The Surgical Critical Care Handbook : Guidelines for Care of the Surgical Patient in the ICU

This handbook considers topics that have general application to the critically ill patient. Basic pathophysiology and understanding of its role in critical care monitoring and management are covered, followed by a close look at trauma related and non-trauma related entities likely to afflict the critically ill surgical patient. The authors consist of practitioners who are experts in their field. They represent the team approach to critical care management where members from the divisions of anesthesia, internal medicine, respiratory medicine, infectious disease and surgical specialties all contribute in formulating intervention, assessment and management plans for the critically ill surgical patient. By emphasising the surgical conditions requiring critical care, The Surgical Critical Care Handbook will serve as a quick and easy reference for any medical trainee or practitioner aspiring to join the ICU. Contents......Page 5 Foreword......Page 9 About the Editor......Page 11 List of Contributors......Page 14 SECTION 1 General Considerations......Page 25 Chapter Overview......Page 26 Preoperative Screening......Page 27 Assessment of Cardiac Morbidity for Non-Cardiac Surgery......Page 28 Preoperative coronary revascularization......Page 30 Intensive perioperative management......Page 31 Transesophageal echocardiography (TEE)......Page 32 Type of Surgery: Type of Anesthetic......Page 33 Recommendations......Page 34 Clinical assessment of pulmonary risk......Page 35 Evaluation of risk prior to pulmonary resection surgery......Page 36 Perioperative preparation......Page 37 Site of surgical incision......Page 38 Recommendations......Page 39 Diabetes Mellitus......Page 40 Risk Reduction......Page 41 Glucocorticoid Supplementation in Chronic Glucocorticoid Users......Page 43 References......Page 44 Appendix 1. Considerations for preoperative Anesthesia assessment......Page 47 Appendix 4. Eagle criteria: Surgery specific risk for cardiac complications......Page 49 Definition of Shock......Page 52 Hypovolemic shock......Page 53 Distributive shock......Page 54 Endocrine and catecholamine release......Page 55 Reperfusion Injury......Page 56 End Points of Resuscitation......Page 57 Monitoring Principles that Govern Treatment......Page 59 Preload......Page 60 Myocardial contractility......Page 62 Afterload......Page 63 References......Page 64 Chapter Overview......Page 66 Normal values for arterial blood gases......Page 67 Calculation of VD......Page 70 Relation between VA and PaCO2......Page 71 The “steady-state”......Page 72 The Va graph......Page 73 Causes of hypercapnia......Page 74 The simplified alveolar air equation for oxygen ......Page 75 Hypoxemia in the presence of a normal alveolar–arterial O2 gradient......Page 76 Shunt and V/Q Mismatch and their Contribution to Hypoxemia......Page 77 V/Q mismatch as a cause of hypoxemia......Page 83 References......Page 85 Chapter Overview......Page 88 Effect of Metabolic Stress, Fluid Volume, Oxygen Requirement, and Nutritional Support on Respiratory Function......Page 89 Oncotic pressure......Page 91 Capillary permeability......Page 92 Atelectasis and Hypoventilation......Page 93 Age, Position, and Lower Airway Closure......Page 94 Diaphragm Dysfunction and Abdominal Surgery......Page 96 Aspiration......Page 99 Prevention of Perioperative Lung Dysfunction......Page 100 Treatment Principles for Perioperative Respiratory Dysfunction......Page 102 References......Page 103 Functions of the respiratory system and its malfunction leading to respiratory failure......Page 106 Patient factors......Page 107 The Alveolar Gas Equation (Age) And Modes of Ventilation......Page 108 Modes of Ventilation......Page 110 Initial Ventilator Settings......Page 112 Other Methods of Mechanical Ventilation......Page 113 Monitoring the Ventilated Patient......Page 114 The slower stepwise liberation process......Page 115 References......Page 117 Physiologic Adaptation to Fasting States, Stress, and Sepsis......Page 120 Nutrition Assessment......Page 121 General Principles......Page 123 Enteral Nutrition......Page 124 Composition in Different Disease States......Page 127 Parenteral Nutrition......Page 130 References......Page 135 Epidemiology and Significance......Page 138 General Principles of Managing a Bleeding Patient on Anticoagulant and Antiplatelet Agents......Page 139 Warfarin......Page 140 Factor IIa inhibitors (Dabigatran)......Page 142 Antiplatelet agents......Page 