SICU management?

[TrustMe]

So I got yelled at by a senior surgery a-hole (I mean resident) for the way I managed a SICU pt. they sent over the other night while I was on call. I need some opinions on what I did wrong (or right as I think the case may be). As an intern I am open to all constructive criticism. (By the way, as interns we take solo call in the SICU so I only had a few calls to the attending at home to bounce thoughts off of, which I did do.)

40 something chronic alcoholic male comes to the ED vomitting blood. Gets scoped, esophogeal and gastric varicies (not bleeding) and Mallory-Weiss tear at GE junction bleeding heavily. GI injects epi and pulls out. Over next 12 hours pt. gets 10 units PRBC's in MICU and they decide to re-scope (ya think). Still bleeding(surprise). To the OR for ex-lap and gastric repair. To me in SICU for post-op care. Intra-op got 3 PRBC, 2 FFP, 500 hespan, 1L LR, minimal UOP. Belly(read liver) too big to close so packed and covered. Surgery wants him "dry" so they can close tomorrow (yeah right!). Post-op Hct. 30, INR 1.6, Plt. 60, LFT's mildly elevated 200's, Creat 2.5 (up from 0.6 on admission). BP marginal. UOP minimal. I start with 2 units FFP and 500ml albumin 5%. Minimal UOP - 500 more of albumin since his belly is open and I know he will just 3rd space crystalloid. Abdominal drain to suction is putting out 300ml/hr serosanguenous (more sanguenous). ABG now looks okay. Re-check labs. Hct. 23, INR 1.6, Plt. 45, fibrinogen low, LFT's ^^ (enzymes in 2,000's and bili increasing), pt. still bleeding from abdominal drain. I order 2 PRBC, 2 FFP, 2 cryo, 2 units plt's and 500 more albumin since he still isn't peeing much (15-20ml/hr). IV med's along with LR has been running at about 200-250 all night (2000-0600). Morning is near but still bleeding so I give 2 more PRBC and re-check labs for 0600. Hct. 27, INR 1.6, Plt. 60, Creat 2.4, LFT's now 3,000, total of 3.5 liters out of abdominal drain (mostly blood) in last 8 hours. Sr. surgery resident comes in and starts yelling at me because I gave to much fluid and he doesn't think he will be able to close the abdomen. #1-I could have let him exsanguenate and you still weren't getting that belly closed and #2-if you don't stop yelling "too much fruid, too much fruid" in that thick Asian accent I'm going to have to stick my foot up your ass.

What else could/should I have done for management of this pt. overnight?

---

Members don't see this ad.

 

[Trisomy13]

So I got yelled at by a senior surgery a-hole (I mean resident) for the way I managed a SICU pt. they sent over the other night while I was on call. I need some opinions on what I did wrong (or right as I think the case may be). As an intern I am open to all constructive criticism. (By the way, as interns we take solo call in the SICU so I only had a few calls to the attending at home to bounce thoughts off of, which I did do.)

40 something chronic alcoholic male comes to the ED vomitting blood. Gets scoped, esophogeal and gastric varicies (not bleeding) and Mallory-Weiss tear at GE junction bleeding heavily. GI injects epi and pulls out. Over next 12 hours pt. gets 10 units PRBC's in MICU and they decide to re-scope (ya think). Still bleeding(surprise). To the OR for ex-lap and gastric repair. To me in SICU for post-op care. Intra-op got 3 PRBC, 2 FFP, 500 hespan, 1L LR, minimal UOP. Belly(read liver) too big to close so packed and covered. Surgery wants him "dry" so they can close tomorrow (yeah right!). Post-op Hct. 30, INR 1.6, Plt. 60, LFT's mildly elevated 200's, Creat 2.5 (up from 0.6 on admission). BP marginal. UOP minimal. I start with 2 units FFP and 500ml albumin 5%. Minimal UOP - 500 more of albumin since his belly is open and I know he will just 3rd space crystalloid. Abdominal drain to suction is putting out 300ml/hr serosanguenous (more sanguenous). ABG now looks okay. Re-check labs. Hct. 23, INR 1.6, Plt. 45, fibrinogen low, LFT's ^^ (enzymes in 2,000's and bili increasing), pt. still bleeding from abdominal drain. I order 2 PRBC, 2 FFP, 2 cryo, 2 units plt's and 500 more albumin since he still isn't peeing much (15-20ml/hr). IV med's along with LR has been running at about 200-250 all night (2000-0600). Morning is near but still bleeding so I give 2 more PRBC and re-check labs for 0600. Hct. 27, INR 1.6, Plt. 60, Creat 2.4, LFT's now 3,000, total of 3.5 liters out of abdominal drain (mostly blood) in last 8 hours. Sr. surgery resident comes in and starts yelling at me because I gave to much fluid and he doesn't think he will be able to close the abdomen. #1-I could have let him exsanguenate and you still weren't getting that belly closed and #2-if you don't stop yelling "too much fruid, too much fruid" in that thick Asian accent I'm going to have to stick my foot up your ass.

