SURGICAL CRITICAL CARE HANDBOOK, THE Guidelines for

Care of the Surgical Patient in the ICU

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 Published by
World Scientific Publishing Co. Pte. Ltd.
5 Toh Tuck Link, Singapore 596224
USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601
UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

Library of Congress Cataloging-in-Publication Data

The surgical critical care handbook : guidelines for care of the surgical patient in the ICU / [edited]
by Jameel Ali.
p. ; cm.
Includes bibliographical references.
ISBN 978-9814663120
I. Ali, Jameel, editor.
[DNLM: 1. Intensive Care--methods--Handbooks. 2. Intensive Care Units--standards--
Handbooks. 3. Monitoring, Physiologic--methods--Handbooks. 4. Surgical Procedures, Operative--
methods--Handbooks. 5. Wounds and Injuries--surgery--Handbooks. WX 39]
RC86.7
616.02'8--dc23
2015009060

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library.

Copyright © 2016 by World Scientific Publishing Co. Pte. Ltd.

All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,
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For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance
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Desk Editor: Dipasri Sardar

Typeset by Stallion Press

Email: [email protected]

Printed in Singapore

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Contents

Foreword ix
About the Editor xi
List of Contributors xv

SECTION 1 General Considerations 1

Chapter 1 Preoperative Assessment of the High-Risk
Surgical Patient 3
Robert Chen and Jameel Ali
Chapter 2 Shock: Cardiovascular Dynamics, Endpoints
of Resuscitation, Monitoring, and Management 29
Jameel Ali
Chapter 3 Gas Exchange 43
Zoheir Bshouty
Chapter 4 Perioperative Respiratory Dysfunction 65
Jameel Ali
Chapter 5 Mechanical Ventilation in the ICU 83
Robert Chen and Jameel Ali
Chapter 6 Nutrition in the Surgical ICU Patient 97
Mohammed Bawazeer and Jameel Ali

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vi Contents

Chapter 7 Management of the Anticoagulated Injured Patient 115

K. Pavenski
Chapter 8 Pneumonia in the Surgical Intensive Care Unit 125
Mohammed Bawazeer and Jameel Ali
Chapter 9 Hypothermia and Hyperthermia 145
John B. Kortbeek
Chapter 10 Thrombo-Embolism in the ICU patient 159
Daniel Roizblatt, Andrew Beckett and Jameel Ali
Chapter 11 Broad Principles of Antibiotic Usage
and Surgical Antimicrobial Prophylaxis 171
Jameel Ali and Addison K. May
Chapter 12 The Coagulopathic Trauma Patient
and Massive Transfusion Protocol 201
Jameel Ali, Sandro Rizoli and Katerina Pavenski
Chapter 13 Geriatric Issues and the ICU 223
Richard M. Bell and Victor Hurth
Chapter 14 Ethical Issues in the Surgical ICU 251
Marshall Beckman, John Weigelt, Jameel Ali
and Richard M. Bell

SECTION 2 Specific Surgical Disorders 263

(a) TRAUMA 263
Chapter 15 Priorities in Multiple Trauma Management 265
Jameel Ali
Chapter 16 Thoracic Trauma 283
Col. (retd.) Mark W. Bowyer and Jameel Ali
Chapter 17 Abdominal Trauma 309
Jameel Ali
Chapter 18 Head Injury 325
Jameel Ali, Lyne Noël de Tilly and R. Loch Macdonald
Chapter 19 Spine and Spinal Cord Injury 357
Safraz Mohammed, Shelly Wang and Jameel Ali

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Contents vii

Chapter 20 Pelvic Fractures 385

Jameel Ali and Jeremie Larouche
Chapter 21 Extremity Fractures 403
Jeremy Hall and Jeremie Larouche
Chapter 22 Extremity Compartment Syndromes 417
Col. (retd.) Mark W. Bowyer
Chapter 23 Burns, Cold Injury and Electrical Injury 439
Karen M. Cross and Joel S. Fish
Chapter 24 Multiorgan Dysfuntion Syndrome in the Surgical Patient 469
P. Dhar and G. Papia

