3. Who is responsible ?
> Open ICU
The surgeon is responsible for
postoperative care of his patients
> Closed ICU (an intensivist - model ICU)
an intensivist - board certified , will care
for ICU - patients
4. Advantage of intensivist – based care
• Shorter ICU – stay
• Fewer days of mechanical ventilation
• Fewer complications
• Lower hospital charges
• Lower mortality
5. The best ICU care according to
American College of Critical Care
Medicine
The intensivist and the surgeon
proactively collaborate in the ongoing
care of surgical patients in the ICU
6. Purposes of ICU admission
1. Availability of electronic monitors
2. Nurse to patient ratio 1:1 or 1:2
3. Early detection of a critical change in
status of surgical patient
4. To ensure optimal outcome
5. Treat M.O.F
7. Requests for ICU Beds
• excellent care
• abundant resources
– high nurse-patient ratios
– pharmacists,nutritionist, RT’s, etc
– high tech equipment
• signs of deterioration quickly identified
• “give them a chance”
• discomfort with death
• convenience
• Demand frequently exceeds supply
8. ICU Admission Criteria
• A service for patients with potentially
recoverable conditions who can benefit
from more detailed observation and
invasive treatment than can be safely
provided in general wards or high
dependency areas
13. ICU Triage
• admission criteria remain poorly defined
• identification of patients who can benefit
from ICU care is extremely difficult
• demand for ICU services exceeds supply
• rationing of ICU beds is common
14. Prioritization Model
Priority 1
– critically ill, unstable
– require intensive treatment and monitoring that
cannot be provided elsewhere
– ventilator support
– continuous vasoactive infusions
– mechanical circulatory support
– no limits placed on therapy
– high likelihood of benefit
15. Prioritization Model
Priority 2
– Require intensive monitoring
– May potentially need immediate intervention
– No therapeutic limits
– Chronic co-morbid conditions with acute severe
illness
16. Prioritization Model
Priority 3
– Critically ill
– Reduced likelihood of recovery
– Severe underlying disease
– Severe acute illness
– Limits to therapies may be set
• no intubation, no CPR
– Metastatic malignancy complicated by
infection, tamponade, or airway obstruction
17. Prioritization Model
Priority 4
– Generally not appropriate for ICU
– May admit on individual basis if unusual
circumstances
– Too well for ICU
• mild CHF, stable DKA, conscious drug overdose,
peripheral vascular surgery
– Too sick for ICU (terminal, irreversible)
• irreversible brain damage, irreversible multisystem
failure, metastatic cancer unresponsive to
chemotherapy
21. Objectives Parameters Model
EKG
–acute MI with complex arrhythmias,
hemodynamic instability, or CHF
–sustained VT or VF
–complete heart block with instability
23. Intermediate Care Units
• monitoring and care of patients with moderate or
potentially severe physiologic instability
• require technical support
• frequent monitoring of vital signs
• frequent nursing interventions
• not necessarily artificial life support
• do not require invasive monitoring
• require less care than ICU
• require more care than general ward
24. Intermediate Care Units
• reduces costs
• no negative impact on outcome
• improves patient/family satisfaction
25. ICU Triage
“Too well to benefit”
– Possibility of being detrimental by providing
overly aggressive care
– Procedure complications
– Increased chance of multi-resistant infections
– Patients who will survive anyway should not be
admitted for anticipatory monitoring
26. ICU Triage
“Too sick to benefit”
–Hopelessly ill patients should not be
admitted to an ICU
27. Critical Care
Patients needing ICU 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
28. Critical Care
Tools 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
30. Advantages of conventional techniques :
• Useful in guiding the initial resuscitation.
• Easy to obtain.
• Not costly.
• Safe.
• Sufficient for non complicated cases.
Disadvantages :
• They do not assess O2 debt and overall tissue
perfusion.
• Not sufficient for complicated cases.
