Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 318 - файл

• FAST exam may be applied to evaluate for tamponade. If

no cardiac activity or tamponade, care may be futile.

team should concomitantly secure a denitive airway

nous access for uid and blood resuscitation, and place a

impossible in a tamponade.

• Before cross-clamping the aorta, incise the parietal pleura

that covers the descending thoracic aorta.

• The descending aorta should not be circumferentially

mobilized to apply a cross-clamp.

during cardiac massage or if the patient regains a

• Removal of the aortic cross-clamp or replacement of the

is so great that despite adequate resuscitation, it overwhelms the capacity for recovery and severe SIRS develops. A sec­ond “activating” event may also occur after the initial injury, which leads to a rapid downward spiral into multiorgan fail­ure. The majority of modern critical care is designed to decrease the likelihood of this second event and/or to abro­gate its effects on the patient.

Point of care ultrasonography (POCUS) has become extremely popular as a monitoring modality in the ICU over the past few years and is relatively inexpensive. It is a skill set that is now being taught routinely in both surgical resi­dencies and critical care fellowships. The diagnostic impact of POCUS has been shown to be as high as 85% whether that be conrming an expected diagnosis or resulting in a change of diagnosis and therefore a change in patient management. The ability to observe directly the heart, lungs, inferior vena cava, aorta, etc., with the ultrasound at bedside greatly improves the decision-making ability of the clinician, espe­cially from a hemodynamics standpoint. Lung ultrasonogra­phy has really come into popular use over the last several years, demonstrating a higher reliability diagnosing a pneu­mothorax than standard chest X-ray. Furthermore, lung ultrasound has proven very useful in the assessment of ade­quacy of intubation, to aid with ventilatory changes and assess weaning strategies. Ultrasonography has also allowed for improvements in bedside procedures, resulting in a lower complication rate, especially when it comes to the cannula­tion of vascular structures. Transesophageal ultrasonography has also gained popularity in the monitoring of volume sta­tus; however, this modality is more invasive and requires the patient to be intubated. Although the disadvantage of ultraso­nography is that it is operator dependent, the application of this technology is vast and has demonstrated both reliability and reproducibility.

As we have come to better understand the physiology behind ARDS, multiple modalities have been developed to better manage these patients. Prevention of ARDS develop­ment is most important through more judicious intravenous uid resuscitation with better monitoring and the use of a “low tidal volume” strategy for ventilation. When ARDS does develop, airway pressure release ventilation (APRV) appears to be effective in reversing atelectasis and improving oxygenation without requiring the deep sedation or paralysis that is usually necessary in the other forms of ventilation. Furthermore, a recent study demonstarted a 16% decrease in mortality for those patients who develop severe ARDS who are placed in the prone position. Although proning a patient is not always easy, it requires minimal resources that should allow it to be performed in most ICUs.

It is very common for trauma surgeons to care for a high number of elderly patients who have multiple cardiac comor­bidities such as coronary artery disease, valvular problems, or arrhythmias. Patients frequently have stents in place and are on clopidogrel and aspirin or are anticoagulated with warfarin, apixaban, dabigatran, or rivaroxaban. The risk of thromboses in these patients needs to be carefully weighed against the risk of ongoing hemorrhage if the anticoagulation is maintained. Furthermore, if there is ongoing bleeding, these medications may need to be reversed. Unfortunately, for many of these newer agents, reversal can be very chal­lenging as there are not many agents to reverse them and the agents that are currently available are very expensive. The reversal of warfarin has been fairly consistent for years uti­lizing vitamin K and fresh frozen plasma, although the pro­thrombin complex concentrates have recently become available and are more effective in reversing the effect of Warfarin. However, for the factor Xa inhibitors (apixaban, rivaroxban), prothrombin complex concentrate (PCC) is rou­tinely used but not always successful. The thrombin inhibi­tors (dabigatran) can undergo hemodialysis to remove the effects of the anticoagulant as well as a recent medication (idarucizumab) was developed to specically reverse the effects of dabigatran. Unfortunately, the factor Xa inhibitors are resistant to hemodialysis; however, new medications are currently being developed and researched as potential rever­sal agents for this group of anticoagulation medications.

