10. CARE OF HIGH RISK PATIENT For Medical students

10. CARE OF HIGH RISK PATIENT.pptx

1. Care of the high risk patient undergoing surgery

2. MEANING OF HIGH RISK PATIENT A patient who need primary, priority and emergency care and prone to critical condition.

3. MEANING OF HIGH RISK PATIENT Complex high-risk surgery is associated with a substantial morbidity and mortality despite recent advances in medical and surgical techniques . It has been estimated that there are approximately 2.3 million operative procedures performed annually in the UK with a mortality of 1.4 %. Similar complication rates have also been reported from around the world . The patients in this subgroup account for 83% of all deaths .

4. Identification of high-risk patients In order to concentrate resources appropriately it is necessary to identify patients who are at high risk of peri -operative morbidity and mortality Once identified, the risk should be discussed with patients and the clinician should plan interventions aimed at decreasing the potential risks, according to the type of surgery . It is important to remember that the risk should only be quantified after all treatable medical co-morbidities have been corrected.

5. High risk identification methods By using simple clinical criteria By using number of monitoring technologies By using clinical research studies.eg Shoemaker criteria Revised cardiac risk index (RCRI ) The ACC/AHA (American College of Cardiology/American Heart Association ) algorithm The Detsky and Goldman scores , ASA status Canadian Cardiovascular Society Index (CCSI ) etc

6. The Shoemaker criteria Risk criteria for mortality following major surgery Previous severe cardio-respiratory illness (acute MI, COPD, stroke, etc.) Extensive ablative surgery planned for carcinoma; e.g. oesophagectomy and total gastrectomy , prolonged surgery (> 8 hours) Age over 70 years and evidence of limited physiologic reserve of one or more vital organs Shock: MAP < 60 mmHg, CVP < 15 cm H20 and urine output < 20 ml/hour Septicaemia , positive blood culture or septic focus, WBC > 13,000, spiking fever to 101°F for 48 hours, and haemodynamic instability

7. The Shoemaker criteria Respiratory failure, e.g. PaO2 60 mmHg on FiO2 > 0.4,mechanical ventilation needed > 48 hours Acute abdominal catastrophe with haemodynamic instability, e.g. pancreatitis, gangrenous bowel, peritonitis, perforated viscus , GI bleeding Acute renal failure Late-stage vascular disease involving aortic disease

8. HIGH RISK PATIENTS: Emergency patients Patients requiring resuscitative services Patients requiring blood and blood products Patients who are on life support or who are comatose Patients with communicable disease and/ or who are immunesuppressed Patients in restraints

9. CARE AND POLICY FOR HIGH RISK PATIENTS Within the hospital the all vulnerable elderly and children will be given all-necessary care needed with consideration. If the patient’s condition demands further care which is not available in our hospital , patient will be transferred to the other hospitals/facilities. While transferring the patients a staff nurse will be accompany the patient along with the caregiver.

10. CARE AND POLICY FOR HIGH RISK PATIENTS If the patient’s condition is critical , will be escorted by a doctor and a nurse while transferring them form hospital to hospital. Staff taking care of high risk patients must have adequate training and skills. The identified vulnerable patients will be under close monitoring at all times during their hospitalization to minimize risks of health care services

11. CARE AND POLICY FOR HIGH RISK PATIENTS All healthcare providers will maintain a safe environment, related but not limited to: equipment, wheelchairs, bed rails, mobility needs, fall precautions . All healthcare providers will encourage family involvement and support in care delivery, education and decisions as appropriate. Special consent considerations will be taken when needed for each individual case following the hospital approved consenting policies

12. CARE AND POLICY FOR HIGH RISK PATIENTS Once the patient is stabilized with the disease process, they will be fit for the discharge. The discharge patient will be discharged with follow-up advise. All documentation required for the team to work and communicate effectively in the care of high risk patients must be maintained as per hospital documentation policy.

13. The ICU patient going to theatre The planning, transfer, and monitoring of a critically ill patient on the ICU needing surgery can be challenging. Physiological instability should be anticipated, detected, and acted upon promptly and effectively. Senior anaesthetists and surgeons must be involved

14. Consent Informed consent is often impossible as the patient may be sedated or comatose. Whilst the family is not able to give consent in law The reasons for surgery and risks should be discussed with them whenever possible.

15. Preoperative assessment Routine aspects of the preoperative assessment (e.g. history of previous anaesthetics , chronic medical conditions, allergies) are just as relevant to the critically ill patient as they are to the elective case. Assess the patient’s current condition from discussion with critical care team and from information on the observation and drug charts. Note the current fluid requirements and rate/concentration of inotrope infusions; ensure that there is an adequate supply of inotrope prepared for theatre; consider which vasopressors may be required.