32. Critical Care
Pulse oximetry
• Gives estimate of percentage saturation of
oxygen binding sites
• Related to Pa02 by oxygendissociation curve
33. 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
Critical Care
34. Critical Care
Arterial line
Indications
• Continuous BP
measurement
• Access for serial arterial
blood gas
analysis
Complications
• Bleeding
• Thrombosis
• Infection
• Pseudoaneurysm
• Accidental drug injection
Site the line in the radial artery of the non-dominant hand. Allen’s test should be
performed.
35. 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.
36. Haemodynamic monitoring
Indications:
Continuous monitoring of blood pressure.
Frequent sampling of arterial blood.
e.g.
Shock (any aetiology).
Acute hypertensive crisis.
Use of vasoactive inotropic drugs.
Respiratory support.
High risk patients (extensive operations).
Sequential analysis of blood gases, pH.
No absolute contraindications, except for specific sites
(infection, prosthesis, distal ischemia, ….).
Arterial Catheterization:
37. Clinical utility of arterial catheterization
Measure SBP.
Measure DBP.
Measure MAP.
Pulse rate.
This reflects:
Intravascular volume.
Heart contractility.
Vascular tree status
(periph. vascular resistance).
38. Sites of catheterization:
Radial A (most common).
Femoral A.
Dorsalis pedis A.
Superficial temporal A.
Axillary A.
Brachial A. (not used; inadequate collateral circ. Frequency of
catastrophic ischemic complication).
For radial A:
Modified Allen test.
Pulse oximetry.
Doppler US.
Disadvantages:
Mean, end diastolic p: accurate;
SBP; overshoot (in stiff, arteriosclerotic A).
39. Axillary A:
Advantages:
Large size.
Close proximity to aorta.
Accurate representation of aortic p. waveform.
Minimal S.P. overshoot.
Pulsations/ pressure are maintained even in
presence of shock (periph. vasoconstriction).
Good collateral circ. bet. subclarian & distal
axillary A.
Clinical utility of arterial catheterization
40. Complications of Arterial Cannulation
Failure to cannulate.
Hematoma formation.
Disconnection with bleeding.
Radial A. thrombosis (use Teflon, smaller size: better)
use Heparin contin flow.
Infections, (0 – 9%)
factors: which ↑catheter infections.
Surgical cut-down.
Duration > 4 days.
Retrograde cerebral embolization.
A-V fistula.
Pseudoaneurysm formation.
41. Central venous Catheterization
Indications:
Access for fluid therapy.
Drug infusions.
Parenteral nutrition.
CVP monitoring.
Placement of cardiac pacemakers.
IVC filters.
Hemodialysis access.
Contraindications to specific site:
Vessel thrombosis.
Local infection inflammation.
Trauma
Previous surgery.
42. Clinical utility of central venous catheter:
Measure CVP. (DD: hypovolemia vs cardiac
tamponade
CVP-tracing:
a-wave: absent in atrial fibrillation.
V-wave: prominent in tricuspid insufficiency.
Measure:
Rt. atrial pressure, Rt. ventricle end-diastolic
pressure.
43. Sites of central venous catheterization:
Subclarian V.
Int. jugular V.
Ext. Jug. V.
Femoral V.
Brachiocephalic V.
Subclavian V:
Easy, high rate & success.
Easy secure of catheter & dressing.
Disadvantages:
Higher risk of penumothorax.
Inability to compress vessel if bleeding occurs.
Internal jugular V:
Easy cannulation, difficult in volume depletion.
Easily compressed if bleeding occurs.
45. 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
46. 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
47. 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.
48. 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
49. 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
50. Critical Care
Pulmonary artery wedge pressure
Complications
• Valvular damage
• Ventricular rupture
• Pulmonary artery rupture
• Aneurysm or infarction
• Those of central venous catheterisation
51. Critical Care
Standard values
• Central venous pressure (CVP): 0-6 mm Hg
• Right ventricular pressure: 25 mm Hg
• Pulmonary artery pressure (PAP): 25 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 / cm2
• Oxygen delivery: 600ml / min / m2
• Oxygen consumption: 150 mls / min / m2
53. 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?
