™ revised 2009 by dorothy w. bird, md suresh agarwal, md, facs department of surgery boston...

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Revised 2009 by

Dorothy W. Bird, MD Suresh Agarwal, MD, FACS

Department of SurgeryBoston University Medical Center

Based on the original presentation created by: N.K. Durrani, MD; M. McCann, DO; M.M. Brandt, MD, FACS, FCCM; P. Patton, MD, FACS; H.M. Horst, MD, FACS, FCCM; I. Rubinfeld, MD

Dept. of Trauma SurgeryHenry Ford Hospital, Detroit

Surgical Issues in Critical Care Medicine

™ Slide 3

Surgical Complications

• Airway: airway loss and emergent management

• Pulmonary: simple and tension pneumothorax

• Cardiac: tamponade

• GI: abdominal pain, ileus, ischemia, abdominal compartment syndrome, GI bleeding

• Extremities: vascular occlusion syndromes, compartment syndrome

™ Slide 4

Surgical Airways

• Only reason not to intubate is inability to do so, nonsurgical always preferred: i.e., orotracheal, nasotracheal

• Relative contraindications to intubation

– C-spine instability

– Midface fractures

– Laryngeal disruption

– Obstruction of lumen

™ Slide 5

Emergent Surgical Airway

• Needle cricothyroidotomy:

– 12-14G Angiocath +syringe

– Hyperextend neck

– Palpate cricothyroid membrone

– Apply Betadyne, Lidocaine

– Advance needle at 45o angle until air is aspirated

– Advance catheter, remove needle, attach hub to 3-mm ET adapter and oxygen

• Only useful for 45min due to poor CO2 exchange!

™ Slide 6

Emergent Surgical Airway

• Cricothyroidotomy

– Hyperextend neck

– Palpate cricothyoid membrane

– Apply Betadyne, Lidocaine

– 3-4cm midline vertical incision through cervical fascia and strap muscles

– Incise cricothyroid membrane horizontally; use hemostat to hold open

– Insert 5-7mm tracheostomy tube (or ET tube), attach to oxygen supply

• Convert to formal tracheostomy in 24h!

™ Slide 7

Surgical Airway

• Tracheostomy: Rarely for emergencies

– Usually for ventilator weaning

• Many techniques (percutaneous, surgical)

• Emergency Indications:

– Laryngeal crush injury

– Fracture of thyroid or cricoid membranes

– Very small children

™ Slide 8

Airway Emergency: Massive Hemoptysis

• Due to pulmonary, bronchial, or innominate artery injury/disease

• Results from erosion (slow, with herald bleed) or iatrogenic (tracheostomy, trauma)

• Bronchoscopy to determine source

• Bronchial blocker for isolation

• Angiography: embolize bleeding source

• Emergent lobectomy or sternotomy if uncontrolled

Innominate a.

trachea

™ Slide 9

Tracheoinnominate Artery Fistula

• Dreaded complication of tracheostomy (1%)

• Due to:

– Erosion of the artery by tracheostomy tube or

– High pressure cuff directly injurs artery

• Temporize by:

– Insert endotracheal tube into tracheostomy stoma, inflate cuff

– Apply downward, outward tamponade to fistula with finger in tracheostomy stoma

™ Slide 10

Surgical Pulmonary Emergencies

• Pneumothorax (simple): partial or complete collapse —increases pulmonary shunt

– Chest tube in emergency

– Attempt catheters as well

– Treat “conservatively” in stable asymptomatic patients

– Aggressive therapy if on positive pressure

– Can progress to tension pneumothorax

™ Slide 11

Tension Pneumothorax

• True Surgical Emergency!