What else could/should I have done for management of this pt. overnight?

should have told him to fix the damn bleed properly the first time and you wouldn't need so much fruid.

 

[2ndyear]

I think everything you did was OK. When I did SICU a few months ago we had a few of these and they all went about 3-4 days in the unit with an open belly. At some point you do have to get them dry, lasix, whatever. But certainly not in the acute phase of resusitation that you describe. It also sounds to me like you got someone from the OR who was inadequately resusitated. 1L LR, 500 hespan and some products for a big ex-lap?

One thing that you didn't mention here is how hemodynamically stable the pt was the whole time. Also were you measuring CVP or did you have a Swan?
You have a few issues here:
1) Shock (he was hemodynamically unstable right?)
2) Acute renal failure
3) Coagulopathy/DIC
4) "shock liver"
5) A bleed somewhere

Now you need some endpoints for your resusitation. You can:
1) Pick a CVP/UOP/MAP/Hct and go with it or
2) Put a swan in if you don't have one. I know lots of people might not use one in this situation, but I'm not that smart and I like the numbers, especially if I'm rather stumped. I'd be looking for CO, SvO2, SVR and fixing accordingly. A Swan isn't going to save this guy. But if you think it would be helpful then go for it, only if you're going to use the numbers that you get when the red cap comes off.

I feel for you doing this as an intern with no backup. That's tough. I did SICU as an intern with resident backup so that wasn't bad. When I took solo SICU call as an anesthesia resident I made sure to involve the primary service as much as possible. Don't pass the buck, but tell them early what you're doing and why. This guy is sick as hell. Closing the abdomen isn't going to fix the problem here.

 

[VentdependenT]

1) Closing the belly is NOT URGENT. Friggen ridiculous. This guy isn't going to have a cosmetic closure for christ sake. Crankin the gut down is only gonna drop preload and thus CO more AND squish down capillaries in this guys abdomen leading to: ATN, Bowel ischemia, Worsening shock liver.

2) This guy has already been under-resucitated. Labs show it. I dont know anything about this guys vitals now but he's already taken a hit by puking out 1/2 of his oxygen carrying capacity. MORE BLOOD. Go easier on the crystalloids until you get the blood (pressure tolerating), which he needs. BUt you gotta do what you gotta do.

3) There is NO perfect volume status monitor. I agree with CVP above. ITs better than nothing and at least you can follow a trend. Get an echo in the am. Check out if his ventricle is full or empty. A swan can help, but no intern is gonna know how to float that thing, let alone interpret it, in july..or june for that matter.

Other crud going on which was already mentioned

ATN------>Check a FENa.
SIRS -------> now looking like DIC.
Impending Liver Failure.
High potential for ischemic bowel---->follow gases and check a lactic acid.
High potential for ARDS.

Delerium Tremens is GONNA HAPPEN in this guy and its gonna complicate the whole clinical picutre if you don't add some benzo's up front. Guy won't wake up sooner? Tough snickers. It beats full blown seizures and an MI.

Speaking of MI------>if his liver was underperfused, and his kidneys, how much you wanna bet his ticker was? Troponins are a good idea....how bout that echo? Not a bad idea either now eh? We'll save the toxic metabolic encephalopathy compounded by global ischemia for later

Point is, closing the belly is the last G@d damn thing that should worry your sr's mind right now.

