【Crit Care Med专题】ICU感控管理

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1. Methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus: Recognition and prevention in intensive care units
Michael Y. Lin, MD, MPH; Mary K. Hayden, MD
(Crit Care Med 2010;38[Suppl.]:S335–S344)
Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-
resistant enterococcus (VRE) have achieved significant
rates of colonization and infection in most intensive care units
(ICUs). Both pathogens share common epidemiologic characteristics
that suggest similar surveillance and control strategies.
MRSA and VRE are readily found on colonized patients and their
environment; healthcare workers’ hands are a major vector of
patient-to-patient transmission. Generally accepted strategies for
control include conducting a baseline risk assessment and establishing
metrics for monitoring MRSA and VRE rates in ICUs;
promoting hand hygiene compliance; guaranteeing adequate
staffing levels; ensuring adequate environmental cleaning; and
using “bundled” interventions to decrease site-specific ICU infections
(e.g., central venous catheter-associated bloodstream infections).
During periods of inadequate control, special strategies are
available, although no consensus exists over which combination
of these interventions is most effective. Some special interventions
are pathogen specific (targeted), such as active surveillance
and decolonization. Others are pathogen nonspecific (global),
such as daily chlorhexidine bathing of all patients in the ICU. We
review the evidence for these interventions to help ICU personnel
better control MRSA and VRE in their units. (Crit Care Med 2010;
38[Suppl.]:S335–S344)
KEY WORDS: Staphylococcus aureus; methicillin resistance; vancomycin-
resistant enterococcus; intensive care unit; surveillance;
prevention; hospital-acquired infection

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题目：Acute care surgery in evolution
作者：Kimberly A. Davis, MD, FACS, FCCM; Grace S. Rozycki, MD, MBA, FACS
杂志：Crit Care Med 2010 Vol. 38, No. 9 (Suppl.)
摘要：
At the center of the development of acute care surgery is the growing difficulty in caring for patients with acute surgical conditions. Care demands continue to grow in the face of an escalating crisis in emergency care access and the decreasing availability of surgeons to cover emergency calls. To compound this problem, there is an ever-growing shortage of general surgeons as technological advances have encouraged subspecialization. Developed by the leadership of the American Association for the Surgery of Trauma, the specialty of acute care surgery offers a training model that would produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and elective and emergency general surgery. This article highlights the evolution of the specialty in hope that these acute care surgeons, along with practicing general surgeons, will bring us closer to providing superb and timely care for patients with acute surgical conditions. (Crit Care Med 2010; 38[Suppl.]:S405–S410)
KEY WORDS: surgery; acute surgical care; training; fellowship
program; accreditation

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题目：Changing paradigms in surgical resuscitation
作者：Yvette Fouche, MD; Robert Sikorski, MD; Richard P. Dutton, MD, MBA
杂志：(Crit Care Med 2010; 38[Suppl.]: S411–S420)
摘要：
Patients undergoing emergency surgery typically require resuscitation,
either because they are hemorrhaging or because they are
experiencing significant internal fluid shifts. Intravascular hypovolemia
is common at the time of anesthesia induction and can lead to
hemodynamic collapse if not promptly treated. Central pressure
monitoring is associated with technical complications and does not
improve outcomes in this population. Newer modalities are in use,
but they lack validation. Fluid resuscitation is different in bleeding
and septic patients. In the former group, it is advisable to maintain a
deliberately low blood pressure to facilitate clot formation and stabilization.
If massive transfusion is anticipated, blood products
should be administered from the outset to prevent the coagulopathy
of trauma. Early use of plasma in a ratio approaching 1:1 with red
blood cells (RBCs) has been associated with improved outcomes. In
septic patients, early fluid loading is recommended. The concept of
“goal-directed resuscitation” is based on continuing resuscitation
until venous oxygen saturation is normalized. In either bleeding or
septic patients, however, the most important goal remains surgical
control of the source of pathology, and nothing should be allowed to
delay transfer to the operating room. We review the current literature
and recommendations for the resuscitation of patients coming for
emergency surgery procedures. (Crit Care Med 2010; 38[Suppl.]:
S411–S420)
KEY WORDS: resuscitation; emergency; trauma; deliberate hypotension;
transfusion; vasopressin; stroke volume variation; plasma;
colloid; monitoring

