An Introduction To Surgical Icu

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An Introduction To Surgical Icu

  1. 1. AN INTRODUCTION TO SURGICAL ICU. MOHAMED EMAD ABDEL-GHAFFAR. PROFESSOR OF ANESTHESIOLOGY, FOM, KING FAISAL UNIVERSITY.
  2. 2. What is meant by SICU? <ul><li>A tertiary care facility in the hospital that provides a state of the art medical care to critically ill patients referred to it via different surgical disciplines. </li></ul>
  3. 3. Indications for SICU admission: <ul><li>Pre and post-operative patients of ASA IV and V, undergoing major and ultra major surgeries. </li></ul><ul><li>All craniotomy patients. </li></ul><ul><li>All thoracotomy patients. </li></ul><ul><li>All ultra major surgeries. </li></ul><ul><li>Unstable multiple trauma patients. </li></ul><ul><li>Patients with head or spine trauma requiring mechanical ventilation. </li></ul><ul><li>Generally speaking, any surgical patient who requires continuous monitoring, 1:1 nursing and /or continuous life support is a candidate for SICU admission. </li></ul>
  4. 4. The main functions of any ICU is to : <ul><li>Provide optimum life support </li></ul><ul><li>and </li></ul><ul><li>Provide adequate monitoring of vital functions. </li></ul>
  5. 5. SICU <ul><li>Monitoring: </li></ul><ul><li>CVS </li></ul><ul><li>Respiratory </li></ul><ul><li>Renal </li></ul><ul><li>CNS </li></ul><ul><li>Metabolic </li></ul><ul><li>Input/ output </li></ul><ul><li>Life support: </li></ul><ul><li>General </li></ul><ul><li>CVS </li></ul><ul><li>Respiratory </li></ul><ul><li>Renal </li></ul><ul><li>CNS </li></ul><ul><li>Metabolic </li></ul>
  6. 6. Types of monitoring in the ICU <ul><li>Physiologic monitoring : its main objective is </li></ul><ul><ul><li>Assess the functions of the vital systems. </li></ul></ul><ul><ul><li>Monitor the effects of different therapeutic interventions on the critically ill, e.g. PA catheter in a CHF patient . </li></ul></ul><ul><li>Safety monitoring : its main objective is </li></ul><ul><ul><li>Warn against serious incidents that can jeopardize the patients life, e.g. . disconnection alarm in ventilated patients . </li></ul></ul>
  7. 7. Hemodynamic monitoring : <ul><li>EKG </li></ul><ul><li>NIBP </li></ul><ul><li>IBP </li></ul><ul><li>CVP </li></ul><ul><li>PA catheter and PCWP. </li></ul>
  8. 8. EKG <ul><li>Heart rate </li></ul><ul><li>Cardiac rhythm ( A fully computerized arrhythmia analysis is now available ) </li></ul><ul><li>Conduction defects . </li></ul><ul><li>Myocardial ischemia ( S - T segment monitoring ) </li></ul>
  9. 9. The five - electrode system <ul><li>Allows the recording of the six standard limb leads ( I, II, III, aVR, aVL, aVF ) , as well as one precordial unipolar lead . </li></ul><ul><li>Computer - assisted arrhythmia analysis and S - T analysis are possible . </li></ul>
  10. 10. NON - INVASIVE BLOOD PRESSURE MONITORING (NIBP) : <ul><li>1 . MANUAL ( RIVA - ROCCI ) TECHNIQUE </li></ul><ul><li>2 . OSCILLOMETRIC BLOOD PRESSURE DEVICES </li></ul><ul><li>3 . PENAZ ( FINAPRES ) TECHNIQUE </li></ul><ul><li>4 . ARTERIAL TONOMETRY </li></ul><ul><li>5 . PULSE TRANSIT TIME ( PHOTOMETRIC METHOD ) </li></ul>
  11. 11. NIBP Manual Automatic
  12. 12. INVASIVE BLOOD PRESSURE MONITORING (IBP): <ul><li>An arterial canula is used. </li></ul><ul><li>A non compliant saline-filled tube is used to connect the canula to the transducer, to the display. </li></ul><ul><li>It measures IBP on beat to beat basis. </li></ul>
  13. 13. CENTRAL VENOUS PRESSURE (CVP) AND PULMONARY ARTERY (PA) MONITORING: <ul><li>Invasive monitoring of the central circulation allows an estimate of cardiac preload . </li></ul><ul><li>For access to the central circulation, various sites have been used including IJV, SCV, basilic vein and femoral vein . </li></ul>
  14. 14. CVP AND PA MONITORING, cont . Anterior and medial approaches to cannulation of the IJV .
  15. 15. CVP AND PA MONITORING, cont . Design of a routine PA catheter .
