Cases in Surgical Critical Care

Hasan Shanawani, MPH MD hshanawani@med.wayne.edu

Cases in Surgical Critical Care
‡ Objectives ‡ Things to consider when caring for the critically ill postoperative patient ‡ Cases
± Postop ± Preop

Objectives
‡ Discuss cases of surgical patients in the ICU ‡ Develop an approach when caring for patients in the SICU ‡ Cite important differences in the management of critically ill surgical patients

Things to consider« ‡ Go with what you know ‡ How did surgery change: ± Anatomy ± Physiology ± Management considerations? ‡ Remember your role .

9(1):68-72. Ann Thorac Cardiovasc Surg. et al. 2003 Feb. ) .Case 1: Postoperative Crisis Management ³My Achy-Brachy Heart«´ 53yo admitted to you after thoracotomy for lung cancer (images adapted from Shimizu J.

9(1):68-72. et al. 2003 Feb.HPI Smoker w/ hemoptysis Found on CXR to have large (R) chest mass No obvious extrathoracic spread Unrevealing mediastinoscopy (images adapted from Shimizu J. Ann Thorac Cardiovasc Surg. .

et al.CT (images adapted from Shimizu J. 2003 Feb. Ann Thorac Cardiovasc Surg.9(1):68-72. .

Case 1 ‡ Exploratory (R) thoracotomy ± Tumor invading truncus inferior of (R) PA. pericardium by superior PV ± Intrapericardial pneumonectomy performed ‡ Vessels controlled outside pericardium ‡ Intercostal muscle pedicle over bronchial stump ‡ Pericardium closed w/ suture .

BP 120/70 Good breath sounds in L lung No pain issues w/ epidural UO 30ml/ hr .Case 1: Postop ‡ ‡ ‡ ‡ ‡ ‡ Extubated in OR EBL <200ml NSR 70-90 bpm.

mucus clearance ‡ R leg swelling. mild drainage at epicardial site ‡ Good air movement. on good DVT prophylaxis ‡ Patient prepped for LP by med student HS: attempted sitting up. delirious.Case 1: POD #3 ‡ Febrile. pulmonary toilet. patient lies down to R side on chest tubes in mid-procedure . tachypneic.

‡ Venous congestion in face ‡ You are called emergently to assist. . no pulse palpable. patient w/ labored breathing pattern.Case 1 ‡ PEA arrest w/ bradycardia.

Case 1: What next? You are performing ACLS Rescucitative efforts are not working «Things to consider« .

can happen w/ lobectomy Shimizu J. 22 (L) ± 21/46 fatal ‡ >75% happened defore end of surgery during repositioning ‡ Most cases are related to pneumonectomy. Cardiac herniation following intrapericardia pneumonectomy with partial pericardiectomy for advanced lung cancer . Ann Thorac Cardiovasc Surg.9(1):68-72. 2003 Feb. et al.Cardiac Herniation ‡ Rare w/ pericardial mesh ‡ 68 case series (Kimura 1999) ± 46 (R).

Cardiac Herniation ‡ Occurs with ± Coughing ± Rapid decompression w/ chest tube ± PPV ± Patient movement ‡ Treatment ± Reposition patient ± Access to pericardium w/ restoration of heart position ± Pericardial patch .

9(1):68-72. et al.Case 1 During decompensation After emergent Procedure (images adapted from Shimizu J. 2003 Feb. Ann Thorac Cardiovasc Surg. Cardiac herniation following intrapericardia pneumonectomy with partial pericardiectomy for advanced lung cancer .

Case 2: Preop ³My Therapist told me I would live longer if I just vent my spleen more´ 47 yo admitted with abdominal pain .

.HPI ‡ Case 2 HPI ‡ He presented to an OSH with abdominal pain ‡ CT interp: ³contained rupture of his spleen. you are consultant intensivist to see patient first.´ ‡ HD#1 hct 22% Post 2u prbcs hct 21% ‡ Transfer to your ICU arranged.

diagnosed in 1970. ± BM Bx 1990: myelofibrosis ± Gout Meds: Folate MVI Procrit Allopurinol Fe Sulfate Indomethacin No allergies .Case 2 PMHx: ± Essential thrombocytosis and splenomegaly.

Case 2-Admission Data ‡ AFVSS INAD ‡ Spleen extends down to pelvic rim. approximately 4cm from midline ‡ Small ventral hernia ‡ Hct 23% .

Radiology .

