Surgical Intensive Care

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1 Surgical Intensive Care JUNYI LI, MD Board certified in Anesthesiology Board certified in Critical Care Medicine Board certified in Transesophageal Echocardiography [email protected] March 31, 2009

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Surgical Intensive Care. Board certified in Anesthesiology Board certified in Critical Care Medicine Board certified in Transesophageal Echocardiography. JUNYI LI, MD. March 31, 2009. [email protected] Subspecialty ICU. Medical Intensive Care Unit (MICU) Coronary Care Unit (CCU) - PowerPoint PPT Presentation

Transcript of Surgical Intensive Care

  • *Surgical Intensive CareJUNYI LI, MD

    Board certified in AnesthesiologyBoard certified in Critical Care MedicineBoard certified in Transesophageal Echocardiography

    [email protected] 31, 2009

  • *Subspecialty ICUMedical Intensive Care Unit (MICU)Coronary Care Unit (CCU)Surgical Intensive Care Unit (SICU)Neurological Intensive Care Unit (NICU)Cardiovascular Intensive Care Unit (CVICU)Pediatric Intensive Care Unit (PICU)Neonatal Intensive Care Unit (NICU)

  • *SICU Admission CriteriaPreoperative status Major trauma Surgical Procedure Pts preexisting diseaseIntraoperative event Large volume shift Unexpected surgical complication Unexpected anesthesia complicationPostoperative status Unexpected postop complication Pts status

  • *Who need to be admitted to SICU ?18 y/o health male presented for right inguinal hernia repair under spinal anesthesia and uneventful intraop and postop.50 y/o female with controlled HTN and DM for lumbar laminectomy under general anesthesia with EBL 500 ml.75 y/o male with stable angina, COPD required home oxygen for TURP under spinal anesthesia60 y/o male presented for AAA repair54 y/o female with esophageal cancer presented for esophagectomy 95 y/o female presented for right hip arthroplasty

  • *SICU ManagementRespiratory care Hemodynamic monitoring and management Noninvasive InvasiveInfection in SICUAcid-base disordersFluid and electrolyte disordersBlood component therapyNutrition support

  • *Respiratory care basic monitorRespiratory rateChest movementBreath soundColor

  • *Respiratory care lung volumeTidal volume (VT)Minute ventilation (Vm)Functional residual capacity (FRC)Vital capacity (VC)

  • *Respiratory care - ventilationVentilation-perfusion (V/Q) ratio: normal V/Q=4L/5L=0.8Dead space ventilation: V/Q>1 anatomic dead space & physiologic dead spaceIntrapulmonary shunt: V/Q
  • *V/Q relationship and associated blood gas

  • *Effect of shunt fraction on PAO2

  • *Effect of shunt fraction on PAO2 and PACO2

  • *Ventilation-perfusionQuantitative determinationsDead space (Vd/Vt) = (PACO2 PECO2)/PACO2Shunt fraction (Qs/Qt) = (CCO2 CAO2)/(CCO2 CVO2)A-a gradient (PAO2 PaO2) PAO2 = PIO2 (Paco2/RQ) PAO2 = FIO2(PB PH2O) (PaCO2/RQ) PAO2 = 0.21(760 47) (40 /0.8) = 100 mmHgPAO2/FIO220% PAO2/FIO2>200, Qs/Qt
  • *Hypoxemia Disorder A-a PO2 PVO2 Hypoventilation Normal Normal Pulmonary disorder Increased Normal DO2/VO2 imbalance Increased Decreased

    DO2/VO2 oxygen deliver and uptake ratio A-a PO2 PO2 difference between alveolar gas and arterial blood PVO2 Mixed venous PO2

  • *Evaluation of hypoxemia

  • *HypercapniaHypercapnia is PACO2>45 mm Hg, due to Increased CO2 productionHypoventilationIncreased dead space ventilation

  • *Evaluation of hypercapniaHigh

  • *Oximetry Oximetry detects arterial blood HbO2 and Hb ratioEar oximetryPulse oximetryCo-Oximeters can detect Met Hb and CO HbMixed venous oximetry measured O2 sat in PA blood

  • *CO2 detector and capnometryCO2 detector is a method for determining the success or failure of ET intubation.Clinical application of capnometry in ICU: - Cardiac output monitor - Ventilator-related mishap detection - Early detection of nosocomial disorders - Ventilator weaning - Controlled hyperventilation

