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Surgical Intensive Care. Board certified in Anesthesiology Board certified in Critical Care Medicine Board certified in Transesophageal Echocardiography. JUNYI LI, MD. March 31, 2009. lijunyiutmb@yahoo.com. Subspecialty ICU. Medical Intensive Care Unit (MICU) Coronary Care Unit (CCU)

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surgical intensive care

Surgical Intensive Care

Board certified in Anesthesiology

Board certified in Critical Care Medicine

Board certified in Transesophageal

Echocardiography

JUNYI LI, MD

March 31, 2009

lijunyiutmb@yahoo.com

subspecialty icu
Subspecialty ICU
  • Medical Intensive Care Unit (MICU)
  • Coronary Care Unit (CCU)
  • Surgical Intensive Care Unit (SICU)
  • Neurological Intensive Care Unit (NICU)
  • Cardiovascular Intensive Care Unit (CVICU)
  • Pediatric Intensive Care Unit (PICU)
  • Neonatal Intensive Care Unit (NICU)
sicu admission criteria
SICU Admission Criteria
  • Preoperative status

Major trauma

Surgical Procedure

Pt’s preexisting disease

  • Intraoperative event

Large volume shift

Unexpected surgical complication

Unexpected anesthesia complication

  • Postoperative status

Unexpected postop complication

Pt’s status

who need to be admitted to sicu
Who need to be admitted to SICU ?
  • 18 y/o health male presented for right inguinal hernia repair under spinal anesthesia and uneventful intraop and postop.
  • 50 y/o female with controlled HTN and DM for lumbar laminectomy under general anesthesia with EBL 500 ml.
  • 75 y/o male with stable angina, COPD required home oxygen for TURP under spinal anesthesia
  • 60 y/o male presented for AAA repair
  • 54 y/o female with esophageal cancer presented for esophagectomy
  • 95 y/o female presented for right hip arthroplasty
sicu management
SICU Management
  • Respiratory care
  • Hemodynamic monitoring and management

Noninvasive

Invasive

  • Infection in SICU
  • Acid-base disorders
  • Fluid and electrolyte disorders
  • Blood component therapy
  • Nutrition support
respiratory care basic monitor
Respiratory care – basic monitor
  • Respiratory rate
  • Chest movement
  • Breath sound
  • Color
respiratory care lung volume
Respiratory care – lung volume
  • Tidal volume (VT)
  • Minute ventilation (Vm)
  • Functional residual capacity (FRC)
  • Vital capacity (VC)
respiratory care ventilation
Respiratory care - ventilation
  • Ventilation-perfusion (V/Q) ratio: normal V/Q=4L/5L=0.8
  • Dead space ventilation: V/Q>1 anatomic dead space & physiologic dead space
  • Intrapulmonary shunt: V/Q<0.8 true shunt (V/Q=0) and venous admixture
ventilation perfusion quantitative determinations
Ventilation-perfusionQuantitative determinations
  • Dead space (Vd/Vt) = (PACO2 – PECO2)/PACO2
  • Shunt fraction (Qs/Qt) = (CCO2 – CAO2)/(CCO2 –CVO2)
  • A-a gradient (PAO2 – PaO2) PAO2 = PIO2 – (Paco2/RQ) PAO2 = FIO2(PB –PH2O) – (PaCO2/RQ) PAO2 = 0.21(760 – 47) – (40 /0.8) = 100 mmHg
  • PAO2/FIO2<200, Qs/Qt>20% PAO2/FIO2>200, Qs/Qt<20%
hypoxemia
Hypoxemia

