to get them out of the sicu! - loyola university chicago...care of the patient in the surgical...

Care of the Patient in the Surgical

Intensive Care Unit

R. Lawrence Reed, II, MD, FACS, FCCMR. Lawrence Reed, II, MD, FACS, FCCM

Professor of SurgeryProfessor of Surgery

Loyola University Medical CenterLoyola University Medical Center

Maywood, ILMaywood, IL

Which patients go to the Surgical

Intensive Care Unit (SICU)?

nn Postoperative patientsPostoperative patients

uu Care needs exceed those that can be provided Care needs exceed those that can be provided

on a regular (nonon a regular (non--ICU) hospital wardICU) hospital ward

nn Preoperative patientsPreoperative patients

uu Patients with acute surgical conditions Patients with acute surgical conditions

requiring resuscitation, complex rapid requiring resuscitation, complex rapid

evaluations, or extensive care prior to surgery evaluations, or extensive care prior to surgery

that cannot be provided by a regular (nonthat cannot be provided by a regular (non--ICU) ICU)

hospital wardhospital ward

To get them out of the SICU!

What are the goals for patients in the

Surgical Intensive Care Unit?

What Keeps a Patient in the SICU?

nn Mechanical ventilationMechanical ventilation

uu Endotracheal/nasotracheal intubationEndotracheal/nasotracheal intubation

FF (Stable tracheostomies may be safely managed in (Stable tracheostomies may be safely managed in

many nonmany non--ICU settings)ICU settings)

nn Hemodynamic supportHemodynamic support

uu Invasive/continuous monitoringInvasive/continuous monitoring

uu Continuous/titrated inotropic/vasoactive drug Continuous/titrated inotropic/vasoactive drug

monitoringmonitoring

uu Ventricular assist devicesVentricular assist devices


nn Intensive physician/nursing/therapist careIntensive physician/nursing/therapist care

uu Large open wounds/burnsLarge open wounds/burns

FF Serious metabolic consequences leading to potential Serious metabolic consequences leading to potential

physiologic instabilityphysiologic instability

uu Frequent wound careFrequent wound care

FF IrrigationsIrrigations

FF Dressing changesDressing changes

FF Heavy sedation and pain control requirements Heavy sedation and pain control requirements

approximating general anesthesiaapproximating general anesthesia


nn Invasive/continuous monitoringInvasive/continuous monitoring

uu Pulmonary artery catheterizationPulmonary artery catheterization

FF Continuous cardiac outputContinuous cardiac output

FF Mixed venous oximetryMixed venous oximetry

uu Intracranial pressure Intracranial pressure

uu Invasive systemic arterial pressureInvasive systemic arterial pressure

uu (Central venous pressure)*(Central venous pressure)*

uu (Pulse oximetry)*(Pulse oximetry)*

uu (Electrocardiography)*(Electrocardiography)*

* (Some hospitals may use these technologies in non* (Some hospitals may use these technologies in non--ICU settings)ICU settings)

Case #1

nn John K. is a 22 yearJohn K. is a 22 year--old male who rolled his old male who rolled his

motorcycle into a flooded ditch. He motorcycle into a flooded ditch. He

sustained:sustained:

uu a severe closed head injurya severe closed head injury

uu bilateral pulmonary contusionsbilateral pulmonary contusions

uu probable pulmonary aspirationprobable pulmonary aspiration

uu an an ““openopen--bookbook”” pelvic fracturepelvic fracture

uu bilateral femur fracturesbilateral femur fractures

nn He was intubated in the ER and given 2,000 He was intubated in the ER and given 2,000

ml of crystalloid and 2 units of PRBCsml of crystalloid and 2 units of PRBCs

Case #1

nn He is transferred to your SICU. Currently, He is transferred to your SICU. Currently,

his BP is 110/85 and his pulse is 125. He is his BP is 110/85 and his pulse is 125. He is

on the ventilator with the following:on the ventilator with the following:

uu FFIIOO2 2 = 0.8= 0.8

uu PaOPaO22 = 160 mm Hg= 160 mm Hg

uu PaCOPaCO22 = 30 mm Hg= 30 mm Hg

uu pH = 7.20pH = 7.20

uu Base excess = Base excess = -- 21 mEq/L21 mEq/L

Case #1

nn Which of the following statements is false?Which of the following statements is false?

