Surgical Critical Care
Core concepts
Surgical critical care integrates shock physiology, sepsis, respiratory failure, renal replacement, nutrition, sedation, and prevention. Distinguish hypovolemic, cardiogenic, distributive, and obstructive shock using examination, lactate, central venous oxygen saturation when available, echocardiography, and response to fluids. Sepsis requires prompt cultures, antibiotics, source control, and balanced fluid resuscitation; vasopressors are added for persistent hypotension. ARDS management uses low tidal volume ventilation based on predicted body weight, plateau pressure limitation, and prone positioning in moderate-to-severe cases. Acute kidney injury requires attention to perfusion, nephrotoxins, and indications for dialysis. Intra-abdominal hypertension is measured via bladder pressure; abdominal compartment syndrome causes organ dysfunction and may require decompression.
Traps
Do not use central venous pressure alone to guide fluids. A normal lactate does not exclude shock. Avoid routine albumin or starches. In ARDS, do not use high tidal volumes to normalize PaCO2. Restrictive transfusion is generally preferred in stable patients. Delirium is common and is not benign.
Worked example
A postoperative patient has fever, hypotension, lactate 4 mmol/L, and cloudy urine. Start sepsis care: cultures, broad-spectrum antibiotics, fluids, and source control, then reassess perfusion. Rule of thumb: follow lactate clearance and physical perfusion, not a single blood pressure reading.