CRITICAL CARE

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CRITICAL CARE

Critical CarePatients needing ITU care : 

Critical CarePatients needing ITU care Emergency Multiple trauma (including burns) Leaking AAA Severe acute pancreatitis Post-operative complications: - Surgical - Cardiac - Respiratory - Renal Severe spesis Elective Major vascular eg, AAA Oesophagectomy Cardiac operations Major procedures - Whipple’s - Patients in ASA 2 category or more

Critical Care : 

Critical Care Indications for ICU transfer Potential incipient or actual organ failure in a remediable condition Advanced monitoring of organ function Treatment of organ failure: Heart – use of inotropes Lungs – ventilation Kidneys – renal replacement therapy A need for 1:1 nursing

Critical CareTools for critical care : 

Critical CareTools for critical care Respiratory Pulse oximetry - O2 saturation of arterial blood Capnography - CO2 tension in expired gas Cardiovascular Arterial lines CVP Pulmonary artery flotation catheter (PAFC) Cardiac output measurement

Critical Care : 

Critical Care Pulse oximetry 95% - 100% = normal 93% =Warning! PaO2 around 8.5 kPa < 90% = patient is in severe trouble ETCC Manual: RCSEd

Critical Care : 

Critical Care Pulse oximetry Gives estimate of percentage saturation of oxygen binding sites Related to Pa02 by oxygen dissociation curve ETCC Manual: RCSEd

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Capnography Infra-red absorption through gas stream Relies on rapid equilibration of CO2 between alveolus and pulmonary capillary Useful guide to PaCO2 but beware of lung disease Continuous measurement ETCC Manual: RCSED

Critical CareArterial line : 

Critical CareArterial line Indications Continuous BP measurement Access for serial arterial blood gas analysis Complications Bleeding Thrombosis Infection Pseudoaneurysm Accidental drug injection

Critical Care : 

Critical Care Arterial Line Allen’s test The fist is tightly clenched, both wrist pulses are tightly obstructed and the fist then released. Pressure is released from the ulnar artery first. Allen’s test is positive when the medial part of the hand remains blanched. ETCC Manual: RCSEd

Critical Care : 

Critical Care Central venous catheterisation Indications Invasive monitoring for estimation of fluid status and right heart function Long term infusions: TPN, chemotherapy Haemodialysis Lack of peripheral venous access Access for pulmonary artery catheterisation ETCC Manual: RCSEd

Critical Care : 

Critical Care Central venous catheterisation Complications Inadvertent - arterial puncture - thoracic duct puncture - lung puncture Air embolus Catheter-related sepsis Clot formation Malposition and rupture of vein ETCC Manual: RCSEd

Critical Care : 

Critical Care Pulmonary artery wedge pressure (PWAP) It is an accurate representation of the left atrial pressure which closely parallels the left ventricular end-diastolic pressure thus helping to guide fluid therapy. ETCC Manual: RCSEd

Critical Care : 

Critical Care Pulmonary artery wedge pressure Introduced in 1970s by two cardiologists, Drs Swan and Ganz. Used to measure: Pressure within the pulmonary artery Pulmonary artery wedge pressure Cardiac output by thermodilution or dye dilution method Sampling of mixed venous blood ETCC Manual: RCSEd

Critical Care : 

Critical Care Pulmonary artery catheterisation Indications Complex operations in patients with complex cardiopulmonary disease Multisystem failure Major trauma Sepsis Situations where accurate haemodynamic status needs to be ascertained ETCC Manual: RCSEd

Critical Care : 

Critical Care Pulmonary artery wedge pressure Complications Valvular damage Ventricular rupture Pulmonary artery rupture Aneurysm or infarction Those of central venous catheterisation ETCC Manual: RCSEd

Critical Care : 

Critical Care Standard values Central venous pressure (CVP): 0-6 mm Hg Right ventricular pressure: 25 / 0-6mm Hg Pulmonary artery pressure (PAP): 25 / 6-12 mm Hg Wedge pressure (PAWP): 6-12 mm Hg Cardiac index (CI): >2.8-3.6 L / min / m2 Systemic vascular resistance(SVR):770-1500 dynes / sec / cm5 Oxygen delivery: 600ml / min / m2 Oxygen consumption: 150 mls / min / m2 ETCC Manual: RCSEd

Critical Care : 

Critical Care A 60 year old man had a right hemicolectomy. On the 1st postoperative day he has developed a temperature of 390 C, is very short of breath and looks slightly cyanosed; his oxygen saturation is 92%. What will you suspect and how will you manage the condition?

