FCCSSurgicalSlides-18-MgmtSpecialPopulations_Live_2021_FINAL (1).pptx

FCCS

1. Management of Special Populations Copyright 2021 Society of Critical Care Medicine

2. 1 Copyright 2021 Society of Critical Care Medicine Objectives Review the epidemiology, risk factors, classification, and treatment of pulmonary embolism Discuss ICU management of bariatric surgery patients Explore postoperative management in organ-specific transplant patients

3. 2 Copyright 2021 Society of Critical Care Medicine Case Study 1 A morbidly obese 56-year-old man presents with progressive shortness of breath 2 days after Roux-en-Y gastric bypass complicated by significant intraoperative splenic bleeding. When he walks, he has increased shortness of breath and syncope. What is your leading diagnosis?

4. 3 Copyright 2021 Society of Critical Care Medicine Case Study 1 (continued) On examination, he is awake and normotensive, with heart rate 132 beats/min, and tachypenic with oxygen saturation 88% on room air. He feels subxiphoid pressure. What are the immediate priorities? Are the symptoms of subxiphod pressure concerning?

5. 4 Copyright 2021 Society of Critical Care Medicine Pulmonary Emboli Epidemiology and incidence Third most common cardiovascular disorder In the United States, about 900,000 events reported annually Silent pulmonary embolism (PE) occurs in 40% to 50% of patients Most venous thromboembolism (VTE) events occur after hospital discharge Mortality in the first 3 months is greater than 15%

6. 5 Copyright 2021 Society of Critical Care Medicine Classification Massive pulmonary emboli Sustained hypotension (systolic blood pressure 90 mm Hg for at least 15 minutes or requiring inotropic support) Shock not due to a cause other than PE Submassive pulmonary emboli Low-risk pulmonary emboli

7. 6 Copyright 2021 Society of Critical Care Medicine Predictors of Mortality From PE at Presentation Syncope Right heart failure Atrial fibrillation Elevated cardiac biomarkers Echocardiographic findings of right heart strain Obstructive shock

8. 7 Copyright 2021 Society of Critical Care Medicine Diagnosis Clinical presentation ECG, echocardiograph, CT angiography Scoring system: simplified Wells score, PE Severity Index (PESI) Cardiac biomarkers

9. 8 Copyright 2021 Society of Critical Care Medicine Treatment Algorithm for Pulmonary Emboli

10. 9 Copyright 2021 Society of Critical Care Medicine Case Study 2 A 61-year-old woman with BMI 43 is admitted with severe pneumonia. Medical history includes diabetes mellitus, hypertension, obstructive sleep apnea, and hypercholesterolemia. Surgical history includes biliopancreatic bypass, caesarean section, and carpal tunnel release. The patient uses BiPAP at bedtime. Of note, since her bariatric surgery 9 months ago, she has lost 90 lb. How would the patient’s morbid obesity or a history of bariatric surgery change the approach to this patient?

11. 10 Copyright 2021 Society of Critical Care Medicine Management of Bariatric Patient Early postoperative complications Anastomotic leak Hemorrhage Venous thromboembolism Acute coronary syndrome (0.2%) Respiratory failure Atelectasis Pneumonia

12. 11 Copyright 2021 Society of Critical Care Medicine Management of Bariatric Patient Late postoperative complications Malabsorption Obstruction

13. 12 Copyright 2021 Society of Critical Care Medicine Criteria for ICU Admission Body mass index greater than 60 Requirement for continuous cardiac monitoring Severe obstructive sleep apnea (OSA) Refractory elevated blood glucose levels Intraoperative complications, eg, bleeding, cardiac, or respiratory event

14. 13 Copyright 2021 Society of Critical Care Medicine Pulmonary Complications Incidence up to 70% Risk factors OSA or obesity hypoventilation syndrome Poor chest wall compliance Obstructive lung disease Atelectasis Uncontrolled abdominal pain Recent tobacco use Increasing age Open procedure

15. 14 Copyright 2021 Society of Critical Care Medicine Recommendations Protective lung ventilation intraoperatively (6-8mL/kg ideal body weight) Early extubation Noninvasive ventilation Pain management Early mobilization Appropriately sized equipment Undersized cuff may result in overestimation of blood pressure Central Catheters maybe too short

16. 15 Copyright 2021 Society of Critical Care Medicine Anastomotic Leakage Usually occurs within the first week Signs and symptoms are often subtle Most common findings: Tachycardia: heart rate >120 beats/min Tachypnea Diagnosis: contrast study or CT Treatment: source control Irrigation Broad-spectrum antibiotics Placement of enteral feeding tube in operating room

