Wessex Intensive Care Society (WICS)

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Steve Mathieu @stevemathieu75

I want to start by sharing a story…

Its around midnight…there is a referral from the ED. They have an 80-year-old lady who presented to the ED 1 hour ago. She has had several day of worsening abdominal pain. She has been vomiting. She looks like she has lost some quite a lot of weight. She is hypotensive. She is hypoxic but able to chat away. She is in atrial fibrillation at 150 b/min (takes rivaroxabin as chronic). She has been catheterised and a few drops of dark, concentrated urine was all that came out. She has had a CT scan, which shows her bowel is obstructed. Her caecum is grossly distended and there are specs of air visible in the bowel wall.
She looks sick
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‘She sounds too sick for surgery at the moment. Admit her to Intensive Care. We will operate tomorrow if she responds to treatment….’
References
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Pearse et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012
Surgical Risk. App download free via itunes
NICE Guidelines [CG169]. Acute kidney injury: Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. August 2013
Marik et al. Does Central Venous Pressure Predict Fluid Responsiveness? 2008. Chest
Glycocalyx in Critical Illness. Life in the Fast Lane
Fluid administration device flow rates. Life in the Fast Lane
Hoste et al. Four phases of intravenous fluid therapy: a conceptual model. 2011. BJA
Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access. REBELEM
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Peri-operative Management of Patients who are Receiving a New Oral Anticoagulant. 2013. Thrombosis Canada
New Oral Anticoagulant - A practical guide on behalf of the Australasian Society of Thrombosis and Haemostasis (ASTH). 2013
Malik et al. Atrial fibrillation in the intensive care setting. 2013. JICS
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Levin. Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality. 2014. BJA
High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. 2014. Lancet
NSC 2013 Prof Mike Grocott - Lessons for Anaesthesia from Extreme Environment Physiology
Grocott M et al. Caudwell Xtreme Everest Expedition. 2010. High Altitude Medicine and Biology
Mercer et al. Haemorrhage and coagulopathy in the Defence Medical Services. Anaesthesia 2013
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Kumar et al. Rapidity of source control implementation following onset of hypotension is a major determinant of survival in human septic shock. 2004. Crit Care Med (presented as poster and no abstract available)
- 950 ICU patients with septic shock requiring surgical (81%) and non-surgical / percutaneous (21%) source control
- 21.4%, source control was not implemented despite a clear indication = 96.4% mortality
- Overall mortality 58.2%; median time to effective antimicrobial therapy and source control was 6.7 and 11.6 hours respectively
- Odd of death increased with delays in source control. By 12-18 hours post hypotension onset, mortality was significantly increased compared to source control within 3 hours (25.1% vs 63.7%, p<0.01)
The Bleeding Trauma Patient. RESUS.ME
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Schreiber. Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room. Critical Care 2014
General - high risk surgical patients
The Higher Risk General Surgical Patient - Royal College of Surgeons 2011
Knowing the Risk. A review of the peri-operative care of surgical patients. NCEPOD. 2011
National Emergency Laparotomy Audit (NELA)
Perioperative Medicine. The Pathway to Better Surgical Care. The Royal College of Anaesthetists
YouTube Video
Further reading
Sobol and Wunch. Triage of high-risk surgical patients for intensive care. 2011. Critical Care
Podcast 111- Fluids in Sepsis, A New Paradigm. Marik
Myburgh. Fluid resuscitation. Which, When and How Much?
Maitland et al. Mortality after fluid bolus in African Children with Severe Infection. 2011. NEJM
Wakeling. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. 2005. BJA
Davies et al. Preoperative optimization of the high-risk surgical patient. 2004. BJA
SMACC-Back: Myburgh on Catecholamines. EMCrit
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