• Signs:– Decreased breath sounds– Ipsilateral tympany– Tracheal shift– Distended neck veins– Asymmetric chest expansion

• Hypotension

• CXR: mediastinal shift

• Emergent decompression– Chest tube– Temporary needle decompression

Tracheal shift

pneumothorax

™ Slide 12

Chest Tube Insertion

• Sterile prep and drape

• +/- Local anesthesia- 1% lidocaine to pleura

• 2-3cm incision at midaxillary line, 5th intercostal space

• Blunt dissection with finger/clamp to pleura

• Listen/feel for gush of air exiting pleural space

• Insert 36F chest tube apically, posteriorly; secure with suture, occlusive dressing

• Attach distal end of tube to suction (-20cm water) with water seal

™ Slide 13

Hemothorax

• Surgical Indications:

• Massive hemothorax = >1500mL immediate return of blood on tube thoracostomy

• Persistent hemothorax = 300mL/h x 3hours

• >1500mL blood/24h

• Chest tube with massive air drainage, or GI contents

™ Slide 14

Cardiac Tamponade

• Blood in pericardial space, compresses heart

• Beck’s triad: hypotension, jugular venous distension, distant heart sounds

• Echocardiogram: impaired diastolic filling

• Treatment: needle decompression or pericardial window

• Image from: http://upennanesthesiology.typepad.com/photos/uncategorized/2007/07/26/tamponade2_b_milas.jpg

Fluid in pericardial space

™ Slide 15

Abdominal Pain

• Abdominal pain syndromes in the ICU:

– Pancreatitis

– Acalculous cholecystitis

– Bowel ischemia

– Bowel obstructive syndromes

™ Slide 16

Pancreatitis

• Epigastric/upper quadrant pain, radiates to back

• + Nausea, vomiting, fever

• ICU Etiology:

– Medications: furosemide, thiazide diuretics, metronidazole, bactrim, ACE-inhibitors, many others

– EtOH, gallstones, ERCP, trauma

– Hyperlipidemia (triglycerides >1,000mg/dl), hypercalcemia

™ Slide 17

Pancreatitis

• Mortality predicted by Ranson Criteria:

– Score 0 to 2 : 2% mortality

– Score 3 to 4 : 15% mortality

– Score 5 to 6 : 40% mortality

– Score 7 to 8 : 100% mortality

• Management

– NPO, IVF, antibiotics if infection or gall stones

– Treat underlying cause

– Surgery only for infected necrosis

On admission Within 48 hours

Age >55 years Hct decreases by >10

WBC >16,000 BUN increases by >5

Glucose >200mg/dl Calcium <8mg/dl

LDH >350 PaO2 <60mmHg

AST >250 Fluid Requirement >6L

Base deficit >4mEq/L

™ Slide 18

Acalculous Cholecystitis

• 5% -10% of all cases of acute cholecystitis

– Observed in the setting of very ill patients, especially trauma and burn victims, also long-term TPN (>3 months)

• Signs/Symptoms: RUQ pain, fever, leukocytosis

• Diagnosis: CT or US: pericholecystic fluid, NO STONES

• Etiology: unclear; stasis vs ischemia

– Higher incidence of gangrene and perforation compared to calculous disease, greater mortality (40%)

• Management: IV fluid, IV antibiotics, emergent cholecystectomy (or cholecystotomy if surgical risk is high and risk of perforation is low)

™ Slide 19

Bowel Ischemia

• Etiology:– ICU patients: Nonocclusive mesenteric ischemia (NOMI) -

splanchnic low flow and/or vasoconstriction• Seen in hemodynamically unstable patients• Decreased CO, hypovolemia, vasoconstrictor medications

– General population: mesenteric arterial embolus, mesenteric arterial thrombus, mesenteric venous thrombus

• NOMI Signs: Abdominal pain, leukocytosis, GI mucosal sloughing, bleeding

• NOMI Diagnosis: Angiography

• NOMI Treatment: optimize volume status, relieve splanchnic vasocontriction; selective intraarterial vasodilators (papaverine, glucagon)

™ Slide 20

Bowel Obstruction

• Mechanical– Gut lumen is blocked due to foreign body, tumor,

intussusception, adhesions; partial vs complete– Open loop obstruction: amenable to proximal decompression;

use NG tube– Closed loop obstruction: inflow and outflow blocked: hernia

incarceration, torsion around adhesive band, volvulus; surgical emergency!