Ridiculous.

 

[atrxnasd]

Anesthesia residents should not take CR*P from surgery residents or attendings. If any give you trouble you should refer them to your attending who hopefully was involved in the care of this sick patient. I don't discipline surgery residents (instead I talk their attendings) and I don't want other services bothering our residents.

 

[nvshelat]

Holy crap you guys are friggin geniuses...

so much to learn, so little time..

 

[TrustMe]

WOW! After those few posts I feel like I know nothing.

Post-op his CVP was 5 (monitor was placed intra-op thankfully). After his first round of products and some albumin his CVP jumps to 10 and SBP in the 140's and he's tachy (120's). At that point I wasn't as worried about him hemodynamically as I was about that fact that he wouldn't stop pouring blood out of that abdominal drain and the fact that his was making very little urine.

I did not think about DT's at the time but when my Sr. got there in the morning he hooked the pt. up with some benzo's. Pt. was also on propofol drip for sedation. I thought that I heard somewhere that that can help prevent DT's (not that I thought about it at the time, but I did after I got home)?

Update - surgery takes him back last night to close belly (*******es). This morning you could bounce quarters off his gut. We transduce his bladder pressure -> 26-28. We call surgery "this dude's developing abdominal compartment syndrome". They come and check him out and are unimpressed. If I get back in the morning and his belly is open again I'm gonna laugh my ass off at that dumb surgery resident.

Thanks everyone for the great teaching points. I like critical care (part of the reason I chose anesthesia) but I know I have tons to learn. Keep the ideas coming so I won't be so lost when my next unit month rolls around.

TM

 

[VentdependenT]

WOW! After those few posts I feel like I know nothing.

Post-op his CVP was 5 (monitor was placed intra-op thankfully). After his first round of products and some albumin his CVP jumps to 10 and SBP in the 140's and he's tachy (120's). At that point I wasn't as worried about him hemodynamically as I was about that fact that he wouldn't stop pouring blood out of that abdominal drain and the fact that his was making very little urine.

I did not think about DT's at the time but when my Sr. got there in the morning he hooked the pt. up with some benzo's. Pt. was also on propofol drip for sedation. I thought that I heard somewhere that that can help prevent DT's (not that I thought about it at the time, but I did after I got home)?

Update - surgery takes him back last night to close belly (*******es). This morning you could bounce quarters off his gut. We transduce his bladder pressure -> 26-28. We call surgery "this dude's developing abdominal compartment syndrome". They come and check him out and are unimpressed. If I get back in the morning and his belly is open again I'm gonna laugh my ass off at that dumb surgery resident.

Thanks everyone for the great teaching points. I like critical care (part of the reason I chose anesthesia) but I know I have tons to learn. Keep the ideas coming so I won't be so lost when my next unit month rolls around.

TM

That tight gut is also gonna drive his ventilation pressures up and cause big time atelectasis. Great.

Propofol will work on DT's for sure because of tts action on GABA receptors. I wouldn't touch a hemodynamically unstable patient with propofol becaise its : 1)myocardial depressant, 2) drops svr like a mo-fo. If stable then ok sure. But its a bandaid.

You're gonna have to start the guy on benzo's at some point. You can still do neuro checks on benzos unless the guy is so completely agitated, psychomotor-wise, that you have to put him wayyyyyyyyyy down with the stuff.

 

[MTGas2B]

If your boy was still bleeding and you've given him a good go with products don't forget about ole Novo 7. It's expensive as hell (last time I looked just over $4000 at my institution). But its like a miracle drug for persistant bleeding.

Last month I had this guy who ended up getting crashed into the OR for a thoracotomy. Had a little PEA code in the ED and a big hemothorax. Loaded him up with lots of FFP, platelets, cryo, still crappy INR, still bleeding. One dose of recombinate factor 7, bleeding stops next INR 1.2. Too bad they didn't scan his head in the ED, massive epidural and traumatic SAH. He was brain dead by morning. But the novo 7 worked great.

