using the Nutrition Risk in Critically Ill (NUTRIC) score; assessing nutritional needs, including protein and calorie needs, with ongoing reassessments; gaining gastrointestinal access for initiating early enteral therapy with a standard polymeric isotonic or near-isotonic 1 to 1.5 kcal/mL formula for surgical critically ill patients within 24 to 48 hours of admission to the intensive care unit; monitoring for gastrointestinal intolerance and complications; and selecting immunonutrition, specifically arginine and omega-3 fatty acids, for the postoperative surgical critical care patient are key strategies in overcoming malnutrition and improving overall morbidity and mortality in critically ill patients.

      This review contains 1 figure, 3 tables, and 52 references.

      Key words: enteral nutrition, immunonutrition, nutritional assessment, nutritional risk, refeeding syndrome

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    • 2

      Nutritional Support

      By Rindi Uhlich, MD; Parker Hu, MD; Patrick L Bosarge, MD, FACS, FCCM
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      Nutritional Support

      • RINDI UHLICH, MDResident, General Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
      • PARKER HU, MDFellow, Surgery Critical Care, Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
      • PATRICK L BOSARGE, MD, FACS, FCCMAssociate Professor of Surgery, Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL

      Nutritional optimization of the surgical patient remains a cornerstone of perioperative care. Significant effort and scrutiny are routinely directed to the field as it has the potential to improve outcomes, limit infectious complications, and decrease hospital length of stay and mortality. As such, previously identified cornerstones of care have been called into question. The timing, route, and intensity of nutritional supplementation remain the subject of controversy in an ever-evolving field. Previous methods of nutritional assessment, such as albumin and transthyretin, have proved unreliable, and their use is no longer recommended. In their place, new scoring systems are available to risk assess patients for malnutrition. We review the most pressing changes and assess the landscape of the field today.

      Key words: critical illness, enteral, glutamine, malnutrition, nutrition, outcomes, parenteral, protein

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  • Critical Illness of Pregnancy
    • 1

      Antepartum Complications of Pregnancy

      By Gaea Moore, MD
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      Antepartum Complications of Pregnancy

      • GAEA MOORE, MDStaff Physician, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kaiser-Permanente Oakland Medical Center, Oakland, CA

      Pregnancy presents unique considerations and challenges to the critical care provider, including the physiologic adaptations to the pregnant state, recruitment and collaboration with a multidisciplinary care team, determination of fetal status, preparing for and managing cardiac arrest in pregnancy, and evaluation and management of diseases unique to pregnancy (including preeclampsia and acute fatty liver of pregnancy).

      This review contains 48 references, and 4 tables.

      Key words: acute fatty liver of pregnancy, maternal cardiac arrest, perimortem cesarean section, preeclampsia, pregnancy

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  • Pediatrics
    • 1

      Fluid and Electrolyte Considerations for the Pediatric Surgical Patient

      By Denise B Klinkner, MD, MEd; Stephanie Polites, MD; TK Pandian, MD
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      Fluid and Electrolyte Considerations for the Pediatric Surgical Patient

      • DENISE B KLINKNER, MD, MED
      • STEPHANIE POLITES, MD
      • TK PANDIAN, MD

      Fluid and electrolyte management is critical to successful care of neonatal and pediatric surgical patients. Although infants and toddlers in particular are clearly different from adults in their fluid requirements, recent literature supports a shift away from hypotonic intravenous fluids to isotonic fluids. The importance of glucose regulation and electrolyte management in the development of neonates has been established, and they are essential goals in the care of these patients. Specific surgical diseases included in this review are hypertrophic pyloric stenosis, gastrointestinal atresia and bowel obstructions, ileostomy management, and burns. 

      Key words: electrolyte replacement; fluid and electrolytes; neonatal surgical critical care; oral rehydration; pediatric hypernatremia; pediatric hyponatremia; pediatric maintenance fluids; pediatric surgical critical care; pediatric total body water 

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    • 2

      Signs of Abuse

      By Richard Sola Jr, MD; David Juang, MD, FACS, FAAP
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      Signs of Abuse

      • RICHARD SOLA JR, MD
      • DAVID JUANG, MD, FACS, FAAP

      An estimated 3.6 million reports of possible child abuse or neglect, also known as nonaccidental trauma (NAT) or nonaccidental injury, involving approximately 6.6 million children were made to child protective services in the United States in 2014. The annual societal cost of child abuse and neglect is estimated conservatively to be over $103 billion. Understanding the history and physical findings specific to NAT will allow physicians to identify those children at risk and avoid missed injuries and recurrent child abuse. Bruising in particular is a cardinal physical finding for NAT. Certain diagnostic tools, such as skeletal surveys and retinal examinations, are used in evaluating for NAT. Abusive head trauma is the most common and deadliest injury. Although less common, abdominal injuries have a high mortality due to nonspecific symptoms and delayed presentation. Solid-organ abdominal injuries and duodenal hematomas can be managed nonoperatively, with a low failure rate. Up to 25% of skeletal fractures for children less than 1 year old are due to NAT. Tools to help medical personnel identify NAT are vitally important because children with recurrent NAT have a higher mortality compared with those identified at the initial episode. In Europe and the United States, checklists and algorithms have been established to standardize management of children with NAT. NAT carries significant morbidity, mortality, and cost to families and hospital resources. The key to prevention is early identification of children with NAT and early involvement of general or pediatric surgeons.

