SURGICAL INTENSIVE CARESURGICAL INTENSIVE CAREBy

Prof. GAMAL ELEWADept. of Anesthesia, Intensive Care and Pain Management

Faculty of Medicine, Ain Shams University

Anesthesia DepartmentAnesthesia Department

© gamal elewa, 2012

IIntended LLearning OOutcomesBy the end of this lecture , the student will be able to:1.Know criteria of intensive care2.Differentiate between different types of intensive care3.Select patients for admission & Identify criteria of discharge4.Care of surgical intensive care patients 5.Use proper monitors in intensive care unit (ICU)6.Suspect and prevent complications7.Understand Management principles of surgical ICU patients

AIM

• What’s ICU? (Definition)

• What’s in? Characteristics?

• Types of ICU? (Classification)

• Indications: In & Out?

• Monitoring

• Care of patients in ICU

• Complications?

• Criteria for Discharge?© gamal elewa, 2012

What’s ICU?

• Place where there’s:• Intensive Monitoring,• Intensive (close) Nursing care,• Special Equipment: ventilators, …• Patient is critically ill,

• Doctor(s): present 24 h, well trained in management of critically ill patients

© gamal elewa, 2012

Characteristics

• Equipment: Monitors & Ventilators, DC Shock, Portable x- Ray, Dialysis, …

• Doctors: 24h on duty, Qualification

• Nursing Staff: 1:2 patients, qualifications

• Communications with: doctors, wards, lab, radiology, O.R., Bl. Bank, other departments, pt. relatives

• Patients: critically ill, life-threatening condition: resp. failure, life threatening dysrrhythmias, p.o. cardiac surgery

© gamal elewa, 2012

Types of ICU

• Design: Closed vs Open• Speciality & subspeciality: • - Surgical (Cardiac, Neurosurgical,

Obstetric, Burn, General), • - Medical (Coronary care unit “CCU”,

Chest, Neurology, Stroke, General),• - General (combined surgical and

medical)

© gamal elewa, 2012

Types of ICU (cont.)

Surgical

• General, Cardiothoracic, Neurosurgical, Obstetric & Gynecologic, Burn

• Intensive Care

• General ICU (Combined Medical & Surgical)

Medical

• CCU, Chest, Neurology, Geriatric

• Intermediate Care

© gamal elewa, 2012

Types of ICU (cont.)

Closed ICU

• Staff & System• Patients: IN & Out (Drain

& Discharge )• Design• Visitors

Open ICU

© gamal elewa, 2012

INDICATIONS For Admission (Causes of Admission to Surgical ICU)

• Surgical: Brain tumor, cervical spine, cardiac surgery, associated medical condition…

• Preoperative: hemodynamically unstable (shocked, serious arrythmias) multiple trauma

• Trauma: Airway, Chest, Cardiac, Brain, Cervical spine, …

• Medical: ischemic heart disease (IHD), cerebro-vascular stroke, uncontrolled hypertension, complicated diabetes, Resp., cardiovascular, multi-organ dysfunction syndrome (MODS), …

• Combined

© gamal elewa, 2012

MonitoringAccording to:

• Patient condition• Type of surgery• Anticipated

complications

Types:• ECG: Rate, rhythm, ischemia• Blood pressure (BP): invasive (IBP) vs

non invasive (NIBP)

• Pulse oximeter (SPO2): O2 saturation, HR

• Capnography (PCO2)• Central venous pressure (CVP),

pulmonary capillary wedge pressure (PCWP), cardiac output (C.O.)

• Urine output, Fluid Balance• Level of Consciousness, • Blood Sugar• Arterial blood gases (ABGs), • Drains, chest tubes,…

© gamal elewa, 2012

CARE OF SURGICAL ICU PATIENTSAccording to:

• Type of surgery and anticipated complications• Associated condition (e.g. trauma, pregnancy)

and/ or diseases (Ischemic heart disease, hypertension, diabetes, liver and renal dysfunction, COPD)

• Level of consciousness• Required Position of patient

© gamal elewa, 2012

CARE OF SURGICAL ICU PATIENTSIncludes:

• Monitoring• Infection control• Position• Vascular lines, catheters,

tubes, drains,…• Connected devices:

ventilators, intra-aortic balloon pump, ..

• Nutrition:

- Route: enetral (oral, Ryle, gastrostomy, jejunostomy, ileostomy), parenteral

- Type: diabetic, liver, renal, resp.

