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