Discuss the principles of intensive care unit in surgery

INTENSIVE CARE UNIT IN SURGERY

1. DISCUSS THE PRINCIPLES OF
INTENSIVE CARE UNIT IN
SURGICAL PRACTICE
PRESENTER:
EZEAKU, CHIZOWA OKWUCHUKWU
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2. Outline
•Introduction
•Classification
•Admission Criteria
•Triage
•Principles of care
–Resuscitation and diagnosis
–Patient stratification
–Monitoring
–Specific and supportive care
–Discharge criteria
–Follow-up/Outcome
•Challenges/ Ethical issues
•Recommendations
•Conclusion
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3. Introduction
•Intensive care unit [ICU]: is a specially dedicated hospital unit
well equipped and staffed, to cater for critically ill patient with
potential reversible cause.
•It is a low volume, high cost care unit for vital target organ[s]
support, critical monitoring and some invasive intervention in
a functional and user friendly environment.
•Word wide, critically ill surgical patient accounts for 60-70% of
the workload of the general intensive care units.
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4. Introduction
•In UBTH, Nigeria, surgical patients constitute 58.4% of
patients admitted in the ICU, with NSU and general surgery
accounting for 23.8% and 21.5% respectively.
•The provision of intensive care has led to increasing
complexity of modern surgery in patients with high levels of
physiological compromise and significant co-morbidities.
•However, Singer etal, noted that it costs twice as much to
die in ICU as it does to survive, thus, it is vital that patients
are carefully selected for ICU care.
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5. Introduction(ICU step up recommendation)
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6. Classification of ICU
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7. Classification of ICU
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8. Admission criteria
•Hallmarks of admission:
–Have potential for recovery.
–The pathological state should have potential for
reversibility.
–According to clear criteria to identify at risk patients.
–Undertaken at senior level using appropriate transfer
equipment or modality.
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9. Admission criteria
•Surgical patients are admitted to ICU:
–Preoperatively
–Post operatively
–Stepping up:
•cared for on a standard ward ,but now require an
increased level of monitoring or support, or who are at
risk of deterioration.
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10. When Should the Critically ill Surgical Patient be Admitted
Preoperatively to ICU?
It has been suggested that
pre-operative admission to
ICU and cardiovascular
optimization may reduce
post-operative mortality.
In a large-scale study, only
5% of surgical patients were
admitted to ICU pre-
operatively, and this was
thought to be due, in part, to
pressure on ICU beds.
Shoemaker et al and Boyd et
al demonstrated a significant
reduction in mortality
following preoperative supra-
optimization of surgical
patients in the ICU.
Effects:
1. increase the ICU beds
usage
2. increase in cost of ICU care
Benefits:
1. reduced hospital stays
2. avoidance of the
extremely high cost from late
ICU admissions, reduce the
total hospital costs and
possibly the total ICU costs
for this large group of surgical
patients.

11. Br J Surg.1998 Jul;85(7):956-61.
Ward versus intensive care management of high-risk
surgical patients.
Curran JE
1
, Grounds RM.
RESULTS: Medical staff allocated patients appropriately. There
was a lower mortality rate than predicted from individual
POSSUM scores. Patients who were admitted to the ITU before
operation had the highest ASA scores, admission criteria and
POSSUM scores; they also had significantly lower mortality and
morbidity rates than predicted by the POSSUM scoring system.
CONCLUSION: Patients with the greatest reduction in
mortality and morbidity rates were admitted to the ITU
before operation and had cardiovascular physiology
'optimized' before surgery.

12. Criteria for Preoperative high risk
patients (Shoemaker)
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Previous severe cardio-respiratory illness (acute myocardial
infarction, stroke, COAD)
Extensive ablative surgery planned for carcinoma (ie
oesophagectomy, gastrectomy, prolonged surgery)
Severe multi-trauma (ie> 2 organs or 3 systems, or opening 2
body cavities)
Massive acute blood loss (> 8 units), blood volume < 1.5 l/ m2,
haematocrit< 0.2
Age > 70 or evidence of limited physiological reserve of one of
more organs
Septicaemia, positive blood cultures or septic focus, WCC >13
000/ml, spiking fever to > 38.3oC for 48 hours