  16. 16. CVP AND PA MONITORING, cont . <ul><li>CVP and PA catheters can measure : </li></ul><ul><li>C‎VP </li></ul><ul><li>PAP </li></ul><ul><li>PCWP </li></ul><ul><li>CO </li></ul><ul><li>Mixed venous SpO2 </li></ul>
  17. 17. Respiratory Monitoring: <ul><li>Monitoring of lung mechanics in ventilated patients ( in-line spirometry ): </li></ul><ul><li>Two techniques are used : </li></ul><ul><li>1 . Main stream spirometry. </li></ul><ul><li>2 . Side stream spirometry. </li></ul>
  18. 18. Respiratory Monitoring ( Mechanics cont .) <ul><li>Inspired and expired lung volumes ( V T and MV ) are measured . </li></ul><ul><li>PIP, Plateau pressure ( PP ) and Mean airway pressure are measured . </li></ul><ul><li>Dynamic lung compliance is calculated as </li></ul><ul><li>DLC = V T / PIP </li></ul><ul><li>Static lung compliance is calculated as </li></ul><ul><li>SLC = V T / PP </li></ul>
  19. 19. Respiratory Monitoring Gas exchange : <ul><li>ABGs . </li></ul><ul><li>Capnography </li></ul><ul><li>Pulse oximetry </li></ul>
  20. 20. ABGs <ul><li>An arterial blood sample is used. </li></ul><ul><li>ABG analysis measures: </li></ul><ul><ul><li>PaO2 </li></ul></ul><ul><ul><li>PaCO2 </li></ul></ul><ul><ul><li>pH </li></ul></ul><ul><ul><li>Some machines also measure Hb conc. And SpO2. </li></ul></ul><ul><li>Calculated Parameters include: </li></ul><ul><ul><li>HCO3 </li></ul></ul><ul><ul><li>Base excess </li></ul></ul><ul><ul><li>Total CO2 content. </li></ul></ul><ul><ul><li>SpO2, if not directly measured. </li></ul></ul>
  21. 21. ABGs: Clinical applications: <ul><li>Assess adequacy of gas exchange. </li></ul><ul><li>Assess adequacy of respiratory support. </li></ul><ul><li>Know the acid-base status of the individual. </li></ul><ul><li>Assess the adequacy of different interventions on acid-base balance. </li></ul>
  22. 22. Capnography <ul><li>A typical capnogram obtained during controlled mechanical ventilation showing : </li></ul><ul><li>Inspiratory baseline </li></ul><ul><li>Expiratory upstroke </li></ul><ul><li>Expiratory plateau </li></ul><ul><li>Inspiratory downstroke </li></ul>
  23. 23. Capnography cont . <ul><li>Its analysis should include the following : </li></ul><ul><li>Verify presence of exhaled CO2 </li></ul><ul><li>Inspiratory baseline </li></ul><ul><li>Expiratory upstroke </li></ul><ul><li>Expiratory plateau </li></ul><ul><li>Inspiratory downstroke </li></ul><ul><li>Check P I CO2min and P E CO2max </li></ul><ul><li>Estimate or measure P a CO2 - P E CO2max </li></ul><ul><li>Search for causes of hypercapnia or hypocapnia, if either is present </li></ul>
  24. 24. CLINICAL APPLICATIONS OF CAPNOGRAPHY <ul><li>One of two sure signs of endotracheal intubation. </li></ul><ul><li>Detection of untoward events e.g.. Disconnections or inadvertent extubations. </li></ul><ul><li>Maintenance of normocapnea </li></ul><ul><li>Cardiopulmonary resuscitation </li></ul><ul><li>Weaning from mechanical ventilation </li></ul><ul><li>Monitoring the nonintubated patient </li></ul>
  25. 25. PULSE OXIMETRY : Spectrophotometry <ul><li>The present generation of pulse oximeters uses two wavelengths of light : 660 nm ( red ) and 940 nm ( near infrared ). </li></ul><ul><li>The pulse oximeter measures the AC component of the light absorbance at each wavelength and then divides it by the corresponding DC component . R = AC660 / DC660 / AC940 / DC940 </li></ul>
  26. 26. PULSE OXIMETRY : CLINICAL APPLICATIONS . <ul><li>The pulse oximeter is the most significant advance in oxygen monitoring since the development of the blood gas analyzer . </li></ul><ul><li>Because it is noninvasive and virtually risk free when used properly, the pulse oximeter should be used in all clinical settings in which there is a potential risk of arterial hypoxemia . </li></ul><ul><li>It is the only oxygen monitor that provides continuous, real - time, noninvasive data on arterial oxygenation . </li></ul>