      Key words: abusive head trauma, ATOMAC guidelines, bruising, child abuse, children, nonaccidental injury, nonaccidental trauma, pediatric surgery, skeletal survey

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    • 3

      Management of Shock in Infants and Children

      By Arianne T Train, DO; David H Rothstein, MD, MS
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      Management of Shock in Infants and Children

      • ARIANNE T TRAIN, DO
      • DAVID H ROTHSTEIN, MD, MS

      The definition of shock has seen multiple iterations in the past several decades. In its most recent form, shock is understood to comprise a series of insults to the body resulting in impaired end-organ perfusion and generalized tissue underoxygenation. Causative factors are protean, although a large proportion of recent attention has been placed on infectious etiologies, particularly those in the compromised host. Diagnosis and treatment of pediatric shock are particularly challenging because of inherent difficulties in examining a young patient, early compensation of advanced shock, and, in some cases, a lack of provider familiarity with early signs and symptoms of impaired perfusion. Perhaps the most important advance in the past several years has been the recognition that shock must be identified early and sometimes treated empirically, without a proven etiology. In addition, systems of practice are essential to focus early, aggressive treatment of shock and prevent associated morbidity and mortality. In this review, we discuss key points to the evaluation of a pediatric patient with suspected shock, define what laboratory and radiologic investigations may be of utility in confirming a diagnosis and defining an etiology and direct treatment, and highlight recent advances in the understanding and treatment of shock. We also discuss some of the important advances in integration of treatment pathways and the use of the electronic medical record as a clinical adjunct.

      Key words: shock, pediatric, critical care, sepsis

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    • 4

      Caustic and Toxic Ingestions

      By CDR Thomas Q Gallagher, DO; CDR Robert L Ricca, MD
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      Caustic and Toxic Ingestions

      • CDR THOMAS Q GALLAGHER, DOPediatric Otolaryngologist , Department of Otolaryngology - Head & Neck Surgery, Naval Medical Center, Portsmouth, VA
      • CDR ROBERT L RICCA, MDPediatric Surgeon, Department of Pediatric Surgery, Naval Medical Center, Portsmouth, VA

      Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion.

      Key words: caustic ingestion, endoscopic management, stricture, surgical management 

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    • 5

      Pediatric Renal Replacement Therapy

      By Nathan A. Vaughan, MD, MPH; Faisal G. Qureshi, MD, MBA FACS, FAAP
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      Pediatric Renal Replacement Therapy

      • NATHAN A. VAUGHAN, MD, MPHTrauma, Acute Care Surgery, and Surgical Critical Care Attending, Baylor University Medical Center
      • FAISAL G. QURESHI, MD, MBA FACS, FAAPAssociate Chief, Pediatric Surgery, Associate Professor, Surgery and Pediatrics University of Texas, Southwestern Children’s Medical Center

      Acute kidney injury (AKI) is common in the critically ill patient, including the traumatically injured and postsurgical setting. Renal replacement therapy (RRT) provides an efficacious therapy in the management of AKI. The expanding knowledge of the technique and its challenges have propagated its application to the treatment of critically ill children. RRT utilizes diffusion and convection to manage electrolytes and toxic metabolites to maintain homeostasis. The various components of the dialysis circuit can be arranged to best address the patient’s physiologic derangements during continuous RRT. A knowledge of the anticoagulation management, circuit priming, and dosing in children is required by the intensivist to provide efficacious care. Understanding the technique for venous and peritoneal access facilitates the surgeon to safely provide a means of therapy. Peritoneal dialysis provides a means of therapy when continuous RRT is not available. As with any therapy, the complication profile determines the role of therapy. Comprehension of the associated outcomes with different pediatric pathologies will allow the surgical team to improve patient care.

      This review contains 5 figures, 7 tables, and 66 references.

      Key Words: acute renal failure, critical care, hemodialysis, pediatric, renal replacement therapy


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  • Pharmacy
    • 1

      Critical Care of the Surgical Patient-pharmacokinetics, Metabolism, and Dose Adjustment

      By Sharon Wilson, PharmD, BCPS, BCCCP; Kaitlin A. Pruskowski, PharmD, BCPS, BCCCP
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      Critical Care of the Surgical Patient-pharmacokinetics, Metabolism, and Dose Adjustment

      • SHARON WILSON, PHARMD, BCPS, BCCCPClinical Specialist-Surgery, Critical Care, Residency Program Director, Critical Care Pharmacy Practice, Clinical Associate Professor, University of Maryland School of Pharmacy, Baltimore, MD
      • KAITLIN A. PRUSKOWSKI, PHARMD, BCPS, BCCCPClinical Pharmacist, Burn Critical Care, U.S. Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX

      Management of critically ill surgery patients is challenging, coupled not only with the acute ICU needs, but surgical changes as well. These patients often require multiple medications, and proper dosing and monitoring is necessary to achieve optimal outcomes and avoid adverse drug events. Understanding the pharmacokinetic changes in this population is important for managing drug therapies and improving patient care outcomes. The purpose of this chapter is to introduce the clinician to changes in pharmacokinetics in the critically ill surgery patient and provide practical applications for drug management when faced with these challenges. This review covers the basics of drug management, pharmacokinetic alterations, drug classes and pharmacokinetic changes in the critically ill surgery patient, select disease states, and pharmacokinetic alterations in select conditions.

