Critical care: other considerations

Summary

Acute neurological problems

Surgical trainees will encounter many patients with an acutely depressed conscious level resulting from:

1. ▪ Trauma

2. ▪ Drugs

3. ▪ Acute intracranial event (e.g. infarction, haemorrhage)

4. ▪ Encephalopathy of critical illness.

There are two important points to make:

1. ▪ Never forget to check the blood sugar level.

2. ▪ Any patient with a Glasgowcoma score (GCS)<8 or who fails to localize to pain requires intubation and ventilation, aswell as investigation and specific treatment.

There is a tendency to try and avoid intubating such patients pending investigation. Unless the patient should not have active management of an intra-cranial disaster under any circumstances (in which case investigation is pointless), this is a mistake. A patient with a GCS < 8needs to be intubated. If a CT scan shows an unrecoverable situation, then treatment can be withdrawn at that point as described in the introduction.

Nutrition

Nutritional support is needed when the patient is unlikely to resume normal oral intake within 7–10 days of it ceasing. If nutritional support is inevitable it should be started as soon as the patient is stabilized.

The timing of commencement of feeding is often a bone of contention between surgeons and intensivists. A mutually acceptable compromise can usually be worked out.

Preferred Routes For Feeding

The ideal route of nutrition is the subject of much dogma and little evidence. There is no doubt that enteral feeding is cheaper and easier, and therefore preferable. The evidence for a protective effect on the intestinal mucosa is much weaker than commonly realized, and the complications of enteral feeding are generally under-reported in the literature.