™ Revised 2009 by Dorothy W. Bird, MD Suresh Agarwal, MD, FACS Department of Surgery Boston University Medical Center Based on the original presentation.
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™
Revised 2009 by
Dorothy W. Bird, MD Suresh Agarwal, MD, FACS
Department of SurgeryBoston University Medical Center
Based on the original presentation created by: N.K. Durrani, MD; M. McCann, DO; M.M. Brandt, MD, FACS, FCCM; P. Patton, MD, FACS; H.M. Horst, MD, FACS, FCCM; I. Rubinfeld, MD
Dept. of Trauma SurgeryHenry Ford Hospital, Detroit
Surgical Issues in Critical Care Medicine
™ Slide 3
Surgical Complications
• Airway: airway loss and emergent management
• Pulmonary: simple and tension pneumothorax
• Cardiac: tamponade
• GI: abdominal pain, ileus, ischemia, abdominal compartment syndrome, GI bleeding
• Extremities: vascular occlusion syndromes, compartment syndrome
™ Slide 4
Surgical Airways
• Only reason not to intubate is inability to do so, nonsurgical always preferred: i.e., orotracheal, nasotracheal
• Relative contraindications to intubation
– C-spine instability
– Midface fractures
– Laryngeal disruption
– Obstruction of lumen
™ Slide 5
Emergent Surgical Airway
• Needle cricothyroidotomy:
– 12-14G Angiocath +syringe
– Hyperextend neck
– Palpate cricothyroid membrone
– Apply Betadyne, Lidocaine
– Advance needle at 45o angle until air is aspirated
– Advance catheter, remove needle, attach hub to 3-mm ET adapter and oxygen
• Only useful for 45min due to poor CO2 exchange!
™ Slide 6
Emergent Surgical Airway
• Cricothyroidotomy
– Hyperextend neck
– Palpate cricothyoid membrane
– Apply Betadyne, Lidocaine
– 3-4cm midline vertical incision through cervical fascia and strap muscles
– Incise cricothyroid membrane horizontally; use hemostat to hold open
– Insert 5-7mm tracheostomy tube (or ET tube), attach to oxygen supply
• Convert to formal tracheostomy in 24h!
™ Slide 7
Surgical Airway
• Tracheostomy: Rarely for emergencies
– Usually for ventilator weaning
• Many techniques (percutaneous, surgical)
• Emergency Indications:
– Laryngeal crush injury
– Fracture of thyroid or cricoid membranes
– Very small children
™ Slide 8
Airway Emergency: Massive Hemoptysis
• Due to pulmonary, bronchial, or innominate artery injury/disease
• Results from erosion (slow, with herald bleed) or iatrogenic (tracheostomy, trauma)
• Bronchoscopy to determine source
• Bronchial blocker for isolation
• Angiography: embolize bleeding source
• Emergent lobectomy or sternotomy if uncontrolled
Innominate a.
trachea
™ Slide 9
Tracheoinnominate Artery Fistula
• Dreaded complication of tracheostomy (1%)
• Due to:
– Erosion of the artery by tracheostomy tube or
– High pressure cuff directly injurs artery
• Temporize by:
– Insert endotracheal tube into tracheostomy stoma, inflate cuff
– Apply downward, outward tamponade to fistula with finger in tracheostomy stoma
™ Slide 10
Surgical Pulmonary Emergencies
• Pneumothorax (simple): partial or complete collapse —increases pulmonary shunt
– Chest tube in emergency
– Attempt catheters as well
– Treat “conservatively” in stable asymptomatic patients
– Aggressive therapy if on positive pressure
– Can progress to tension pneumothorax
™ Slide 11
Tension Pneumothorax
• True Surgical Emergency!
