< Back What happens during Surgical ICU (SICU) Rounds? This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine. Flash Rounds A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.). Working Rounds A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan. 1. Systems-Based Rounds- presented by resident or APP - Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging. - Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication. - Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph). - Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph). - Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel). - Endocrine- review glycemic control. - Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets). - Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy. - Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis. 2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle] - Assess, prevent, and manage pain - Breathing (Spontaneous awakening and breathing trials) - Choice of analgesia and sedation - Delirium assessment, prevention, and management - Early mobility and exercise - Family engagement 3. Develop a management plan based on comprehensive patient assessment. Previous Next

< Back Pain and Anxiety...pending Management of Pain and Anxiety Previous Next

< Back GI Dysmotility...pending GI Dysfunction Previous Next

< Back Ultrasound: Misc Abdomen Assess for intra-abdominal fluid to rule-out an intra-abdominal source of hypotension. Examine the gallbladder- gallstones, wall thickening (>3 mm) and pericholecystic fluid are consistent with cholecystitis Examine the kidneys and bladder- overt hydronephrosis concerning for mechanical obstruction. Distended bladder despite foley suggests obstructed foley. Vascular Presence of DVT- patent veins are fully collapsible with light ultrasound compression- pressure has to be lower than the pressure needed to collapse the artery. Vascular access for arterial and central line placement. Previous Next

< Back Free Fluid in the Abdomen A 62-year-old male presents following a motor vehicle collision in which he was an unrestrained driver. He was intubated in the trauma bay for decreased mental status. A focused assessment with sonography for trauma (FAST) was performed, which did not reveal intra-abdominal fluid. Computed tomography (CT) of the head demonstrated minimal intra-cranial injury. CT of the abdomen and pelvis (see below) revealed decreased blood supply to the left kidney, small irregularity of the splenic contour, and a moderate amount of free fluid in the abdomen and pelvis. Hounsfield units are consistent with simple fluid. CT of the abdomen and pelvis What is the differential diagnosis for the free fluid in the abdomen? Free fluid due to trauma can be urine, enteric contents (bowel injury with spillage of succus) or blood. It is possible to have fluid present prior to the trauma, such as ascites from chronic liver disease. In this case, the free fluid in the abdomen had characteristics of “simple fluid,” based on Hounsfield units, suggesting that the fluid was not blood. In females, free fluid in the pelvis can be normal (physiologic fluid). However, free fluid is NOT normal in a male, and it's concerning for hollow viscus injury. What are the possible causes of decreased blood flow to the kidney? The renal artery can be injured in blunt trauma. Blunt injury can disrupt the layers of the artery wall, leading to thrombosis and decreased blood flow beyond the injury. He was admitted to the intensive care unit. A foley catheter was placed and demonstrated pink-tinged urine [NOT frank gross blood/ clots]. What are the possible causes of blood-tinged urine? Bloody urine indicates a traumatic injury to the genitourinary tract, anywhere from the kidneys down to the urethra. A CT cystogram was performed, which did not reveal any extravasation of contrast from the bladder. CT Cystogram Next steps? Based on an unreliable physical exam and a normal CT cystogram, it is necessary to rule out bowel injury. The patient was hemodynamically stable and had normal laboratory values. He remained with a decreased mental status, and therefore serial abdominal exams were not a viable management plan. The patient was taken to the operating room and underwent diagnostic laparoscopy. His small bowel, colon, and mesentery were examined in there entirety and found to be completely normal. There was a small amount of clear thin fluid in the pelvis, but there was no evidence of bile staining or bleeding. After completing the evaluation of the gastrointestinal tract, we repositioned the patient in Trendelenburg. The pelvis was inspected, and it was quickly apparent that the patient in fact had a large defect in the dome of the bladder. We elected to proceed with a low midline laparotomy. The bladder was easily mobilized, and the extent of the defect was defined. The edges were grasped, and the defect was closed in two layers with absorbable suture. Postoperatively, we reviewed the preoperative CT cystogram. In retrospect, there was a suggestion of bladder irregularity. We reviewed the CT cystogram with the radiologist and there was no evidence of contrast extravasation. However, the bladder does not appear to have been completely distended with contrast. It is very atypical that a large bladder wall defect was not associated with contrast extravasation, and this highlights the importance and ensuring complete filling of the bladder with contrast. Evaluation and Management of Bladder Injuries Bladder injuries can occur from blunt or penetrating trauma. For example, bladder injuries can occur when blunt force is exerted on a full bladder or in the setting of a pelvis fracture. Diagnosis Gross hematuria is seen in most patients with bladder injuries. Cystography, either using plain x-ray or CT, is the diagnostic test of choice. Management The management of bladder injuries is based on location. Intra-peritoneal injuries require operative management. This is done in two or three layers with absorbable suture. A decompressive foley catheter is left following repair. Extra-peritoneal injuries can typically be managed non-operatively with a foley catheter for 10-14 days. Exceptions include large bony segments protruding into the bladder wall, associated rectal or vaginal injuries, bladder neck injuries, or an associated pelvic fracture undergoing operative intervention to prevent hardware contamination. Current guidelines recommend a cystogram before foley removal, except for the most uncomplicated injuries. Yeung LL et al. Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2019;86(2):326-336. Previous Next

