Post Operative Care

for
Trauma and Critically Ill patient

Definitive Surgery for Trauma and Acute Care Surgery

The College of Surgeons of Indonesia
First Edition, 2019

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Male, 25 yrs, 9/10-2019 : Accident pk. 19.30,
Admission ER : 20.55, ISS : 50
M : Motorcyclist, fell-down, crushed by truck
I
S
T
 Initial Assessment

• Patient could speak, RR 28x/min. SpO2 88% without O2

supplementation, 100% with NRM O2 10 lpm.
• Cold, pale, clammy, BP 46/32 mmHg, 142 bpm, weak pulse,
CRT > 2”,
• Unstable pelvic.
• Abdomen : no free fluid, no muscle guarding.
• Awake, GCS 15, Isochor pupil
Regional Exam

– Pelvic deformity
– Laceration of right scrotum until perineum (Grade II
perineum rupture)
– Active bleeding in the perineum region
– Palpable inferior pubic ramus bone fragments
– Rectal toucher : spinchteric tonus normal, floating
prostate (+)
– Bloody meatal discharge
– Crush injury at right cruris extension to the right
pedis
– Close degloving right humerus, right antebrachii, left
femur
 INITIAL ASSESSMENT
 Unstable hemodynamic unresponse to resuscitation
 Unstable pelvic with Pelvic binding applied
 Laceration of scrotum D until perineum (Grade II
perineum rupture) with active bleeding controlled with
direct pressure
 Blunt abdominal trauma
 Suspect posterior urethral rupture
 Close degloving right humerus, right antebrachii, left
femur
 Crush injury at right cruris extends to the right pedis
 Laceration of the right manus and left knee
 Metabolic acidosis
 Surgery

• Pelvic external fixation

• Diagnostic peritoneal lavage
• Open cystostomy
• Vascular evaluation on right lower extremity
and right below knee amputation if needed
• Debridement scrotum + perineum + right
manus
 What will you do post-operatively ?

• Post operative care

 How do you do post-operative care

• Intensive Care Unit

• High Dependency Unit
PHTLS & Prevention
Traumatologist = Total Care
Three peaks of trauma related deaths
First peak
Laceration of brain
Third peak
brainstem
Sepsis
aorta
Multi organ failure
spinal cord Second peak Secondary Brain Injury
heart Extradural
Subdural
Hemopneumothorax
Pelvic fractures
Long bone fractures
DEATHS

Abdominal injuries

s
eek
s wee k
4
2w
1 hour 3 hours
 11-10 12-10 13-10
Hemoglobin 8.9 7.9 10.1

WBC (/Ul) 10.3 5.410 0.95

Platelet (/Ul ) 35.000 35.000 49.000

BUN/Creatinine 5.10/ 0.52 70/ 7.68 970/ 11.3

Na/K/ Cl 146/4.8 /110 152/4.9/113 152/5/109

Albumin 3.0 2.5 3

OUTCOME
Blood sugar 106 108 44
Ph /Pco2/Po2 7.35/29/120 7.27/37/124 7.05/ 53/56 PATIENT
DEAD
HCO3- /BE 16.5/ - 9.6 17 / -9.9 14.7/15.3
PT/APTT ( Sec.) 16.2 / 36
 Female, 38 yrs.( Admitted : Oct,21st, 2019 )

• Cervicitis, Adeno-Endometriosis Uteri, Right Ovarial cyst.

• Surgery :
• Moderate to severe adhesion of Iintestines with uterus and ovary.
• Laparotomy, release adhesion, SVH, Right
• Complication : injury (rupture) of intestine, suspect rectum.
• Consultation to surgeon : lesion on ileum (not total) . No rectal injury.
• Procedure : primary repair, two layer suturing, sump drain in
Douglass cavity
 Postoperative care

• Day-3 :
• Stable hemodynamic, awake.
• Abdominal distention, nausea, no flatus or stool.
Day-3 POD. Day-5 POD
 Day-7, POD

