Surgical Issues


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Surgical Issues

  1. 1. N.K. Durrani, MD M. McCann, DO M.M. Brandt, MD, FACS, FCCM P. Patton, MD, FACS H.M. Horst, MD, FACS, FCCM I. Rubinfeld, MD Dept. of Trauma Surgery Henry Ford Hospital, Detroit Surgical Issues in Critical Care Medicine
  2. 2. Objectives <ul><li>Discuss surgical issues that develop in ICU patients </li></ul><ul><li>Discuss peri-operative issues relevant to nonsurgical intensivists </li></ul><ul><li>Not inclusive of trauma </li></ul>
  3. 3. User’s Guide to Your Surgical Consultant <ul><li>Surgeons do not have “admission cap” </li></ul><ul><li>The are rarely on a “consult” service </li></ul><ul><li>They, too, have emergencies, primary patients, and lack of sleep </li></ul><ul><li>If your patient can’t tolerate a haircut, you may not want to call for a surgical consult </li></ul><ul><li>In some cases surgeons may feel pressured to operate solely because you have consulted! </li></ul>
  4. 4. Surgical Complications in Intensive Care Patients <ul><li>Airway: Airway loss and emergent management </li></ul><ul><li>Pulmonary: Simple and tension pneumothorax </li></ul><ul><li>Cardiac: Tamponade </li></ul><ul><li>Abdominal Treasures: Abdominal pain, catastrophe, and ileus </li></ul><ul><li>Bleeding and NOT Bleeding: GI bleeding, lines, hematomas, cold legs, ischemic bowel, etc. </li></ul>
  5. 5. Surgical Airways: Crichothyroidectomy and Tracheostomy <ul><li>Only reason not to intubate is inability to do so, nonsurgical always preferred: i.e., orotracheal, nasotracheal </li></ul><ul><li>Relative contraindications to intubation </li></ul><ul><ul><li>C-spine instability </li></ul></ul><ul><ul><li>Midface fractures </li></ul></ul><ul><ul><li>Laryngeal disruption </li></ul></ul><ul><ul><li>Obstruction of lumen </li></ul></ul>
  6. 6. Airway <ul><li>Upper airway obstruction from whatever cause: Trauma, angioedema, etc. </li></ul><ul><li>Considerations: Do they need something done? How fast? How desperate are we? </li></ul><ul><ul><ul><li>Traditional intubation </li></ul></ul></ul><ul><ul><ul><li>Nasotracheal </li></ul></ul></ul><ul><ul><ul><li>Fiberoptic and other adjuncts </li></ul></ul></ul>
  7. 8. Airway: Surgical <ul><li>Needle Cricothyroidotomy: Short-term solutions, user dependant, no CO 2 clearance </li></ul><ul><li>Cricothyroidotomy: smaller tube, can clear CO 2 , needs experience, percutaneous kits available </li></ul>
  8. 9. Airway: Surgical <ul><li>Tracheostomy: Not usually for emergencies, need experience, “knife and a tube” </li></ul><ul><li>Percutaneous Tracheostomy: Not for emergency situations </li></ul>
  9. 10. Airway: Surgical <ul><li>Massive hemoptysis </li></ul><ul><li>Emergent bronch for source and possible treatment </li></ul><ul><li>Consider bronchial blocker for isolation </li></ul><ul><li>Angio options: Embolize bleeding source </li></ul><ul><li>Emergent lobectomy if localized </li></ul>
  10. 11. Surgical Pulmonary Emergencies <ul><li>Pneumothorax (Simple): Partial or complete collapse—increases pulmonary shunt </li></ul><ul><ul><li>Chest tube in emergency </li></ul></ul><ul><ul><li>Attempt catheters as well </li></ul></ul><ul><ul><li>Treat “conservatively” in stable asypmtomatic patients </li></ul></ul><ul><ul><li>Aggressive therapy if on positive pressure </li></ul></ul><ul><ul><li>Can progress to tension pneumothorax </li></ul></ul>