Total parenteral nutrition (TPN) retains a place in surgical nutrition, specically in those patients who cannot tolerate enteral feeds or who have enterocutaneous stulas. Use of a PICC line for administration rather than a central line decreases some of the mechanical complications, but patients are still at risk for metabolic and infectious problems. Close monitoring of electrolytes is mandatory with TPN.Transition to enteral feeding should be established as soon as possible as this will help maintain bowel integrity and provide bene­ts with regard to healing, hepatic protein synthesis, hor­monal function of the gut, and immune function. TPN should only be used in cases where the patient will be unable to tolerate enteral feeds for at least 7days.

Many hospitals have protocols for electrolyte replace­ment on standard order sets, although in the asymptomatic patient who is tolerating a diet, most of these electrolyte abnormalities are of little consequence. In contrast, the intu­bated patient in the ICU with arrhythmias should have elec­trolyte levels closely monitored and aggressively corrected. Hypo- or hypernatremia may be the result of an underlying serious disease such as the syndrome of inappropriate ADH or diabetes insipidus and needs to be appropriately investi­gated and treated. Hypophosphatemia and hypomagnesemia are two other conditions that are common in the ICU setting and should be treated aggressively due to the serious conse­quences that can arise, especially prolonged ventilation.

Injury is the still the leading cause of death for patients 44 years of age or less. Twenty to forty percent of trauma deaths occurring after hospital admission involve massive hemorrhage from truncal injury and are potentially prevent­able with rapid hemorrhage control and improved resuscita­tion techniques. Damage control resuscitation, dened as rapid hemorrhage control through early administration of blood products in a balanced ratio (1:1:1 for units of plasma to platelets to red blood cells; a ratio that is the closest approxi­mation to reconstituted whole blood), has emerged as the stan­dard of care for traumatic resuscitation through prevention and immediate correction of coagulopathy, as well as minimiza­tion of crystalloid uids. A recent large, prospective trial dem­onstrated the efcacy of a 1:1:1 ratio of traumatic transfusion when compared to a 1:1:2 ratio. Although there was no signi­cant difference in mortality, the group receiving blood product transfusions in a 1:1:1 ratio achieved hemostasis faster and fewer patients experienced death by exsanguination in 24h. Whole blood resuscitation has also been gaining traction in civilian trauma resuscitation. Already demonstrating superior-

Multiple protocols (i.e., ventilator bundles) have been established as part of ICU sepsis preventive care and should be established in all intensive care units regardless of size, location, resources, etc., as these protocols will provide better patient care and decrease overall hospital costs. Unfortunately, even with strong preventative measures, infections do occur. Source control remains an important part of the ght against infection in the trauma patient, which may require surgical drainage, aggressive debridement of soft tissue infections, and multiple operations to obtain nal control of the infec­tion. Although the tissue defects created may be large, an aggressive initial debridement will serve the patient much better than leaving a continued source of sepsis behind.

A guiding principle for antibiotic use in the ICU should be the early use of empiric antibiotics in suspected cases of infection. Although at times challenging, early implementa­tion of empiric antibiotics has been shown to decrease over­all mortality. Furthermore, all attempts should be made to cover likely bacteria within the given infected tissue and de­escalation opportunities for antibiotic coverage should be assessed daily to prevent the development of resistant bacte-

Prevention of UTIs also remains a problem, with many patients requiring indwelling Foley catheters due to the sever­ity of illness, the need for accurate urine output monitoring, or an inability to spontaneously void. UTIs are the second most common nosocomial infection and can prolong length of stay as well as lead to unnecessary morbidity. As the risk for devel­opment of an UTI linearly increases with length of time the catheter remains in place, patients should have their need for an indwelling catheter assessed daily, and it should be removed as soon as possible. Early removal of the catheter is the only proven intervention to reduce the risk of UTI.Of note, the presence of an epidural for analgesia is not an indication to keep a Foley catheter in place and can be safely removed with less than a 10% occurrence of urinary retention.