143 References......Page 145 Chapter Overview......Page 148 Classification......Page 149 Diagnosis and Microbiology......Page 150 Treatment......Page 151 Management of Organ Failure......Page 153 Risk factors and pathophysiology......Page 154 Prevention......Page 155 Diagnosis......Page 159 Treatment......Page 163 References......Page 165 Maintenance of Temperature......Page 168 Etiology and classifi cation......Page 169 Pathophysiology......Page 171 Diagnosis......Page 172 Management......Page 173 Prognosis......Page 174 Etiology......Page 175 Diagnosis......Page 177 Management......Page 178 References......Page 179 Risk for Venous Thromboembolism in the ICU......Page 182 VTE Prevention......Page 183 Diagnosis......Page 188 Treatment......Page 189 References......Page 192 A Listing And Brief Considerations of Broad General Principles of Antibiotic Usage......Page 194 Surgical Antimicrobial Prophylaxis......Page 202 Classification of Wounds......Page 204 The Key Updates in the Revised Guidelines are......Page 206 Common Principles......Page 207 Common Surgical Pathogens......Page 208 Summary......Page 220 References......Page 221 Chapter Overview......Page 224 The Coagulopathy of Trauma......Page 225 Fibrinogen consumption and fi brinolysis......Page 226 Triggers for Massive Transfusion Protocols and the Protocols......Page 228 The protocols......Page 229 Point of care parameters and their measurement to guide massive transfusion......Page 230 Massive Transfusion Protocol Logistics......Page 231 MTP TEAM- Roles and responsibilities......Page 232 Responsibilities during MTP......Page 233 MTP Activation criteria......Page 235 Patient Clinical Area......Page 236 Portering services......Page 238 Transfusion Medicine Laboratory (TM)......Page 239 Ongoing management during MTP......Page 240 Transfusion Management......Page 241 Supportive Measures......Page 242 References......Page 243 Chapter Overview......Page 246 Outcome following ICU admission for the elderly......Page 247 Cardiovascular ......Page 248 Pulmonary......Page 255 Renal......Page 256 Hepatic......Page 258 Gastrointestinal tract ......Page 259 Central Nervous System ......Page 260 Polypharmacy......Page 263 Malnutrition......Page 264 Decreased immunity......Page 265 End-of-life Issues, Palliative Careand Withdrawal/Withholding Of Care......Page 266 Summary......Page 269 References......Page 270 Chapter Overview......Page 274 General Principles of Biomedical Ethics Applied to the Critical Care Environment......Page 275 Ethical Principles and the Law ......Page 278 Withholding and Withdrawing Care ......Page 281 Clinical Research in the ICU ......Page 282 Role of the Ethics Committee......Page 283 References......Page 284 (a) TRAUMA......Page 286 Chapter Overview......Page 288 The Order of Priorities......Page 289 Removal of the spine board......Page 290 Airway, oxygenation, ventilation, and cervical spine control......Page 291 Caution-Iatrogenic Tension Pneumothorax......Page 294 Circulation......Page 295 Differentiation of Non-hemorrhagic from Hemorrhagic Shock and Confounding Presentations......Page 298 The Secondary Survey......Page 300 Transfer to Definitive Care......Page 301 Summary......Page 302 References......Page 303 Introduction......Page 306 Classification of Thoracic Trauma......Page 307 Thoracic Injuries Requiring Immediate Intervention (The “Fearsome Fatal Five”)......Page 308 Tension pneumothorax (one of the fearsome five) ......Page 309 Open pneumothorax......Page 312 Massive pneumothorax/ tracheobronchial disruption......Page 313 Cardiac tamponade......Page 314 Massive hemothorax (one of the fearsome fi ve)......Page 316 Traumatic Air Embolism......Page 317 Flail Chest......Page 318 Thoracic Injuries that have the Potential to Become Life-Threatening in a Delayed Fashion (The “ Serious Seven”)......Page 320 Pulmonary contusion......Page 321 Blunt cardiac injury (one of the serious seven)......Page 322 Traumatic aortic disruption (one of the serious seven)......Page 323 Diaphragmatic Rupture......Page 326 Rib and Other Chest Wall Fractures......Page 327 Simple Hemopneumothorax......Page 328 References......Page 329 Chapter Overview......Page 332 General Principles......Page 333 Role of Peritoneal Lavage, CT, Ultrasound, and Laporoscopy in Assessing Abdominal Trauma......Page 335 General Conduct of the Trauma Laparotomy......Page 336 Abdominal compartment syndrome......Page 338 Highlights in Management of Specific Intra-Abdominal Injuries......Page 339 Summary......Page 344 References......Page 