Module 3: Postoperative Principles Flashcards
Admission to ICU
- 15% surgical procudures requires ICU
- Decision made by surgeon & anesthesiologist
- **Elderly patients or significant comorbidities
Delivery of care
**Accurate Data collection: **
* Surgical Procedure
* Patient positioning
* Unexpected Events
**Efficient Among surgeon, Anesthesiologists & Intensivist: **
* Typically informal
Brief and Incomplete
Continue Medications
Eye drops (Glycoma)
Antiseizure
Bronchodilators
Thyroid Replaceement
DM agent: add Sliding Scale; levemir
Hold Medications
*** Glucorticoids **
* Should be given before Surgery
* Avoid Stress dosing:
* To Avoid : Hyperglycemia, Increased Infection Risk, and wound complications
* Talk to surgen ( ok to Hold )
- Hold CCB, Diuretics, ACE : untile hemodynamically stable post up
- Long Standing Insulin ( lantus or Levimir) , Metoforming, Glyburide: Hold Addd sliding scale SQ or IV, or Levemir
- Maintain Glucose <180 mg/dl
Goal for Blood Surgar Post Up
< 180 mg/dl
Opiate Management :
**Fentanyl **
For Mechanically Vented Patients.
Analgesia Properities, Rapid Onset, short Sedation.
Opiate Management :
Other opiods
Morphine, Dilaudid, Oxycodone, MS Contin
Non-Opiate Management
Ketamine
Robaxin
Toradol (check Kidney Function)
Acetaminophed
and/or Gabaptin
Quantifying Pain and Sedation
*** Richmond Agitation Sedation Scale (RASSS) **
- Universal language to achieve adequite Sadation
* **Confusion Assessment Methord for the ICU (CAM-ICU) **
- check for delirium
Those scale help to avoid delirium, and shorter stay in ICU
Opiate Risk
- Dependance and Withdrawal
if on medication for > 7 days - Lethargy
- Depressed Respitory Efforst
- Vomiting and Ileus
Equivalent Dose
**Morphine **
Dose: 10 mg
Duration 4 to 5 HRS
**Dilaudid **
Dose: 1.5 mg
Duration : 4 to 5 hrs
**Fentanyl **
0.1 or 100 mcg
1 to 1.5 hrs
Fentanyl
- Full-mu receptor agonist
- High Potency, short duration of action, Rapid onset of action
- Lipohilic- ideal drug for transdermal and transmucosal administration
- Biovailability - 50 %
> **25 mcg/hour trasdernal Fentanyl patch = 1mg/1 hour IV Morphine ** - Ideal for childern and incooperative adults
Super POtent ( only in ICU )
Morphine
*** GOLD Standard - For Treatment of Moderate to Severe Pain **
* Full mu-receptor agonist
* Bioavailability: 30 % (PO: IV dose is 3: 1)
Easilty available is wide range of preparations
Most widely used opioids analgesic
CAVEAT : BID /TID : Active Morpphine metabolites
Hydromorphone
Semisynthetic opioid, Hydrogenated, of morphine
Full, Potent
Short duratio n
Oxycodone
- **Most Utilized opiod worldwide **
- *** IR and ER **
-
sustained Release Preperatio of Oxycontin : has 2 phase Release (Immediate and EXtended the the same pill)
Chronic pain management
Keep off IV madications
Hypothermia
Risk for ?
< 36 C
Riks of deloping
* Coagulopathy and
Hemorrhage
Mild Hypothermia
- 32 to 36C or 89.6 to 96.8
- **Passive External Rewarning **: warm Blankets
Moderate Hypothermia:
28 to 32 C or 82.4 to 89.6F
Active External Rewarning
Air Warming system
Severe Hypothermia
< 28 C
Active **core **rewarming
Warm IV fluids (Crystolids )
Do not warm Blood
Assessemtn of Volume status
- **Post Up (I/O ) **
**Crystalloids : 0.9% +LR (keep eye on Na) **
Change to NSS
**MAP >65 **
**UO >/= 0.5 mg/kg **
*** Echocardium : ** monitor resuscitatio efforts
**Maintenance Fluids : D5 1/2 NS (To prevent Catabolism) **
Rapid Shallow Breathing (RSBI)
Predicts successful extubation and suctain off vent
GOAL : < 105 Value ( TV Devided by RR rate )
Mechanical Vent
RR 12 to 16
PEEP: 5
FIO : 100% to 40%
**Tidal Volumes: 6ml/kg **
ARD: Neuro blockag (paralize; prone)
***Nutrition Requirment
- 25 to 30 kcal /kg/day
1.2 to 2.5 g/kg/day of protein
24 to 48 hrs nurtrition
Surgical Complications
Hemorrhage
Overwiew
- **Frequent cause for ICU admission **
- Persistent Postoperative Hypotension: ( early sigh for bleeding )
- Early Identification can prevent :
Prevent multi Organ Failure
Hemodynamic monitoring
Surgical Complications
Hemorrhage
Treatement Plan
- blood
- Fluid: Isotonic Crystalloids (Avoid
- Hypovolic Shock ; MAP >65)
Surgical Complications:
Pulmonary Embolus
Manifestation
Hemodynamic Instability
- Origin: Femoral, Iliac, Popliteal Veins
**Manifestation: **
* SOB, chest pain, ST. DVT (s/s )
* Altered Ventilation Perfusion RAtio
- **Hemodynamic Instability **:
- Blockage of main or major branch of PA –> Resulting - in Increase PVR (Increase Pulmonary Vascular Resistance)
-Leads to RT Heart Dialation leading to
-LV Dysfunction - Rt Heart comprase Left Heaert –> decrease Preload and Decrease CO
DX : PE
*** D-Dimer : Will be elevated post-up **
* **DD is protein fragment of blood clot that been dissolved in a body. **
Therefore, D-D elevated with present of PE.