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题目：Damage control in trauma and abdominal sepsis
作者：Brett H. Waibel, MD, FACS; Michael F. Rotondo, MD, FACS
杂志：(CritCare Med 2010; 38[Suppl.]:S421–S430)
摘要：Damage control surgery, initially formalized <20 yrs ago, was
developed to overcome the poor outcomes in exsanguinating
abdominal trauma with traditional surgical approaches. The core
concepts for damage control of hemorrhage and contamination
control with abbreviated laparotomy followed by resuscitation
before definitive repair, although simple in nature, have led to an
alteration in which emergent surgery is handled among a multitude
of problems, including abdominal sepsis and battlefield
surgery. With the aggressive resuscitation associated with damage
control surgery, understanding of abdominal compartment
syndrome has expanded. It is probably through avoiding this
clinical entity that the greatest improvement in surgical outcomes
for various emergent surgical problems has occurred in the past
two decades. However, with its success, new problems have
emerged, including increases in enterocutaneous fistulas and
open abdomens. But as with any crisis, innovative strategies are
being developed. New approaches to control of the open abdomen
and reconstruction of the abdominal wall are being developed
from negative pressure dressing therapies to acellular allograft
meshes. With further understanding of new resuscitative strategies,
the need for damage control surgery may decline, along with
its concomitant complications, at the same time retaining the
success that damage control surgery has brought to the critically
ill trauma and general surgery patient in the past few years. (Crit
Care Med 2010; 38[Suppl.]:S421–S430)

KEY WORDS: damage control; resuscitation; abdominal wounds;
sepsis; trauma

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题目：Current trends in neurotrauma care
作者：Shelly D. Timmons, MD, PhD, FACS
杂志：(Crit Care Med 2010; 38[Suppl.]:S431–S444)
摘要：Severe traumatic brain injury remains a significant cause of
mortality and morbidity worldwide. The use of therapeutic interventions
such as hypertonic saline administration and decompressive
craniectomy have solid foundations and can improve
outcomes, although questions remain about patient selection,
optimal timing, and comparisons to other treatments. Hypothermia,
while having promise, has not definitively been shown to
benefit patients with traumatic brain injury, although clinical
trials are underway. The use of
-blockers in traumatic brain
injury has been proposed as a neuroprotective measure, but data
are lacking to support widespread clinical use. Brain tissue oxygenation
monitoring is gaining widespread acceptance as a safe
tool to provide additional information both to guide therapeutic
interventions and to further elucidate mechanisms of secondary
brain injury. Evidence is also mounting that guided therapy using
brain tissue oxygenation in addition to intracranial pressure and
cerebral perfusion pressure monitoring leads to better outcomes
after traumatic brain injury. (Crit Care Med 2010; 38[Suppl.]:
S431–S444)
KEY WORDS: neurotrauma; neurocritical care; traumatic brain
injury; hypertonic saline; decompressive craniotomy; hypothermia;