Management? .

pt diaphoretic. and w/ an enlarging belly. pale. .On arrival ‡ Pt complains of ³feeling like [he is] going to die´ ‡ BP 70/palp.

You¶re the ICU doc« ‡ How will you manage this patient? ‡ What events do you anticipate in this patient? ‡ To manage this patient immediately. what will you need? ‡ What needs will you develop ³down the road?´ .

Hospital course. continued ‡ PEA arrest within 10 minutes of arrival ‡ ³trauma code´ called ± ³Level One´ mangement ± eventual emergent exploratory laparatomy ‡ ACLS ensued w/ concurrent volume resucitation. In first 20 minutes: ± 10L of crystalloid ± 6u of uncrossmatched PRBCs ± goal SBP •90 ‡ The patient stabilized and on OR table within 25 minutes of arrival to ICU .

Surgery ‡ Spleen weighed 5400gm and measured 44x18x9.5cm ‡ Rupture of splenic vein at base of spleen identified ‡ Over course of 6h surgery he continues to bleed ± Total ~100u blood products .

You¶re stuck ‡ Patient survives surgery ± ± ± ± 20units crossmatched blood 70units uncrossmatched blood 10u FFP 18u platelets PTT 80 Cai 0.65 ‡ Initial postop values PT 30 Hgb 11 K+ 3.65 Fibrinogen 80 pH 7.3 ‡ What will consequences of massive transfusion be? .

Massive Transfusions ‡ Rarely occur in the MICU ‡ Differing definitions ± •50% of patient¶s blood volume/ 12-24hrs ‡ Defines ³Support of Surgical Team´ ‡ Medical management of a surgical patient O2 Delivery Electrolyte shifts Acid-Base Balance Coagulopathies .

13(4):456-9.5 6. et al. Arrow International sales staff .How fast can you go? Device (with 0.6 14G Interlink® Catheter (without interlink) 18G Interlink® Catheter (without interlink) 16G lumen (brown port) of Arrow® TLC 18G (proximal white port) of Arrow® TLC Refs: Saw S.5 3.´ The effect of the InterLink cannula on fluid flow rates and haemolysis.´ Emerg Med 2001 Dec. Arrow device package insert personal communication.5 3.5 10.9% NS) Arrow 9F Percutaneous sheath introducer Arrow 8F Percutaneous sheath introducer Flow Rate (100cm above entry site) (L/hr) 33.3 1.

Level 1 Infuser (Belmont Corp) ‡ 75-30.000ml/ h ‡ Pressure at 300mmHg ‡ Rapidly warms fluids to 37ºC ‡ Requires specialized nurse training to operate Spikes Drip Chamber Top Socket Heat Exchanger Guide Heat Exchanger Bottom Socket Gas Vent Gas Vent Holder Patient line From Belmont Corp Product Literature .

Coagulopathy ‡ ‡ ‡ ‡ ‡ Dilutional Coagulopathy Chemical Coagulopathy Transfusion-induced DIC Dilutional thrombocytopenia When to give: ± ± ± ± Platelets FFP Cryoprecipitate Factor VIIa .

Other Issues ‡ ‡ ‡ ‡ ‡ ‡ Hypothermia Citrate Load Metabolic alkalosis Old blood metabolic acidosis Citrate toxicity (•8 u prbcs/ hour) Hypokalemia and/ or hyperkalemia Hypocalcemia .

on-call hematologist notified ‡ Rapid blood matching . clinical labs.Role of other services ‡ Treated like a ³stroke code´ ‡ OR. blood bank.

Preparing an ICU patient for surgery ‡ Preop eval is simultaneous w/ resuscitation ‡ What are opportunities to improve patient¶s condition before surgery? ABC HR. BP Ascites ‡ What concurrent diseases will affect pre/ peri/ postop management? ‡ What are endpoints of preop resuscitation? .

Preparing an ICU patient for surgery ‡ What is planned surgery? ‡ What are preop needs? ± Blood products ± Invasive/ non-invasive monitoring ± Vasoactive medications ‡ What is periop/postop monitoring plan? ‡ What is postop sedation/ extubation plan? ‡ What is postop antibiotic plan? .

Don¶t forget« Preop information you wish you had after the surgery ± Peripheral vascular exam ± Neuro exam ± Steroid use history and risk of adrenal insufficiency If non-elective: NGT decompression of stomach Pregnancy test .

MPH MD hshanawani@med.edu .wayne.Thanks! Cases in Surgical Critical Care Hasan Shanawani.

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