1. SURGICAL INTENSIVE CARE By Prof. GAMAL ELEWA Dept. of Anesthesia, Intensive Care and Pain Management Faculty of Medicine, Ain Shams University Anesthesia Department

2. © gamal elewa, 2012 I L O Intended Learning Outcomes By the end of this lecture, the student will be able to: 1.Know criteria of intensive care 2.Differentiate between different types of intensive care 3.Select patients for admission & Identify criteria of discharge 4.Care of surgical intensive care patients 5.Use proper monitors in intensive care unit (ICU) 6.Suspect and prevent complications 7.Understand Management principles of surgical ICU patients

3. AIM What’s ICU? (Definition) What’s in? Characteristics? Types of ICU? (Classification) Indications: In & Out? Monitoring Care of patients in ICU Complications? Criteria for Discharge? © gamal elewa, 2012

4. What’s ICU? Place where there’s: Intensive Monitoring, Intensive (close) Nursing care, Special Equipment: ventilators, … Patient is critically ill, Doctor(s): present 24 h, well trained in management of critically ill patients © gamal elewa, 2012

5. Characteristics Equipment: Monitors & Ventilators, DC Shock, Portable x- Ray, Dialysis, … Doctors: 24h on duty, Qualification Nursing Staff: 1:2 patients, qualifications Communications with: doctors, wards, lab, radiology, O.R., Bl. Bank, other departments, pt. relatives Patients: critically ill, life- threatening condition: resp. failure, life threatening dysrrhythmias, p.o. cardiac surgery © gamal elewa, 2012

6. Types of ICU Design: Closed vs Open Speciality & subspeciality: - Surgical (Cardiac, Neurosurgical, Obstetric, Burn, General), - Medical (Coronary care unit “CCU”, Chest, Neurology, Stroke, General), - General (combined surgical and medical) © gamal elewa, 2012

7. Types of ICU (cont.) Surgical General, Cardiothoracic, Neurosurgical, Obstetric & Gynecologic, Burn Intensive Care General ICU (Combined Medical & Surgical) Medical CCU, Chest, Neurology, Geriatric Intermediate Care © gamal elewa, 2012

8. Types of ICU (cont.) Closed ICU Staff & System Patients: IN & Out (Drain & Discharge ) Design Visitors Open ICU © gamal elewa, 2012

9. INDICATIONS For Admission (Causes of Admission to Surgical ICU) Surgical: Brain tumor, cervical spine, cardiac surgery, associated medical condition… Preoperative: hemodynamically unstable (shocked, serious arrythmias) multiple trauma Trauma: Airway, Chest, Cardiac, Brain, Cervical spine, … Medical: ischemic heart disease (IHD), cerebro- vascular stroke, uncontrolled hypertension, complicated diabetes, Resp., cardiovascular, multi-organ dysfunction syndrome (MODS), … Combined © gamal elewa, 2012

10. Monitoring According to: Patient condition Type of surgery Anticipated complications Types: ECG: Rate, rhythm, ischemia Blood pressure (BP): invasive (IBP) vs non invasive (NIBP) Pulse oximeter (S P O 2 ): O 2 saturation, HR Capnography (PCO2) Central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac output (C.O.) Urine output, Fluid Balance Level of Consciousness, Blood Sugar Arterial blood gases (ABGs), Drains, chest tubes,… © gamal elewa, 2012

11. CARE OF SURGICAL ICU PATIENTS According to: Type of surgery and anticipated complications Associated condition (e.g. trauma, pregnancy) and/ or diseases (Ischemic heart disease, hypertension, diabetes, liver and renal dysfunction, COPD) Level of consciousness Required Position of patient © gamal elewa, 2012

12. CARE OF SURGICAL ICU PATIENTS Includes: Monitoring Infection control Position Vascular lines, catheters, tubes, drains,… Connected devices: ventilators, intra-aortic balloon pump,.. Nutrition: - Route: enetral (oral, Ryle, gastrostomy, jejunostomy, ileostomy), parenteral - Type: diabetic, liver, renal, resp. - Amount - Timing © gamal elewa, 2012