Critical Care : 

Critical Care Postoperative pulmonary collapse Although atelectasis and collapse are often used synonymously, atelectasis strictly speaking refers to lung parenchyma that has never been expanded. Cuschieri A, Steele RJC & Moosa AR: Patients with postoperative complications in Essential Surgical Practice, 2000, 418

Critical Care : 

Critical Care Postoperative pulmonary collapse Clinical features Tachypnoea Pyrexia Productive cough Cyanosis Dullness on percussion Bronchial breathing

Critical Care : 

Critical Care Postoperative pulmonary collapse Management Antibiotic – amoxycillin O2 therapy with inspired O2 concentration of 30-40% with humidification Vigorous physiotherapy + / - iv Doxapram Urgent fibreoptic bronchoscopy Minitracheostomy Continue with physiotherapy and monitor with blood gases and pulse oximetry- aim for oxygen tension to be no less than 10kPa

Critical Care : 

Critical Care Postoperative pulmonary collapse This arises from reduced ventilation of the lung bases resulting in accumulation of bronchial secretions. This may be basal, segmental, lobar or complete lung collapse. The degree of hypoxia depends upon the extent of collapse. Infection with consolidation supervenes with the organisms being Haemophilus influenza, streptococcus pneumoniae, coliform, MRSA and pseudomonas.

Critical Care : 

Critical Care Post-operative hypoxia Surgical patients at risk of hypoxia Smokers Chronic pulmonary disease Elderly Obesity Pre-operative opiates and sedatives Abdominal emergency surgery Orthopaedic surgery (fat emboli)

Critical Care : 

Critical Care Effects of post-operative hypoxia Central nervous system - Obtunded pain sensation - Post-operative confusion Cardiovascular system - Tachycardia - Myocardial ischaemia Respiratory system - Hypercapnoea (airway obstruction) - Respiratory muscle failure Renal - Renal failure

Critical Care : 

Critical Care Effects of post-operative hypoxia (contd) Gastrointestinal - Ulceration - Reduced immunoprotection Hepatic - Ischaemic necrosis of hepatocytes Haematological - Reduced platelet function - Coagulation problems Wound healing - Impaired wound healing

Critical Care : 

Critical Care Respiratory failure Respiratory failure is defined as an arterial oxygen tension (PaO2) at sea level of less than 8 kPa, i.e. hypoxia due inadequate gas exchange within the lung.

Critical Care : 

Critical Care Respiratory failure Respiratory distress Look Listen Feel Anderson I D ed; Care of the Critically Ill Surgical Patient; RCSEng, Arnold 1999

Critical Care : 

Critical Care Respiratory Failure Type I Hypoxia Failed O2 uptake PaO2 <8kPa (Hypoxia) + Normal PaCO2 (7kPa) or low

Critical Care : 

Critical Care Respiratory Failure Type II Hypoxia + Hypercapnia Failed O2 uptake + Failed CO2 removal PaO2 < 8kPa + PaCO2 > 7kPa

Critical CareHypoxia : 

Critical CareHypoxia Types Hypoxic Anaemic Stagnant Histotoxic Factor affected O2 saturation Haemoglobin Cardiac output Tissue utilisation

Critical Care : 

Critical Care A 65 year old lady had a hip replacement 10 days ago. She is ready to be discharged. She went to the toilet just prior to leaving the ward for home. She collapsed in the toilet. What is your diagnosis and management?

Critical Care : 

Critical Care Pulmonary embolus Clinical diagnosis Dyspnoea Tachypnoea Pleuritic chest pain Small haemoptysis Calf tenderness and swelling

Critical Care : 

Critical Care Pulmonary embolus Management Resuscitation Investigations Treatment

Critical Care : 

Critical Care Pulmonary embolus Management The stable patient The unstable patient

Critical Care : 

Critical Care Pulmonary embolus Investigations The stable patient ECG & CXR; blood gases VQ scan Duplex Doppler u/s of leg veins Pulmonary angiogram Contrast venography & plethysmography

Critical Care : 

Critical Care Pulmonary embolus Investigations The unstable patient Echocardiogram Pulmonary angiogram Spiral CT – very sensitive

Critical Care : 

