surgical intensive care by prof. gamal elewa dept. of anesthesia, intensive care and pain management...

SURGICAL INTENSIVE CARESURGICAL INTENSIVE CAREBy

Prof. GAMAL ELEWADept. of Anesthesia, Intensive Care and Pain Management

Faculty of Medicine, Ain Shams University

Anesthesia DepartmentAnesthesia Department

© gamal elewa, 2012

IIntended LLearning OOutcomesBy the end of this lecture , the student will be able to:1.Know criteria of intensive care2.Differentiate between different types of intensive care3.Select patients for admission & Identify criteria of discharge4.Care of surgical intensive care patients 5.Use proper monitors in intensive care unit (ICU)6.Suspect and prevent complications7.Understand Management principles of surgical ICU patients

AIM

• What’s ICU? (Definition)

• What’s in? Characteristics?

• Types of ICU? (Classification)

• Indications: In & Out?

• Monitoring

• Care of patients in ICU

• Complications?

• Criteria for Discharge?© gamal elewa, 2012

What’s ICU?

• Place where there’s:• Intensive Monitoring,• Intensive (close) Nursing care,• Special Equipment: ventilators, …• Patient is critically ill,

• Doctor(s): present 24 h, well trained in management of critically ill patients

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Characteristics

• Equipment: Monitors & Ventilators, DC Shock, Portable x- Ray, Dialysis, …

• Doctors: 24h on duty, Qualification

• Nursing Staff: 1:2 patients, qualifications

• Communications with: doctors, wards, lab, radiology, O.R., Bl. Bank, other departments, pt. relatives

• Patients: critically ill, life-threatening condition: resp. failure, life threatening dysrrhythmias, p.o. cardiac surgery

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Types of ICU

• Design: Closed vs Open• Speciality & subspeciality: • - Surgical (Cardiac, Neurosurgical,

Obstetric, Burn, General), • - Medical (Coronary care unit “CCU”,

Chest, Neurology, Stroke, General),• - General (combined surgical and

medical)

© gamal elewa, 2012

Types of ICU (cont.)

Surgical

• General, Cardiothoracic, Neurosurgical, Obstetric & Gynecologic, Burn

• Intensive Care

• General ICU (Combined Medical & Surgical)

Medical

• CCU, Chest, Neurology, Geriatric

• Intermediate Care

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Types of ICU (cont.)

Closed ICU

• Staff & System• Patients: IN & Out (Drain

& Discharge )• Design• Visitors

Open ICU

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INDICATIONS For Admission (Causes of Admission to Surgical ICU)

• Surgical: Brain tumor, cervical spine, cardiac surgery, associated medical condition…

• Preoperative: hemodynamically unstable (shocked, serious arrythmias) multiple trauma

• Trauma: Airway, Chest, Cardiac, Brain, Cervical spine, …

• Medical: ischemic heart disease (IHD), cerebro-vascular stroke, uncontrolled hypertension, complicated diabetes, Resp., cardiovascular, multi-organ dysfunction syndrome (MODS), …

• Combined

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MonitoringAccording to:

• Patient condition• Type of surgery• Anticipated

complications

Types:• ECG: Rate, rhythm, ischemia• Blood pressure (BP): invasive (IBP) vs

non invasive (NIBP)

• Pulse oximeter (SPO2): O2 saturation, HR

• Capnography (PCO2)• Central venous pressure (CVP),

pulmonary capillary wedge pressure (PCWP), cardiac output (C.O.)

• Urine output, Fluid Balance• Level of Consciousness, • Blood Sugar• Arterial blood gases (ABGs), • Drains, chest tubes,…

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CARE OF SURGICAL ICU PATIENTSAccording to:

• Type of surgery and anticipated complications• Associated condition (e.g. trauma, pregnancy)

and/ or diseases (Ischemic heart disease, hypertension, diabetes, liver and renal dysfunction, COPD)

• Level of consciousness• Required Position of patient

© gamal elewa, 2012

CARE OF SURGICAL ICU PATIENTSIncludes:

• Monitoring• Infection control• Position• Vascular lines, catheters,

tubes, drains,…• Connected devices:

ventilators, intra-aortic balloon pump, ..

• Nutrition:

- Route: enetral (oral, Ryle, gastrostomy, jejunostomy, ileostomy), parenteral

- Type: diabetic, liver, renal, resp.