uu His oxygenation is adequateHis oxygenation is adequate

uu He is receiving too much oxygenHe is receiving too much oxygen

uu He is being hyperventilatedHe is being hyperventilated

uu He is acidoticHe is acidotic

uu His circulation is adequateHis circulation is adequate

AA

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DD

EE

NextNext

FIO2 = 0.8, PaO2 = 160 mm Hg

PaCO2 = 30 mm Hg

pH = 7.20, Base excess = - 21 mEq/L

His oxygenation is adequate

nn FFIIOO2 2 = 0.8= 0.8

nn PaOPaO22 = 160 mm Hg= 160 mm Hg

nn Therefore, his Therefore, his P/F (PaOP/F (PaO2/2/FFIIOO22) ratio) ratio is 200, is 200,

which is marginal and corresponds roughly which is marginal and corresponds roughly

with an intrapulmonary shunt of 20%.with an intrapulmonary shunt of 20%.

nn Yet, his arterial oxygen level is adequate Yet, his arterial oxygen level is adequate

and his hemoglobin saturation will be 100%and his hemoglobin saturation will be 100%

Go BackGo Back

He is receiving too much oxygen

nn An 80% FAn 80% FIIOO22 is associated with a high is associated with a high

incidence of pulmonary toxicityincidence of pulmonary toxicity

nn With a With a P/F ratioP/F ratio of 200, he can be safely of 200, he can be safely

turned down to an Fturned down to an FIIOO22 of 0.4, while of 0.4, while

monitoring his pulse oximetermonitoring his pulse oximeter

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He is being hyperventilated

nn PaCOPaCO22 = 30 mm Hg= 30 mm Hg

nn Hyperventilation can be used to decrease Hyperventilation can be used to decrease

intracranial pressure through intracranial pressure through

vasoconstrictionvasoconstriction

nn However, vasoconstriction will produce However, vasoconstriction will produce

ischemiaischemia

nn Hyperventilation can promote pulmonary Hyperventilation can promote pulmonary

injury via barotraumainjury via barotrauma

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He is acidotic

nn pH = 7.20pH = 7.20

nn PaCOPaCO22 = 30 mm Hg= 30 mm Hg

nn Base excess = Base excess = -- 21 mEq/L21 mEq/L

nn Bonus question: What kind of acidosis is Bonus question: What kind of acidosis is

this?this?

uu A metabolic acidosis with an incompletely A metabolic acidosis with an incompletely

compensating respiratory alkalosiscompensating respiratory alkalosis

Go BackGo Back

His circulation is INadequate

nn His base deficit of His base deficit of --21 mEq/L indicates a 21 mEq/L indicates a

severesevere metabolic disordermetabolic disorder

nn Given his history of recent trauma with a Given his history of recent trauma with a

great potential for internal and occult great potential for internal and occult

hemorrhage, circulatory shock from hemorrhage, circulatory shock from

hypovolemia is the most likely culprithypovolemia is the most likely culprit

nn The most likely cause of his hypovolemia is The most likely cause of his hypovolemia is

hemorrhagehemorrhage

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Case #1

nn At this point, you would:At this point, you would:

uu Turn up his FTurn up his FIIOO22

uu Turn down his FiOTurn down his FiO22

uu Increase his minute ventilationIncrease his minute ventilation

uu Decrease his minute ventilationDecrease his minute ventilation

uu Withhold fluids because of the worsening Withhold fluids because of the worsening

pulmonary edemapulmonary edema

uu Administer fluids to treat his impaired Administer fluids to treat his impaired

circulationcirculation

AA

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DD

EE

FF

NextNext

Turn up his FIO2

nn His PaOHis PaO22 is already more than adequate at is already more than adequate at

160 mm Hg160 mm Hg

nn Increasing the FIncreasing the FIIOO22would increase his risks would increase his risks

of oxygen toxicityof oxygen toxicity

uu Pulmonary inflammationPulmonary inflammation

uu Interstitial fibrosisInterstitial fibrosis

uu Seen at FSeen at FIIOO22s above 60%s above 60%

Duration of Survival in Oxygen by

Fraction of Inspired O2 Exposure

0

10

20

30

40

50

60

70

80

0.21

0.26

0.31

0.36

0.41

0.46

0.51

0.56

0.61

0.66

0.71

0.76

0.81

0.86

0.91

0.96

Fraction of Inspired Oxygen

Yea

rs o

f S

urv

ivab

ilit

y

Go BackGo Back

Turn down his FIO2

nn His PaOHis PaO22 is already more than adequate at is already more than adequate at