Critical Care Pulmonary embolus Treatment Anticoagulation Emergency embolectomy IVC filters Thrombolysis – in haemodynamically unstable patient with refractory shock - Intravenous - Pulse spray directly into embolus

Indications for insertion of IVC filter : 

Indications for insertion of IVC filter Therapeutic Recurrent PE despite effective anticoagulation Anticoagulation is contraindicated Post pulmonary embolectomy to prevent recurrence Pulmonary hypertension from chronic recurrent PE Extensive PE Iliofemoral DVT propagation despite adequate anticoagulation Free-floating IVC thrombus Bilateral free-floating DVT Prophylactic Venous thrombolysis ( 20% develop PE ) Hip and knee replacement ( controversial ) Multiple trauma ( controversial ) Adam D & Ruckley CV: Venous thromboembolism in Essential Surgical Practice: ed Cuschieri A, Steele RJC & Moosa AR 2002. Arnold

Critical Care : 

Critical Care Shock Definition Shock is a clinical state and is defined as inadequate tissue oxygenation which leads to impairment of cellular function.

Critical Care : 

Critical Care Shock Clinical features Hypotension Tachycardia Tachypnoea Cold, clammy extremities Sweating

Critical Care : 

Critical Care Shock Types Hypovolaemic Septicaemic Cardiogenic Neurogenic Anaphylactic

Critical Care : 

Critical Care A 60 year old patient of ASA 1 anaesthetic risk underwent a total gastrectomy for cancer stomach. While in the ITU, 12 hours postoperatively, his BP has fallen to 80 mm hg systolic, has not put out any urine over the last 3 hours and is hypoxic with O2 saturation of 92%. What will you suspect and how will you manage?

Critical Care : 

Critical Care Answer Post-operative hypotension from bleeding Q. Where would the bleeding come from? Slipped left gastric artery ligature Q. Where does the left gastric artery arise from? The coeliac axis

Critical Care : 

Critical Care Post-operative hypotension Investigations Monitor BP Continuous ECG, pulse oximetry Monitor urine output Monitor core and peripheral temperature Blood samples: U&Es,FBC, Cross match Coagulation screen

Critical Care : 

Critical Care Post-operative hypotension Management ABC Oxygen Raise legs IV Fluids CVP line – particularly in over 60 years Control bleeding – re-exploration

Critical Care : 

Critical Care Hypotension One of the commonest post-operative complications Definition Systolic BP < 90 mm hg or Reduction from usual BP of > 30% ETCC Manual: RCSEd

Critical Care : 

Critical Care Hypotension Causes Inadequate pre-load Decreased contractility ETCC Manual: RCSEd

Critical CareCauses of inadequate pre-load in hypotension : 

Critical CareCauses of inadequate pre-load in hypotension Absolute reduction of fluid Blood loss (obvious or occult) Dehydration with inadequate fluid replacement Relative reduction of fluid Venodilatation Mechanical interference - tension pneumothorax - pulmonary embolism - IPPV / CPAP - tachycardia - arrythmia

Critical CareCauses of decreased contractility in hypotension : 

Critical CareCauses of decreased contractility in hypotension Toxic Ischaemic Hypoxic Acidosis Drugs Electrolyte disturbance Sepsis Jaundice Mechanical Fluid overload Cardiac tamponade

Critical Care : 

Critical Care A 60 year old woman has been admitted as an emergency with a 4 day history of severe right upper quadrant pain, vomiting, jaundice and intense pruritis and is very toxic – high temperature with rigors and hyperdynamic circulation. What will you suspect and outline the management.

Critical Care : 

Critical Care Septic shock from acute calculous biliary obstruction +/- Acute pancreatitis Management Resuscitation Confirmation of diagnosis Definitive treatment

Critical Care : 

Critical Care Acute calculous biliary obstruction + Septic shock +/- Acute pancreatitis Resuscitation Analgesia IV Dextrose; Mannitol; Antibiotics after blood culture Urinary catheter CVP line

Critical Care : 

Critical Care Acute calculous biliary obstruction Investigations & definitive treatment Blood: Culture, U&Es, FBC, CRP, LFTs, Serum amylase, Coagulation profile Radiological: Urgent US of biliary tract ?MRCP ERCP + Endoscopic papillotomy +/- stenting ? Laparoscopic cholecystectomy later

Critical Care : 

