N.K. Durrani, MDN.K. Durrani, MDM. McCann, DOM. McCann, DO

M.M. Brandt, MD, FACS, FCCM M.M. Brandt, MD, FACS, FCCM P. Patton, MD, FACS P. Patton, MD, FACS

H.M. Horst, MD, FACS, FCCMH.M. Horst, MD, FACS, FCCM I. Rubinfeld, MDI. Rubinfeld, MD

Dept. of Trauma SurgeryDept. of Trauma SurgeryHenry Ford Hospital, DetroitHenry Ford Hospital, Detroit

Surgical Issues in Surgical Issues in Critical Care MedicineCritical Care Medicine

ObjectivesObjectives

Discuss surgical issues that develop in ICU patients

Discuss peri-operative issues relevant to nonsurgical intensivists

Not inclusive of trauma

User’s Guide to Your Surgical ConsultantUser’s Guide to Your Surgical Consultant

Surgeons do not have “admission cap”

The are rarely on a “consult” service

They, too, have emergencies, primary patients, and lack of sleep

If your patient can’t tolerate a haircut, you may not want to call for a surgical consult

In some cases surgeons may feel pressured to operate solely because you have consulted!

Surgical Complications in Surgical Complications in Intensive Care PatientsIntensive Care Patients

Airway: Airway loss and emergent management

Pulmonary: Simple and tension pneumothorax

Cardiac: Tamponade

Abdominal Treasures: Abdominal pain, catastrophe, and ileus

Bleeding and NOT Bleeding: GI bleeding, lines, hematomas, cold legs, ischemic bowel, etc.

Surgical Airways: Surgical Airways: Crichothyroidectomy and TracheostomyCrichothyroidectomy and Tracheostomy

Only reason not to intubate is inability to do so, nonsurgical always preferred: i.e., orotracheal, nasotracheal

Relative contraindications to intubation• C-spine instability• Midface fractures• Laryngeal disruption• Obstruction of lumen

AirwayAirway

Upper airway obstruction from whatever cause: Trauma, angioedema, etc.

Considerations: Do they need something done? How fast? How desperate are we?

• Traditional intubation• Nasotracheal• Fiberoptic and other adjuncts

Airway: SurgicalAirway: Surgical

Needle Cricothyroidotomy: Short-term solutions, user dependant, no CO2 clearance

Cricothyroidotomy: smaller tube, can clear CO2, needs experience, percutaneous kits available

Airway: SurgicalAirway: Surgical

Tracheostomy: Not usually for emergencies, need experience, “knife and a tube”

Percutaneous Tracheostomy: Not for emergency situations

Airway: SurgicalAirway: Surgical

Massive hemoptysis

Emergent bronch for source and possible treatment

Consider bronchial blocker for isolation

Angio options: Embolize bleeding source

Emergent lobectomy if localized

Surgical Pulmonary EmergenciesSurgical Pulmonary Emergencies

Pneumothorax (Simple): Partial or complete collapse—increases pulmonary shunt

• Chest tube in emergency• Attempt catheters as well• Treat “conservatively” in stable

asypmtomatic patients• Aggressive therapy if on positive

pressure• Can progress to tension

pneumothorax

Tension PneumoTension Pneumo

True Surgical Emergency

• Say it! “This is a tension...”• Can relieve with needle or catheter, but it’s not definitive

therapy! • Any patient who has been needled needs a tube, now!

