The Surgical clinics of North America
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Several changes in the way patients with hemorrhagic shock are resuscitated have occurred over the past decades, including permissive hypotension, minimal crystalloid resuscitation, earlier blood transfusion, and higher plasma and platelet-to-red cell ratios. Hemostatic adjuncts, such as tranexamic acid and prothrombin complex, and the use of new methods of assessing coagulopathy are also being incorporated into resuscitation of the bleeding patient. These ideas have been incorporated by many trauma centers into institutional massive transfusion protocols, and adoption of these protocols has resulted in improvements in mortality and morbidity. This article discusses each of these new resuscitation strategies and the evidence supporting their use.
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Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. ⋯ Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.
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The treatment of respiratory failure requiring mechanical ventilation has advanced significantly over the last 20 years. The goal of therapy in patients with acute respiratory distress syndrome should be to optimize oxygenation while minimizing the risk of ventilator-induced lung injury and providing adequate ventilation. Appropriate use of ventilation modes and strategies, positive-end expiratory pressure levels, and recruitment maneuvers can improve oxygen delivery. Salvage therapies, such as prone positioning, inhaled epoprostenol and nitric oxide, and high-frequency oscillatory ventilation, have a well-established role in supportive management and are associated with improved oxygenation but not survival.
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The Institute of Medicine strongly recommends a health care system that supports family members. Nowhere is the need for family-centered care greater than with critically ill patients. ⋯ This article reviews some strategies to improve communication, including family meetings and family presence at resuscitation. It also highlights some of the areas within the realm of ICU care in which family engagement is particularly important, including advance directives, end-of-life care, brain death, and organ donation.
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Intra-abdominal infections are a common problem for the general surgeon and major sources of morbidity and mortality in the intensive care unit. Some of these patients present with peritonitis that can rapidly progress to septic shock. ⋯ This article will use a detailed case study to outline the management of a patient with severe intra-abdominal infection from diverticulitis from initial resuscitation to reconstruction. Components of the Surviving Sepsis Campaign as they pertain to surgical patients are discussed and updated, and the concept of damage control general surgery is applied.