  27. 27. TEMPERATURE MONITORING : IMPORTANCE <ul><li>Temperature regulation is crucial to the survival of intact animals </li></ul><ul><li>Although uncommon, hypothermia below 32° C is ominous . </li></ul><ul><li>Ventricular irritability increases, and if the temperature decreases to 28° C cardiac arrest is likely . </li></ul><ul><li>shivering can increase oxygen demand 135% to 468%,when respiratory and cardiovascular systems may be unable to respond normally to increased demand </li></ul>
  28. 28. Sites for monitoring body temperature <ul><li>1.Oral. </li></ul><ul><li>2 . Tympanic membrane </li></ul><ul><li>3 . Esophageal </li></ul><ul><li>4 . Nasopharyngeal </li></ul><ul><li>5 . Pulmonary arterial blood </li></ul><ul><li>6 . Rectal </li></ul><ul><li>7 . Bladder </li></ul><ul><li>8 . Axillary </li></ul><ul><li>9 . Forehead </li></ul><ul><li>10 . Great toe </li></ul>
  29. 29. Renal Function Monitoring <ul><li>The three general functions of the kidneys are : ( 1 ) Excrete potentially toxic metabolic end products, </li></ul><ul><li>( 2 ) Regulate water and tonicity, and </li></ul><ul><li>( 3 ) Produce hormones . </li></ul>
  30. 30. Renal Function Monitoring, cont . <ul><li>Urine Volume : Normal 0.5- 1.0 ml / kg / hr </li></ul><ul><li>oliguria : < 0.5 ml / kg / hr </li></ul><ul><li>Urine Specific Gravity : is a measure of concentrating / diluting capacity of the kidney, </li></ul><ul><li>Urine Osmolality : urine osmolality of greater than 500 mOsm / kgH 2 O indicates prerenal azotemia and less than 350 mOsm / kgH 2 O indicates acute tubular necrosis . </li></ul>
  31. 31. Renal Function Monitoring, cont . <ul><li>Serum Creatinine : 0.4- 1.2 mg / dl . </li></ul><ul><li>Blood Urea Nitrogen : normal range is 8 to 20 mg / dl . </li></ul><ul><li>Urinary Sodium : It is traditionally accepted that a urinary sodium level of less than 20 mEq suggests prerenal azotemia and a level of greater than 40 mEq, acute tubular necrosis . </li></ul><ul><li>Creatinine Clearance: Normal 1- 1.5 ml/kg/min. </li></ul>
  32. 32. Life support: General <ul><li>General body care include: </li></ul><ul><ul><li>Regular turning every 1 hour. </li></ul></ul><ul><ul><li>Body and mouth hygiene </li></ul></ul><ul><ul><li>Bowl and bladder care. </li></ul></ul><ul><ul><li>Passive or active physiotherapy. </li></ul></ul><ul><ul><li>Adequate nutrition. </li></ul></ul>
  33. 33. Life support: CVS <ul><li>Hemodynamic manipulation is done to optimize CV function to achieve adequate tissue perfusion. </li></ul><ul><li>This is done by: </li></ul><ul><ul><li>Optimizing preload, input/ output. </li></ul></ul><ul><ul><li>Optimizing afterload, vasodilators or vasoconstrictors. </li></ul></ul><ul><ul><li>Optimizing cardiac contractility, +ve ionotropes, -ve ionotropes. </li></ul></ul>
  34. 34. Life support: Respiratory <ul><li>Simple O2 therapy using various O2 masks e.g.. Venturi masks of various FiO2, 21- 60 %, non-rebreathing mask with a reservoir bag give FiO2 > 80 %. </li></ul><ul><li>CPAP, BIPAP. </li></ul><ul><li>Mechanical ventilation. </li></ul>
  35. 35. Indications for Mechanical Ventilation <ul><li>A. Respiratory failure </li></ul><ul><ul><li>Respiratory arrest, the need is apparent </li></ul></ul><ul><ul><li>If there is rapid deterioration, it is better to intubate early before the patient's condition worsens, making intubation more likely to be associated with complications </li></ul></ul><ul><ul><li>In cases of severe myocardial ischemia, the added work of breathing can substantially worsen ischemia. </li></ul></ul><ul><ul><li>In general, a PaO 2 < 50 or PaCO 2 > 55 while the patient is receiving supplemental oxygen is an indication for ventilatory support. </li></ul></ul>
  36. 36. Indications for Mechanical Ventilation <ul><li>B. Protection of upper airway </li></ul><ul><li>C. Relief of airway obstruction </li></ul><ul><li>D. Improved pulmonary toilet </li></ul><ul><li>E. Refractory cardiogenic pulmonary edema </li></ul>
  37. 37. Life support: Renal <ul><li>Maintain adequate fluid and electrolyte balance and correct any abnormalities. </li></ul><ul><li>Avoid hypovolemia, hypotension </li></ul><ul><li>Avoid use of nephrotoxic drugs especially in those with a compromised renal function. </li></ul><ul><li>Use of various forms of kidney dialysis. </li></ul>
  38. 38. Thank you

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