An Introduction To Surgical Icu

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AN INTRODUCTION
TO SURGICAL ICU.
MOHAMED EMAD ABDEL-GHAFFAR.
PROFESSOR OF ANESTHESIOLOGY,
FOM, KING FAISAL UNIVERSITY.

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What is meant by SICU?
A tertiary care facility in the hospital that
provides a state of the art medical care to
critically ill patients referred to it via different
surgical disciplines.

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Indications for SICU admission:
Pre and post-operative patients of ASA IV and V,
undergoing major and ultra major surgeries.
All craniotomy patients.
All thoracotomy patients.
All ultra major surgeries.
Unstable multiple trauma patients.
Patients with head or spine trauma requiring
mechanical ventilation.
Generally speaking, any surgical patient who
requires continuous monitoring, 1:1 nursing and /or
continuous life support is a candidate for SICU
admission.

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The main functions of any ICU is to:
Provide optimum life support
and
Provide adequate monitoring
of vital functions.

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SICU
Monitoring:
•CVS
•Respiratory
•Renal
•CNS
•Metabolic
•Input/ output
Life support:
•General
•CVS
•Respiratory
•Renal
•CNS
•Metabolic

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Types of monitoring in the ICU
Physiologic monitoring: its main objective is
Assess the functions of the vital systems.
Monitor the effects of different therapeutic
interventions on the critically ill, e.g. PA
catheter in a CHF patient.
Safety monitoring: its main objective is
Warn against serious incidents that can
jeopardize the patients life, e.g.. disconnection
alarm in ventilated patients.

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Hemodynamic monitoring:
EKG
NIBP
IBP
CVP
PA catheter and PCWP.

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EKG
Heart rateHeart rate
Cardiac rhythm Cardiac rhythm ((A fully computerized A fully computerized
arrhythmia analysis is now availablearrhythmia analysis is now available))
Conduction defectsConduction defects..
Myocardial ischemia Myocardial ischemia ((SS--T segment T segment
monitoringmonitoring))

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The five-electrode system
Allows the recording of Allows the recording of
the six standard limb the six standard limb
leads leads ((I, II, III, aVR, aVL, I, II, III, aVR, aVL,
aVFaVF)), as well as one , as well as one
precordial unipolar leadprecordial unipolar lead..
ComputerComputer- - assisted assisted
arrhythmia analysis and arrhythmia analysis and
SS--T analysis are possibleT analysis are possible..

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NON-INVASIVE BLOOD PRESSURE
MONITORING (NIBP):
1. MANUAL (RIVA-ROCCI) TECHNIQUE
2. OSCILLOMETRIC BLOOD PRESSURE
DEVICES
3. PENAZ (FINAPRES) TECHNIQUE
4. ARTERIAL TONOMETRY
5.PULSE TRANSIT TIME (PHOTOMETRIC
METHOD)

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NIBP
Manual
Automatic

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INVASIVE BLOOD PRESSURE
MONITORING (IBP):
An arterial canula is used.
A non compliant saline-filled tube is used to connect
the canula to the transducer, to the display.
It measures IBP on beat to beat basis.

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CENTRAL VENOUS PRESSURE (CVP) AND
PULMONARY ARTERY (PA) MONITORING:
Invasive monitoring of the central circulation
allows an estimate of cardiac preload.
For access to the central circulation, various
sites have been used including IJV, SCV,
basilic vein and femoral vein.

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CVP AND PA MONITORING, cont.
Anterior and medial approaches to cannulation of the IJVAnterior and medial approaches to cannulation of the IJV..

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CVP AND PA MONITORING, cont.
Design of a routine PA catheterDesign of a routine PA catheter..

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CVP AND PA MONITORING, cont.
CVP and PA catheters can measure:
CVP
PAP
PCWP
CO
Mixed venous SpO2

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Respiratory Monitoring:
Monitoring of lung mechanics in ventilated patients (in-
line spirometry):
Two techniques are used:
1.Main stream spirometry.
2.Side stream spirometry.

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Respiratory Monitoring (Mechanics cont.)
Inspired and expired lung volumes (V
T
and
MV)are measured.
PIP, Plateau pressure (PP) and Mean airway
pressure are measured.
Dynamic lung compliance is calculated as
DLC= V
T
/ PIP
Static lung compliance is calculated as
SLC= V
T / PP

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Respiratory Monitoring Gas exchange:
ABGs.
Capnography
Pulse oximetry

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ABGs
An arterial blood sample is used.
ABG analysis measures:
PaO2
PaCO2
pH
Some machines also measure Hb conc. And SpO2.
Calculated Parameters include:
HCO3
Base excess
Total CO2 content.
SpO2, if not directly measured.

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ABGs: Clinical applications:
Assess adequacy of gas exchange.
Assess adequacy of respiratory support.
Know the acid-base status of the individual.
Assess the adequacy of different
interventions on acid-base balance.

