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12 Surgical Intensive Care
Complications of intubation and mechanical
ventilation
Complication Prevention/treatment
393
Local trauma to
teeth and lips
Esophageal
intubation
Mainstem intubation
Ventilator- associated
pneumonia,
ventilator- associated
tracheobronchitis
Prevent this complication by extending the blade up and out, rather than levering the blade
on the teeth ➔ask an assistant to retract the lips laterally as the blade is inserted.
Promptly identify this complication with lack of end-tidal CO2 ➔ remove the tube and
restart the intubation process
Endotracheal tube located in a bronchus
Incidence of endobronchial intubation is
greatest following emergency intubation
AP chest radiograph demonstrates a right
mainstem intubation (arrow); the carina is
outlined in black. Also note the left
retrocardiac opacication causing silhouette
sign of the aorta, secondary to the
consolidation and associated small pleural
effusion
Occurs because biolms develop on the
ETT
“Bundles” have been used to prevent
ventilator-associated pneumonia that
include:
1. Keeping the head of the bed elevated
above 30
2. Providing daily sedation vacations
3. Venous thromboembolism prophylaxis
4. Stress ulcer prophylaxis
5. Providing daily oral care (including
decontamination regimens), frequent
oropharyngeal suctioning, and deep
tracheobronchial suctioning
AP chest radiograph demonstrates medial
right lower lung opacication (arrow),
concerning for a pneumonia. Note the
endotracheal tube tip projecting between the
clavicular heads (arrowhead)
Ventilator- associated
sinusitis
Occurs because of impaired sinus drainage
due to ETT placement or nasogastric
feeding tube placement
394
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Surgical
airway
A. H. Sohail et al.
• Palpate landmarks
• Hold the larynx and upper airway steady with the non-dominant hand
• Make a 2–3-cm vertical midline incision.
• Identify the cricothyroid membrane (CTM)
• Incise the cricothyroid membrane transversely
• Insert the tracheostomy tube
Cricothyroidotomy
Or
Rapid four-step technique
Basic technique
• Step 1 ➔identify the CTM by palpation
• Step 2 ➔make a single horizontal stab incision through the skin, subcutaneous tissue, and CTM
• Step 3 ➔place the hook
• Step 4 ➔insert the tracheostomy tube
Hypoxemix Syndromes
Pulmonary embolism
Physiology
Presentation Dyspnea, pleuritic chest pain, wheezing, hypoxemia, and tachycardia
The mechanical obstruction in the pulmonary vasculature alters the ventilation-perfusion ratio ➔
alveoli that are ventilated are not perfused ➔ altering the ventilation-perfusion ratio
Inammation ➔constriction of airways, surfactant dysfunction and atelectasis ➔ functional
intrapulmonary shunting ➔ hypoxemia
Computed tomography (CT) pulmonary
angiogram, V/Q scan (need a pre-test
probability)
Diagnosis
Axial chest CTA demonstrates a saddle pulmonary
embolism (solid and outlined arrows), with distal extension
into segmental pulmonary arterial branches. Note the
bowing of the interventricular septum (arrowhead) into the
left ventricle, indicative of right heart strain
12 Surgical Intensive Care
Pulmonary embolism
395
Management
CT pulmonary angiogram cannot be done ➔ treatment is initiated due to presumed diagnosis based
on nuclear medicine studies, bedside echocardiography, and even strong clinical suspicion
Hemodynamically unstable ➔ catheter-directed thrombolysis, catheter-based embolectomy, or
surgical embolectomy
Acute respiratory distress syndrome (ARDS)
Pathophysiology
Risk factors Pneumonia, extrapulmonary sepsis, aspiration
Prevention of ARDS Fluid conservative resuscitation (crystalloid and blood products):
Injury ➔ inammatory cytokine ➔ results in damaged leaky alveolar capillaries
➔results in protein and uid efux into the interstitium ➔ airway collapse
➔decreased lung compliance, increased pulmonary hypertension, and ventilation-
perfusion mismatch ➔ hypoxemia
• Timely and thoughtful treatment of sepsis
Lung protective ventilation (low tidal volumes during surgery decreases the need
for postoperative ventilatory support)
Chest radiographic ndings:
bilateral or diffuse pulmonary
opacities/inltrates
Diagnosis
AP chest radiograph demonstrates bilateral
hazy opacications thought the lungs,
indicating acute respiratory distress syndrome
Four criteria need to be present to make a
diagnosis of ARDS:
1. Acute onset of respiratory symptoms
beginning within 1week of a clinical insult
2. Bilateral patchy inltrates on a chest X-ray
or chest CT scan
3. Cardiogenic pulmonary edema or uid
overload is not the primary cause of the
respiratory failure conrmed with
echocardiography
4. PaO2/FIO2 consistent with an impairment
of oxygenation
396
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Acute respiratory distress syndrome (ARDS)