• Signs:– Decreased breath sounds– Ipsilateral tympany– Tracheal shift– Distended neck veins– Asymmetric chest expansion
• Hypotension
• CXR: mediastinal shift
• Emergent decompression– Chest tube– Temporary needle decompression
Tracheal shift
pneumothorax
™ Slide 12
Chest Tube Insertion
• Sterile prep and drape
• +/- Local anesthesia- 1% lidocaine to pleura
• 2-3cm incision at midaxillary line, 5th intercostal space
• Blunt dissection with finger/clamp to pleura
• Listen/feel for gush of air exiting pleural space
• Insert 36F chest tube apically, posteriorly; secure with suture, occlusive dressing
• Attach distal end of tube to suction (-20cm water) with water seal
™ Slide 13
Hemothorax
• Surgical Indications:
• Massive hemothorax = >1500mL immediate return of blood on tube thoracostomy
• Persistent hemothorax = 300mL/h x 3hours
• >1500mL blood/24h
• Chest tube with massive air drainage, or GI contents
™ Slide 14
Cardiac Tamponade
• Blood in pericardial space, compresses heart
• Beck’s triad: hypotension, jugular venous distension, distant heart sounds
• Echocardiogram: impaired diastolic filling
• Treatment: needle decompression or pericardial window
• Image from: http://upennanesthesiology.typepad.com/photos/uncategorized/2007/07/26/tamponade2_b_milas.jpg
Fluid in pericardial space
™ Slide 15
Abdominal Pain
• Abdominal pain syndromes in the ICU:
– Pancreatitis
– Acalculous cholecystitis
– Bowel ischemia
– Bowel obstructive syndromes
™ Slide 16
Pancreatitis
• Epigastric/upper quadrant pain, radiates to back
• + Nausea, vomiting, fever
• ICU Etiology:
– Medications: furosemide, thiazide diuretics, metronidazole, bactrim, ACE-inhibitors, many others
– EtOH, gallstones, ERCP, trauma
– Hyperlipidemia (triglycerides >1,000mg/dl), hypercalcemia
™ Slide 17
Pancreatitis
• Mortality predicted by Ranson Criteria:
– Score 0 to 2 : 2% mortality
– Score 3 to 4 : 15% mortality
– Score 5 to 6 : 40% mortality
– Score 7 to 8 : 100% mortality
• Management
– NPO, IVF, antibiotics if infection or gall stones
– Treat underlying cause
– Surgery only for infected necrosis
On admission Within 48 hours
Age >55 years Hct decreases by >10
WBC >16,000 BUN increases by >5
Glucose >200mg/dl Calcium <8mg/dl
LDH >350 PaO2 <60mmHg
AST >250 Fluid Requirement >6L
Base deficit >4mEq/L
™ Slide 18
Acalculous Cholecystitis
• 5% -10% of all cases of acute cholecystitis
– Observed in the setting of very ill patients, especially trauma and burn victims, also long-term TPN (>3 months)
• Signs/Symptoms: RUQ pain, fever, leukocytosis
• Diagnosis: CT or US: pericholecystic fluid, NO STONES
• Etiology: unclear; stasis vs ischemia
– Higher incidence of gangrene and perforation compared to calculous disease, greater mortality (40%)
• Management: IV fluid, IV antibiotics, emergent cholecystectomy (or cholecystotomy if surgical risk is high and risk of perforation is low)
™ Slide 19
Bowel Ischemia
• Etiology:– ICU patients: Nonocclusive mesenteric ischemia (NOMI) -
splanchnic low flow and/or vasoconstriction• Seen in hemodynamically unstable patients• Decreased CO, hypovolemia, vasoconstrictor medications
– General population: mesenteric arterial embolus, mesenteric arterial thrombus, mesenteric venous thrombus
• NOMI Signs: Abdominal pain, leukocytosis, GI mucosal sloughing, bleeding
• NOMI Diagnosis: Angiography
• NOMI Treatment: optimize volume status, relieve splanchnic vasocontriction; selective intraarterial vasodilators (papaverine, glucagon)
™ Slide 20
Bowel Obstruction
• Mechanical– Gut lumen is blocked due to foreign body, tumor,
intussusception, adhesions; partial vs complete– Open loop obstruction: amenable to proximal decompression;
use NG tube– Closed loop obstruction: inflow and outflow blocked: hernia
incarceration, torsion around adhesive band, volvulus; surgical emergency!
