AN INTRODUCTION

TO SURGICAL ICU.

MOHAMED EMAD ABDEL-GHAFFAR.

PROFESSOR OF ANESTHESIOLOGY,
FOM, KING FAISAL UNIVERSITY.

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What is meant by SICU?
 A tertiary care facility in the hospital that
provides a state of the art medical care to
critically ill patients referred to it via different
surgical disciplines.

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Indications for SICU admission:
 Pre and post-operative patients of ASA IV and V,
undergoing major and ultra major surgeries.
 All craniotomy patients.
 All thoracotomy patients.
 All ultra major surgeries.
 Unstable multiple trauma patients.
 Patients with head or spine trauma requiring
mechanical ventilation.
 Generally speaking, any surgical patient who
requires continuous monitoring, 1:1 nursing and /or
continuous life support is a candidate for SICU
admission.

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The main functions of any ICU is
to:
Provide optimum life
support
and
Provide adequate
monitoring of vital
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 SICU

Life support: Monitoring:

•General •CVS
•CVS •Respiratory
•Respiratory •Renal
•Renal •CNS
•CNS •Metabolic
•Metabolic •Input/ output

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Types of monitoring in the ICU
 Physiologic monitoring: its main objective is
 Assess the functions of the vital systems.
 Monitor the effects of different therapeutic
interventions on the critically ill, e.g. PA
catheter in a CHF patient.
 Safety monitoring: its main objective is
 Warn against serious incidents that can
jeopardize the patients life, e.g.. disconnection
alarm in ventilated patients.

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Hemodynamic monitoring:
 EKG

 NIBP

 IBP

 CVP

 PA catheter and PCWP.

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EKG

 Heart rate
 Cardiac rhythm (A fully computerized
arrhythmia analysis is now available)
 Conduction defects.
 Myocardial ischemia (S-T segment
monitoring)
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 The five-electrode system
 Allows the recording of
the six standard limb
leads (I, II, III, aVR, aVL,
aVF), as well as one
precordial unipolar lead.
 Computer- assisted
arrhythmia analysis and
S-T analysis are possible.

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NON-INVASIVE BLOOD PRESSURE
MONITORING (NIBP):
1. MANUAL (RIVA-ROCCI) TECHNIQUE
2. OSCILLOMETRIC BLOOD PRESSURE
DEVICES
3. PENAZ (FINAPRES) TECHNIQUE
4. ARTERIAL TONOMETRY
5.PULSE TRANSIT TIME (PHOTOMETRIC
METHOD)

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NIBP
Manual

Automatic

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INVASIVE BLOOD PRESSURE
MONITORING (IBP):

 An arterial canula is used.

 A non compliant saline-filled tube is used to connect
the canula to the transducer, to the display.
 It measures IBP on beat to beat basis.

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CENTRAL VENOUS PRESSURE (CVP) AND
PULMONARY ARTERY (PA) MONITORING:

 Invasive monitoring of the central circulation

allows an estimate of cardiac preload.

 For access to the central circulation, various

sites have been used including IJV, SCV,
basilic vein and femoral vein.

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CVP AND PA MONITORING, cont.

Anterior and medial approaches to cannulation of the IJV.

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CVP AND PA MONITORING, cont.

Design of a routine PA catheter.

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CVP AND PA MONITORING, cont.

CVP and PA catheters can measure:

 CVP
 PAP
 PCWP
 CO
 Mixed venous SpO2

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 Respiratory Monitoring:

 Monitoring of lung mechanics in ventilated patients (in-

line spirometry):
Two techniques are used:
 1.Main stream spirometry.
 2.Side stream spirometry.

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Respiratory Monitoring (Mechanics cont.)

 Inspired and expired lung volumes (VT and

MV)are measured.
 PIP, Plateau pressure (PP) and Mean airway
pressure are measured.
 Dynamic lung compliance is calculated as

DLC= VT / PIP
 Static lung compliance is calculated as

SLC= VT / PP
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Respiratory Monitoring Gas exchange:

 ABGs.

 Capnography

 Pulse oximetry

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ABGs
 An arterial blood sample is used.
 ABG analysis measures:
 PaO2
 PaCO2
 pH
 Some machines also measure Hb conc. And SpO2.
 Calculated Parameters include:
 HCO3
 Base excess
 Total CO2 content.
 SpO2, if not directly measured.

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ABGs: Clinical applications:
 Assess adequacy of gas exchange.

 Assess adequacy of respiratory support.

 Know the acid-base status of the individual.

 Assess the adequacy of different

interventions on acid-base balance.