13. CARE OF COMATOSED PATIENTS Suspected complications: Bed sores Respiration: obstruction, infection, Aspiration Infection Malnutrition Deformities Care: Position, physiotherapy Resp.Rate, pattern, SpO2, temp., auscultation, CXR Nutrition support: Route (enteral, parenteral), constituents, amount © gamal elewa, 2012

14. CARE OF NEUROSURGICAL ICU PATIENTS Suspected complications: Consciousness Fits Bleeding Fluid imbalance Other neurological deficits Care: Glasgow Coma Scale (E/V/M) (4/) CT Brain ? Antiepileptics Fluid Chart, Drains Motor & sensory monitoring © gamal elewa, 2012

15. CARE OF CARDIAC SURGERY ICU PATIENTS Suspected Complications: Dysrhythmias & heart block Cardiac Failure & pulmonary edema Bleeding & Tamponade Blood pressure changes Neurological complications Renal dysfunction Care: ECG, Antiarrythmic Pace Maker CVP, PCWP, Inotropes, vasopressors, vasodilators Intra-aortic baloon pump Neurological assessment Renal assessment & protection © gamal elewa, 2012

16. CARE OF INVASIVE DEVICES Suspected Complications: Infection Displacement Trauma Care: Hand wash Gloves Sterilization Antiseptic Exchange C&S © gamal elewa, 2012

17. CONTROL AND PREVENTION OF INFECTION To patient Hand wash Gloves, Masks Equipment Sterilization Air condition Isolation Carrier detection Antimicrobials To ICU staff Hygiene measures Hand wash Gloves, Masks Check up © gamal elewa, 2012

18. Prevention of Iatrogenic Complications Suspected Complications: Antibiotic sensitivity & Drug anaphylaxis Inadvertant intra-arterial injection Wrong drug injection & blood transfusion Infection Care: Drug sensitivity test Lablling Re-check vigilance © gamal elewa, 2012

19. Indications of Mechanical Ventilation Respiratory failure Delayed post operative (P.O.) recovery Increased intra cranial pressure (ICP) CPR (Cardiac arrest) P. O. Hemodynamically unstable © gamal elewa, 2012

20. Acid Base & blood Gases Normal ABG pH=7.40±0.04 PCO2=40±4 mmHg PO2= 60-100 mmHg HCO3 - = 24±2 mmol/l BE=± 2 mmol/l S.K + =3.5 – 5 mmol/l S. Na + =135 ± 4 mmol/l S. Ca ++ (ionized) =0.9 - 1.4 mmol/l Acidosis: pH<7.36 Alkalosis: pH>7.44 Respiratory vs Metabolic 1ry vs 2ry Compensated vs Decompensated © gamal elewa, 2012

21. COMPLICATIONS & HOW TO PREVENT AND TREAT Specific to: Operation: Cardiac, Brain, Spine, Urology Patient illness: Diabetes, HTN, IHD, Bed ridden Interference: CVP, Urinary catheter, Mechanical Ventilation General Sepsis ICU Psychosis Trauma Drug interactions & Idiosyncrasy © gamal elewa, 2012

22. GENERAL COMPLICATIONS Sepsis: Resistant organisms Psychic trauma & depression Myopathy & Neuropathy Drug complications & dependence Of interference: Central Line, Urinary Catheter, Mechanical Ventilation Bleeding Deteriorated level of consciousness Hemodynamically unstable Epileptic fits Trauma Nutritional Bed Sores © gamal elewa, 2012

23. COMPLICATIONS Of Cardiac surgery Heart Failure Dysrhythmias Bleeding Cardiac Tamponade Neurological Renal Of Neurosurgical Operations Delayed Recovery & Deteriorated conscious level, Coma Epileptic Fits Bleeding Fluid Imbalance & Dehydration Paralysis or paresis © gamal elewa, 2012

24. CRITERIA FOR DISCHARGE Conscious? Cardiovascular system Respiratory System Renal Surgically (controlled or stable) Metabolic Other organ functions © gamal elewa, 2012

25. Summary of important points What’s ICU: Types of ICU: Indications for admission and discharge Complications: Diagnosis, prevention, management Care of surgical ICU Patients © gamal elewa, 2012

26. THANK YOU BEST WISHES © gamal elewa, 2012