Critical Care Bacteraemic shock Caused by release of endotoxins Vasoactive substances eg, kinins released Capillary permeability increased Peripheral resistance decreased Fever: hyperdynamic circulation Treatment: O2; circulatory support; inotropes

Critical Care : 

Critical Care The Septic Patient The term SIRS is used to describe the widely disseminated inflammatory reaction which can complicate a wide range of disorders eg, pancreatitis, trauma, ischaemia. The term SEPSIS is used in those patients in whom SIRS is associated with proven infection

Critical Care : 

Critical Care Systemic inflammatory response syndrome ( SIRS ) Cytokine mediators of SIRS: TNF, IL-1, IL-6, IL- 8 Secondary inflammation mediators: - Arachidonic acid metabolites - Nitric oxide - Oxygen radicals - Platelet activating factor

Critical Care : 

Critical Care Systemic inflammatory response syndrome ( SIRS ) Systemic changes Loss of microvascular integrity Increased vascular permeability Systemic vasodilatation Depressed myocardial contractility Poor oxygen delivery Increased microvascular clotting

Critical Care : 

Critical Care Early features of sepsis Fever or hypothermia Leucocytosis or leucopenia Tachycardia Tachypnoea Organ dysfunction: Brain - altered mental state Lungs - hypoxia Kidneys - oliguria

Critical Care : 

Critical Care Nosocomial Infections (Hospital acquired infections) ( Gk: nosokomeion ) Gk: nosos- of disease; komeo – to nurse The patient in the ITU who has some degree of organ dysfunction is vulnerable to nosocomial infections. Good principles of infection control and avoidance of cross-infection by staff Bacteria in the GI tract of the patient is the commonest source Nosocomial pneumonia occurs from spillage from the upper GI tract into the lungs H2 receptor antagonists encourages nosocomial infections Sucralfate used as stress ulcer prophylaxis is also bacteriostatic and thus reduces the incidence

Critical Care : 

Critical Care A 70 year old patient, ASA anaesthetic category 3, underwent an emergency closure of a perforated duodenal ulcer. The anaesthetic and operation were uneventful. On the 1st post-operative day he complained of feeling very unwell with a systolic bp of 80 mm hg with no unusual signs in his abdomen; there was impaired conscious level and peripheral vasoconstriction. What will go through your mind and outline your management.

Critical Care : 

Critical Care Cardiogenic shock from myocardial infarction Patient already has a drip ECG - ST elevation in precordial leads - Development of new Q waves – wide & / or deep - T wave inversion Pulse oximeter Blood for: CK-MB ( creatine kinase, membrane bound ) ALT ( alanine aminotransferase ) AST ( aspartate aminotransferase ) LDH ( lactic dehydrgenase ) Troponin T assay Transfer to CCU

Critical Care : 

Critical Care Cardiogenic shock from myocardial infarction CCU management CVP Consider PAFC O2 therapy Aspirin Nitrates, ACE inhibitors and opiates IV beta blockers Consider reperfusion strategy

Critical Care : 

Critical Care Cardiogenic shock Complications of MI Cardiac arrest ( ventricular fibrillation, VF ) Pump failure Arrhythmias Ventricular septal defect ( VSD ) Cardiac rupture Pericardial tamponade Ventricular aneurysm Mitral regurgitation MunschC & Shah R in Handbook of Postoperative Complications .Ed Leaper DJ & Peel ALG. 2003, OUP

Critical Care : 

Critical Care Cardiogenic shock Risk of perioperative MI in the general surgical population = 0.07% Risk of MI if surgery is performed within 3 months of MI = 25% Risk factors Previous MI Unstable angina Disabling angina Silent ischaemia Hypertension MunschC & Shah R in Handbook of Postoperative Complications .Ed Leaper DJ & Peel ALG. 2003, OUP

Critical Care : 

Critical Care Cardiogenic shock Definition Cardiogenic shock indicates a state of inadequate circulatory perfusion caused by cardiac dysfunction. Causes Mycardial infarction Cardiac arrhythmias Tension pneumothorax Cardiac tamponade Vena caval obstruction Dissecting aneurysm

Critical Care : 

Critical Care Management of a critically ill patient is a medical skill you must gain it. Dr. Sami abd alhameid

Critical Care : 

Critical Care Neurogenic and spinal shock

Critical Care : 

Critical Care A fit 30 year old lady while gardening suddenly became very short of breath, had intense itching with rash and complained of a painful red spot on her arm. She has been brought to the A&E department and is hypotensive, hypoxic and cold. What is your diagnosis and how will you manage?