• Functional (neurogenic)– Ileus (small bowel): +/-NG tube, judicious narcotic use– Olgvie’s pseudoobstruction (large bowel): neostigmine +/-

colonoscopic decompression if cecum>10-12cm or if symptomatic >48h; correct electrolytes, reduce narcotics, NG tube

™ Slide 21

Abdominal Compartment Syndrome

• Acute increase in intra-abdominal pressure with resultant critical organ dysfunction

• Seen in trauma patients after laparoptomy, non-operative hepatic or renal trauma victims, burn victims, any patient who receives large-volume resuscitation

™ Slide 22

Abdominal Compartment Syndrome

• Consequences of elevated intraabominal pressure:

– decreases ventilation→ hypoxia, acidosis

– reduces venous return →decreased cardiac output

– venous congestion → reduced capillary perfusion, ischemia, inflammation

– decreased blood flow to kidney →oliguia, renal failure

– decreased blood flow to liver, gut →impaired function

• Early recognition and diagnosis are vital to prevent complications!

– Identify those at risk, measure baseline IAP!

™ Slide 23

Abdominal Compartment Syndrome

• Clinical triad:

– Tense, distended abdomen

– Increased airway pressures

– Oliguira (despite ample resuscitation)

• Diagnosis: Bladder pressure

– Surrogate for intraabdominal pressure

– Bladder filled with 50 cc of sterile saline via Foley and pressure monitor connected to side port with 18-gauge needle

™ Slide 24

™ Slide 25

Abdominal Compartment Syndrome

• Intraabdominal pressure (IAP)

– Normal: <10mm Hg

– Intraabdominal hypertension (IAH): ≥12mmHg

– Abdominal compartment syndrome (ACS): ≥20mmHg with new organ dysfunction

– WSACS IAP Grading:• I 12-15mmHg

• II 16-20mmHg

• III 21-25mmHg

• IV >25mmHg

™ Slide 26

Abdominal Compartment Syndrome

• Management:

– Prevention! Judicious resuscitation!

– Neuromuscular blockade

– Diuresis (only with hemodynamic monitoring)

– Catheter drainage: bedside ultrasound to guide catheter drainage of intraabdominal fluid

– Decompressive laparotomy- definitive• Abdominal fascia left open, often with VAC or Bogota bag

covering wound

• Delayed primary closure

™ Slide 27

Bogota Bag

™ Slide 28

Upper GI Bleeding

• Gastric (ulcer vs. gastritis)

• Duodenal

• Esophageal varices

• Mallory-Weiss

™ Slide 29

Upper GI Bleeding

• Immediately:– 2 large-bore peripheral IVs

– 2 L crystalloid

– STAT labs: CBC, PT/PTT, Type & screen

– NGT, gastric lavage

– Foley catheter

– Consider central line (CVP) or Swan catheter

™ Slide 30

Upper GI Bleeding

• Management

– PPI, H2-blocker

– EGD

– Arteriography

• Treat Varices: vasopressin, octreotide, sclerotherapy, Sengstaken-Blakemore tube, TIPS

• Operative intervention if bleeding remains uncontrolled

™ Slide 31

Mallory-Weiss tear

• UGI bleeding after violent emesis

– Gastric mucosal tear at cardia

– Typically (not always) in alcoholic patients

• Usually stops spontaneously

• May attempt Blakemore tube using gastric balloon for direct pressure.

• Nonoperative treatment: endoscopic electrocoagulation, banding, injection

• Operative intervention rarely needed: oversew laceration

™ Slide 32

Lower GI Bleeding

• Most arise from the colon and rectum

• Large bowel etiologies: diverticula, angiodysplastic lesions, neoplasms, IBD, hemorrhoids, and anal fissures

• Small bowel etiologies: neoplasm, IBD, Meckel’s diverticulum

™ Slide 33

Lower GI Bleeding

• Initial management: as for upper GI bleeding

• Diagnosis:

– Rectal exam

– Colonoscopy

– Radionuclide scan• Bleeding scan

– Arteriography

™ Slide 34

Lower GI Bleeding

Bleeding scan

Source of LGIB

Angiography

Source of LGIB

From: http://brighamrad.harvard.edu/Cases/bwh/hcache/126/full.html

™ Slide 35

Lower GI Bleeding

• Management:

• Arteriographic intervention: vasopressin, coils, gel foam

• 80% success, 50% rebleed risk

• Operative: hemodynamic unstable with >8 units PRBC

• Localization is key, unlocalized LGI bleeding will lead to a blind subtotal colectomy, which is a higher mortality procedure for your patient!