Berlin criteria: Classication based on degree of hypoxemia
A. H. Sohail et al.
Classication
Mild
Moderate
Severe
All these calculations are done on a positive end-expiratory pressure (PEEP) of at
least 5cm H2O ➔ only PEEP is a component of the Berlin denition of ARDS
200mm Hg<PaO2/FIO2≤300mm Hg
100mm Hg<PaO2/FIO2≤200mm Hg
PaO2/FIO2≤100mm Hg
Evidence based management of ARDS
Intervention Pathophysiology Evidence
6ml/kg ➔ tidal volume
Plateau pressure≤30
ARDS net goals:
PaO2: 55–80mm Hg or
Lung protective
ventilation
Corticosteroids
SpO2: 88–95%
pH: 7.30–7.45
Permissive hypercapnia refers to accepting lower
minute ventilation and CO2 clearance in order to
prioritize lower airway pressures
Any resultant acidosis can be managed with sodium
bicarbonate
Benecial for patients with prolonged courses of
ARDS (> 14days) patients with refractory ARDS
can be treated with a 30-day course of steroids
starting between days 7 and 14
Standard of care for mechanical
ventilation in ARDS
Reduced mortality
Corticosteroids show an
improvement in oxygenation and
ventilator-free days, but mortality
data are mixed
The OMEGA study showed that
Omega-3, linolenic
acid, antioxidants
Nitric oxide (NO) Improves oxygenation NO did not improve mortality
Paralytic infusion
Prone positioning
Direct anti-inammatory effects
Avoidance of excessive tidal volumes
Reduction of work of breathing and metabolic
demand
Direct anti-inammatory effects
Improves V/Q mismatch by placing the bestventilated anterior lung segments in the posterior
position, where pulmonary blood ow is highest
An “hourglass phenomenon” occurs as mucus and
uid slowly shift from the upper to lower lung
segments, not only allowing consolidated lung to be
opened, but permitting secretions to be suctioned by
bronchoscopy
omega-3 fatty acids, γ-linolenic acid,
and antioxidants did not improve
ventilator-free days or other clinical
outcomes
Associated with decreased 90-day
mortality in patients with PaO2/FIO2
ratio<120mm Hg within 48h of
onset
Improve mortality only in patients
with moderate and severe ARDS
(PaO2/FIO2 ratio<150)
Bipap
Airway
CPAP
Airway
12 Surgical Intensive Care
Evidence based management of ARDS
Intervention Pathophysiology Evidence
Two recent trials showed highHigh frequency
oscillating ventilation
(HFOV)
Active inspiratory and expiratory phases and small
tidal volumes at a constant mean airway pressure
frequency oscillatory ventilation
(HFOV) did not improve outcomes
in ARDS and may even increase
harm
Respiratory failure
Type 1 Hypoxemic (partial pressure of arterial oxygen [PaO2]<60mm Hg)
Type 2 Hypercapnic with or without hypoxemic (partial pressure of arterial carbon dioxide
[PaCO2]>50mm Hg without evidence of chronic compensation)
Mechanical Ventilation
Invasive and non-invasive ventilation options
Nasal cannula: 25–40% FIO2 delivered
397
Noninvasive
options
Face mask: 35–50% FIO2 (humidied vs Venturi that delivers dry gas)
Nonrebreather face mask: 65–95% FIO
Self-inating ventilation (Ambu bag): 95–100%
Bilevel positive airway pressure (BiPAP):
• Two pressure settings (inhalation-high ipap, and
exhalation-low-epap)
Continuous positive airway pressure (CPAP):
• Single pressure that remains constant
• Effective and safe intervention for the treatment of adults
with acute respiratory failure after upper abdominal
surgery
Relative contraindications: Recurrent vomiting, large
amounts of pulmonary secretions and an inability to tolerate
the devices
High-ow nasal cannula (HFNC)
Used to provide supplemental oxygen to patients with
hypoxemia and respiratory insufciency
Delivers heated humidied oxygen at a ow rate of 10 to
60L/min
2
pressure
pressure
Delivery of oxygen at high-ow rates ➔creates a positive
pressure effect➔ increases end-expiratory lung volume,
reduces anatomic dead space, and reduces work of
breathing
398
Airway
P low
Inspiratory
Release
Airway
Pressure control
Volume control
Airway
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Invasive and non-invasive ventilation options