Critical Care : 

Critical Care Anaphylactic Shock Acute medical emergency Follows insect bites, drugs, vaccines, shellfish Apprehension, urticaria, bronchospasm, laryngeal oedema, respiratory distress, hypoxia, massive vasodilatation, hypotension and shock Treatment: Lie patient down, elevate leg, adrenaline, oxygen, iv hydrocortisone

Critical Care : 

Critical Care Anaphylactic Shock Mechanism The antigen combines with immunoglobulin (IgE) on the mast cells and basophils, releasing large amounts of histamine and SRS-A (slow-release substance-anaphylaxis). These compounds cause the symptoms. Mortality about 10%

Critical Care : 

Critical Care A 50 year old man underwent a laparoscopic closure of a perforated duodenal ulcer. His post-operative period during the first 4 to 5 days was uneventful. However, thereafter he did not progress satisfactorily, had a swinging pyrexia, hiccoughs, was tachypnoeic, toxic and complained of pain in the right upper quadrant and right shoulder tip . What would you suspect and outline the management.

Critical Care : 

Critical Care Intra-abdominal sepsis Sub-phrenic abscess Management Resuscitation Confirmation of diagnosis Definitive treatment

Critical Care : 

Critical Care Sub-phrenic abscess Resuscitation Oxygen Analgesia IV fluids Antibiotics after blood has been sent for culture

Critical Care : 

Critical Care Sub-phrenic abscess “Pus somewhere, pus nowhere, pus under the diaphragm.” Investigations for confirmation Blood: Culture, FBC, CRP CXR Ultrasound ?CT

Critical Care : 

Critical Care Sub-phrenic abscess Treatment US or CT guided needle drainage. This may require more than one attempt because there may be several loculi of the abscess. Open operation – extra-peritoneal approach – anterior or posterior depending upon the site

Critical Care : 

Critical Care How many sub-phrenic spaces are there and what are they? 7 spaces in all 4 intra - peritoneal – 2 right and 2 left ( important ones ) 3 extra - peritoneal 2 right intra-peritoneal – Right anterior ( R subdiaphragmmatic ) Right posterior (R subhepatic or Morison’s hepato-renal pouch) 2 left intra-peritoneal – Left anterior ( L subdiaphragmmatic ) Left posterior ( L subhepatic or lesser sac or omental bursa ) 3 extra-peritoneal – 2 around the upper pole of each kidney and 1 over bare area of liver The extra-peritoneal spaces are not clinically important. Rarely the bare area of the liver may be involved in a liver abscess from amoebic infection.

Critical Care : 

Critical Care The Septic Patient Investigations Blood cultures U&Es, FBC, CRP, Clotting studies, LFTs CXR Appropriate imaging studies for source

Critical Care : 

Critical Care The Septic Patient Management Supportive measures: - Oxgenation - Ventilation if necessary - IV fluids - Inotropic support - Nutritional support Specific measures - Antibiotics - Drainage

Critical Care : 

Critical Care A 70 year old man underwent emergency operation for a leaking AAA. While in the ITU, after 2 days, he became oliguric, has abdominal distension and cardio-respiratory compromise. His CVP is 10 cm of water. He is still on the ventilator. What will you suspect and how will you manage?

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome This is a condition in which there is a sustained increase in intra-abdominal pressure resulting in inadequate ventilation from type 2 respiratory failure, disturbed cardiovascular and renal function. Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes ;Br J Surg (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Aetiology Trauma : Blunt Penetrating Haemorrhage: Post-operative Leaking AAA Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes. Br J Surg, (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Aetiology Blunt and penetrating abdominal trauma with liver, vascular and splenic damage More likely after abdominal and pelvic trauma Risk increases with increase in Injury Severity Score Repair of AAA (Emergency or Elective) – 3.8% after repair of ruptured AAA Burns – should be suspected as a cause for renal failure inspite of adequate fluid resuscitation Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes. Br J Surg (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Diagnosis Patients usually in ITU Tense abdomen Cardio-respiratory compromise in the absence of hypovolaemia Renal failure Round belly sign ( Ratio of AP to transverse abdominal diameter > 0.80 ) Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes, Br J Surg, (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Presentation Tense abdomen Cardio-respiratory compromise Oliguria / Anuria Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes; Br J Surg (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Pressures Measure intra-abdominal pressure (IAP) with a catheter directly into peritoneal cavity Transurethral bladder pressure reflects IAP – most commonly used Normal IAP: Men: 3.5 - 10.5 mm hg Women: 3.0 - 8.8 mm hg IAP . 15 – 25 mm hg is diagnostic Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes: Br J Surg, (April) 2002, 89, 397 - 412

