“Someone to Watch Over Me”A multidisciplinary approach to manage a complex case in

ICU

Presented by: Dr. Manoj Sayal, MD, FRCSC (C), FACS, Richard Bishop, RN, BScN, IIWCC, Catherine Duffin, RN, BScN, & Danielle Dunwoody, RN, MS,

CNCC(C)

FRED’S JOURNEY BEGINSDr Manoj Sayal

3

Case Presentation

• Fred—70 year old male who “doesn’t see doctors”

• has no past medical history, on no medication and has no allergies

• 5d history of lower abdominal pain which was worsening; progressively became more confused/febrile/solmnescent

• had worsening scrotal pain at the same time

4

• on examination—looked toxic and unwell

• HR 105 (sinus), BP 110/60, tachypenic, T37.8C, confused

• tender, red swollen lower abdomen with some questionable crepitus on deep palpation; markedly tender and swollen scrotum; rectal exam normal

• WBC 14.7; Hb 122; Pl 263, K 5.1, CO2 16, BUN 18.4; creatinine 335; lactate 7.7; BS 7

5

• CT scan of abdomen—extensive gas and tissue edema in scrotum bilaterally extending to the base of the penis, and to the sq tissues anterior to the pubic bone; it is contiguous with gas in the lower abdominal wall, greater on the right than on the left; there are small amounts of gas in the rectus muscles bilaterally and extending to the back and epigastic areas

6

• patient was aggressively resuscitated, given broad spectrum antibiotics, IVIG and ICU contacted

• urology and plastics contacted and patient taken to the OR on May 26

• to ICU vented and on ionotropes post-op

• returned to OR daily for 3 days and then wound was dressed/debrided in ICU daily for a number of days until VAC was applied

7

• May 27 – Initial OR to ICU

• May 30—CRRT

• June 9—tracheostomy

• end of June—transf to Inpatient Surgery

• July 30—rehab

• August 21—home

• November 4—wound essentially closed up

AN EXPLANATION OF THE DIAGNOSIS

Dr. Manoj Sayal

9

Necrotizing Soft Tissue Infections

• can arise primarily in the dermis and epidermis, but more commonly affect the deeper layers of the adipose tissue, fascia or muscle

• typically caused by toxin-producing bacteria and are characterized clinically by very rapid progression of disease with significant local tissue destruction

• early diagnosis and treatment are crucial to survival

Hippocrates in the 5th century

“…The erysipelas would quickly spread widely in all directions. Flesh, sinews and bones fell away in large quantities...Fever was sometimes present and sometimes absent...There were many deaths. The course of the disease was the same to whatever part of the body it spread.”

Necrotizing fasciitis

• Colloquially known as “flesh eating disease”• Necrotizing fasciitis is an infection of the

deeper tissues that results in rapidly progressive destruction of the muscle fascia and overlying subcutaneous fat

• Muscle tissue is frequently spared because of its generous blood supply

Microbiology• Type I – Polymicrobial

• Bacteroides species, Klebsiella species, Enterococci, Acinetobacter baumanii, Eschericia coli

• Type II – Monomicrobial• Group A Strep• S. Aureus (incl. MRSA)

• Type III – Gram Negative Marine Organisms• V. vulnificus• Warm water coastal regions

Risk Factors

• Diabetes• Peripheral vascular disease • IV drug use (esp. for MRSA)• Obesity• Immunosuppression• Recent surgery• Traumatic wounds

Signs and Symptoms

Clinical Finding Type 1(poly) Type 2 (mono)Fever ++ ++++Local Pain ++ ++++Systemic toxicity ++ ++++Gas in Tissue ++ -Port of Entry ++++ +Diabetes (less pain) ++++ +

Lab Tests

Score >5 had PPV of 92% and NPV of 96%

Radiography• CT Scans often

reveal soft tissue stranding and edema

• Occasionally will show gas between the tissues – this is specific but not sensitive

Diagnosis

• Surgical exploration is the only way to definitively and reliably establish the diagnosis of necrotizing infection and distinguish it from other entities

• Patients with high suspicion should proceed to OR for urgent exploration

• Surgical exploration should not be delayed while awaiting results of radiology, blood cultures or skin aspirates

At Surgery

• Pale or necrotic soft tissue/muscle/fascia, absence of abrupt bleeding on sharp tissue surgical dissection

• “Dishwasher-like” gray discharge• Effortless separation and elevationof tissue

planes with easy finger “sliding” between the muscle and fascia layers

• It also smells horrible

Treatment

• Aggressive surgical exploration and debridement of necrotic tissue

• Broad spectrum empiric antibiotic therapy– Carbapenam/Beta-Lactam with BL inhibitor– An agent with activity against MRSA– Clindamycin for anti-toxin effect

• Hemodynamic support • IVIG can be considered for Group A Strep

20

Treatment

• initial treatment usually has to be coordinated with the ICU

• after initial treatment (resuscitation, surgery, antimicrobials), treatment continues with a multimodal and multidisciplinary approach involving wound care/management, pain control, management of complications (AKI, VAP, arrythmias, sepsis, MI etc)

• multiple trips are often required to the OR (on average 3-5) for further debridements initially and then the debridements and dressing changes are shifted over to the ICU/ward

21

Treatment

• often large amounts of skin and tissue are taken with exposure of bone, tendons, cartilage, testicles, stomas etc needed to preserve the patient

• this presents unique challenges to wound management that necessitates the multidisciplinary team involvement, including, wound teams, pain teams, ICU care, plastic surgery, urology, general surgery, rehabilitation, psychological support, etc

1st Post Operative Assessment

Wound measured 56 cm across from skin edge to skin edge. Undermining extended approximately 10 cm further on each side.