A. H. Sohail et al.
Invasive
ventilation
modes
Airway pressure release ventilation (APRV)
High levels of CPAP + release breath
High CPAP➔ improves arterial oxygenation by opening
collapsed alveoli (alveolar recruitment)
Pressure release phase ➔ CO2 removal
Delivers a high continuous positive airway pressure (P high)
or a long duration (T high) and then falls to a lower pressure
(P low) for a shorter duration (T low)
Tidal volume (TV): Is related to the driving pressure
(difference between P high and P low)
T high and T low determine the frequency of inations and
deations (respiratory rate)
Spontaneous breathing is possible at both P high and P low
Pressure controlled ventilation (PCV):
Inspiration ends after delivery of the set inspiratory pressure
Requires setting: RR, inspiratory pressure level, PEEP,
FIO2; I:E ratio
Peak airway pressure is constant
P high
pressure
pressure
phase
APRV
phase
Advantages: Control peak alveolar pressure, increased
inspiratory to expiratory time (I:E ratio) ➔ increase mean
airway pressure for any given tidal volume but at a lower
peak airway pressure ➔functional residual capacity also
increases
Disadvantage: Decrease in alveolar volume that occurs
when there is an increase in airway resistance or decrease in
lung compliance
Volume controlled ventilation (VCV):
Inspiration ends after delivery of a set tidal volume
pressure
Requires setting: Peak ow rate, ow pattern, tidal volume,
respiratory rate, positive end-expiratory pressure (PEEP)
Advantage: Constant TV despite changes in mechanical
properties of the lung
Disadvantage: Airway pressures at the end of inspiration
are higher during VCV than PCV; risk of ventilator-induced
lung injury is related to peak alveolar pressure
12 Surgical Intensive Care
Case Management
399
Trouble shooting
Inadequate oxygenation Increase PEEP and/or FIO
Hypercarbia Increase RR and/or TV
2
Extubation
Calculation of rapid shallow breathing index (RSBI), CROP, and negative inspiratory force (NIF) are
measures utilized in weaning readiness:
Criteria Description Threshold
RSBI—Rapid shallow
breathing index
CROP score (respiratory compliance/(respiratory rate)×paO2/
NIF—Negative inspiratory
force
RR—Respiratory rate 30–38
SPT—spontaneous
breathing trial
Cuff leak test
RR/TV<105 breaths/min/L ➔ increased probability
of successful weaning
pAO2×(maximum inspiratory pressure)
Patient draws maximum inspiration against an
occluded airway to assess strength of respiratory
muscles. Goal is to have less than 10cm H2O of
variability between multiple inspiratory efforts
Spontaneous breathing trial with respiratory pressure augmentation of 5–8cm H2O
rather than a T-piece for a period of at least 30min and may be extended to 2h
➔cuff leak test should be performed on mechanically ventilated patients who meet
criteria for extubation but who are deemed to be a high risk for post-extubation
stridor
<65
>13.5
−20 to −30
Patients who do not have evidence of audible breathing after deation of the cuff
➔should receive systemic steroids at least 4h before an attempt at extubation
Research
Reference Conclusion
Juern JS.Removing the critically ill
patient from mechanical ventilation. Surg
Clin North Am. 2012;92(6):1475–1483
Easterday TS, Moore JW, Redden MH,
etal. Percutaneous tracheostomy under
bronchoscopic visualization does not
affect short-term or long-term
complications. Am Surg.
2017;83(7):696–698
Heyrosa MG, Melniczek DM, Rovito P,
Nicholas GG.Percutaneous
tracheostomy: a safe procedure in the
morbidly obese. J Am Coll Surg.
2006;202(4):618–622
Regardless of the time on the ventilator, the use of spontaneous
breathing trials in conjunction with “daily sedation holidays” has the
greatest effect on decreasing ventilator days
Percutaneous dilatational tracheostomy is a safe and effective
alternative to open tracheostomy. The percutaneous approach tends to
have lower overall costs and can be carried out in an intensive care
unit setting, rather than the operating room, without an increase in
complication rates. The original technique for percutaneous
tracheostomy included the use of a bronchoscope
One recent study evaluated percutaneous tracheostomy in patients
with a BMI greater than 35 and found no increase in rates of
complication compared with similar patients undergoing open
tracheostomy
400
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Research
A. H. Sohail et al.
Reference Conclusion
Kaczmarek C, Aach M, Hoffmann MF,
etal. Early percutaneous dilatational
tracheostomy does not lead to an
increased risk of surgical site infection
following anterior spinal surgery
[published correction appears in J
Trauma Acute Care Surg.
2018;84(4):679.]. J Trauma Acute Care
Surg. 2017;82(2):383–386
Zilahi G, McMahon MA, Povoa P,
Martin- Loeches I.Duration of antibiotic
therapy in the intensive care unit. J
Thorac Dis. 2016;8(12):3774–3780
Rochwerg B, Brochard L, Elliott MW,
etal.; Members of the Task Force.
Ofcial ERS/ATS clinical practice
guidelines: Noninvasive ventilation for
acute respiratory failure. Eur Respir J.