160 mm Hg.160 mm Hg.

nn His FIOHis FIO22 can be turned down safely to 40%, can be turned down safely to 40%,

using the using the P/F ratioP/F ratio

Go Go BackBack

P/F Ratio

nn PaOPaO22=160 & F=160 & FIIOO22=0.8=0.8

nn PaOPaO22/F/FIIOO22 = 160/0.8 = 200= 160/0.8 = 200

nn If an FIf an FIIOO22 of 0.4 is chosen and 200 = P/F, of 0.4 is chosen and 200 = P/F,

then 200 = PaOthen 200 = PaO22/0.4/0.4

uu PaOPaO22 = 200 x 0.4 = 80= 200 x 0.4 = 80--FF = 80 FF = 80 -- 10 =70mmHg10 =70mmHg

FF just to be safe, we use a just to be safe, we use a ““fudge factorfudge factor”” (FF) of 10(FF) of 10

uu So the PaOSo the PaO22 will be 70 mmHg or better on an will be 70 mmHg or better on an

FFIIOO22 of 0.4of 0.4

FF (You(You’’ll win more of these bets than youll win more of these bets than you’’ll lose)ll lose)

FF Monitor change with pulse oximetryMonitor change with pulse oximetry

Go Go BackBack

Increase his minute ventilation

nn Minute ventilation = tidal volume x respiratory Minute ventilation = tidal volume x respiratory

raterate

nn The PaCOThe PaCO22 of 30 mm Hg indicates an excessive of 30 mm Hg indicates an excessive

minute ventilationminute ventilation

uu Normal PaCONormal PaCO22 = 40 mm Hg= 40 mm Hg

nn Increasing the Increasing the minute ventilationminute ventilation would lower his would lower his

PaCOPaCO22 even further, resulting in:even further, resulting in:

uu Further inhibition of spontaneous respiratory effortsFurther inhibition of spontaneous respiratory efforts

uu Cerebral vasoconstrictionCerebral vasoconstriction

Go Go BackBack

Decrease his minute ventilation

nn Minute ventilationMinute ventilation = tidal volume x respiratory = tidal volume x respiratory

raterate

nn The PaCOThe PaCO22 of 30 mm Hg indicates an excessive of 30 mm Hg indicates an excessive

minute ventilationminute ventilation

uu Normal PaCONormal PaCO22 = 40 mm Hg= 40 mm Hg

nn His His minute ventilationminute ventilation should be decreasedshould be decreased

Go BackGo Back

Adjusting Minute Ventilation to

Normalize PaCO2

Vco2 = VA x Fco2

. .

Vco2 ~ VA x Paco2. .

Assuming that the minute ventilation is 12 L/min

and the Paco2 is 30 mmHg:

Vco2 ~ 12 x 30 = 360.

To achieve a PaCO2 of 40 mmHg:

Vco2 ~ 360 = VA x Paco2 = VA x 40 = 9 x 40. . .

Thus, a minute ventilation of 9 L/min will produce a

Paco2 of 40 mmHgGo BackGo Back

How do you adjust the minute

ventilation?

nn Alveolar minute ventilation is the product of Alveolar minute ventilation is the product of

respiratory rate times the alveolar ventilation, which is, respiratory rate times the alveolar ventilation, which is,

in turn, the total ventilation minus the dead space in turn, the total ventilation minus the dead space

ventilationventilation

nn Assuming no change in dead space, alveolar ventilation Assuming no change in dead space, alveolar ventilation

is changed by adjusting the rate or the tidal volumeis changed by adjusting the rate or the tidal volume

nn If there is no problem with inflation pressures, If there is no problem with inflation pressures,

adjusting the rate will maintain alveolar inflationadjusting the rate will maintain alveolar inflation

nn If inflation pressures are excessive, tidal volume can be If inflation pressures are excessive, tidal volume can be

alteredaltered

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Withhold fluids because of the