(b) NonTRAUMA 491

Chapter 25 Intra-abdominal Sepsis 493
Shuyin Liang and Joao B. de Rezende-Neto
Chapter 26 Bowel Obstruction 517
Dave D. Paskar and Neil G. Parry
Chapter 27 Mesenteric Ischemia 531
John B. Kortbeek
Chapter 28 Upper GI Hemorrhage 543
Brad S. Moffat, Sarah Knowles and Neil G. Parry
Chapter 29 Lower Gastrointestinal (GI) Hemorrhage 557
Jonathan Hong and Marcus Burnstein
Chapter 30 Acute Pancreatitis 567
John B. Kortbeek
Chapter 31 Colorectal Disorders 577
Jonathan Hong, D. Kagedan and Marcus Burnstein
Chapter 32 The Bariatric Surgical Patient 597
Andrew Smith, Jameel Ali and Timothy D. Jackson
Chapter 33 The Transplant Patient 619
Andrew S. Barbas and Anand Ghanekar

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viii Contents

Chapter 34 Soft Tissue Infection in Critical Care 639

Sami Alissa, Nawaf Al-Otaibi and James Mahoney
Chapter 35 The Pediatric Surgical ICU Patient 653
Arthur Cooper, Pamela Feuer, Logeswary Rajagopalan,
Ranjith Kamity and Mary Joan Marron-Corwin

Index 703

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Foreword

As care givers we are frequently required to manage patients with life threat-
ening disorders. This is more likely in the ICU environment where surgical
patients are treated. These patients not only require management of their
surgical disorders but also correction of abnormalities characteristic of the
critically ill. The surgical intensivist must therefore be well informed in many
disciplines other than the surgical disorders in order to care for these patients
appropriately. This frequently requires a team approach which includes input
from anesthesiologists, internists, respirologists, nurses, respiratory thera-
pists, social workers, ethicists and frequently members of the clergy.
To address all these issues, this handbook has benefited from input from
many sources. The authors and coauthors are experts in their disciplines or
have had recent personal exposure to management of the critically ill surgical
patient during extensive postgraduate training. The first section of the text
discusses pathophysiologic processes common to the critically ill patient and
sets the stage for applying these general principles in managing specific surgi-
cal disorders, dividing these into two subsections — trauma and no trauma.
The geriatric population continues to increase with our improvements in
technology and medical/surgical care in general leading to larger numbers of
these patients requiring intensive care. Our chapter on the geriatric critically ill
patient focuses on problems unique to this population as well general ICU
management issues. Likewise there is great emphasis on the care of the critically
ill pediatric patient where special skills are required in dealing with the psycho-
logical component as well as unique pathophysiologic response to illness.

ix

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x Foreword

Family dynamics, life and death issues, futility of treatment, consent for
treatment and cessation of treatment are all very important issues in the ICU
requiring sensitivity, empathy and honest open discussion with not only the
patient but also with their family members and stakeholders. The chapter on
application of biomedical ethical principles is aimed at preparing the inten-
sive care team to deal with these issues.
As physicians we are very privileged to be afforded the precious gift of
knowledge and skills to make a difference in the lives of our patients and with
this privilege comes a deep sense of responsibility and gratitude for having
been the recipients of these special gifts. This gratitude is best expressed by
applying our skills to the ultimate benefit of our patients and expressing
thanks for these gifts to our teachers and the Giver of all knowledge. We are
also very privileged not only as physicians but also as teachers giving to our
students and patients the benefits of our knowledge in such a way that when
our students touch their patients it should be as if our own hands are touch-
ing those patients. This brings a level of solemnity and spirituality to our
day-to-day care of our patients and their families.
It is my hope that this handbook will enhance the readers’ ability to care
for the critically ill patient, not only in a very knowledgeable fashion but also
with kindness, sensitivity, and humility.
I am deeply indebted to my coauthors who toiled unceasingly in their
efforts to make this handbook a special part of the educational armamen-
tarium of our students at all levels.
This handbook is dedicated to my family, my teachers, my students and
especially my patients from whom I continue to learn so much, to whom I
am forever grateful and through whom I am able to practice this treasured
art with (as mentioned by one of my dear colleagues) heart, humility and
humanity.
— Jameel Ali, MD, MMedEd