  11. 12. Tension Pneumo <ul><li>True Surgical Emergency </li></ul><ul><ul><li>Say it! “This is a tension...” </li></ul></ul><ul><ul><li>Can relieve with needle or catheter, but it’s not definitive therapy! </li></ul></ul><ul><ul><li>Any patient who has been needled needs a tube, now! Don’t leave the patient until it’s in! </li></ul></ul><ul><ul><li>Clinical DX, x-rays suggest missed diagnosis </li></ul></ul>
  12. 13. Hemothorax <ul><li>Massive Hemothorax </li></ul><ul><ul><li>Can be result of lines or thoracentesis </li></ul></ul><ul><ul><li>Limited diagnostic use of thoracentesis </li></ul></ul><ul><ul><li>Chest tube is intial management </li></ul></ul><ul><ul><li>Larger size tube 40FR </li></ul></ul><ul><ul><li>If large quantity or persistent then surgery </li></ul></ul>
  13. 14. Cardiac Tamponade <ul><li>Equalization of pressures  compression of RA reduces and then eliminates preload </li></ul><ul><li>Temporized with needle or catheter decompression </li></ul><ul><li>Definitive surgery: pericardial window, pericardiotomy </li></ul><ul><li>If blood, may need operation for trauma </li></ul>
  14. 15. The Abdominal Treasure Box <ul><li>Abdominal pain syndromes in the ICU: </li></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Acalculous Cholecystitis </li></ul></ul><ul><ul><li>Bowel ischemia </li></ul></ul><ul><ul><li>Bowel obstruction/ileus/Ogilvie’s </li></ul></ul>
  15. 16. Pancreatitis <ul><li>Pain—“steady, dull” —epigastric/upper quadrant , back </li></ul><ul><li>Nausea/vomiting/fever </li></ul><ul><li>Due to medications/other illnesses/hypotension </li></ul><ul><li>One reason for shock in the “nonsurgical patient” </li></ul><ul><li>Can become surgical, if necrotizing or infected </li></ul>
  16. 17. Acalculous Cholecystitis <ul><li>5-10% of all cases of acute cholecystitis </li></ul><ul><li>Observed in the setting of very ill patients </li></ul><ul><li>Higher incidence of gangrene and perforation compared to calculous disease </li></ul><ul><li>Those on TPN for more than 3 months </li></ul><ul><li>Bile stasis and increased lithogenicity of bile </li></ul><ul><li>Critically ill patients are more predisposed </li></ul>
  17. 18. Bowel Ischemia <ul><li>Nonocclusive mesenteric ischemia can occur without arterial or venous abnormalities. </li></ul><ul><li>20-30% have nonocclusive disease </li></ul><ul><li>Poor perfusion secondary to congestive heart failure, MI, or hypovolemia </li></ul><ul><li>Low-flow states cause peripheral vasodilation and shunting of the blood from gut to the periphery. </li></ul><ul><li>Digitalis causes vasoconstriction of both arterial and venous smooth muscle cells in mesenteric vasculature. </li></ul>
  18. 19. Bowel Obstruction <ul><li>Multiple etiologies of obstipation in ICU </li></ul><ul><li>Bowel obstruction, ileus, Ogilvie’s </li></ul><ul><li>Patients can develop obstruction at any time </li></ul><ul><li>Ileus associated with many nonsurgical diseases </li></ul><ul><li>Nonoperative therapy </li></ul><ul><li>Ogilvie’s occurs in the elderly and debilitated </li></ul><ul><li>Medical (fix electrolytes, avoid narcotic) and surgical therapy </li></ul><ul><li>Surgery for true peritonitis or complete bowel obstruction </li></ul>
  19. 20. Abdominal Compartment Syndrome <ul><li>Acute increase in intra-abdominal pressure </li></ul><ul><li>Affects renal, pulmonary, and cardiovascular systems </li></ul><ul><li>Decreases ventilation, causes hypoxia, decreased blood flow to lower extremities, and kidney failure </li></ul>
  20. 21. Abdominal Compartment Syndrome <ul><li>Caused by intra-abdominal swelling or hemorrhage </li></ul><ul><li>Increase in volume of retroperitoneum such as with pancreatitis also seen </li></ul><ul><li>Even reports of retroperitoneal hemorrhage such as with pelvic fracture or from anticoagulation </li></ul>