      This review contains 4 figures, 10 tables and 105 references

      Key Words: Pharmacokinetics, surgery, critical care, therapeutic drug monitoring

       

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  • Acute Respiratory Events
    • 1

      Assessment of Acute Respiratory Failure

      By Nathan R. Manley, MD/MPH; Martin A Croce, MD, FACS
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      Assessment of Acute Respiratory Failure

      • NATHAN R. MANLEY, MD/MPHResident, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
      • MARTIN A CROCE, MD, FACSProfessor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

      Acute respiratory failure (ARF) is fundamentally a dysfunction of gas exchange and can be due to either inadequate carbon dioxide elimination causing hypercapnia or poor oxygen exchange and delivery causing hypoxemia. A variety of etiologies exist that cause ARF in the surgical patient, including previous lung disease, such as chronic obstructive pulmonary disease or asthma, neurologic compromise of respiratory drive, nutritional and metabolic derangements that can alter respiratory metabolism and mechanics, direct lung injury, and infection. The type of surgery and the time since surgery are other key factors that influence medical decision making and that will influence priorities in the assessment and management of ARF. This review explores the full spectrum of ARF in the surgical patient, focusing particularly on its assessment and initial management. Figures illustrate algorithms in the approach to the surgical patient with ARF and show example radiographic images of acute respiratory distress syndrome (ARDS), a common complication. Tables summarize indications for emergent intubation, key etiologies of ARF, and the evolving definitions of acute lung injury and ARDS.

      Key words: acute respiratory distress syndrome, acute respiratory failure, hypercapnia, hypoxemia, mechanical ventilation 

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    • 2

      Noninvasive and Invasive Ventilatory Support I

      By Pauline K. Park, MD, FACS, FCCM; Nicole L Werner, MD, MS; Carl Haas, MLS,2 RRT-ACCS
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      Noninvasive and Invasive Ventilatory Support I

      • PAULINE K. PARK, MD, FACS, FCCMAssociate Professor, Dept. of Surgery, University of Michigan
      • NICOLE L WERNER, MD, MSFellow, Surgical Critical Care, University of Michigan Health System, Ann Arbor, MI
      • CARL HAAS, MLS,2 RRT-ACCSEducation and Research Coordinator, Adult Respiratory Care, University of Michigan Health System, Ann Arbor, MI

      Invasive and noninvasive ventilation are important tools in the clinician’s armamentarium for managing acute respiratory failure. Although these modalities do not treat the underlying disease, they can provide the necessary oxygenation and ventilatory support until the causal pathology resolves. Care must be taken, as even appropriate application can cause harm. Knowledge of pulmonary mechanics, appreciation of the basic machine settings, and an understanding of how common and advanced modes function allow the clinician to optimally tailor support to the patient while limiting iatrogenic injury. This first chapter reviews pulmonary mechanics, machine settings, and current options for noninvasive and invasive support of respiratory failure.

      This review contains 7 figures, 3 tables and 44 references

      Key Words: hypoxemia, hypercapnia, mechanical ventilation, noninvasive ventilation, respiratory failure

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    • 3

      Noninvasive and Invasive Ventilatory Support II

      By Pauline K. Park, MD, FACS, FCCM; Nicole L Werner, MD, MS; Carl Haas, MLS,2 RRT-ACCS
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      Noninvasive and Invasive Ventilatory Support II

      • PAULINE K. PARK, MD, FACS, FCCMAssociate Professor, Dept. of Surgery, University of Michigan
      • NICOLE L WERNER, MD, MSFellow, Surgical Critical Care, University of Michigan Health System, Ann Arbor, MI
      • CARL HAAS, MLS,2 RRT-ACCSEducation and Research Coordinator, Adult Respiratory Care, University of Michigan Health System, Ann Arbor, MI

      Invasive and noninvasive ventilation are important tools in the clinician’s armamentarium for managing acute respiratory failure. Although these modalities do not treat the underlying disease, they can provide the necessary oxygenation and ventilatory support until the causal pathology resolves. Care must be taken as even appropriate application can cause harm. Knowledge of pulmonary mechanics, appreciation of the basic machine settings, and an understanding of how common and advanced modes function allows the clinician to optimally tailor support to the patient while limiting iatrogenic injury. This second chapter reviews indications for mechanical ventilation, routine management, troubleshooting, and liberation from mechanical ventilation

      This review contains 6 figures, 7 tables and 60 references

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  • Research Principles
    • 1

      Evaluating the Quality of Evidence

      By Zach W Brown, DO, CDR, MC, USN; Herb A. Phelan, MD, MSCS
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      Evaluating the Quality of Evidence

      • ZACH W BROWN, DO, CDR, MC, USN
      • HERB A. PHELAN, MD, MSCS

      One of the most important skills a medical practitioner must develop is the ability to evaluate the evidence as evidence-based practice is the best way to provide patient care. Critical appraisal of an article requires a systematic approach to identify a clear and novel hypothesis, a relevant topic, valid study methods, and the overall importance of the research. This review identifies how to establish a baseline level of quality per the hierarchy of study designs. It then deconstructs each section of the standard IMRAD format article (Introduction, Methods, Results, Analysis, and Discussion), including a brief discussion of statistical methods. Finally, it shows how to apply some of the evaluation methods of the GRADE guidelines that were devised specifically to provide a process for determining quality of evidence through modifiers reflecting priorities in clinical decision making. In particular, the overall quality can be downgraded based on five criteria: imprecision, inconsistency, indirectness, publication bias, and lack of internal validity. In contrast, quality can be upgraded when the size of the effect seen is very large, when a dose-response relationship exists, or when plausible confounders or other biases paradoxically increase confidence in the direction or magnitude of the signal. Taken together, a final assessment of quality may be applied, and the practitioner may accept the research for inclusion into practice or reject it as low-quality evidence. Both are examples of appropriate evidence-based practice, and both result in better patient care.

