Basis of surgical ICU

describe the care of surgical patients

1. ميحرلا نحمرلا للها مسب

2. Patient management in
surgical ICU
by
Dr. Radhwan Hazem AL-Khashab
consultant anaesthesia & ICU
2020
ICU, AL-jamhoryteaching hospital

3. 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 department.

4. Indication of admission to
SICU
1. Surgical causes includes:
◼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.

5. 2-Severely injured patient : whether there is
indication for mechanical ventilation or not.
3-Medical factors: any previous medical problems in
which the anesthesia & surgery increase the severity of
pre-existing disease e.g. patient with COPD, restrictive
lung disease ,heart failure , uncontrolled DM or H.T. .
4-Perioperative complication :
Cardiac arrest , sudden hyper or hypotension, cardiac
dysrrhythmias , delay recovery from anaesthesia , oliguria
or anuria.

6. Generally speaking, any surgical patient who
requires continuous monitoring, 1:1 nursing
and /or continuous life support is a candidate
for SICU admission.

7. General care of critical patients

8. 1. CNS relating care:
Pain , agitation , psychosis: what are the
causes ?
Management:Can be relieved by analgesia ,
sedative & antipsychotic drugs respectively
,especially if pat. Remain in ICU > one week.
LOC: Neurological assessment mainly by GCS.

9. 2. Care of the eyes: Critical patients
especially coma patient need daily care of
both eyes.
Why?
This done by using eye medication , distal
water drops, plastering the lids

10. 3. Careof Airway :
Natural airways
Care of oral cavity especially unconscious pat.
To avoid dryness of oral cavity due to mouth
breathing & 2dry fungal infection.
How?
Artificial airways:
-Frequent bronchial washout by distal water or
normal saline injected into ETT or Ts, with aid of
ambu bag & sucker to lubricate the retained
secretion & prevent tubal obstruction by clot or
dry crust .
Technique?

11. Note :
Contraindication to use sodium bicarbonate as
irrigation fluid , this will cause damage to
alveolar cells (pneumocyte type 2 ,surfactant
producing cells) which lead to alveolar collapse.

12. 4. Alimentation:
Assessment of Nutritional Status
When to Feed?
Feeding Route:
1 -Enteral Feeding
2 -Parenteral Feeding:
-Central Access
-Peripheral Access
Monitoring to prevent complications.

13. 5. Prophylaxis of Gastric upset :
Indications :
preexistinggastricillness , H.C.>250mg/d,
burn>35%, head inj. ICU stay, patient On MV ,sepsis
, hepatic problems , S.C. inj., hypovolemic or
hypotensive pat.
Types of drugs used :
H2-receptor antagonists (ranitidine,famotidine).
PPI ( lansoprazole, omeprazole)..

14. 6. Fluids:
Aims : Tissue perfusion
O2 carrying capacity
Coagulation
What are the types of replacements :
Replacement of deficit.
Replacement of maintenance.
Replacement of loss (blood loss & 3
rd
space loss).

15. 7. DVT prophylaxis :
Site , Predisposing factors, prophylaxis &
treatment
8. Infection:
Nosocomial inf.
Acquired outside hosp.
Predisposing Factors:e.g.
Extremes of age
Immunocompromized
Invasive procedures…..etc.

16. 9.Renal :Monitoring of UOP is very
important in intensive patient :
oliguria is: If UOP < 0.5 ml/kg/h for
successive 2 h.
10. Prevention of bed sore:By using
pneumatic bed or changing position of pat. every 2
h.
12. Physiotherapy:
-Upper & lower limbs.
-Bladder
-Chest

17. 13. Other care:
*Bowel :bedridden pat. tend to develop
constipation
* Catheter.
14.MV:
care of pat. On MV.
Indication, setting ,weaning

18. Indication of E.T.T.
1. Comatose patient: ( head injury : 1ry or 2dry).
2. Loss of upper airway reflexes
,( comatose patient, neuronal & neuromuscular
diseases ,e.g. guillain barre , myasthenia gravis ).
3.In patient need mechanical ventilation.
4. Upper airway obstruction .e.g. vocal cord paralysis
, acute epiglotitis, F.B. inhalation , faciomaxillary inj
.

19. Endotracheal tube size
Length (cm)Internal
diameter
Age
11 -122.5 –3 Premature
infant
123 –3.5 Full term infant
14+age/24+ age/4Child
21 –24
21 -23
7 -8
6.5 –7.5
Adult
Male
Female

20. Some of the equipment needed for tracheal
intubation.

21. Indication of
Mechanical Ventilation
1.Clinical parameters.
2.Mechanical parameters.
3.ABG parameters.

22. Indication of Mechanical Ventilation
1. Clinical parameters :-
❑C.N.S.: Restlessness , coma , loss of reflexes.
❑Resp.sys.: Apnea , tachypnea , resp. M. fatigue .
❑C.V.S.: dysrrhythmias , severe hypotension.

23. 2. Mechanical parameters :-
❑R.R. > 35 B.P.M.
❑VT < 5 ml/kg. (tidal volume: each normal
breath cycle 6-10ml/kg).
❑Vital capacity < 15 ml /kg.
( vital capacity : maximum volume of gas that
can be exhaled after maximal inspiration 60 –
70ml/kg).
❑RSBI: RR/Vt(L) > 100. (60-100)
❑VD/Vt > 0.6 (normally less than 0.3)

24. 3. ABG parameters :-
❖PaO2< 60 mmHg , when F.I.O2= 0.5
❖PaCO2>50 mmHg ,with low PH.
❖PaCO2 < 25 mmHg.
❖PH< 7.35 , or > 7.45

25. Parameter of ventilator setting
1.Tidal volume: 6-10 ml/kg.
2. Respiratory rate : 10-18 BPM.
3. FIO2 ( O2 %): start with 100% & then decrease
according to SPO2 % every 4-6 h
4. PEEP: up to 5 cm/H2O.if there is no
hemodynamic disturbances.
5. Modes of ventilation:
-CMV: In patient with no any ventilatory
effort e.g.: spinal cord inj. above C3, or postop.
Residual muscle relaxant effect
-SIMV: In patient with insufficient ventilation.