• Awake, tachypnea, tachycardia,

• BP 110/70 mmHg, RR 28x/min,t : 36.7 oC.
• Abdominal pain, distention, absent of bowel sound, muscle
guarding all quadrant, positive free fluid.
• Diffuse peritonitis
• Bowel ( suture ) leakage ?
• Re-laparotomy.
 Day-7
• Re-laparotomy :
• Adhesion of Omentum, forming “cystic mass”.
• Content : liquid fecal ( 850 mL )
• Gentle release of adhesion, rupture of intestine ( distal
ileum ? )
• DCS : “ Temporary Foley catheter insertion, ballon-inflated “
– abdominal wash out, sump drainage, open abdomen.
• Re-open on day-10 : repair and suturing bowel rupture,
wash out and drain. Open abdomen
• Re-open on day -15 : adhesion , wash out, closed abdominal
wall.
What is the goals Trauma ICU Care / Postoperative care ?
• Early restoration and maintenance of tissue oxygenation
• Diagnosis and treatment of occult injuries
• Prevention and treatment of infection
• Prevention and treatment of MOF
• Aware of post-traumatic ( disease ) complications.
• Aware of postoperative complication
O2
 METABOLISME AEROBE
METABOLISME ANAEROBE
Lactic acid
The Metabolic Stress Response to Surgery
and Trauma
E R A S

Singer, Blaser, Berger et al : ESPEN guidelines on clinical nutrition in intensive care unt. Clinical Nutrition 2019, 38 : 53
 First 24 hours post-injury
• Resuscitative phase.
• Fluid Resuscitation
• Why ?
• Decreased tissue Oxygen Delivery due to impaired perfusion
or severe hypoxemia
• Goal of treatment : maintenance of adequate Tissue
Oxygenation, immediately
• Problem : inadequate resuscitation.
• Think : Hypovolemia and Ongoing Blood loss.
• Simultaneously :
 CO CaO2
DO2 =
5 L/men
X
200 cc/L

HR X SV 1,34 x Hb x SaO2 + 0,003 x PaO2

PRELOAD CONTRACTILITY AFTERLOAD

 “ Traditional” End Points of Resuscitation

• Clinical examination
• Base deficit and Lactic Acidosis
• Gastric tonometry
• Tissue Oxymetry
 Post Traumatic Respiratory Failure

• Chest trauma • Post traumatic ARDS

• Fluid overload • Spinal cord injury
• Shock • Fat embolism
• Aspiration • Co-morbid : Respiratory
disease
 Respiratory Assessment and Monitoring

• Work of breathing
• Respiratory rate
• ABG
• DO2 and VO2
• Bronchoscopy
• Ventilatory support.
 24-72 hours post injury = Early life support phase

• Focus on :
• Post-traumatic respiratory failure
• Progresive Intracranial Hypertension ( Severe TBI)
• Problems :
• ICH
• Respiratory Insuffiency
• SIRS - Sepsis
• Early MODS
• Postoperative complications
 24-72 hours post injury = Early life support phase

• Main Priorities :
• Maintenance of tissue Oxygenation
• Control of ICP
• Ongoing search of occult (mis) injury
• Start Nutritional support
 24-72 hours post injury = Early life support phase

• Actions :
• Gas exchanged and ventilator support
• Monitoring and control of ICP
• Fluid and Electrolyte balance
• Hematological parameters
• Occult injuries : Intracranial, Cervical, Intra abdominal,
• Spine and extremity injury
• Nerve injury
 Prolonged Life Support ( > 72 hours post injury )

• The more seriously injured or critically ill patients.

• Ongoing life support to prevent MODS.
• Clinical concern : Infectious complication
• Main objectives :
• Support the Organs Failure.
 Organs Disfunctions

• AKI
• POI
• Gut Failure
• Liver disfunction
• Post traumatic Acute Pancreatitis
• Respiratory Failure
• Sepsis
 Main Objectives of Management

• Ventilation and Oxygenation : Tracheostomy (?)