13. Criteria for Preoperative high risk patients
(Shoemaker)
Shock, MAP < 60mmHg, CVP < 15cmH2O and urine output <
20ml/hr.
Respiratory failure, PaO2 < 8mmHg on FIO2 > 0.4,
intrapulmonary shunt fraction > 30%, mechanical ventilation
needed > 48 hours .
Acute abdominal catastrophe with hemodynamic instability (ie
pancreatitis, gangrenous bowel, perforated viscus, GI
bleeding)
Acute renal failure: serum urea > 17.9 mmol/l, creatinine>
265mmol/l
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14. Other candidates for preoperative
admission
•Burns –TBSA>50%
•Electrical injuries with physiologic, metabolic, acid-base
imbalance.
•Late stage vascular disease involving aortic disease
•Dissecting aortic aneurysm etc
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15. Candidates for Post operative
admission
Elective admission into ICU:
Cardiac surgeries
Major neurosurgeries
Post organ transplant(renal, liver)
ELCS for major placenta praevia
ELCS on parturient with heart failure
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16. Candidates for Post operative
admission
Emergency admission to the ICU:
Intraoperative cardiac arrest
Severe hemorrhage with shock
Complicated thyroidectomy
Post surgical patient requiring inotropic support
Prolonged surgery (>4-6 hrs.)
–Especially when associated with complicated
intraoperative event or prolonged post op recovery.
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17. Candidates for “Step up” ICU
admission
•The objective parameter model is handy here:
–Potentially reversible pathology
–RR<8, >35 cycles/min
–PR< 40, ≥150 beats/min
–GCS ≤ 8
–Sudden fall in the level of GCS
–SPO
2<90% on 100% O
2
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18. Candidates for “Step up” ICU
admission
•Other objective parameter include:
–SBP < 80mmHg, MAP<60mmHg, DBP>120mmHg
–Repeated prolonged seizure
–Repeated cardiac arrest
–PaO
2< 50mmHg
–PaCO
2 increase with respiratory acidosis
–RBS >800mg/dl
–HCO
3⁻ <10mmol/l ; >30mmol/l
–Ca
2+
>15mg/dl
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19. Other models Of ICU admission
decision
•Diagnosis model
–Based on specific disease condition determines ICU
admission appropriateness.
•Prioritization model
–Defines those who will benefit (Priority1) from those who
will not benefit (Priority 4)
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20. Prioritization model
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21. Triage
•Due to limited bed space, factors taking into account:
–Diagnosis
–Severity of illness
–Age and functional status
–Co-morbid disease
–Physiological reserve
–Prognosis
–Availability of suitable treatment
–Response of treatment to date
–Recent cardiopulmonary arrest
–Anticipated quality of life
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22. Exclusion criteria for ICU admission
•Terminally ill patients from metastatic cancer, unresponsive to
available management options.
•Patients with living wills:
–DNR
–DNAR
•Irreversible brain damage/death who are non organ donor.
•Non traumatic coma leading to PVS.
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23. Principles of care
•Resuscitation and diagnosis
•Patient stratification
•Monitoring
•Specific and supportive care
•Discharge criteria
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24. Resuscitation
•Initiation of ATLS protocol, where indicated.
•Timely activation of the basic life support and advanced
cardiac life support.
•Brief history from relatives ,primary team members, case
notes, anesthetic note especially for the preoperative or step
up patient.
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25. History (postop)
•Accurate, structured and timely handover of patient care.
•Pertinent points in the post operative patient:
–Age, Highlights of the medical and surgical history
–Nature, details of surgery and anesthesia
–Use of drains, vascular access points etc
–Medication history, adjuncts egpacemakers, prosthesis.
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26. Examination and investigations
•Head to toe , and systemic
•Surgical wound site
•Proper placement of adjuncts egEndotracheal tube, ECG
electrodes, NG tube, Surgical drains etc.
•Vital signs
•Appropriate investigation guided by prevailing clinical
condition.
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27. Patient Stratification
•Scoring system to predict severity, outcome and prognosis.
Include:
–APACHE II
–qSOFA
–MPM
–SAPS
–ASA
–POSSUM
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28. Monitoring
•Aid in decision marking, diagnosis and detecting early sign of
deterioration or improvement.
•May be invasive or non invasive
•Attention is paid to trend not a single one time
measurement.
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29. Parameters monitored
•Respiratory system:
–RR, Chest movement, CXR, Vitalograph, Capnography, etc
•Cardiovascular system:
–PR,HR, BP, Continuous ECG, CVP etc
•Renal system:
–GFR, SEUCr,
•Hematological system
–PT, APTT, INR, D-Dimer etc
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30. Parameters monitored
•LFT, ABG, Urinalysis, RBS
•Radiological investigations
•Microscopy, culture and sensitivity studies
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31. Specific Treatment
•Specific treatment could be medical, surgical or combined.
•It varies from patient to patient depending on the diagnosis
and patient’s physiologic needs.
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32. Role of family meeting
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Conclusion:
It is worrisome that majority of family members of
critically ill patients were neither carried along in the
management of their patients nor were they informed of
likely outcome.
A timely, well-planned and regular family meeting is
therefore advocated in the management of critically ill
patients.

