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
 Case 1: Postoperative Crisis
Management

“My Achy-Brachy Heart…”

53yo ♂ admitted to you after thoracotomy for

lung cancer

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

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

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;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
 Case 1: Postop
• Extubated in OR
• EBL <200ml
• NSR 70-90 bpm, BP 120/70
• Good breath sounds in L lung
• No pain issues w/ epidural
• UO 30ml/ hr
 Case 1: POD #3
• Febrile, delirious, tachypneic, mild
drainage at epicardial site
• Good air movement, pulmonary toilet,
mucus clearance
• R leg swelling, on good DVT prophylaxis
• Patient prepped for LP by med student
HS: attempted sitting up, patient lies down
to R side on chest tubes in mid-procedure
 Case 1
• PEA arrest w/ bradycardia, no pulse
palpable, patient w/ labored breathing
pattern.
• Venous congestion in face
• You are called emergently to assist.
 Case 1: What next?
You are performing
ACLS

Rescucitative efforts are

not working

…Things to consider…
 Cardiac Herniation
• Rare w/ pericardial mesh
• 68 case series (Kimura 1999)
– 46 (R), 22 (L)
– 21/46 fatal
• >75% happened defore end of surgery
during repositioning
• Most cases are related to
pneumonectomy; can happen w/
lobectomy
Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation following intrapericardia pneumonectomy
with partial pericardiectomy for advanced lung cancer
 Cardiac Herniation
• Occurs with • Treatment
– Coughing – Reposition patient
– Rapid decompression – Access to pericardium
w/ chest tube w/ restoration of heart
– PPV position
– Patient movement – Pericardial patch
 Case 1

During decompensation After emergent Procedure

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation
following intrapericardia pneumonectomy with partial pericardiectomy for advanced lung cancer
 Case 2: Preop
“My 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: “contained rupture of his
spleen.”
• HD#1 hct 22%Post 2u prbcshct 21%
• Transfer to your ICU arranged; you are
consultant intensivist to see patient first.
 Case 2
PMHx: Meds:
– Essential Folate
thrombocytosis and MVI
splenomegaly, Procrit
diagnosed in 1970.
Allopurinol
– BM Bx 1990:
myelofibrosis Fe Sulfate
– Gout Indomethacin

No allergies
 Case 2-Admission Data
• AFVSS INAD
• Spleen extends down to pelvic rim,
approximately 4cm from midline
• Small ventral hernia

• Hct 23%
Radiology
Management?
 On arrival
• Pt complains of “feeling like [he is] going to
die”

• BP 70/palp, pt diaphoretic, pale, and w/ an

enlarging belly.
 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 “down the
road?”
 Hospital course, continued
• PEA arrest within 10 minutes of arrival
• “trauma code” called
– “Level 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
• Initial postop values
PT 30 PTT 80 Fibrinogen 80
Hgb 11 Cai 0.65 pH 7.65
K+ 3.3
• 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 “Support of Surgical Team”
• Medical management of a surgical patient
O2 Delivery Acid-Base Balance
Electrolyte shifts Coagulopathies
 How fast can you go?
Device Flow Rate
(100cm above entry site)
(with 0.9% NS) (L/hr)
Arrow 9F Percutaneous sheath introducer 33.5
Arrow 8F Percutaneous sheath introducer
10.5
14G Interlink® Catheter (without interlink) 6.5
18G Interlink® Catheter (without interlink) 3.5
16G lumen (brown port) of Arrow® TLC 3.3
18G (proximal white port) of Arrow® TLC 1.6
Refs: Saw S, et al.” The effect of the InterLink cannula on fluid flow rates and haemolysis.” Emerg Med 2001 Dec;13(4):456-9.
Arrow device package insert
personal communication, Arrow International sales staff
 Level 1 Infuser (Belmont Corp)
• 75-30,000ml/ h
Spikes
• Pressure at
Drip Chamber
300mmHg
Top Socket
• Rapidly warms fluids Heat Exchanger
to 37ºC Guide
Heat Exchanger
• Requires specialized Bottom Socket
nurse training to
Gas Vent
operate
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
 Role of other services

• Treated like a “stroke code”

• OR, clinical labs, blood bank, on-call
hematologist notified
• Rapid blood matching
 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
 Thanks!

Cases in Surgical Critical Care

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