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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 requiringmechanical ventilation.
Generally speaking, any surgical patient whorequires continuous monitoring, 1:1 nursing and /orcontinuous life support is a candidate for SICUadmission.
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The main functions of any ICU isto:
Provide optimum life
support
and
Provide adequatemonitoring 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 rhythmCardiac rhythm ((A fully computerizedA fully computerized
arrhythmia analysis is now availablearrhythmia analysis is now available))
Conduction defectsConduction defects..
Myocardial ischemiaMyocardial ischemia ((SS--T segmentT segment
monitoringmonitoring))
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The five-electrode system
Allows the recording ofAllows the recording of
the six standard limbthe six standard limb
leadsleads ((I, II, III, aVR, aVL,I, II, III, aVR, aVL,
aVFaVF)), as well as one, as well as oneprecordial unipolar leadprecordial unipolar lead..
ComputerComputer-- assistedassisted
arrhythmia analysis andarrhythmia 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
DEVICES3. 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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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 (VT and
MV)are measured.
PIP, Plateau pressure (PP) and Mean airway
pressure are measured.
Dynamic lung compliance is calculated as
DLC= VT
/ PIP
Static lung compliance is calculated as
SLC= VT / 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 obtainedA typical capnogram obtained
during controlled mechanicalduring controlled mechanical
ventilation showingventilation 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 PICO2min and PECO2max
Estimate or measure PaCO2 - PECO2max
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 nm660 nm ((redred)) and 940 nmand 940 nm ((near infrarednear infrared).).
The pulse oximeter measures the AC component of the light absorbanceThe pulse oximeter measures the AC component of the light absorbance
at each wavelength and then divides it by the corresponding DCat each wavelength and then divides it by the corresponding DC
componentcomponent.. RR== 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 whenused 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% to468%,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 ofconcentrating/ diluting capacity of the kidney,
Urine Osmolality: urine osmolality of greater
than 500 mOsm/kgH2O indicates prerenalazotemia and less than 350 mOsm/kgH2O
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 to20 mg/dl.
Urinary Sodium:It is traditionally acceptedthat a urinary sodium level of less than 20mEq suggests prerenal azotemia and a levelof 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, makingintubation more likely to be associated withcomplications
In cases of severe myocardial ischemia, the addedwork of breathing can substantially worsen ischemia.
In general, a PaO2 < 50 or PaCO2 > 55 while the
patient is receiving supplemental oxygen is anindication 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