33. System support(Respiratory support)
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34. Cardiovascular support
•Aim is to restore end organ perfusion and oxygenation.
•Appropriate fluid and blood where indicated.
•Inotropes/vasoactive agents egdobutamine, dopamine,
norepinephrine, epinephrine.
•Pacemakers
•Mechanical assist devices egintra aortic balloon
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35. Renal support
•Fluid balance
•Avoid nephrotoxic agent or adjust dose when necessary.
•Timely use of diuretics
•Prompt renal replacement therapy , when indicated.
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36. Neurological support
•Aim: Prevent secondary brain injury, ensure adequate
cerebral perfusion and normalized ICP.
•Sedation +/-paralysis
•Controlled hyperventilation to PCO2(30-35mmHg)
•Barbiturate coma
•Hypothermia
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37. General supportive measures
•Good nursing care:
–General, oral and ocular hygiene
–Prevention of pressure ulcers
•Role of physiotherapy
•Adequate sedation and analgesia
•Nutritional support
•DVT prophylaxis
•Psychological support
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38. DAILY CHECK LIST(I hug fast)
-I-Infection control: barrier
nursing, cap, facemask etc
-H-Hand hygiene and head
end elevation: hand
washing (53% compliance.
Enyi-NwaforKA ,2013)
-U-Ulcer prophylaxis: H2
blocker, PPI etc
-G-Glycaemiccontrol: daily
RBS. Maintain blood sugar
b/w 6-10mmol/L
-F-Feeding/Fluid: enteralvs.
parenteral, UO b/w 0.5-
1ml/kg/hr, CVP b/w 4-
10cmH20
-A-Analgesia: opioids, NSAIDs,
nerve blocks
-S-Sedation: Ramsay score b/w
3-4, intubated/or ventilated
-T-Thrombophylaxis:
compression stockings,
clexaneetc

39. Discharge criteria
•When a patients physiological status has stabilized and the
need for ICU care and monitoring no longer necessary, or
•Deteriorated and becomes irreversible and active
intervention is no longer beneficial, withdrawal of care done
in the ICU .
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40. Discharge criteria
•Stable hemodynamic parameters.
•Stable respiratory status, post extubation.
•No longer on inotropic support.
•Cardiac dysrhythmias are controlled.
•Oxygen requirement < 60%.
•Patient on chronic mechanical ventilation with resolution of
acute critical problems.
•Neurologic stability with control of seizures.
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41. Outcome/Follow up
•Number transferred to the ward, or discharge home with or
without deficits.
•Follow up on discharge, rehabilitation and re-integration back
into the society.
•Monitor of duration of survival, quality of life after discharge
and ability to return to normal daily activity of life.
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42. Challenges
•Patient factors:
–Infection control
–Care of unconscious patients
–Financial constraints
–Multiple comorbidities
–Psychological problems
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43. Challenges
•Institutional factors:
–Poor funding
–Inadequate man-power
–Poor infrastructural support
•Role of HDU
–Poor power supply
–Poor support services
–Social patient
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44. Ethical issues
•Discharging a recuperating patient to create space for a
gravely ill one.
•Conflicts over withholding or withdrawing life support.
•Admitting patient in ICU for organ support or harvest
•End of life issues
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45. Recommendations
•Role of high dependency unit
–The availability of HDU is one of the most important factors in determining the
availability of ICU beds. (GallimoreS C et al, Rowan KM et al.)
–The ability to discharge ICU patients to an appropriately equipped and staffed
HDU reduces the pressure on ICU beds and reduces the rate of ICU
readmission.
•The role of ICU in training of surgical staff
–Training: rotation of surgical residents through the unit.
–Advice: early consult and involvement of the ICU team.
–Ward round for patients not in ICU yet, by ICU team.
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46. Conclusion
•Adequate knowledge of surgical intensive care is
needed in selection of high risk patient, delivery of
high level critical care, for optimum outcome of the
surgical patient with life threatening condition.
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47. Reference
•Update in anaesthesia; vol28; special edition on intensive
care medicine
•Worthley, L.I. “The ideal intensive care unit: ‘Open’, ‘Closed’ or
somewhere in between?”. Critical Care and Resuscitation 9.2
(2007): 219.
•The International Surgical Outcomes Study Group. Global
patient outcomes & after elective surgery: prospective cohort
study in 27 low-, middle-, and high income countries. Br J
Anaesth2016; 117: 601-609.
•Weiser TG, SemelME, Simon AE, et al. In-hospital death
following inpatient surgical procedures in the United States,
1996–2006. World J Surg2011; 35:1950–1956.
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48. Reference
•Churchill Livingstone; Textbook of anaesthesia4
th
edition;
ch60; pg722-738
•GoelA, Joshi R and Jain AP. Administrative effectiveness
and Organization In: ICU manual 3
rd
ed. Parasmedical
publisher, Hyderabad, India. 2013: 1-5)
•EskiciogluC, Forbes SS, AartsMA, et al. Enhanced
recovery after surgery (ERAS) programs for patients
having colorectal surgery: a meta-analysis of randomized
trials. J GastrointestSurg2009; 13:2321–2329.
•HilbermanM. The evolution of intensive care units. Crit
Care Med 1975; 3: 159 –163
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49. Reference
•Principles and practice of Intensive care management in
surgery-A seminar delivered by DrIromehC
•Intensive care of the surgical Patient,-A lecture delivered by
DrUtobiK
•Taskforce of the American College of Critical Care Medicine,
CritCare Med 1999;27(3):633-638
•PetrovicMA, Etal: Implementing a perioperative handoff tool
to improve postproceduralpatient transfers. JtCommJ Qual
Patient Saf2012;38(3):135-142.
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50. Thanks for listening
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