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12 Surgical Intensive Care
Research
Reference Conclusion
373
Jia X, Kowalski RG, Sciubba DM, Geocadin
RG.Critical care of traumatic spinal cord injury. J
Intensive Care Med. 2013;28(1):12–23
Evans CH, Duby JJ, Berry AJ, Schermer CR,
Cocanour CS.Enteral albuterol decreases the need for
chronotropic agents in patients with cervical spinal
cord injury-induced bradycardia. J Trauma Acute
Care Surg. 2014;76(2):297–301; discussion 301–2
Anaphylactic shock
IgE-mediated anaphylaxis: IgE activates mast cells and basophils ➔ release of
Types
Risk factors
Presentation
Diagnosis
mediators
Non-IgE-mediated anaphylaxis: Mast cells and basophils are directly activated
by allergens ➔ release of mediators
Female, history of anaphylaxis, allergic drug reactions, and multiple past
surgeries or procedures
Three patterns of anaphylactic syndromes
Uniphasic type: Most common type, peaks at 30–60min, and resolves over the
next hour with no recurrence of symptoms
Biphasic type: The second most common type, may recur hours after the
resolution of initial event even in the absence of re-exposure to the allergen
Protracted or persistent anaphylaxis: Involves a reaction that lasts for days to weeks
Anaphylaxis is diagnosed if any one of the following three is present:
• Acute occurrence with mucocutaneous involvement and either respiratory
complications or hypotension
• ≥2 occurring rapidly after exposure to an allergen: Mucocutaneous
involvement, respiratory complications, hypotension/end-organ damage, or
persistent gastrointestinal symptoms
• Hypotension soon after exposure to a known allergen
For acute spinal cord injury: recommendation is against
the use of steroids
Enteral albuterol may reduce the frequency of
symptomatic bradycardia in patients with cervical spinal
cord injury, resulting in less rescue therapy using
chronotropic agents
Diagnostic tests
Management
Total serum tryptase level: Levels increase signicantly, peaks within 60–90min
of symptom onset, and persists for 6h
The plasma histamine level: Level increases rapidly 5–10min after the onset of
anaphylaxis and returns to normal within 60min
0.3–0.5mg of epinephrine (1:1000) in the mid-to-outer aspect of the thigh (can
be repeated every 5–15min up to three times)
Antihistamines and corticosteroids
Condition Management
Respiratory distress
Impeding respiratory failure/
oropharyngeal obstruction/laryngeal
edema
Refractory hypotension
Short-acting β-2 agonist
bronchodilator (such as albuterol)
• Racemic epinephrine (decrease
laryngeal edema)
• Intubate or surgical airway
• Volume resuscitation ➔ bolus
epinephrine ➔ epinephrine
infusion
374
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A. H. Sohail et al.
CVP PCWP CI SVR SVO2
Septic shock Low Low
Obstructive Shock (cardiac
tamponade/pulmonary
embolism)
Cardiogenic shock High High Low High Decreased SVO
Hypovolemic shock Low Low Low High Decreased (or low)
Neurogenic shock Low Low High Low
High
High (≥ 18)
High ➔ low
Low High Decreased (or low)
Low Mixed venous
oxygen saturation
in septic shock is
normal to
elevated,
indicating the lack
of adequate oxygen
extraction
2
Adrenergic receptors
Receptor Function
Alpha-1 receptor
Alpha-2 receptor Venous smooth muscle constriction
Beta-1 receptor
Beta-2 receptor Relaxes bronchial smooth muscles and vascular smooth muscles
Vascular smooth muscle contraction➔ increase SVR
Myocardial contraction and rate➔ chronotropic (heart rate) and inotropic (contractility)
Norepinephrine
(Levophed)
Phenylephrine
(NeoSynephrine)
Receptor Dose Uses Disadvantages
5–15mcg/min
Leads to a more
signicant increase in
blood pressure than
increased heart rate
Pure alpha-adrenergic
vasoconstrictor
May decrease stroke
volume and cardiac
output
(0.05–0.15 mcg/
kg/min)
Cardiogenic
shock: 0.05 mcg/
kg/min
0.5–2 mcg/kg/min
Initial vasopressor of
choice in septic,
cardiogenic, and
hypovolemic shock
Alternative vasopressor
for patients with septic
shock who: develop
tachyarrhythmias on
norepinephrine,
epinephrine, or
dopamine; have
persistent shock despite
the use of two or more
vasopressor / inotropic
agents; high cardiac
output with persistent
hypotension
Can induce
tachyarrhythmias and/or
cardiac ischemia
Reex bradycardia
Increased afterload
12 Surgical Intensive Care
375
Receptor Dose Uses Disadvantages
Epinephrine
(adrenalin)
Vasopressin
(vasopressin
(argininevasopressin)
Dopamine
(Inotropin)
Increases heart rate;
may induce
tachyarrhythmias and
ischemia
Elevates lactate
concentrations
Decrease mesenteric
perfusion
Decrease stroke volume
and cardiac output
Alpha-2>alpha-1
receptor activation
Pure vasoconstrictor
➔only BP and SVR
is increased with
vasopressin
0.01–0.2 mcg/kg/
min
0.03units per min
Initial vasopressor of
choice in anaphylactic
shock
Typically, an add-on
agent to norepinephrine
in septic shock when an
additional agent is
required
Add-on to
norepinephrine to raise
blood pressure to target
MAP or decrease
norepinephrine
requirement
Receptor Dose Uses Disadvantages
Tachycardia, arrhythmias
Activate dopamine,
alpha-1, and beta-1
receptors
2–5mcg/kg/min