Abdominal Compartment Syndrome : 

Abdominal Compartment Syndrome Treatment Decompression Leave abdomen open and cover temporarily with mesh, plastic bag fascial closure, plastic or silicone sheet or vacuum pack Mortality: 63 – 72% Ventral hernia: 63% Tiwari A, Haq A I , Myint F, Hamilton G: Acute compartment syndromes: Br J Surg (April) 2002, 89, 397 - 412

Critical Care : 

Critical Care A 77 year old man underwent a TURP. On the 2nd post-operative day he is confused, restless and has some visual disturbance. What will you suspect and how will you manage?

Critical Care : 

Critical Care Post TURP syndrome ( Dilutional hyponatraemia) Clinical features Restlessness, muscle twitching, disorientation, visual disturbances, seizures & collapse Hypertension, severe hyponatraemia

Critical Care : 

Critical Care Post TURP syndrome Cause Occurs following prolonged prostatic resection of large glands and likely when more than 9 L of glycine (1.5%) irrigation is used. Large volume of irrigating fluid enters the vascular space causing dilutional hyponatraemia resulting in disturbance of muscle and nerve function.

Critical Care : 

Critical Care Post TURP syndrome Treatment Needs ITU monitoring – CVP, serum osmolality, serum Na Supportive Frusemide Hypertonic saline through CVP line (250-500 mls of 3 to 5 %) when there are seizures

Critical Care : 

Critical Care Post TURP syndrome Prevention Keep level of irrigating fluid below 20cm above the operating table Stop resection if large veins are opened Use irrigating resectoscope IV normal saline postoperatively for 12 hours

Critical Care : 

Critical Care A 60 year old man underwent a Whipple’s operation for periampullary carcinoma. On the 2nd postoperative day, while still in the ITU, his urinary output has reduced to 300 mls in the previous 12 hours. The catheter is not blocked. What will you suspect and how will you manage?

Critical Care : 

Critical Care Hepato-renal syndrome Can occur following an operation in a patient with obstructive jaundice Reduced GFR – not known why Circulating endotoxins - endotoxinaemia Absorption of endotoxin produced by the intestinal microflora In the jaundiced patient there is a relationship between impaired renal function and the presence of circulating endotoxins Cuschieri A, Steele RJC & Moosa AR: Essential Surgical Practice – HST in General Surgery 2002; 401

Critical Care : 

Critical Care Hepato-renal syndrome Prevention Adequate hydration and pre-operative induction of diuresis For 12 - 24 hours pre-operative 5% dextrose saline iv Mannitol (osmotic diuretic) or Frusemide (loop diuretic) iv at anaesthetic induction Catheterise - hourly urine output Further diuretics if urine output < 40ml/hr in peri-operative and post-operative period Pre-operative oral chenodeoxycholate and oral lactulose for a few days – controversial Cuschieri A, Steele RJC & Moosa AR: Essential Surgical Practice – HST in General Surgery 2002; 401

Critical Care : 

Critical Care Hepato-renal syndrome Treatment Treat hyperkalaemia Peritoneal dialysis Hemofiltration Haemodialysis

Critical Care : 

Critical Care Renal failure Treatment of hyperkalaemia 10 to 20 mls of10% Ca gluconate or chloride iv : stabilises the myocardial membrane 50 mls of 50% dextrose + 10 units of soluble insulin: drives potassium into cells 200 to 300 mls of 1.4% sodium bicarbonate iv: drives potassium into cells and corrects acidosis; beware of fluid overload in ARF Calcium resonium 15 g tds orally or rectally: binds potassium and releases Ca in exchange Renal replacement therapy Cuschieri A, Steele RJC & Moosa AR: Essential Surgical Practice – BST 2000; 287

Critical Care : 

Critical Care Renal failure Predisposing causes Preoperative renal impairment Surgery associated with major blood loss and fluid shifts Hypovolaemia Hypotension Sepsis Nephrotoxic drugs Leaper DJ & Peel ALG: Handbook of Postoperative Complications 2003 OUP; 195

Critical Care : 

Critical Care A 60 year old man underwent a successful embolectomy of his leg. The next day he developed severe throbbing pain in the leg which on examination did not look ischaemic and was warm to touch. What would you suspect and how would you manage the condition?