 

[GasEmDee]

I wouldnt call NovoSeven a miracle drug. It is a huge sword with two very sharp edges, at best. Last time I saw it used to correct a coagulopathy, the patient developed DVTs, threw PEs, and died.

If your boy was still bleeding and you've given him a good go with products don't forget about ole Novo 7. It's expensive as hell (last time I looked just over $4000 at my institution). But its like a miracle drug for persistant bleeding.

Last month I had this guy who ended up getting crashed into the OR for a thoracotomy. Had a little PEA code in the ED and a big hemothorax. Loaded him up with lots of FFP, platelets, cryo, still crappy INR, still bleeding. One dose of recombinate factor 7, bleeding stops next INR 1.2. Too bad they didn't scan his head in the ED, massive epidural and traumatic SAH. He was brain dead by morning. But the novo 7 worked great.

 

[toughlife]

That tight gut is also gonna drive his ventilation pressures up and cause big time atelectasis. Great.

Propofol will work on DT's for sure because of tts action on GABA receptors. I wouldn't touch a hemodynamically unstable patient with propofol becaise its : 1)myocardial depressant, 2) drops svr like a mo-fo. If stable then ok sure. But its a bandaid.

You're gonna have to start the guy on benzo's at some point. You can still do neuro checks on benzos unless the guy is so completely agitated, psychomotor-wise, that you have to put him wayyyyyyyyyy down with the stuff.

Why not precedex instead of propofol?

 

[VentdependenT]

Why not precedex instead of propofol?

Ahhh precedex. Ever try it in somone who is dry? If this dude bleeds out or is hemodynamically unstable then precedex will potentially bottom his pressures out. It'll just complicate the picture.

 

[Jeff05]

cvp has not been show to correlate with EDV. using it as a relative marker is also unreliable (i.e. studies have shown it may increase, decrease or stay the same after volume resuscitation). the most recent literature suggests it should not be used as endpoint for volume loading.

same goes for PAC. large studies have shown NO improvement in outcome with PAC placement and, in fact, worse outcomes in the sickest pts.

so, if it makes YOU feel better go for it.

 

[Planktonmd]

This guy has hepato-renal syndrome and whatever you do he is not going to get better.
His next step is hepatic coma accelerated by the Benzos your "senior" is giving him.
There isn't much you can do.
Is he still with us?

 

[VentdependenT]

cvp has not been show to correlate with EDV. using it as a relative marker is also unreliable (i.e. studies have shown it may increase, decrease or stay the same after volume resuscitation). the most recent literature suggests it should not be used as endpoint for volume loading.

same goes for PAC. large studies have shown NO improvement in outcome with PAC placement and, in fact, worse outcomes in the sickest pts.

so, if it makes YOU feel better go for it.

It makes everybody feel better.

Sure I can go by heart rate, blood pressure, UOP (worthless in acute setting), Ph's and serial HB's (worthless in acute hemorrhage), but why the hell not add in something else. HR and BP aren't always reliable. Its ALWAYS a best guess anyways. Especially when the bleeding is concealed.

Swan may NOT improve outcome but its the best damn volume monitor we have at this point if its limitations are known.

I sure as hell am not putting an echo anywhere NEAR this guys variceal loaded guts.

WHats next? Skin turgor and conjunctival paleness?

 

[Jeff05]

TTE is an excellent option.

if adding a monitor does not MEANINGFULLY alter management then that monitor should probably not be added. especially, if it has a potential for complications (ex. albeit, rare, PA rupture; bleeding, infection).

just because we don't have anything better does not mean we should continue to use poor options. i really believe in primum no nocere.

back surgery does not provide long term relief of back pain vs conservative management. angioplasty is not better than medical management in stable CAD. yet this is not a deterrent for the proceduralists that perform them - because proceduralists like to DO stuff.


----------------
FOr the above pt. i would have stayed away from the albumin (increased mortality, temporary BP elevation, and ultimately more tissue edema). agree with FFP, RBC, and platelets,would do CVVH as tolerated to get some fluid off. also i would have limited the crystalloid and considered going to pressors after all the colloid failed to increase BP. phenylephrine would be a good choice. at the end of the night, once liver pts are bleeding - you can do everything right and still have a poor outcome.

