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Anesthesia ICU

Apr 10, 2018

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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