Trauma, Surgical, and Transplant Critical Care
Trauma resuscitation
ATLS sequencing still applies, but damage-control resuscitation dominates bleeding patients: permissive hypotension (systolic 80–90 mmHg) in penetrating trauma without traumatic brain injury, early blood products, tranexamic acid within 3 hours, prevention of the lethal triad (hypothermia, acidosis, coagulopathy), and rapid hemorrhage control. In traumatic brain injury, permissive hypotension is contraindicated - maintain cerebral perfusion pressure.
Abdominal compartment syndrome
Intra-abdominal hypertension is bladder pressure ≥12 mmHg; abdominal compartment syndrome is pressure >20 mmHg with new organ dysfunction. Decompress: sedation, paralysis, nasogastric and rectal drainage, fluid removal, and decompressive laparotomy if refractory.
Perioperative and transplant issues
Anticipate anastomotic leak, aspiration, postoperative respiratory failure, and acute kidney injury. In transplant recipients, recognize rejection, infection amplified by immunosuppression, drug toxicities (calcineurin inhibitors causing nephrotoxicity and neurotoxicity), and graft dysfunction. Brain-dead organ donors need hormonal resuscitation and careful hemodynamic support to preserve organs.
Traps
- Over-resuscitating with crystalloid and creating dilutional coagulopathy and edema.
- Missing compartment syndrome because the abdomen looks soft.
- Allowing hypotension in a patient with a severe TBI.
- Ignoring adrenal insufficiency in a chronically steroid-treated transplant patient.
- Attributing postoperative hypotension solely to bleeding when the graft is failing.
Rule of thumb
A bladder pressure >20 mmHg plus new organ dysfunction equals abdominal compartment syndrome; if sedation, paralysis, and drainage fail, take the patient to the operating room.