3. Problems
Ageing population
Concomitant disease processes
Complexity of surgery
Greater number of post-operative interventions
& therapies
Shortage of experienced staff
Expectations by patients, relatives & staff
4. Aim
Identification & correction of complications and
problems at the earliest stage
Prevents critical illness ( multiple organ failure)
with overall mortality of 50% Predict, Prevent and
Treat Critically Ill Surgical Patients Successfully
5. Practical Management
Clinical Methods – To assess patients & identify
problems
Practical Skills – To initiate the appropriate
management
Communication & Organizational Skills – To seek
help from colleagues or specialists in other fields to
tackle a difficult or unfamiliar problems
6. Patients at Risk
Emergencies
Elderly
Coexisting diseases
Non progression
Severe illness / complex surgery
Massive transfusion
Re-operation / re- bleeding
Failure / delay to diagnose & treat underlying
problems
Multiple complications
Established shock state
7. Risk Practices
Incomplete or infrequent assessment
Failure to act on abnormal findings
Failure to ensure that interventions have been
successful
Failure of continuity of care
Poor communication (Clear, Concise, Confident)
Failure of supporting care
Lack of expertise / Number of staff / Wrong ward
8. A 58-year-old man with a history of
hypertension presents to the emergency
department
with a 3-day history of fever, cough, and
increasing shortness of breath. On arrival to the
hospital, the patient has a temperature of 38.5°C ,
heart rate of 118 beats/min, respiratory rate of 26
breaths/min, a blood pressure of 100/72 mm Hg,
and a pulse oximetry reading of 90% on room air.
10. Tachycardia in response to physiologic abnormalities
(ie, fever,
low cardiac output) may be increased with pain
and anxiety or suppressed in patients who have
conduction abnormalities or are receiving ß-
blocker medications.
11. Tachypnea is the single most important indicator of
critical illness.
12. A decrease in the blood pressure may be a late
sign of cardiovascular disturbance signaling failure
of the compensatory mechanisms.
13. Difficulty in obtaining a pulsatile waveform by
pulse oximetry may be indicative of a
vasoconstricted state.
14.
15. . In older patients with cognitive impairment at
baseline, changes in mental status are commonly
associated with serious illness and may be the first
and only presenting sign.
The Glasgow Coma Scale score should be recorded
during the initial assessment of central nervous
system function and limb movement.
16. An accurate measure of urine output, usually with
an indwelling catheter, is essential in critically ill
patients.
17. The presence of a metabolic acidosis is one of the
most important indicators of critical illness.
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65. Early identification of a patient at risk for
Critical illness is essential to improving patient
outcomes.
66. The clinical manifestations of impending critical
illness are often nonspecific. Tachypnea and
metabolic acidosis are two of the most important
predictors of risk; they signal the need for more
detailed monitoring and investigation.
67. Resuscitation and physiologic stabilization often
precede a definitive diagnosis and treatment of
the underlying cause.
68. A detailed history is essential for making
an accurate diagnosis, determining a patient’s
physiologic reserve, and establishing a patient’s
treatment preferences.
69. Frequent clinical and laboratory monitoring of a
patient’s response to treatment is essential.
70. A 67-year-old man with a history of chronic obstructive
pulmonary disease (COPD) and coronary artery disease
presents with abdominal pain and distension
accompanied
71. CASE STUDY
A 67-year-old man with a history of chronic
obstructive pulmonary disease (COPD) and coronary
artery disease presents with abdominal pain and
distension accompanied
by fevers, tachycardia, and hypotension, which is
responsive to a fluid challenge. A workup reveals
evidence of perforated sigmoid diverticulitis with free
72. On examination, he has generalized peritonitis, and
he is taken to the operating room and undergoes a
sigmoid colectomy with creation of an end
colostomy.
At the time of the surgery, he has a large amount of
feculent fluid throughout his pelvis with a significant
inflammatory response. Intraoperatively he had
significant bleeding requiring a blood transfusion
and developed progressive hypotension requiring
the initiation of a norepinephrine drip to maintain
adequate blood pressure
73. He remains intubated and is admitted to the ICU
postoperatively for further resuscitation and
management.
Several hours later, his abdomen is becoming
progressively distended, his hemodynamics are
worsening, and he is developing hypoxia with high
peak airway pressures.
74. What interventions needed? – What is the
probable differential diagnosis? – Is there any role
for repeat surgical consultation or intervention?
75. Effective management of the postoperative patient
involves attention both to basic critical care
principles as well as specific issues related to
anesthesia and the surgical procedure performed.
77. B. Volume Status A fall in intravascular volume is
often a crucial factor in the initiation of the systemic
response.
Perioperative hypovolemia has multiple potential
causes
78. C. Cardiac Output
Many factors can influence cardiac output and
peripheral perfusion in the perioperative period.
Circulatory efficiency may be impaired by
hypovolemia, and myocardial contractility may be
depressed by anesthetic agents and other drugs.
Anesthetic drugs can cause peripheral dilatation, and
positive-pressure ventilation diminishes venous return.
79. D. Hypothermia imposes enormous metabolic
demands on the patient.
Pediatric and geriatric patients are especially at risk.
The causes are multifactorial, including excess heat loss
during a prolonged surgical procedure or through skin
with burn damage, as well as direct cooling caused by
massive resuscitation
80. significant hypothermia can lead to multiple
complications, including: Inhibition of tissue oxygen
delivery Predisposition to dysrhythmias Coagulopathies
(with difficulty in maintaining homeostasis and
increased risk of bleeding-related complications)
Electrolyte abnormalities Oliguria Shivering which
increases oxygen requirements and potentially
predisposes patients to
cardiac ischemia and delay in wound healing
81. E. Coagulopathy Response to injury is associated with
blood coagulation changes.
The general metabolic responses to injury activate
thrombotic mechanisms and initially depress intrinsic
intravascular thrombolysis.
Thus, the postoperative patient is in a prothrombotic
state and may sustain intravenous thrombosis and
consequent thromboembolism
82. Changes in intravascular volume status, cardiac
output, coagulopathy, as well as malnutrition are
common findings in the postoperative patient.
83. The metabolic responses to anesthesia and
surgical stress can have profound
implications for
the patient in the perioperative and postoperative
periods.
Reestablishing normal perfusion is more critical
than replacing an arbitrary estimation of third-
space fluid loss.
84. Postoperative Goals By encouraging early gut
function and enteral feeding, the patient achieves
these benefits: hormonal effects of duodenal feeding,
maintenance of gut perfusion, reduced surgical
insult,
avoidance of nasogastric tubes, and regular
quantities of nutrition.
Early mobilization to minimize complications, such as
chest infection and deep vein thrombosis/pulmonary
embolism, stimulates muscle function to maintain
strength and reduce insulin resistance.
85. Patients in the immediate postoperative period are
subject to disorders in normal respiratory, cardiac,
homeostatic, and autonomic function.
86. Specific complications related to the effects of
anesthesia, as well as the interaction with the
patient’s routine medication regimen and disease
processes, must be considered in the perioperative
period.
87. Postoperative hypotension should raise the
concern for
possible bleeding as well as the consideration for
other sources, such as sepsis or effects of neuraxial
anesthesia.
88. Effective communication during handoffs in the
postoperative period is essential for providing
safe care by all team members involved.