Critical Care : 

Critical Care Acute limb compartment syndrome What are the causes of this condition? How do you diagnose it? How do you treat the condition?

Acute Limb Compartment Syndrome : 

Acute Limb Compartment Syndrome This is a condition in which raised pressure within a closed fascial space reduces capillary perfusion below a level necessary for tissue viability. Tiwari A, Haq A I, Myint F, Hamilton G:Acute compartement syndromes Br J Surg (April) 2002, 89, 397-412

Acute Limb Compartment Syndrome : 

Acute Limb Compartment Syndrome Aetiology Orthopaedic Vascular Iatrogenic Soft tissue injury Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes: Br J Surg (April) 2002, 89, 397 - 412

Acute Limb Compartment Syndrome : 

Acute Limb Compartment Syndrome Presentation Pain – severe and out of proportion to the apparent injury Pain on passive movement Swollen and tense compartment Progression of the above over a short time period Paraesthesia – especially loss of two point discrimination Pallor and pulselessness – usually with a vascular injury Paralysis – late symptom Tiwari A, Haq A I ,Myint F, Hamilton G: Acute compartment syndromes; Br J Surg (April) 2002, 89, 397-412

Acute Limb Compartment Syndrome : 

Acute Limb Compartment Syndrome Pressures Normal resting: 0 - 8 mm hg Pain and paraesthesia: 20 – 30 mm hg Fasciotomy: > 30 mm hg If pressure of > 30 mm hg is present for 6 – 8 hours irreversible damage occurs Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes; BrJj Surg (April) 2002, 89, 397 - 412

Acute Limb Compartment Syndrome : 

Acute Limb Compartment Syndrome Treatment Fasciotomy Forearm: Volar and dorsal compartment Hand: Carpal tunnel decompression Thigh: 3 compartments – anterior, posterior, medial Leg: 4 compartments – anterior, lateral,deep and superficial posterior Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes, Br J Surg (April) 2002; 89, 397 -412

Critical Care : 

Critical Care Pain relief Post-operative Intractable pain

Critical Care : 

Critical Care Pain relief Post-operative pain Diclofenac suppositories LA to incision site IV narcotic drugs Regional analgesia eg, caudal block, intercostal block Continuous epidural analgesia Continuous IV opiate analgesia PCA by IV or epidural opioid analgesia

Critical Care : 

Critical Care Drugs for treatment of post-operative pain Simple analgesics: Paracetamol, Aspirin NSAIDs Intermediate drugs: Tramadol, Co-dydramol Opioids: Morphine, Diamorphine Local anaesthetics: Lignocaine, Bupivacaine

Critical Care : 

Critical Care Pain relief Intractable pain ‘As doctors we are there to cure sometimes, to relieve often and to comfort always’ Sir James Calnan Intractable pain is defined as chronic and continuous pain where the cause cannot be removed or the origin cannot be determined. Causes: Benign Malignant

Critical Care : 

Critical Care Relief of Benign Intractable Pain LA + / - steroid injections Nerve stimulation procedures Nerve decompression Sympathectomy

Critical Care Relife of Malignant Intractable Pain : 

Critical Care Relife of Malignant Intractable Pain Neurolytic techniques Subcostal phenol injection Coeliac plexus block – alcohol Intrathecal phenol Percutaneous anterolateral cordotomy Miscellaneous methods Injection of opiate: - subcutaneous - intravenous - intrathecal - epidural Hormone analogues Radiotherapy Steroids

Relief of Cancer Pain : 

Relief of Cancer Pain

Nutrition : 

Nutrition Clinical indications for nutritional support Preoperative malnutrition Postoperative complications: ileus > 4 days, sepsis, fistula Intestinal fistulae Massive bowel resection Severe acute pancreatitis Inflammatory bowel disease Maxillofacial trauma Multiple trauma Burns Malignant disease Renal failure Coma

Nutrition : 

Nutrition Assessment Body weight Upper arm circumference : < 23cm in females, < 25 cm in males Triceps skinfold thickness : < 13 mm in females, < 10 mm in males Serum albumin : < 35 g / l Lymphocyte count : < 1500 / c mm Candida skin test : -ve reaction indicates defective immunity Nitrogen balance studies Goode A W : Nutritional support and rehabilitation in Bailey and Love, 23rd Ed, 2000