17. 16 Copyright 2021 Society of Critical Care Medicine Anastomotic Leakage Nutritional support Thromboembolic prophylaxis Glycemic control Accurate medication dosing Pain management

18. Case Study 3 17 Copyright 2021 Society of Critical Care Medicine A 34-year-old man with cystic fibrosis undergoes bilateral lung transplant on cardiopulmonary bypass. Intraoperatively he has minimal blood loss without overt complications. Apical and basal chest tubes are placed bilaterally. He is transferred to the ICU on mechanical ventilation with 100% F io 2 , positive end-expiratory pressure 7 cm H 2 O, and tidal volume 360 mL (6 mL/kg). He is hemodynamically stable with Sp o 2 95%. Immunosuppressive therapy is initiated with methylprednisolone and tacrolimus. Prophylactic voriconazole, trimethoprim/sulfamethoxazole, and broad-spectrum antibiotics are initiated.

19. Case Study 3 (continued) 18 Copyright 2021 Society of Critical Care Medicine Twelve hours after surgery, F io 2 is decreased to 60%. One right-sided chest tube is removed. Sixteen hours after surgery, the ventilator alarms for high peak pressures and hypoxia. Hemodynamics remain stable, and plateau pressure is 45 cm H 2 O. Emergent chest radiograph is shown below. I s this finding concerning? How does the surgical history change the approach to this patient’s care ? Image courtesy of Nazia Mashriqi, MD

20. 19 Copyright 2021 Society of Critical Care Medicine Lung Transplant Indication: interstitial pulmonary fibrosis and chronic obstructive pulmonary disease Single or double lung transplant Double lung transplants usually for recipients with cystic fibrosis Complications Primary graft dysfunction Airway complications (tracheobronchomalacia, bronchial fistulas, and bronchial stenosis)

21. 20 Copyright 2021 Society of Critical Care Medicine Primary Graft Dysfunction Major risk factors Increased ischemic time Donor lung pathology Grade system developed by the International Society for Heart and Lung Transplantation (ISHLT) helped identify severity of graft dysfunction: Grade 1: P/F ratio > 300 Grade 2: P/F ratio 200-300 Grade 3: P/F ratio < 200 Acute rejection typically occurs after first week to a year Treatment: systemic steroids

22. 21 Copyright 2021 Society of Critical Care Medicine Heart Transplant Most common causes of death: Allograft rejection Infection Vasculopathy Malignancy Primary heart graft failure accounts for about 20% to 40% of deaths in the early postoperative period Severe graft failure described as low cardiac output and high filling pressures (heart failure)

23. 22 Copyright 2021 Society of Critical Care Medicine Rejection Mostly occurs within first 30 days Endomyocardial biopsies performed weekly within first 30 days More than 50% of patients develop coronary artery disease within 5 years Mortality 7%

24. 23 Copyright 2021 Society of Critical Care Medicine Liver Transplant Monitor signs of bleeding Assess sepsis versus hyperdynamic circulatory state given underlying portal hypertension Monitor lactate, INR, liver function tests, CBC, and bilirubin every 6 hours Doppler ultrasound of liver performed within first 24 hours to assess hepatic vein and artery flow

25. 24 Copyright 2021 Society of Critical Care Medicine Surgical and Medical Complications Primary graft failure: incidence of 3% to 5% Vascular: venous and arterial thrombosis. Bile Leak: 15% Sepsis Respiratory: pleural effusions, pneumonia, pulmonary edema Cardiovascular: high cardiac output Renal: 27% to 67% acute kidney injury Neurologic: encephalopathy, intracranial hypertension, seizure

26. 25 Copyright 2021 Society of Critical Care Medicine Immunosuppressive Therapy Corticosteroid, calcineurin inhibitors, and antiproliferative agents Prophylactic antibiotics Depending on patient’s history: antivirals for prophylaxis against: Cytomegalovirus Epstein-Barr virus Hepatitis C virus Hepatitis B virus

27. Copyright 2021 Society of Critical Care Medicine 26 Questions

28. 27 Copyright 2021 Society of Critical Care Medicine Key Points VTE is the third most common cardiovascular disorder. Approximately half of cases are related to current or recent hospitalization. The mortality rate for acute PE exceeds 15% in the first 3 months after diagnosis. Anastomotic leak occur within the first week after bariatric surgery. Dumping syndrome and nutritional deficiencies are common after bariatric surgery.

29. 28 Copyright 2021 Society of Critical Care Medicine Key Points Diagnosis and management of organ-specific postoperative complications are essential in treating transplant patients. Autograft rejection occurs mostly within the first 30 days after transplant and is associated with high mortality. Transplanted organ function should be monitored.