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8 Decision-Making inCritical Care Rescue forRe-operative Surgery
Fig. 8.3 Nonsurgical
complications in the
operated or re-operated
patient, which will
require perioperative
critical care support.
(Original gure by the
authors)
71
Technological Adjuncts
Perioperative Monitoring
Enhanced monitoring of critically ill patients
before, during, and after interventional rescue
from complications provides actionable data to
guide effective resuscitation. Technological
advancements providing cues such as trended
cardiac output (CO), stroke volume variation
(SVV) and systemic vascular resistance (SVR)
can help guide resuscitation endpoints. The pulmonary artery catheter (PAC), historically the
gold standard for CO monitoring in the ICU, has
fallen out of favor in the past decades [8], due to
a combination of factors including the risk of
procedural complications related to the insertion
of invasive monitors (arrhythmia, infection, pulmonary artery injury), and the more recent observation that universal PAC monitoring was not
associated with improved survival outcomes in
the critically ill [8–10]. More recently, noninvasive cardiac output monitoring devices that
can be attached to peripherally-inserted arterial
lines, such as the FloTrac or LiDCO systems,
have gained in popularity [11], although the
accuracy of these devices is currently limited in
unstable patients with severe aortic valve pathol-
ogy or severe arrhythmias [12]. Ongoing ran-
domized validation studies, such as the
“Non-Invasive Cardiac Output Monitor (NICOM)
for Goal-directed Fluid Resuscitation for
Inpatients With Hypotension and/or Septic
Shock” randomized control trial (RCT) out of the
University of Minnesota (NCT05630716) are
attempting to answer the association between the
use of non-invasive cardiac output monitors and
the reproducible and clinically-useful outcome
measures, such as hospital mortality, hospital and
ICU lengths of stay, duration of vasopressor use,
change from baseline serum creatinine and net
and cumulative uid balance at 72hours or ICU
discharge. Previous RCT data showed no causal
association between early continuous cardiac
output and stroke volume monitoring and
improved hemodynamic rescue of hemodynami-
cally bioinappropriate patients admitted to the
ICU [13]. However, goal directed hemodynamic
therapy, particularly in the operating room utiliz-
ing similar non-invasive devices have been asso-
ciated with decreased postoperative
complications, particularly in abdominal surgery
and very high-risk patients [14]. Identifying the
optimal use case and population for these devices
has the potential to improve the care of critically
ill re-operative patients.
72
D. N. Haddad and G. A. Bass
Point ofCare Ultrasound
Point of Care Ultrasound (POCUS) is a useful
non-invasive adjunct increasingly available to
ICU providers to determine dynamic changes in
inferior vena caval caliber as a surrogate for
response to intravascular volume expansion.
Rapid evaluation of life-threatening pathology
such as pneumothorax, cardiac tamponade and
right ventricular strain from a massive pulmonary
embolism are accessible at bedside with the use
of heart and lung ultrasonography. While this
skill requires dedicated training, it is readily
deployable across all levels of learners and is
now recognized as an essential component of
critical care training [15].
Functional Coagulation Assay Driven Resuscitation
Fluid imbalance, acute blood loss anemia, and
sepsis are all associated with an acquired coagulopathy in patients with post-operative complications. Thromboelastographic (TEG) and
rotational thromboelastometric (ROTEM) analysis of clot kinetics, clot strength, and brino-
lysis provide real-time guidance for
perioperative blood component-based balanced
resuscitation with whole blood, packed red
cells, fresh frozen plasma, platelets, clotting
factor concentrates, tranexamic acid (TXA),
and cryoprecipitate [16, 17].
Acute Kidney Injury
Acute kidney injury (AKI) is a frequent occur-
rence when complications following surgical
intervention induce sustained hypotension, with
approximately 50% of postoperative patients
developing AKI while in the ICU [18, 19]
(Fig.8.4). Sepsis-related acute kidney injury or
disease are associated with short- and long-term
morbidity and mortality [20]. Irrespective of
speculation regarding causality or “which came
rst”, renal malperfusion is the likely sequel of
systemic shock, but can itself further exacerbate
systemic dysregulation. Initiation of renal
replacement therapy in the ICU is indicated if
noninvasive management fails. Indications for
dialysis include volume overload, impacting
other organ systems, metabolic acidosis, electro-
lyte abnormalities (including hyperkalemia and
Fig. 8.4 Acute kidney injury progression in the perioperative period. (Original gure by the authors [Ref: Bass GA,
etal. Cameron’s Current Surgical Therapy14th Edition; 2022; pp.: 1554–1563])
8 Decision-Making inCritical Care Rescue forRe-operative Surgery
73
hyperphosphatemia), uremia contributing to
worsening encephalopathy and pericarditis, and
drug and toxin removal. The use of Continuous
Renal Replacement Therapy (CRRT) may be preferred over intermittent Hemodialysis (iHD) as it
allows for slower removal of uids with less
hemodynamic lability [21, 22]. However, existing evidence suggests no difference in survival
between CRRT and iHD despite propensity and
other adjustment for disease severity [25–27].