      Key words: appraisal, evaluate, evidence, grade, statistics

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    • 2

      Interpreting Output of Statistical Studies

      By Aparna Sodhi, BA; Marie Crandall, MD, MPH, FACS
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      Interpreting Output of Statistical Studies

      • APARNA SODHI, BA
      • MARIE CRANDALL, MD, MPH, FACS

      This review provides an overview of the elements of statistical analysis so that the reader may better understand the output of statistical studies, which is essential to the modern practice of critical care, in a rapidly evolving field. Beginning with hypothesis testing, the review progresses through an explanation of variable types and demonstrates how to quantify and categorize variables, with examples; it then goes on to explain the principles of basic comparative analysis, which helps identify simple differences between cohorts, and then highlights the importance of potential confounders to help readers understand simple strategies used to control for confounding, such as using different types of study designs and different methods of statistical analysis. By using contemporary, influential articles from the critical care literature to illustrate these principles, we hope to illuminate the importance of interpreting output from statistical studies to better inform evidence-based practice.

      Key words: confounding, hypothesis testing, statistical analysis

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    • 3

      Critical Care of the Surgical Patient: Principles of Study Design

      By Patrick E Georgoff, MD; Vahagn C Nikolian, MD; Hasan B Alam, MD, FACS
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      Critical Care of the Surgical Patient: Principles of Study Design

      • PATRICK E GEORGOFF, MD
      • VAHAGN C NIKOLIAN, MD
      • HASAN B ALAM, MD, FACSProfessor of Surgery, Harvard Medical School, Boston, MA

      Conducting research in an intensive care unit (ICU) is both challenging and rewarding. ICU patients are heterogeneous, complex, and critically ill. Despite these challenges, the ICU is a data-rich research environment that lends itself to cutting-edge clinical investigation. To optimize research outcomes, investigators must carefully consider the principles of study design. This review discusses the most commonly used observational, experimental, and meta-analytic study designs, as well as the theoretical underpinnings of each study type. Published ICU-based research studies are used as examples to highlight key concepts. 

      Key words: clinical research, experimental studies, intensive care, meta-analyses, observational studies, study design

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  • Transplant
    • 1

      Immunosuppression for the Transplant Surgical Patient

      By Bharath R Ravichandran, PharmD, BCPS; Tracy M Sparkes, , PharmD, BCPS; Srijana D Jonchhe, PharmD, BCPS; Mary C Moss, PharmD, BCPS; Brian M Masters, PharmD, BCPS
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      Immunosuppression for the Transplant Surgical Patient

      • BHARATH R RAVICHANDRAN, PHARMD, BCPSTransplant Clinical Pharmacy Specialist, Clinical Associate Professor, Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
      • TRACY M SPARKES, , PHARMD, BCPSTransplant Clinical Pharmacy Specialist, Clinical Associate Professor, Department of Phar¬macy, University of Maryland Medical Center, Baltimore, MD
      • SRIJANA D JONCHHE, PHARMD, BCPSTransplant Clinical Pharmacy Specialist, Clinical Associate Professor, Department of Phar¬macy, University of Maryland Medical Center, Baltimore, MD
      • MARY C MOSS, PHARMD, BCPSClinical Pharmacy Specialist, Solid Organ Transplant, Clinical Associate Professor, Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD
      • BRIAN M MASTERS, PHARMD, BCPSTransplant Clinical Pharmacy Specialist, Clinical Associate Professor, Department of Phar¬macy, University of Maryland Medical Center, Baltimore, MD

      Immunosuppression brings with it many additional challenges in the management of the surgical patient already fraught with complexity. Given advances in surgery and medicine, transplantation has become a therapeutic option for patients once considered too ill. In the medical management of these patients, it is always most important to take into account the clinical status of the patient to balance the risk of infection and rejection. The management of immunosuppression in the surgical patient is challenging depending on the clinical scenario. In addition to patient-specific factors, there are many medication-related factors to consider, including toxicity, interactions, and pharmacokinetics. It is always important to consult a transplant specialist prior to initiating or reinitiating immunosuppression in these patients as the therapeutic goals are likely to be modified. Additionally, consideration of the patient’s history as it pertains to infection, rejection, and malignancy is highly pertinent in their immunosuppression management. Appropriate management and augmentation of immunosuppression are critical to the success of these patients, both at the time of transplantation and in the years that follow. The goal of this review is to provide a basis for the understanding of the complexities of immunosuppression in the surgical transplant patient.

      Key Words: immunosuppression; infection; rejection; solid-organ transplantation

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    • 2

      Postoperative Management of Liver Transplant Patients

      By Aleah L. Brubaker, MD, PhD; Marianne Chen, MD; Amy Gallo, MD
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      Postoperative Management of Liver Transplant Patients

      • ALEAH L. BRUBAKER, MD, PHD
      • MARIANNE CHEN, MD
      • AMY GALLO, MD

      Management of the postoperative liver transplant patient can be extremely challenging. The combination of preoperative comorbidities and intraoperative complexity can make for a tenuous postoperative critical care course. Consideration and monitoring of graft function are paramount as poor graft function or primary graft nonfunction will affect every aspect of care. Our goal in this review is to use a systems-based approach to highlight the key tenets for postoperative management of liver transplant patients to help orchestrate integrated care across subspecialties. 