  21. 22. Abdominal Compartment Syndrome <ul><li>Early recognition and diagnosis vital to prevent complications </li></ul><ul><li>Distended, tense abdomen first sign </li></ul><ul><li>Bladder pressure confirms elevated pressure and is easy to perform </li></ul><ul><li>Bladder is direct transmitter of pressure at volumes of less than 100 cc. </li></ul>
  22. 23. Bladder Pressure Measurement <ul><li>Bladder filled with 50 cc. of sterile saline via foley and pressure monitor connected to side port with 18 ga. Needle </li></ul><ul><li>Normal pressure up to 10 cm H 2 O </li></ul><ul><li>Grade I = 10-15 </li></ul><ul><li>Grade II = 15-25 </li></ul><ul><li>Grade III = 25-35 </li></ul><ul><li>Grade IV = >35 </li></ul>
  23. 25. Abdominal Compartment Syndrome <ul><li>Grade I-II can be treated with muscle relaxants as long as clinical situation improves </li></ul><ul><li>Laparotomy with open abdomen </li></ul><ul><li>Grade III and over </li></ul><ul><li>Failure of improvement with conservative measures </li></ul>
  24. 27. UGI Bleed <ul><li>Gastric (ulcer vs. gastritis) </li></ul><ul><li>Duodenal </li></ul><ul><li>Esophageal varices </li></ul><ul><li>Mallory-Weiss </li></ul>
  25. 28. Monitor <ul><li>2 large bore perph. IVs </li></ul><ul><li>2 L crystalloid, T&C </li></ul><ul><li>Labs: CBC, Plts., Coags </li></ul><ul><li>CVP, Swan, Foley </li></ul><ul><li>NGT </li></ul>
  26. 29. Therapeutic <ul><li>H 2 blockers ,PPI </li></ul><ul><li>EGD </li></ul><ul><li>Arteriography </li></ul><ul><li>Varices: vasopressin, octreotide, sclerotherapy, Sengstaken-Blakemore tube, TIPS </li></ul><ul><li>Operative intervention </li></ul>
  27. 30. Mallory-Weiss tear <ul><li>Usually stops spontaneously </li></ul><ul><li>Ngt to decrease distention and emesis </li></ul><ul><li>May attempt Blakemore tube using gastric balloon for direct pressure. </li></ul><ul><li>Operative intervention rarely needed (but a cool case never the less) </li></ul>
  28. 31. LGI Bleed <ul><li>Most arise from the colon and rectum </li></ul><ul><li>Diverticula, angiodysplastic lesions, neoplasms, IBD, hemorrhoids, and anal fissures </li></ul><ul><li>Small bowel, neoplasms, IBD, Meckel’s diverticulum </li></ul>
  29. 32. Diagnostic <ul><li>Radionuclide scan </li></ul><ul><li>Arteriography </li></ul><ul><li>Colonoscopy </li></ul><ul><li>Rectal exam </li></ul>
  30. 33. Therapeutic <ul><li>Arteriographic intervention; vasopressin, coils, gel foam, (and localization!) </li></ul><ul><li>80% success, 50% rebleed risk </li></ul><ul><li>Operative; hemodynamic unstable with >8 units PRBC </li></ul><ul><li>Localization is key, unlocalized LGI bleed will lead to a blind subtotal colectomy, which is a higher mortality procedure for your patient! </li></ul>
  31. 34. Cold Legs <ul><li>Acute arterial insufficiency </li></ul><ul><li>5 Ps: pain, pallor, pulselessness, paresthesia, and paralysis </li></ul><ul><li>Usually remember when pain began </li></ul>
  32. 35. Cold Legs (cont.) <ul><li>Immediate evaluation needed; irreversible injury if not reversed after 6 hours </li></ul><ul><li>Anticoagulation and to OR if DX is clear or DX unclear angiogram to delineate chronic vs. embolic </li></ul>
  33. 36. Postoperative <ul><li>Reperfusion of ischemic extremity; wash out of byproducts leads to acidosis, hyperkalemia, myglobinemia; these must be treated </li></ul><ul><li>Myoglobinemia; to renal failure—hydration is the key </li></ul><ul><li>Watch for compartment syndrome of extremities 2 nd to reperfusion </li></ul>