The types of CRRT vary by the method of solute removal. Appropriate renal replacement prescription requires specialized knowledge, as well
as a trained nurse capable of supervising and
maintaining therapy delivery. Continuous
Venovenous Hemoltration (CVVH) removes a
large volume of water across a semipermeable
membrane, using hydrostatic pressure to facilitate
removal of solutes in a process called ultraltration or convection. Continuous Venovenous
Hemodialysis (CVVHD) removes smaller waste
molecules by diffusion using a transmembrane
concentration gradient created by dialysate uid.
Continuous Venovenous Hemodialtration
(CVVHDF) combines both ultraltration and diffusion methods of ltration. When CRRT is utilized just for volume removal via ultraltration, it
is referred to as slow continuous ultraltration
(SCUF). Choice of CRRT modality takes into
account patient indication, however depends on
provider preferences and local resource availability [23].
Initiation of CRRT requires central vascular
access, ideally via the right internal jugular or
femoral vein. Subclavian venous access should
be avoided due to risk of developing central stenosis in patients who may go on to need longterm dialysis. The choice of systemic
anticoagulation (heparinization) versus regional
anticoagulation (citrate) should take into account
the patient’s condition, planned procedures, and
risk factors for bleeding. However, citrate is contraindicated in patients with liver failure, due to
inability to hepatically convert citrate to bicarbonate for excretion. Frequent, intermittent saline
ushes can be employed if other methods of anticoagulation are contraindicated [24].
Despite complexity in distinguishing the etiology of AKI along the causal pathway, supporting
renal failure in critical illness is essential in managing acidosis, electrolyte abnormalities and volume overload in patients requiring re-operative
surgery.
Extracorporeal Membrane Oxygenation
Extracorporeal membrane oxygenation (ECMO),
when used appropriately, may provide cardiopulmonary rescue in critically-ill surgical patients.
Extracorporeal life support can also be used as an
adjunct to cardiopulmonary resuscitation (CPR)
in the case of refractory cardiac arrest, commonly
referred to as extracorporeal CPR or ECPR [31].
Cannulation has been reported by prehospital
personnel, as well as inpatient intensivists, surgeons and cardiologists, but must be coordinated
with a team of critical care intensivists and perfusionists. Time to ECMO initiation has been identied as the strongest predictor of mortality for
patients receiving ECPR [32]. Insertion of cannulas is currently recommended within
10–20 min after failed resuscitation efforts to
avoid risk of anoxic brain injury. Venovenous
(VV) ECMO is used in cases of severe respiratory failure with preserved cardiac function. VV
ECMO is indicated in severe hypoxia refractory
to conventional management—when the partial
pressure of oxygen (PaO2) is less than 80mmHg
on 100% fraction of inspired oxygen (FiO2) with
or without hypercarbia (pH <7.20). VV ECMO
has demonstrated benet in conditions of reversible respiratory failure, including acute respiratory distress syndrome (ARDS), trauma, bacterial
or viral pneumonia, including COVID-19 and
aspiration pneumonia. This involves percutaneous insertion of either two cannulas or one duallumen cannula into the central veins for transfer
of deoxygenated blood through an oxygenator
and then back to the right side of the heart
(Fig. 8.5). Contraindications are determined by
institution specic protocols and include conditions such as advanced age, active malignancy,
74
D. N. Haddad and G. A. Bass
Fig. 8.5 Schematic representation of extracorporeal membrane oxygenation (ECMO) for heart and/or lung support
liver failure, non-recoverable brain injury, prolonged ventilator dependence, and severe obesity.
Use of VV ECMO for refractory hypoxia has
demonstrated mixed results regarding improving
mortality, however randomized control trials
have been complicated by high crossover rates
are inserted percutaneously or centrally with
drainage of deoxygenated blood and return of
oxygenated blood to the systemic circulation.