-blockers

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题目：Compartment syndromes from head to toe
作者：Zsolt J. Balogh, MD, PhD, FRACS; Nerida E. Butcher, MD
杂志：(Crit Care Med 2010; 38[Suppl.]:S445–S451)
摘要：Compartment syndrome is defined as the dysfunction of organs/
tissues within the compartment due to limited blood supply
caused by increased pressure within the compartment. The aim of
this article is to introduce and discuss acute compartment syndromes
that are essential for critical care physicians to recognize
and manage. Various pathophysiological mechanisms (ischemiareperfusion
syndrome, direct trauma, localized bleeding) could
lead to increased compartmental pressure and decreased blood
flow through the intracompartmental capillaries. Although compartment
syndromes are described in virtually all body regions,
the etiology, diagnosis, treatment, and prevention are best characterized
for three key body regions (extremity, abdominal, and
thoracic compartment syndromes). Compartment syndromes can
be classified as either primary (pathology/injury is within the
compartment) or secondary (no primary pathology or injury within
the compartment), and based on the etiology (e.g., trauma, burn,
sepsis). A recently described phenomenon is the “multiple” compartment
syndrome or “poly”-compartment syndrome, which is
usually a complication of a severe shock and massive resuscitation.
The prevention of compartment syndromes is based on
preemptive open management of compartments (primary syndromes)
in high-risk patients and/or careful fluid resuscitation
(both primary and secondary syndromes) to limit interstitial
swelling. (Crit Care Med 2010; 38[Suppl.]:S445–S451)
KEY WORDS: extremity compartment syndrome; abdominal compartment
syndrome; acute compartment syndrome; organ/tissue
dysfunction; multiple compartment syndrome

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题目：Geriatric care in the surgical intensive care unit
作者：Jay Menaker, MD; Thomas M. Scalea, MD
杂志：(CritCare Med 2010; 38[Suppl.]:S452–S459)
We describe the physiology of aging and its effect on elderly,
critically ill, surgical patients. Postoperative age-specific complications
and their management will be reviewed. The number of
elderly persons, defined as those >65 yrs of age, is the fastest
growing segment of the U.S. population. As a result, the frequency
of surgery, both elective and emergent, performed on elderly
patients will increase. Aging is associated with a decrease in the
physiologic reserve; thus, many elderly persons are unable to
compensate for the increased metabolic demands that accompany
acute illness or injury. This inability to compensate leads to
increased rates of postoperative complications and death. Aggressive,
goal-directed management in the surgical intensive care
unit is beneficial for the geriatric patient. The management of the
elderly, surgical, critical care patient is extremely challenging.
Understanding age-related physiologic changes will help guide
treatment to maximize outcome and prevent complications. (Crit
Care Med 2010; 38[Suppl.]:S452–S459)
KEY WORDS: elderly; geriatric; intensive care unit; respiratory
failure; coagulopathy; monitoring; atrial fibrillation; myocardial
ischemia; nutritional support

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题目：Necrotizing soft tissue infections in the intensive care unit
作者：Ho H. Phan, MD; Christine S. Cocanour, MD, FACS, FCCM
杂志：(Crit Care Med 2010;38[Suppl.]:S460 –S468)
摘要：
Necrotizing soft tissue infection is a severe illness that is
associated with significant morbidity and mortality. It is often
caused by a wide spectrum of pathogens and is most frequently
polymicrobial. Care for patients with necrotizing soft tissue infection
requires a team approach with expertise from critical care,
surgery, reconstructive surgery, and rehabilitation specialists.
The early diagnosis of necrotizing soft tissue infection is challenging,
but the keys to successful management of patients with
necrotizing soft tissue infection are early recognition and complete
surgical debridement. Early initiation of appropriate broadspectrum
antibiotic therapy must take into consideration the
potential pathogens. Critical care management components such
as the initial fluid resuscitation, end-organ support, pain management,
nutrition support, and wound care are all important
aspects of the care of patients with necrotizing soft tissue infection.
Soft tissue reconstruction should take into account both
functional and cosmetic outcome.
KEY WORDS: necrotizing soft tissue infection; fasciitis; methicillin-
resistant Staphylococcus aureus; intensive care unit; hyperbaric
oxygenation; Laboratory Risk Indicator for Necrotizing Fasciitis

