1 / 26

Management of Critical Perioperative Patients

Management of Critical Perioperative Patients. Christiana Weng, M.D. Surgical Registrar. Objectives. Learn the ICU resident responsibilities Maximize fluid resuscitation Recognize post-op complications promptly Initiate appropriate post-op complication managment. Your responsibilities.

lalaine
Télécharger la présentation

Management of Critical Perioperative Patients

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of Critical Perioperative Patients Christiana Weng, M.D. Surgical Registrar

  2. Objectives • Learn the ICU resident responsibilities • Maximize fluid resuscitation • Recognize post-op complications promptly • Initiate appropriate post-op complication managment

  3. Your responsibilities • Admit surgical ICU patients • From ER, OR, or the floor • Take sign-outs from the surgeons • Admit to ICU/IMCU accordingly • Delegate post-op check if floor patient • Assign resident surgical assistance

  4. A real case.. • “Doctor, my post-op patient has had no urine output for the last 4 hours. Should we give her some Lasix?” • What do you say?

  5. Fluid Management Fluid Good. Lasix Bad.

  6. Resuscitation Fluids • Crystalloid- NS and LR boluses • Colloid- • Hespan-max 1500ml/day • Impairs platelet function • Be ware of DIC, thrombocytopenia, bleeding patients • Albumin

  7. Fluid Resuscitation • Colloid is not better than crystalloid. • Give enough NS/LR before giving Hespan. • Must give back all volume lost to NGT, drains, open wounds, etc. • Usually give at least 3+ liters of fluid before using pressors.

  8. Action plan • Go see the patient! • Gather pertinent history • Perform a focused exam • Gather data • Think! DDx, your plan • Call appropriate consultants

  9. Go See the Patient! • 54yo female with DM2, HTN; charge nurse at the jail by profession • Temp 102.4, BP 108/64, HR 138, RR28, O2Sat 94% on 2L • Patient moaning in pain, not answering questions, breathing hard.

  10. Gather pertinent history • What surgery did they have? • How has the post-op course been?

  11. More history.. • POD #1 lap chole, enterotomy repair by small bowel resection with primary anastomosis, liver biopsy x3 • Persistent nausea post-op • On PCA but abd pain 10/10 • Was 98% on 2L at the beginning of shift; now 94% on 2L

  12. Perform a Focused Exam • Altered mental status? • Arrhythmia? Weak pulses? • Unequal breath sounds? Crackles? • Acute abdomen? • Cold extremity with unequal pulses? • Wounds and drains • Succus entericus? Blood? Acsitic fluid?

  13. On exam • Tachycardic but regular rhythm • Decreased breath sound left lower lobe • Abd distended with absent bowel sound • Patient moans with each percussion • Fascia intact, dressing clean • Foley with 50ml dark yellow urine

  14. Gather data • Vitals – UOP, temp, CVP, BP, HR, O2Sat • Drain quantity • Labs- hgb drop, lactic acid • ABG • Abdominal compartment pressure • KUB or CXR What would you order on this patient?

  15. Labs came back • Cr 1.3 (was 0.9) • BiCarb 19 (was 26) • Total bili 1.6 (was 0.9); direct bili 0.6 • WBC 2.9 (was 6.1) • Hgb 12.6 (was 12.3) • Lactic acid 4.7 • 7.38/37/61/21/91% • Abdominal compartment pressure 25

  16. KUB

  17. CXR

  18. Think! • Think about the surgery/procedure and everything that could go wrong. • You won’t find the cause if you don’t think of it. • A good plan of action depends on a good list of differential.

  19. Differential Diagnosis • Shock- hypovolemic, septic, cardiogenic • Dehiscence/evisceration • Abd or limb compartment syndrome • Neurovascular injury • PE/DVT • Pneumothorax • MI/Stroke

  20. Septic Shock • Overwhelming infection = vasodilation • Bowel perforation? Anastomotic leak? • Any pus under pressure • Intra-abdominal abscesses, psoas abscesses, epidural abscesses, obstructing kidney stone • Aspiration pneumonia or urosepsis? • Broaden empiric abx coverage

  21. Fascial dehiscence/Evisceration • Tell-tale sign: dressing drenched with ascitic fluid • Malnurished, obese, immunosuppressed • Yes, that’s 90% of our patients! • Check and feel for the integrity of the midline incision • If eviscerating… • Cover eviscerated bowel with wet gauze • Call the surgeon right away

  22. Abdominal compartment syndrome • Tell tale signs: progressive oligurea, tense abdomen, increased respiratory distress • Ex-lap patients, cirrhotics, malnurished • Measure IAP by connecting a foley to the CVP monitor • Abnormal if >20cm H2O • Dangerous if >30cm H2O

  23. Abd Compartment Syndrome • Treatment: Decompression • Remove the wound vacuum suction • Drain the ascites (repeat if necessary) • Surgically

  24. Limb Compartment Syndrome • Tell tale signs: weak or absent pulses, blue or dusky limb, tense, extreme tenderness • Release all external pressure • Call the orthopod for emergent fasciotomy

  25. Back to our patient… • Worsening septic shock suspected based on AMS, low WBC, and peritoneal signs • DDx: PE, unrecognized enterotomy, anastomotic leak, early intra-abd abscess, occult intra-abd bleeding, bile peritonitis • Stat chest CT negative for PE • Surgeon was called and patient taken back to OR emergently • An enterotomy was found and repaired

  26. Bottom Line… • Aggressive fluid resuscitation • Lasix bad. Fluids good. • Adequate resuscitation= when you see pee. • Really examine your patient. • Think, then you’ll know what to do.

More Related