  • *Acute respiratory distress syndrome (ARDS)A leading cause of acute respiratory failure with high mortality A diffuse inflammatory injury in the lungNot an accumulation of watery edema fluidNot a primary disease, but a complication

  • *Common conditions that predispose to ARDS

  • *ARDS microscopic changes and CXR

  • *Diagnostic criteria for ALI and ARDSAcute onsetPresence of predisposing conditionPaO2/FiO2 < 200 mm Hg for ARDS, < 300 mm Hg for ALICXR bilateral infiltratesPAOP < 18 mm Hg or no clinical evidence of high LA pressure

  • *Management of ARDSNo real treatment for ARDS, only supportiveMechanical ventilation: low-volume ventilation permissive hypercapnia positive end-expiratory pressure Fluid management reducing extravascular lung waterPharmacotherapy uncertain effect

  • *Respiratory therapyOxygen inhalation therapyChest physical therapyRespiratory pharmacotherapyMechanical ventilation

  • *Oxygen inhalation therapyArterial hypoxemia: PaO2 < 60 mm Hg (SaO2 < 90 %)Tissue hypoxia: blood lactate > 4 mmHgEndpoint of O2 therapy is tissue oxygenationTissue hypoxia may not consistent with arterial hypoxemia

  • *Effect of Oxygen on blood flowOxygen tends to reduce systemic blood flow due to: 1. vasoconstrction in all vascular bed except the pulmonary circulation 2. decrease in cardiac output 3. negative inotropic effect

  • *Method of oxygen inhalationLow-flow oxygen delivery system with variable FiO2High-flow oxygen delivery system with constant FiO2

  • *Device Reservoir Oxygen flow FiO2 capacity (L/min) Nasal cannula 50 ml 1 0.21-0.24 2 0.24-0.28 3 0.28-0.34 4 0.34-0.38 5 0.38-0.42 6 0.42-0.46Oxygen face mask 150-250 ml 5-10 0.40-0.60Mask-reservoir bag 750-1250 ml Partial rebreather 5-7 0.35-0.75 Nonrebreather 5-10 0.40-1.0Low-flow oxygen delivery systemsFiO2 = 20 + 4 X oxygen flow (L/ml)

  • *Respiratory pharmacotherapyBronchodilators

    Corticosteroids

    Mucokinetic therapy

  • *Mechanical Ventilation

  • *Mechanical ventilationMechanical ventilation is positive pressure ventilationIndications of mechanical ventilation Rate ABG: hypoxia and hypercapnia Mechanical parameter: MV, VC and NIP Dead space and shuntContraindication of mechanical ventilation

  • *Normal lungNoncompliant lungEffect of positive pressure ventilation

  • *Effect of positive pressure ventilation

  • *Respiratory parameterRate: 10 20/minVT: 6 10/kgFiO2: 40 100%PEEP: 5 10 cm H2OPS: 5 10 cm H2OI:E ratio: 1:2

  • *Patterns of mechanical ventilationControl mode ventilation

    Assist-control ventilation

  • *Pattern of mechanical ventilationVolume-controlled ventilation ACV (assist control ventilation) IMV (intermittent mandatory ventilation) SIMV (synchronized IMV)Pressure-controlled ventilationPressure support ventilationSpecial pattern:

  • *Functional mode of ventilatorPEEP (positive end expiratory pressure)

    PS (pressure support)

    I:E reversal ratio

  • *Ventilatory mode of mechanical ventilation

  • *Volume-controlled ventilation

  • *Pressure-controlled & Pressure support

  • *PEEP and CPAP

  • *Effect of PEEP on arterial oxygenation and CI

  • *Discontinuing mechanical ventilationVentilator required for brainstem respiratory depression (e.g.,GA in OR or drug overdose) is easy to discontinueVentilator required for cardiopulmonary insufficiency is weaning in gradual process

  • *Discontinuing mechanical ventilationClinical evaluation: Awake Spontaneous breathing Ability of airway protection Stable hemodynamics

  • *Discontinuing mechanical ventilationSequence of weaning: FiO2 to 50% or less PEEP to 5 cm H2O or less PS to 10 cm H2O or less

  • *Discontinuing mechanical ventilation Bedside weaning parameters:Parameter Normal range Threshold for weaningPaO2/FiO2 >400 200 VT 5-7 ml/kg 5 ml/kg Rate 10-20/min -120 cm H2O (M) Rate/VT
  • *Predictive value of selected weaning parameters