CTA (Gold Standard DX for PE )
**VQ Scan : Miss Match
- For pt Kidney Issues; or Allergy to Diy
- VQ Not Reliable in ICU pt with Disorders: ( COPD, Cystic Fibrosis, Bronchiectasis, Interstadial Lung Diseas)
**ECHO **
TX PE
Heparing ( PTT 60 to 90 seconds): ICU
Lovenoz 1mg/mg BID
NOAC
IVC Filter (if down leg)
Surgical Complications
Anastomotic Leak
Most Devistating Surgical Complication Result in Mortality and Morbility
**Anastomotic Leak
Clinical Findings:**
*** fever, **
**Elevated WBC,
**ST,
**Hypotension
* Enteric Contents in Perianastomotic drain
Anstomotic Leak
**Diagnosis : **
* CT W/PO Or IV contrast (not Always ask colorectal Surgery )
* Identify leak
* Detect other Pathologies
Anatomotic Leak
Treatment Plan
**Septic shock and Generalized Peritonitis **
Surgical Revision
Hemodynamically Stable
- **Antibiotics and Percutaneous Drainage (zosy +Microfungil (Antifungal ) **
- Endoscopy with Stent Depoyement
- Consult: ID, GI, Surgery
Intraabdominal Compartment Syndrome
Causes
- Severe Abdominal TRauma
- Abdominal Surgery
- Deep Burns
- Obesety
- Intraabdoninal or Retroperitoneal Hemorrhage
- Excessive Crystalloid or Blood Products **
Intraabdominal Hypertension (IAH)
Intraabdominal Pressure > 12mmHG
Abdominal Compartemetn Syndrome (ACS)
Incraabdonial Pressure > 20
New or Worseing organ Dysfunction
Intraabdominal Compartment Syndrome
Clinical Findings
- Tense and distended abdomen
- Increased peak airway pressure
- or Decrased Tidal Volume
- Postoperative persistent** metabolic Acidosis and Shock: Suggest Bowel Ischemia
Intraabdominal Compartment Syndrome
Diagnosis
CT scan or endoscopy
Abdominal pressure measurement
Intraabdominal Compartment
Treatment : IAH or early ACS?
- N0n Surgically
- Decreasing volume resuscitation
- Sedation and Neuromuscular blockage
Intraabdominal Compartment: ACS
Surgical Decompression via **Celiostomy **
Negative Pressure dressing
Surgical Complications
Acute Kidney Injury
Increases mortality and Morbidity
Emergen or high-risk surgeries
Surgical Complications
Acute Kidney Injury:
**Prerental AKI **
Hypovolemia d/t bleeding
Impaired cardiac Function
* Cardiac Renal Syndrome
Surgical Complications
Acute Kidney Injury:
**Intrarenal **
**Acute tubular necrosis: **
* Hypovolemia
* Shock
* nephrotoxic agents
Postrenal AKI
**Obstruction to urine Flow
Damage to ureters
Urinal drainage obstruction **
**non obstructive **
Have urge cannot go
enlarge Prostate : Flomax
Surgical Complication
Malignant Hyperthermia (MHS_ )
**Overview **
- Severe reaction to anesthesia
- Genetic Mutation
(Autosoma Dominant : one gene from parent to be affected
50% chanses - Fatall if not treated Promptly
Surgical Complication
**Malignant Hyperthermia **
Clinical Manifestations
- High body temperature (crasy high)
- Rigid muscles or spasms
- Tachycardia
- Rhabdomyolysis
- Acute renal failure
- Coagulation issues (clotting and bleeding )
Surgical Complication
**Malignant Hyperthermia **
Risk Factors :
**Inherited Gene Affected **
Malignant Hyperhtermia Susceptibiltity (MHS)
****RYR1 Mutation: RYR 1 mutation ** **Rarely affected genes **: CACNA1S and STAC 3
Surgical Complication
Malignant Hyperthermia (MHS)
Diagsosis
- Genetic Testing
- Muschle Biopsy **
(Tissue subjected to triggering Chemicals )
Surgical Complication
Malignant Hyperthermia (MHS)
Treatment
**Dantrolene **
* 2.5 mg/kg IV bolus
TO
10 mg/kg PRN
**maintenace OPtion: **
* 1mg/kg IV Q 4 to 6 hrs
0.25 mg/kg /hr IV infusion
Oxygen
IV fluids x
body cooling