Recent randomized trials have not demonstrated
improved outcomes in patients with cardiogenic
shock secondary to myocardial infarction [30].
and intention-to-treat analysis. [28, 29]
Venoarterial (VA) ECMO, also referred to as
extracorporeal life support, is indicated in cardio-
Bedside Laparotomy
genic shock with refractory hypotension and
depressed cardiac output, despite maximum inotropic and intra-aortic balloon pump support.
Causes of cardiogenic shock where VA ECMO is
indicated include acute coronary syndrome,
refractory cardiac arrythmia, sepsis-induced cardiomyopathy, myocarditis, pulmonary embolism,
drug toxicity, cardiac trauma, anaphylaxis and
heart failure. Arterial and venous access cannulas
As the spectrum of bedside therapeutic interventions are limited by illumination, equipment
availability, and staff familiarity, re-operation is
usually preferable to transporting the patient to
the operating room (OR), where intervention
rather than exploration will be more readily feasible. Infrequently, severe hemodynamic or respiratory instability precludes transportation of the
8 Decision-Making inCritical Care Rescue forRe-operative Surgery
75
decompensating surgical patient to the OR [6]. In
this circumstance, rescue efforts may require
bedside surgical intervention in the ICU.Common
indications for bedside exploratory laparotomies
include but are not limited to re-exploration in
the setting of severe, refractory shock, where
there is concern for uncontrolled hemorrhage,
irreversible bowel ischemia, or abdominal compartment syndrome [33].
While studies have demonstrated the safety of
operative intervention in the ICU, the operating
surgeon must be aware of several essential logistic elements to ensure availability of all necessary
equipment. [33] Safe and effective emergent reoperation, albeit in the OR or at the patient bedside in the ICU, requires close coordination with
not only the ICU team administrating the intravenous general anesthetic, but also the ICU nursing
staff, as well as the operating room scrub and circulating staff. Preparation should include
provision for continuous ICU monitoring with
frequent recording of the vitals, appropriate sedation, and analgesia to facilitate paralysis, availability of personnel familiar with operating room
equipment and logistics, including adequate
lighting and electrocautery. We recommend that
each institution establishes its own protocol to
facilitate safe bedside laparotomies when indicated in critically ill patients. Recognizing that
these rare high-stake interventions are rescue
therapy with high associated mortality, abbreviated operation is vital, and temporary abdominal
closure with a negative pressure wound system is
preferred [34].
Management oftheOpen Abdomen
During re-operative surgery, disrupted intestinal
continuity, ischemia, or visceral edema in the
presence of adverse physiology (hypothermia,
acidosis and coagulopathy) should prompt consideration of a damage control surgery approach
incorporating laparostomy(open abdomen) with
negative pressure wound therapy and recovery to
the ICU with a plan for interval serial surgical
re- explorations to manage bacterial bioburden
and progress toward conditions favorable for
abdominal closure [6]. This approach serves to
minimize the risk of intraabdominal hypertension
or abdominal compartment syndrome and allow
for easy access to the peritoneal cavity [35, 36].
Advances in resuscitation efforts away from massive crystalloid resuscitation have helped avoid
these potentially fatal complications. However,
the overutilization of the damage control open
abdomen approach is not without risk [37, 38].
Rates of primary fascial closure and postoperative complications increase with prolonged duration of open abdomen [39].
Multiple strategies have been explored to
facilitate abdominal closure. Decreasing the
number of subsequent laparotomies as well as
time to rst re-laparotomy have both been associated with improved rates of primary fascial closure [40]. The use of intravenously administered
hypertonic saline has been demonstrated to
increase primary fascial closure in single center
observational studies, however recent randomized control trials have questioned the generalizability this nding [41, 42] (Fig.8.6). Additionally,
hypertonic saline carries a risk of renal dysfunction due to the high chlorine load and patients
should be monitored closely for worsening renal
function and hypernatremia. Direct peritoneal
resuscitation has been demonstrated in certain
centers to facilitate abdominal closure through
the reduction in local inammatory mediators
and minimize visceral edema [43]. Direct peritoneal resuscitation (DPR) provides targeted volume resuscitation into the splanchnic
microcirculation using direct intraperitoneal
delivery of a hyperosmolar glucose-based solution. The goal is to reverse vasoconstriction and
prevent hypoperfusion at the splanchnic cellular
level and simultaneously reduce endothelial dysfunction and organ necrosis mitigated by the
local inammatory cytokines [43]. A percutaneous catheter, placed with its tip at the root of the
mesentery or the pelvis, instills the hyperosmolar
solution into the peritoneal cavity, and continuous suction applied using commercial or noncommercial negative pressure wound vacuum
options continuously drain the efuent. Infusion
rates are described at 400 mL/h or 1.5 ml/kg/h
until denitive closure is obtained [44].