An alternative to
norepinephrine in
septic shock in
patients with
compromised systolic
function or
bradycardia
Less effective than
norepinephrine for
reversing hypotension in
septic shock
Lower doses should not
be used for renal
protective effect
Dobutamine
(Dobutrex)
Milrinone
(Primacor)
Dobutamine increases
contractility and CO with
minimal effects on BP
Increases cardiac
contractility and heart rate
and afterload reduction
Phosphodiesterase
inhibitor that causes
increased levels of the
cyclic AMP
Increases cardiac
contractility and afterload
reduction
0.5–1mcg/kg/min
0.125–0.75mcg/
kg/min
Initial agent of choice
in cardiogenic shock
with low cardiac
output and maintained
blood pressure
Alternative for
short-term cardiac
output augmentation
to maintain organ
perfusion in
cardiogenic shock
refractory to other
agents
Increased mortality with
prolonged use
Hypokalemia
May cause hypotension
and tachyarrhythmias
Elevated LFTs,
thrombocytopenia, and
increased mortality with
long-term use
Causes peripheral
vasodilation, hypotension,
and/or ventricular
arrhythmia
376
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Hemodynamic Monitoring
Variable Characteristic Landmark studies Limitations
Measures CVP as a surrogate
Central venous
pressure (static)
Pulse pressure
variation (PPV)
(dynamic)
for RV lling pressure
Both physical exam and
central venous pressure
measurement are poor
predictors of uid
responsiveness
Difference between systolic
and diastolic arterial blood
pressure
Monnet X, Marik PE, Teboul
JL.Prediction of uid
responsiveness: an update.
Ann Intensive Care. 2016
Dec;6(1):111
PPV of at least 13–15% is
strongly associated with
volume responsiveness
Marik PE, Cavallazzi R, Vasu
T, Hirani A.Dynamic changes
in arterial waveform derived
variables and uid
responsiveness in
mechanically ventilated
patients: a systematic review
of the literature. Crit Care
Med 2009; 37:2642
Affected by volume status
RV function & tricuspid
valve function
Technique is limited to
patients who are
mechanically ventilated
without spontaneous breath
receiving ≥8mL/kg of tidal
volume, in sinus rhythm,
closed chest, absence of RV
failure
A. H. Sohail et al.
Vena cava diameter
and dynamic
measures of vena cava
Passive leg raise
Because there is no valve
between the vena cava and
right atrium, fullness of the
vena cava is thought to
correlate with increased right
atrial pressure
Thought to provide a bolus
of the patient’s own
intravascular blood from the
capacitance veins of the
lower extremities
Static measurement of IVC
diameter and variation with
spontaneous respiration has
been shown to correlate with
central venous pressure
Prekker ME, Scott NL, Hart
D, etal. Point-of-care
ultrasound to estimate central
venous pressure: a
comparison of three
techniques. Crit Care Med
2013; 41:833
One meta-analysis of 23
studies reported a sensitivity
of 86 percent and a specicity
of 92 percent for PLR for
predicting uid
responsiveness; the predictive
value of PLR was best when a
ow variable such as CO was
used in conjunction with PLR
Duus N, Shogilev DJ,
Skibsted S, etal. The
reliability and validity of
passive leg raise and uid
bolus to assess uid
responsiveness in
spontaneously breathing
emergency department
patients. J Crit Care 2015;
30:217.e1
Images obtained are
operator-dependent
Several patient factors such
as pulmonary hypertension,
valvular regurgitation, and
right ventricular
dysfunction may also
confound ndings
Poorly dened
12 Surgical Intensive Care
Variable Characteristic Landmark studies Limitations
377
Mixed venous
oxygenation
saturation
(SvO2)
Pulmonary
capillary wedge
pressure
(PCWP)
Represents a balance between
oxygen delivery and oxygen
consumption
Pulmonary artery catheter passes
through the central venous
circulation ➔ the right atrium➔
right ventricle➔ pulmonic valve
➔and into the distal pulmonary
artery (location of the tip of the
pulmonary artery catheter is in a
branch of the pulmonary artery)
Contraindications: saddle
pulmonary embolus, recent
repair of the right heart or
pulmonary artery, presence of
left bundle branch block
Pulmonary capillary wedge
pressures are reective of left
heart lling (left ventricular end
diastolic volume=left
ventricular end diastolic
pressure=left atrial end diastolic
pressure=pulmonary artery
occlusion pressure since there
are no valves in the pulmonary
circulation)
Renner J, Scholz J, Bein
B.Monitoring uid therapy. Best
Pract Res Clin Anaesthesiol. 2009
Jun;23(2):159–171
A multicenter study of physicians’
knowledge of the pulmonary artery
catheter. Pulmonary artery catheter
study group
T J Iberti1, E P Fischer, A B
Leibowitz, E A Panacek, J H
Silverstein, T E Albertson
Sandham JD, Hull RD, Brant RF,
Knox L, Pineo GF, Doig CJ, Laporta
DP, Viner S, Passerini L, Devitt H,
Kirby A, Jacka M.A randomized,
controlled trial of the use of
pulmonary artery catheters in
high-risk surgical patients. N Engl J
Med 2003, 348: 5–14. 10.1056/
NEJMoa021108
Does not improve
survival as compared
to standard care
without a pulmonary
artery catheter
378
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A. H. Sohail et al.
