2.11

Management of Surgical Emergencies Part 1 : Critical Care Monitoring in Critical Care Copyright UKCS #284661815

Learning Objectives Why monitor? Where should patients be monitored? When should patients be monitored? Methods of monitoring Copyright UKCS #284661815

Monitoring “Repeated or continuous observations or measurements of the patient, physiological function, and the function of life support equipment, for the purpose of guiding management decisions” [Hudson, 1985] Systematic approach to monitoring - A,B,C,D,E Copyright UKCS #284661815

Critical Care Monitoring Why? Where? Provide trends to identify improvement or deterioration in patient condition. Alert caregivers to potentially life-threatening events Early identification of deteriorating patient Critical Care environment HDU / ICU Theatre & recovery Emergency Department General ward??? Copyright UKCS #284661815

Methods of monitoring

Scenario 0230am – theatre recovery 31 year old male 3 day history of abdominal pain, nausea and anorexia Pyrexial, tachycardic. Peritonism. Laparotomy – perforated appendix abscess with contamination Extubated and self ventilating Copyright UKCS #284661815

AIRWAY MONITORING Observation: Extubated and self-ventilating Talking? Listen – partial obstruction? Clearing secretions? Intubated and ventilated Capnography Airway pressures Fi02 Copyright UKCS #284661815

BREATHING MONITORING Observation: Respiratory rate, effort, accessory muscle use, colour, additional noises? Pulse oximetry and saturations – limitations ?Arterial blood gas – pH, PaCO2, PaO2 ? Capnography – measure end-tidal CO2 Oxygen requirements – FiO2 Copyright UKCS #284661815

CIRCULATION MONITORING ECG monitoring – rate, rhythm Capillary refill Colour Non-invasive blood pressure Invasive blood pressure – beat to beat blood pressure (? ICU) Urine output Copyright UKCS #284661815

DISABILITY MONITORING GCS – Eyes, motor, verbal Modifications for intubated patients or paediatric patients AVPU Pupil response EEG (specialist) ICP (specialist) Copyright UKCS #284661815

Temperature – Core v periphery (less perfusion = cooler periphery) Blood sugar Lactate Urine output – 1ml/Kg/hour Drain output including surgical, chest drains and NG tubes Fluid balance charts Copyright UKCS #284661815

Oxygen Saturation SpO2, using a finger or other probe, measures the proportion of saturated to desaturated hemoglobin Requires adequate perfusion for accuracy Affected by light, jaundice etc Not indicator of ventilation COHb Copyright UKCS #284661815

MEWS Modified Early Warning Scoring Heart rate Systolic Blood pressure Respiratory Rate Oxygen Saturations Temperature AVPU Score dependant upon patient physiology - more abnormal physiology = higher score Useful for identifying deteriorating patient (rising score) Improved decision making and standardisation of monitoring Improved clinical practice Prioritising patients (sicker = higher MEWS)

QUESTIONS

SUMMARY Monitoring does not always have to be technical - eyes, ears, hands & brain most useful Observation and vital signs recording most useful Easy to perform - untrained staff or family Trends more useful that single reading MEWS Don’t forget the patient! Copyright UKCS #284661815