Surgical Intensive Care Unit (SICU) Introduction

Jul 18, 2024

Surgical Intensive Care Unit (SICU) Introduction

Speaker

  • Rich Savelle
    • Director of the Surgical Intensive Care Unit at Maimonides Medical Center

Key Topics Overview

  1. Basics of different categories of shock states
  2. Differential diagnosis during cardiopulmonary arrest
  3. Three-hour and six-hour bundles for severe sepsis syndrome
  4. Acid-base disorders and intensivist approach
  5. Defining ARDS and using ARDSnet protocol
  6. Abdominal compartment syndrome
  7. Ventilator bundle
  8. Catheter-related bloodstream infection bundle

Categories of Shock States

  1. Types and Examples
    • Hypovolemic shock: Bleeding, hemorrhagic shock, diabetic ketoacidosis
    • Distributive shock: Septic shock (common in SICU), spinal shock, anaphylactic shock
    • Cardiogenic shock: Pump dysfunction (less common in SICU)
    • Non-cardiogenic obstructive shock: Pericardial tamponade, pulmonary embolism, tension pneumothorax, abdominal compartment syndrome
  2. Focus on Septic Shock
    • Subcategory of distributive shock

Differential Diagnosis During Cardiopulmonary Arrest

  • Key points to consider during CPR:
    • Hypovolemia
    • Hypoxia
    • Hypothermia
    • Hypo-/Hyperkalemia
    • Massive MI
    • Pericardial tamponade
    • Pulmonary embolism
    • Tension pneumothorax
    • Overdose
    • Acidosis

Surviving Sepsis Campaign Bundles

  1. Three-Hour Bundle
    • Check lactate level
    • Get cultures prior to antibiotics
    • Start broad-spectrum antibiotics
    • Administer 30 ml/kg crystalloid bolus
  2. Six-Hour Bundle
    • Administer vasopressors if hypotensive
    • Target MAP > 65 mmHg
    • Consider placing a central line and checking CVP (target 8-12)
    • Re-measure lactate if initially elevated
  3. Definitions
    • Sepsis: Infection with organ dysfunction
    • Severe Sepsis: Sepsis with acute organ dysfunction
    • Septic Shock: Vasopressor-dependent after volume resuscitation

Understanding Acid-Base Disorders

  1. Importance
    • Critical for decision-making in ICU
  2. Metabolic Acidosis
    • Calculate Anion Gap: Identify cause (MUDPILES: Methanol, Uremia, Diabetic ketoacidosis, Paraldehyde, Iron/INH, Lactate, Ethylene glycol, Salicylate)
    • Non-Anion Gap: Loss of bicarbonate from gut (diarrhea) or kidney, resuscitation with bicarb-poor fluids (normal saline)
    • Renal Tubular Acidosis (RTA)
      • Types: Type 1 (distal), Type 2 (proximal), Type 4 (hyperaldosteronism)
      • Causes of Type 4 RTA: Adrenal insufficiency, drug-induced (ACE inhibitors, NSAIDs, heparin)
  3. Metabolic Alkalosis
    • Work-up: Spot urine chloride
      • Chloride Responsive (< 25): Vomiting, NG tube suctioning
      • Chloride Non-Responsive (> 40): Hyperaldosteronism, Liddle’s syndrome, diuretics, Bartter’s and Gitelman syndromes, licorice
    • Link with hypokalemia: Often necessary to treat potassium/magnesium deficiencies

ARDS and ARDSnet Protocol

  • ARDS Definition: Criteria for acute respiratory distress syndrome
  • ARDSnet Protocol: Standardized approach for management

Abdominal Compartment Syndrome

  • Overview of diagnosis and management in ICU

Ventilator and Catheter Bundles

  • Protocols to prevent ventilator-associated pneumonia and catheter-related bloodstream infections