THE CARE OF THE CRITICALLY ILL SURGICAL PATIENT

  • Slides: 23
Download presentation

THE CARE OF THE CRITICALLY ILL SURGICAL PATIENT Dr. K. S. S Ranatunga Consultant

THE CARE OF THE CRITICALLY ILL SURGICAL PATIENT Dr. K. S. S Ranatunga Consultant Surgeon Base Hospital Panadura

Problems Ageing population q Concomitant disease processes q Complexity of surgery q Greater number

Problems Ageing population q Concomitant disease processes q Complexity of surgery q Greater number of post-operative interventions & therapies q Shortage of experienced staff q Expectations by patients, relatives & staff q

Aim Identification & correction of complications and problems at the earliest stage Prevents critical

Aim Identification & correction of complications and problems at the earliest stage Prevents critical illness ( multiple organ failure) with overall mortality of 50% q Predict, Prevent and Treat Critically Ill Surgical Patients Successfully

Methods Critical illness is often detectable and can be successfully treated at an initial

Methods Critical illness is often detectable and can be successfully treated at an initial stage (30 -40)% Of ICU patients had suboptimal ward management q q Prediction – Identifying high risk patients Prevention – Initiate simple remedial measures Prompt identification of problems & initiate early appropriate treatment

Practical Management Clinical Methods – To assess patients & identify problems q Practical Skills

Practical Management Clinical Methods – To assess patients & identify problems q Practical Skills – To initiate the appropriate management q Communication & Organizational Skills – To seek help from colleagues or specialists in other fields to tackle a difficult or unfamiliar problems q

Patients at Risk q q q q q Emergencies Elderly Coexisting diseases Non progression

Patients at Risk q q q q q Emergencies Elderly Coexisting diseases Non progression Severe illness / complex surgery Massive transfusion Re-operation / re- bleeding Failure / delay to diagnose & treat underlying problems Multiple complications Established shock state

Risk Practices Incomplete or infrequent assessment q Failure to act on abnormal findings q

Risk Practices Incomplete or infrequent assessment q Failure to act on abnormal findings q Failure to ensure that interventions have been successful q Failure of continuity of care Poor communication (Clear, Concise, Confident) q Failure of supporting care Lack of expertise / Number of staff / Wrong ward q

Assessing the Critically Ill Surgical Patient q Immediate management - Life threatening illness kills

Assessing the Critically Ill Surgical Patient q Immediate management - Life threatening illness kills in a predictable & reproducible patterns Systematic evaluation - Assessment and treatment may have to be done simultaneously A – Airway Assessment and Treatment with Cervical Cord Protection q q q Look, listen, feel High flow O 2 / (10 -15)l /mt Secure & protect airway ( Airways , ETT, Surgical Airways)

B – Breathing Assessment & Restoration of Mechanics of Ventilation Look, listen, feel q

B – Breathing Assessment & Restoration of Mechanics of Ventilation Look, listen, feel q Clinically identify & treat life threatening conditions Tension pneumothorax, Open pneumothorax, Massive haemothorax, Large flail chest & Pericardial effusion q 80% Of thoracic injuries can be managed with tubethoracostomy q

C – Circulation Assessment and Arrest of Bleeding q Hypovolaemia should be considered as

C – Circulation Assessment and Arrest of Bleeding q Hypovolaemia should be considered as the primary cause of circulatory dysfunction in surgical patients unless proven otherwise. Assessment (LOC, Pulse, BP, Capillary Return, UOP) & arrest of bleeding q Establish & secure adequate venous access. 16 G cannula at antecubital fossa. Send blood for cross matching & investigations q Fluid replacement Fluid challenge – Normotensive 10 ml /kg - Hypotensive 20 ml/kg Fluid requirement > 1500 -2000 ml blood transfusion q Assess adequacy of resuscitation q Appropriate action - Exanguinating Emergency surgery - Unstable Urgent surgery - Stable Monitor q Clear Diagnosis & Plan Mandatory !

D – Dysfunction of the Nervous System q q q A- Alert V- Response

D – Dysfunction of the Nervous System q q q A- Alert V- Response to verbal stimuli P- Response to painful stimuli U- Unresponsive Exclude Hypoxia, Hypercapnia, Shock, Hypoglycaemia & Sedative Drugs E – Exposure and Thorough Examination q Prevent Hypothermia and Preserve Dignity

Re-evaluation Vital parameters Signs of improvement q Resuscitative measures IV fluids, O 2, Drugs

Re-evaluation Vital parameters Signs of improvement q Resuscitative measures IV fluids, O 2, Drugs q Judicial investigations CXR, ECG, ABG q Other procedures Urinary Catheter, CVP q Communications Colleagues, Superiors, Other Specialists, Patient, Relatives and Others q

Full Patient Assessment q q Hx & Ex - Patient, Nurses, Junior Staff, Notes

Full Patient Assessment q q Hx & Ex - Patient, Nurses, Junior Staff, Notes - Repeated clinical examination Chart review - Temperature, Fluid Balance, Absolute values Trends - Drugs Dosage, Frequency, Interactions, Complications

Review of Available Results Biochemistry – Profile, ABG, RBS q Heamatology – FBC, Clotting,

Review of Available Results Biochemistry – Profile, ABG, RBS q Heamatology – FBC, Clotting, Blood film q Microbiology – Cultures and ABST q Radiology – Examine films & review reports q Relate to the Clinical Condition!

Daily Plan q q Problems Remedial Measures Aims - SBP - Sa. O 2

Daily Plan q q Problems Remedial Measures Aims - SBP - Sa. O 2 - Fluid Balance Actions - Ix. R - Specialist Opinion - Nutrition Requirement / Route - Fluid Balance / Prescription - Drugs (therapeutic , preventive, routine) & Analgesics - Removal of drains & tubes - Level of care The Patient’s Condition and the Investigations should be Reviewed at least Twice a day !

Accept responsibility for patient management q Adopt a systematic approach to patient management q

Accept responsibility for patient management q Adopt a systematic approach to patient management q Appreciate that complications tends to cascade rapidly q Anticipate and prevent problems with simple timely actions q Apply effective communications skills to facilitate care q Ask for appropriate assistance in a timely manner q

THANK YOU

THANK YOU