54. 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.
55. Critical Care
Postoperative pulmonary collapse
Clinical features
• Tachypnoea
• Pyrexia
• Productive cough
• Cyanosis
• Dullness on percussion
• Bronchial breathing
56. 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.
57. Critical Care
Postoperative pulmonary collapse
Management
• Antibiotic – amoxycillin
• O2 therapy with inspired O2 concentration of 30-40% with humidification
• Vigorous physiotherapy
• 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
58. 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)
59. 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
60. 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
61. 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.
66. Lung Volumes (CONT)
Vital capacity = (VC):
The maximal expiration following a maximal inspiration.
VC is reduced in diseases involving respiratory muscles,
in obstructive & restrictive diseases of lungs.
Minute volume (VE):
Is the total volume of air leaving the lung each minute.
Dead space (VD):
Is the portion of tidal volume that doesn’t participate in
gas exchange; 2 parts:
Anatomical dead space.
Alveolar dead space
67. Blood gas analysis
Parameters
70 – 100 mmHg
o Arterial blood O2 tension
(PaO2)
> 92%
o Arterial hemoglobin O2
saturation (SaO2)
35 – 45 mmHg
o Mixed venous O2 tension
(PVO2)
65 – 80%
o Mixed venous hemoglobin O2
saturation (SVO2)
o O2 consumption
o O2 utilization coefficient
o Physiologic shunt
o Alveolar O2 tension
68. Respiratory Monitoring (Contin…)
Capnography:
Is the graphic display of CO2
concentration as a waveform.
Capnometry:
Is the numerical presentation of the
concentration of CO2 without a
waveform.
69. Pulse Oximetry:
Measures arterial hemoglobin saturation, by
measuring the absorbance of light transmitted
through well-perfused tissue, such as finger or ear.
The absorbance differs according to
oxyhemoglobin & deoxyhemoglobin.
Pulse-oximetry is influenced by:
Hypotension Hypovolemia
Hypothermia Vasoconstrictor infusions
Motion artifact Electrosurgical interference
70. 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?
81. 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?
82. 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
89. 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.
90. Critical Care
Septic shock from acute calculous biliary obstruction +/-
Acute pancreatitis
Management
• Resuscitation
• Confirmation of diagnosis
• Definitive treatment
91. Critical Care
Acute calculous biliary obstruction
+
Septic shock +/- Acute pancreatitis
Resuscitation
• Analgesia
• IV Dextrose; Mannitol; Antibiotics after blood culture
• Urinary catheter
• CVP line
93. 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
94. 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
97. Critical Care
Early features of sepsis
• Fever or hypothermia
• Leucocytosis or leucopenia
• Tachycardia
• Tachypnoea
• Organ dysfunction: Brain - altered mental state
Lungs - hypoxia
Kidneys - oliguria
98. 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
99. 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.
100. 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
101. 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
102. 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
103. 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
104. 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
108. A) Intracranial pressure monitoring:
Indications of measurement of ICP:
Severe head injury:
GCS ≤ 8
Or Motor Score ≤ 5
Value:
Permits calculation of cerebral perfusion pressure (CPP)
CPP = MAP – ICP
Thus increase of ICP or decrease of MAP will result in
decrease in CPP.
Maintaining CPP at least 70 mmHg is just sufficient to
maintain adequate cerebral blood flow especially to
injured brain.
111. Transcranial Doppler
ultrasonography: (TCD)
To monitor cerebral blood flow.
It records blood flow-velocity in the basal
cerebral arteries.
It detects vasospasm and it helps in
identification of hypremic/ low-flow areas.
Neurologic monitoring (contin…)
112. Glasgow Coma Score (GCS)
Eyes Open:
Spontaneous 4
To verbal command 3
To painful stimulus 2
Do not open 1
……………………………………........................