76
D. N. Haddad and G. A. Bass
Fig. 8.6 Fluid management in the open abdomen. The
most-studied adjuncts to current care are direct peritoneal
resuscitation and parenteral hypertonic saline. Thoughtful
Maintaining a cautious uid balance is necessary
to avoid abdominal compartment syndrome, as is
warming of the uid to avoid hypothermia, which
would worsen coagulopathy.
In both animal and human models, use of DPR
not only improves splanchnic blood ow and vascular organ perfusion, but also decreases local
tissue hypoxia and injury. Decreased levels of
inammatory markers, including proinammatory cytokines, have also been observed [43, 45].
Benets of DPR include improved timing and
successful rates of primary fascial closure, as
well as decreased ICU related duration of stay
[46]. The best outcomes for DPR occur when it is
coupled with targeted conventional resuscitation,
optimizing local and systemic tissue perfusion.
Lack of familiarity with DPR protocols, rather
than lack of evidence appears to be the major barrier to widespread use. Future, multicenter,
optimal care revolves around determining optimal timing
for resuscitation and de-resuscitation. (Original gure by
the authors)
randomized studies will help to test the efcacy
across broader populations.
Nutritional Considerations
Nutrition is an essential component of recovery
for critically ill patients undergoing re-operation.
Ischemia, inammation and tissue edema facilitate gut bacterial translocation, antimicrobial
therapy compromises commensal bacterial
defense, while prolonged fasting depletes luminal brush border enzymes required for digestion
(Fig.8.7). Guidelines for critical illness recommend early enteral nutrition initiated within 48h
of admission and advancing to goal during the
early phase of critical illness [47]. Early use of
enteral nutrition has been demonstrated to be
superior to either parental nutrition or late enteral
8 Decision-Making inCritical Care Rescue forRe-operative Surgery
77
Fig. 8.7 Consequences of critical illness on gut function
nutrition. Early enteral nutrition has not only
been demonstrated to be safe, but also associated
with improved outcomes in critically-ill patients
with temporary abdominal closure where there is
intestinal continuity [48]. Supplementation of
amino acids, omega-3 fatty acids and Vitamin C
and D may further help counteract the inammatory catabolism associated with critical illness
[6]. Any nutrition strategy must account for the
additional catabolic state associated with the
open abdomen. Parenteral nutrition remains infe-
rior to enteral nutrition, and should only be considered if enteral nutritional is not feasible in
malnourished patients with expected 7days without adequate nutrition [49–51].
Patient Centered Care Goals
Critical illness provides a challenging time for
both patients and their families on whom physicians often rely to make life-or-death decisions
78
D. N. Haddad and G. A. Bass
Fig. 8.8 Patient-centered decision making
(Fig.8.8). Often patients are frequently unable to
participate in complex care conversations due to
mechanical ventilation, sedation, or encephalopathy. Discussions by the surgical and intensive care
teams should include surrogate decision- makers,
such as close family members, from whom consent for invasive, life-altering procedures is
obtained. Mobilizing all the available hospital
resources to support patients and families during
this time is imperative. Support from social workers, chaplains, and palliative care consultation can
all enhance the families’ experience regardless of
the outcome. Engaging the services of the
Palliative Care Medicine consultation team early
and often helps to establish support for the individual and the family for the impending life
changes, as well as facilitate discussions regarding patient preferences and goals of care [52].
Maintaining patient dignity while supporting
multisystem organ failure in patients requiring reoperative surgery is a team endeavor leveraging
expertise across multiple specialties.
Summary
In this chapter, we delve into the intricate landscape of critical care for patients in whom postoperative complications require repeat radiologic,
endoscopic or surgical intervention. Surgeons
will nd a comprehensive analysis of the challenges inherent in managing critically ill patients
before, during, and after re-operation, with a
focus on decision-making, optimization strategies, technological advances, ethical considerations, and a glimpse into future innovations.
This review aims to equip surgeons with a
nuanced understanding to enhance the care and
outcomes of these complex patients.
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