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Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.

Background: Adequate nutritional replacement of critically ill and injured patients is of paramount importance, as it decreases infectious morbidity and mortality. However, multiple methods of determining nutritional requirements exist, including mathematical formulas, weight based calculations, and the use of metabolic cart measurements, the latter of which is associated with significant labor and equipment costs. We hypothesized that metabolic cart measurements, despite increasing the cost of care, would more accurately determine nutritional requirements in a critically ill population than formulaic or weight-based calculations., Methods: Consecutive metabolic cart measurements were prospectively obtained on 59 critically ill surgery and trauma patients, and compared with predicted values as determined by the Harris-Benedict equation and weight-based calculations. Comparison was made to actual resting energy expenditure data acquired via indirect calorimetry data obtained from serial metabolic carts., Results: There were 59 patients who formed the study population, with 37% of the population having two or more metabolic cart readings (total number of cart readings was 106). There was no statistically significant difference between the metabolic cart results, the predicted resting energy expenditure as calculated by the Harris-Benedict equation adjusted with a factor of 1.5, and a weight based calculation at 30 kcal/kg adjusted body weight. Metabolic requirements were stable over time (4-48 days) without significant variation. Nutritional parameters, as evaluated by the visceral proteins prealbumin and transferrin significantly increased with time in injured patients., Conclusions: Either 30 kcal/kg adjusted body weight or the resting energy expenditure calculated from the Harris-Benedict equation multiplied by 1.5 adequately predicts the nutritional requirements of critically ill surgery and trauma patients. The addition of metabolic cart data does not provide any additional information in the determination of caloric needs in the critically ill and injured patient. In this population, omission of metabolic cart data would have saved 33,000 dollars without adversely affecting patient outcome.

Intermittent measurement of cardiac output is routine in the critically ill surgical patient. A new catheter allows real-time continuous measurement of cardiac output. This study evaluated the impact of body temperature variation on the accuracy of these measurements compared to standard intermittent bolus thermodilution technique. This prospective study in a university hospital surgical intensive care unit included 20 consecutive trauma patients. Data were collected with pulmonary artery catheters, which allowed both continuous (CO[sub C]) and bolus (CO[sub B]) thermodilution measurements. The catheter was placed through either the subclavian or internal jugular vein. Measurements for CO[sub B] were performed using a bolus (10cm[sup 3]) of ice-cold saline with a closed-injectate delivery system at end-expiration. Computer-generated curves were created on a bedside monitor, and the average of three measurements within 10% of one another was used as CO[sub B]. CO[sub C] was determined as the average of the displayed CO before and after thermodilution CO measurements. Body temperature was measured from the pulmonary artery catheter and was grouped as ≤36.5°C, 36.6-38.4°C, and ≤38.5°C. CO[sub B] and CO[sub C] were compared for agreement by plotting the mean of the differences (CO[sub B] CO[sub C]) between the methods. The differences were plotted against the average of each pair and analyzed with linear regression. One hundred seventy-eight paired measurements were made over a period of 1 to 3 days. CO ranged from 3.7 to 15.5 L/min. Eighty-one percent of measurements were at a temperature of 36.5-38.4°C. Approximately 7% of measurements were at a temperature below 36.5°C and 11.2% were in patients with a core temperature above 38.5°C. Correlation between the two techniques was 0.96, 0.91, and 0.82 for temperatures of ≤36.5°C, 36.6-38.4°C, and 38.5°C, respectively. In conclusion, the CO measurements correlate well with CO[sub B] in trauma patients with a core temperature ≤38.5°C. The accuracy degraded at higher temperatures, which may be related to the smaller signal-to-noise ratio at elevated body temperatures. [ABSTRACT FROM AUTHOR]

The article presents a study that aims to provide a clinical practice guideline on red blood cell (RBC) transfusion in adult trauma and critical care medicine. The guideline was jointly made by Eastern Association for Surgery and Trauma (EAST) and American College of Critical Care Medicine (ACCM). It includes categories including RBC transfusion in sepsis, RBC transfusion risk and alternatives to RBC transfusion. The study suggests that the guideline will benefit critical care practitioners.