• Treat the infections : HAP - VAP
• Nutritional support.
• Chest physiotherapy
• Physiotherapy of extremity
• Prevention of pressure sore
 Infectious Complications
• HAP - VAP
• Lung Abscess and Empyema
• Surgical Site Infection
• IV-Catheter –realated sepsis
• Bloodstream infection
• Urinary tract infection
• Acalculous cholecystitis
• Sinusitis and Otitis Media
• Ventriculitis and Meningitis
• Fungal infection
 Hypothermia

• Potential complication of trauma. Remember !!!

• Hypothermia may cause Cardiac Arrest
• Hypothermia may protective to brain injury
• Core temperature < 30 oC = Vo2 reduced by 50 %
• Core temperature < 29.5 oC: high risk of Ventricular Arrhytmia.
• Harmful to trauma patients
• It alters Oxygen delivery
• Rewarming as soon as possible.
 Rewarming
External
• Removal of wet or cold clothing
• Electrical heating blankets
• Warm air heating blankets
• Infrared (radiant) heat
Internal
• Heated humidified respiratory
gases to 42 Oc.
• IV Fluids warmed to 37 oC
• Gastric lavage with warmed fluids
( NaCl 42 oC )
• Continuous bladder lavage
• Peritoneal lavage
• Extracorporeal rewarming
 SIRS
• Temperature < 36 oC or > 38 oC
• Heart rate > 90 bpm
• Respiratory rate > 20 breaths per minutre
• Deranged arterial gases : partial pressure of CO2 ( PCO2 ) < 32 mmHg
• WBC Count > 12.0 x 109 /L OR < 4.0 X 109 /L, or 0.1 % immature neutrophils.

JAMA 2016, Vol. 315 (8) : 801.

 MODS

• “Two hit models”

• Risk factors :
• Persistent shock
• Lactic acidosis and elevated base deficit
• High ISS
• Multiple blood transfusion
• Co-morbity
• Elderly
Biphasic model of Organ Failure

World J. Emerg. Surg. , 2006; 1 : 15

Factors involved in post-traumatic organ failure
 ENDOGENOUS
RESPONSE • AUTO HEPARINIZATION
• • HYPERFIBRINOLYSIS
SHOCK
• • REDUCED CLOT STRENGTH
TISSUE INJURY
• • REDUCED THROMBIN
CLASSIC TRIAD • INCREASED ACTIVATED PROTEIN
HEMODILUTION FORMATION
C
HYPOTHERMIA • ENDOTHELIAL GLYCOCALIX
ACIDEMIA DISRUPTION
• PLATELETS DYSFUNCTION ACUTE TRAUMATIC
EXHAUSTION
• FIBRINOGEN DEPLETION COAGULOPATHY
TRAUMA

ACUTE TRAUMATIC COAGULOPATHY

ACUTE TRAUMATIC COAGULOPATHY.

Simmons and Powell ; Acute Traumatic Coagulopathy : Pathophysiology and Resuscitation,

BJA, 2016 ; 117 (S3) : iii35.
 Limit
Rapid Cristalloid/
Rewarming Colloid
Infusion

Early Ratio
Based Blood
Permissive
Component
Hypotension
therapy

Correction of
Hyperfibrinolysis
Damage Damage
Hypofibrinogenemia
Control Control
And others
Surgery Resuscitation
Coagulopathies

Tennant of Damage Control Resuscitation.

Simmons and Powell ; Acute Traumatic Coagulopathy : Pathophysiology and Resuscitation, BJA, 2016 ; 117
(S3) : iii36.
 ACIDOSIS

D E A T H

HYPOTHERMIA COAGULOPATHY

The Lethal Triad : Physiologic perturbations in death by exsanguination.

Source : Rotondo & Zonies, Surg.Clin.North.Am, 1997, (77) : 4, p.762

 SUMMARY
• ABCDE
• Occult Injuries
• Acute Traumatic Coagulopathy
• Trauma-related Complications
• Post-operative Complications
• HAI – HAP – VAP .
• MODS
• PAIN Control : VAPS
• Nutritional therapy
• Antimicrobes .
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 OBJECTIVES

To discuss:

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SUMMARY

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THANK YOU

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