• Functional (neurogenic)– Ileus (small bowel): +/-NG tube, judicious narcotic use– Olgvie’s pseudoobstruction (large bowel): neostigmine +/-
colonoscopic decompression if cecum>10-12cm or if symptomatic >48h; correct electrolytes, reduce narcotics, NG tube
™ Slide 21
Abdominal Compartment Syndrome
• Acute increase in intra-abdominal pressure with resultant critical organ dysfunction
• Seen in trauma patients after laparoptomy, non-operative hepatic or renal trauma victims, burn victims, any patient who receives large-volume resuscitation
™ Slide 22
Abdominal Compartment Syndrome
• Consequences of elevated intraabominal pressure:
– decreases ventilation→ hypoxia, acidosis
– reduces venous return →decreased cardiac output
– venous congestion → reduced capillary perfusion, ischemia, inflammation
– decreased blood flow to kidney →oliguia, renal failure
– decreased blood flow to liver, gut →impaired function
• Early recognition and diagnosis are vital to prevent complications!
– Identify those at risk, measure baseline IAP!
™ Slide 23
Abdominal Compartment Syndrome
• Clinical triad:
– Tense, distended abdomen
– Increased airway pressures
– Oliguira (despite ample resuscitation)
• Diagnosis: Bladder pressure
– Surrogate for intraabdominal pressure
– Bladder filled with 50 cc of sterile saline via Foley and pressure monitor connected to side port with 18-gauge needle
™ Slide 24
™ Slide 25
Abdominal Compartment Syndrome
• Intraabdominal pressure (IAP)
– Normal: <10mm Hg
– Intraabdominal hypertension (IAH): ≥12mmHg
– Abdominal compartment syndrome (ACS): ≥20mmHg with new organ dysfunction
– WSACS IAP Grading:• I 12-15mmHg
• II 16-20mmHg
• III 21-25mmHg
• IV >25mmHg
™ Slide 26
Abdominal Compartment Syndrome
• Management:
– Prevention! Judicious resuscitation!
– Neuromuscular blockade
– Diuresis (only with hemodynamic monitoring)
– Catheter drainage: bedside ultrasound to guide catheter drainage of intraabdominal fluid
– Decompressive laparotomy- definitive• Abdominal fascia left open, often with VAC or Bogota bag
covering wound
• Delayed primary closure
™ Slide 27
Bogota Bag
™ Slide 28
Upper GI Bleeding
• Gastric (ulcer vs. gastritis)
• Duodenal
• Esophageal varices
• Mallory-Weiss
™ Slide 29
Upper GI Bleeding
• Immediately:– 2 large-bore peripheral IVs
– 2 L crystalloid
– STAT labs: CBC, PT/PTT, Type & screen
– NGT, gastric lavage
– Foley catheter
– Consider central line (CVP) or Swan catheter
™ Slide 30
Upper GI Bleeding
• Management
– PPI, H2-blocker
– EGD
– Arteriography
• Treat Varices: vasopressin, octreotide, sclerotherapy, Sengstaken-Blakemore tube, TIPS
• Operative intervention if bleeding remains uncontrolled
™ Slide 31
Mallory-Weiss tear
• UGI bleeding after violent emesis
– Gastric mucosal tear at cardia
– Typically (not always) in alcoholic patients
• Usually stops spontaneously
• May attempt Blakemore tube using gastric balloon for direct pressure.
• Nonoperative treatment: endoscopic electrocoagulation, banding, injection
• Operative intervention rarely needed: oversew laceration
™ Slide 32
Lower GI Bleeding
• Most arise from the colon and rectum
• Large bowel etiologies: diverticula, angiodysplastic lesions, neoplasms, IBD, hemorrhoids, and anal fissures
• Small bowel etiologies: neoplasm, IBD, Meckel’s diverticulum
™ Slide 33
Lower GI Bleeding
• Initial management: as for upper GI bleeding
• Diagnosis:
– Rectal exam
– Colonoscopy
– Radionuclide scan• Bleeding scan
– Arteriography
™ Slide 34
Lower GI Bleeding
Bleeding scan
Source of LGIB
Angiography
Source of LGIB
From: http://brighamrad.harvard.edu/Cases/bwh/hcache/126/full.html
™ Slide 35
Lower GI Bleeding
• Management:
• Arteriographic intervention: vasopressin, coils, gel foam
• 80% success, 50% rebleed risk
• Operative: hemodynamic unstable with >8 units PRBC
• Localization is key, unlocalized LGI bleeding will lead to a blind subtotal colectomy, which is a higher mortality procedure for your patient!
