The Surgical clinics of North America
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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.
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Critically ill patients in intensive care units are subject to many complications associated with therapy. Many of these complications are health care-associated infections and are related to indwelling devices, including ventilator-associated pneumonia, central line-associated bloodstream infection, catheter-associated urinary tract infection; surgical site infection, venous thromboembolism, deep venous thrombosis, and pulmonary embolus are other common complications. All efforts should be undertaken to prevent these complications in surgical critical care, and national efforts are under way for each of these complications. In this article, epidemiology, risk factors, diagnosis, treatment, and prevention of these complications in critically ill patients are discussed.
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Initial evaluation of severely injured patients requires an organized, rapid, and thorough evaluation of the patient where life-threatening injuries are identified and treated simultaneously. A case study provides the basis for discussion of the management of the multiply injured trauma patient. The ultimate goal in rehabilitation of a multiply injured patient is to return each patient to as much independent function and ability to contribute to society as possible.