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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5524_Библиотеки_им_академика_М_И_Перельмана.pdf
188 C. J. Fox
surgical preparation and longitudinal incisions to expose multiple arterial
beds or perform a fasciotomy. The arteriotomy may be transverse if there
is no suspicion for atherosclerosis and need for a bypass; otherwise a
longitudinal arteriotomy is made. A balloon embolectomy catheter is inserted, carefully infl ated with a volume of saline that is annotated on the
hub of the catheter. A 5-6 French (Fr) catheter is used for Aorto-iliac and
subclavian vessels, 3-4 French for femoropopliteal or brachioaxillary
vessels, and a 2 Fr for the tibial or radioulnar vessels. Caution should be
exercised such that the intimal surface is not injured yet properly aligned
to the wall. Certain embolectomy catheters can be guided over wires and
used in conjunction with fl uoroscopy to easily pass the catheter to the
desired location. Successful passage may require several attempts and
should be repeated until all thromboemboli is removed. Back bleeding
should be brisk and a completed angiogram should confi rm restoration
of fl ow. Intra-arterial injection of 30–60 mg of papaverine or 200–400
µg of nitroglycerin may be given along with a liberal amount of heparinized saline to relieve vasospasm. When thrombectomy is incomplete,
consider using 5–10 mg of tissue plasminogen activator (TPA) in 20 cc
of saline. Fasciotomy should always be considered in any patient with
prolonged (>2 hrs) of ischemia.
• Final Points
The simultaneous management of peripheral vascular injuries in the pursuit
of life and limb is very challenging. The decision to amputate or reconstruct
an ischemic requires sound judgment that often comes with experience. These
patients have significant transfusion requirements and the resuscitation
should not be separated from the surgery. A two-team approach is an effective
method that will keep speed on your side. Not all vessels have to be repaired,
as brachial and tibial vessels can be ligated when a Doppler signal is obtainable in the distal limb. Systemic heparin is not necessary; however adequate
intimal debridement and liberal flushing with heparinized saline vein during
the repair is essential. A well-covered interposed saphenous vein graft is a
durable conduit and favored over prosthetic materials. Venous reconstruction
should be performed when time permits. Completion arteriography is not
usually necessary, but you should confirm your pulse exam with a continuous
wave Doppler. Remember, your completion assessment should be continuous
over the next 24 hours. Trust yourself, give the patient time to “catch-up”, and
recognize that the vascular exam will improve over time with successful
repairs. The following references are highly recommended for additional
reading about the management of peripheral vascular injury on the front line.
Vascular Emergencies 189
Practical Algorithm(s)/Diagrams
Fig. 1. Management algorithm for peripheral vascular injuries (Adapted from Feliciano
et al. J Trauma Acute Care Surg. 75: 3 2013).
190 C. J. Fox
TRIAGE CATEGORIES AND MANAGEMENT GUIDELINES FOR EXTREMITY VASCULAR INJURIES
CATEGORY I: ISOLATED VASCULAR INJURY
• One surgical team required
• Vascular injury, restoration of flow, reconstruction, and limb salvage take priority
• Extremity tourniquet may be removed in the operating room in coordination with the anesthesia team
• Venous injury should be repaired
• Complex or lengthy reconstructions acceptable
CATEGORY II: VASCULAR INJURY IN CONJUNCTION WITH OTHER NON–LIFE-THREATENING INJURIES
• Two-team approach preferable to treat vascular and other injury
• Vascular injury, restoration of flow, reconstruction, and limb salvage take priority
• Extremity tourniquet may be removed in the operating room in coordination with the anesthesia team
• Venous injury should be repaired
• Complex or lengthy reconstructions acceptable
CATEGORY III: MULTIPLE VASCULAR INJURIES
• Two-team approach preferable to treat multiple vascular injuries
• Vascular injury, restoration of flow, reconstruction, and limb salvage take priority
• Extremity tourniquet may be removed in the operating room in coordination with the anesthesia team
• Diminished role for venous injury repair
• Diminished role for complex or lengthy reconstructions
CATEGORY IV: VASCULAR INJURY IN CONJUNCTION WITH LIFE-THREATENING INJURIES
• Two-team approach optional after life-threatening injury is stabilized
• Life-threatening torso, neck, or head injury takes priority
• Extremity tourniquets should remain in place until the life-threatening injury* is stabilized
• Diminished role for venous injury repair
• Diminished role for complex or lengthy reconstructions
Fig. 2. Triage categories for severe extremity vascular injury in conjunction with other
injuries. [Adapted from Rutherford’s Textbook of Vascular Surgery. 8
th
ed. Box 160-1,
Section 26, Vascular Trauma (eds). J. Cronenwett, W. Johnston. Elsevier. Philadelphia, PA.