      This review contains 2 figures, 2 tables, and 94 references.

      Key words: critical care, liver transplant, systems-based management

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  • Ultrasound
    • 1

      Focused Assessment With Sonography for Trauma

      By David Barounis, MD ; Elise Hart, MD
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      Focused Assessment With Sonography for Trauma

      • DAVID BAROUNIS, MD Attending Physician, Departments of Emergency Medicine and Critical Care Medicine, Advocate Christ Medical Center, Oak Lawn, IL
      • ELISE HART, MDPostgraduate Year 3, Emergency Medicine Residency Program, Advocate Christ Medical Center, Oak Lawn, IL

      The focused assessment with sonography for trauma (FAST) is a screening ultrasound examination used to identify traumatic free fluid in the pericardium and peritoneum through four key windows: the subxiphoid, the hepatorenal recess, the splenorenal recess, and the suprapubic views. The primary role for the FAST examination is in the bedside evaluation of hemodynamically unstable blunt trauma patients to help direct operative management. The extended FAST (E-FAST) examination involves additional evaluation of the thorax and can reliably identify hemothorax and pneumothorax. The advantages of these modalities include rapid speed, low cost, and a lack of ionizing radiation. The limitations include operator dependence, although validated assessments hold promise in mitigating this issue, and poor sensitivity in identifying retroperitoneal hemorrhages, diaphragmatic injuries, and solid-organ injuries that do not produce significant intraperitoneal hemorrhage. In the future, contrast-enhanced ultrasonography may improve ultrasonographic evaluation of solid-organ injury. Nevertheless, significant concerns remain regarding the wide ranges of sensitivity reported for the FAST examination overall, and ongoing research may better identify its optimal role in evaluating trauma patients.

      Key words: Blunt trauma; focused assessment with sonography for trauma (FAST); extended FAST (E-FAST); hemothorax; pneumothorax; ultrasonography

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    • 2

      Critical Care Ultrasonography

      By S Patrick Bender, MD; Thomas R Pace, MD; Joshua Farkas, MD
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      Critical Care Ultrasonography

      • S PATRICK BENDER, MD
      • THOMAS R PACE, MD
      • JOSHUA FARKAS, MD

      The use of bedside ultrasonography in the intensive care unit continues to expand due to its broad utility, including diagnosis of various conditions, evaluation of hemodynamics, and improvement in the speed and safety of certain bedside procedures. In this review, the reader will gain a better understanding of the physical properties of ultrasound waves and potential artifacts. The five standard views to perform a basic echocardiographic evaluation are described. This examination provides an adequate assessment of the left ventricle, helping to differentiate acute coronary syndrome, stress cardiomyopathy, and regional or global left ventricular dysfunction. Right ventricular function can be assessed qualitatively or, if desired, quantitatively via measurement of tricuspid annular plane excursion. Echocardiography also allows for assessment of volume status, detection of cardiac tamponade, and signs of hemodynamically significant pulmonary embolism. We also describe bedside ultrasound use for pulmonary assessment and for guidance of thoracentesis. Lung ultrasonography is very sensitive for the detection of pneumothoraces and pleural effusions. The lung parenchyma may also be evaluated by identifying various artifacts such as A-lines and B-lines to delineate underlying pulmonary pathology. Understanding these artifacts allows an experienced practitioner to detect various pathologies such as pneumonia, cardiogenic pulmonary edema, atelectasis, and other conditions. Finally, we discuss abdominal ultrasonography, including the performance of a focused assessment with sonography in trauma examination, performance of a paracentesis, and diagnosis of a pneumoperitoneum.

      This review contains 11 figures, 1 table, and 53 references.

      Key words: bedside ultrasonography, echocardiography, focused assessment with sonography in trauma (FAST), focused cardiac ultrasonography (FoCUS), point-of-care ultrasonography

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  • Trauma
    • 1

      Initial Management of Life-threatening Trauma

      By Emily Cantrell, MD; Jay Doucet, MD, FACS, FRCSC, RDMS
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      Initial Management of Life-threatening Trauma

      • EMILY CANTRELL, MDAssistant Professor of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, Department of Surgery, University of California, San Diego, CA
      • JAY DOUCET, MD, FACS, FRCSC, RDMSProfessor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA

      Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.

      This review contains 12 figures, 8 tables and 63 references

      Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey

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    • 2

      Traumatic Brain and Spinal Cord Injuries

      By Mohit Datta, MD; Geoffrey S.F. Ling, MD, PhD, FAAN
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      Traumatic Brain and Spinal Cord Injuries

      • MOHIT DATTA, MD
      • GEOFFREY S.F. LING, MD, PHD, FAANUniformed Services University of the Health Sciences, Bethesda, MD

      Traumatic brain injury (TBI), the most common cause of death and disability in young adults in the United States, is classified by severity (mild, moderate, or severe). This chapter reviews the pathogenesis of TBI, the types and severity of injuries, and management of TBI. Figures include computed tomography (CT) images of brains showing bi-frontal hemorrhagic contusions with associated peri-hematomal edema, a right-sided hyperdense lenticular-shaped space-occupying lesion with minimal midline shift, and evolution of the CT appearance of a subdural hematoma (from a hyperdense lesion, through to an isodense lesion, to a hypodense space-occupying lesion). Tables present the Glasgow Coma Scale, indications for CT scan in mild TBI (based on the Canadian head rule), guidelines for the management of moderate to severe TBI, and return to play or work criteria for patients suffering from concussion. This chapter contains 61 references.