Arterial catheterization
Sites Common sites of cannulation include radial, femoral, and axillary arteries
Complications Bleeding, infection, and vascular insufciency
Brachial artery Brachial artery catheters are associated with an increased risk of thrombosis and should be
used only when other options have been exhausted
Even though over-dampening and under-dampening may change the pulse pressure recorded
by an arterial cannula, the mean arterial pressure remains unaffected
Complication Causes Characteristics Prevention/management
Attenuation of the
peak systolic BP and
an overestimation of
diastolic blood
pressure ➔ falsely
reduced pulse
pressure
Augmentation of the
peak systolic blood
pressure and a
blunting of diastolic
blood pressure ➔
falsely elevated
pulse pressure
Swelling, erythema,
tenderness,
uctuance, and may
progress to abscess
formation
Trouble shooting
Overdamped
Underdamping
Infection
Partial thrombus
within the
catheter, air
bubbles kinking
of the catheter or
tubing
Long length of
tubing and is
characterized by
sharp peaks in
the waveform
Femoral site
associated with
more infection
than radial site
Research
Reference Findings
Cherpanath TG, Hirsch A, Geerts BF, etal.
Predicting uid responsiveness by passive leg raising:
a systematic review and meta-analysis of 23 clinical
trials. Crit Care Med. 2016;44(5):981–991
A large meta-analysis of 23 trials involving more than
2200 patients found that passive leg raising with
monitoring of cardiac response was the best method for
assessing uid responsiveness
Aspirate bubbles, unkink
catheter
No long catheters
• Avoid of a cutdown technique
• Replacement of the
connector tubing every 48h
• Remove when no longer
required
12 Surgical Intensive Care
379
Cardiac Arrhythmias
The evaluation of tachycardias (heart rate>100
beats/min) is based on three ECG ndings: i.e.,
Narrow-complex-tachycardia
(QRS <0.12s)
Tachycardia (HR >100)
Wide-Complex-Tachycardia
(QRS>0.12sec)
Atrial brillation(AF)
the duration of the QRS complex, the uniformity
of the R-R intervals, and the characteristics of the
atrial activity.
Regular rhythm Sinus tachycardia:
uniform P waves
Paroxysmal SVT: No P
waves
Atrial utter: saw tooth
waves
Irregular Rhythm Atrial brillation:
Fibrillation waves
Multifocal atrial tachycardia
(MAT): Non-uniform P
waves
Regular Rhythm Ventral tachycardia
Irregular Rhythm SVT with prolonged AV
conduction
Adverse Consequences
Management
Atrial brillation is the most common post-operative arrhythmia
Postoperatively➔ atrial brillation is likely due to volume overload
The adverse consequences of AF include impaired cardiac performance and
thromboembolism
• Control of the heart rate
• Cardioversion (electrical and pharmacological)
• Thromboprophylaxis
380
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Atrial brillation(AF)