Nutrition : 

Nutrition Requirements Carbohydrate Fat Protein Vitamins Minerals Trace elements

Nutrition : 

Nutrition A healthy adult at rest requires 6300 – 8400 nonprotein kilojoules per day for energy ( 1500 – 2000 calories). Goode A W : Nutritional support and rehabilitation in Bailey and Love 23rd Ed, 2000

Nutrition : 

Nutrition In Burns Give 25 kcl/kg body weight + 40 kcl / % body surface area burnt in the adult The child needs more calories / kg body weight The infant needs 90 – 100 kcl / kg Cuschieri A, Steele R J , Moosa A R : Management of the burns victim in Essential Surgical Practice, Basic Surgical Training, 4th Ed. 2001, p 116

Nutrition : 

Nutrition Requirements Carbohydrate provides 16.8 kJ/g (4.1 kcal/g) Fat provides 37.8 kJ/g (9.1 kcal/g) The number of nonprotein kilojoules given should bear a definite relationship to the nitrogen intake. A typical regime would feature 8400 kJ (2000 kcal) to 13 g nitrogen ( about 150 to 1 ). Goode A W : Nutritional support and rehabilitation in Bailey and Love, 23rd Ed 2000

Nutrition : 

Nutrition Nitrogen requirements A healthy adult in positive nitrogen balance needs 35-40 g of protein or 5.5 -6.5g of nitrogen a day.The hypercatabolic patient requiring hyperalimentation may need 3 to 4 times this amount of protein. Goode A W: Nutritional support and rehabilitation in Bailey & Love 23rd ed 2000

Nutrition : 

Nutrition Methods of feeding Enteral Oral Nasogastric tube Gastrostomy : Stamm temporary Janeway permanent PEG Jejunostomy

Nutrition : 

Nutrition Complications of enteral nutrition Nutritional and metabolic Complications of nutrient delivery Gastrointestinal complications Cuscgeri A, Steele R J C & Moosa A R :Enteral nutrition in Essential Surgical Practice, 4th Ed 2001

Nutrition : 

Nutrition Methods of feeding Parenteral Used in < 4 – 5% of all hospital admissions Used when enteral feeding is not possible or to supplement enteral feeding Indications: Short term Long term ( HPN )

Nutrition : 

Nutrition Complications of parenteral nutrition Catheter related Nutritional and metabolic Effect on other organ systems Cuscheri A, Steele R J C and Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4th Ed. 2001

Nutrition : 

Nutrition Complications of parenteral nutrition Catheter related Infection Thrombosis Occlusion Fracture Cuscheri A, Steele R J C& Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4th Ed 2001

Nutrition : 

Nutrition Complications of parenteral nutrition Nutritional and metabolic Fluid overload Hyperglycaemia Electrolyte imbalance Micronutrient deficiencies eg selenium in long-term patients Cuscheri A, Steele & Moosa A R: Parenteral nutrition in Essential Surgical Practice, 4th Ed 2001

Nutrition : 

Nutrition Complications of parenteral nutrition Effect on other organ systems Hepatobiliary system – biliary sludge, hepatic steatosis, cholestasis The immune system Skeleton – metabolic bone disease Cuscheri A, Steele JR J C & Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4thEd 2001

Nutrition : 

Nutrition Monitoring feeding regimens in parenteral nutrition Daily Body weight Fluid balance FBC, U&E Blood glucose Urine and plasma osmolality Electrolyte and nitrogen analysis of urine and gastrointestinal losses Acid-base status Goode A W : Nutritional support and rehabilitation in Bailey and Love 23rd Ed, 2000

Nutrition : 

Nutrition Monitoring feeding regimens in parenteral nutrition Every 10 days Serum B12, Folate, Iron, lactate and triglycerides Trace elements Goode A W: Nutritional support and rehabilitation in Bailey & Love 23rd Ed, 2000

Nutrition : 

Nutrition Monitoring feeding regimens in parenteral nutrition Three times weekly Serum Calcium, magnesium and phosphate Plasma proteins LFTs Clotting studies Goode A W : Nutritional support and rehabilitation in Bailey & Love, 23rd Ed 2000

Nutrition : 

Nutrition “Imprisoned in every fat man, a thin one is wildly signalling to be let out” - Cyril Connolly (1903 – 1974)

Slide 154: 

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