- Amount

- Timing

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CARE OF COMATOSED PATIENTSSuspected complications:

• Bed sores• Respiration: obstruction,

infection, Aspiration• Infection• Malnutrition• Deformities

Care:

• Position, physiotherapy• Resp.Rate, pattern,

SpO2, temp., auscultation, CXR

• Nutrition support: Route (enteral, parenteral), constituents, amount

© gamal elewa, 2012

CARE OF NEUROSURGICAL ICU PATIENTSSuspected complications:

• Consciousness• Fits• Bleeding• Fluid imbalance• Other neurological

deficits

Care:

• Glasgow Coma Scale (E/V/M) (4/)

• CT Brain ?• Antiepileptics• Fluid Chart, Drains• Motor & sensory

monitoring

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CARE OF CARDIAC SURGERY ICU PATIENTSSuspected Complications:

• Dysrhythmias & heart block

• Cardiac Failure & pulmonary edema

• Bleeding & Tamponade• Blood pressure changes• Neurological

complications• Renal dysfunction

Care:

• ECG, Antiarrythmic• Pace Maker• CVP, PCWP, Inotropes,

vasopressors, vasodilators

• Intra-aortic baloon pump• Neurological assessment• Renal assessment &

protection

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CARE OF INVASIVE DEVICES

Suspected Complications:

• Infection• Displacement• Trauma

Care:

• Hand wash• Gloves• Sterilization• Antiseptic• Exchange• C&S

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CONTROL AND PREVENTION OF INFECTIONTo patient

• Hand wash• Gloves, Masks• Equipment• Sterilization• Air condition• Isolation• Carrier detection• Antimicrobials

To ICU staff

• Hygiene measures• Hand wash• Gloves, Masks• Check up

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Prevention of Iatrogenic ComplicationsSuspected Complications:

• Antibiotic sensitivity & Drug anaphylaxis

• Inadvertant intra-arterial injection

• Wrong drug injection & blood transfusion

• Infection

Care:

• Drug sensitivity test• Lablling• Re-check• vigilance

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Indications of Mechanical Ventilation

• Respiratory failure• Delayed post operative

(P.O.) recovery• Increased intra cranial

pressure (ICP)• CPR (Cardiac arrest)• P. O. Hemodynamically

unstable

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Acid Base & blood Gases

Normal ABG

• pH=7.40±0.04• PCO2=40±4 mmHg• PO2= 60-100 mmHg• HCO3- = 24±2 mmol/l• BE=± 2 mmol/l• S.K+=3.5 – 5 mmol/l• S. Na+=135 ± 4 mmol/l• S. Ca++ (ionized) =0.9 -

1.4 mmol/l

• Acidosis: pH<7.36• Alkalosis: pH>7.44• Respiratory vs Metabolic• 1ry vs 2ry• Compensated vs

Decompensated

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COMPLICATIONS & HOW TO PREVENT AND TREATSpecific to:

• Operation: Cardiac, Brain, Spine, Urology

• Patient illness: Diabetes, HTN, IHD, Bed ridden

• Interference: CVP, Urinary catheter, Mechanical Ventilation

General

• Sepsis• ICU Psychosis• Trauma• Drug interactions &

Idiosyncrasy

© gamal elewa, 2012

GENERAL COMPLICATIONS

• Sepsis: Resistant organisms

• Psychic trauma & depression

• Myopathy & Neuropathy• Drug complications &

dependence• Of interference: Central

Line, Urinary Catheter, Mechanical Ventilation

• Bleeding• Deteriorated level of

consciousness• Hemodynamically

unstable• Epileptic fits• Trauma• Nutritional• Bed Sores

© gamal elewa, 2012

COMPLICATIONS

Of Cardiac surgery

• Heart Failure• Dysrhythmias• Bleeding• Cardiac Tamponade• Neurological• Renal

Of Neurosurgical Operations

• Delayed Recovery & Deteriorated conscious level, Coma

• Epileptic Fits• Bleeding• Fluid Imbalance &

Dehydration• Paralysis or paresis

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CRITERIA FOR DISCHARGE

• Conscious?• Cardiovascular system• Respiratory System• Renal• Surgically (controlled or stable)• Metabolic • Other organ functions

© gamal elewa, 2012

Summary of important pointsSummary of important points

• What’s ICU:• Types of ICU:• Indications for admission

and discharge• Complications: Diagnosis,

prevention, management• Care of surgical ICU

Patients

© gamal elewa, 2012

THANK YOU

BEST WISHES

© gamal elewa, 2012