Category Archives: Critical Care

Surgical Care Highlights

Surgical Care – Perioperative

  • “Never Events” Root cause analysis needed – surgery at wrong site or wrong patient
  • Circulating nurses see things differently than surgeons
  • Tight glucose control blood glucose 90-110 mg/dl is associated with higher mortality rate in post operative patients than liberal control  <180.
  • statement that  >age 60 all need stress test – not valid
  • PEG tubes has risk of cellulitis
  • Removal of the distal ileum removal steatorrhea, impaired vitamin B12 absorption, and calcium oxalate stones.
  • Immunization is not needed hemisplenectomy and nonoperative spleen salvage.
  • Patient co-morbidities dictates BKA vs. AKA.  AKA has higher mortality rate.
  • Hepatic cirrhosis is now relative rather than absolute contraindication laparoscopic cholecystectomy
  • Dehydration occurs after some bowel preps
  • Sepsis and dilution from massive transfusions cause thrombocytopenia than heparin induced thrombocytopenia.
  • Day 1 post op – can consider feeding younger healthy patients, after colon surgery.
  • Today, PA catheters are reserved for cardiac surgery patients and occasional major vascular case with significant CAD and heart dysfunction.
  • Contrast induced nephropathy is at highest risk in patients who are hypotensive, chronic renal disease, or congestive heart failure.
  • Metformin (Glocophage) – Guidline for withdrawal prior to surgery:  discontinue for at least a day, and then RESTART 2-3 days after po intake (after surgery).  Discontinued before surgery because during withdrawal lactic acidosis can develop high Mortality >50% if not adequately treated.
  • Beta blockade may increase stroke risk in high risk cardiac patients
  • Hyperkalemia (medical emergency, manage cardiac effects) – quickest way to manage:  give calcium gluconate IV.  On the other hand IV glucose and Insulin useful for shifting potassium into the cell but needs >30 minutes to be effective.  Calcium gluconate doesn’t have effects on potassium levels in the blood, it reduces the excitability of cardiomyocytes.
  • In patients who present for emergent surgery with drug eluting stents that have been in place for at least three months, dual aspirin and plavix therapy is maintained.
  • Atrial Fib:  Amiodarone or metoprolol after 48 hours can result in good blood pressure results however the patients may still be in atrial fibrillation.  Atrial Fibrillation may correct itself with volume status and electrolyte correction.
  • Febrile patients with Staph infection on their central line and blood  – remove their central line catheter as their first line of defense.
  • Technical errors occur more often in simple / routine procedures than complicated ones.
  • DVT in the arm – location (proximal vs. distal) doesn’t matter in risk of PE.
  • Insulin drips (perioperative to maintain glucose control) should be done in the ICU or other monitored setting.
  • Hemostatic agents – gel foam with bovine thrombin – are used in the OR for coagulation.
  • Give FFP (fresh frozen plasma) when using cell saver for autotransfusion – because when processing blood in the cell saver, there is some depletion of coagulation factors.
  • Let alcohol dry before operating to prevent fires.
  • Hip fracture patients – get them to OR urgently for repair; otherwise there’s morbidities associated with bed rest.
  • Betablockers can be cardioprotective, but take precautions in giving beta blockers to patients with bradycardia, heart blocks, heart failure
  • Mechanical bowel prep doesn’t add much to infection reduction in colon surgeries
  • MRSA can even be found in skin abscesses of patients who have NOT been exposed to antibiotics.
  • NG tubes should be removed as soon as possible to maximize coughing ability and pulmonary toilet.
  • Neostigmine causes motility and contraction of the colon – give only if distal colon is not obstructed.
  • Fondaparinux seems to have equal ability to prevent DVT compared to other heparin formulations.  Trade name Arixtra.  Chemically related to low molecular weight heparins.  Fondaparinux is a synthetic Factor Xa inhibitor.

Perioperative General Surgery Highlights

Perioperative ICU Topics

Transfusion related acute lung injury must be distinguished from cardiogenic and non cardiogenic pulmonary edema and pulmonary contusion.

