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Surgical Intensive Care

JUNYI LI, MD


Board certified in Anesthesiology
Board certified in Critical Care Medicine
Board certified in Transesophageal
Echocardiography

lijunyiutmb@yahoo.com
March 31, 2009
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Subspecialty ICU
Medical Intensive Care Unit (MICU)
Coronary Care Unit (CCU)
Surgical I ntensive Care Unit (SI CU)
Neurological Intensive Care Unit (NICU)
Cardiovascular Intensive Care Unit (CVICU)
Pediatric Intensive Care Unit (PICU)
Neonatal Intensive Care Unit (NICU)
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SICU Admission Criteria
Preoperative status
Major trauma
Surgical Procedure
Pts preexisting disease
Intraoperative event
Large volume shift
Unexpected surgical complication
Unexpected anesthesia complication
Postoperative status
Unexpected postop complication
Pts status


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SICU Management
Respiratory care
Hemodynamic monitoring and management
Noninvasive
Invasive
Infection in SICU
Acid-base disorders
Fluid and electrolyte disorders
Blood component therapy
Nutrition support

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Who need to be admitted to SICU ?
18 y/o health male presented for right inguinal hernia repair
under spinal anesthesia and uneventful intraop and postop.
50 y/o female with controlled HTN and DM for lumbar
laminectomy under general anesthesia with EBL 500 ml.
75 y/o male with stable angina, COPD required home oxygen
for TURP under spinal anesthesia
60 y/o male presented for AAA repair
54 y/o female with esophageal cancer presented for
esophagectomy
95 y/o female presented for right hip arthroplasty
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Respiratory care basic monitor
Respiratory rate
Chest movement
Breath sound
Color
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Respiratory care lung volume
Tidal volume (VT)
Minute ventilation (Vm)
Functional residual capacity (FRC)
Vital capacity (VC)
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Respiratory care - ventilation
Ventilation-perfusion (V/Q) ratio:
normal V/Q=4L/5L=0.8
Dead space ventilation: V/Q>1
anatomic dead space & physiologic dead space
Intrapulmonary shunt: V/Q<0.8
true shunt (V/Q=0) and venous admixture
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V/Q relationship and associated blood gas
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Effect of shunt fraction on PAO2
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Effect of shunt fraction on PAO2 and PACO2
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Ventilation-perfusion
Quantitative determinations
Dead space (Vd/Vt) = (PACO2 PECO2)/PACO2
Shunt fraction (Qs/Qt) =
(CCO2 CAO2)/(CCO2 CVO2)
A-a gradient (PAO2 PaO2)
PAO2 = PIO2 (Paco2/RQ)
PAO2 = FIO2(PB PH2O) (PaCO2/RQ)
PAO2 = 0.21(760 47) (40 /0.8) = 100 mmHg
PAO2/FIO2<200, Qs/Qt>20%
PAO2/FIO2>200, Qs/Qt<20%
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Hypoxemia
Disorder A-a PO2 PVO2
Hypoventilation Normal Normal
Pulmonary disorder Increased Normal
DO2/VO2 imbalance Increased Decreased

DO2/VO2 oxygen deliver and uptake ratio
A-a PO2 PO2 difference between alveolar gas and arterial blood
PVO2 Mixed venous PO2
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Evaluation of hypoxemia
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Hypercapnia
Hypercapnia is PACO2>45 mm Hg, due to
Increased CO2 production
Hypoventilation
Increased dead space ventilation
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Evaluation of hypercapnia
High
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Oximetry
Oximetry detects arterial blood HbO2 and Hb
ratio
Ear oximetry
Pulse oximetry
Co-Oximeters can detect Met Hb and CO Hb
Mixed venous oximetry measured O2 sat in PA
blood
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CO2 detector and capnometry
CO2 detector is a method for determining the
success or failure of ET intubation.
Clinical application of capnometry in ICU:
- Cardiac output monitor
- Ventilator-related mishap detection
- Early detection of nosocomial disorders
- Ventilator weaning
- Controlled hyperventilation


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Acute respiratory distress syndrome
(ARDS)
A leading cause of acute respiratory failure
with high mortality
A diffuse inflammatory injury in the lung
Not an accumulation of watery edema fluid
Not a primary disease, but a complication