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    • 3

      New Techniques in Hemorrhage Control

      By Megan Brenner, MD, MS, RPVI, FACS; Joseph DuBose, MD, RPVI, FCCM, FACS
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      New Techniques in Hemorrhage Control

      • MEGAN BRENNER, MD, MS, RPVI, FACSAssociate Professor of Surgery, R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
      • JOSEPH DUBOSE, MD, RPVI, FCCM, FACSAssociate Professor of Surgery, Uniformed Services University of the Health Sciences, Associate Professor of Surgery, University of California, Davis Davis, CA

      The use of interventional procedures in trauma has increased steadily over the past 10 years. With advancements in both imaging and device technology, endovascular techniques have become part of the treatment algorithm for both large and small vessel injury. Endovascular therapy in trauma involves a minimally invasive, catheter-based approach, which can be used as a temporizing measure in patients in extremis or as definitive therapy in a wide variety of diagnoses. Sheaths, catheters, and guide wires are universal instruments, regardless of procedure. Devices passed over guide wires form the basis of diagnosis and treatment. Using this technology provides many advantages to traditional open surgical therapy, namely the avoidance of large and potentially morbid incisions. Angioembolization, stent grafting, and resuscitative endovascular balloon occlusion of the aorta (REBOA) are being used with increasing frequency in trauma centers, with established algorithms, multiinstitutional trials, and more published data available, particularly for solid-organ and pelvic hemorrhage.

      Key words: angiography, embolization, hemorrhage, resuscitative endovascular balloon occlusion of the aorta, stent graft

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    • 4

      Basic Management of Pelvic Fractures

      By Amelia Simpson, MD; Raul Coimbra, MD, PhD, FACS; Todd W Costantini, MD, FACS
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      Basic Management of Pelvic Fractures

      • AMELIA SIMPSON, MDTrauma Attending Surgeon, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, CA
      • RAUL COIMBRA, MD, PHD, FACSMonroe E. Trauma Professor of Surgery, Surgeon-in-Chief, UCSD Health System, Executive Vice-Chairman, Department of Surgery, Chief, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, CA
      • TODD W COSTANTINI, MD, FACSAssistant Professor, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, UC San Diego Health, San Diego, CA

      The management and treatment of complex pelvic fractures require knowledge of the initial evaluation of a trauma patient, pertinent anatomy, and techniques available for hemorrhage control. Trauma patients with complex pelvic fractures are at high risk for hemorrhage and require thoughtful and expeditious management. A multidisciplinary team including a trauma surgeon, an orthopedic surgeon, and an interventional radiologist is required for optimal treatment of these complex injuries. The team must be managed by the trauma surgeon to guide ongoing resuscitation as the patient may travel throughout the hospital to undergo several interventions to control hemorrhage. A number of techniques can be emergently implemented for fracture stabilization and hemorrhage control, including temporary application of a pelvic binder, preperitoneal pelvic packing, external fixation, and angioembolization. The patient’s clinical status, fracture pattern, and bleeding source must be considered when deciding which hemorrhage control techniques should be performed. New temporary hemorrhage control interventions, such as resuscitative endovascular balloon occlusion of the aorta, have shown early success in control of pelvic fracture–related hemorrhage and require further investigation. Pelvic fractures are associated with a number of neurovascular and genitourinary injuries, which can carry long-term morbidity. This review discusses the diagnosis, management, and treatment of complex pelvic fracture and associated hemorrhage.

      This review contains 5 figures, and 55 references. 

      Key words: angioembolization, pelvic fixation, pelvic fracture, preperitoneal packing, resuscitative endovascular balloon occlusion of the aorta

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    • 5

      Central Nervous System Injury

      By Brandon R Bruns, MD; Deborah M Stein, MD, MPH
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      Central Nervous System Injury

      • BRANDON R BRUNS, MDAssociate Professor of Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD
      • DEBORAH M STEIN, MD, MPHR Adams Cowley Professor of Shock and Trauma, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD

      Traumatic brain injury (TBI) accounts for 2.5 million hospital visits annually and is the leading cause of death and disability in patients age 1 to 44 years. Evaluation of patients with suspected TBI requires prompt physical examination with a focus on calculation of the Glasgow Coma Score and pupillary examination as early treatments can be initiated at this stage in patient management. Diagnostic studies include basic laboratory parameters and prompt evaluation with brain computed tomography to identify space-occupying lesions (blood) within the rigid calvarium. Distinction between the different types of traumatic intracerebral hemorrhage is imperative and enables prompt neurosurgical consultation, as well as initiation of appropriate medical therapies to treat elevated intracranial pressure and maintain cerebral perfusion pressure. Paramount in managing patients with suspected TBI is the avoidance of hypotension and hypoxia. Intracranial pressure monitoring remains controversial but is a cornerstone in TBI management. Patients with TBI may have lifelong complications and require careful follow-up. Many new prognostic tools are currently available.

      This review contains 4 figures, 4 tables, and 47 references.

