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Management of Critical Perioperative Patients

Learn the responsibilities and actions for ICU residents, maximize fluid resuscitation, recognize and manage post-op complications promptly. Includes a real case scenario, fluid management guidelines, and differential diagnosis for critical situations.

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Management of Critical Perioperative Patients

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  1. Management of Critical Perioperative Patients Christiana Weng, M.D. Surgical Registrar

  2. Objectives • Learn the ICU resident responsibilities • Maximize fluid resuscitation • Recognize post-op complications promptly • Initiate appropriate post-op complication managment

  3. Your responsibilities • Admit surgical ICU patients • From ER, OR, or the floor • Take sign-outs from the surgeons • Admit to ICU/IMCU accordingly • Delegate post-op check if floor patient • Assign resident surgical assistance

  4. A real case.. • “Doctor, my post-op patient has had no urine output for the last 4 hours. Should we give her some Lasix?” • What do you say?

  5. Fluid Management Fluid Good. Lasix Bad.

  6. Resuscitation Fluids • Crystalloid- NS and LR boluses • Colloid- • Hespan-max 1500ml/day • Impairs platelet function • Be ware of DIC, thrombocytopenia, bleeding patients • Albumin

  7. Fluid Resuscitation • Colloid is not better than crystalloid. • Give enough NS/LR before giving Hespan. • Must give back all volume lost to NGT, drains, open wounds, etc. • Usually give at least 3+ liters of fluid before using pressors.

  8. Action plan • Go see the patient! • Gather pertinent history • Perform a focused exam • Gather data • Think! DDx, your plan • Call appropriate consultants

  9. Go See the Patient! • 54yo female with DM2, HTN; charge nurse at the jail by profession • Temp 102.4, BP 108/64, HR 138, RR28, O2Sat 94% on 2L • Patient moaning in pain, not answering questions, breathing hard.

  10. Gather pertinent history • What surgery did they have? • How has the post-op course been?

  11. More history.. • POD #1 lap chole, enterotomy repair by small bowel resection with primary anastomosis, liver biopsy x3 • Persistent nausea post-op • On PCA but abd pain 10/10 • Was 98% on 2L at the beginning of shift; now 94% on 2L

  12. Perform a Focused Exam • Altered mental status? • Arrhythmia? Weak pulses? • Unequal breath sounds? Crackles? • Acute abdomen? • Cold extremity with unequal pulses? • Wounds and drains • Succus entericus? Blood? Acsitic fluid?

  13. On exam • Tachycardic but regular rhythm • Decreased breath sound left lower lobe • Abd distended with absent bowel sound • Patient moans with each percussion • Fascia intact, dressing clean • Foley with 50ml dark yellow urine

  14. Gather data • Vitals – UOP, temp, CVP, BP, HR, O2Sat • Drain quantity • Labs- hgb drop, lactic acid • ABG • Abdominal compartment pressure • KUB or CXR What would you order on this patient?

  15. Labs came back • Cr 1.3 (was 0.9) • BiCarb 19 (was 26) • Total bili 1.6 (was 0.9); direct bili 0.6 • WBC 2.9 (was 6.1) • Hgb 12.6 (was 12.3) • Lactic acid 4.7 • 7.38/37/61/21/91% • Abdominal compartment pressure 25

  16. KUB

  17. CXR

  18. Think! • Think about the surgery/procedure and everything that could go wrong. • You won’t find the cause if you don’t think of it. • A good plan of action depends on a good list of differential.

  19. Differential Diagnosis • Shock- hypovolemic, septic, cardiogenic • Dehiscence/evisceration • Abd or limb compartment syndrome • Neurovascular injury • PE/DVT • Pneumothorax • MI/Stroke

  20. Septic Shock • Overwhelming infection = vasodilation • Bowel perforation? Anastomotic leak? • Any pus under pressure • Intra-abdominal abscesses, psoas abscesses, epidural abscesses, obstructing kidney stone • Aspiration pneumonia or urosepsis? • Broaden empiric abx coverage

  21. Fascial dehiscence/Evisceration • Tell-tale sign: dressing drenched with ascitic fluid • Malnurished, obese, immunosuppressed • Yes, that’s 90% of our patients! • Check and feel for the integrity of the midline incision • If eviscerating… • Cover eviscerated bowel with wet gauze • Call the surgeon right away

  22. Abdominal compartment syndrome • Tell tale signs: progressive oligurea, tense abdomen, increased respiratory distress • Ex-lap patients, cirrhotics, malnurished • Measure IAP by connecting a foley to the CVP monitor • Abnormal if >20cm H2O • Dangerous if >30cm H2O

  23. Abd Compartment Syndrome • Treatment: Decompression • Remove the wound vacuum suction • Drain the ascites (repeat if necessary) • Surgically

  24. Limb Compartment Syndrome • Tell tale signs: weak or absent pulses, blue or dusky limb, tense, extreme tenderness • Release all external pressure • Call the orthopod for emergent fasciotomy

  25. Back to our patient… • Worsening septic shock suspected based on AMS, low WBC, and peritoneal signs • DDx: PE, unrecognized enterotomy, anastomotic leak, early intra-abd abscess, occult intra-abd bleeding, bile peritonitis • Stat chest CT negative for PE • Surgeon was called and patient taken back to OR emergently • An enterotomy was found and repaired

  26. Bottom Line… • Aggressive fluid resuscitation • Lasix bad. Fluids good. • Adequate resuscitation= when you see pee. • Really examine your patient. • Think, then you’ll know what to do.

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