DisorderA-a PO2PVO2

Hypoventilation Normal Normal

Pulmonary disorder Increased Normal

DO2/VO2 imbalance Increased Decreased

DO2/VO2 – oxygen deliver and uptake ratio

A-a PO2 – PO2 difference between alveolar gas and arterial blood

PVO2 – Mixed venous PO2

hypercapnia
Hypercapnia
  • Hypercapnia is PACO2>45 mm Hg, due to
  • Increased CO2 production
  • Hypoventilation
  • Increased dead space ventilation
oximetry
Oximetry
  • Oximetry detects arterial blood HbO2 and Hb ratio
  • Ear oximetry
  • Pulse oximetry
  • Co-Oximeters can detect Met Hb and CO Hb
  • Mixed venous oximetry measured O2 sat in PA blood
co 2 detector and capnometry
CO2 detector and capnometry
  • CO2 detector is a method for determining the success or failure of ET intubation.
  • Clinical application of capnometry in ICU:

- Cardiac output monitor

- Ventilator-related mishap detection

- Early detection of nosocomial disorders

- Ventilator weaning

- Controlled hyperventilation

acute respiratory distress syndrome ards
Acute respiratory distress syndrome (ARDS)
  • A leading cause of acute respiratory failure with high mortality
  • A diffuse inflammatory injury in the lung
  • Not an accumulation of watery edema fluid
  • Not a primary disease, but a complication
diagnostic criteria for ali and ards
Diagnostic criteria for ALI and ARDS
  • Acute onset
  • Presence of predisposing condition
  • PaO2/FiO2 < 200 mm Hg for ARDS, < 300 mm Hg for ALI
  • CXR – bilateral infiltrates
  • PAOP < 18 mm Hg or no clinical evidence of high LA pressure
management of ards
Management of ARDS
  • No real treatment for ARDS, only supportive
  • Mechanical ventilation: low-volume ventilation permissive hypercapnia positive end-expiratory pressure
  • Fluid management – reducing extravascular lung water
  • Pharmacotherapy – uncertain effect
respiratory therapy
Respiratory therapy
  • Oxygen inhalation therapy
  • Chest physical therapy
  • Respiratory pharmacotherapy
  • Mechanical ventilation
oxygen inhalation therapy
Oxygen inhalation therapy
  • Arterial hypoxemia: PaO2 < 60 mm Hg (SaO2 < 90 %)
  • Tissue hypoxia: blood lactate > 4 mmHg
  • Endpoint of O2 therapy is tissue oxygenation
  • Tissue hypoxia may not consistent with arterial hypoxemia
effect of oxygen on blood flow
Effect of Oxygen on blood flow
  • Oxygen tends to reduce systemic blood flow due to: 1. vasoconstrction in all vascular bed except

the pulmonary circulation 2. decrease in cardiac output 3. negative inotropic effect

method of oxygen inhalation
Method of oxygen inhalation
  • Low-flow oxygen delivery system with variable FiO2
  • High-flow oxygen delivery system with constant FiO2
slide28

Low-flow oxygen delivery systems

Device Reservoir Oxygen flow FiO2

capacity (L/min)

Nasal cannula 50 ml 1 0.21-0.24

2 0.24-0.28

3 0.28-0.34

4 0.34-0.38

5 0.38-0.42

6 0.42-0.46

Oxygen face mask 150-250 ml 5-10 0.40-0.60

Mask-reservoir bag 750-1250 ml

Partial rebreather 5-7 0.35-0.75

Nonrebreather 5-10 0.40-1.0

FiO2 = 20 + 4 X oxygen flow (L/ml)

respiratory pharmacotherapy
Respiratory pharmacotherapy
  • Bronchodilators
  • Corticosteroids
  • Mucokinetic therapy
mechanical ventilation
Mechanical ventilation
  • Mechanical ventilation is positive pressure ventilation
  • Indications of mechanical ventilation

Rate

ABG: hypoxia and hypercapnia

Mechanical parameter: MV, VC and NIP

Dead space and shunt

  • Contraindication of mechanical ventilation
slide32

Effect of positive pressure ventilation

Noncompliant lung

Normal lung

respiratory parameter
Respiratory parameter
  • Rate: 10 – 20/min
  • VT: 6 – 10/kg
  • FiO2: 40 – 100%
  • PEEP: 5 – 10 cm H2O
  • PS: 5 – 10 cm H2O
  • I:E ratio: 1:2
patterns of mechanical ventilation
Patterns of mechanical ventilation
  • Control mode ventilation
  • Assist-control ventilation
pattern of mechanical ventilation
Pattern of mechanical ventilation
  • Volume-controlled ventilation