worsening pulmonary edema

nn His P/F ratio of 200 reflects an His P/F ratio of 200 reflects an

intrapulmonary shunt of about 20%intrapulmonary shunt of about 20%

nn Pulmonary edema from aspiration and Pulmonary edema from aspiration and

pulmonary contusion is likely responsible pulmonary contusion is likely responsible

for this shuntfor this shunt

nn The edema is therefore more likely from an The edema is therefore more likely from an

altered permeability in the pulmonary altered permeability in the pulmonary

microcirculation rather than an elevated microcirculation rather than an elevated

pulmonary hydrostatic pressurepulmonary hydrostatic pressure

Go BackGo Back

Administer fluids to treat his impaired

circulation

nn His severe base deficit identifies a profound His severe base deficit identifies a profound

metabolic acidosismetabolic acidosis

nn The most likely cause for the metabolic The most likely cause for the metabolic

acidosis in this scenario would be the acidosis in this scenario would be the

development of anaerobic metabolism from development of anaerobic metabolism from

tissue hypoperfusiontissue hypoperfusion

nn The most likely cause for the hypoperfusion The most likely cause for the hypoperfusion

in this situation would be hypovolemia from in this situation would be hypovolemia from

hemorrhagehemorrhage

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Management of Hemorrhage

nn The tachycardia and narrowed pulse The tachycardia and narrowed pulse

pressure also suggest hypovolemia, being pressure also suggest hypovolemia, being

consistent with a consistent with a Class II hemorrhageClass II hemorrhage

nn As such, aggressive volume replacement is As such, aggressive volume replacement is

appropriate initiallyappropriate initially

nn However, excessive fluid may be harmfulHowever, excessive fluid may be harmful

nn Therefore, a cutTherefore, a cut--off threshold should be off threshold should be

established, over which level confirmation established, over which level confirmation

of hypovolemia should be obtain prior to of hypovolemia should be obtain prior to

administering further volumeadministering further volumeGo BackGo Back

Classes of hemorrhage - Class I

B lood Loss (m l) <750

B lood Loss (% BV ) <15%

Pulse R ate <100

B lood Pressure N orm al

Pulse Pressure N orm al

C apillary R efill N orm al

R espiratory R ate 14-20

U rine O utput (m l/hr) >30

CN S, M ental Status Slightly anxious

Classes of hemorrhage - Class I

Blood Loss (ml) <750

Blood Loss (%BV) <15%

Pulse Rate <100

Blood Pressure Normal

Pulse Pressure Normal

Capillary Refill Normal

Respiratory Rate 14-20

Urine Output (ml/hr) >30

CNS, Mental Status Slightly anxious

Fluid Replacement

(3:1 Rule)

Crystalloid

Total Body Weight

Total Body Water (60%)Total Body

Water=60% of

Body Weight

Body Fluid Compartments

Dry Weight (40%)

Intracellular Fluid (40%)

Extracellular Fluid (20%)ECF=

20% Body

Wt.Interstitial Fluid (15%)

Blood Volume (5%)

Classes of hemorrhage - Class II

Blood Loss (ml) 750-1,500

Blood Loss (%BV) 15-30%

Pulse Rate >100


Pulse Pressure Narrowed

Capillary Refill Diminished


Urine Output (ml/hr) 20-30

CNS, Mental Status Mildly anxious

Classes of hemorrhage - Class II

Blood Loss (ml) 750-1,500


Pulse Rate >100






CNS, Mental Status Mildly anxious

Fluid Replacement

(3:1 Rule)

Crystalloid

Classes of hemorrhage - Class III

Blood Loss (ml) 1,500-2,000


Pulse Rate >120

Blood Pressure Decreased





CNS, Mental Status Anxious and Confused

Classes of hemorrhage - Class III

Blood Loss (ml) 1,500-2,000


Pulse Rate >120






CNS, Mental Status Anxious and Confused

Fluid Replacement

(3:1 Rule)

Crystalloid + Blood

Classes of hemorrhage - Class IV

Blood Loss (ml) >2,000

Blood Loss (%BV) >40%

Pulse Rate >140




Respiratory Rate >35

Urine Output (ml/hr) Negligible

CNS, Mental Status Confused, lethargic

Classes of hemorrhage - Class IV

Blood Loss (ml) >2,000

Blood Loss (%BV) >40%

Pulse Rate >140




Respiratory Rate >35

Urine Output (ml/hr) Negligible

CNS, Mental Status Confused, lethargic

Fluid Replacement

(3:1 Rule)

