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Foreword

Critically ill patients encountered in the practice of acute care surgery are a diverse lot. They may have widely divergent patterns of injury, or profound immunosuppression from injury, massive transfusion, neoplastic disease, or therapy, as after solid organ transplantation. Moreover, they may present at the extremes of age, with diverse physiology and responsiveness to stress, particu­larly among elderly patients, who have senescent immunity and impaired wound healing, and may have multiple medical co-morbidities — such as car­diovascular disease or diabetes mellitus — that may impair responsiveness to injury-related stress, whether it be due to multiple injuries or major surgery, or both.
Despite this diversity, there are crucial aspects of their disease states and the care that critically ill surgical patients receive have much in common. The practice of acute care surgery is inherently invasive. Incisions, percutaneous inter­ventions, and indwelling monitoring catheters breach natural epithelial barriers to invasion of the host by pathogens, posing incremental risk to a vulnerable popula­tion. The risk of nosocomial infectionis increased by about one-third compared with comparably ill medical intensive care patients. In turn, such infections have
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xii Foreword
been associated with increased risk of mortality and other types of morbidity related to multiple organ dysfunctions syndrome. The financial cost is enormous, and survivors of complicated ICU courses may need months or years to achieve full functional recovery.
The great paradox of critical surgical illness is that the most unstable, at-risk patients often need the most aggressive, invasive care to achieve favorable outcomes. The experienced acute care surgeon combines detailed knowledge of anatomy, physiology, biochemistry, pharmacology, immunology, medical imag­ing, ethics, rehabilitation medicine, communication skills, team building, monitors, devices, and biomaterials with consummate technical skill to integrate pathophysiology and balance risk and benefit. Complex decision-making must occur continuously and in parallel for multiple issues in several patients, and must often be followed by decisive interventions. There is no substitute for experience; computerized decision support systems and artificial intelligence engines have yet to prove that they are equal to the task.
This procedure-oriented volume is directed appropriately and suited espe­cially to medical students, surgery residents, and fellows in acute care surgery or surgical critical care. Described herein are all of the common procedures that may be indicated in daily practice in the surgical intensive care unit or the trauma bay. Experienced practitioners will recognize that the descriptions in these pages represent “a way” of doing things, not necessarily “the way.” There is indeed, as the saying goes (with apologies to all animal-lovers), “more than one way to skin a cat.” These procedure descriptions represent the collective wisdom and experi­ence of the skilled, dedicated practitioners at Denver Health Medical Center (DHMC), an institution of renown that is recognized for expertise and compas­sionate care for an underserved patient population. In their hands, these interventions are effective and rendered as safe as they can be. Doctors Pieracci and Moore and the group at DHMC are to be commended for this valuable con­tribution. It is hoped that the readership will be guided and inspired to master these techniques and develop their own technical refinements to incorporate into their own practices.
More than just a “how-to” manual, disease-state information is provided to orient the reader to the appropriate use of these interventions. This contextual information is fundamental by design, so the reader is reminded and encouraged to look elsewhere for the detailed knowledge of critical illness and critical care described above, which is mandatory and essential. Early command of these techniques will provide the readership the opportunity to devote maximal effort
Foreword xiii
to mastery of the vast body of knowledge needed to practice acute care surgery effectively and safely. Experience will accrue with time and effort.