Early Wound Care Management

Assess the Whole patient and not just the hole in the patient.

Local Wound Care• Adequate source

control• Presence of infection• Presence of non-

viable tissue• Amount and type of

wound drainage

Patient factors• Nutrition status• Pain• Hemoglobin• Glycemic control• Fluid balance• Use of vasopressors

Team Members Required

• Intensivist • ICU nurses• RT• Physiotherapy• Dietician• Pharmacy• Dialysis RN

• Wound Care / Plastics • General Surgeon• Infectious Disease

Service• Acute Pain Service• Chaplain service• Ward Aides

Dressing selection

• Manage moisture• Encourage circulation• Splint the abdomen• Create a environment conducive

for healing• Decrease pain by decreasing

frequency of dressing changes

The decision to Use Negative Pressure Wound Therapy – VAC Dressing

A SNAPSHOT OF FRED’S NURSING CARE IN ICU

Catherine Duffin

Post operative Nursing Care

Arrived in ICU post surgery Heavily sedated requiring significant pain

management and fully ventilator dependent Central line, arterial line, dialysis line Large amounts of sedation : Propofol Midazalom Fentanyl

Complications

Transient atrial fibrillation Renal dysfunction Low hemoglobin requiring intermittent

transfusions: Blood 10 units 6 albumin 2 Fresh frozen plasma

Hypertension Constipation

Fred’s Cognitive Progression

Admitted Alert & Oriented

Sedated & Ventilated

Periods of Delirium

Periods of loss of recall or

disorientationLOC stabilized

Fred’s Frustration

• From Nurses notes:• “Pt. refusing NGT/OGT insertion, MD aware,

wife aware, attempted x 2 today –Pt. shaking head and saying no” (ICU RN).

• “Patient then proceeded to refuse his crushed pills” (ICU RN).

Supportive care

• Psychological support for Fred and his family from the whole Multidisciplinary Team was an important component of his recovery.

The ICU nurses and staff were a critical part of my ongoing bridge back to reality, but our "conscious" relationship was a short-lived one.

ICU Nursing Considerations

• Airway management• Dressing change & pain management

coordination • Intermittent dialysis co-ordination • Nursing workload• Time management concerns

MANAGING PROCEDURAL PAIN IN THE ICU

Danielle Dunwoody

APS Considerations

• Airway management within ICU & beyond• Safety, safety, safety• Time = Drug• Pharmacological management plan• Developing a comprehensive plan

Pharmacological Management

• Fentanyl • Ketamine• Midazolam • Why not propofol?• What about hydromorphone?• Where does multi-modal analgesia fit into the

picture?

Incorporating Music into Fred’s Care

Fred’s Care Plan-de-medicalize the process for Fred, please make all plans regarding dressing logistics, nursing logistics, etc… outside of the patient room prior to the dressing change.

-Keeping discussion to a minimum

-Ensure all possible dressing supplies are readily available prior to starting the dressing.

-keep personal in and out of the room to a minimum.

-Comments - Fred is tired of hearing how great his abdomen and scrotum are looking (as per Fred).

-Play jazz music if possible (provided by APS)

-Complete the scrotal dressing first, then the abdominal dressing next

-Drape the patient accordingly and respect his privacy during the dressing changes.

-Following the dressing change, assist in repositioning Fred

Most importantly, please note that the primary goal of this procedure is to effectively and efficiently change Fred’s dressing. Any increase in disturbance and time, increases the pain and the amount of drug required. More time and more people, costs more drug and more distress to Fred.

Fred’s Response to Music

Bob Marley said, "When the music hit you, feel no pain“

“I looked forward to hearing familiar music during these extensive dressings” (Fred).

Actual Time/Workload Considerations while Fred was in Hospital

QMon/Wed/Fri for 60-120 minutes for 8 weeks

Post Dressing ICU Nursing Notes

• Pain medication administered timely prior to dressing changes‘Pt had vac dressing changed today, writer monitored

patient and vital signs while pain meds given by APS. Pt received 20mg ketamine, 200mg fentanyl, 2mg versed in

total. Pt tolerated procedure, tired and a little drowsy post procedure but is able to follow commands, keep eye

contact longer than 10 seconds, oriented to place and nurse but not to time’

Fred’s Analgesic Requirements

• ↑time = ↑healing = ↓analgesic requirements• By the time Fred was transferred to inpatient

surgery, there was minimal to no opioid used. APS’s role changed to providing music and supportive care during the dressing changes.

Transition Plan for Fred

• Considerations for keeping Fred in ICU• CCOT involvement once transferred to

inpatient surgery• Additional CCOT follow-up • Back-up resources

It is time to consider moving the patient out of ICU

The wound and patient continued to show significant progress while on

the surgical unit

Off to the floor, Rehab then Home!

On the rehab unit prior to D/C home

In follow up in the outpatient clinic

CLOSED!!

COMMENTS FROM FRED

What were some of your best moments while in hospital?

• Regular visits (daily for quite sometime) from the surgeon and ICU team.

• Time spent with the wound care team.

Their empathy, emotional support and professionalism.

What Could We Have Done Better?

• Better communication between patient/ family, and staff.

i.e.- I am being sent for an x-ray. Why, and what was the outcome.

• Transfers from one unit to another were all conducted with " undue haste." – I did not get a chance to say thank you to so many

caring individuals.

The Patient’s Summary Comments

• This was a traumatic experience for me, and several groups were involved in my recovery. For this I will remain forever grateful.

• I developed a new found admiration for the professionalism, excellence and compassion of most staff.

Questions