4 Everything is Obvious ...Once You Know the Answer - Countless examples of how we understand cause and effect much less than we think. - "No matter where we live, our lives are guided and shaped by unwritten rules-so many of them, in fact, that we couldn't write them all down if we tried." - The relative number of people who are organ donors varies between countries. Why? Religion, education, fear about receiving less aggressive care if you are an organ donor, et cetera. The default option for registration can explain the difference between two neighboring European countries. One country requires the citizen to actively elect to be a donor, while another country requires a citizen to decline the default option for being a donor. - "We claim...that the Mona Lisa is the most famous painting in the world because it has attributes X, Y and Z. But really what we’re saying is that the Mona Lisa is famous because it’s more like the Mona Lisa than anything else." Previous Next

< Back Ultrasound: Cardiac Exam Purpose: identify possible causes of hemodynamic instability, respiratory distress, assessment of volume status. Probe The phased array can be used for the entire exam. The curvilinear can also be used for the subxiphoid and IVC views. Views There are 4 basic views, including the parasternal long axis, parasternal short axis, the apical four chamber and the subcostal view. Additionally, the inferior vena cava can be visualized. Cardiac ultrasound is more challenging to learn than most other ultrasound studies, because probe usage (position, angle, rotation, translation, etc) have drastic impact on visualization. It’s necessary to understand what is shown in each view, so take time reviewing these so you can have a better appreciation for what you are seeing when you perform a study on a real patient. One recommendation, if it is difficult to visualize the heart, moving the patient into the lateral decubitus with their left side down can significantly improve visualization as the heart is closer to the chest wall in this position. For video and pictorial explanations of the views, please refer to these sites. Basic Cardiac Views, #1 Basic Cardiac Views, #2 Findings Gross abnormalities- decreased ventricular function, arrhythmias Profound hypovolemia Small hyperdynamic left ventricle with end-systolic collapse Inferior vena cava- assess volume status, either static measurement of diameter or calculation of collapsibility (>50% correlates with volume responsiveness). Respiratory variation (collapsibility/distensibility index). Takotsubo cardiomyopathy Akinesia of the apical and mid-ventricular segment, hypercontractile basal segments. Apical sparing (dilated). Acute cor pulmonale Respiratory disorder→ pulmonary hypertension→ right heart failure. Dilated right heart. Cardiac tamponade Effusion with end-diastolic collapse of the right atrium, effusion in front of the aorta Pulmonary embolism Free-floating thrombus in the right ventricle or pulmonary artery; right ventricular dilation/ systolic dysfunction; septal bowing into the left ventricle; dilated IVC without inspiratory collapse. Most sensitive/ specific indirect sign- right ventricular apical sparing (McConnell's sign). References Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography Previous Next

< Back Bowel Anastomosis A handsewn small bowel anastomosis can be created end to end or side to side. When creating a side to side anastomosis, the planned enterotomy site on each limb of bowel is identified. The backwall is created first, just lateral to the planned enterotomy sites- it would be very challenging to access this portion of the anastomosis after creating the inner layer. The back layer is followed by inner layers of absorbable suture. My personal preference is Vicryl, but PDS can also be used. Finally, the anterior outer seromuscular layer of silk is created. Posterior outer layer of interrupted 3-0 Silk Limbert sutures Posterior inner layer of interrupted 3-0 Vicryl sutures Anterior inner layer of Connell with 3-0 Vicryl Anterior outer layer or interrupted 3-0 Silk Limbert sutures Inner layer of absorbable sutures and outer seromuscular layer of silk. Two different depictions of side to side anastomoses (1,2). Rao SD. Small Intestine, In: Snapshots in Gastroenterology. Jaypee Brothers Medical Publishers (P) Ltd. 2016. Rao SD. Pre- and Postoperative Management in Midgut (Small Bowel) Surgery, In: Gastrointestinal Surgery Step by Step Management. Jaypee Brothers Medical Publishers (P) Ltd. 2005. Previous Next