 

[Planktonmd]

TTE is an excellent option.

I thought he has esophageal varices!

 

[Jeff05]

TTE - trans-thoracic echo is not a problem with varices. TEE - trans-esophageal echo would be problematic.

 

[johankriek]

So I got yelled at by a senior surgery a-hole (I mean resident) for the way I managed a SICU pt. they sent over the other night while I was on call. I need some opinions on what I did wrong (or right as I think the case may be). As an intern I am open to all constructive criticism. (By the way, as interns we take solo call in the SICU so I only had a few calls to the attending at home to bounce thoughts off of, which I did do.)

40 something chronic alcoholic male comes to the ED vomitting blood. Gets scoped, esophogeal and gastric varicies (not bleeding) and Mallory-Weiss tear at GE junction bleeding heavily. GI injects epi and pulls out. Over next 12 hours pt. gets 10 units PRBC's in MICU and they decide to re-scope (ya think). Still bleeding(surprise). To the OR for ex-lap and gastric repair. To me in SICU for post-op care. Intra-op got 3 PRBC, 2 FFP, 500 hespan, 1L LR, minimal UOP. Belly(read liver) too big to close so packed and covered. Surgery wants him "dry" so they can close tomorrow (yeah right!). Post-op Hct. 30, INR 1.6, Plt. 60, LFT's mildly elevated 200's, Creat 2.5 (up from 0.6 on admission). BP marginal. UOP minimal. I start with 2 units FFP and 500ml albumin 5%. Minimal UOP - 500 more of albumin since his belly is open and I know he will just 3rd space crystalloid. Abdominal drain to suction is putting out 300ml/hr serosanguenous (more sanguenous). ABG now looks okay. Re-check labs. Hct. 23, INR 1.6, Plt. 45, fibrinogen low, LFT's ^^ (enzymes in 2,000's and bili increasing), pt. still bleeding from abdominal drain. I order 2 PRBC, 2 FFP, 2 cryo, 2 units plt's and 500 more albumin since he still isn't peeing much (15-20ml/hr). IV med's along with LR has been running at about 200-250 all night (2000-0600). Morning is near but still bleeding so I give 2 more PRBC and re-check labs for 0600. Hct. 27, INR 1.6, Plt. 60, Creat 2.4, LFT's now 3,000, total of 3.5 liters out of abdominal drain (mostly blood) in last 8 hours. Sr. surgery resident comes in and starts yelling at me because I gave to much fluid and he doesn't think he will be able to close the abdomen. #1-I could have let him exsanguenate and you still weren't getting that belly closed and #2-if you don't stop yelling "too much fruid, too much fruid" in that thick Asian accent I'm going to have to stick my foot up your ass.

What else could/should I have done for management of this pt. overnight?

i never heard not being able to close because of too much fluid.. thats assinine..

 

[Planktonmd]

TTE - trans-thoracic echo is not a problem with varices. TEE - trans-esophageal echo would be problematic.

Ah,
OK,
I think I am just too old for all these abbreviations.
I didn't even know that TTE means trans-thoracic Echo.

 

[VentdependenT]

TTE is a great option for checking out his heart. I already advocated getting one earlier. Looking for RWMA, pulmonary pressures, and volume in the ventricle (which may be hypertrophied, or dilated, either of which will confuse matters).

But, thats a one shot deal. You cant ask the tech to leave the TTE attached to the guys chest for a few hours while you bump in fluid, watch the heart, the heart rate, and the blood pressure. With an echo you can do all of the above...

plank, I didn't edit your post above. T'was an accident.

 

[2ndyear]

I'm still putting a swan in this guy. I know outcome studies show no difference, but none of those studies were done on this guy, in this situation, on this night. What I want here is cardiac output. I might even put in a CCO swan for kicks. Again, I'm only putting it in if it may change management and in this case, for me, it does or at least may. When I start a pressor, I want to know how much I have to flog the heart. I'd like to know SVO2 as well and while this is a poor indication, it's a decent number.

