1.9 Copyright UKCS #284661815.

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Presentation transcript:

1.9 Copyright UKCS #284661815

Management of Surgical Emergencies Part 1 : Critical Care POST-OPERATIVE HYPOXIA Copyright UKCS #284661815

Learning Outcomes Definition of hypoxia Pathophysiology How to assess Symptoms and Signs Management protocols Copyright UKCS #284661815

B A — C — T An important ETCC concept: ABC exist to support tissue oxygenation and organ function. Copyright UKCS #284661815

Definition Hypoxia is impaired tissue oxygenation Hypoxia is one of the most common post-operative complications Copyright UKCS #284661815

Definition Hypoxia is impaired tissue oxygenation Hypoxia is one of the most common post-operative complications Copyright UKCS #284661815

Oxygen delivery is fundamental to managing sick patients. oxygen content x cardiac output Oxygen content = (Hb x 1.36 x SaO2) + (0.0032 x PaO2) (At Hb=15 and SaO2=99 blood carries 200ml O2/liter) CO = SV x HR BP = CO x PR Copyright UKCS #284661815

Oxygen delivery depends on: Airway Ventilation: Central drive, volume, rate, FRC Oxygen availability: %, pA (air and alveoli), pulmonary capillaries Oxygen transport: Hb, Cardiac output, Peripheral resistance Tissues: Oxygen release, Diffusion, Utilisation Copyright UKCS #284661815

What needs to be maintained to prevent tissue hypoxia? Patent airway and effective ventilation Effective gas interchange Arterial oxygen saturation (SaO2) Effective circulation (BP=COxPR) Haemoglobin concentration and integrity O2 release from Hb Extracellular diffusion Oxygen use by cells Copyright UKCS #284661815

Causes of Hypoxia: ↓pAO2 or ∆FiO2 ↓V ∆V/∆Q ↓Hb ↓CO Copyright UKCS #284661815

Surgical patients at risk of Hypoxia: Pre-op hypoxia Smokers, COPD Reduced FRC Elderly, Obesity, Diabetes, GA Surgical pathology Restricted ventilation, SIRS Post-op Sedation Hypothermia Fluid overload Copyright UKCS #284661815

Assessment: History Examination Investigations Risk groups, recent events, charts, medication Examination Signs of organ dysfunction Investigations Pulse oximetry CXR ABGs, Hb ECG Copyright UKCS #284661815

Clinical signs of tissue hypoxia? Altered mental state Altered respiratory rate Arrhythmias Peripheral vasodilatation Systemic hypotension Cyanosis (?) Copyright UKCS #284661815

What does Pulse Oximetry measure? Gives an estimate of percentage saturation on oxygen binding sites on Hb NOT the same as PaO2 Related to PaO2 through sigmoid shaped O2-Hb dissociation curve Copyright UKCS #284661815

Oxygen dissociation curve 100 80 % saturation 60 40 20 30 60 90 120 150 pO2 mmHg

Pulse Oximetry Remember: 95%-100% = normal <93% = warning! (ask “Why?”) <90% = patient in serious trouble (do something now) Double check that you distinguish the SaO2 from the pulse rate when looking at the monitor. Copyright UKCS #284661815

Copyright UKCS #284661815

Error readings in pulse oximetry: Low cardiac output Vasoconstriction SaO2 <70% Poor positioning Movement Hypothermia (often in trauma patients) Abnormal Hb (COHb, MetHb) Hyperthermic limb Dirty probe Black, blue or green nail polish External light Copyright UKCS #284661815

Error readings in pulse oximetry: Low cardiac output Vasoconstriction SaO2 <70% Poor positioning Movement Hypothermia (often in trauma patients) Abnormal Hb (COHb, MetHb) Hyperthermic limb Dirty probe Black, blue or green nail polish External light Copyright UKCS #284661815

Likely causes of Hypoxia Pulmonary oedema Bronchopneumonia Lobar pneumonia Pre-existent COPD Atelectasis with hypoventilation Pulmonary embolism ARDS Copyright UKCS #284661815

Pulmonary Oedema Bronchopneumonia Diffusion barrier “at risk” patient, fluid balance CXR: diffuse bilateral changes Bronchopneumonia Shunting “at risk” patient CXR: localised woolly unilateral shadowing Copyright UKCS #284661815

Pulmonary Embolism ARDS Ventilation/perfusion mismatch “at risk” patient CXR: usually normal ARDS Shunting “at risk”patient CXR: bilateral widespread diffuse shadowing Copyright UKCS #284661815

Copyright UKCS #284661815

Copyright UKCS #284661815

Copyright UKCS #284661815

Copyright UKCS #284661815

Management Airway Oxygen Ventilation Circulation Other supportive Physiotherapy; Bronchodilators; Mucolitics Specific Antibiotics; Anti-coagulation Copyright UKCS #284661815

Questions? Copyright UKCS #284661815

Summary Aim to prevent hypoxia Thorough assessment of any postoperative hypoxic patient Think: Stable or Unstable/Unsure? Consider all factors in the oxygen delivery pathway. Think “Why?” Assessment guides Management Copyright UKCS #284661815