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Introduction

Critical care medicine traces its origins to the Crimean War of the 1850s, when Florence Nightingale designated a separate treatment space for the most severely wounded soldiers.1 At this point, the emphasis was on proximity to the nursing station and a higher level of nursing care. In 1923, Dr. Walter Dandy, a student of Harvey Cushing, created one of the first surgical intensive care units when he grouped his postoperative neurosurgical patients together in the same treatment area at Johns Hopkins.2 The original emphasis on intensive nursing care continued into World War II, with the development of “shock units” for care of the severely wounded.1

As medicine evolved, so did critical care. With the advent of organ system support devices, intensive nursing units transitioned into intensive therapy units. In the 1940s, iron lung wards (supplemented, where necessary, by medical students providing round-the-clock manual ventilation) supported patients with respiratory paralysis from polio. In the 1950s, hantavirus became a major cause of renal failure in Korean War soldiers, leading to the development of the first hemodialysis units. Concurrently, electrical defibrillators and transvenous cardiac pacing allowed the creation of specialized cardiac care units.1 In the 1960s, the creation of positive-pressure machines was a crucial step in the transition from iron lung wards to ventilatory care units.3

The isolated support of individual systems began to merge into true, multiorgan system support with the advent of improved vital sign monitoring, point-of-care analyzers, and STAT labs. This was supplemented by organizational restructuring, creating closed units and specialization for physicians and nurses.2 With the structure in place, major advances in treatment became possible. In particular, with critical care units in hospitals throughout the world, multicenter clinical research groups developed. These groups allowed for larger sample sizes, higher statistical power, and more rigorous and generalizable studies.4

Many of these studies are described in detail in the following chapter. They include the ARDSNet group in the United States, who in the 1990s and early 2000s demonstrated the benefit of low-tidal-volume ventilation for ARDS.5 In Canada, the Canadian Critical Care Trials Group demonstrated a mortality benefit to restrictive transfusion requirements that dramatically changed standard of care and resource utilization internationally.6 When single-center studies called into question the standard of care, as with early goal-directed therapy in the Rivers Trial,7 multicenter groups quickly formed to confirm or contest the results.8

Today, critical care units represent an increasing percentage of hospital beds, and that percentage is likely to continue to rise in the next few decades.9 Although trauma and burn surgeons dedicate their practices to critical care, surgeons in all specialties will be increasingly called on to care for patients with septic shock, hemorrhagic shock, and multiorgan system failure. Surgeons must remain informed as critical care evolves; evidence may prove common practices in the multidisciplinary, highly monitored units of today ...

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