Cases in Surgical Critical Care

8/6/2019 Cases in Surgical Critical Care

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Cases in Surgical Critical Care

� Objectives

� Things to consider when caring for the

critically ill postoperative patient� Cases

± Postop

± Preop



Objectives

� Discuss cases of surgical patients in the

ICU

� Develop an approach when caring for patients in the SICU

� Cite important differences in the

management of critically ill surgical

patients



Things to consider«

� Go with what you

know

� How did surgery

change:

± Anatomy

± Physiology

± Management

considerations?

� Remember your role



Case 1: Postoperative Crisis

Management

³My Achy-Brachy Heart«´

53yo admitted to you after thoracotomy for

lung cancer

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. )



HPI

Smoker w/ hemoptysis

Found on CXR to have

large (R) chest mass

No obvious

extrathoracic spread

Unrevealing

mediastinoscopy

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72.



CT

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72.



Case 1

� Exploratory (R) thoracotomy

± Tumor invading truncus inferior of (R) PA,

pericardium by superior PV

± Intrapericardial pneumonectomy performed

� Vessels controlled outside pericardium

� Intercostal muscle pedicle over bronchial stump� Pericardium closed w/ suture



Case 1: Postop

� Extubated in OR

� EBL <200ml

� NSR 70-90 bpm, BP 120/70� Good breath sounds in L lung

� No pain issues w/ epidural

� UO 30ml/ hr



Case 1: POD #3

� Febrile, delirious, tachypneic, mild

drainage at epicardial site

� Good air movement, pulmonary toilet,mucus clearance

� R leg swelling, on good DVT prophylaxis

� Patient prepped for LP by med studentHS: attempted sitting up, patient lies down

to R side on chest tubes in mid-procedure



Case 1

� PEA arrest w/ bradycardia, no pulse

palpable, patient w/ labored breathing

pattern.

� Venous congestion in face

� You are called emergently to assist.



Case 1: What next?

You are performing

ACLS

Rescucitative efforts are

not working

«Things to consider«



Cardiac Herniation

� Rare w/ pericardial mesh

� 68 case series (Kimura 1999)

± 46 (R), 22 (L)

± 21/46 fatal

� >75% happened defore end of surgeryduring repositioning

� Most cases are related topneumonectomy; can happen w/lobectomy

Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation following intrapericardia pneumonectomywith partial pericardiectomy for advanced lung cancer



Cardiac Herniation

� Occurs with

± Coughing

± Rapid decompression

w/ chest tube ± PPV

± Patient movement

� Treatment

± Reposition patient

± Access to pericardium

w/ restoration of heartposition

± Pericardial patch



Case 1

(images adapted from Shimizu J, et al. Ann Thorac Cardiovasc Surg. 2003 Feb;9(1):68-72. Cardiac herniation

following intrapericardia pneumonectomy with partial pericardiectomy for advanced lung cancer

During decompensation After emergent Procedure



Case 2: Preop

³My Therapist told me I would live longer if I just

vent my spleen more´

47 yo admitted with abdominal pain



HPI

� Case 2 HPI

� He presented to an OSH with abdominal

pain� CT interp: ³contained rupture of his

spleen.´

� HD#1 hct 22%Post 2u prbcs

hct 21%

� Transfer to your ICU arranged; you are

consultant intensivist to see patient first.



Case 2

PMHx:

± Essential

thrombocytosis and

splenomegaly,diagnosed in 1970.

± BM Bx 1990:

myelofibrosis

± Gout

Meds:

Folate

MVI

Procrit

Allopurinol

Fe Sulfate

Indomethacin

No allergies



Case 2-Admission Data

� AFVSS INAD

� Spleen extends down to pelvic rim,

approximately 4cm from midline� Small ventral hernia

� Hct 23%



Radiology



Management?



On arrival

� Pt complains of ³feeling like [he is] going to

die´

� BP 70/palp, pt diaphoretic, pale, and w/ an

enlarging belly.



You¶re the ICU doc«

� How will you manage this patient?

� What events do you anticipate in this

patient?� To manage this patient immediately, what

will you need?

� What needs will you develop ³down theroad?´





Surgery

� Spleen weighed 5400gm and measured

44x18x9.5cm

� Rupture of splenic vein at base of spleenidentified

� Over course of 6h surgery he continues to

bleed

± Total ~100u blood products



You¶re stuck

� Patient survives surgery ± 20units crossmatched blood

± 70units uncrossmatched blood

± 10u FFP

± 18u platelets

� Initial postop valuesPT 30 PTT 80 Fibrinogen 80

Hgb 11 Cai 0.65 pH 7.65

K+ 3.3� What will consequences of massive transfusion

be?



Massive Transfusions

� Rarely occur in the MICU

� Differing definitions

± �50% of patient¶s blood volume/ 12-24hrs� Defines ³Support of Surgical Team´

� Medical management of a surgical patient

O2 Delivery Acid-Base BalanceElectrolyte shifts Coagulopathies



How fast can you go?

Device

(with 0.9% NS)

Flow Rate(100cm above entry site)

(L/hr)

Arrow 9F Percutaneous sheath introducer 33.5

Arrow 8F Percutaneous sheath introducer 10.5

14G Interlink® Catheter (without interlink) 6.5

18G Interlink® Catheter (without interlink) 3.5

16G lumen (brown port) of Arrow® TLC 3.3

18G (proximal white port) of Arrow® TLC 1.6Refs: Saw S, et al.´ The effect of the InterLink cannula on fluid flow rates and haemolysis.´ Emerg Med 2001 Dec;13(4):456-9.

Arrow device package insert

personal communication, Arrow International sales staff



Level 1 Infuser (Belmont Corp)

� 75-30,000ml/ h

� Pressure at

300mmHg

� Rapidly warms fluids

to 37ºC

� Requires specialized

nurse training tooperate

Patient line

Spikes

Drip Chamber

Gas Vent Holder

Gas Vent

Bottom Socket

Top Socket

Heat Exchanger

Heat Exchanger

Guide

F rom Belmont Corp Product Literature



Coagulopathy

� Dilutional Coagulopathy

� Chemical Coagulopathy

� Transfusion-induced DIC

� Dilutional thrombocytopenia

� When to give:

± Platelets

± FFP ± Cryoprecipitate

± Factor VIIa



Other Issues

� Hypothermia

� Citrate Load Metabolic alkalosis

� Old bloodmetabolic acidosis� Citrate toxicity (�8 u prbcs/ hour)

� Hypokalemia and/ or hyperkalemia

� Hypocalcemia



Role of other services

� Treated like a ³stroke code´

� OR, clinical labs, blood bank, on-call

hematologist notified� Rapid blood matching



Preparing an ICU patient for

surgery

� Preop eval is simultaneous w/resuscitation

� What are opportunities to improve

patient¶s condition before surgery? ABC HR, BP Ascites

� What concurrent diseases will affect pre/

peri/ postop management?� What are endpoints of preop

resuscitation?



Preparing an ICU patient for

surgery

� What is planned surgery?

� What are preop needs?

± Blood products ± Invasive/ non-invasive monitoring

± Vasoactive medications

� What is periop/postop monitoring plan?

� What is postop sedation/ extubation plan?

� What is postop antibiotic plan?



Don¶t forget«

Preop information you wish you had after the surgery

± Peripheral vascular exam

± Neuro exam

± Steroid use history and risk of adrenalinsufficiency

If non-elective: NGT decompression of stomach

Pregnancy test



Thanks!

Hasan Shanawani, MPH MD

[email protected]

Cases in Surgical Critical Care

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Cases in Surgical Critical Care