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.