Crystalloid + blood +

immediate surgery

Classes of hemorrhage (as defined by the

Committee on Trauma of the American College of Surgeons)

Clinical Finding Class I Class II Class III Class IV

Blood Loss (ml) <750 750-1,500 1,500-2,000 >2,000

Blood Loss (%BV) <15% 15-30% 30-40% >40%

Pulse Rate <100 >100 >120 >140

Blood Pressure Normal Normal Decreased Decreased

Pulse Pressure Normal Narrowed Narrowed Narrowed

Capillary Refill Normal Diminished Diminished Diminished

Respiratory Rate 14-20 20-30 30-40 >35

Urine Output (ml/hr) >30 20-30 5-15 Negligible

CNS, Mental Status Slightly anxious Mildly anxious

Anxious

and

Confused

Confused,

lethargic

Fluid Replacement

(3:1 Rule)Crystalloid Crystalloid

Crystalloid

+ Blood

Crystalloid

+ blood +

immediate

surgeryGo BackGo Back

Case #1

nn You turn down the FYou turn down the FIIOO22, decrease the , decrease the

ventilatory rate, and administer IV fluids in ventilatory rate, and administer IV fluids in

the form of blood and crystalloidthe form of blood and crystalloid

nn After a total of 8 liters of fluid, his pulse is After a total of 8 liters of fluid, his pulse is

still 115/min, his BP is 115/85, and his still 115/min, his BP is 115/85, and his

urine output is <30 ml/minurine output is <30 ml/min

Case #1


uu Give more fluidGive more fluid

uu Give Lasix (furosemide) to stimulate a urine Give Lasix (furosemide) to stimulate a urine

outputoutput

uu Get a nephrology consultGet a nephrology consult

uu Place a pulmonary artery catheterPlace a pulmonary artery catheter

AA

BB

CC

DD

NextNext

Give more fluid

nn While it is still quite likely the patient is While it is still quite likely the patient is

hypovolemic, he has received a significant amount hypovolemic, he has received a significant amount

of fluid thus farof fluid thus far

nn Given his severe pulmonary injuries, it could be Given his severe pulmonary injuries, it could be

harmful to administer fluids indiscriminatelyharmful to administer fluids indiscriminately

uu Other conditions, such as myocardial contusion, Other conditions, such as myocardial contusion,

could be at fault instead of pure hypovolemiacould be at fault instead of pure hypovolemia

nn It would be best to determine more definitively the It would be best to determine more definitively the

presence and degree of any hypovolemiapresence and degree of any hypovolemia

Go BackGo Back

Give Lasix (furosemide) to stimulate a

urine output

nn The patient is oliguric, loop diuretics like The patient is oliguric, loop diuretics like

furosemide can produce more urinefurosemide can produce more urine

nn However, such diuretics do not improve renal However, such diuretics do not improve renal

perfusion, prevent acute renal failure, or change perfusion, prevent acute renal failure, or change

the mortality of acute renal failurethe mortality of acute renal failure

uu Controversy exists over whether they facilitate fluid Controversy exists over whether they facilitate fluid

management by maintaining a diuresismanagement by maintaining a diuresis

nn If the patient is oliguric from hypovolemia, If the patient is oliguric from hypovolemia,

diuretics are diuretics are CONTRAINDICATED!CONTRAINDICATED!

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Get a nephrology consult

nn Although the patient may ultimately develop acute Although the patient may ultimately develop acute

renal failure and require dialysis, he does not have renal failure and require dialysis, he does not have

renal failure at this timerenal failure at this time

nn His kidneys are responding to a period of severe His kidneys are responding to a period of severe

hypoperfusionhypoperfusion

uu They have evolved to preserve circulating volume at the They have evolved to preserve circulating volume at the

expense of building up metabolic wasteexpense of building up metabolic waste

nn Aggressive and effective resuscitation of renal Aggressive and effective resuscitation of renal

perfusion will often reverse the oliguric renal perfusion will often reverse the oliguric renal

responseresponse

Go BackGo Back

Place a pulmonary artery catheter

nn This patient now represents a dilemma in that he This patient now represents a dilemma in that he

has received a significant amount of volume but has received a significant amount of volume but

remains oliguricremains oliguric

nn The presence and degree of hypovolemia should The presence and degree of hypovolemia should

be confirmed with a pulmonary artery catheter to be confirmed with a pulmonary artery catheter to

resolve any questions regarding the etiology of his resolve any questions regarding the etiology of his

hypoperfusion (i.e., hypovolemia vs. pump hypoperfusion (i.e., hypovolemia vs. pump

failure)failure)