- Amount

- Timing

© gamal elewa, 2012

CARE OF COMATOSED PATIENTSSuspected complications:

• Bed sores• Respiration: obstruction,

infection, Aspiration• Infection• Malnutrition• Deformities

Care:

• Position, physiotherapy• Resp.Rate, pattern,

SpO2, temp., auscultation, CXR

• Nutrition support: Route (enteral, parenteral), constituents, amount

© gamal elewa, 2012

CARE OF NEUROSURGICAL ICU PATIENTSSuspected complications:

• Consciousness• Fits• Bleeding• Fluid imbalance• Other neurological

deficits

Care:

• Glasgow Coma Scale (E/V/M) (4/)

• CT Brain ?• Antiepileptics• Fluid Chart, Drains• Motor & sensory

monitoring

© gamal elewa, 2012

CARE OF CARDIAC SURGERY ICU PATIENTSSuspected Complications:

• Dysrhythmias & heart block

• Cardiac Failure & pulmonary edema

• Bleeding & Tamponade• Blood pressure changes• Neurological

complications• Renal dysfunction

Care:

• ECG, Antiarrythmic• Pace Maker• CVP, PCWP, Inotropes,

vasopressors, vasodilators

• Intra-aortic baloon pump• Neurological assessment• Renal assessment &

protection

© gamal elewa, 2012

CARE OF INVASIVE DEVICES

Suspected Complications:

• Infection• Displacement• Trauma

Care:

• Hand wash• Gloves• Sterilization• Antiseptic• Exchange• C&S

© gamal elewa, 2012

CONTROL AND PREVENTION OF INFECTIONTo patient

• Hand wash• Gloves, Masks• Equipment• Sterilization• Air condition• Isolation• Carrier detection• Antimicrobials

To ICU staff

• Hygiene measures• Hand wash• Gloves, Masks• Check up

© gamal elewa, 2012

Prevention of Iatrogenic ComplicationsSuspected Complications:

• Antibiotic sensitivity & Drug anaphylaxis

• Inadvertant intra-arterial injection

• Wrong drug injection & blood transfusion

• Infection

Care:

• Drug sensitivity test• Lablling• Re-check• vigilance

© gamal elewa, 2012

Indications of Mechanical Ventilation

• Respiratory failure• Delayed post operative

(P.O.) recovery• Increased intra cranial

pressure (ICP)• CPR (Cardiac arrest)• P. O. Hemodynamically

unstable

© gamal elewa, 2012

Acid Base & blood Gases

Normal ABG

• pH=7.40±0.04• PCO2=40±4 mmHg• PO2= 60-100 mmHg• HCO3- = 24±2 mmol/l• BE=± 2 mmol/l• S.K+=3.5 – 5 mmol/l• S. Na+=135 ± 4 mmol/l• S. Ca++ (ionized) =0.9 -

1.4 mmol/l

• Acidosis: pH<7.36• Alkalosis: pH>7.44• Respiratory vs Metabolic• 1ry vs 2ry• Compensated vs

Decompensated

© gamal elewa, 2012

COMPLICATIONS & HOW TO PREVENT AND TREATSpecific to:

• Operation: Cardiac, Brain, Spine, Urology

• Patient illness: Diabetes, HTN, IHD, Bed ridden

• Interference: CVP, Urinary catheter, Mechanical Ventilation

General

• Sepsis• ICU Psychosis• Trauma• Drug interactions &

Idiosyncrasy

© gamal elewa, 2012

GENERAL COMPLICATIONS

• Sepsis: Resistant organisms

• Psychic trauma & depression

• Myopathy & Neuropathy• Drug complications &

dependence• Of interference: Central

Line, Urinary Catheter, Mechanical Ventilation

• Bleeding• Deteriorated level of

consciousness• Hemodynamically

unstable• Epileptic fits• Trauma• Nutritional• Bed Sores

© gamal elewa, 2012

COMPLICATIONS

Of Cardiac surgery

• Heart Failure• Dysrhythmias• Bleeding• Cardiac Tamponade• Neurological• Renal

Of Neurosurgical Operations

• Delayed Recovery & Deteriorated conscious level, Coma

• Epileptic Fits• Bleeding• Fluid Imbalance &

Dehydration• Paralysis or paresis

© gamal elewa, 2012

CRITERIA FOR DISCHARGE

• Conscious?• Cardiovascular system• Respiratory System• Renal• Surgically (controlled or stable)• Metabolic • Other organ functions

© gamal elewa, 2012

Summary of important pointsSummary of important points

• What’s ICU:• Types of ICU:• Indications for admission

and discharge• Complications: Diagnosis,

prevention, management• Care of surgical ICU

Patients

© gamal elewa, 2012

THANK YOU

BEST WISHES

© gamal elewa, 2012