2013].
Review of Current Literature with References
• A case control study of 40 patients with life-threatening hemorrhage who
underwent arterial vascular reconstructions using a saphenous graft for 10
upper (25%) and 30 lower extremity (75%) wounds. The study illustrates the
effectiveness of blood product resuscitation during simultaneous limb salvage
and provides important emphasis on the correction of physiological derangements upon completion of the vascular reconstruction [J Trauma. 2008;
64(2): S99–S107].
• Kragh et al. performed a large prospective survey of tourniquet use in 232
combat casualties with 428 tourniquets to describe the actual morbidity of its
use. No limbs were lost because of tourniquet use and tourniquet use was not
associated with increased morbidity [J Trauma 2008; 64(2 Suppl): S38–S49].
Vascular Emergencies 191
• Starnes and colleagues provide an excellent summary of important technical
tips for successful extremity arterial reconstruction. This publication is a very
important referent for the practicing community general surgeon [J Trauma
2006; 60(2): 432–442].
• This is an important synopsis of important lessons learned during U.S. com-
bat operations that has set the standard for contemporary surgical management
of military vascular injuries [Surg Clin North Am 2007; 87(1): 157–184, vii].
• Gifford and colleagues published an outcome analysis study. Data was
collected from the Joint theater trauma registry (JTTR), Balad vascular
registry (BVR), and the Walter reed vascular registry (WRVR). It compared
64 shunted U.S. casualties sustaining extremity vascular injury from June
2003 through December 2007 to 61 not shunted. After propensity score
adjustment, use of TVS suggested a reduced risk of amputation, particularly
in more severely injured limbs, but was not statistically significant. The
authors concluded that temporary vascular shunting used as a damage control
adjunct in management of wartime extremity vascular injury does not lead to
worse outcomes. The use of temporary vascular shunts has now gained
popularity as a result of its use during the wars in Iraq and Afghanistan [J Vasc
Surg 2009; 50(3): 549–555].
• This detailed analysis of the modern combat experiences during the Global
War on Terror in approximately 500 patients has characterized the improved
limb salvage seen with rapid evacuation, immediate repair or reconstruction,
and use of damage control principles. Also provided is important epidemiologic data to compare with the civilian experience and to highlight major
differences and unique aspects of modern vascular trauma (J Trauma Acute
Care Surg 2012; 73: 1515–1520).
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6. Respiratory
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Chapter 6-(i)
Airway Management
Michael M. Sawyer, MD*
*Associate Professor of Anaesthesia, University of Colorado School of Medicine
Take Home Points
• Airway management in the ICU requires knowledge of cardio-pulmonary
physiology, advanced airway practices and facile ability with a multitude of
airway devices.
• A thoughtful team based approach is the most important thing when
addressing the critically ill.
• The ICU patient and their therapy present numerous caveats to normal airway
management, both anatomically and physiologically.
• Ability to move quickly down the difficult airway algorithm and modify that
algorithm for your institution is essential in developing an Airway Care Plan.
• This care plan requires a pre packed airway cart or box and ready availability
of tools to address the unforeseen difficult airway.
• The care plan also requires daily examination and long term planning around
extubation.
• While anesthesia staff may not be required for all intubations and extubations
in the ICU, a close communication between the ICU and the Anesthesiology
service allows anesthesiology to be present when requested.