Verbal:
Normal oriented conversation 5
Confused 4
Inappropriate words 3
Sounds 2
No sounds 1
Intubated T
………………………………………………………
Motor:
Obeys commands 6
Localize pain 5
Withdrawal/ Flexion 4
Abnormal flexion (Decorticate) 3
Extension (Decerebrate) 2
No motor response 1
113. Jugular venous oximetry:
An invasive method of continuous monitoring
of jugular venous bulb oxyhemoglobin
saturation.
Readings of 55 to 71%: normal cerebral
perfusion
Measurement < 50% is indicative of cerebral
ischemia.
Neurologic monitoring (contin…)
114. 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?
116. 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%
117. 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.
120. Critical Care
Sub-phrenic abscess
“Pus somewhere, pus nowhere, pus under the
diaphragm.”
Investigations for confirmation
• Blood: Culture, FBC, CRP
• CXR
• Ultrasound
• ?CT
121. 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
122. 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.
123. Critical Care
The Septic Patient
Investigations
• Blood cultures
• U&Es, FBC, CRP, Clotting studies, LFTs
• CXR
• Appropriate imaging studies for source
124. Critical Care
The Septic Patient
Management
• Supportive measures:
- Oxgenation
- Ventilation if necessary
- IV fluids
- Inotropic support
- Nutritional support
• Specific measures
- Antibiotics
- Drainage
125. 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?
126. 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.
127. 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
128. Abdominal Compartment Syndrome
Diagnosis
• Patients usually in ICU
• Tense abdomen
• Cardio-respiratory compromise in the absence of
hypovolaemia
• Renal failure
• Round belly sign ( Ratio of AP to transverse abdominal
diameter > 0.80 )
130. 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
131. 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%
132.
133. 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?
134. Critical Care
Post TURP syndrome
( Dilutional hyponatraemia)
Clinical features
• Restlessness, muscle twitching, disorientation,
visual disturbances, seizures & collapse
• Hypertension, severe hyponatraemia
135. 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.
136. 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
137. Caritical 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
138. Critical Care
A 60 year old man underwent a Whipple’s
operation for periampullary carcinoma. On
the 2nd postoperative day, while still in the
ICU, 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?
139. 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
140. 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
142. 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
143. Critical Care
Renal failure
Predisposing causes
• Preoperative renal impairment
• Surgery associated with major blood loss and fluid shifts
• Hypovolaemia
• Hypotension
• Sepsis
• Nephrotoxic drugs
144.
145.
146. 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?
147. Critical Care
Acute limb compartment syndrome
What are the causes of this condition?
How do you diagnose it?
How do you treat the condition?
148. Acute Limb Compartment Syndromea
This is a condition in which raised pressure
within a closed fascial space reduces
capillary perfusion below a level necessary
for tissue viability.
151. 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
152. 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
158. 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
159. 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
160. Critical Care
Pain relief
Intractable pain
Intractable pain is defined as chronic and continuous pain
where the cause cannot be removed or the origin cannot
be determined.
Causes: Benign
Malignant
161. Critical Care
Relief of Benign Intractable Pain
• LA + / - steroid injections
• Nerve stimulation procedures
• Nerve decompression
• Sympathectomy
173. 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
175. Nutrition
A healthy adult at rest requires 6300 – 8400
nonprotein kilojoules per day for energy
( 1500 – 2000 calories).
176. 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
177. 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 ).
178. 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.
180. Nutrition
Complications of enteral nutrition
• Nutritional and metabolic
• Complications of nutrient delivery
• Gastrointestinal complications
181. 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 )
184. Nutrition
Complications of parenteral nutrition
Nutritional and metabolic
• Fluid overload
• Hyperglycaemia
• Electrolyte imbalance
• Micronutrient deficiencies eg selenium in long-term patients
185. Nutrition
Complications of parenteral nutrition
Effect on other organ systems
• Hepatobiliary system – biliary sludge, hepatic steatosis, cholestasis
• The immune system
• Skeleton – metabolic bone disease
186. 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