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题目：Management of the crushed chest
作者：Laszlo Kiraly, MD; Martin Schreiber, MD
杂志：(CritCare Med 2010; 38[Suppl.]:S469 –S477)
摘要：Thoracic injuries are very common among trauma victims. This
article reviews the current literature on the management of multiple
aspects of the care of the patient with severe chest injury.
The mechanics of chest injury are complex and varied. Chest wall
injuries are the most common and noticeable manifestation of
thoracic trauma. Overall morbidity and mortality are primarily
determined by associated injuries. New ventilatory strategies
permit oxygenation of the severely hypoxic patient. Acute pain
management modalities offer the potential of decreasing associated
pulmonary complications. Surgical chest wall fixation is
clearly indicated in extreme cases of pulmonary herniation and
chest wall disruption. There are potential benefits of surgical
fixation in other settings, although further trials are needed. (Crit
Care Med 2010; 38[Suppl.]:S469 –S477)
KEY WORDS: rib fracture; trauma; flail chest; pulmonary contusion;
acute respiratory distress syndrome; airway pressure release
ventilation; high-frequency oscillatory ventilation

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题目：Difficulties in managing the surgical patient who is morbidly obese
作者：David R. King, MD; George C. Velmahos, MD, PhD
杂志：(Crit Care Med 2010;38[Suppl.]:S478 –S482)
摘要：Managing patients who are morbidly obese in the intensive
care unit is associated with a variety of problems uncommonly
experienced with the those who are not morbidly obese. Clinicians
experience a myriad of unique problems and circumstances, from
the need for special beds and lifts to unusual and unknown
volumes of distribution resulting in unclear drug dosing. This
review examines several issues including sedation, invasive monitoring,
venous thromboembolism prophylaxis, surgical infections,
nutritional support, and other complications that may be of particular
importance to the critically ill patient who is morbidly
obese. In many cases, care is altered based on the complicating
issues surrounding morbid obesity. In other cases, the presence
of obesity suggests no alterations in our routine critical care
delivery. A comprehensive review of the literature is undertaken,
data are critically considered, and overall opinion is rendered
based on the available peer-reviewed literature. In many cases,
data are not available that address the specific patient population
in question, so related papers (like gastric bypass data) are
considered. Many issues do not have definitive answers based on
randomized controlled trials, and much is left to treating clinician
opinion and local practice patterns. Where good data exist, however,
one should consider carefully and individually deviation
from the evidence-based approach. (Crit Care Med 2010;
38[Suppl.]:S478 –S482)

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题目：Common complications in the surgical intensive care unit
作者：Robert G. Sawyer, MD, FACS; Carlos A. Tache Leon, MD
杂志：(Crit Care Med 2010;38[Suppl.]:S483–S493)
摘要：
resources, and personnel needed to care for patients who have been
severely injured, present with acute surgical emergencies, require
prolonged and complex elective surgical procedures, or have severe
underlying medical conditions. Correcting the immediately evident
physiologic derangement is only the first step in the care of these
patients, because in many cases their prognosis and ultimate outcome
will depend on whether additional insults accrued during their
intensive care unit and hospital stay will prevent them from a full
recovery. The nature, number, and complexity of the interventions
used to provide advanced support requires a unique attention to the
concept of patient safety, particularly when the population involved
is that most vulnerable to injury and with the least amount of
physiologic reserve to recover from it. The medical community, the
public, and even regulatory agencies have focused on specific preventable
complications that are common in surgical and injured
patients, such as medical errors, healthcare-associated infections,
and venous thromboembolism. Enough scientific knowledge has
been obtained through well-conducted clinical trials to generate
detailed evidence-based guidelines for the prevention and management
of some of these pathologies, but still there are outstanding
questions in terms of the applicability of the recommendations to the
critically ill. In addition to clinical and technical expertise, performance
improvement and quality monitoring activities provide direction
for system solutions required to properly address many complications
that are not provider specific. (Crit Care Med 2010;
38[Suppl.]:S483–S493)
KEY WORDS: intensive care units; cross infection; pneumonia;
ventilator-associated; catheter-related infections; pulmonary embolism;
venous thromboembolism; postoperative complications;
medical errors; critical care; quality assurance; health care

piaoliangliuliu

有点晕！英文文章看起来十分吃力，佩服蓝鱼老师的英文水平，自己也努力一下

harmoni

仔细看看，同时也是锻炼阅读能力了。