ACV (assist control ventilation)

IMV (intermittent mandatory ventilation)

SIMV (synchronized IMV)

  • Pressure-controlled ventilation
  • Pressure support ventilation
  • Special pattern:
functional mode of ventilator
Functional mode of ventilator
  • PEEP (positive end expiratory pressure)
  • PS (pressure support)
  • I:E reversal ratio
discontinuing mechanical ventilation
Discontinuing mechanical ventilation
  • Ventilator required for brainstem respiratory depression (e.g.,GA in OR or drug overdose) is easy to discontinue
  • Ventilator required for cardiopulmonary insufficiency is weaning in gradual process
discontinuing mechanical ventilation44
Discontinuing mechanical ventilation

Clinical evaluation:

Awake

Spontaneous breathing

Ability of airway protection

Stable hemodynamics

discontinuing mechanical ventilation45
Discontinuing mechanical ventilation

Sequence of weaning:

FiO2 to 50% or less

PEEP to 5 cm H2O or less

PS to 10 cm H2O or less

discontinuing mechanical ventilation46
Discontinuing mechanical ventilation

Bedside weaning parameters:

Parameter Normal range Threshold for weaning

PaO2/FiO2 >400 200

VT 5-7 ml/kg 5 ml/kg

Rate 10-20/min <40/min

VC 65-75 ml/kg 10 ml/kg

VE 5-7 L/min <10 L/min

Pi max >-90 cm H2O (F) -24 cm H2O

>-120 cm H2O (M)

Rate/VT <50/min/L <100/min/L

discontinuing mechanical ventilation48
Discontinuing mechanical ventilation

Methods of weaning:

T-piece weaning

IMV weaning

CPAP weaning

hemodynamic monitoring noninvasive
Hemodynamic monitoringNoninvasive
  • ECG: heart rate, rhythm, ischemia (ST-T)
  • Noninvasive BP
  • Echocardiography: TTE, TEE, color-doppler

Contractility

Volume status

EF

Ischemia (RWMA)

  • Noninvasive cardiac output (through A-line)
hemodynamic monitoring invasive
Hemodynamic monitoringInvasive
  • Arterial blood pressure
  • Central venous pressure
  • Pulmonary artery catheter and wedge pressure
  • Cardiac output
invasive arterial blood pressure
Invasive arterial blood pressure

Indication

  • Major CV surgery
  • Surgery with great hemodynamic change
  • Surgery with large volume shift and bleeding
  • Shock and other critical ill patients
  • Surgery requiring hemodilution and control hypotension
  • Frequent ABG
invasive arterial blood pressure53
Invasive arterial blood pressure
  • Contraindication: only relative contraindication except for puncture site infection
invasive arterial blood pressure selection of artery for cannulation
Invasive arterial blood pressureSelection of artery for cannulation
  • Radial artery
  • Ulnar artery
  • Brachial artery
  • Femoral artery
  • Dorsalis pedis and posterior tibial arteries
  • Axillary artery
  • Carotid artery – do not use
invasive arterial blood pressure complication
Invasive arterial blood pressureComplication
  • Bleeding and hematoma
  • Vasospam
  • Thrombosis and thrombi
  • Aneurysm
  • Infection
  • Nerve damage
  • Necrosis of skin overlying the catheter
invasive arterial blood pressure waveform
Invasive arterial blood pressureWaveform