Go BackGo Back

Case #1

nn You place a pulmonary artery catheter and You place a pulmonary artery catheter and

determine the following:determine the following:

uu Pulmonary capillary wedge pressure (PCWP) = Pulmonary capillary wedge pressure (PCWP) =

7 mm Hg7 mm Hg

uu Cardiac output (CO) = 3.2 L/minCardiac output (CO) = 3.2 L/min

uu Mixed venous saturation (SMixed venous saturation (SvvOO22) = 58%) = 58%

uu Central venous pressure (CVP) = 3 cm HCentral venous pressure (CVP) = 3 cm H22OO

Case #1


uu Give more fluidGive more fluid

uu Give Lasix (furosemide) to stimulate a urine Give Lasix (furosemide) to stimulate a urine

outputoutput

uu Get a cardiology consultGet a cardiology consult

uu Check a hemoglobin levelCheck a hemoglobin level

AA

BB

CC

DD

PCWP = 7 mm Hg; CO = 3.2 L/min;

SvO2 = 58%; CVP = 3 cm H2O

NextNext

Give more fluid

nn This patientThis patient’’s low Ss low SVVOO22 confirms the confirms the

presence of a severe hypoperfusionpresence of a severe hypoperfusion

nn The low PCWP indicates that hypovolemia The low PCWP indicates that hypovolemia

is at fault, contributing to the low cardiac is at fault, contributing to the low cardiac

outputoutput

nn More fluid is warranted, administering it More fluid is warranted, administering it

rapidly to correct the perfusion deficit as rapidly to correct the perfusion deficit as

rapidly as possible, but titrating it carefully rapidly as possible, but titrating it carefully

against the hemodynamics and Sagainst the hemodynamics and SvvOO22

Go BackGo Back

Give Lasix (furosemide) to stimulate a

urine output

�� Furosemide could actually produce more Furosemide could actually produce more

urine, even in this individualurine, even in this individual

��However, it will not improve his renal function However, it will not improve his renal function

(i.e., GFR), and(i.e., GFR), and

��There is no commercial market for human urineThere is no commercial market for human urine

�� Given his confirmed hypovolemic state, Given his confirmed hypovolemic state,

loop diuretics are loop diuretics are

CONTRAINDICATED!CONTRAINDICATED!

Go BackGo Back

Get a cardiology consult

�� The patient does have a low cardiac output, The patient does have a low cardiac output,

possibly from myocardial contusionpossibly from myocardial contusion

�� However, given his hypovolemic state, it is However, given his hypovolemic state, it is

difficult to determine if there is any functional difficult to determine if there is any functional

impairment of myocardial performance until impairment of myocardial performance until

the volume deficit has been correctedthe volume deficit has been corrected

�� Indeed, the low filling pressures speak against Indeed, the low filling pressures speak against

any significant myocardial dysfunctionany significant myocardial dysfunction

Go BackGo Back

Check a hemoglobin level

�� In all likelihood, this patient has already had In all likelihood, this patient has already had

numerous hemoglobin levels obtained as a numerous hemoglobin levels obtained as a

matter of routinematter of routine

��Hgb probably low due to bleeding and dilution Hgb probably low due to bleeding and dilution

by crystalloidsby crystalloids

�� However, this is the However, this is the appropriateappropriate time to time to

determine the hemoglobin, given the determine the hemoglobin, given the

hypovolemia and evidence of impaired hypovolemia and evidence of impaired

organ oxygen deliveryorgan oxygen delivery

Go BackGo Back

Case #2

�� A 65A 65--year old female underwent an year old female underwent an

emergency sigmoid resection and emergency sigmoid resection and

colostomy formation 6 days ago for a colostomy formation 6 days ago for a

perforated diverticulumperforated diverticulum

�� She has been unable to be extubated due to She has been unable to be extubated due to

her weak ventilatory effortsher weak ventilatory efforts

�� The nurse calls you at 1 in the morning to The nurse calls you at 1 in the morning to

tell you the patienttell you the patient’’s temperature is 39.2s temperature is 39.2°°CC

