Surgical Critical Care Handbook, The: Guidelines For Care Of The Surgical Patient In The Icu

Guidelines for Care of the Surgical Patient in the ICU

Jameel Ali

• Éditeur: WSPC
• Année: 2016
• ISBN:
  9789814663144
• Sujet: Medicine
• Sous-sujet: Emergency Medicine & Critical Care

This handbook considers topics that have general application to the critically ill patient. Basic pathophysiology and understanding of its role in critical care monitoring and management are covered, followed by a close look at trauma related and non-trauma related entities likely to afflict the critically ill surgical patient.

The authors consist of practitioners who are experts in their field. They represent the team approach to critical care management where members from the divisions of anesthesia, internal medicine, respiratory medicine, infectious disease and surgical specialties all contribute in formulating intervention, assessment and management plans for the critically ill surgical patient.

By emphasising the surgical conditions requiring critical care, The Surgical Critical Care Handbook will serve as a quick and easy reference for any medical trainee or practitioner aspiring to join the ICU.

Contents:

• Foreword (Jameel Ali)
• The High Risk Surgical Patient ȁ Assessment (Robert Chen)
• Overview of Gas Exchange Abnormalities (Z Bshouty)
• Principles of Mechanical Ventilation (Robert Chen)
• Cardiovascular Dynamics and Hemodynamic Monitoring in the Surgical ICU (Andrew Beckett & Jameel Ali)
• Perioperative Respiratory Dysfunction (Jameel Ali)
• Nutrition in Surgical ICU Patient (Mohammed Bawazeer & Jameel Ali)
• Thrombo-Embolism in the ICU Patient (Andrew Beckett & Jameel Ali)
• The Coagulopathic Surgical Patient (Sandro Rizoli)
• Management of the Anticoagulated Bleeding Patient (Katerina Pavenski)
• Massive Transfusion Protocol (Sandro Rizoli)
• Applications of Ultrasound Imaging in the ICU (Robert Chen)
• Hypothermia and Hyperthemia (John Kortbeeks)
• Priorities in Multiple Trauma Management (Jameel Ali)
• Thoracic Injuries (M Bowyer & Jameel Ali)
• Abdominal Injuries (Jameel Ali)
• Abdominal Compartment Syndrome (Lorraine Tremblay)
• Head Injury (J Ali)
• Spinal Injury (Safraz Mohammed & M Fehlings)
• Pelvic Fractures (Jeremie Larouche & J Ali)
• Extremity Fractures (Jeremie Larouche & J Hall)
• Vascular Injuries (M Bowyer)
• Extremity Compartment Syndromes (M Bowyer)
• Burns, Cold Injury and Electrical Injury (Joel Fish)
• Multiple Organ Dysfunction Syndrome (Giuseppe Papia)
• Pneumonia in Surgical ICU (M Bawazeer & Jameel Ali)
• Upper GI Hemorrhage (N Parry)
• Lower GI Hemorrhage (Marcus Burnstein)
• Colorectal Disorders (Marcus Burnstein)
• Bowel Obstruction (Neil Parry)
• Pancreatitis (John Kortbeek)
• Mesenteric Ischemia (John Kortbeek)
• Intra-abdominal Sepsis (J B Rezende)
• The Pediatric Surgical ICU Patient (Arthur Cooper)
• The Geriatric Surgical Patient (Richard Bell)
• The Bariatric Surgical Patient (Timothy Jackson)
• The Transplant Patient (Anand Ghanekar)
• Soft Tissue Infections (James Mahoney)

Readership: Intensivists and surgeons including trauma specialists.Critical Care;Trauma;Surgical Critical Care Key Features:

• The major feature of this book compared to others is its emphasis on surgical conditions requiring critical care
• Pragmatic approach to critical care

SECTION 1

General Considerations

Chapter 1

Preoperative Assessment of the High-Risk Surgical Patient

Robert Chen and Jameel Ali

Key Points

1.Perioperative risk assessment by careful history, physical examination, and selective investigation is essential for directing therapy in the high-risk surgical patient.

2.To decrease mortality and morbidity, major medical illnesses must be identified and appropriately managed.

3.Delirium is a common postoperative complication that can be anticipated given risk factors.

4.Perioperative cardiac morbidity can be minimized with preoperative medical evaluation which includes appropriate perioperative testing. Routine beta-blockade is likely harmful.

5.Postoperative pulmonary complications can be reduced by aggressive pre- and postoperative care.

6.Diabetes mellitus and steroid dependence must be completely managed to significantly influence perioperative morbidity and mortality.

Chapter Overview

Anesthesiologists have described elective surgery as “planned trauma”. Thus they prepare for all the traumatic sequelae that will occur such as blood loss and fluid shifts, increased myocardial oxygen demands, respiratory changes caused by intubation and ventilation with supplemental oxygen, increased plasma cortisol of the stress response and coagulopathy to name a few. In the average otherwise healthy patient these responses result in no major untoward postoperative events. However, in the medically compromised patient, the additional burden of surgical stress can prove to be very challenging and sometimes insurmountable. Such patients frequently require detailed evaluation and monitoring in the preoperative as well as postoperative periods in the intensive care unit (ICU). Careful planning, preoperative assessment and management of identified abnormalities in these patients are crucial to optimize chances of a good postoperative outcome. A major component of this planning involves the assessment of risks for intraoperative and post-operative morbidity. Patients with cardiac, respiratory, and renal abnormalities pose special risks for postoperative complications. In this chapter, we present guidelines for identifying and managing patients at risk of developing postoperative morbidity.

