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In the United States, the typical approach is to wait 1 week for a patient who was previously well nourished to recover gastroin- testinal function before starting parenteral nutrition. fte Society for Critical Care Medicine and ASPEN support this approach in their guidelines because of concerns about complications of par- enteral nutrition, including hypertriglyceridemia, hyperglycemia, cholestasis, and central line-associated bloodstream infections (CLABSI).
In 1999, the TRICC trial, a landmark ran- domized trial that examined transfusion requirements in critical care, showed decreased mortality when a restrictive transfusion practice was compared with a liberal transfusion practice. ftis study established hemoglobin less than 7 mg/dL as a "transfusion trigger" for most patients, and the mortality benefit was still observed in patients with preexisting cardiac disease.33 Additional research confirmed that hemoglobin levels of 7 mg/dL are well tolerated by ICU patients, and the only patients who benefit from more liberal transfusion are patients who are actively bleeding or manifesting acute coronary ischemia.
Hemorrhagic shock, trauma, wounds and incisions, drains, catheters, tubes, devitalized tissue, hematomas, immunosuppressants, and malnutrition are just some of the many reasons why surgical ICU patients have the greatest risk of infection among all critical care settings.
Modern ICU care has made significant progress as technology and medications have improved, but some of the most dramatic advancements in the quality of care have been driven by the embrace of evidence-based practice. ftese changes coupled with an aging population who are living longer with more comor- bidities has called into question some of the purpose of critical care as the focus turns from quantity of life to quality of life.
"Surviving intensive care: a report from the 2002 Brussels Roundtable" was a landmark article in Intensive Care Medicine that suggested that short-term outcomes such as in-hospital mortality were poor mea- sures of "patient-centered outcomes." fte authors also introduced the concept that the health and well-being of families of ICU patients should also be included in research looking at outcomes of critical care.،Critical care of the nervous system is based on control of cerebral and spinal cord physiology and the prevention of secondary insults.
Critical care of the central nervous system (CNS) involves collaboration among several disciplines-neurosurgery, anesthesiology, neurology, neuroradiology, and electrophysi- ology.
The use of a neurocritical care team, rather than single specialty care, has been asso- ciated with reduced in-hospital mortality and the length of stay.2 Although other specialists can train to be neurointen- sivists, anesthesiologists with training in neuroanesthesia and critical care are particularly well suited to demonstrate the combination of airway and cardiovascular support skills that, together with an understanding of the physiology and phar- macology of the nervous system, may improve the outcome.
Therefore, in the critical care setting, the management of TBI patients should follow established protocols with close monitoring of parameters, including CPP, ICP, and oxygenation status.118 Clinical assessments like continuous measurement of arterial blood pressure, heart rate, and pulse oximetry in combination with monitoring volume status, urine output, and GCS have to be performed.
Cerebrovascular diseases are the leading cause of death and disability worldwide.143 Although clinical presentations and outcomes are highly variable, initial management often requires critical care resuscitation.
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