AA

BB

CC

DD

Case #2

�� At this point, you should:At this point, you should:

��Tell the nurse to obtain urine, sputum, and Tell the nurse to obtain urine, sputum, and blood culturesblood cultures

��Tell the nurse to give the patient a Tylenol Tell the nurse to give the patient a Tylenol (acetaminophen) suppository(acetaminophen) suppository

��Examine the patientExamine the patient

��Start broadStart broad--spectrum antibioticsspectrum antibiotics

NextNext

Tell the nurse to obtain urine, sputum,

and blood cultures

�� Unfortunately, this has become the Unfortunately, this has become the ““kneeknee--

jerkjerk”” response for many housestaffresponse for many housestaff

�� While culture data may be necessary, it is While culture data may be necessary, it is

sometimes not needed and is often not the sometimes not needed and is often not the

most efficient way to evaluate a fevermost efficient way to evaluate a fever

�� Cultures should not be obtained unless they Cultures should not be obtained unless they

are guided by a pertinent physical are guided by a pertinent physical

examinationexamination

Go BackGo Back

Tell the nurse to give the patient a

Tylenol (acetaminophen) suppository

�� This degree of temperature elevation is This degree of temperature elevation is

indeed worrisomeindeed worrisome

�� Increased metabolic demandIncreased metabolic demand

�� Compromises circulatory effectivenessCompromises circulatory effectiveness

��Potential for seizuresPotential for seizures

�� Further increases metabolic demandFurther increases metabolic demand

•• Further compromises circulatory effectivenessFurther compromises circulatory effectiveness

�� If it is safe to do so from a surgical If it is safe to do so from a surgical

standpoint, an acetaminophen suppository standpoint, an acetaminophen suppository

could reduce the febrile stresscould reduce the febrile stressGo BackGo Back

Examine the patient

�� This is absolutely keyThis is absolutely key

�� Central to the physicianCentral to the physician’’s roles role

�� The most costThe most cost--effective way of determining effective way of determining

the potential significance and source of any the potential significance and source of any

feverfever

�� Based upon the examination, a decision for Based upon the examination, a decision for

specific studies (U/A, sputum Gram stain, specific studies (U/A, sputum Gram stain,

CXR, lumbar puncture, CT scans, etc.) can CXR, lumbar puncture, CT scans, etc.) can

be made. Cultures may be helpful.be made. Cultures may be helpful.Go BackGo Back

Start broad-spectrum antibiotics

�� Antibiotics are therapeutic only when there is an Antibiotics are therapeutic only when there is an actual infectionactual infection

�� Not all postoperative fevers represent infectionNot all postoperative fevers represent infection

�� Antibiotics started before obtaining appropriate Antibiotics started before obtaining appropriate cultures are likely to compromise the ability to cultures are likely to compromise the ability to culture susceptible organismsculture susceptible organisms

�� An examination of the patient should be An examination of the patient should be performed first. Antibiotics are started after a performed first. Antibiotics are started after a presumptive diagnosis of an infection is made and presumptive diagnosis of an infection is made and after appropriate cultures have been obtainedafter appropriate cultures have been obtained

Go BackGo Back

AA

BB

CC

DD

Case #2

�� Which of the following infections is not Which of the following infections is not

very likely in this patient?very likely in this patient?

