Introduction to
CCrISP
Key Points
1. Preventing deterioration more effective than attempting salvation
later.
2. Surgical critical care includes prediction and prevention of
problems, besides investigation.
3. There is a continuum of surgical critical care from ward to HDU
and ICU.
4. Simple logical thought and actions will usually be effective.
Aim:
To predict, prevent and treat illness long before the
patient becomes critical, by improving clinical methods, practical skills, communication, organizational skills and focused knowledge.
--> thus to provide early
definitive treatment.
--> and ongoing reassessment
Predicting
Problems:
Consider at-risk populations:
- age, comorbidities
- complex or major surgery
- emergency operations
- the non-progressing patient
- severity of illness
- massive transfusions
- rebleeding
- failure / delay in diagnosis
- established shock state
Risky Practices
- Incomplete / infrequent assessments
- Failure to act on abnormal findings
- Failure to ensure interventions successful
- Failure of continuity of care
- Failure of nursing support
The
Continuum of Care
Ward --> HDU --> ICU
- HDU has more nurses (1:2
pts), monitoring, and nursing expertise.
--> pts are usually high-risk or complicated post-op pts.
- ICU has intensive nursing
ratios, monitoring and support, and ICU staff.
The requirement of surgical team input is present throughout, but
more
in ward, less in ICU.
Preoperative
Patients
Strike a balance between necessity
of operation and individual risk.
Emergency
Admissions
Wide range of acute conditions, and comorbidities recognised and
unrecognised.
- prompt and effective
resuscitation
is cornerstone of problem prevention
- remember anaesthesia removes
vascular tone: catastrophic in the hypotensive patient.
Remember even #NOF patients need careful resuscitation.
On the other hand, bleeding patients need simultaneous resuscitation and
surgery.
Thinking on the run:
- think early: what do I
know, what will I do when they arrive?
- think basics: ABCs
secure,
observations.
- think simply: how
quickly
must I act? diagnosis? what help?
Routine Rounds
Review all patients logically and thoroughly
- this is the best way to practice good critical care.
The major pitfall is not taking
further prompt action when initial interventions are not
successful.
Pts failing to progress
are
important.
- there is often an underlying problem eluding detection.