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Capnography
A typical capnogram obtained A typical capnogram obtained
during controlled mechanical during controlled mechanical
ventilation showing ventilation showing ::
•Inspiratory baselineInspiratory baseline
•Expiratory upstrokeExpiratory upstroke
•Expiratory plateauExpiratory plateau
•Inspiratory downstrokeInspiratory downstroke

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Capnography cont.
Its analysis should include the following:
Verify presence of exhaled CO2
Inspiratory baseline
Expiratory upstroke
Expiratory plateau
Inspiratory downstroke
Check P
ICO2min and P
ECO2max
Estimate or measure P
a
CO2 - P
E
CO2max
Search for causes of hypercapnia or hypocapnia, if
either is present

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CLINICAL APPLICATIONS OF
CAPNOGRAPHY
One of two sure signs of endotracheal
intubation.
Detection of untoward events e.g..
Disconnections or inadvertent extubations.
Maintenance of normocapnea
Cardiopulmonary resuscitation
Weaning from mechanical ventilation
Monitoring the nonintubated patient

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PULSE OXIMETRY:
Spectrophotometry
The present generation of pulse oximeters uses two wavelengths of lightThe present generation of pulse oximeters uses two wavelengths of light: :
660 nm 660 nm ((redred) ) and 940 nm and 940 nm ((near infrarednear infrared). ).
The pulse oximeter measures the AC component of the light absorbance The pulse oximeter measures the AC component of the light absorbance
at each wavelength and then divides it by the corresponding DC at each wavelength and then divides it by the corresponding DC
componentcomponent.. R R = = AC660AC660//DC660DC660 / / AC940AC940//DC940DC940

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PULSE OXIMETRY: CLINICAL
APPLICATIONS.
The pulse oximeter is the most significant advance in
oxygen monitoring since the development of the
blood gas analyzer.
Because it is noninvasive and virtually risk free when
used properly, the pulse oximeter should be used in
all clinical settings in which there is a potential risk of
arterial hypoxemia.
It is the only oxygen monitor that provides
continuous, real-time, noninvasive data on arterial
oxygenation.

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TEMPERATURE MONITORING :
IMPORTANCE
Temperature regulation is crucial to the survival of
intact animals
Although uncommon, hypothermia below 32° C is
ominous.
Ventricular irritability increases, and if the
temperature decreases to 28° C cardiac arrest is
likely.
shivering can increase oxygen demand 135% to
468%,when respiratory and cardiovascular systems
may be unable to respond normally to increased
demand

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Sites for monitoring body temperature
1.Oral.
2.Tympanic membrane
3.Esophageal
4.Nasopharyngeal
5.Pulmonary arterial blood
6.Rectal
7.Bladder
8.Axillary
9.Forehead
10.Great toe

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Renal Function Monitoring
The three general functions of the kidneys are:
(1) Excrete potentially toxic metabolic end
products,
(2) Regulate water and tonicity, and
(3) Produce hormones.

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Renal Function Monitoring, cont.
Urine Volume: Normal 0.5- 1.0 ml/kg/hr
oliguria: < 0.5 ml/kg/hr
Urine Specific Gravity: is a measure of
concentrating/ diluting capacity of the kidney,
Urine Osmolality: urine osmolality of greater
than 500 mOsm/kgH
2
O indicates prerenal
azotemia and less than 350 mOsm/kgH
2
O
indicates acute tubular necrosis.

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Renal Function Monitoring, cont.
Serum Creatinine: 0.4- 1.2 mg/dl.
Blood Urea Nitrogen: normal range is 8 to
20 mg/dl.
Urinary Sodium: It is traditionally accepted
that a urinary sodium level of less than 20
mEq suggests prerenal azotemia and a level
of greater than 40 mEq, acute tubular
necrosis.
Creatinine Clearance: Normal 1- 1.5 ml/kg/
min.

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Life support: General
General body care include:
Regular turning every 1 hour.
Body and mouth hygiene
Bowl and bladder care.
Passive or active physiotherapy.
Adequate nutrition.

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Life support: CVS
Hemodynamic manipulation is done to
optimize CV function to achieve adequate
tissue perfusion.
This is done by:
Optimizing preload, input/ output.
Optimizing afterload, vasodilators or
vasoconstrictors.
Optimizing cardiac contractility, +ve
ionotropes, -ve ionotropes.

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Life support: Respiratory
Simple O2 therapy using various O2 masks
e.g.. Venturi masks of various FiO2, 21- 60
%, non-rebreathing mask with a reservoir bag
give FiO2 > 80 %.
CPAP, BIPAP.
Mechanical ventilation.

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Indications for Mechanical Ventilation
A. Respiratory failure
Respiratory arrest, the need is apparent
If there is rapid deterioration, it is better to intubate
early before the patient's condition worsens, making
intubation more likely to be associated with
complications
In cases of severe myocardial ischemia, the added
work of breathing can substantially worsen ischemia.
In general, a PaO
2
< 50 or PaCO
2
> 55 while the
patient is receiving supplemental oxygen is an
indication for ventilatory support.

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Indications for Mechanical Ventilation
B. Protection of upper airway
C. Relief of airway obstruction
D. Improved pulmonary toilet
E. Refractory cardiogenic pulmonary edema

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Life support: Renal
Maintain adequate fluid and electrolyte
balance and correct any abnormalities.
Avoid hypovolemia, hypotension
Avoid use of nephrotoxic drugs especially in
those with a compromised renal function.
Use of various forms of kidney dialysis.

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Thank
you