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KEY POINTS

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KEY POINTS

  1. Demand is growing for postoperative intensive care services due to changing surgical techniques and the aging of the population. Because of advances in minimally invasive surgery, improved anesthetic techniques and options for post-operative analgesia, the critically ill patient population has changed.

  2. Anesthesiologists and surgical intensivists play a major role in ensuring responsible use of this costly resource.

  3. Critically ill patients are at risk for a variety of pulmonary complications, including aspiration, ventilator-associated pneumonia, and acute lung injury. Intensive care management is directed at minimizing the risk factors predisposing patients to these complications.

  4. The concept of chronic critical illness has become more adequately characterized as a state of anergy, immunosuppression, chronic multiorgan system dysfunction, cognitive dysfunction, and critical illness polyneuropathy and myopathy that is difficult to reverse and carries a high morbidity and mortality.

  5. Advanced monitoring devices such as noninvasive ICP monitors, cerebral oximeters, BIS monitors, continuous TEE (transesophageal echo), noninvasive cardiac output monitors, and continuous end-tidal CO2 (carbon dioxide) assist the intensivist in complex decision making.

  6. Conservative fluid management results in improved lung function and shortens the duration of both mechanical ventilation and intensive care stay without altering the rate of extrapulmonary organ failure.

  7. The stress response after major surgery or injury is often accompanied by a period of endothelial cell dysfunction and capillary leak with loss of plasma volume into the extracellular third space. The stress response may be initiated by tissue hypoperfusion due to inadequate fluid resuscitation, ischemia-reperfusion injury, cytokine release, or exposure of the circulating blood volume to an extracorporeal circuit (ie, blood salvage circuits, cardiopulmonary bypass).

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INTRODUCTION

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The surgical intensive care unit (SICU), or a combined medical-surgical ICU, is a specialized patient care area designed to care for critically ill surgical patients in the perioperative period, which may include preoperative, postoperative, and posttrauma injury management. As critical care techniques have evolved, it has become possible to both save the lives of some who might previously have died and prolong the lives of others who will nevertheless still not survive. The percentage of critical care beds has grown in many hospitals, and it is still an increasingly expensive and constrained resource, due in part to shortages of qualified physicians, nurses, and ancillary personnel. Because of supply and demand constraints for this scare and expensive resource, it is a continual challenge to ICU practitioners to find models of efficient and appropriately targeted intensive care.

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The types of patients admitted to ICUs have changed considerably over the past several decades. The evolution of trauma systems with rapid transportation of critically injured patients has resulted in the concentration of high-acuity multitrauma patients in trauma centers. The evolution of ventricular assist devices, thoracic aortic surgery, and heart and lung transplantation has revolutionized cardiothoracic surgery and changed the nature of perioperative cardiac intensive care. New approaches to the management of head injury and advanced neurosurgical techniques require increased technological ...

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