7. THE CARE OF THE CRITICALLY ILL SURGICAL PATIENT Dr.K.S.S Ranatunga Consultant Surgeon Base Hospital Panadura

8. Problems  Ageing population  Concomitant disease processes  Complexity of surgery  Greater number of post-operative interventions & therapies  Shortage of experienced staff  Expectations by patients, relatives & staff

9. Aim  Identification & correction of complications and problems at the earliest stage  Prevents critical illness ( multiple organ failure) with overall mortality of 50% Predict, Prevent and Treat Critically Ill Surgical Patients Successfully

10. Methods  Critical illness is often detectable and can be successfully treated at an initial stage  (30-40)% Of ICU patients had suboptimal ward management  Prediction – Identifying high risk patients  Prevention – Initiate simple remedial measures  Prompt identification of problems & initiate early appropriate treatment early appropriate treatment

11. Practical Management  Clinical Methods – To assess patients & identify problems  Practical Skills – To initiate the appropriate management  Communication & Organizational Skills – To seek help from colleagues or specialists in other fields to tackle a difficult or unfamiliar problems

12. Patients at Risk  Emergencies  Elderly  Coexisting diseases  Non progression  Severe illness / complex surgery  Massive transfusion  Re-operation / re- bleeding  Failure / delay to diagnose & treat underlying problems  Multiple complications  Established shock state

13. Risk Practices  Incomplete or infrequent assessment  Failure to act on abnormal findings  Failure to ensure that interventions have been successful  Failure of continuity of care  Poor communication (Clear, Concise, Confident)  Failure of supporting care  Lack of expertise / Number of staff / Wrong ward

14. Assessing the Critically Ill Surgical Patient  Immediate management - Life threatening illness kills in a predictable & reproducible patterns  Systematic evaluation - Life threatening illness kills in a predictable & reproducible patterns  Systematic evaluation - Assessment and treatment may have to be done simultaneously - Assessment and treatment may have to be done simultaneously A – Airway Assessment and Treatment with Cervical Cord Protection  Look, listen, feel  High flow O2 / (10-15)l /mt  Secure & protect airway ( Airways, ETT, Surgical Airways)

15. B – Breathing Assessment & Restoration of Mechanics of Ventilation  Look, listen, feel  Clinically identify & treat life threatening conditions  Tension pneumothorax, Open pneumothorax, Massive haemothorax, Large flail chest & Pericardial effusion  80% Of thoracic injuries can be managed with tubethoracostomy

16. C – Circulation Assessment and Arrest of Bleeding  Hypovolaemia should be considered as the primary cause of circulatory dysfunction in surgical patients unless proven otherwise.  Assessment (LOC, Pulse, BP, Capillary Return, UOP) & arrest of bleeding  Establish & secure adequate venous access.  16G cannula at antecubital fossa.  16G cannula at antecubital fossa.  Send blood for cross matching & investigations  Send blood for cross matching & investigations  Fluid replacement  Fluid challenge  Fluid challenge – Normotensive 10ml /kg – Normotensive 10ml /kg - Hypotensive 20ml/kg - Hypotensive 20ml/kg  Fluid requirement > 1500-2000ml  blood transfusion  Fluid requirement > 1500-2000ml  blood transfusion  Assess adequacy of resuscitation  Appropriate action - Exanguinating  Emergency surgery - Exanguinating  Emergency surgery - Unstable  Urgent surgery - Unstable  Urgent surgery - Stable  Monitor - Stable  Monitor Clear Diagnosis & Plan Mandatory ! Clear Diagnosis & Plan Mandatory !

17. D – Dysfunction of the Nervous System  A- Alert  V- Response to verbal stimuli  P- Response to painful stimuli  U- Unresponsive  Exclude  Hypoxia, Hypercapnia, Shock, Hypoglycaemia & Sedative Drugs E – Exposure and Thorough Examination  Prevent Hypothermia and Preserve Dignity

18. Re-evaluation  Vital parameters  Signs of improvement  Resuscitative measures  IV fluids, O2, Drugs  Judicial investigations  CXR, ECG, ABG  Other procedures  Urinary Catheter, CVP  Communications  Colleagues, Superiors, Other Specialists, Patient, Relatives and Others

19. Full Patient Assessment  Hx & Ex - Patient, Nurses, Junior Staff, Notes - Patient, Nurses, Junior Staff, Notes - Repeated clinical examination - Repeated clinical examination  Chart review - Temperature, Fluid Balance, - Temperature, Fluid Balance,  Absolute values  Absolute values  Trends  Trends - Drugs - Drugs  Dosage, Frequency, Interactions, Complications  Dosage, Frequency, Interactions, Complications

20. Review of Available Results  Biochemistry – Profile, ABG, RBS  Heamatology – FBC, Clotting, Blood film  Microbiology – Cultures and ABST  Radiology – Examine films & review reports Relate to the Clinical Condition! Relate to the Clinical Condition!

21. Daily Plan  Problems  Remedial Measures  Aims - SBP - SBP - SaO2 - SaO2 - Fluid Balance - Fluid Balance  Actions - IxR - IxR - Specialist Opinion - Specialist Opinion - Nutrition Requirement / Route - Nutrition Requirement / Route - Fluid Balance / Prescription - Fluid Balance / Prescription - Drugs (therapeutic, preventive, routine) & Analgesics - Drugs (therapeutic, preventive, routine) & Analgesics - Removal of drains & tubes - Removal of drains & tubes - Level of care - Level of care The Patient’s Condition and the Investigations should be Reviewed at least Twice a day !

22.  Accept responsibility for patient management  Adopt a systematic approach to patient management  Appreciate that complications tends to cascade rapidly  Anticipate and prevent problems with simple timely actions  Apply effective communications skills to facilitate care  Ask for appropriate assistance in a timely manner

23. THANK YOU THANK YOU