™ Slide 36

Cold Legs

• Acute arterial embolus

– Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis

– Contralateral leg is normal

– No chronic ischemic changes

– Etiology: atrial fibrillation (most common)• Embolus usually obstructs common femoral artery

• Treatment: Embolectomy +/- fasciotomy

• Rare: aortoiliac emboli- loss of pulses to both feet, requires bilateral embolectomies

™ Slide 37

Cold Legs

• Acute arterial thrombosis

– Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis

– History of claudication, signs of chronic ischemia

– Poor pulses in contralateral leg

– Not associated with atrial fibrillation

• Treatment: heparin anticoagulation, OR for thrombectomy or angiography for catheter-directed thrombolysis

™ Slide 38

Swollen Legs

• Most common “surgical” etiology is DVT

• Does your patient need an IVC filter?

• Indications:

– DVT and

– Contraindication to anticoagulation and

– High risk of PE

• Percutaneous placement of IVC filter (femoral or jugular)

™ Slide 39

Phlegmasia Cerulea Dolens

• Simultaneous thrombosis of iliac, femoral, common femoral, and superficial femoral veins

• Associated with other critical illnesses, cachexia, dehydration

• Appearance: massively swollen, blue, mottled

• Treatment:

– Limb elevation

– Heparin anticoagulation

– +/- catheter-directed thrombolysis

– +/- thrombectomy

™ Slide 40

Extremity Compartment Syndrome

• Acute increase in pressure within myofascial compartment of an extremity

• Can occur in any compartment, most often lower extremity, anterior compartment

• Complications related to compression of contents of compartment

• Causes rhabdomyolysis, ischemic neuritis, arterial insufficiency, venous gangrene, and limb loss

™ Slide 41

Compartment Syndrome

• Etiology: increase in muscle swelling, hematoma, or interstitial fluid; often secondary to reperfusion injury, burns, fractures, crush injury, tight cast

• Signs/Symptoms:– Extreme pain on flexion is often first sign– Swollen, tense extremity– Loss of sensation first neurologic sign followed by weakness– Last sign is decrease in pulses

• Diagnose: Direct pressure measurement using 18-gauge needle and arterial monitor or Stryker monitor– Pressure >20mmHg OR clinical suspicion– Delta P method: diastolic blood pressure – compartment

pressure ≤30mmHg is indicative of compartment syndrome

™ Slide 42

Compartment Syndrome

• Treatment: Release pressure immediately!

• Evacuate hematoma

• Perform fasciotomy

– +/- VAC wound therapy

– delayed closure

– split-thickness skin graft

™ Slide 43

References

• Koster W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury, Int. J. Care Injured (2005) 36, 992-998.

• Ridley RW, Zwischenberger JB. Tracheoinnominate fistula: surgical managemnt of an iatrogenic disaster. The Journal of Laryngology and Otology (2006) 120, 676-680.

• An G, West MA, Abdominal compartment syndrome: A concise clinical review. Crit Care Med (2008) 36, 1304-1310.

• Maerz L, Kaplan LJ. Abdominal compartment syndrome. Crit Care Med (2008) 36 Suppl, S212-215.

™ Slide 44

References

• Greenfield’s Surgery: Scientific Principles and Practice. Fourth Edition. Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch Jr. GR. New York, NY, Lippincott Williams and Wilkins.

• ACS Surgery: Principles and Practice. Online Edition. Ashley SW et al. http://www.acssurgey.com

• Bowers Rebecca C, Weaver Jeffrey D, "Chapter 8. Compromised Airway" (Chapter). Stone CK, Humphries RL: CURRENT Diagnosis & Treatment: Emergency Medicine, 6th Edition: http://www.accessmedicine.com/content.aspx?aID=3118968.

• Gomella LG, Haist SA, "Chapter 13. Bedside Procedures" (Chapter). Gomella LG, Haist SA: Clinician's Pocket Reference: The Scut Monkey, 11th Edition: http://www.accessmedicine.com/content.aspx?aID=2694363.