11 < Back Board Examinations American Board of Surgery: General Surgery Boards Exam Prep Master the General Surgery Oral Boards by Dr Hassan Aziz . Dr Aziz reviews key surgical topics, including trauma, thoracic, pediatric, HPB, GI, breast cancer, endocrine, vascular. [Reference courtesy of Hassan Aziz, MD @Sharpknife_Aziz ] Surgical Education and Self-Assessment Program (SESAP). Resource for general surgeons- stay current with the latest surgical knowledge and prepare for examinations. American Board of Surgery: Surgical Critical Care Boards Exam Prep Evidence-Based Practice of Critical Care. 3rd edition, 2019. Reviews the literature regarding specific high yield critical care topics. Trauma, Critical Care, and Surgical Emergencies: A Case and Evidence-Based Textbook. 1st edition, 2010. 64 cases that review the basic principles of ACS. Previous Next

< Back Nasogastric Tubes Nasogastric tubes (NGTs) are frequently placed in surgical patients to decompress the stomach and minimize nausea/ vomiting while allowing bowel rest. For intubated ICU patients, this is frequently an orogastric tube, passed from the mouth to the stomach. The anatomy of an NGT Lumen: this is the inner cylindrical hollow conduit that allows gastric contents to be suctioned out and potentially allows medication and nutrition to be given (depending on the clinical situation). Multiple holes to allow gastric contents to be suctioned into the lumen of the tube Side port: if nasogastric tubes were like straws, with only one lumen, they would adhere tightly to the stomach wall when suction was applied. Thankfully, NG tubes have a side port (the blue ventilation port) that allows air to flow into the stomach, preventing the tube from giving the stomach a suction hickey. Markings on the tube indicate how far the tube has been inserted. A white line along the length of the tube (radiopaque). When viewed on an x-ray, the tube position can be confirmed by noting the location of the break in the radio-opaque line, which corresponds with the most proximal hole in the tube. Basic Equipment There is some basic equipment that you need to have at the bedside before inserting an NGT The NG tube and a packet of lubricant A large basin (in case the patient vomits) Suction tubing to connect to a canister with working suction Cup of water with straw (if not contraindicated) Placement Preparation Picking your tube size. Tubes range from 8-18 French. For adults, use 16 or 18. Avoid using a pediatric tube or anything smaller than a 16 Fr. Small tubes will just end up clogged. You can consider having one size smaller just in case you meet a lot of resistance and want to attempt a smaller caliber. Running the tube underwater. Some suggest that warm water helps by making the tube more pliable, others say cold water helps by making the tube softer. I haven't found one to be more helpful than the other. Try and see what works for you. Explain the procedure to the patient. Advise them that they might gag and vomit, and that’s ok. It’s not unexpected when you have a plastic tube through your nose and esophagus. Have the basin ready. Tell the patient their job is to swallow and keep swallowing. Tell them they might feel an urge to cough or gag, but they should try to resist that and focus on swallowing. If not contraindicated (ie aspiration risk, etc), have the patient hold a cup of water (with straw) in the hand opposite from where you're standing. Note- bowel obstruction is not a contraindication- once you place the tube, you will evacuate whatever the patient swallowed. Positioning and insertion Raise the head of the bed and have the patient upright as much as possible and have them put their chin to their chest. Lubricate the end of the tube. Place the tip of the tube just inside the nares and then advance parallel to the floor…not up. You can place your hand on the back of the patient's head to gently keep their head from flying back, which is the natural reaction to a huge piece of plastic in your nose. Keep advancing the tube while encouraging the patient to swallow. The gastroesophageal (GE) junction is usually about 40 cm from the beginning of the esophagus. The tube must get past the GE junction to effectively decompress the stomach. Post-placement Connect your tube to suction. There is a small plastic connector with tapered ends- one end connects to the suction tubing and the other end connects to the clear port. You can place to low intermittent or continuous suction- this is usually provider or institution dependent. You do NOT need a chest x-ray to confirm that an NGT is in the stomach before you place it to suction- if gastric contents are being suctioned, this confirms the position. You DO need a radiograph before instilling medication or enteral feeds. Risks of nasogastric tubes Non-functional tube- an NGT is nothing more than a straw or a garden hose- except for one thing. If you were to place a garden hose into someone's stomach and apply suction, it would just adhere to the stomach wall. This can lead to suction hickeys, which are precursors to ulcers/ bleeding. But most importantly, this will cause the tube to be ineffective. The solution is the blue ventilation port- it allows air to pass into the stomach and keeps the tube from being suctioned against the stomach wall. [this was explained above in the anatomy section- but it's so important that it deserves repetition] Naso-pulmonary tube- accidental insertion into the lung. For an awake interactive patient, this will be evident by your patient's reaction- if they have a