™ Slide 36
Cold Legs
• Acute arterial embolus
– Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis
– Contralateral leg is normal
– No chronic ischemic changes
– Etiology: atrial fibrillation (most common)• Embolus usually obstructs common femoral artery
• Treatment: Embolectomy +/- fasciotomy
• Rare: aortoiliac emboli- loss of pulses to both feet, requires bilateral embolectomies
™ Slide 37
Cold Legs
• Acute arterial thrombosis
– Signs: 6 Ps: pain, pallor, pulselessness, paresthesia, poikilothermia, paralysis
– History of claudication, signs of chronic ischemia
– Poor pulses in contralateral leg
– Not associated with atrial fibrillation
• Treatment: heparin anticoagulation, OR for thrombectomy or angiography for catheter-directed thrombolysis
™ Slide 38
Swollen Legs
• Most common “surgical” etiology is DVT
• Does your patient need an IVC filter?
• Indications:
– DVT and
– Contraindication to anticoagulation and
– High risk of PE
• Percutaneous placement of IVC filter (femoral or jugular)
™ Slide 39
Phlegmasia Cerulea Dolens
• Simultaneous thrombosis of iliac, femoral, common femoral, and superficial femoral veins
• Associated with other critical illnesses, cachexia, dehydration
• Appearance: massively swollen, blue, mottled
• Treatment:
– Limb elevation
– Heparin anticoagulation
– +/- catheter-directed thrombolysis
– +/- thrombectomy
™ Slide 40
Extremity Compartment Syndrome
• Acute increase in pressure within myofascial compartment of an extremity
• Can occur in any compartment, most often lower extremity, anterior compartment
• Complications related to compression of contents of compartment
• Causes rhabdomyolysis, ischemic neuritis, arterial insufficiency, venous gangrene, and limb loss
™ Slide 41
Compartment Syndrome
• Etiology: increase in muscle swelling, hematoma, or interstitial fluid; often secondary to reperfusion injury, burns, fractures, crush injury, tight cast
• Signs/Symptoms:– Extreme pain on flexion is often first sign– Swollen, tense extremity– Loss of sensation first neurologic sign followed by weakness– Last sign is decrease in pulses
• Diagnose: Direct pressure measurement using 18-gauge needle and arterial monitor or Stryker monitor– Pressure >20mmHg OR clinical suspicion– Delta P method: diastolic blood pressure – compartment
pressure ≤30mmHg is indicative of compartment syndrome
™ Slide 42
Compartment Syndrome
• Treatment: Release pressure immediately!
• Evacuate hematoma
• Perform fasciotomy
– +/- VAC wound therapy
– delayed closure
– split-thickness skin graft
™ Slide 43
References
• Koster W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury, Int. J. Care Injured (2005) 36, 992-998.
• Ridley RW, Zwischenberger JB. Tracheoinnominate fistula: surgical managemnt of an iatrogenic disaster. The Journal of Laryngology and Otology (2006) 120, 676-680.
• An G, West MA, Abdominal compartment syndrome: A concise clinical review. Crit Care Med (2008) 36, 1304-1310.
• Maerz L, Kaplan LJ. Abdominal compartment syndrome. Crit Care Med (2008) 36 Suppl, S212-215.
™ Slide 44
References
• Greenfield’s Surgery: Scientific Principles and Practice. Fourth Edition. Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch Jr. GR. New York, NY, Lippincott Williams and Wilkins.
• ACS Surgery: Principles and Practice. Online Edition. Ashley SW et al. http://www.acssurgey.com
• Bowers Rebecca C, Weaver Jeffrey D, "Chapter 8. Compromised Airway" (Chapter). Stone CK, Humphries RL: CURRENT Diagnosis & Treatment: Emergency Medicine, 6th Edition: http://www.accessmedicine.com/content.aspx?aID=3118968.
• Gomella LG, Haist SA, "Chapter 13. Bedside Procedures" (Chapter). Gomella LG, Haist SA: Clinician's Pocket Reference: The Scut Monkey, 11th Edition: http://www.accessmedicine.com/content.aspx?aID=2694363.
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