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Common conditions that predispose to ARDS
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ARDS microscopic changes and CXR
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Diagnostic criteria for ALI and ARDS
Acute onset
Presence of predisposing condition
PaO2/FiO2 < 200 mm Hg for ARDS,
< 300 mm Hg for ALI
CXR bilateral infiltrates
PAOP < 18 mm Hg or no clinical evidence of
high LA pressure
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Management of ARDS
No real treatment for ARDS, only supportive
Mechanical ventilation:
low-volume ventilation
permissive hypercapnia
positive end-expiratory pressure
Fluid management reducing extravascular
lung water
Pharmacotherapy uncertain effect
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Respiratory therapy
Oxygen inhalation therapy
Chest physical therapy
Respiratory pharmacotherapy
Mechanical ventilation
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Oxygen inhalation therapy
Arterial hypoxemia:
PaO2 < 60 mm Hg (SaO2 < 90 %)
Tissue hypoxia:
blood lactate > 4 mmHg
Endpoint of O2 therapy is tissue oxygenation
Tissue hypoxia may not consistent with arterial
hypoxemia

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Effect of Oxygen on blood flow
Oxygen tends to reduce systemic blood flow
due to:
1. vasoconstrction in all vascular bed except
the pulmonary circulation
2. decrease in cardiac output
3. negative inotropic effect

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Method of oxygen inhalation
Low-flow oxygen delivery system with
variable FiO2
High-flow oxygen delivery system with
constant FiO2


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Device Reservoir Oxygen flow FiO2
capacity (L/min)
Nasal cannula 50 ml 1 0.21-0.24
2 0.24-0.28
3 0.28-0.34
4 0.34-0.38
5 0.38-0.42
6 0.42-0.46
Oxygen face mask 150-250 ml 5-10 0.40-0.60
Mask-reservoir bag 750-1250 ml
Partial rebreather 5-7 0.35-0.75
Nonrebreather 5-10 0.40-1.0
Low-flow oxygen delivery systems
FiO2 = 20 + 4 X oxygen flow (L/ml)
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Respiratory pharmacotherapy
Bronchodilators

Corticosteroids

Mucokinetic therapy
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Mechanical Ventilation
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Mechanical ventilation
Mechanical ventilation is positive pressure
ventilation
Indications of mechanical ventilation
Rate
ABG: hypoxia and hypercapnia
Mechanical parameter: MV, VC and NIP
Dead space and shunt
Contraindication of mechanical ventilation
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Normal lung
Noncompliant lung
Effect of positive pressure ventilation
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Effect of positive pressure ventilation
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Respiratory parameter
Rate: 10 20/min
VT: 6 10/kg
FiO2: 40 100%
PEEP: 5 10 cm H2O
PS: 5 10 cm H2O
I:E ratio: 1:2
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Patterns of mechanical ventilation
Control mode ventilation

Assist-control ventilation
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Pattern of mechanical ventilation
Volume-controlled ventilation
ACV (assist control ventilation)
IMV (intermittent mandatory ventilation)
SIMV (synchronized IMV)
Pressure-controlled ventilation
Pressure support ventilation
Special pattern:
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Functional mode of ventilator
PEEP (positive end expiratory pressure)

PS (pressure support)

I:E reversal ratio
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Ventilatory mode of mechanical ventilation
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Volume-controlled ventilation
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Pressure-controlled & Pressure support
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PEEP and CPAP
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Effect of PEEP on arterial oxygenation and CI
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Discontinuing mechanical ventilation
Ventilator required for brainstem respiratory
depression (e.g.,GA in OR or drug overdose) is
easy to discontinue
Ventilator required for cardiopulmonary
insufficiency is weaning in gradual process
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Discontinuing mechanical ventilation
Clinical evaluation:
Awake
Spontaneous breathing
Ability of airway protection
Stable hemodynamics
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Discontinuing mechanical ventilation
Sequence of weaning:
FiO2 to 50% or less
PEEP to 5 cm H2O or less
PS to 10 cm H2O or less

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Discontinuing mechanical ventilation
Bedside weaning parameters:
Parameter Normal range Threshold for weaning
PaO2/FiO2 >400 200
VT 5-7 ml/kg 5 ml/kg
Rate 10-20/min <40/min
VC 65-75 ml/kg 10 ml/kg
VE 5-7 L/min <10 L/min