  34. 37. Swollen Legs <ul><li>Most common “surgical” etiology is DVT </li></ul><ul><li>Does your patient need a filter? </li></ul><ul><li>Failure of or contraindication to anticoagulation </li></ul><ul><li>Others include limb compartment syndrome </li></ul>
  35. 38. Extremity Compartment Syndrome <ul><li>Acute increase in pressure within myofascial compartment of an extremity </li></ul><ul><li>Can occur in any compartment </li></ul><ul><li>Complications related to contents of compartment </li></ul><ul><li>Causes rhabdomyolysis, ischemic neuritis, arterial insufficiency, venous gangrene, and limb loss </li></ul>
  36. 39. Compartment Syndrome <ul><li>Due to increase muscle swelling, hematoma, or interstitial fluid </li></ul><ul><li>Swollen, tense extremity is first sign </li></ul><ul><li>Loss of sensation first neurologic sign followed by weakness </li></ul><ul><li>Last sign is decrease in pulses </li></ul>
  37. 40. Compartment Syndrome <ul><li>Early diagnosis is key to avoiding complications </li></ul><ul><li>Direct pressure measurement using 18 ga. needle and arterial monitor </li></ul><ul><li>Or the more popular Stryker pressure monitor </li></ul>
  38. 41. Compartment Syndrome <ul><li>Early diagnosis is key to avoiding complications </li></ul><ul><li>Direct pressure measurement using 18 ga. needle and arterial monitor </li></ul><ul><li>Or the more popular Stryker pressure monitor </li></ul>
  39. 42. Compartment Syndrome <ul><li>Treatment depends on cause </li></ul><ul><li>Arterial injury requires repair and evacuation of the hematoma, fractures require immobilization and elevation. </li></ul><ul><li>Severe swelling from any cause is treated with fasciotomy to release pressure. </li></ul>
  40. 43. Compartment Syndrome <ul><li>Pressure of <30 mmHg can be observed. </li></ul><ul><li>Pressure between 30-40 mmHg should be decompressed unless it can be controlled within short time (1-2 hrs). </li></ul><ul><li>Pressure >40 mmHg requires immediate decompression. </li></ul>
  41. 44. Case 1 <ul><li>62-year-old male undergoes cardiac catheterization and sustains a retroperitoneal hematoma requiring blood and fluids </li></ul><ul><li>He is in your unit, getting sicker, and is intubated. </li></ul><ul><li>Inspiratory pressures are rising on ventilator </li></ul><ul><li>Urinary output diminishing despite resuscitation and the creatinine rising </li></ul><ul><li>Now, the abdomen seems distended. </li></ul>
  42. 45. Case 1 (cont.) <ul><li>What else do you want to know? </li></ul><ul><li>His x-ray shows low lung volumes, no PTX. </li></ul><ul><li>His ABG demonstrates difficulty with ventilation, and increasing metabolic acidosis. </li></ul><ul><li>His bladder pressure is 40 mmHg. </li></ul><ul><li>What is the diagnosis? How does it occur? </li></ul><ul><li>What should be done? </li></ul>
  43. 46. Case 2 <ul><li>89-year-old male with Legionnaire's pneumonia is admitted to the MICU </li></ul><ul><ul><li>Intubated, then trached, on antibiotics and TPN </li></ul></ul><ul><ul><li>Finally now on tube feeds via PEG </li></ul></ul><ul><ul><li>Starts to develop high residuals </li></ul></ul><ul><ul><li>The abdomen seems distended </li></ul></ul>
  44. 47. Case 2 (cont.) <ul><li>What do you want to know? </li></ul><ul><li>Abdominal XR shows dilated loops of bowel. </li></ul><ul><li>ABG reflects acidosis. </li></ul><ul><li>What labs do you want? </li></ul><ul><li>US gallbladder normal </li></ul><ul><li>AMYLASE, LIPASE elevated </li></ul><ul><li>What to do? </li></ul>