Don’t leave the patient until it’s in!• Clinical DX, x-rays suggest missed diagnosis

HemothoraxHemothorax

Massive Hemothorax

• Can be result of lines or thoracentesis• Limited diagnostic use of

thoracentesis• Chest tube is intial management• Larger size tube 40FR• If large quantity or persistent then

surgery

Cardiac TamponadeCardiac Tamponade

Equalization of pressures compression of RA reduces and then eliminates preload

Temporized with needle or catheter decompression

Definitive surgery: pericardial window, pericardiotomy

If blood, may need operation for trauma

The Abdominal Treasure Box The Abdominal Treasure Box

Abdominal pain syndromes in the ICU:

• Pancreatitis• Acalculous Cholecystitis• Bowel ischemia• Bowel obstruction/ileus/Ogilvie’s

PancreatitisPancreatitis

Pain—“steady, dull” —epigastric/upper quadrant, back

Nausea/vomiting/fever

Due to medications/other illnesses/hypotension

One reason for shock in the “nonsurgical patient”

Can become surgical, if necrotizing or infected

Acalculous CholecystitisAcalculous Cholecystitis

5-10% of all cases of acute cholecystitis

Observed in the setting of very ill patients

Higher incidence of gangrene and perforation compared to calculous disease

Those on TPN for more than 3 months

Bile stasis and increased lithogenicity of bile

Critically ill patients are more predisposed

Bowel IschemiaBowel Ischemia

Nonocclusive mesenteric ischemia can occur without arterial or venous abnormalities.

20-30% have nonocclusive disease

Poor perfusion secondary to congestive heart failure, MI, or hypovolemia

Low-flow states cause peripheral vasodilation and shunting of the blood from gut to the periphery.

Digitalis causes vasoconstriction of both arterial and venous smooth muscle cells in mesenteric vasculature.

Bowel ObstructionBowel Obstruction

Multiple etiologies of obstipation in ICU

Bowel obstruction, ileus, Ogilvie’s

Patients can develop obstruction at any time

Ileus associated with many nonsurgical diseases

Nonoperative therapy

Ogilvie’s occurs in the elderly and debilitated

Medical (fix electrolytes, avoid narcotic) and surgical therapy

Surgery for true peritonitis or complete bowel obstruction

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

Acute increase in intra-abdominal pressure

Affects renal, pulmonary, and cardiovascular systems

Decreases ventilation, causes hypoxia, decreased blood flow to lower extremities, and kidney failure

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

Caused by intra-abdominal swelling or hemorrhage

Increase in volume of retroperitoneum such as with pancreatitis also seen

Even reports of retroperitoneal hemorrhage such as with pelvic fracture or from anticoagulation

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

Early recognition and diagnosis vital to prevent complications

Distended, tense abdomen first sign

Bladder pressure confirms elevated pressure and is easy to perform

Bladder is direct transmitter of pressure at volumes of less than 100 cc.

Bladder Pressure MeasurementBladder Pressure Measurement

Bladder filled with 50 cc. of sterile saline via foley and pressure monitor connected to side port with 18 ga. Needle

Normal pressure up to 10 cm H2O

Grade I = 10-15

Grade II = 15-25

Grade III = 25-35

Grade IV = >35

Abdominal Compartment SyndromeAbdominal Compartment Syndrome

Grade I-II can be treated with muscle relaxants as long as clinical situation improves

Laparotomy with open abdomen

Grade III and over

Failure of improvement with conservative measures

UGI BleedUGI Bleed

Gastric (ulcer vs. gastritis)

Duodenal

Esophageal varices

Mallory-Weiss

MonitorMonitor

2 large bore perph. IVs

2 L crystalloid, T&C

Labs: CBC, Plts., Coags

CVP, Swan, Foley

NGT

TherapeuticTherapeutic

H2 blockers ,PPI

EGD

Arteriography

Varices: vasopressin, octreotide, sclerotherapy, Sengstaken-Blakemore tube, TIPS

Operative intervention

Mallory-Weiss tearMallory-Weiss tear

Usually stops spontaneously

Ngt to decrease distention and emesis

May attempt Blakemore tube using gastric balloon for direct pressure.