Philip S. Barie, MD, MBA, Master CCM, FIDSA, FACS
Professor of Surgery
Professor of Public Health in Medicine
Joan and Sanford I. Weill Medical College of Cornell University
Attending Surgeon
Chief, Preston A. (Pep) Wade Acute Care Surgery Service
NewYork-Presbyterian Hospital/Weill Cornell Medical Center
New York, New York
USA
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Contributing Authors

Ashok Babu, MD
Assistant Professor of Surgery University of Colorado School of Medicine 12505 E. 16th Ave. Aurora, CO 80045 Email: Ashok.babu@ucdenver.edu
CARDIOTHORACIC
James R. Bailey, MD
Orthopaedic Surgery Fellow University of Colorado School of Medicine 777 Bannock St. MC 0188 Denver, CO 80204 Email: James.Bailey@dhha.org
ORTHOPAEDICS
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xvi Contributing Authors
Carlton C. Barnett, MD
Professor of Surgery University of Colorado School of Medicine 777 Bannock Street, MC0206 Denver, CO 80204 Email: Carlton.barnett@dhha.org
HEPATOPANCREATICOBILIARY INTRA-ABDOMINAL INFECTIONS
Kathryn Beauchamp, MD
Chief of Neurosurgery Denver Health Medical Center University of Colorado Health Sciences Center 777 Bannock Street, MC0206 Denver, CO 80204 Email: kathryn.beauchamp@dhha.org
CEREBRAL BLOW FLOW INTRA-CRANIAL HYPERTENSION LUMBAR PUNCTURE
Marshall T. Bell, MD
Surgical Resident University of Colorado School of Medicine 12631 E. 17th Ave, C-305 Aurora, CO 80045 Email: Marshall.bell@ucdenver.edu
BLOODSTREAM/CENTRAL VENOUS CATHETER-ASSOCIATED INFECTIONS
Bethany Benish, MD
Assistant Professor of Anesthesiology University of Colorado School of Medicine 777 Bannock Street Denver, CO 80204 Email: Bethany.benish@dhha.org
ARTERIAL CANNULATION
Contributing Authors xvii
Daine T. Bennett, MD
Surgical Resident University of Colorado School of Medicine 12631 East 17th Ave MS 302 Aurora, CO 80045 Email: daine.bennett@ucdenver.edu
PLEURAL SPACE AND MEDIASTINUM
Denis Bensard, MD
Professor of Surgery University of Colorado School of Medicine 777 Bannock Street, MC0206 Denver, CO 80204 Email: denis.bensard@dhha.org
PEDIATRIC
Clay Cothren Burlew, MD
Director of Surgical Intensive Care Unit Denver Health Medical Center Professor of Surgery, University of Colorado School of Medicine 777 Bannock Street, MC 0206 Denver, CO 80204 Email: clay.cothren@dhha.org
ABDOMINAL COMPARTMENT SYNDROME PERCUTANEOUS TRACHEOSTOMY BEDSIDE LAPAROTOMY
Dominykas Burneikis, MD
Surgical Resident University of Colorado School of Medicine 12631 East 17th Ave, MS C313, Aurora CO 80045 Email: Dominylas.Burneikis@ucdenver.edu
ACID-BASE PHYSIOLOGY
xviii Contributing Authors
Walter L. Biffl, MD
Associate Director of Surgery, Denver Health Medical Center Professor of Surgery, University of Colorado School of Medicine 777 Bannock St., MC 0206 Denver, CO 80204 Email: walter.biffl@dhha.org
RECOGNITION AND CHARACTERIZATION OF SHOCK TUBE FEED INTOLERANCE
Brandon C. Chapman, MD
Surgical Resident University of Colorado School of Medicine 777 Bannock Street, MC0206 Denver, CO 80204 Email: Brandon.Chapman@ucdenver.edu
HEPATOPANCREATICOBILIARY
Shea Cheney, MD
Emergency Department Resident Denver Health Medical Center Department of Emergency Medicine 777 Bannock Street Denver, CO 80204 Email: sheajcheney@gmail.com
CENTRAL VENOUS CANNULATION
Theresa L. Chin, MD, MPH
Surgical Resident University of Colorado School of Medicine 12631 East 17th Ave, C313 Email: Theresa.chin@ucdenver.edu
GLYCEMIC CONTROL
Contributing Authors xix
Daniel Craig, MD
Neurosurgical Resident University of Colorado School of Medicine 777 Bannock St, MC 0206 Denver, CO 80204 Email: daniel.craig@ucdenver.edu
LUMBAR PUNCTURE
Maria Albuja Cruz, MD
Assistant Professor of Surgery University of Colorado School of Medicine 12631 East 17th Ave, MS C313 Aurora, CO 80045 Email: Maria.albujacruz@ucdenver.edu
ENDOCRINE EMERGENCIES
Thomas M. Dunn, PhD
Associate Professor of Psychological Science University of Northern Colorado, Greeley Greeley Clinical Instructor of Psychiatry University of Colorado School of Medicine Email: Thomas.Dunn@dhha.org
SURGICAL CRITICAL CARE AND BEHAVIORAL HEALTH ETHICS OF SURGICAL CRITICAL CARE
C.N. Eisenhauer, MD
Surgical Resident, University of Colorado School of Medicine 12631 East 17th Ave, MS C313 Aurora, CO 80045 Email: Charles.Eisenhauer@ucdenver.eud
INITIAL APPROACH TO THE TRAUMA PATIENT