�� IntraIntra--abdominal abscessabdominal abscess

��MeningitisMeningitis

��SinusitisSinusitis

��CholecystitisCholecystitis

��PneumoniaPneumoniaEE

NextNext

Intra-abdominal abscess

�� Because of the patientBecause of the patient’’s recent history of s recent history of

surgery for perforated diverticulitis, the surgery for perforated diverticulitis, the

likelihood of an intralikelihood of an intra--abdominal abscess is abdominal abscess is

very highvery high

�� She has probably been on antibiotics for She has probably been on antibiotics for

peritonitis since the time of surgeryperitonitis since the time of surgery

�� A febrile response could indicate the A febrile response could indicate the

presence of undrained puspresence of undrained pus

�� An abdominal CT scan is warrantedAn abdominal CT scan is warrantedGo BackGo Back

Meningitis

�� Although possible, meningitis is not very Although possible, meningitis is not very

likely given the lack of any history of likely given the lack of any history of

violation of the cranial or spinal barriers to violation of the cranial or spinal barriers to

infectioninfection

�� However, should other more likely sources However, should other more likely sources

of sepsis prove negative, meningitis and of sepsis prove negative, meningitis and

other less likely infections should be other less likely infections should be

considered and investigatedconsidered and investigated

Go BackGo Back

Sinusitis

�� Critically ill patients not infrequently Critically ill patients not infrequently

develop sinusitis, particularly those with develop sinusitis, particularly those with

nasogastric or other nasallynasogastric or other nasally--placed cathetersplaced catheters

�� If this patient has had nasal tubes in place If this patient has had nasal tubes in place

for more than a brief period, the presence of for more than a brief period, the presence of

sinusitis should be investigatedsinusitis should be investigated

��Sinus films (can be portable)Sinus films (can be portable)

��CT scan (more definitive)CT scan (more definitive)

��Exploratory sinus aspirationExploratory sinus aspiration

Go BackGo Back

Cholecystitis

�� Critically ill and injured patients who go for Critically ill and injured patients who go for

days without eating can develop acalculous days without eating can develop acalculous

cholecystitis, presumably from stasis of bile cholecystitis, presumably from stasis of bile

and sludge within an inactive gallbladderand sludge within an inactive gallbladder

�� Evaluation can be done with Evaluation can be done with

ultrasonography or HIDA radionuclide ultrasonography or HIDA radionuclide

scanningscanning

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Pneumonia

�� Because of the patientBecause of the patient’’s prolonged s prolonged

endotracheal intubation, she has a high endotracheal intubation, she has a high

likelihood of having developed pneumonialikelihood of having developed pneumonia

��100% of those intubated for more than 48 hours 100% of those intubated for more than 48 hours

have a have a colonizedcolonized tracheatrachea

�� Evaluation should consist of a chest Xray, Evaluation should consist of a chest Xray,

sputum Gram stain to look for WBCs and sputum Gram stain to look for WBCs and

organisms, and a sputum C&Sorganisms, and a sputum C&S

�� GramGram--negative pneumoniasnegative pneumonias tend to tend to

predominate (60predominate (60--85%)85%)Go BackGo Back

Differences between colonization and

infection

�� InflammationInflammation

��Presence of an inflammatory cellular infiltratePresence of an inflammatory cellular infiltrate

�� ColonizationColonization

��Presence of bacteria on surfacesPresence of bacteria on surfaces

�� InfectionInfection

��Presence of bacteria in tissuePresence of bacteria in tissue

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Host Resistance Mechanisms Preventing

Pneumonia

Gag reflex

Mucociliary transport

Cough reflex

Alveolar macrophages

High acid content

Glottic closure

with swallowing

Gravity

Peristalsis

Competent LES

Gastric emptying


Pneumonia

Gag reflex

Mucociliary transport

Cough reflex

High acid content

Glottic closure

with swallowing

Gravity

Peristalsis

Competent LES


Pneumonia

Gag reflex

Mucociliary transportCough reflex

High acid content

Glottic closure with

swallowing Gravity Peristalsis Competent LES


Pneumonia

Gag reflex


High acid content


swallowing Peristalsis Competent LES


Pneumonia

Gag reflex


High acid content


swallowing


Pneumonia

High acid content


Pneumonia

Aha!

Let’s Go!


Pneumonia

Charge!!!

Yes!


Pneumonia

Gotcha!

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Summary

�� Critically ill surgical patients (either preCritically ill surgical patients (either pre-- or or

postpost--op) present challenging physiological op) present challenging physiological

problemsproblems

�� Multiple organ systems must be monitored Multiple organ systems must be monitored

and their function must be preserved in and their function must be preserved in

order to enhance the chances for survival order to enhance the chances for survival

and reduce the opportunity for and reduce the opportunity for

complications and financial lossescomplications and financial losses

to get them out of the sicu! - loyola university chicago...care of the patient in the surgical...

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