Preoperative Screening

Appendix 1 is the perioperative screening tool for surgical patients at St. Michael’s Hospital in Toronto, Canada. Patients identified preoperatively with severe disease or gravid patients for non-obstetric surgery should be seen by an anesthesiologist in an outpatient clinic where there is time for preoperative risk stratification and disease optimization if possible. If conditions are found that warrant a delay in surgery, early identification minimizes the impact of other scheduled surgeries. At that juncture, additional advice from Internal Medicine or medical subspecialties is sought as necessary for postoperative management.

Codifying or classification leads to more rapid and precise communication among clinicians: Shock classification, solid organ injury grading, and subarachnoid hemorrhage classification are such examples. The American Society of Anesthesiologists (ASA) physical status classification was created with a similar goal (Appendix 2) and is still commonly used as an index of surgical risk.¹ The Dripps American Surgical Association classification is essentially identical.² Not surprisingly, for a non-parametric scale, morbidity and mortality does not rise regularly with increasing score. The risk for anesthesia and surgery for ASA 1–2 patients is thought to be better than 1:50,000. The risk rises acutely for ASA 4 but is not 100% for ASA 5.³ Additionally, statistics are made more difficult to interpret as the score is assigned by a clinician who is free to interpret “constant threat to life”. A patient critically dependent on dialysis may logically be called ASA 4 but such patients have competed in triathlons.⁴ Therefore, clinicians should not depend entirely on such scales for risk assessment but critically assess the individual.

Assessment of Preoperative CNS risk

Delirium is common postoperative, particularly in elderly patients who are thought to have a 50% occurrence.⁵ Longitudinal studies have demonstrated long term cognitive dysfunction in patients who have suffered delirium as inpatients.⁶

The risk factors for delirium are numerous and include surgery and anesthesia (Appendix 3). Patients who have received regional anesthetics, thus likely exposed to less opiates, have the same rate of delirium as those who have undergone general anesthetics.⁷ Other factors common to our aging population such as structural (stroke, brain injury) and non-structural (psychiatric) brain disease increase the risk for delirium. A recognized risk of delirium allows early treatment.

Postoperative pain is an important risk factor for delirium. Patients may enter a terrible feedback loop of suffering from delirium only to have opiates removed from their postoperative regime to then experience more pain and more delirium. Inadequate pain control is even more frequent in the critical care units with reliance on PL sedation without concomitant analgesia. Many ICU’s do not have a formal sedation and analgesia protocol and, patients risk being sedated without analgesia,⁸ increasing risk for postoperative delirium.

Postoperative delirium requires a multimodal treatment strategy. While haloperidol is sometimes considered, the evidence for improved outcomes is lacking. Pre-treating patients at risk for delirium has had limited success.¹⁰

Identifying risk of delirium allows preventive treatment. This is done by ensuring that environmental, medical and pharmacological factors favor recovery. Examples of such measures include: Ensuring the patient has appropriate vision and hearing aids in place, controlling noise and lighting that affect sleep-wake cycles, ensuring adequate pain control, treatment of dehydration, appropriate nutrition and avoiding polypharmacy.

Assessment of Cardiac Morbidity for Non-Cardiac Surgery

Our aging population, rising rates of obesity and Type II diabetes suggest that more patients presenting for non-cardiac surgery will have diagnosed or clinically suspected ischemic heart disease and thus increased risk for perioperative complications. Using multivariate analysis of 1,001 consecutive patients presenting for non-cardiac surgery, Goldman and associates developed an index for perioperative risk (Cardiac Risk Index; CRI) based on clinical, electrocardiographic (ECG), and routine biochemical parameters.⁹ The strongest predictors of cardiac morbidity were the severity of CAD, a recent myocardial infarction (MI) and perioperative heart failure. Detsky and coworkers reworked the scoring system to allow for broader applicability and less dependence on clinical exam findings. At present, the standard for perioperative cardiac risk assessment combines surgery specific risk, the Eagle criteria, (Appendix 4) and medical risk (Revised Lee CRI).⁴ The Lee index also includes surgical risks as one of the variables however only considers supra-inguinal vascular surgery to be high risk as opposed to Eagle who considers all vascular surgery risky. Low risk is defined as less than 1% possibility of perioperative cardiac complications. High-risk patients have a predicted risk of greater than 10%. Modern vascular surgery techniques such as endovascular aortic aneursysm repair (EVAR) compared to open surgery, demonstrate reduced perioperative risk thus calling into question Eagle’s definition.

In 2007, the American College of Cardiology and the American Heart Association published their guidelines for preoperative assessment. The guidelines were updated only two years later to reflect new perioperative beta blockade information.¹²

Their conclusion was that patients in the low-risk category may proceed directly to surgery with an expectation of a low rate of cardiac complications. Clearly, patients who require emergent surgery should proceed immediately to the operating theatre without delay for cardiac testing. Patients deemed to be in the high-risk group (those who suffer from unstable coronary artery disease (CAD), decompensated congestive heart failure (CHF), severe valvular disease and unstable arrhythmias) should have their non-cardiac surgery delayed for full cardiac evaluation and treatment.

Patients in the intermediate-risk category will benefit most from the investigations, in an effort to further elucidate the extent of their underlying cardiac disease and to attempt to quantify and possibly reduce the perioperative risks before the commencement of the surgical procedure.

Testing becomes more important as patients face intermediate or high risk surgery without good preoperative functional capacity. Patients who suffer from functional limitation due to surgical disease may mask important cardio-respiratory disease. In addition, North America and many other Western countries are in the midst of an obesity epidemic with associated sedentary lives. The lack of symptoms in this large segment of the population results from “auto Beta blockade.” The patients never achieve, in their day-to-day activities, enough physiologic challenge to revea...