Pi max >-90 cm H2O (F) -24 cm H2O
>-120 cm H2O (M)
Rate/VT <50/min/L <100/min/L

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Predictive value of selected weaning parameters
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Discontinuing mechanical ventilation
Methods of weaning:
T-piece weaning
IMV weaning
CPAP weaning
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Diagram of T-shaped circuit
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Hemodynamic monitoring
Noninvasive
ECG: heart rate, rhythm, ischemia (ST-T)
Noninvasive BP
Echocardiography: TTE, TEE, color-doppler
Contractility
Volume status
EF
Ischemia (RWMA)
Noninvasive cardiac output (through A-line)
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Hemodynamic monitoring
Invasive
Arterial blood pressure
Central venous pressure
Pulmonary artery catheter and wedge pressure
Cardiac output

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Invasive arterial blood pressure

Major CV surgery
Surgery with great hemodynamic change
Surgery with large volume shift and bleeding
Shock and other critical ill patients
Surgery requiring hemodilution and control
hypotension
Frequent ABG
Indication
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Invasive arterial blood pressure
Contraindication:
only relative contraindication except for
puncture site infection
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Invasive arterial blood pressure
Selection of artery for cannulation
Radial artery
Ulnar artery
Brachial artery
Femoral artery
Dorsalis pedis and posterior tibial arteries
Axillary artery
Carotid artery do not use
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Invasive arterial blood pressure
Complication
Bleeding and hematoma
Vasospam
Thrombosis and thrombi
Aneurysm
Infection
Nerve damage
Necrosis of skin overlying the catheter



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Invasive arterial blood pressure
Waveform

SBP gradually increases
MBP remains unchanged
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Invasive arterial blood pressure
Waveform distortion
Normal test
underdamped
overdamped
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Central venous pressure
Indication
Fluid administration for severe hypovolemia
and shock
Infusion of cardiac drugs
Aspiration of air emboli in craniotomy
Insertion of transcutaneous pacing leads
Total parenteral nutrition (TPN)
Venous access for patients with poor
peripheral veins
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Central venous pressure
Contraindication
Renal cell Ca extension into RA, RA myxoma,
or fungating tricuspid valve vegetations
Skin infection at cannulation site
Severe coagulopathy
Ipsilateral carotid endarterectomy (IJ),
pneumothorax and hemothorax are relative
contraindication
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Central venous pressure
Selective sites of cannulation
Internal jugular veins
Subclavian veins
Femoral veins
External veins
Basilic veins
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Central venous pressure
Measurement
Catheters tip lies above or the junction of SVC
and RA
CVP is measured with cm H2O
CVP should be measured during end expiration
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Central venous pressure
Waveform
a wave atrial contraction, absent in A fib and
exaggearted in JR (cannon wave)
c wave TV elevation@early ventricular contraction
v wave venous return against to closed TV
x descent downward displacement of TV (systole)
y descent TV opening during diastole
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Central venous pressure
Complication
Bleeding and hemotoma
Pneumothorax and hemothorax
Pleural effusion and chylothorax
Line-related infection
Air thrombi
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Pulmonary artery catheterization
Length 110 cm
OD 2.3 mm
Distal port
Proximal port
Balloon at tip
Themistor
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It Is Time To Pull The PAC
PAC dose not improve outcome
in critically ill patients
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Background
Pulmonary artery catheter(PAC) has been used in
critical care practice for three decades
Majority of PAC are inserted to aid in
management of critically ill pts in ICU and high
risk surgical pts in OR
Observational studies & small randomized
controlled trials (RCT) showed variable results:
Worse outcome
No difference in outcome
Some benefit
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Summary
PAC-directed management in high risk
surgical, severe sepsis, shock and RADS
pts is a safe procedure
PAC use dose not improve outcome
PAC use may not increase cost of care

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Pulmonary artery catheterization
Indication
Cardiac disease: CAD with LV dysfunction, valvular
heart disease, heart failure
Pulmonary disease: ARDS, severe COPD, Pulmonary
hypertension
Complex fluid management: shock, acute burn ARF,
MOF
Specific surgical procedure: aortic cross clamp
pheochromocytoma, liver transplants,
Hemodynamic unstability required cardiovascular
drug therapy
High-risk obstetrics: severe toxemia
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Pulmonary artery catheterization
Contraindication
Severe TV or PV stenosis
RA or RV tumor
Endocarditis with vegetation on TV or PV
Other contraindication related to central
venous cannulation

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Pulmonary artery catheter
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Pulmonary artery catheterization
Insertion of catheter
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PCWP and CVP
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Pulmonary artery catheter in chest x-ray
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Pulmonary artery catheterization
Complication
Complication associated with CV cannulation
Bacteremia and endocarditis
Thrombogenesis and pulmonary infarction
Pulmonary artery rupture and hemorrhage
Arrhythmias and conduction abnormalities
Pulmonary valve damage
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Pulmonary capillary wedge pressure