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 Capnography
A typical capnogram obtained
during controlled mechanical
ventilation showing :
•Inspiratory baseline
•Expiratory upstroke
•Expiratory plateau
•Inspiratory downstroke

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Capnography cont.
Its analysis should include the following:
 Verify presence of exhaled CO2
 Inspiratory baseline
 Expiratory upstroke
 Expiratory plateau
 Inspiratory downstroke
 Check PICO2min and PECO2max
 Estimate or measure PaCO2 - PECO2max
 Search for causes of hypercapnia or hypocapnia, if
either is present
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CLINICAL APPLICATIONS OF
CAPNOGRAPHY
 One of two sure signs of endotracheal
intubation.
 Detection of untoward events e.g..
Disconnections or inadvertent extubations.
 Maintenance of normocapnea
 Cardiopulmonary resuscitation
 Weaning from mechanical ventilation
 Monitoring the nonintubated patient

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 PULSE OXIMETRY:
Spectrophotometry

The present generation of pulse oximeters uses two wavelengths of light:

660 nm (red) and 940 nm (near infrared).
The pulse oximeter measures the AC component of the light absorbance
at each wavelength and then divides it by the corresponding DC
component. R = AC660/DC660 / AC940/DC940
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PULSE OXIMETRY: CLINICAL
APPLICATIONS.
 The pulse oximeter is the most significant advance in
oxygen monitoring since the development of the
blood gas analyzer.
 Because it is noninvasive and virtually risk free when
used properly, the pulse oximeter should be used in
all clinical settings in which there is a potential risk of
arterial hypoxemia.
 It is the only oxygen monitor that provides
continuous, real-time, noninvasive data on arterial
oxygenation.

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TEMPERATURE MONITORING:
IMPORTANCE
 Temperature regulation is crucial to the survival of
intact animals
 Although uncommon, hypothermia below 32° C is
ominous.
 Ventricular irritability increases, and if the
temperature decreases to 28° C cardiac arrest is
likely.
 shivering can increase oxygen demand 135% to
468%,when respiratory and cardiovascular systems
may be unable to respond normally to increased
demand

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Sites for monitoring body temperature
1.Oral.
2.Tympanic membrane
3.Esophageal
4.Nasopharyngeal
5.Pulmonary arterial blood
6.Rectal
7.Bladder
8.Axillary
9.Forehead
10.Great toe

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Renal Function Monitoring
The three general functions of the kidneys are:
(1) Excrete potentially toxic metabolic end
products,
(2) Regulate water and tonicity, and
(3) Produce hormones.

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Renal Function Monitoring, cont.
 Urine Volume: Normal 0.5- 1.0 ml/kg/hr

oliguria: < 0.5 ml/kg/hr

 Urine Specific Gravity: is a measure of
concentrating/ diluting capacity of the kidney,
 Urine Osmolality: urine osmolality of greater
than 500 mOsm/kgH2O indicates prerenal
azotemia and less than 350 mOsm/kgH2O
indicates acute tubular necrosis.
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Renal Function Monitoring, cont.
 Serum Creatinine: 0.4- 1.2 mg/dl.
 Blood Urea Nitrogen: normal range is 8 to
20 mg/dl.
 Urinary Sodium: It is traditionally accepted
that a urinary sodium level of less than 20
mEq suggests prerenal azotemia and a level
of greater than 40 mEq, acute tubular
necrosis.
 Creatinine Clearance: Normal 1- 1.5
ml/kg/min.

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Life support: General
 General body care include:
 Regular turning every 1 hour.
 Body and mouth hygiene
 Bowl and bladder care.
 Passive or active physiotherapy.
 Adequate nutrition.

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Life support: CVS
 Hemodynamic manipulation is done to
optimize CV function to achieve adequate
tissue perfusion.
 This is done by:
 Optimizing preload, input/ output.
 Optimizing afterload, vasodilators or
vasoconstrictors.
 Optimizing cardiac contractility, +ve
ionotropes, -ve ionotropes.

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Life support: Respiratory
 Simple O2 therapy using various O2 masks
e.g.. Venturi masks of various FiO2, 21- 60
%, non-rebreathing mask with a reservoir bag
give FiO2 > 80 %.
 CPAP, BIPAP.

 Mechanical ventilation.

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Indications for Mechanical Ventilation

A. Respiratory failure
 Respiratory arrest, the need is apparent
 If there is rapid deterioration, it is better to intubate
early before the patient's condition worsens, making
intubation more likely to be associated with
complications
 In cases of severe myocardial ischemia, the added
work of breathing can substantially worsen ischemia.
 In general, a PaO2 < 50 or PaCO2 > 55 while the
patient is receiving supplemental oxygen is an
indication for ventilatory support.

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Indications for Mechanical Ventilation

B. Protection of upper airway

C. Relief of airway obstruction
D. Improved pulmonary toilet
E. Refractory cardiogenic pulmonary edema

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Life support: Renal
 Maintain adequate fluid and electrolyte
balance and correct any abnormalities.
 Avoid hypovolemia, hypotension

 Avoid use of nephrotoxic drugs especially in

those with a compromised renal function.
 Use of various forms of kidney dialysis.

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Thank
you
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