Operative intervention rarely needed (but a cool case never the less)

LGI BleedLGI Bleed

Most arise from the colon and rectum

Diverticula, angiodysplastic lesions, neoplasms, IBD, hemorrhoids, and anal fissures

Small bowel, neoplasms, IBD, Meckel’s diverticulum

DiagnosticDiagnostic

Radionuclide scan

Arteriography

Colonoscopy

Rectal exam

TherapeuticTherapeutic

Arteriographic intervention; vasopressin, coils, gel foam, (and localization!)

80% success, 50% rebleed risk

Operative; hemodynamic unstable with >8 units PRBC

Localization is key, unlocalized LGI bleed will lead to a blind subtotal colectomy, which is a higher mortality procedure for your patient!

Cold LegsCold Legs

Acute arterial insufficiency

5 Ps: pain, pallor, pulselessness, paresthesia, and paralysis

Usually remember when pain began

Cold Legs (cont.)Cold Legs (cont.)

Immediate evaluation needed; irreversible injury if not reversed after 6 hours

Anticoagulation and to OR if DX is clear or DX unclear angiogram to delineate chronic vs. embolic

PostoperativePostoperative

Reperfusion of ischemic extremity; wash out of byproducts leads to acidosis, hyperkalemia, myglobinemia; these must be treated

Myoglobinemia; to renal failure—hydration is the key

Watch for compartment syndrome of extremities 2nd to reperfusion

Swollen LegsSwollen Legs

Most common “surgical” etiology is DVT

Does your patient need a filter?

Failure of or contraindication to anticoagulation

Others include limb compartment syndrome

Extremity Compartment SyndromeExtremity Compartment Syndrome

Acute increase in pressure within myofascial compartment of an extremity

Can occur in any compartment

Complications related to contents of compartment

Causes rhabdomyolysis, ischemic neuritis, arterial insufficiency, venous gangrene, and limb loss

Compartment SyndromeCompartment Syndrome

Due to increase muscle swelling, hematoma, or interstitial fluid

Swollen, tense extremity is first sign

Loss of sensation first neurologic sign followed by weakness

Last sign is decrease in pulses

Compartment SyndromeCompartment Syndrome

Early diagnosis is key to avoiding complications

Direct pressure measurement using 18 ga. needle and arterial monitor

Or the more popular Stryker pressure monitor

Compartment SyndromeCompartment Syndrome

Early diagnosis is key to avoiding complications

Direct pressure measurement using 18 ga. needle and arterial monitor

Or the more popular Stryker pressure monitor

Compartment SyndromeCompartment Syndrome

Treatment depends on cause

Arterial injury requires repair and evacuation of the hematoma, fractures require immobilization and elevation.

Severe swelling from any cause is treated with fasciotomy to release pressure.

Compartment SyndromeCompartment Syndrome

Pressure of <30 mmHg can be observed.

Pressure between 30-40 mmHg should be decompressed unless it can be controlled within short time (1-2 hrs).

Pressure >40 mmHg requires immediate decompression.

Case 1Case 1

62-year-old male undergoes cardiac catheterization and sustains a retroperitoneal hematoma requiring blood and fluids

He is in your unit, getting sicker, and is intubated.

Inspiratory pressures are rising on ventilator

Urinary output diminishing despite resuscitation and the creatinine rising

Now, the abdomen seems distended.

Case 1 (cont.)Case 1 (cont.)

What else do you want to know?

His x-ray shows low lung volumes, no PTX.

His ABG demonstrates difficulty with ventilation, and increasing metabolic acidosis.

His bladder pressure is 40 mmHg.

What is the diagnosis? How does it occur?

What should be done?

Case 2Case 2

89-year-old male with Legionnaire's pneumonia is admitted to the MICU

• Intubated, then trached, on antibiotics and TPN• Finally now on tube feeds via PEG• Starts to develop high residuals• The abdomen seems distended

Case 2 (cont.)Case 2 (cont.)

What do you want to know?

Abdominal XR shows dilated loops of bowel.

ABG reflects acidosis.

What labs do you want?

US gallbladder normal

AMYLASE, LIPASE elevated

What to do?