SBP gradually increases

MBP remains unchanged

slide57

Invasive arterial blood pressure

Waveform distortion

Normal test

underdamped

overdamped

central venous pressure indication
Central venous pressureIndication
  • Fluid administration for severe hypovolemia and shock
  • Infusion of cardiac drugs
  • Aspiration of air emboli in craniotomy
  • Insertion of transcutaneous pacing leads
  • Total parenteral nutrition (TPN)
  • Venous access for patients with poor peripheral veins
central venous pressure contraindication
Central venous pressureContraindication
  • Renal cell Ca extension into RA, RA myxoma, or fungating tricuspid valve vegetations
  • Skin infection at cannulation site
  • Severe coagulopathy
  • Ipsilateral carotid endarterectomy (IJ), pneumothorax and hemothorax are relative contraindication
central venous pressure selective sites of cannulation
Central venous pressureSelective sites of cannulation
  • Internal jugular veins
  • Subclavian veins
  • Femoral veins
  • External veins
  • Basilic veins
central venous pressure measurement
Central venous pressureMeasurement
  • Catheter’s tip lies above or the junction of SVC and RA
  • CVP is measured with cm H2O
  • CVP should be measured during end expiration
central venous pressure waveform
Central venous pressureWaveform
  • a wave – atrial contraction, absent in A fib and exaggearted in JR (cannon wave)
  • c wave – TV elevation@early ventricular contraction
  • v wave – venous return against to closed TV
  • x descent – downward displacement of TV (systole)
  • y descent – TV opening during diastole
central venous pressure complication
Central venous pressureComplication
  • Bleeding and hemotoma
  • Pneumothorax and hemothorax
  • Pleural effusion and chylothorax
  • Line-related infection
  • Air thrombi
slide64

Pulmonary artery catheterization

Length 110 cm

OD 2.3 mm

Distal port

Proximal port

Balloon at tip

Themistor

it is time to pull the pac

“It Is Time To Pull The PAC”

PAC dose not improve outcome in critically ill patients

background
Background
  • Pulmonary artery catheter(PAC) has been used in critical care practice for three decades
  • Majority of PAC are inserted to aid in management of critically ill pts in ICU and high risk surgical pts in OR
  • Observational studies & small randomized controlled trials (RCT) showed variable results:

Worse outcome

No difference in outcome

Some benefit

summary
Summary
  • PAC-directed management in high risk surgical, severe sepsis, shock and RADS pts is a safe procedure
  • PAC use dose not improve outcome
  • PAC use may not increase cost of care
pulmonary artery catheterization indication
Pulmonary artery catheterizationIndication
  • Cardiac disease: CAD with LV dysfunction, valvular heart disease, heart failure
  • Pulmonary disease: ARDS, severe COPD, Pulmonary hypertension
  • Complex fluid management: shock, acute burn ARF, MOF
  • Specific surgical procedure: aortic cross clamp pheochromocytoma, liver transplants,
  • Hemodynamic unstability required cardiovascular drug therapy
  • High-risk obstetrics: severe toxemia
pulmonary artery catheterization contraindication
Pulmonary artery catheterizationContraindication
  • Severe TV or PV stenosis
  • RA or RV tumor
  • Endocarditis with vegetation on TV or PV
  • Other contraindication related to central venous cannulation
pulmonary artery catheterization complication
Pulmonary artery catheterizationComplication
  • Complication associated with CV cannulation
  • Bacteremia and endocarditis
  • Thrombogenesis and pulmonary infarction
  • Pulmonary artery rupture and hemorrhage
  • Arrhythmias and conduction abnormalities
  • Pulmonary valve damage
pulmonary capillary wedge pressure
Pulmonary capillary wedge pressure

CVP = RAP = RVEDP

PCWP = LAP = LVEDP

hemodynamic parameter
Hemodynamic parameter
  • BSA = (Ht + Wt – 60)/100, nl 1.6 to 1.9 m2
  • CO = HR x SV
  • CI = CO/BSA
  • DO2 = CI x 13.4 x Hb x SaO2
  • VO2 = CI x 13.4 x Hb x (SaO2 – SvO2)

* SvO2 obtained from PAC distal port

hemodynamic profiles
Hemodynamic Profiles
  • Heart failure:

Right heart failure Left heart failure

High RAP High PCWP

Low CI Low CI

High PVRI High SVRI

hemodynamic profiles78
Hemodynamic profiles
  • Hypotension:

Hypovolemic Cardiogenic Vasogenic

Low CVP High CVP Low CVP

Low CI Low CI High CI

High SVRI High SVRI Low SVRI

cardiac output monitoring
Cardiac output monitoring
  • Thermodilution methods

Pulmonary artery catheter

Peripheral artery catheter (Picco)

  • Dye dilution methods
  • Echocardiography
  • Thoracic bioimpedance
slide80

Cardiac output monitoring

Fick principle

Oxygen consumption

CO =

a – v O2 content difference

VO2

=

CaO2 – CvO2

Fick principle is the basis of all indicator

dilution methods of determining cardiac

output

hemodynamic management
Hemodynamic management
  • Preload
  • Afterload
  • Cardiac contractility
hemodynamic management preload
Hemodynamic managementPreload
  • Monitoring via CVP or PCWP
  • Increased preload by giving volume
  • Decreased preload by giving diuretics and/or vasodilators (nitroglycerin)
hemodynamic management afterload
Hemodynamic managementAfterload
  • Vascular resistance
  • Balance between cardiac work and organ perfusion
  • Vasodilators:

Systemic vasodilators: nitroprusside,

calcium channel blockers, a1-blockers

Pulmonary vasodilators: PGE1, PGI, NO

  • Vasocontrictors: levophed, epinephrine, vasopresin
hemodynamic management inotropic agents
Hemodynamic managementInotropic agents
  • Positive inotropic agents: epinephrine, dopamine, dobutamine, PDEI (milrinone)
  • Negative inotropic agents: beta blocker and calcium channel blockers
hemodynamic effect of iabp
Hemodynamic effect of IABP
  • Decrease afterload and promote SV
  • Increased diastolic pressure and coronary blood flow in hypotensive patients
  • Indication: AMI, cardiac shock, unstable angina, acute MR
  • Contraindication: AI, aortic dissection and aortic graft in thoracic aorta
  • Complication: leg ischemia, septicemia
acute renal failure arf
Acute renal failure (ARF)
  • The hallmark of ARF is azotemia and oliguria
  • Lab: blood urea nitrogen(BUN), criatinine(Cr), blood electrolytes, glumerular filtration rate
  • Etiology: prerenal, renal and postrenal

Renal ischemia (50%),

Nephrotoxines (35%),

Intrinsic renal disease (15%)

50% of ARF in SICU due to major trauma or surgery

treatment of arf
Treatment of ARF
  • Supportive management
  • Diuretics and mannitol to maintain urine output in nonoliguric patients
  • Renal dose dopamine?
  • Glucocorticoids for ARF due to vasculitis or glomerulonephritis
  • Other: restrict fluid, sodium, potassium, posph
  • Renal replacement therapy (dialysis)
infection in sicu
Infection in SICU
  • Infections are leading cause of death in ICUs
  • Community acquired and hospital acquired infection
  • Strains of bacteria resistant to commonly used antibiotics are common
  • Advanced age, prolonged use of invasive devices, respiratory failure, renal failure and head trauma are established risk factors for hospital acquired infection
  • Multiple antibiotics and broad spectrum antibiotics are commonly used in SICU
nutrition support in sicu
Nutrition support in SICU
  • Maintaining adequate nutrition in critically ill patients improves wound healing. Restore immune competence and reduces morbidity and mortality
  • Critically ill patients generally required 1.0-1.5g/kg/day instead of 0.5g/kg/day for nonstressed patients
  • Enteral nutrition and parenteral nutrition
enteral nutrition in sicu
Enteral Nutrition in SICU
  • GI tract is the route of choice for nutrition support when its functional integrity is intact
  • Enteral nutrition is simpler, cheaper, less complicated, and fewer complication
  • Enteral nutrition can better preserve GI structure and function
  • Diarrhea is most common problem related to hyperosmolarity of the solution or lactose intolerance
parenteral nutrition in sicu
Parenteral Nutrition in SICU
  • Total parenteral nutrition (TPN) is indicated if the GI tract cannot be used of if absorption is inadequate
  • Complications of TPN are catheter-related and metabolic
  • The most common problem in TPN is hyperglycermia