345 Chapter Overview......Page 348 Anatomic Considerations......Page 349 Physiologic Considerations......Page 350 Classification of Head Injuries......Page 353 Classifi cation based on mechanism......Page 354 Classifi cation Based on Morphology......Page 355 Classifi cation based on severity of injuries......Page 361 Interpretation of the CT Scan in Brain Injury......Page 362 General principles......Page 363 Monitoring Techniques......Page 365 Specific monitoring ......Page 366 Brain tissue oxygen tension......Page 367 Electrophysiologic monitoring......Page 368 The Emergency Neurological Life Support ( ENLS) Algorithm for Initial Management of Intracranial Hypertension......Page 369 General principles......Page 370 Depressed skull fractures......Page 371 Decompressive Craniectomy......Page 372 General intensive care measures......Page 373 Other measures......Page 374 Ventilation......Page 375 Hypothermia......Page 376 References......Page 377 Chapter Overview......Page 380 Anatomical Considerations......Page 381 Dermatomes and Myotomes......Page 382 Pathophysiology......Page 383 Clinical Features and Presentations......Page 384 Spinal Cord Syndromes......Page 385 Investigations: X-ray, CT, MRI......Page 386 Specific Traumatic Spine Injuries......Page 387 Sub-axial Injury Classification (SLIC) Scale......Page 390 Penetrating Injuries......Page 392 Vascular Injuries......Page 393 Non-Traumatic SCI......Page 394 Scales and Grading......Page 395 MANAGEMENT......Page 397 Unique Challenges in SCI Management......Page 398 References......Page 406 Introduction......Page 408 Classification......Page 409 Assessment of pelvic stability......Page 412 Application of Pelvic Binder......Page 413 Assessment of the lower urinary tract......Page 416 Open Pelvic Injuries......Page 417 Radiographic Assessment......Page 418 Initial Management of the Hemodynamically Compromised Patient with a Pelvic Fracture......Page 419 Pelvic Packing......Page 420 Embolization......Page 422 Postoperative Considerations......Page 423 References......Page 424 Chapter Overview......Page 426 Clinical Assessment......Page 427 Initial Treatment......Page 429 Open Fractures......Page 431 General Management Principles......Page 432 Timing of Surgery......Page 433 The Mangled Extremity......Page 434 Thromboembolic disease......Page 435 Fat emboli syndrome (FES)......Page 436 References......Page 438 Introduction......Page 440 Pathophysiology......Page 442 Diagnosis......Page 443 Fasciotomy of the Lower Leg......Page 446 The lateral incision of the lower leg......Page 448 The medial incision of the lower leg......Page 452 Wound Care......Page 454 Complications......Page 456 Fasciotomy of Other Compartments......Page 457 CS and Fasciotomy of the Thigh......Page 458 References......Page 459 Primary survey......Page 462 Secondary survey......Page 463 Treatment......Page 464 Criteria for transfer to a burn unit and transport safety......Page 466 Direct thermal injury......Page 467 Inhalation injury......Page 468 Fluid Resuscitation and Edema Management......Page 469 General......Page 471 Specifi c wound treatments based on anatomic location......Page 472 Escharotomies versus fasciotomies......Page 473 Surgical excision......Page 474 Sedation/analgesia......Page 475 Definitions/etiology ......Page 476 Factors infl uencing electrical burn severity......Page 477 Management......Page 479 Lightning injury......Page 482 Chemical Injuries......Page 484 Hydrofl uoric acid......Page 485 Cold Injury......Page 488 References......Page 489 Chapter Overview......Page 492 ARDS......Page 494 Ventilation Strategies......Page 495 Extracorporeal Membrane Oxygenation ( ECMO)......Page 496 Prevention......Page 497 Cardiovascular......Page 498 Ischemic Hepatopathy......Page 500 Cholestasis......Page 501 Dysmotility/Feeding Intolerance......Page 502 Renal......Page 503 Neurologic......Page 504 Hematologic......Page 506 Medications......Page 507 Conclusion......Page 508 References......Page 509 (b) NonTRAUMA......Page 514 Epidemiology......Page 516 Definitions......Page 517 Pathophysiology......Page 519 Microbiology......Page 520 Clinical Manifestations and Physical Examination......Page 521 Diagnostic Tests......Page 525 Management......Page 526 References......Page 535 Overview......Page 540 Epidemiology/Risk Factors......Page 541 Pathophysiology......Page 542 Diagnosis......Page 546 Treatment......Page 549 References......Page 551 Anatomy......Page 554 Epidemiology......Page 555 Classification and Pathophysiology......Page 558 Diagnosis......Page 