A. H. Sohail et al.
Beta-blockers are the rst line therapy for postoperative atrial brillation to achieve
rapid ventricular rate control and conversion to sinus rhythm
Diltiazem is second line rate control agent when ß-blocker therapy has failed
Amiodarone can provide both rate and rhythm control and is an alternative therapy to
beta-blockade for postoperative atrial brillation especially when the patient is
hemodynamically unstable or has a known ejection fraction of <40%
Drug Uses Side effects
Heart rate control
Metoprolol
Diltiazem
Amiodarone
Esmolol
Preferred agents for
rate control when AF
is associated with
hyperadrenergic states
(such as acute MI and
post-cardiac surgery)
Acute response to
diltiazem is superior to
amiodarone and
digoxin
Less effective for
acute rate control than
diltiazem
Favored by some for
AF with heart failure
Ultra-short-acting drug
(with a serum half-life
of 9min), which
allows rapid dose
titration
Bolus dosing is not
optimal for strict rate
control
• Hypotension
• Negative inotropic
effects, but has been
used safely in
patients with heart
failure
Can convert AF to
sinus rhythm, which
can be risky without
adequate
thromboprophylaxis
Hypotension (15%),
infusion phlebitis
(15%), bradycardia
(5%), and elevated
liver enzyme
Effective in AF
associated with
hyperadrenergic states
Slow-acting drug that
Response to
Digoxin
AF that is complicated by hypotension, pulmonary edema, angina ➔treated with
direct-current cardioversion
Biphasic shocks have replaced monophasic shocks as the standard of care for
cardioversion because they require less energy for a successful result
An energy of 100J is usually enough for successful cardioversion using biphasic shocks
(200J is recommended for the initial cardioversion attempt in the most recent guidelines
on AF)
intravenous digoxin is
slow to develop
should not be used
alone for acute rate
control
Preferred for AF with
heart failure
12 Surgical Intensive Care
Atrial brillation(AF)
381
The CHADS2-VASC score is the best tool for decision-making for anticoagulation for
atrial brillation
Current guidelines recommend oral anticoagulation for a score of 2 or more
Risk factor CAH2DS2-VASC
Thromboprophylaxis
Congestive heart failure/left ventricular
dysfunction
Hypertension 1
Age>75 2
Diabetes mellitus 1
Stroke/TIA/thromboembolism 2
Vascular disease 1
Age 65–74 1
Gender category (i.e., female) 1
Maximum score 9
1
Arrythmia Description Management
Widened QRS complex with all of the
Monomorphic ventricular
tachycardia
Monomorphic ventricular
ectopy
complexes appear the same
➔ the same ventricular focus initiates the
conduction within the ventricle
Premature ventricular contractions (PVCs)
that have the same morphology
Immediate cardioversion when
monomorphic ventricular tachycardia
occurs with hypotension
Single PVCs are not concerning
Couplets (two sequential PVCs) are
more concerning
Monomorphic ventricular ectopy often
does not need to be treated
When required, the treatment of choice
is amiodarone
Narrow complex
tachycardia
Torsade de pointe
Bradycardia Heart rate<60 Atropine
Caused by an electrical impulse being
initiated above the atrioventricular node and
the impulse traveling down the Purkinje
bers
Most commonly precipitated with a drug that
prolongs the Q–T interval, such as
methadone, haloperidol, and levooxacin
The treatment of this arrhythmia is to
block the AV node with a calcium
channel blocker
Treatment is targeted at removing the
offending agent and administering
magnesium
382
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Non-invasive and invasive cardiac pacing
Symptomatic bradycardia
Indications
Acute myocardial ischemia
Cardiogenic shock
Prevention of tachyarrhythmias post-cardiotomy
A. H. Sohail et al.
Contraindication
Non-invasive
cardiac pacing
Invasive cardiac
pacing types
Prosthetic tricuspid valve
Systemic anticoagulation or antiplatelet therapy (relative contraindication)
Transcutaneous pacing
Transvenous: Right IJ is preferred access due to ease of access of right atrium
Epicardial: Usually during cardiac surgery
Leads can be placed into the myocardium at either ventricle or atrium
Type Indication
Ventricular rate is insufcient for adequate cardiac output
Ventricular pacing
Atrial pacing
Dual chamber pacing
North American Society of Pacing and Electrophysiology [NASPE]) Nomenclature
Category Description
1st letter Chamber Paced: Describes location of pacing
in the setting of AV nodal dysfunction
Most common form of pacing
If the sinus or AV nodes are functional, then atrial or
dual-chamber pacing is preferred
Provides a physiologic style of pacing, where the atrium is
paced just prior to ventricular pacing, simulating the “atrial
kick”
wires (A, atrial; V, ventricular; D, dual; O,
asynchronous)
2nd letter Chamber Sensed: Describes which chamber is
sensed, if that mode of pacing is present (O,
asynchronous)
Nomenclature
3rd letter Response to sensing: Describes how the pacer
responds to a sensed event (I, inhibits; T, triggers;
D, dual; O, no response)
4th letter Indicates rate modulation (R, rate modulation; O,
absent)
5th letter Indicates multisite pacing. It is rarely used
The OO designation indicates the pacer is functioning in an asynchronous mode
Electrocautery and certain monitoring devices can interfere with conduction sensing
in some pacemakers. Asynchronous modes will re independently of input,
minimizing the risk of arrhythmias
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