      Key words: cerebral contusion, epidural hematoma, intracranial pressure monitoring, subdural hematoma, traumatic brain injury 

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    • 6

      Surgical Critical Care of Special Populations (pregnant, Geriatric, Pediatric)

      By Lisa Marie Knowlton, MD, MPH; Stephanie D Chao, MD; Chad M Thorson, MD, MSPH; Kristan L Staudenmayer, MD, MS
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      Surgical Critical Care of Special Populations (pregnant, Geriatric, Pediatric)

      • LISA MARIE KNOWLTON, MD, MPH
      • STEPHANIE D CHAO, MD
      • CHAD M THORSON, MD, MSPH
      • KRISTAN L STAUDENMAYER, MD, MS

      This review covers the specialized care of populations who present different management challenges when critically injured. The text is divided into three sections: pregnant, geriatric, and pediatric patients. For each population, the discussion focuses on the unique diagnostic and treatment algorithms that the surgical intensivist must consider. In addition to management of trauma in these special populations, other common diagnoses warranting surgical intensive care unit (ICU) admission are reviewed. Current guidelines on diagnostic imaging and medication safety are outlined. Injury prevention and outcomes improvement are an essential component of optimizing trauma care. The epidemiology of traumatic injury within each specialized population is included in this review. Outcomes are discussed in depth, particularly with respect to the geriatric ICU patient, including a section on barriers to disposition, decision-making capacity, and end-of-life care in the surgical ICU.  

      This review contains 2 figures, 4 tables, and 72 references.

      Key words: end of life in the ICU, geriatric trauma, injury prevention, pediatric trauma, pregnancy

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    • 7

      Management of Extremity Fractures and Complications

      By Tim H Lee, MD, MS; Kenji Inaba, MD, MS, FRCSC, FACS
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      Management of Extremity Fractures and Complications

      • TIM H LEE, MD, MS
      • KENJI INABA, MD, MS, FRCSC, FACS

      Trauma-associated extremity injuries are common and may lead to significant morbidity and mortality and can even be immediately life threatening. A thorough understanding of the management principles for traumatic extremity injuries is essential. Proper management of traumatic extremity fractures can mitigate development of detrimental inflammatory and infectious sequelae and preserve function. Gram-positive antibiotic prophylaxis with débridement and washout within 24 hours of injury is supported for all open fractures, with broader antibiotic coverage against gram-negative bacteria supported for Gustilo-Anderson type III open fractures. Extremity vascular injury in civilian trauma is rare but must be promptly identified to prevent irreversible limb ischemia. Rhabdomyolysis and compartment syndrome are feared complications of severe extremity trauma. Aggressive volume resuscitation for rhabdomyolysis is widely accepted to support renal function. When compartment syndrome is suspected, maintaining extremity perfusion is critical, and fasciotomy may be necessary for compartmental decompression. The mangled extremity can threaten limb viability, function, rehabilitation potential, and, in some cases, life. It is best treated in a multidisciplinary setting with the decision to salvage or amputate based on careful expert consensus evaluation.

      This review contains 4 figures, 5 tables, and 88 figures.

      Key words: compartment syndrome, extremity injury, extremity vascular injury, open fracture, mangled extremity, rhabdomyolysis, tourniquet use, trauma

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    • 8

      Thoracic Injuries and Management Options

      By Michal Radomski, MD; Babak Sarani, MD, FACS, FCCM
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      Thoracic Injuries and Management Options

      • MICHAL RADOMSKI, MDFellow, Critical Care Surgery and Trauma, Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
      • BABAK SARANI, MD, FACS, FCCMAssociate Professor of Surgery, Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC

      Thoracic trauma accounts for nearly 25% of deaths secondary to blunt trauma. The most common chest injury is a rib fracture, which can be associated with a mortality risk as high as 35%. Other injuries include pneumothorax, hemothorax, esophageal injury, aortic transection, blunt cardiac injury, tracheobronchial disruption, and pulmonary contusion. The majority of thoracic injuries can be treated successfully with either observation or tube thoracostomy and general supportive care alone. Independent contributors to mortality include inadequate pain control, poor pulmonary hygiene, failure to intubate appropriately, and excessive crystalloid-based resuscitation.

       

      This review contains 3 figures, 5 tables and 64 references

      Key words: aorta, bronchus, esophagus, hemothorax, pneumothorax, pulmonary contusion, rib fracture, thoracic, trachea, tracheobronchial

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    • 9

      Principles of Initial Trauma Management and Evaluation

      By Shelby Resnick, MD; Brian Smith, MD; Patrick Reilly, MD, FCCP, FACS
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      Principles of Initial Trauma Management and Evaluation

      • SHELBY RESNICK, MD
      • BRIAN SMITH, MD
      • PATRICK REILLY, MD, FCCP, FACS

      Trauma accounts for almost 10% of deaths worldwide and is the fourth most common cause of death in the United States. Treatment of the injured patient requires multiple unique resources, including multidisciplinary teams, surgical subspecialties, and dedicated resuscitation areas. Evaluation and initial management of the trauma patient is performed systematically to quickly identify and treat life-threatening injuries. This review serves as an introduction to care for the critically injured patient. It covers the initial steps for evaluation, resuscitation, diagnosis and treatment of the trauma patient and provides a brief overview of various injury patterns resulting from both blunt and penetrating trauma.

