Transcript AICU-SG-1_SurgIssu - Thomas Jefferson University

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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
™
Slide 3
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
™
Slide 4
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!
™
Slide 5
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!
™
Slide 6
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
™
Slide 7
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.
Slide 8
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
™
Slide 9
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
™
Slide 10
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
™
Slide 11
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
™
Slide 12
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
™
Slide 13
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
™
Slide 14
Fluid in
pericardial space
Abdominal Pain
• Abdominal pain syndromes in the ICU:
– Pancreatitis
– Acalculous cholecystitis
– Bowel ischemia
– Bowel obstructive syndromes
™
Slide 15
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
™
Slide 16
Pancreatitis
•
On admission
Within 48 hours
Age >55 years
Hct decreases by >10
– Score 0 to 2 : 2% mortality
WBC >16,000
BUN increases by >5
– Score 3 to 4 : 15% mortality
Glucose >200mg/dl
Calcium <8mg/dl
– Score 5 to 6 : 40% mortality
LDH >350
PaO2 <60mmHg
AST >250
Fluid Requirement >6L
Mortality predicted by Ranson
Criteria:
– Score 7 to 8 : 100% mortality
•
Management
– NPO, IVF, antibiotics if
infection or gall stones
– Treat underlying cause
– Surgery only for infected
necrosis
™
Slide 17
Base deficit >4mEq/L
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)
™
Slide 18
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)
™
Slide 19
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
™
Slide 20
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
™
Slide 21
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!
™
Slide 22
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 18gauge needle
™
Slide 23
™
Slide 24
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:
• I
12-15mmHg
• II
16-20mmHg
• III
21-25mmHg
• IV
>25mmHg
™
Slide 25
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
™
Slide 26
Bogota Bag
™
Slide 27
Upper GI Bleeding
• Gastric (ulcer vs. gastritis)
• Duodenal
• Esophageal varices
• Mallory-Weiss
™
Slide 28
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
™
Slide 29
Upper GI Bleeding
• Management
– PPI, H2-blocker
– EGD
– Arteriography
• Treat Varices: vasopressin, octreotide, sclerotherapy,
Sengstaken-Blakemore tube, TIPS
• Operative intervention if bleeding remains uncontrolled
™
Slide 30
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
™
Slide 31
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
™
Slide 32
Lower GI Bleeding
• Initial management: as for upper GI bleeding
• Diagnosis:
– Rectal exam
– Colonoscopy
– Radionuclide scan
• Bleeding scan
– Arteriography
™
Slide 33
Lower GI Bleeding
From:
http://brighamrad.harvard.edu/Cases/bwh/hcache/126/full.html
Source
of LGIB
Source
of LGIB
Bleeding scan
™
Slide 34
Angiography
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!
™
Slide 35
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
™
Slide 36
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
™
Slide 37
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)
™
Slide 38
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
™
Slide 39
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
™
Slide 40
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
™
Slide 41
Compartment Syndrome
• Treatment: Release pressure immediately!
• Evacuate hematoma
• Perform fasciotomy
– +/- VAC wound therapy
– delayed closure
– split-thickness skin graft
™
Slide 42
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.
™
Slide 43
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.
™
Slide 44