Surgical Issues in Critical Care Medicine Revised 2009 by Dorothy W. Bird, MD Suresh Agarwal, MD, FACS Department of Surgery Boston University Medical Center Based on the original presentation created by: N.K. Durrani, MD; M. McCann, DO; M.M. Brandt, MD, FACS, FCCM; P. Patton, MD, FACS; H.M. Horst, MD, FACS, FCCM; I. Rubinfeld, MD Dept. of Trauma Surgery Henry Ford Hospital, Detroit
Surgical Complications • Airway: airway loss and emergent management • Pulmonary: simple and tension pneumothorax • Cardiac: tamponade • GI: abdominal pain, ileus, ischemia, abdominal compartment syndrome, GI bleeding • Extremities: vascular occlusion syndromes, compartment syndrome
Surgical Airways • Only reason not to intubate is inability to do so, nonsurgical always preferred: i.e., orotracheal, nasotracheal • Relative contraindications to intubation • C-spine instability • Midface fractures • Laryngeal disruption • Obstruction of lumen
Emergent Surgical Airway • Needle cricothyroidotomy: • 12-14G Angiocath +syringe • Hyperextend neck • Palpate cricothyroid membrone • Apply Betadyne, Lidocaine • Advance needle at 45o angle until air is aspirated • Advance catheter, remove needle, attach hub to 3-mm ET adapter and oxygen • Only useful for 45min due to poor CO2 exchange!
Emergent Surgical Airway • Cricothyroidotomy • Hyperextend neck • Palpate cricothyoid membrane • Apply Betadyne, Lidocaine • 3-4cm midline vertical incision through cervical fascia and strap muscles • Incise cricothyroid membrane horizontally; use hemostat to hold open • Insert 5-7mm tracheostomy tube (or ET tube), attach to oxygen supply • Convert to formal tracheostomy in 24h!
Surgical Airway • Tracheostomy: Rarely for emergencies • Usually for ventilator weaning • Many techniques (percutaneous, surgical) • Emergency Indications: • Laryngeal crush injury • Fracture of thyroid or cricoid membranes • Very small children
Airway Emergency: Massive Hemoptysis • Due to pulmonary, bronchial, or innominate artery injury/disease • Results from erosion (slow, with herald bleed) or iatrogenic (tracheostomy, trauma) • Bronchoscopy to determine source • Bronchial blocker for isolation • Angiography: embolize bleeding source • Emergent lobectomy or sternotomy if uncontrolled trachea Innominate a.
Tracheoinnominate Artery Fistula • Dreaded complication of tracheostomy (1%) • Due to: • Erosion of the artery by tracheostomy tube or • High pressure cuff directly injurs artery • Temporize by: • Insert endotracheal tube into tracheostomy stoma, inflate cuff • Apply downward, outward tamponade to fistula with finger in tracheostomy stoma
Surgical Pulmonary Emergencies • Pneumothorax (simple): partial or complete collapse —increases pulmonary shunt • Chest tube in emergency • Attempt catheters as well • Treat “conservatively” in stable asymptomatic patients • Aggressive therapy if on positive pressure • Can progress to tension pneumothorax
Tension Pneumothorax • True Surgical Emergency! • Signs: • Decreased breath sounds • Ipsilateral tympany • Tracheal shift • Distended neck veins • Asymmetric chest expansion • Hypotension • CXR: mediastinal shift • Emergent decompression • Chest tube • Temporary needle decompression Tracheal shift pneumothorax
Chest Tube Insertion • Sterile prep and drape • +/- Local anesthesia- 1% lidocaine to pleura • 2-3cm incision at midaxillary line, 5th intercostal space • Blunt dissection with finger/clamp to pleura • Listen/feel for gush of air exiting pleural space • Insert 36F chest tube apically, posteriorly; secure with suture, occlusive dressing • Attach distal end of tube to suction (-20cm water) with water seal
Hemothorax • Surgical Indications: • Massive hemothorax = >1500mL immediate return of blood on tube thoracostomy • Persistent hemothorax = 300mL/h x 3hours • >1500mL blood/24h • Chest tube with massive air drainage, or GI contents
Cardiac Tamponade • Blood in pericardial space, compresses heart • Beck’s triad: hypotension, jugular venous distension, distant heart sounds • Echocardiogram: impaired diastolic filling • Treatment: needle decompression or pericardial window • Image from: http://upennanesthesiology.typepad.com/photos/uncategorized/2007/07/26/tamponade2_b_milas.jpg Fluid in pericardial space
Abdominal Pain • Abdominal pain syndromes in the ICU: • Pancreatitis • Acalculous cholecystitis • Bowel ischemia • Bowel obstructive syndromes
Pancreatitis • Epigastric/upper quadrant pain, radiates to back • + Nausea, vomiting, fever • ICU Etiology: • Medications: furosemide, thiazide diuretics, metronidazole, bactrim, ACE-inhibitors, many others • EtOH, gallstones, ERCP, trauma • Hyperlipidemia (triglycerides >1,000mg/dl), hypercalcemia
Pancreatitis • Mortality predicted by Ranson Criteria: • Score 0 to 2 : 2% mortality • Score 3 to 4 : 15% mortality • Score 5 to 6 : 40% mortality • Score 7 to 8 : 100% mortality • Management • NPO, IVF, antibiotics if infection or gall stones • Treat underlying cause • Surgery only for infected necrosis