      This review contains 6 figures, 6 tables and 49 references

      Key Words: blunt trauma, damage control resuscitation, FAST exam, lateral canthotomy, penetrating trauma, primary survey, rapid sequence intubation, secondary survey, trauma systems

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    • 10

      Cerebral Metabolism and Blood Flow Following Traumatic Brain Injury

      By Ryan Martin, MD; Lara Zimmermann, MD; Marike Zwienenberg-Lee, MD; Kee D Kim, MD; Kiarash Shahlaie, MD, PhD
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      Cerebral Metabolism and Blood Flow Following Traumatic Brain Injury

      • RYAN MARTIN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • LARA ZIMMERMANN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • MARIKE ZWIENENBERG-LEE, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KEE D KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA

      The management of traumatic brain injury focuses on the prevention of second insults, which most often occur because of a supply/demand mismatch of the cerebral metabolism. The healthy brain has mechanisms of autoregulation to match the cerebral blood flow to the cerebral metabolic demand. After trauma, these mechanisms are disrupted, leaving the patient susceptible to episodes of hypotension, hypoxemia, and elevated intracranial pressure. Understanding the normal and pathologic states of the cerebral blood flow is critical for understanding the treatment choices for a patient with traumatic brain injury. In this chapter, we discuss the underlying physiologic principles that govern our approach to the treatment of traumatic brain injury.

      This review contains 3 figures, 1 table and 12 references

      Key Words: cerebral autoregulation, cerebral blood flow, cerebral metabolic rate, intracranial pressure, ischemia, reactivity, vasoconstriction, vasodilation, viscosity

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    • 11

      Traumatic Spinal Cord Injury

      By Ryan Martin, MD; Lara Zimmermann, MD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD; Kiarash Shahlaie, MD, PhD
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      Traumatic Spinal Cord Injury

      • RYAN MARTIN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • LARA ZIMMERMANN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • KEE D. KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • MARIKE ZWIENENBERG-LEE, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA

      Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management.

      This review contains 9 figures, 4 tables and 30 references

      Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction

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    • 12

      Severe Traumatic Brain Injury

      By Ryan Martin, MD; Lara Zimmermann, MD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD; Kiarash Shahlaie, MD, PhD
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      Severe Traumatic Brain Injury

      • RYAN MARTIN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • LARA ZIMMERMANN, MDAssistant Professor, Department of Neurological Surgery and Neurology, University of California, Davis School of Medicine, Sacramento, CA, United States,
      • KEE D. KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • MARIKE ZWIENENBERG-LEE, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA

      Traumatic brain injury remains a leading cause of death and disability worldwide. Patients with severe traumatic brain injury are best treated with a multidisciplinary, evidence-based, protocol-directed approach, which has been shown to decrease mortality and improve functional outcomes. Therapy is directed at the prevention of secondary brain injury through optimizing cerebral blood flow and the delivery of metabolic fuel (ie, oxygen and glucose). This is accomplished through the measurement and treatment of elevated intracranial pressure (ICP), the strict avoidance of hypotension and hypoxemia, and in some instances, surgical management. The treatment of elevated ICP is approached in a protocolized, tiered manner, with escalation of care occurring in the setting of refractory intracranial hypertension, culminating in either decompressive surgery or barbiturate coma. With such an approach, the rates of mortality secondary to traumatic brain injury are declining despite an increasing incidence of traumatic brain injury.

      This review contains 3 figures, 5 tables and 69 reference

      Key Words: blast traumatic brain injury, brain oxygenation, cerebral perfusion pressure, decompressive craniectomy, hyperosmolar therapy, intracranial pressure, neurocritical care, penetrating traumatic brain injury, severe traumatic brain injury

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  • Burns
    • 1

      Management of the Patient With Thermal Injuries

      By Nicole S. Gibran, MD, FACS; Michael J. Mosier, MD, FACS, FCCM
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      Management of the Patient With Thermal Injuries

      • NICOLE S. GIBRAN, MD, FACSProfessor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA
      • MICHAEL J. MOSIER, MD, FACS, FCCMAssociate Professor of Surgery, Loyola Burn Center, Loyola University Medical Center, Maywood, IL

      Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients.

      This review contains 3 highly rendered figures, 12 tables, and 134 references

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    • 2

      Inhalation Injury

      By Madhu Subramanian, MD; Erica I Hodgman, MD; Steven E Wolf, MD
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      Inhalation Injury

      • MADHU SUBRAMANIAN, MDResearch Fellow, Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas – Southwestern Medical Center, Dallas, TX
      • ERICA I HODGMAN, MDResearch Fellow, Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas – Southwestern Medical Center, Dallas, TX
      • STEVEN E WOLF, MDProfessor and Vice-Chair for Research, Division of Burn, Trauma, and Critical Care, Department of Surgery, University of Texas – Southwestern Medical Center, Dallas, TX

      Among those who have been burned in fires, inhalation injury is common from high-temperature air in the upper airway and inhaled toxins in smoke, causing metabolic poisoning and chemical burns in the trachea and lower airways. The diagnosis of inhalation injury is difficult as it is often based on qualitative measures in the history and physical examination, although measurement of carboxyhemoglobin and untoward acidosis are effective indirect measures. The use of CT for diagnosis is also playing a greater role. Treatment is generally supportive with airway and ventilator support, including the use of volumetric diffuse respiration and occasionally hydrogen cyanide antidotes. Inhalation injury is contributory to morbidity and mortality in the severely burned but is often a signal of the severity of the burns as well. This review discusses the pathophysiology, diagnosis, and treatment of inhalation injury, with an emphasis on potential complications. 

       

      This review contains 1 figure, 4 tables and 159 references

      Key words: airway pressure release ventilation, bronchodilator therapy, carbon monoxide poisoning, cyanide poisoning, inhalation injury

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