Category Archives: Surgery

Critical Care Refresher Course: Trauma and Surgery

GI Bleed (Kumar)

What is a massive GI bleed?

  • Bleeding resulting in CVS collapse
  • mortality up to 40%
  • over 75% due to upper GI bleed (lower GI bleed mortality 2%)

Etiology

  • Ulcers (Duodenal > Gastric)
  • Gastritis
  • Varices
  • Oesophagitis

Team: Gastroenteritis, Surgeon, Interventional Radiologists

Pharmacotherapy

Acute pancreatitis (Marshall)

Pancreatitis is a chemical burn of the retroperitoneum

Incidence 10-80/100,000

Mortality 10-25%

Pathophysiology

  • Fluid collection, ascites
  • Pseudocyst
  • Fat necrosis

Severity scores –

Resist antibiotics

No other intervention except PATIENCE!

Early surgery for pancreatitis do badly.

Intensive Care for Neurosurgical Interventions

Should we admit elective neurosurgical patients to ICU?

Deciding on which patients to admit to ICU after neurosurgery depends upon pre-op comorbidity, intra-operative interventions and likely course post-operatively.

Traditional Concerns

  • Unexpected neuroworsening
    • Bleeding
    • Oedema
    • Seizures
  • Medical compilation related to procedure per se (e.g. diabetes insipidus)
  • Unrelated medical complications
  • Lack of awareness on the ward

Continue reading Intensive Care for Neurosurgical Interventions

Critical Care Refresher Course: Trauma and Surgery

Polytrauma Patient (Duranteau)

Early mortality is usually due to uncontrolled haemorrhage. Late mortality and disability is due to brain injury and multiorgan failure

Control of haemorrhage

  • Low volume volume resuscitation – SAP 80-90mmHg until bleeding stopped; MAP > 80mmHG in TBI. vaopressor may have role (animal models)
  • Trauma-induced coagulopathy: multifactorial, complex and dynamic. Use TEG
  • Euro recommends plasma:red cell ratio of at least 1:2
  • Plts > 50 ( >100 if ongoing bleeding or TBI)
  • Fibrinogen target of between 1.5-2g/L
  • Early transexamic acid (1g load, followed by 1gm over 8)

 

References

European guidelines of major trauma

Damage control haematology

Trauma-Associated Severe Haemorrhage (TASH) Score

PROPPR Trial

CRASH-2 Trial

 

Perioperative Intensive Care Medicine  (Hiesmayr)

Post op issues on the ICU

  • Volume instability
  • Bleeding – surgical and anaesthetics (lines)
  • Fever
  • Residual anaesthetic drugs
  • Delirium

Know the patient (premorbid state) and know the surgery

Types of surgery and specific problems

  • Vascular – comorbidities, bleeding, ischaemia
  • Ortho – fat embolism, bone-cement cardiac event
  • Solid organ transplant – infection, graft failure, vascular complications
  • Neurosurgery – brain oedema, vascular spasm, hydrocephalus, CNS disturbances e.g. DI
  • Cardiac – hear failure, stiff heart, pulmonary complications, cerebral complications

Consider post-op checklist

References

Post-operative hypoxia

Transplantation and Immunosuppression (Meyfroidt)

HLA; class 1 on all nucleated cells, class 2 on antigen presenting cells

Immunosuppresant drugs

  • Glucocorticoids
  • Calcineurin-inhibitors; cyclosporine, tacrolimus
  • DNA-synthesis inhibitors; AZT, mycophenolate
  • Antibodies; depleting or non-depleting
  • mTOR inhibitors; sirolimus, everolimus

Rejection

  • Hyperacute rejection
  • Cellular rejection
  • Humoral rejection

Kidney transplant complications

  • Surgical complications; vascular, ureter
  • Delayed graft function – living donor 5%, DBD 30%, DCD 50%

Liver transplant complications

  • Monitor liver function
  • Bleeding
  • Arterial complications: ultrasound – early/late hepatic arterial thrombosis

Heart transplant complications

  • Bleeding
  • Rhythm – denervated
  • RV failure – inotropes, iNO
  • LV dysfunction/failure – inotropes, mechanical assist
  • Renal dysfunction – calcineurin inhibitors

Lung transplant complications

  • Respiratory – protective ventilation, assess structures with bronchoscopy, chest tubes, phrenic nerve injury, ischaemia/reperfusion, difficult weaning (anxious/pain)
  • AF
  • Cystic fibrosis: other manifestation e.g. liver GI
  • Infections

Infections – bacterial, viral, fungal, protozoal

References

Review of immunosuppresant drugs