  • *Discontinuing mechanical ventilationMethods of weaning: T-piece weaning IMV weaning CPAP weaning

  • *Diagram of T-shaped circuit

  • *Hemodynamic monitoring NoninvasiveECG: heart rate, rhythm, ischemia (ST-T)Noninvasive BPEchocardiography: TTE, TEE, color-doppler Contractility Volume status EF Ischemia (RWMA) Noninvasive cardiac output (through A-line)

  • *Hemodynamic monitoringInvasiveArterial blood pressureCentral venous pressurePulmonary artery catheter and wedge pressureCardiac output

  • *Invasive arterial blood pressure Major CV surgerySurgery with great hemodynamic changeSurgery with large volume shift and bleedingShock and other critical ill patientsSurgery requiring hemodilution and control hypotensionFrequent ABG Indication

  • *Invasive arterial blood pressureContraindication: only relative contraindication except for puncture site infection

  • *Invasive arterial blood pressureSelection of artery for cannulationRadial arteryUlnar arteryBrachial arteryFemoral arteryDorsalis pedis and posterior tibial arteriesAxillary arteryCarotid artery do not use

  • *Invasive arterial blood pressureComplicationBleeding and hematomaVasospamThrombosis and thrombiAneurysmInfectionNerve damageNecrosis of skin overlying the catheter

  • *Invasive arterial blood pressureWaveformSBP gradually increasesMBP remains unchanged

  • *Invasive arterial blood pressure Waveform distortionNormal testunderdampedoverdamped

  • *Central venous pressureIndicationFluid administration for severe hypovolemia and shockInfusion of cardiac drugsAspiration of air emboli in craniotomyInsertion of transcutaneous pacing leadsTotal parenteral nutrition (TPN)Venous access for patients with poor peripheral veins

  • *Central venous pressureContraindicationRenal cell Ca extension into RA, RA myxoma, or fungating tricuspid valve vegetationsSkin infection at cannulation siteSevere coagulopathy Ipsilateral carotid endarterectomy (IJ), pneumothorax and hemothorax are relative contraindication

  • *Central venous pressureSelective sites of cannulationInternal jugular veinsSubclavian veinsFemoral veinsExternal veinsBasilic veins

  • *Central venous pressureMeasurementCatheters tip lies above or the junction of SVC and RACVP is measured with cm H2OCVP should be measured during end expiration

  • *Central venous pressureWaveforma wave atrial contraction, absent in A fib and exaggearted in JR (cannon wave)c wave TV [email protected] ventricular contractionv wave venous return against to closed TVx descent downward displacement of TV (systole)y descent TV opening during diastole

  • *Central venous pressureComplicationBleeding and hemotomaPneumothorax and hemothoraxPleural effusion and chylothoraxLine-related infectionAir thrombi

  • *Pulmonary artery catheterizationLength 110 cmOD 2.3 mmDistal portProximal portBalloon at tipThemistor

  • *It Is Time To Pull The PACPAC dose not improve outcome in critically ill patients

  • *BackgroundPulmonary artery catheter(PAC) has been used in critical care practice for three decadesMajority of PAC are inserted to aid in management of critically ill pts in ICU and high risk surgical pts in ORObservational studies & small randomized controlled trials (RCT) showed variable results: Worse outcome No difference in outcome Some benefit

  • *SummaryPAC-directed management in high risk surgical, severe sepsis, shock and RADS pts is a safe procedurePAC use dose not improve outcomePAC use may not increase cost of care

  • *Pulmonary artery catheterizationIndicationCardiac disease: CAD with LV dysfunction, valvular heart disease, heart failurePulmonary disease: ARDS, severe COPD, Pulmonary hypertensionComplex fluid management: shock, acute burn ARF, MOFSpecific surgical procedure: aortic cross clamp pheochromocytoma, liver transplants, Hemodynamic unstability required cardiovascular drug therapyHigh-risk obstetrics: severe toxemia

  • *Pulmonary artery catheterizationContraindicationSevere TV or PV stenosisRA or RV tumorEndocarditis with vegetation on TV or PVOther contraindication related to central venous cannulation

  • *Pulmonary artery catheter

  • *Pulmonary artery catheterization Insertion of catheter

  • *PCWP and CVP

  • *Pulmonary artery catheter in chest x-ray

  • *Pulmonary artery catheterizationComplication Complication associated with CV cannulationBacteremia and endocarditisThrombogenesis and pulmonary infarctionPulmonary artery rupture and hemorrhageArrhythmias and conduction abnormalitiesPulmonary valve damage