tube in their lung, they will cough. This can even cause a pneumothorax (personally never seen it, but it's been described). In an intubated patient, it might not be noticed until x-ray for checking placement. Tube curled and tip directed upward in the esophagus. Two risks- ineffective gastric decompression and misdirected meds and feeds (back up in esophagus instead of into stomach). Aspiration- an NGT essentially stents the lower esophageal sphincter open. So if your patient is lying flat (ie asleep), you MUST ensure that the NGT is functional. Especially in the case of a bowel obstruction (patient can vomit and aspirate) or if your patient has decreased mobility and isn’t able to reposition themselves quickly to avoid aspirating. Clogged tube- risk of aspiration, inability to give meds/ enteral nutrition. The anti-reflux valve You might notice another piece of plastic in the NGT packaging. I didn't mention the anti-reflux valve, that short blue and white plastic piece that suspiciously seems to fit perfectly into the blue ventilation port. According to the manufacturer (CR Bard), this piece of plastic is supposed to be inserted at the end of the blue port and allow air entrainment to prevent the suction hickey on the stomach. It also prevents gastric contents that reflux into the port from spilling onto the sheets. HOWEVER-- the caveat is that when gastric contents are refluxing into the blue ventilation port, it's supposed to be take as an indicator that the valve must be removed and air must be flushed into the blue ventilation port. This is the reason the anti-reflux valves are despised by most surgeons- once the blue ventilation port is coated with gastric contents, if they're not flushed, the NGT is essentially converted to a straw. Yes, the port may spit up some gastric contents. However, the solution is NOT to replace the anti-reflux valve into the blue side port. Instead, the solution is to flush air into the blue port to clear it out . This is the primary task of maintaining a functional tube. You should hear faint sounds of air movement when you listen to the blue port- this means it’s working! [see video] The problem, and the reason we routinely throw these away, is the fact that they aren’t routinely removed and flushed, so they get clogged. When the blue port is clogged, the tube becomes non-functional, which can lead to gastric distension, nausea/ vomiting, and aspiration. “Minimal output” is not always reassuring with an NGT- it might be because the patient is improving, but it’s just as likely that the tube isn’t working because it isn't being maintained correctly. It's not an exaggeration to say this is a life or death issue. An elderly patient with a bowel obstruction and a non-functional tube→ gastric distention + widely patent gastroesophageal junction + laying flat at night→ aspiration, pneumonia, death. Functional tubes are also crucial for patients with foregut procedures. For example, a repair of a stomach or proximal small bowel injury can be protected by a functional nasogastric tube- this minimizes air/ fluid passing by and exerting pressure on the repair. Please note- the blue ventilation port MAY reflux and spill out gastric contents. Two solutions are to place a chux under the end or to place the syringe of a Toomey at the end (see video). Just remember- if this happens, do NOT solve the problem by inserting the anti-reflux valve. Instead, use a Toomey syringe to flush air into the blue ventilation port. CAUTION! There are caveats to this- specifically patients with foregut surgery (anywhere from the mouth through the first part of the small intestine). Patients with these clinical scenarios should have explicit instructions to the nursing staff on how the tubes are to be maintained. But it makes too much noise?! A patient who can complain about a whistling NGT is a patient who is much less likely like to aspirate and need to be intubated than a patient who doesn't have a whistling NGT. But it makes a mess?! See solutions above- chux pad or place a Toomey syringe. How to maintain a functional NGT How to use the anti-reflux valve So those are the basics. If I didn’t teach you any handy tricks, hold on for one last disclosure… the final secret to my success. I've used this trick many times for patients who are overly anxious or distressed at the process of having an NGT placed. For example, the patient who has had traumatic NGT placements previously (patients have shared so many horror stories with me) or is on edge in general. Two years ago, I was managing a burn patient in the ED. While the ED physician was prepping for a nasal laryngoscopy, he showed me a trick that I still use to this day. Using CTAs (cotton tip applicators, or Q-tips if you insist on a brand name), he anesthetized the patient's nasal passage with viscous lidocaine. He covered the cotton tip of 1-2 CTAs with the clear hair-gel consistency goop (the lidocaine), and then slowly advanced this along the nasal passage. Initially, they sat right inside the opening of the nares, resting for maybe 30-45 seconds. Then the lidocaine was reapplied, and the CTAs were advanced slightly to repeat the process. This continued through the entire length of the nasal passage. In addition to the nasal anesthetic, the patient was given a medicine cup with more viscous lidocaine to swallow. *Note- warn the patient that they MIGHT get the sensation that they can't breathe. They will still be able to breathe fine, but when the upper airway is anesthetized, it alters the sensation of airflow. Previous Next