 

[TrustMe]

So....a little follow up info since we last spoke.

First, I like the discussion on monitoring. I can't float a swan and can barely interpret the numbers, but all this talk should help me next time around. Thanks for all the input.

First off, Vent you were right in your first post. I said the dudes liver and kidney's took a hit and you said his heart probably did as well. Troponin was 15 then went to 34 then ?? Surgery closed his abdomen on POD #3 (I think). Anyway, we trasduce bladder pressure and are concerned, call the surgery team and they are unimpressed. Next day they finally are concerned about abdominal compartment syndrome and open his belly. Bowel looks like $#@t (ischemic). I'm on that night. Dude goes south throughout the day and is on vaso, levo, and epi with systolic's in the 90's. Family decides no additional treatment and DNR. Overnight pressures steadily decline until his systemic pressure matches his PA pressure (just an intern here but I think that is bad). Official time of death 0625.

TM

 

[Planktonmd]

So....a little follow up info since we last spoke.

First, I like the discussion on monitoring. I can't float a swan and can barely interpret the numbers, but all this talk should help me next time around. Thanks for all the input.

First off, Vent you were right in your first post. I said the dudes liver and kidney's took a hit and you said his heart probably did as well. Troponin was 15 then went to 34 then ?? Surgery closed his abdomen on POD #3 (I think). Anyway, we trasduce bladder pressure and are concerned, call the surgery team and they are unimpressed. Next day they finally are concerned about abdominal compartment syndrome and open his belly. Bowel looks like $#@t (ischemic). I'm on that night. Dude goes south throughout the day and is on vaso, levo, and epi with systolic's in the 90's. Family decides no additional treatment and DNR. Overnight pressures steadily decline until his systemic pressure matches his PA pressure (just an intern here but I think that is bad). Official time of death 0625.

TM

Exactly the outcome I expected (refer to my post # 14).
This is why it didn't matter what you did to this guy, because people never recover from Hepatorenal Syndrome.

 

[VentdependenT]

Exactly the outcome I expected (refer to my post # 14).
This is why it didn't matter what you did to this guy, because people never recover from Hepatorenal Syndrome.

Plank, you got any more info on Hepatorenal/hepatopulmonary that is clinically applicable?

 

[Planktonmd]

Plank, you got any more info on Hepatorenal/hepatopulmonary that is clinically applicable?

There is plenty of literature out there on hepatorenal syndrome as a terminal stage of chronic liver failure or in the context of fulminant hepatitis.
This is usually a functional renal failure that is secondary to the hemodynamic and oncotic changes associated with advanced liver disease.
In acute settings, when hepato renal syndrome develops it's prognosis is very bad because you enter in a vicious cycle:
Liver failing leading to secondary renal failure, and renal failure worsening the metabolic and oncotic changes, making the liver failure worse and accelerating the progress of hepatic coma especially in the presence of GI bleeding dumping ammonia and other toxins in the circulation.
Giving CNS depressants to the patient might sound like a good idea to prevent DT's but it's very easy to precipitate the development of hepatic coma in these patients.
Early dialysis might (in rare occasions) break the vicious cycle but in my experience hepato renal syndrome in acute settings( trauma or acute bleeding for example), is almost always fatal.

Concerning Hepato-pulmonary syndrome it's another complication of advanced liver disease, it's mainly responsible for hypoxemia in these patients and the etiology is considered multi factorial although pulmonary micro vascular shunts seem to be the main mechanism.
here is a nice article I found about that syndrome:
http://www.annals.org/cgi/content/full/122/7/521

This syndrome should always be on your mind when anesthetizing someone with advanced liver disease, they get hypoxic much faster, and they have a significant intrapulmonary right to left shunt that can complicate your anesthetic.

 

[coprolalia]

Great post! I wouldn't have done anything differently. You were screwed from the get go. Liver shock is a bad, bad thing.

copro

 

[TrustMe]

Thanks for all the info. Terrible case for this dude and his family but great learning opportunity for me and others. For other interns that haven't had to talk to a family about their loved one dying, this is the second time I have had to since starting a month ago. It's not fun but it's much easier the second time.

TM