CVP = RAP = RVEDP
PCWP = LAP = LVEDP
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Hemodynamic parameter
BSA = (Ht + Wt 60)/100, nl 1.6 to 1.9 m2
CO = HR x SV
CI = CO/BSA
DO2 = CI x 13.4 x Hb x SaO2
VO2 = CI x 13.4 x Hb x (SaO2 SvO2)
* SvO2 obtained from PAC distal port

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Hemodynamic Profiles
Heart failure:
Right heart failure Left heart failure
High RAP High PCWP
Low CI Low CI
High PVRI High SVRI
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Hemodynamic profiles
Hypotension:
Hypovolemic Cardiogenic Vasogenic
Low CVP High CVP Low CVP
Low CI Low CI High CI
High SVRI High SVRI Low SVRI

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Cardiac output monitoring
Thermodilution methods
Pulmonary artery catheter
Peripheral artery catheter (Picco)
Dye dilution methods
Echocardiography
Thoracic bioimpedance

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Cardiac output monitoring
Fick principle
CO =
Oxygen consumption
a v O2 content difference
=
VO2
CaO2 CvO2
Fick principle is the basis of all indicator
dilution methods of determining cardiac
output
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Thermodilution method
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Hemodynamic management

Preload
Afterload
Cardiac contractility
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Hemodynamic management
Preload
Monitoring via CVP or PCWP
Increased preload by giving volume
Decreased preload by giving diuretics and/or
vasodilators (nitroglycerin)
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Hemodynamic management
Afterload
Vascular resistance
Balance between cardiac work and organ
perfusion
Vasodilators:
Systemic vasodilators: nitroprusside,
calcium channel blockers, a1-blockers
Pulmonary vasodilators: PGE1, PGI, NO
Vasocontrictors: levophed, epinephrine,
vasopresin

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Hemodynamic management
Inotropic agents
Positive inotropic agents: epinephrine,
dopamine, dobutamine, PDEI (milrinone)
Negative inotropic agents: beta blocker and
calcium channel blockers
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Hemodynamic management
Mechanical support (IABP)

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Hemodynamic effect of IABP
Decrease afterload and promote SV
Increased diastolic pressure and coronary
blood flow in hypotensive patients
Indication: AMI, cardiac shock, unstable
angina, acute MR
Contraindication: AI, aortic dissection and
aortic graft in thoracic aorta
Complication: leg ischemia, septicemia
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Acute renal failure (ARF)
The hallmark of ARF is azotemia and oliguria
Lab: blood urea nitrogen(BUN), criatinine(Cr), blood
electrolytes, glumerular filtration rate
Etiology: prerenal, renal and postrenal
Renal ischemia (50%),
Nephrotoxines (35%),
Intrinsic renal disease (15%)

50% of ARF in SICU due to major trauma or surgery
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Etiology of ARF
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Treatment of ARF
Supportive management
Diuretics and mannitol to maintain urine
output in nonoliguric patients
Renal dose dopamine?
Glucocorticoids for ARF due to vasculitis or
glomerulonephritis
Other: restrict fluid, sodium, potassium, posph
Renal replacement therapy (dialysis)
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Renal Replacement Therapy
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Infection in SICU
Infections are leading cause of death in ICUs
Community acquired and hospital acquired infection
Strains of bacteria resistant to commonly used
antibiotics are common
Advanced age, prolonged use of invasive devices,
respiratory failure, renal failure and head trauma are
established risk factors for hospital acquired infection
Multiple antibiotics and broad spectrum antibiotics
are commonly used in SICU

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Nutrition support in SICU
Maintaining adequate nutrition in critically ill
patients improves wound healing. Restore
immune competence and reduces morbidity
and mortality
Critically ill patients generally required 1.0-
1.5g/kg/day instead of 0.5g/kg/day for
nonstressed patients
Enteral nutrition and parenteral nutrition
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Enteral Nutrition in SICU
GI tract is the route of choice for nutrition
support when its functional integrity is intact
Enteral nutrition is simpler, cheaper, less
complicated, and fewer complication
Enteral nutrition can better preserve GI
structure and function
Diarrhea is most common problem related to
hyperosmolarity of the solution or lactose
intolerance
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Parenteral Nutrition in SICU
Total parenteral nutrition (TPN) is indicated if
the GI tract cannot be used of if absorption is
inadequate
Complications of TPN are catheter-related and
metabolic
The most common problem in TPN is
hyperglycermia