What is ACS? A day in the life of an Acute Care Surgeon. FAQs. ICU Rounds. Trauma Surgery. Acute Care Surgery What is Acute Care Surgery? Medicine, particularly surgery, has become increasingly specialized, with providers developing progressively narrower expertise. Previously, surgical critical care fellowship was the primary pathway for specialization in the management of critically ill and injured patients. Management of "sick" surgical patients, regardless of the underlying surgical etiology, requires flexibility in addition to width and breadth of knowledge to manage a wide spectrum of clinical challenges, including deranged physiology and complex surgical pathology. Balancing an acutely hemorrhaging patient, an elderly patient with severe poly-trauma, a ventilator-dependent patient with an acute abdomen...the list is endless. Acute Care Surgery (ACS) was brought about to ensure that there is access to a specialized physician that can manage a spectrum of critically ill patients, including trauma, emergency general surgery (EGS), and surgical rescue . Surgical rescue involves the management of procedural complications or clinical situations that require emergent surgical intervention: "airway emergency, hemorrhage, intestinal obstruction, perforated viscus, tube/line/device dysfunction, uncontrolled sepsis with a surgical etiology, visceral ischemia, and wound complication." Management can include the following interventions: "airway intervention, biliary repair/ reconstruction, bowel resection, hernia repair, hemorrhage control, source control of infection, surgeon-guided resuscitation, tube/line/device repair, and wound debridement."(1) Pillars of Acute Care Surgery 1. Kutcher ME et al. Surgical rescue: The next pillar of acute care surgery. J Trauma Acute Care Surg. 2017;82(2):280-286. 2. Kutcher M.E., Peitzman A.B. (2017) A History of Acute Care Surgery (Emergency Surgery). In: Di Saverio S., Catena F., Ansaloni L., Coccolini F., Velmahos G. (eds) Acute Care Surgery Handbook. Springer, Cham.

< Back Pruritis Ani What is Pruritis Ani? Patient information: Pruritis Ani [American College of Colon and Rectal Surgeons] Pruritis ani is an unpleasant itching of the perianal skin (around the anus). Scratching can lead to further irritation and sets up a vicious cycle. Caused by other anorectal diseases, primary dermatology conditions, hygiene issues (sweat, stool, mucus on the skin), foods, soaps, clothing, or over-vigorous hygiene (aggressive wiping with rough material, use of topical cleaning agents). Diagnosis- detailed history, thorough exam to rule out underlying anorectal pathology What is conservative management for pruritis ani? Try not to scratch/ wipe/ scrub. It will just itch more, and things will get worse. Clean the anal area after bowel movements with hypoallergenic personal wipes. Do NOT over clean, as this may worsen your condition. Dry with a hairdryer on the cool setting instead of wiping the area dry. Use unscented Dove soap or dilute white vinegar for cleansing. AVOID potential contributing factors Citrus foods, caffeine-containing foods/ beverages- coffee, tea, cola, chocolate. Scented soaps, lotions, creams, powders, medicated wipes, witch hazel. Keep the area dry (can use cotton ball or a gauze pad). Avoid tight synthetic clothing that doesn’t breathe. Wear cotton undergarments. Maintain regular bowel movement with normal consistency (minimize stool leakage). Increase stool bulk by increasing fiber intake. Maintain adequate hydration- you MUST drink at least 64 ounces of fluid per day, in addition to increasing fiber intake. Medication Capsaicin- causes a low-grade burning sensation and decreases the perception of itching Zinc oxide- Apply a small amount of a barrier cream to the perianal skin in a thin layer. This will protect the skin from irritants. Mix Benadryl cream with the zinc oxide cream and apply it to the affected area. Benadryl- 25 mg by mouth at night for itching Patient Info- Pruritis Ani .pdf Download PDF • 58KB Patient Info- Fiber Guide .pdf Download PDF • 68KB Previous Next