Wessex ICS Blog

Surgery and Critical Care

Facilitators: Andrew Nash & Julian Nixon
Venue: University Hospital, Southampton
Date: 19th January 2016
Summary blog by: Andrew Nash

Mr Bailey -Upper GI Consultant Surgeon

The acute abdomen

Discussion around surgical perspective to the acutely unwell and intensive care patient. NELA outcome data and management of critically ill patients have and are evolving, with an improvement in outcomes from sepsis. Arguably operating on patients with increasing predicted mortality but with no mandatory intensive care intervention.

Approach to ICU patient with an acute abdomen: Ischaemic gut – common and fatal frequently. Suspicion highest in AF (new or old); DM; Peripheral vascular disease/arteriopath. Symptoms often vague.

Failure to absorb feed is not diagnostic and in fact is non-specific and should not be relied upon to help diagnosis. Lactate rising is often a late sign and a normal lactate is frequently falsely reassuring. In order to have best outcomes, surgical intervention should be early!

The most likely cause of an acute (short history) abdomen, in a patient with AF will be ischaemic bowel and this virtually mandates a laparotomy. CT scans are useful in excluding other pathologies, but in these cases theatre is the most appropriate destination.

Cardiac ICU

Examination on ICU is difficult – especially cardiac ICU post theatre. Suspect an ischameic gut if a “well” patients deteriorates suddenly. Differential is embolus vs low flow/hypoperfusion. ALL should be CT scanned (to exclude pancreatitis). Anyone who is increasingly unwell, early on, should have a surgical review and a laparotomy.

Laparotomy vs laparoscopy

The role of these two is in doubt. Laparoscopy is increasingly difficult in ICU patients – complex patients, obesity and cardiovascular instability. Laparotomy is a diagnostic tool as well a curative.

Small Bowel Obstruction
Increasingly common – suspect in a patient with previous surgery, SIRS and peritonism. Requires emergency intervention – however patients should have a CT first to confirm true vs pseudo obstruction. These patients need to be seen immediately.

The role of the surgeon is something the intensivist can influence i.e a discussion regarding the management of a septic patient – damage control operation, removal of dead tissue, abscess drainage, leaving the abdomen open to limit the operative insult and time. Repeated visits. Always remember there may be a radiological intervention in many cases and surgery not always required for sepsis source control.

Older patients

Frailty and co-morbidity and resource allocation means the decision needs to be right.
Stoma vs anastomosis – choice to the patient? Consideration of futility – conservative option?
CT scan younger patients and think twice in a frail patient.

Take home messages:
1) Be confident in suspecting acute surgical abdomen ischaemia and or pus
2) challenge and contribute to surgical thought process
3) Laparotomy is a diagnostic test

Mr King - Consultant colorectal surgeon

The complex surgical abdomen on ICU

3 common complex disease patterns:
  • Short bowel syndromes
  • Diseased (IBD)
  • Post-operative complications

All of these can be considered as surgical conditions in terms of:
  • Resuscitation
  • Restitution
  • Sepsis
  • Nutrition
  • Anatomy
  • Plan for surgery
  • Reconstruction

These can develop immediately but the high RISK time is 2-6 weeks (10 days to 6 weeks). During this time the adhesions intensify in number and strength with maximal strength between 2-6 weeks. This is the worrying period for surgeons (often a time of fluctuating illness in a post operative/ICU patient) and the mortality from operative intervention is massive due to adhesion density.

This may explain to us as ICU clinicians, why IR options are always considered around day 10 – and the reluctance to operate.

SIRS & CARS (Compensatory Anti-inflammatory Response Syndrome) discussed

  • Complex nutritional and electrolyte issues:
  • Require 100cm small bowel and 50 jejunal and colon to maintain health
  • Use PN to get some control of electrolytes and disease state
  • Try enteral route and monitor water losses and electorlytes carefully
  • If PEG in situ and working poorly – slow the rate (increase absorption) using loperamide or PPI (for high lesions); hypersalination.
  • The colonic stoma can be used retrograde for water and electrolyte absorption. Water loss (colonic) 1100ml (max. normal range) per day

Nutrition on ICU – The surgical patient perspective

Common dogmas on nutrition:
- mandatory treatment
- Not ICU doctors job but merely a dietitcian and nurse job

Nutrition assessment
  • Assessment within ICU is hard and arguably none of them work
  • BMI triceps thickness, Mid arm circumference, bio impedance
  • Deltatrax – doesn’t work with fio2 above 0.6 (so not in the ICU patient)
    • All these inaccurate in oedema

So use the History and food chart (good method)
Laboratory - albumin, pre albumin, micronutrients Mg/PO4/selenium (good method)

Bedside ultrasound - quads thickness (frailty) (research method)
CT abdomen paravertebral lumber muscular thickness (research method)

European and British Guidelines

  • Any patient if not established or likely to be on a full diet within 3 days they should receive EN
    • Requirement is 20-25kcl/kg/day (schofield) nice guideline
    • 1-1.5g/kg protein
    • Protein is utilised differently in the critically ill – so anymore than this is a waste

Historical question - Hypocaloric vs close to normal energy requirements

When critically ill - body can't cope with extra calories. It requires energy to metabolise food and thus does worse. Significant risk of AKI. History tells us nutrition not needed in critical illness – i.e when feeling unwell appetite is lost.

Trickle feeding (10-15ml/HR) is feeding gut only. Advantage is hypocaloric and it has immune function role in maintaining IgA function hence these ICU patients do well as proven in….
• Paul marik and Michael hooper intensive care medicine paper
• This looked at medical patients only, single organ dysfunction. No difference in type of feeding. In the multiple organ failure group – trickle feeding was beneficial.

ICU patient considerations

As part of the new process for sepsis management:

Fluid restriction from day 2 onwards
Fluid restriction in terms of fluid balance is difficult to work with TPN in the least volume (centrally 1kcal/ml).

Low no-fibre diet to be instigated post-op from major surgery (causes anastomotic pressure to increase when fibre utilised). Specific formulas and can vary

Enteral is always the preferred route. First choice! In ICU patients (avoids complications of PN)

Calories trial - 2014 sponsored by NICE compared TPN and EN compared functional GI tract
  • Aim 20-25kcal/kg/day aim to reach within 2-3days
  • Target was NOT reached. Reason not reaching target – parenteral diet was only changed once a day. Whereas enteral changed regularly!

TBL summary of CALORIES

PN is used in malnourished and at risk patients e.g Unsafe or non functioning gut (EPaNIC trial) 2011
  • Early PN - within 48 hours , late - day 8
  • Late feeding reduced ICU stay, faster recovery, fewer infections and reduced costs

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