Thermal Regulation

• Hypothermia
Mild hypothermia is common during surgery
and anesthesia, including both general and
neuraxial anesthesia that causes an increase in
adverse outcomes, including cardiac
complications, wound infections, coagulopathy,
need for transfusion, prolonged recovery times,
and increased hospital length of stay.
 Thermal Regulation

• Hyperthermia
Etiologies of increased core temperature result
from augmented thermogenesis (i.e., malignant
hyperthermia), excessive heating (i.e., passive
hyperthermia), or an increase in the
thermoregulatory target (i.e., fever). The
particular cause should be sought and treated.
 Thermal Regulation

• Malignant Hyperthermia
An anesthetic-related disorder of increased
skeletal muscle metabolism. Anesthetic drugs
known to trigger MH include ether, halothane,
enflurane, isoflurane, desflurane, sevoflurane,
and depolarizing muscle relaxants
(succinylcholine).
SPECIAL SCENARIOS IN THE MANAGEMENT OF
THE CRITICALLY ILL SURGICAL PATIENT
Transporting the Critically Ill Patient to and
From the Operating Room

• General Principles
The first rule of transport is that the patient
must be stabilized prior to transport. The
critically ill patient in transit should be
monitored just as closely as was necessary in the
ICU immediately prior to transport.
• Maintenance of Therapies
Whatever specific therapies the patient is being
treated with must continue en route and at the
destination. The most important example is
mechanical ventilation.
In patients whose hemodynamics are dependent
on ventricular assist devices and IABP
counterpulsation, personnel experienced in the
operation of these devices must be present
during the transport and at the destination.
• Contraindications to Transport
Transport out of the ICU is contraindicated when
there is an inability to provide adequate
oxygenation and ventilation during transport or
at the receiving location. It is also
contraindicated when there is an inability to
adequately monitor cardiovascular
hemodynamics during transport or at the
destination.
Specific Operations in Critically Ill Patients
• Abdominal Compartment Syndrome
Definitions
Abdominal compartment syndrome is distinct
from intraabdominal hypertension.
Intraabdominal pressure (IAP) can be measured
by determining bladder pressure as transmitted
through a Foley catheter (normal: 2–5 mmHg)
Specific Operations in Critically Ill Patients
• Abdominal Compartment Syndrome
Significance: Progressive Organ Failure
The common characteristic of all types of
abdominal compartment syndrome is
progressive organ failure, including failure of the
kidneys, splanchnic bed, lungs, heart, and brain.
Specific Operations in Critically Ill Patients
• Abdominal Compartment Syndrome
Treatment
Nonoperative management of abdominal compartment
syndrome includes sedation and paralysis to relax the
abdominal wall, evacuation of intraluminal
gastrointestinal contents, evacuation of large
abdominal fluid collections, optimization of abdominal
perfusion pressure with vasopressor support if
necessary, and correction of a positive fluid balance. If
these unsuccessful, definitive management includes a
decompressive laparotomy and temporary abdominal
closure until the underlying disease process is reversed.
Specific Operations in Critically Ill Patients
• Damage Control in the Trauma Patient
The Initial Operation: A Band-Aid for Anatomy to
Facilitate Repair of Physiology
The initial operation is limited to control of hemorrhage
and gross contamination.

The SICU Resuscitation: Abrogation of the Lethal Triad

On arrival to the SICU the patient is aggressively
rewarmed and resuscitation is ongoing, with infusion of
blood, blood products, vasopressors, and inotropes if
indicated to manage hemorrhagic and traumatic shock.
Specific Operations in Critically Ill Patients
• Damage Control in the Trauma Patient
The Definitive Operation: Restoration of
Anatomy
Ideally the patient is taken back to the OR when
hypotension, coagulopathy, acidosis, and
hypothermia have resolved, and when the
postresuscitation diuretic phase has begun.
Specific Operations in Critically Ill Patients
• After Damage Control: Subsequent Operative
Interventions
Some of the patients who survive injury and the
damage control required to repair it must
undergo multiple subsequent interventions and
operations. Particularly after damage control for
abdominal trauma, definitive closure of the
surgical incision is not always feasible at the
time of the first repeat laparotomy.
Specific Operations in Critically Ill Patients
• Common Operations to Facilitate Management
of the Critically Ill Patien
Tracheostomy
Tracheostomy is indicated in critically ill patients
who require prolonged intubation, typically longer
than 2 weeks.

Enteral Feeding Access

If nasoenteric feeding is anticipated for longer
than 30 days, long-term percutaneous or surgical
feeding access should be considered.
KEY POINTS
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TERIMA KASIH