26. Note:
O2% of inspired gas shouldn't be given
above 50% more than 10-20 h in adult age
& not more than 5-10h in pediatric age
group , because this may lead to O2 toxicity
with respiratory & non respiratory
complication.

27. Monitoring of ICU patient
1. Pulse rate
2. Blood pressure
3. Respiratory rate
4. Temperature.
5. SpO2: Measured by pulse oximeter which show any
evidence of hypoxemia, the normal value is above 90%
which correspond PaO2 of about 60 mmHg,
Note : tissue hypoxia start when SpO2 decrease below
75%which correspond PaO2 40 mmHg , so it's very
important to continue monitoring SpO2 frequently .

29. 5. ECG.
6. UOP : Oliguria , UOP< 0.3-0.5 ml/kg for successive
two hours.
7. ETco2: This measure the concentration of CO2 in
exhaled gases which reflect the intra-alveolar
concentration of CO2, it's 4-5mmHg less than PaCO2 . (
normal value for PaCO2 35-45 mmHg).
8. Invasive parameter this done in certain cases &
not routinely, which includes : IBP , CVP , PAP ,ABG ,
9. Monitoring of mechanical ventilator parameters ;
O2% ,VT , RR ,Airway pressure, minute ventilation &
disconnection alarms.

30. Monitoring chart
يميلعتلا يروهمجلا ىفشتسم
يحارجلا شاعنلإاو ةزكرملأ ةيانعلا ةدحو
ضيرملا مسا : بيبطلا
يصاصتخلاأ:
رمعلأ :ةلاحلإا ناكم:
يلولأا صيخشتلا : خيرأت و تقو
لوخدلا:
Date of chart :-/ /2007
مدقلاا ميقملا يرودلا ميقملا
notedrugsOUT
PUT
ML
IN
PUT
ML
GCStempSPO2
%
RR
(BPM)
BP
S/D
)PR
(B/M
Time

31. Criteria for weaning From mechanical
ventilation
1.Clinical parameters:-
1. C.N.S. : Patient conscious ,oriented, ,intact reflexes
(e.g.: Gag &cough reflex).
2. Resp.sys .:Good M. power ,normal & regular breathing
.
3. C.V.S. :Normal hemodynamic state.
4. Metabolic state: No metabolic disorder
(i.e. no acidosis or alkalosis ).& No temp. Abnormality).

32. 2. Mechanical parameters:-
1. R.R. = ( 8 -16 ) B.P.M.
2. Vt > 6ml/kg.
3. VC > 20 ml/kg.
4. RSBI < 100.
VD/Vt < 0.5
3. ABG parameters :
PaO2 > 80 mmHg .
PaCO2=( 35-45) mmHg.
PH=(7.35-7.45).

33. Criteria for discharging patients
from postanaesthesia care unit
Aldrete's score

34. *Activity: 2 = move four limbs.
1= move two limbs.
0= no movement.
*Respiration: 2 = normal regular breath & able to
cough.
1 = shallow breathing ( dyspneic).
0 = apnea

35. *Circulation : 2 = Bp ( 20% +/-) of preanaesthetic
reading.
1 = Bp( 20% -50 %+/-) of preanaesthetic
reading.
0 = Bp ( > 50% +/-) of preanaesthetic
reading.
*Consciousness: 2 = fully awake.
1 = arrousable on calling.
0 = non responding.

36. SpO2 : 2 = >92% on room air.*
1 = need O2 therapy to maintain SpO2 >90%.
0 = < 90% on O2 therapy.
*Scoring : patient can be discharged
from PACU when Score > 9 .

37. Case presentation :
M.A.4 years female sustained an blast injury to neck
associated with tracheal injury , patient developed aspiration of
blood to both lung , so patient developed sign of respiratory
distress , tracheostomy done for her.

38. Clinical assessment
The child was distressed , tachycardia , tachypnea, agitated.
SPO2= 60-66% on T-piece.
HR= 133-159 /BPM
RR> 47 /min.
PH=7.29
PaCO2> 52 mmHg
So patient have many parameters for MV , at start a SIMV
used to support her condition after stabilization of
metabolic state changed to PSV.

39. SIMV parameters:-
* Vt= 165 ml.
*frequency = 20+spontaneous breaths about
22 BPM
* PEEP= 5 cm/ H2O.
*FIO2 = 100 % at start.
* I/E =1/1.9

40. Patient start to improve in which an SPO2 = 89 –92%
& patient become quit .
CXR show diffuse opacities of both lungs.
On examination there was a sign of bronchospasm , so
start treatment which includes ( bronchodilator,
systemic steroids, nebulization with beta 2 agonist) in
addition to bronchial hygiene therapy.
On next few hours

41. On 2
nd
day with frequent bronchial lavage ,
the patient show more signs of improvement
of vital signs & hemodynamic parameters &
ABG result.

42. On 3
rd
day patient gets a good criteria for
weaning (SPo2 =91-93%), (HR=121-129
BPM),(PH=7.33),(PaCO2=39 mmHg).
So weaning starts & continue for few hours.
The patient discharged from SICU few days
later with complete improvement.

43. M.A. on 1
st
day of MV

44. 2
nd
day on MV.

45. 1
ST
hour of weaning

46. 2
nd
hours of weaning

47. 3rd hours of weaning

48. End of presentation