cases in surgical critical care
TRANSCRIPT
8/6/2019 Cases in Surgical Critical Care
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Cases in Surgical Critical Care
� Objectives
� Things to consider when caring for the
critically ill postoperative patient� Cases
± Postop
± Preop
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Objectives
� Discuss cases of surgical patients in the
ICU
� Develop an approach when caring for patients in the SICU
� Cite important differences in the
management of critically ill surgical
patients
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Things to consider«
� Go with what you
know
� How did surgery
change:
± Anatomy
± Physiology
± Management
considerations?
� Remember your role
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Case 1: Postoperative Crisis
Management
³My Achy-Brachy Heart«´
53yo admitted to you after thoracotomy for
lung cancer
(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. )
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HPI
Smoker w/ hemoptysis
Found on CXR to have
large (R) chest mass
No obvious
extrathoracic spread
Unrevealing
mediastinoscopy
(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72.
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CT
(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72.
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Case 1
� Exploratory (R) thoracotomy
± Tumor invading truncus inferior of (R) PA,
pericardium by superior PV
± Intrapericardial pneumonectomy performed
� Vessels controlled outside pericardium
� Intercostal muscle pedicle over bronchial stump� Pericardium closed w/ suture
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Case 1: Postop
� Extubated in OR
� EBL <200ml
� NSR 70-90 bpm, BP 120/70� Good breath sounds in L lung
� No pain issues w/ epidural
� UO 30ml/ hr
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Case 1: POD #3
� Febrile, delirious, tachypneic, mild
drainage at epicardial site
� Good air movement, pulmonary toilet,mucus clearance
� R leg swelling, on good DVT prophylaxis
� Patient prepped for LP by med studentHS: attempted sitting up, patient lies down
to R side on chest tubes in mid-procedure
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Case 1
� PEA arrest w/ bradycardia, no pulse
palpable, patient w/ labored breathing
pattern.
� Venous congestion in face
� You are called emergently to assist.
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Case 1: What next?
You are performing
ACLS
Rescucitative efforts are
not working
«Things to consider«
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Cardiac Herniation
� Rare w/ pericardial mesh
� 68 case series (Kimura 1999)
± 46 (R), 22 (L)
± 21/46 fatal
� >75% happened defore end of surgeryduring repositioning
� Most cases are related topneumonectomy; can happen w/lobectomy
Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation following intrapericardia pneumonectomywith partial pericardiectomy for advanced lung cancer
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Cardiac Herniation
� Occurs with
± Coughing
± Rapid decompression
w/ chest tube ± PPV
± Patient movement
� Treatment
± Reposition patient
± Access to pericardium
w/ restoration of heartposition
± Pericardial patch
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Case 1
(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation
following intrapericardia pneumonectomy with partial pericardiectomy for advanced lung cancer
During decompensation After emergent Procedure
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Case 2: Preop
³My Therapist told me I would live longer if I just
vent my spleen more´
47 yo admitted with abdominal pain
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HPI
� Case 2 HPI
� He presented to an OSH with abdominal
pain� CT interp: ³contained rupture of his
spleen.´
� HD#1 hct 22%Post 2u prbcs
hct 21%
� Transfer to your ICU arranged; you are
consultant intensivist to see patient first.
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Case 2
PMHx:
± Essential
thrombocytosis and
splenomegaly,diagnosed in 1970.
± BM Bx 1990:
myelofibrosis
± Gout
Meds:
Folate
MVI
Procrit
Allopurinol
Fe Sulfate
Indomethacin
No allergies
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Case 2-Admission Data
� AFVSS INAD
� Spleen extends down to pelvic rim,
approximately 4cm from midline� Small ventral hernia
� Hct 23%
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Radiology
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Management?
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On arrival
� Pt complains of ³feeling like [he is] going to
die´
� BP 70/palp, pt diaphoretic, pale, and w/ an
enlarging belly.
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You¶re the ICU doc«
� How will you manage this patient?
� What events do you anticipate in this
patient?� To manage this patient immediately, what
will you need?
� What needs will you develop ³down theroad?´
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Surgery
� Spleen weighed 5400gm and measured
44x18x9.5cm
� Rupture of splenic vein at base of spleenidentified
� Over course of 6h surgery he continues to
bleed
± Total ~100u blood products
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You¶re stuck
� Patient survives surgery ± 20units crossmatched blood
± 70units uncrossmatched blood
± 10u FFP
± 18u platelets
� Initial postop valuesPT 30 PTT 80 Fibrinogen 80
Hgb 11 Cai 0.65 pH 7.65
K+ 3.3� What will consequences of massive transfusion
be?
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Massive Transfusions
� Rarely occur in the MICU
� Differing definitions
± �50% of patient¶s blood volume/ 12-24hrs� Defines ³Support of Surgical Team´
� Medical management of a surgical patient
O2 Delivery Acid-Base BalanceElectrolyte shifts Coagulopathies
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How fast can you go?
Device
(with 0.9% NS)
Flow Rate(100cm above entry site)
(L/hr)
Arrow 9F Percutaneous sheath introducer 33.5
Arrow 8F Percutaneous sheath introducer 10.5
14G Interlink® Catheter (without interlink) 6.5
18G Interlink® Catheter (without interlink) 3.5
16G lumen (brown port) of Arrow® TLC 3.3
18G (proximal white port) of Arrow® TLC 1.6Refs: Saw S, et al.´ The effect of the InterLink cannula on fluid flow rates and haemolysis.´ Emerg Med 2001 Dec;13(4):456-9.
Arrow device package insert
personal communication, Arrow International sales staff
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Level 1 Infuser (Belmont Corp)
� 75-30,000ml/ h
� Pressure at
300mmHg
� Rapidly warms fluids
to 37ºC
� Requires specialized
nurse training tooperate
Patient line
Spikes
Drip Chamber
Gas Vent Holder
Gas Vent
Bottom Socket
Top Socket
Heat Exchanger
Heat Exchanger
Guide
F rom Belmont Corp Product Literature
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Coagulopathy
� Dilutional Coagulopathy
� Chemical Coagulopathy
� Transfusion-induced DIC
� Dilutional thrombocytopenia
� When to give:
± Platelets
± FFP ± Cryoprecipitate
± Factor VIIa
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Other Issues
� Hypothermia
� Citrate Load Metabolic alkalosis
� Old bloodmetabolic acidosis� Citrate toxicity (�8 u prbcs/ hour)
� Hypokalemia and/ or hyperkalemia
� Hypocalcemia
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Role of other services
� Treated like a ³stroke code´
� OR, clinical labs, blood bank, on-call
hematologist notified� Rapid blood matching
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Preparing an ICU patient for
surgery
� Preop eval is simultaneous w/resuscitation
� What are opportunities to improve
patient¶s condition before surgery? ABC HR, BP Ascites
� What concurrent diseases will affect pre/
peri/ postop management?� What are endpoints of preop
resuscitation?
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Preparing an ICU patient for
surgery
� What is planned surgery?
� What are preop needs?
± Blood products ± Invasive/ non-invasive monitoring
± Vasoactive medications
� What is periop/postop monitoring plan?
� What is postop sedation/ extubation plan?
� What is postop antibiotic plan?
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Don¶t forget«
Preop information you wish you had after the surgery
± Peripheral vascular exam
± Neuro exam
± Steroid use history and risk of adrenalinsufficiency
If non-elective: NGT decompression of stomach
Pregnancy test
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Thanks!
Hasan Shanawani, MPH MD
Cases in Surgical Critical Care