SURGICAL INTENSIVE CARE By Prof. GAMAL ELEWA Dept. of Anesthesia, Intensive Care and Pain Management...
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Transcript of SURGICAL INTENSIVE CARE By Prof. GAMAL ELEWA Dept. of Anesthesia, Intensive Care and Pain Management...
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