Contact information: Denver Health Medical Center, University of Colorado Health Center,
777 Bannock St., MC 0206, Denver, CO 80204; Email: Michael.Sawyer@dhha.org
195
196 M. M. Sawyer
• The Anesthesia department as well as the ICU department is responsible for
constant review and improvements of practice.
Background
• The Advent of the Difficult Airway Algorithm in 1993 was the first step in the
unified approach to the teaching of advanced airway techniques as a comprehensive measure.
• Evaluation of the Anesthesiology Closed Claims database noted the differ-
ence in outcomes after the advent of the algorithm.
• A time period before the advent of the algorithm was compared to the initial
five years after the algorithm which noted a significantly decrease in the
amount of death/brain death on induction of anesthesia. (Peterson et al. from
airway grand rounds)
• This success created the birth of a whole industry dedicated strictly to airway
device technology.
• Also, these improvements prompted the development of the Society for
Airway management in 1995.
• The algorithm was reworked after the introduction of the LMA on 2003 into
its current state today.
• The use of the supraglottic airways in routine use as well as their emergence
in the emergency pathway has caused a relative inexperience with advanced
airway techniques that are essential to the management of the critically ill
patient. (46 in Nolan)
• Improvement of airway equipment and algorithms have improved the success
rates of managing the ICU airway.
• These advances, though, still come with a learning curve and require
numerous intubations before a user is facile.
• Yet, these advanced tools often create a scenario when the airway is being handled
by personnel that is not comfortable with the sophisticated airway techniques.
• For these reasons, a systematic approach to the airway of the ICU patient is
mandatory.
Main Body
ICU patient/physiology
• A myriad of issues are compounded in the critically ill patient needing airway
manipulation. These can include rapidly worsening illness, continued
Airway Management 197
hypoxia, tenuous cardiopulmonary status, aspiration risks, facial/airway
swelling and injury, poor access to equipment and inexperience of those using
the equipment. (NOLAN)
• Long-term intubations often lead to inadvertent extubation due to transport,
self-extubation or lack of vigilance.
• The incidence of inadvertent extubations has been seen to increase as patient
sedation is decreased for evaluation.
• The incidence of difficult intubation in the Emergent Non OR setting has been
shown to be twice that of the patient undergoing general anesthesia (NOLAN
and Ref. [18] out of NOLAN).
• Factors affecting this include, the changes in pulmonary function of the critically
ill, airway changes that often accompany massive resuscitation or injury, also the
less than optimal position of the patient for airway manipulation in the ICU bed.
• For this reason the need to train ICU physicians in advanced airway manage-
ment, as well as creation of an ICU advanced airway team has been adopted
in some institutions. (REYNOLd) And at Denver Health, we have Airway
Care Plan that allows ICU personnel to realize when they are moving toward
an advance airway.
• Many of the medications given in the ICU for long-term sedation are sub-
jected to increasing Context Sensitive half times that alter the patients return
to baseline. For many of the drugs used in the ICU, their metabolism and
clearance are more complex than first order kinetics and requires knowledge
of their individual pharmacokinetics to plan for a return to baseline.
• Many of these medications also alter the patient’s own response to CO
.
2
• These known sequelae of the sedative medications and the known mechanical
functional change in airway anatomy in the ICU patient makes proper
handling the airway of the critically ill very eloquent.
• Shunt is an area of lung that is perfused but poorly ventilated. The equation
Qs/Qt = (CcO2–CaO2)(CcO2–CvO2) represents the shunt flow as a proportion
of total lung volume.
{ Where CaO
• CcO
and CvO2 are end capillary and mixed venous oxygen contents respec-
2
= (1.34 × Hgbx O2 Sat) + (0.003 × PaO2).
2
tively. This is dependent on cardiac output, tissue O2 consumption and lung
function. Critically ill patients often suffer from poor ventilatory mechanics
for many reasons that increase their closing capacity and worsen shunt. Once
a shunt fraction is found to be greater than 30%, simply increasing the FiO
will not improve oxygenation. Hence even with appropriate preoxygenation,
ICU patients often quickly desaturate as they are induced for intubation.
2