2017;50(2). pii: 1602426
Diaz-Fuentes G, Hashmi HRT,
Venkatram S.Perioperative evaluation of
patients with pulmonary conditions
undergoing non-cardiothoracic surgery.
Health Serv Insights. 2016;9(suppl
1):9-23
A recent study evaluated percutaneous tracheostomy in patients after
anterior cervical spinal surgery and found no increase in surgical site
infection
The duration of antibiotic therapy for ventilator- associated
pneumonia: A short course of 7–8days is as safe and effective as a
14- to 15-day course
In a prospective observational study of patients with respiratory
failure after abdominal surgery, non-invasive ventilation markedly
reduced the incidence of reintubation, length of hospital stay, and
mortality
Multidisciplinary team planning should occur for all patients with
pulmonary hypertension (New York Heart Association classes III or
IV), or anyone else deemed high risk
Electrolytes andAcid Base Disturbances
Body uids
Physiology of Body Fluids Total body water (TBW): 50–60% of body weight:
Extracellular uids: one-third of TBW
• Plasma ➔ 5% of body weight
• Interstitial uids➔ 15% of body weight
Intracellular uids: two-thirds of TBW (40% body weight)
Principal component of uid
compartments
Plasma Osmolarity Plasma osmolarity=(2×Na)+(glucose/18)+(BUN/2.8)
Sodium ➔ principal cation in extracellular uid
Potassium ➔principal cation in intracellular uid
Normal osmolarity=280–295
12 Surgical Intensive Care
Maintenance therapy
Maintenance uid requirements (4-2-1 rule):
• 4mL/kg/h for rst 10kg
• 2mL/kg/h for second 10kg
• 1mL/kg/h for every kilogram above 20kg
Replace Reason
401
Maintenance after surgery
for rst 24h
Maintenance after 24h
from surgery
Administration of NS ➔ hyperchloremic metabolic acidosis
LR Avoids acidosis induced by excess chloride administration
D5½ NS Most adults who have no prior losses or excesses of uid require
approximately 2L of D5½NS+20mmEq KCl/liter per day to
maintain normal homeostasis
Composition of common crystalloid infusion
Acetate
Fluid Glucose Na Cl K Lactate
NS (0.9%
NaCl)
½NS (0.45%
NaCl)
Lactated
ringers
Plasmalyte
(Normasol)
3% NaCl 0 513 513 0 0 0 0 0 1026 5
D5W 50 0 0 0 0 0 0 0 154 4.5
0 154 154 0 0 0 0 0 308 5.5
0 77 77 0 0 0 0 0 154 5.5
0 130 109 4 28 3 0 0 272 6.5
0 140 98 5 0 27
Gluconate Ca Mg Phos Osm pH
0 3 0 294 7.4
23
D10W 100 0 0 0 0 0 0 0
D5NS 50 154 154 0 0 0 0 0
D5½NS 50 77 77 0 0 0 0 0
5% Albumin 0 145 <
2
25% Albumin 0 145 <
2
Hetastarch 6%
in NS
Extracellular
uid
0 154 154 310 5.9
100 142 103 4 24 (HCO
-
) 5 3 3 285–
3
330 7.4
330 7.4
7.35–
295
7.45
402
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A. H. Sohail et al.
Body uid electrolyte composition
L/day Na
Saliva 1–2 20–50 20 30–40 0–40
Stomach 1–2 20–70 10–20 90–130 0
Biliary 0.5–1 140 5–10 100 20–45
Small bowel 1–5 110 5–20 110–150 30–40
Pancreas 0.5–1 140 5–10 70–100 45–115
Duodenum 0.5–2 140 5 75
Sweat 10–50 0–10 10–60 25
Diarrhea 10–120 15–50 25–90 40–65
CSF 0.5 141 3 127 25
+
K
+
Cl
-
Common case scenarios for uid replacement
Case scenario Result Replace Reason
HCO
-
3
Patient with upper
gastrointestinal losses
(NGT output, gastric
outlet obstruction, high
output proximal stula)
Patient with pancreas,
biliary, small bowel or
hepatic drainage
Patient with lower
gastrointestinal losses
(diarrhea or stula)
Hypokalemic,
hypochloremic metabolic
alkalosis + paradoxical
aciduria
Hypokalemic metabolic
acidosis
Hypokalemic metabolic
acidosis
NS or D5NS+20meq
KCL/liter
LR
LR+20meq KCl/liter
Vomiting causes
hyponatremia,
hypochloremia, and
hypokalemia (kidneys
compensating ➔getting rid
of K+ to save H+)
➔using NS replaces
chloride and treats the
hypochloremic,
hypokalemic, hypovolemic
metabolic alkalosis
➔using LR replaces loss of
bicarbonate
➔using LR replaces loss of
bicarbonate
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