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Triaging of critically ill patients.pptx
1. Triage: Decision to Admit Critically ill
Surgical
Patients for ICU Care
Irene bandoh
2. Introduction
• Patients who undergo surgical procedures sometimes end up on admission
to intensive care units (ICUs) the world over.
• The decision to triage critically ill patients to the intensive care unit (ICU)
involves both objective and subjective patient-specific factors (e.g., co-
morbidities, severity of illness, likelihood to benefit), as well as system
factors (e.g., ICU bed availability, other waiting patients, availability of
intermediate care beds).
• High demand for critical care services lead to significant increases in the
number of critically ill patients awaiting ICU admission
• Critical care admission delays due to limited inpatient ICU bed availability
have been associated with poorer patient outcomes.
• Decision to admit depends on available beds and patient’s likelihood to
benefit from this highest level of postoperative care.
3. • As Anaesthetists, you would be very involved in triage decision as
to which surgical patients will need special post-op care at an ICU
especially in the district hospitals
• Generally-be able to reasonably predict bad post-op outcomes early
for prompt ICU admission
• Elective vs. Emergency admissions: most post op admissions are
emergencies
• Patients who have terminal illness or are brain dead will not benefit
from ICU care
4. Recognising the Critically Ill Patient
clinical signs of critical illness are similar whatever the
underlying process
Assessment of very simple vital signs, such as respiratory
rate, heart rate, blood pressure help to predict critical illness.
To help early detection of critical illness, many hospitals
use early warning scores (EWS) and other screening
schemes
Early warning scoring systems allocate points to
measurements of routine vital signs on basis of their
derangement from an arbitrarily agreed ‘normal range’
5. Early Warning Scores
Simple physiological scoring system that can be
calculated at the patient's bedside, using parameters
measured in majority of unwell patients.
does not require complex, expensive equipment to
measure parameters.
reproducible and can be used to quickly identify patients
clinically deteriorating and who need urgent intervention.
EWS can be used to monitor medical, pre and
postoperative surgical, and Accident and Emergency
patients.
9. Calculation of EWS
• Respiratory rate most important for assessing clinical
state of patient
• Respiratory rate thought to be most sensitive indicator
of a patients physiological well being.
• Respiratory rate reflects not only respiratory function
as in hypoxia or hypercapnia, but cardiovascular status
as in pulmonary oedema, and metabolic imbalance
such as that seen in diabetic ketoacidosis (DKA).
10. When and Why to Use an Early Warning
Score?
• EWS score should be calculated for any patient that
you are concerned about.
• Patients who have suffered major trauma, or have
undergone major surgery, can be started on an EWS
observation chart as soon as they arrive at the recovery
ward to monitor clinical progress, and give early
warning of any deterioration.
• Serial EWS readings more informative than isolated
readings as they give a picture of the patient's clinical
progress over time.
11. When and Why to Use an Early Warning Score? Contd
• Once unwell patient identified, with EWS score of 3 or more,
should stimulate rapid assessment of patient by ward doctor or,
if available, intensive care unit (ICU) team.
• If deteriorating patients identified early enough, simple
interventions such as oxygen, or fluid therapy, may prevent
further deterioration and imminent collapse.
• Use of EWS shown to be effective in reducing mortality and
morbidity of deteriorating patients as well as preventing ICU
admissions
13. Airway
• Is the airway patent?
• Is patient able to oxygenate?
• Is patient snoring or desaturating? Airway obstruction?
• Airway maintainable with manoeuvres? Jaw thrust, chin lift, airway
etc
• If not maintainable, intubate!
14. Breathing
• What's the RR?
• What's the work of breathing?
• Chest examination findings
• ABG
• CXR
• POCUS
• If ventilation is not adequate, ventilate either manually or with
ventilator
15. Circulation
• Is perfusion adequate?
• Capillary refill test
• Heart rate
• Bp, more importantly MAP
• Temperature difference?
• If patient is in shock, act swiftly to prevent cardiovascular collapse/
cardiac arrest
16. Disability
• Neurological assessment
• Consciousness level- has there been a sudden drop?
GCS- Intubate if GCS is 8 or less
AVPU
• Pupillary response
• Muscle tone and power
• Reflexes
• Is patient in pain?
19. Judgement
• Make an impression after thorough assessment
• What are the problems?
• Is there organ failure or impending organ failure?
• What is your plan for the patient?
20. Picking up the critically ill surgical patient?
• Prediction of postoperative outcomes/critical illness depends on
Known preoperative risk factors;
the risk associated with the specific surgical procedure; Surgical risk
Intra-op events
Post op events
• Preoperative evaluation
ASA status; ASA III, IV considered high risk for surgery
Surgical Risk Score/organ system-specific scores like, the Revised Cardiac Risk
Index (RCRI)
The pre-op health of the patient; e.g. very weak patients, severe functional
deficits, poor nutrition, severe comorbidities
21. Intraoperative events
• Surgical duration and urgency have both been shown to impact
postoperative outcomes, with longer duration and emergent procedures
associated with worse.
• Operative complexity became a significant predictor with highly complex
procedures.
• Pearse et al. defined high-risk surgical procedures as those with at least a
5% risk of mortality and found that these procedures, in combination with
advanced age, comorbidities, and emergency surgery, were highly
predictive of increased risk of death postoperatively.
• In particular, hemodynamic stresses to the body manifested as extremes of
vital signs may affect postop outcomes.
22. Post-operative events
• Surgical Apgar Score
• Physiological and Operative Severity Score for the enumeration of
Mortality and morbidity (POSSUM)
• Recognition and avoidance of postoperative complications reduce
morbidity and mortality in the short and long term
• The Post Anaesthesia Care Unit(PACU) or Recovery ward can be used
as an HDU for postoperative surgical patients who are not stable
enough for ward care with no ICU facilities.
• ICU scoring systems- APACHE II score, SOFA score etc.
27. Conclusion
• Being able to identify the critically ill surgical patient early saves lives
• The use of warning scoring systems and a systematic approach to
diagnose in critical illness are important to know which patient
requires monitored care
• A few patients may require advance care in the ICU setting, please
refer early if you do not have the facilities
• When in doubt, always treat as critically ill