Acalculous Cholecystitis • 5% -10% of all cases of acute cholecystitis • Observed in the setting of very ill patients, especially trauma and burn victims, also long-term TPN (>3 months) • Signs/Symptoms: RUQ pain, fever, leukocytosis • Diagnosis: CT or US: pericholecystic fluid, NO STONES • Etiology: unclear; stasis vs ischemia • Higher incidence of gangrene and perforation compared to calculous disease, greater mortality (40%) • Management: IV fluid, IV antibiotics, emergent cholecystectomy (or cholecystotomy if surgical risk is high and risk of perforation is low)
Bowel Ischemia • Etiology: • ICU patients: Nonocclusive mesenteric ischemia (NOMI) -splanchnic low flow and/or vasoconstriction • Seen in hemodynamically unstable patients • Decreased CO, hypovolemia, vasoconstrictor medications • General population: mesenteric arterial embolus, mesenteric arterial thrombus, mesenteric venous thrombus • NOMI Signs: Abdominal pain, leukocytosis, GI mucosal sloughing, bleeding • NOMI Diagnosis: Angiography • NOMI Treatment: optimize volume status, relieve splanchnic vasocontriction; selective intraarterial vasodilators (papaverine, glucagon)
Bowel Obstruction • Mechanical • Gut lumen is blocked due to foreign body, tumor, intussusception, adhesions; partial vs complete • Open loop obstruction: amenable to proximal decompression; use NG tube • Closed loop obstruction: inflow and outflow blocked: hernia incarceration, torsion around adhesive band, volvulus; surgical emergency! • Functional (neurogenic) • Ileus (small bowel): +/-NG tube, judicious narcotic use • Olgvie’s pseudoobstruction (large bowel): neostigmine +/- colonoscopic decompression if cecum>10-12cm or if symptomatic >48h; correct electrolytes, reduce narcotics, NG tube
Abdominal Compartment Syndrome • Acute increase in intra-abdominal pressure with resultant critical organ dysfunction • Seen in trauma patients after laparoptomy, non-operative hepatic or renal trauma victims, burn victims, any patient who receives large-volume resuscitation
Abdominal Compartment Syndrome • Consequences of elevated intraabominal pressure: • decreases ventilation→ hypoxia, acidosis • reduces venous return →decreased cardiac output • venous congestion → reduced capillary perfusion, ischemia, inflammation • decreased blood flow to kidney →oliguia, renal failure • decreased blood flow to liver, gut →impaired function • Early recognition and diagnosis are vital to prevent complications! • Identify those at risk, measure baseline IAP!
Abdominal Compartment Syndrome • Clinical triad: • Tense, distended abdomen • Increased airway pressures • Oliguira (despite ample resuscitation) • Diagnosis: Bladder pressure • Surrogate for intraabdominal pressure • Bladder filled with 50 cc of sterile saline via Foley and pressure monitor connected to side port with 18-gauge needle
Abdominal Compartment Syndrome • Intraabdominal pressure (IAP) • Normal: <10mm Hg • Intraabdominal hypertension (IAH): ≥12mmHg • Abdominal compartment syndrome (ACS): ≥20mmHg with new organ dysfunction • WSACS IAP Grading: • I12-15mmHg • II16-20mmHg • III21-25mmHg • IV>25mmHg
Abdominal Compartment Syndrome • Management: • Prevention! Judicious resuscitation! • Neuromuscular blockade • Diuresis (only with hemodynamic monitoring) • Catheter drainage: bedside ultrasound to guide catheter drainage of intraabdominal fluid • Decompressive laparotomy- definitive • Abdominal fascia left open, often with VAC or Bogota bag covering wound • Delayed primary closure
Upper GI Bleeding • Gastric (ulcer vs. gastritis) • Duodenal • Esophageal varices • Mallory-Weiss
Upper GI Bleeding • Immediately: • 2 large-bore peripheral IVs • 2 L crystalloid • STAT labs: CBC, PT/PTT, Type & screen • NGT, gastric lavage • Foley catheter • Consider central line (CVP) or Swan catheter
Upper GI Bleeding • Management • PPI, H2-blocker • EGD • Arteriography • Treat Varices: vasopressin, octreotide, sclerotherapy, Sengstaken-Blakemore tube, TIPS • Operative intervention if bleeding remains uncontrolled
Mallory-Weiss tear • UGI bleeding after violent emesis • Gastric mucosal tear at cardia • Typically (not always) in alcoholic patients • Usually stops spontaneously • May attempt Blakemore tube using gastric balloon for direct pressure. • Nonoperative treatment: endoscopic electrocoagulation, banding, injection • Operative intervention rarely needed: oversew laceration
Lower GI Bleeding • Most arise from the colon and rectum • Large bowel etiologies: diverticula, angiodysplastic lesions, neoplasms, IBD, hemorrhoids, and anal fissures • Small bowel etiologies: neoplasm, IBD, Meckel’s diverticulum
Lower GI Bleeding • Initial management: as for upper GI bleeding • Diagnosis: • Rectal exam • Colonoscopy • Radionuclide scan • Bleeding scan • Arteriography
Lower GI Bleeding From: http://brighamrad.harvard.edu/Cases/bwh/hcache/126/full.html Source of LGIB Source of LGIB Angiography Bleeding scan
Lower GI Bleeding • Management: • Arteriographic intervention: vasopressin, coils, gel foam • 80% success, 50% rebleed risk • Operative: hemodynamic unstable with >8 units PRBC • Localization is key, unlocalized LGI bleeding will lead to a blind subtotal colectomy, which is a higher mortality procedure for your patient!
