Caring for critically ill patients began through recognizing the unique needs of the acutely injured and postoperative patient. In the 1850s during the Crimean War, Florence Nightingale placed the most seriously ill patients in beds near the nursing station. This stressed the importance of a separate geographic location for critically ill and injured patients. Dr Walter E. Dandy, in 1923, at the Johns Hopkins Hospital created a three bed postoperative unit for neurosurgical patients and staffed the unit with specially trained nurses to manage and monitor these patients. The Second World War brought about the creation of specialized shock units to provide resuscitation for the large number of critically injured soldiers. The 1950s experienced the widespread development of shock units and postoperative recovery units. In addition, respiratory units were created due to the large number of polio patients requiring mechanical ventilation. In 1986, the American Board of Medical Specialties approved certification in Critical Care for the four primary boards: anesthesiology, internal medicine, pediatrics, and surgery.
Surgical Critical Care is a core competency of surgical training and relates to the care of patients with acute, life-threatening or potentially life-threatening surgical conditions. Surgical Critical Care brings together the art of critical care management of severely ill patients with the science of surgical procedures targeted at improving their altered physiology. These surgeons are well versed in the pre and postoperative management of patients after undergoing surgical procedures from any surgical discipline and of any age group. While much of the knowledge base is shared with other critical care specialists, fellowship training provides the surgical critical care specialist with specific expertise relating to the interactions between the patients disease process and the pathophysiologic response to infections, inflammation, ischemia, trauma, burns, and operations. Given the rising rate of Hospitalist comanagement of surgical patients, this chapter will cover the most common surgical critical care patient types, and the management of the most common surgical conditions encountered among these patients for the Hospitalist.
SURGICAL CRITICAL CARE ADMIT TYPES
Patients may be admitted to the ICU from the Emergency Department, preoperatively, immediately postoperatively, or postoperatively after initial admission to the postanesthesia care unit or the ward. Preoperative admission may be required for resuscitation in the event of preoperative respiratory failure, shock, or sepsis. ICU admission may also be required for patients who need invasive monitoring for hemodynamic optimization prior to undergoing surgical procedures.
Postoperatively, patients may be admitted to the ICU for respiratory failure, hemodynamic instability, or close monitoring for complications such as bleeding or other physiologic derangements. Patients may also require admission to the ICU due to exacerbation of underlying comorbidities or after procedures with significant blood loss or massive fluid shifts. Some patients need prolonged mechanical ventilation due to the effects of general anesthesia, airway edema, dysfunctional pulmonary mechanics, acute lung injury, traumatic injury to the respiratory tract, ...