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About the Editor

Jameel Ali

Dr Jameel Ali was born in Trinidad and Tobago where he underwent early
education at Roman Catholic Missionary Schools. Dr Ali then moved to
Winnipeg, Manitoba for Medical School followed by Residency training
and clinical Fellowship in General Surgery with basic research training in
respiratory physiology.
From Winnipeg, Manitoba he went on to Critical Care and Trauma fel-
lowships at Boston University Medical Centre and San Francisco General
Hospital of the University of California — San Francisco. Dr Ali returned to
Winnipeg as Assistant Professor and was later promoted as Full Professor in
1985. During this period Dr. Ali continued doing research in respiratory
physiology and established one of the first Surgical Critical Care units in
Canada. He became the Director of Trauma and established the Advanced
Trauma Life Support (ATLS) training program in Manitoba. He was also the
Director for Post graduate Training in Surgery for four years there and Chief
of the Region XI of the Committee on Trauma of the American College
of Surgeons as well as President of the Manitoba Chapter of the American
College of Surgeons, National ATLS faculty and member of the ATLS
subcommittee. Dr Ali is a Fellow of the Royal College of Surgeons of
Canada and of the American College of Surgeons and has a Master’s degree
in Medical Education from the University of Dundee.
Dr. Ali moved to the University of Toronto in 1987 as the Head of the
Divisions of General Surgery at Sunnybrook and later to the Toronto
Western Hospital where he was Medical Director of the Trauma Program.

xi

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xii About the Editor

Dr Ali is also the Director of the University of Toronto Advanced Trauma

Life support program and was Chairman of the Postgraduate Surgery
Committee of the University for 11 years, during which period the
Postgraduate Program underwent two successful Royal College reviews.
Under Dr. Ali’s tenure the Surgical Scientist Program of the University of
Toronto secured Ministry of Health funding, under the leadership of Dr.
Ori Rotstein with the foresight of the Chair of the Department, Dr. Bernard
Langer. The Surgical Scientist Program has trained PhD and MSc surgeons
that have gone on to major academic surgical careers in Canada and world-
wide including myself.
Dr. Ali has been a prominent member of the international ATLS educa-
tor faculty, which trains educators and ATLS faculty across the world. Dr. Ali
was a contributing author of 7 editions of the ATLS Provider and Instructor
manuals, the Prehospital Trauma Life support manual, the Advanced Trauma
Operative Management course and pioneered the TEAM (Trauma Evaluation
and Management) program for training medical students in principles of
trauma resuscitation. He has also promulgated the Rural Trauma Team
Development program in Canada, the Middle East and the Caribbean. Dr.
Ali directed the first ATLS course outside North America, which took place
in Trinidad and Tobago in 1986. This course was the start of the interna-
tional ATLS promulgation program through which more than 2 million
physicians have been trained in over 65 countries. Dr. Ali has received
numerous awards for undergraduate, postgraduate and international teach-
ing including the W T Aikins Faculty teaching award for course development
and coordination for undergraduate teaching as well as the Bruce Tovee
award for postgraduate teaching at the University of Toronto, the ATLS
Meritorious Service Award, the Trauma Achievement award of the American
College of Surgeons and the Prehospital Trauma Life Support Scott Frame
Award. A measure of Dr. Ali’s compassion and zeal for humanitarian care is
his receiving the Dr. Vincent J Hughes Physician humanitarian award
through the Medical staff association as well as the award named after him —
the Jameel Ali St. Michaels Hospital Award in Continuing Education in
Surgery. Dr. Ali has been the Associate Editor for 3 editions of one of the
leading Text books in Critical Care, and a member of the editorial Board of
the Journal of Trauma and Journal of Surgical Research. He has over 240
publications in the areas of respiratory physiology, critical care, trauma and
trauma education. After a five-year experience at the Breast Cancer Center at
St. Michaels Hospital in Toronto, Dr. Ali travelled to Trinidad and Tobago
where he continues his clinical practice in breast cancer and research in a

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About the Editor xiii

public free Breast Cancer Clinic. Dr. Ali is part of a funded research program
in breast cancer genetics in the Caribbean while maintaining his trauma
focused teaching activities at the University of Toronto and overseas.
Dr. Ali’s wealth of experience in clinical and basic science research and
educational aspects of trauma and critical care is quite evident in this hand-
book which is an excellent guide for those interested in surgical critical care
at all levels of training.