16. Preoperative assessment Note the patient’s oxygen requirement, lung compliance, minute volume, PEEP, etc., to enable prediction of the ventilator settings that will be necessary in theatre. In the absence of a suitable ventilator in the operating room, it will be necessary to use a ventilator from the ICU. Check IV access and consider if any additional cannulae may be required. Many ICU patients have had all peripheral access removed. Check which antibiotics the patient is receiving and whether any doses will be due in theatre.

17. Preoperative assessment Check the most recent FBC, U&E, and ABG, and ensure that blood is available. If the patient is being transferred to a more remote facility, such as the X-ray department, ensure adequate anaesthetic assistance. If the patient has very poor lung compliance and is requiring high levels of PEEP, it may be necessary to use an ICU ventilator.

18. Preoperative assessment On rare occasions it may be necessary to undertake an MRI scan on a critically ill patient—the inability to take ferrometallic objects into the scan room is problematic

19. Transfer to the operating room Familiarise yourself with the transport equipment and ensure it is functioning before leaving the ICU. If the patient is already ventilated, establish on the transfer ventilator before leaving the ICU to ensure adequate ventilation can be maintained. Modern transfer ventilators have a PEEP facility and the more sophisticated machines can provide pressure control ventilation with variable I:E ratios. Consider increasing the patient’s sedation for the transfer.

20. Transfer to the operating room If the patient is not already sedated and ventilated decide whether to induce in ICU, the anaesthetic room, or theatre: Factors influencing the decision will be safety, available assistance, haemodynamic instability, and patient comfort. Monitor the patient fully en-route. Disentangle all lines, re-establish full monitoring, and check IV access before the start of surgery

21. Intervention strategies Major surgery is associated with a significant inflammatory response,which to a certain extent is necessary to facilitate healing The main strategies recommended to facilitate good outcome from major surgery are based on ensuring adequate DO2I during the peri -operative period without causing further complications.

22. Cardiovascular interventions The concept of augmenting cardiac output peri -operatively to improve the outcome of surgical patients has been described by many authors as‘optimisation ’ The main aim of all optimisation strategies for high-risk surgical patients has been to ensure that the circulatory status of the patients is adequate for their needs in the peri -operative period. This has been achieved with a number of differing protocols using different time periods , resuscitation endpoints and pharmacological agents.

23. Cardiovascular care Thus there are three factors of primary importance when managing high-risk patients: 1) Haemoglobin ( Hb ) concentration, Should be keep above 9g/dl 2) The arterial saturation of Hb with oxygen (SaO2) targeted 95% with increased FiO2 and/or continuous positive airways pressure 3) Cardiac output.

24. Cardiovascular care Traditionally most investigators have measured cardiac output with a pulmonary artery catheter or more recently using an oesophageal Doppler probe. If cardiac output is too low, strategies to increase it include optimisation of heart rate (HR), preload , afterload and use of inotropic drugs.

25. Cardiovascular care Identify patient using risk assessment criteria Invasive monitoring CVC/arterial line/flow monitoring Volume loading MAP > 70 mmHg Target DO2I/CI/ScvO2/Hb as per appropriate transfusion trigger Optimal fluid loading IF DO2I not achieved consider inotropic support – dopexamine / dobutamine / – noradrenaline Reduce support if ischaemia or tachycardia predominates

26. Fluids Appropriate intravenous fluid administration is a cornerstone of post-operative optimisation. Excessive fluid administration is detrimental to critically ill patients Fluid administration and its effects must be monitored invasively where clinical signs of preload status are inadequate

27. GDT The timing of goal-directed therapy (GDT) may influence its efficacy. Most of the interventions that have had significant impacts on mortality have been started prior to surgery and continued throughout the peri -operative period.

28. Intra-operative management Admission to critical care If CVC/A-line not in situ then insert Take arterial/CVC gas. Give 250 ml colloid stat and start crystalloid 1.5 ml/kg/h Ensure A-line/CVC transduced Record DO2I Maintain: SaO2 > 94% Hb 8–10 g dl Temperature 37°c MAP 60–100 mmHg Use Noradrenaline or GTN as required

29. Prevention of myocardial ischaemia Patients should where possible have all co-morbidities, including ischaemic heart disease, treated prior to surgery . If a patient is at high risk of an ischaemic cardiac event peri -operatively, pre-operative treatment may include beta-blockade and in some instances coronary intervention

30. Conclusions Stratification of risk. Early aggressive GDT/optimisation/resuscitation Avoidance of tachycardia. Tailored goals according to individual physiological requirements/needs . Cardiac output/flow and biochemical marker monitoring. Care in a high-dependency area with sufficient numbers of adequately trained staff.