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KEY POINTS

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KEY POINTS

  1. It is of the utmost importance that the staff of the intensive care unit (ICU) understands exactly the type and purpose of each of the foreign bodies and tubes as well as how these tubes should be managed.

  2. The aggregate of evidence from the last 15 years generally supports the notion that limited transfusion thresholds are correlated with superior outcomes in most patient populations.

  3. Early parenteral nutrition (< 7 days post-ICU admission) has been associated with increased risk of nosocomial infections without benefit.

  4. Stress dose steroids should only be considered in refractory septic shock after fluids have been given. There is no benefit to performing adrenocorticotropic hormone (ACTH) stimulation test or random cortisol level.

  5. Early mobility decreases length of stay and ventilator duration, and it has been shown to be cost-effective.

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INTRODUCTION: INTENSIVE CARE UNIT VERSUS POSTANESTHESIA CARE UNIT

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Postoperative patients who require critical care include: those planned for intensive care unit (ICU) admissions because of an anticipated lengthy operative course and recovery and those requiring ICU care because of unforeseen clinical circumstances or emergencies. Patients who require standard immediate postoperative care are generally admitted to a postanesthesia care unit (PACU). Depending on a hospital's unique capabilities, a PACU is capable for caring for the general ongoing mechanical ventilation and hemodynamic needs of a patient, under the supervision of an anesthesiologist.

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Though a PACU can and should be capable of functioning at the same level of an ICU, in reality the day-to-day comprehensive multidisciplinary management is efficiently accomplished in the medium and long-term in a formal ICU with trained intensivists. In the circumstance where a PACU cares for patients who are awaiting an ICU bed, formal consultation with an intensivist for ongoing care is highly valuable.

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There are some patient populations, such as those undergoing liver transplant, cardiac and trauma surgery, for whom assured direct postoperative admission to an ICU and avoiding the PACU altogether are essential to ensure optimal care by experienced specialized staff.

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Hand-Offs

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A unique aspect of the critical care management of surgical patients is that the information about the patient needed by the intensivist from the preoperative and intraoperative care is often fragmented. In the United States, surgical patients are always followed primarily by the surgeon(s) who performed the operation. Subspecialists who cared for the patient preoperatively and the anesthesiologist who cared for the patient intraoperatively may have important information relevant to the ICU clinicians. For example, the estimated blood loss value may vary widely depending on who reports these data (surgeons often underestimate blood loss). Data about unforeseen difficult airways, intraoperative hypotension, greater than expected blood loss, and other complications are often not readily available or communicated to the ICU, and the intensivist should be aware of this phenomenon and assured that they have the most accurate and comprehensive picture of the patient admitted to the ICU. When feasible, the intensivist should make every effort to begin their consultation ...

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