Sandro Rizoli MD PhD FRCSC FACS

Professor Surgery & Critical Care Medicine, University of Toronto
Medical Director Trauma & Acute Care Service, St Michael’s Hospital
Chair in Trauma Care
Past President Trauma Association of Canada

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List of Contributors

EDITOR
Jameel Ali, MD, M. Med. Ed., FRCSC, FACS
Professor of Surgery, University of Toronto,
Division of General Surgery, Trauma Program
St. Michael’s Hospital
55 Queen Street E. Suite 402
Toronto, ON M5C 1R6 CANADA
Tel: 416 864-6019
Fax: 416 864-6008
Email: [email protected]
CONTRIBUTORS
Addison K. May, MD, FACS, FCCM
Professor of Surgery and Anesthesiology Director,
Surgical Intensive Care Program Director,
Surgical Critical Care, Acute Care Surgery,
and Burn Fellowship Director,
Critical Care Education 1211, 21st Avenue South
404 Medical Arts Bldg.
Nashville, TN 37212-1750
Tel: (615) 936-0303
Fax: (615) 936-0185
Email: [email protected]

xv

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xvi List of Contributors

Anand Ghanekar, MD, PhD, FRCSC

Assistant Professor of Surgery,
Abdominal Organ Transplant Surgeon,
Multi Organ Transplant Program,
University of Toronto, University Health Network
190 Elizabeth Street Toronto,
Ontario M5G 2C4, Canada
Email: [email protected]

Andrew Beckett, MD, FRCSC

Trauma and Acute Care Surgery
McGill University Health Centre Montreal,
Quebec Canada H3G 1A4

Andrew S. Barbas, MD
Transplant Fellow,
University Health Network, Toronto
Duke University Hospital
2301 Erwin Rd
Durham, NC 27705
Tel: (919) 970-4267

Andrew Smith, MD, FRCSC

Department of Surgery
Thunder Bay Regional Health Sciences Centre
Northern Ontario School of Medicine
980 Oliver Road
Thunder Bay, Ontario,
Canada P7B 6V4

Arthur Cooper, MD, MS, FACS, FAAP, FCCM, FAHA

Professor of Surgery, Columbia University College
of Physicians & Surgeons;
Director of Trauma & Pediatric Surgical Services
Harlem Hospital Center
Department of Surgery
506 Lenox Avenue, Suite 11-103
New York, NY 10037
Tel: (212) 939-4003
Email: [email protected]

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List of Contributors xvii

Brad S. Moffat, MD, MSc

501-1460 Beaverbrook Ave
London, ON, N6H 5W7

D. Kagedan, MD
General Surgery Resident,
University of Toronto
1 King’s College Circle Medical Sciences Building Room 7358
Toronto, Ontario M5S 1A8 Canada

Daniel Roizblatt, MD
Professor of Surgery
Universidad Andres Bello
Trauma and General Surgery
Hospital del Trabajador,
Providencia, Santiago, Chile

David D. Paskar, MD, MSc

University of Western Ontario
General Surgery Resident,
LHSC University Hospital
Department of General Surgery
Room C8 114,339 Windermere Road
London, ON N6A 5A5

G. Papia, MD, MSc, FRCS(C)

Assistant Professor
Department of Surgery
University of Toronto
Division of Vascular Surgery
Department of Critical Care Medicine
Sunnybrook Health Sciences Centre
2075 Bayview Ave.
Toronto, ON M4N 3M5
Tel: 416-480-6100, ext. 83680
Fax: 416-480-5815
Email: [email protected]

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xviii List of Contributors

James Mahoney, MD, FRCS

Chief, Division of Plastic Surgery
Medical Director, Perioperative Services
St. Michael’s Hospital
30 Bond St., Rm 4080
Toronto, Ontario M5B 1W8
Tel: (416)-864-5385
Fax: (416)-864-5888
Email: [email protected]

Joao B. de Rezende-Neto, MD, PhD, FACS

Associate Professor of Surgery,
University of Toronto
Trauma and Acute Care Surgery,
St. Michaels Hospital, Toronto

Jeremie Larouche, MD, FRCSC

Division of Orthopedics
University of Toronto
27 King’s College Circle
Toronto, Ontario M5S 1A1 Canada
Tel: 416-978-2011

Jeremy Hall, MD, FRCSC

Assistant Professor of Surgery, Dept of Orhopedics,
University of Toronto,
St. Michael’s Hospital
30 Bond St.
Toronto, ON M5B 1W8 Canada
Tel: 416-864-6006
Email: [email protected]

Joel S. Fish, MD, MSc, FRCSC

Associate Professor of Surgery,
University of Toronto
Medical Director
Burn Program

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