Cold Legs • Acute arterial embolus • Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis • Contralateral leg is normal • No chronic ischemic changes • Etiology: atrial fibrillation (most common) • Embolus usually obstructs common femoral artery • Treatment: Embolectomy +/- fasciotomy • Rare: aortoiliac emboli- loss of pulses to both feet, requires bilateral embolectomies
Cold Legs • Acute arterial thrombosis • Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis • History of claudication, signs of chronic ischemia • Poor pulses in contralateral leg • Not associated with atrial fibrillation • Treatment:heparin anticoagulation, OR for thrombectomy or angiography for catheter-directed thrombolysis
Swollen Legs • Most common “surgical” etiology is DVT • Does your patient need an IVC filter? • Indications: • DVT and • Contraindication to anticoagulation and • High risk of PE • Percutaneous placement of IVC filter (femoral or jugular)
Phlegmasia Cerulea Dolens • Simultaneous thrombosis of iliac, femoral, common femoral, and superficial femoral veins • Associated with other critical illnesses, cachexia, dehydration • Appearance: massively swollen, blue, mottled • Treatment: • Limb elevation • Heparin anticoagulation • +/- catheter-directed thrombolysis • +/- thrombectomy
Extremity Compartment Syndrome • Acute increase in pressure within myofascial compartment of an extremity • Can occur in any compartment, most often lower extremity, anterior compartment • Complications related to compression of contents of compartment • Causes rhabdomyolysis, ischemic neuritis, arterial insufficiency, venous gangrene, and limb loss
Compartment Syndrome • Etiology: increase in muscle swelling, hematoma, or interstitial fluid; often secondary to reperfusion injury, burns, fractures, crush injury, tight cast • Signs/Symptoms: • Extreme pain on flexion is often first sign • Swollen, tense extremity • Loss of sensation first neurologic sign followed by weakness • Last sign is decrease in pulses • Diagnose: Direct pressure measurement using 18-gauge needle and arterial monitor or Stryker monitor • Pressure >20mmHg OR clinical suspicion • Delta P method: diastolic blood pressure – compartment pressure ≤30mmHg is indicative of compartment syndrome
Compartment Syndrome • Treatment: Release pressure immediately! • Evacuate hematoma • Perform fasciotomy • +/- VAC wound therapy • delayed closure • split-thickness skin graft
References • Koster W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury, Int. J. Care Injured (2005) 36, 992-998. • Ridley RW, Zwischenberger JB. Tracheoinnominate fistula: surgical managemnt of an iatrogenic disaster. The Journal of Laryngology and Otology (2006) 120, 676-680. • An G, West MA, Abdominal compartment syndrome: A concise clinical review. Crit Care Med (2008) 36, 1304-1310. • Maerz L, Kaplan LJ. Abdominal compartment syndrome. Crit Care Med (2008) 36 Suppl, S212-215.
References • Greenfield’s Surgery: Scientific Principles and Practice. Fourth Edition. Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch Jr. GR. New York, NY, Lippincott Williams and Wilkins. • ACS Surgery: Principles and Practice. Online Edition. Ashley SW et al. http://www.acssurgey.com • Bowers Rebecca C, Weaver Jeffrey D, "Chapter 8. Compromised Airway" (Chapter). Stone CK, Humphries RL: CURRENT Diagnosis & Treatment: Emergency Medicine, 6th Edition: http://www.accessmedicine.com/content.aspx?aID=3118968. • Gomella LG, Haist SA, "Chapter 13. Bedside Procedures" (Chapter). Gomella LG, Haist SA: Clinician's Pocket Reference: The Scut Monkey, 11th Edition: http://www.accessmedicine.com/content.aspx?aID=2694363.