559 Management......Page 561 Summary......Page 563 References......Page 564 Introduction......Page 566 Risk Factors......Page 567 Pathophysiology......Page 568 Duodenum......Page 569 Clinical Presentation......Page 570 Initial Resuscitation......Page 572 Treatment......Page 574 Outcomes and Complications......Page 576 References......Page 577 Introduction and Chapter Overview......Page 580 Diverticular disease......Page 581 Ischemic colitis......Page 582 Infectious colitis......Page 583 Localization and intervention......Page 584 Colonoscopy......Page 585 Selective catheter angiography and embolization......Page 586 Surgical intervention......Page 587 References......Page 588 Significance and History......Page 590 Anatomy, Etiology, and Pathophysiology......Page 591 Diagnosis and Classification......Page 592 Medical Management and Outcomes......Page 594 Surgery and Interventional Procedures......Page 596 Conclusion......Page 597 References......Page 598 Introduction......Page 600 Presentation......Page 601 Diagnosis......Page 602 Treatment......Page 603 Introduction......Page 604 Presentation......Page 605 Treatment......Page 606 Epidemiology......Page 608 Pathophysiology......Page 609 Treatment......Page 610 Introduction......Page 611 Pathophysiology......Page 613 Diagnosis......Page 614 Treatment......Page 615 References......Page 616 General considerations in the morbidly obese that could impact ICU care......Page 620 Bariatric Surgery Procedures......Page 624 Evolution of Bariatric Surgery......Page 625 Laparoscopic Adjustable Gastric Band (LAGB)......Page 626 Laparoscopic Sleeve Gastrectomy (LSG)......Page 627 Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)......Page 628 Outcomes......Page 629 Complications......Page 630 Perioperative complications......Page 631 Short-term complications......Page 632 Long-term complications......Page 634 References......Page 636 Chapter Overview......Page 642 Neurologic......Page 643 Cardiovascular......Page 645 Pulmonary......Page 646 Renal......Page 649 Graft function......Page 651 GI function/nutrition......Page 652 Biliary complications......Page 653 Hematologic......Page 654 Infectious Disease......Page 655 Immunosuppression......Page 656 Other Transplant Patients......Page 657 References......Page 660 Incidence......Page 662 Pathophysiology......Page 663 Classification......Page 664 Presentation......Page 667 Diagnosis......Page 668 Treatment......Page 669 Other Therapies......Page 671 References......Page 672 Overview......Page 676 Introduction......Page 677 Bedside Assessment......Page 679 Airway, Lungs, and Ventilation......Page 681 Critical Care of Life Threatening Respiratory Compromise......Page 685 Heart, Vessels, and Circulation......Page 689 Critical Care of Life Threatening Circulatory Compromise......Page 691 Fluids, Electrolytes, and Nutrition......Page 694 Critical Care of Fluids, Electrolytes, and Nutrition......Page 699 Neurological Assessment and Brain Death......Page 704 Life Threatening Pediatric Traumatic Emergencies......Page 705 Critical Care of Life Threatening Pediatric Traumatic Injuries......Page 707 Brain......Page 708 Chest......Page 711 Abdomen......Page 712 Skeleton......Page 714 Emotional support......Page 715 Disasters......Page 716 Congenital diaphragmatic hernia......Page 717 Malrotation/midgut volvulus......Page 718 Esophageal atresia with distal tracheoesophageal fi stula......Page 719 Life Threatening Postoperative Surgical Emergencies......Page 720 Use and Misuse of Analgesic and Sedative Agents......Page 721 References......Page 723 Index......Page 726 "This handbook considers topics that have general application to the critically ill patient. Basic pathophysiology and understanding of its role in critical care monitoring and management are covered, followed by a close look at trauma related and non-trauma related entities likely to afflict the critically ill surgical patient. The authors consist of practitioners who are experts in their field. They represent the team approach to critical care management where members from the divisions of anesthesia, internal medicine, respiratory medicine, infectious disease and surgical specialties all contribute in formulating intervention, assessment and management plans for the critically ill surgical patient. By emphasizing the surgical conditions requiring critical care, The Surgical Critical Care Handbook will serve as a quick and easy reference for any medical trainee or practitioner aspiring to join the ICU."--Provided by publisher