  • TRALI – acute onset of non-cardiogenic pulmonary edema after transfusion of blood products.
  • Leading cause of transfusion related fatalities in the US
  • Occurs within first 6 hours following transfusion
  • Due to leukocyte antibodies in transfused plasma
  • Incidence 1:5000

Transfusion related circulatory overload – diurese early

  • Furosemide is a loop diuretic

Intubated patients should be transported in Semi fowler recumbent position, 30 degree head of bead to help prevent ventilator associated pneumonia

  • Semi fowler – knees bent, head of bed not as high as fowler position

Hydration of the patient is an important measure to prevent contrast induced nephropathy

With ICU patients with Renal insufficiency, aggressive dialysis does not lead to significant improvements in renal recovery and 30 day mortality rates

Analgesics and sedatives may blunt ACTH stimulation test for adrenal insufficiency

  • ACTH stim test for asessing the functioning of adrenal glands.
  • ACTH is made by the anterior pituitary gland which stimulates the adrenal glands to release cortisol, DHEAS, and aldosterone.
  • Adrenal insufficiency is a potentially life threatening problem
  • ACTH stimulation test is primarily used to deterine the presence of Addison’s diaseas and pituitary impairment
  • Addison’s disease: Adrenal glands do not produce sufficient steroid hormones.  Also known as primary adrenal insufficiency.
  • The test is extremely sensitive to primary adrenal insufficiency but less so to secondary adrenal insufficiency.  Secondary adrenal insufficiency is caused by deficiency of ACTH.

Precedex:  use less than 24-48 hours.

  • Dexmedetomidine – a sedative used in ICU which does not cause respiratory depression

Outcomes protonics vs. H2 blockers not that different in stress gastritis prophylaxis

Advanced directives in ICU – pastoral care staff to bring up on initial contact

Family like ICU rounds – transparency

Refeeding syndrome – low phosphate levels is a hallmark.  Happens in 10 days or more of not feeding.  When feeding resumes:  hyperglycemia – creates even lower levels by moving phosphate and potassium into cells.

Abdominal Compartment Syndrome – open abdomen immediately with elevated intra-abdominal pressure and renal failure, hypotension, or high pulmonary ventilation pressures.

Use of diuretics in ACS (Abdominal Compartment Syndrome) is controversial.  Some surgeons diurese early to decrease bowel edema and to get the abdomen closed.

ICU central lines to be assessed daily and document need for it daily

Trauma patients, erythropoetin may predispose to DVT

  • Liver production of erythropoetin predominates in the fetal and perinatal period
  • Renal production is dominant during adulthood

Induced coma clouds the issue of brain death in regards to organ donation.

Elderly ICU with hyperactive delirium have better outcomes than those with hypoactive delirium.

Elevated CK levels hallmark in propofol infusion syndrome.

  • Potentially and often fatal
  • cardiac failure, rhabdomyolysis, renal failure, hyperkalemia, hypertriglycerdemia, hepatomegaly.
  • Maybe caused by impaired mitochondrial function
  • CK = creatine kinase = present in all muscles
  • Elevated CK levels indicated muscle damage/strain – could be from heart attack or muscles being overworked (ie. weight lifting).
  • Propofol infusion syndrome is at higher risk when patients are already on catecholamines or corticosteroids.

Inhaled PGE2, selectively vasodiates the pulmonary vasculature, it improves VQ mismatch in severe hypoxemia

  • An area with no ventilation (V/Q = zero) = shunt
  • The area with no perfusion = dead space
  • PGE2 = prostaglandin E2
  • PGE2 softens cervix and causes uterine contraction, causes fever, direct vasodilator, relaxes smooth muscles.

In sepsis, norepinephrine raises heart rate less than dopamine.

  • Vasoactive drug use in septic shock
  • Used to increase blood pressure
  • Dopamine is the immediate precursor of norepinephrine and epinephrine
  • Less tachycardic reaction with NorEpinephrine compared to Dopamine.