  • *Pulmonary capillary wedge pressureCVP = RAP = RVEDPPCWP = LAP = LVEDP

  • *Hemodynamic parameterBSA = (Ht + Wt 60)/100, nl 1.6 to 1.9 m2CO = HR x SVCI = CO/BSADO2 = CI x 13.4 x Hb x SaO2VO2 = CI x 13.4 x Hb x (SaO2 SvO2) * SvO2 obtained from PAC distal port

  • *Hemodynamic ProfilesHeart failure: Right heart failure Left heart failure High RAP High PCWP Low CI Low CI High PVRI High SVRI

  • *Hemodynamic profilesHypotension: Hypovolemic Cardiogenic Vasogenic Low CVP High CVP Low CVP Low CI Low CI High CI High SVRI High SVRI Low SVRI

  • *Cardiac output monitoringThermodilution methods Pulmonary artery catheter Peripheral artery catheter (Picco)Dye dilution methodsEchocardiographyThoracic bioimpedance

  • *Cardiac output monitoring Fick principleCO =Oxygen consumptiona v O2 content difference= VO2CaO2 CvO2Fick principle is the basis of all indicatordilution methods of determining cardiac output

  • *Thermodilution method

  • *Hemodynamic management

    PreloadAfterloadCardiac contractility

  • *Hemodynamic managementPreloadMonitoring via CVP or PCWPIncreased preload by giving volumeDecreased preload by giving diuretics and/or vasodilators (nitroglycerin)

  • *Hemodynamic managementAfterloadVascular resistanceBalance between cardiac work and organ perfusion Vasodilators: Systemic vasodilators: nitroprusside, calcium channel blockers, a1-blockers Pulmonary vasodilators: PGE1, PGI, NOVasocontrictors: levophed, epinephrine, vasopresin

  • *Hemodynamic managementInotropic agentsPositive inotropic agents: epinephrine, dopamine, dobutamine, PDEI (milrinone) Negative inotropic agents: beta blocker and calcium channel blockers

  • *Hemodynamic managementMechanical support (IABP)

  • *Hemodynamic effect of IABPDecrease afterload and promote SVIncreased diastolic pressure and coronary blood flow in hypotensive patientsIndication: AMI, cardiac shock, unstable angina, acute MRContraindication: AI, aortic dissection and aortic graft in thoracic aortaComplication: leg ischemia, septicemia

  • *Acute renal failure (ARF)The hallmark of ARF is azotemia and oliguriaLab: blood urea nitrogen(BUN), criatinine(Cr), blood electrolytes, glumerular filtration rateEtiology: prerenal, renal and postrenal Renal ischemia (50%), Nephrotoxines (35%), Intrinsic renal disease (15%) 50% of ARF in SICU due to major trauma or surgery

  • *Etiology of ARF

  • *Treatment of ARFSupportive managementDiuretics and mannitol to maintain urine output in nonoliguric patientsRenal dose dopamine?Glucocorticoids for ARF due to vasculitis or glomerulonephritisOther: restrict fluid, sodium, potassium, posphRenal replacement therapy (dialysis)

  • *Renal Replacement Therapy

  • *Infection in SICUInfections are leading cause of death in ICUsCommunity acquired and hospital acquired infection Strains of bacteria resistant to commonly used antibiotics are commonAdvanced age, prolonged use of invasive devices, respiratory failure, renal failure and head trauma are established risk factors for hospital acquired infectionMultiple antibiotics and broad spectrum antibiotics are commonly used in SICU

  • *Nutrition support in SICUMaintaining adequate nutrition in critically ill patients improves wound healing. Restore immune competence and reduces morbidity and mortalityCritically ill patients generally required 1.0-1.5g/kg/day instead of 0.5g/kg/day for nonstressed patientsEnteral nutrition and parenteral nutrition

  • *Enteral Nutrition in SICUGI tract is the route of choice for nutrition support when its functional integrity is intactEnteral nutrition is simpler, cheaper, less complicated, and fewer complicationEnteral nutrition can better preserve GI structure and functionDiarrhea is most common problem related to hyperosmolarity of the solution or lactose intolerance

  • *Parenteral Nutrition in SICUTotal parenteral nutrition (TPN) is indicated if the GI tract cannot be used of if absorption is inadequateComplications of TPN are catheter-related and metabolicThe most common problem in TPN is hyperglycermia