Introduction

The term ‘critical illness’ describes the condition of a patient who has a likely, imminent or established requirement for organ support; in simple terms where death is possible without timely and appropriate intervention. Some patients are at greater risk of developing critical illness than others (Box 3.1). Also certain conditions bring a likelihood of severe physiological stress (Box 3.2). It is unfortunately commonplace for the junior surgeon to be faced with a critically ill surgical patient, in various situations-from the peritonitic teenager admitted to A&E to the elderly postoperative hip replacement on HDU. It is crucial that a systematic approach is taken to assessment and treatment.

While it is more challenging to manage the patient with multiple organ failure it is rarely rewarding; rescuing the elderly post-laparotomy patient from cardiac failure brought about by fast atrial fibrillation is far harder than anticipating the hypokalaemia (causing the cardiac irritability) associated with ileus: prediction and prevention is essential. Prediction can begin with pre-operative assessment (such as identifying chronic airways disease or poor nutritional state) but continues through knowledge of the common problems associated with the condition/operation (such as the risk of chest infection after laparotomy). Prevention encompasses specific steps such as adequate replacement of fluid and electrolytes, adequate analgesia, chest physiotherapy and thromboprophylaxis, but the role of regular review (e.g. ward rounds) cannot be overstated.

Conversely a failure to assess patients regularly, to identify and act upon abnormal findings, to check whether one’s interventions have been carried out and whether they have been effective/sufficient, will make successful management less likely.

Finally, communication has become ever more important. The maxim ‘if it’s not in the notes it didn’t happen’ is not only for the benefit of the medical defence unions but reminds us that colleagues rely heavily on written information, not only if the case is complex but especially if the author is not available to discuss the case in person. The junior surgeon will often be working shifts and be responsible for many patients, in different clinical areas and will also have to leave the hospital at the end of his/her shift. Continuity of care relies entirely on this written ‘handover’ information. A schematic is suggested in Box 3.3.

Immediate management

There are two broad clinical scenarios facing the surgeon in critical care management: those patients who are ‘unstable’ (newly arrived or recently deteriorated on the ward) and those who are more ‘stable’ (typically on HDU/ITU with organ support established). Even in such a place of relative safety, ‘stable’ patients can become destabilised; the approach, even on the HDU/ITU ward round, should be structured as for the ‘unstable’ patient. This also assists the creation of an ordered management plan for the rest of the shift.

Unfortunately the junior surgeon is faced more often, as the attending doctor, with an unstable patient and there is a need to identify what is going on at the same time as institution of resuscitative measures (see Table 3.1). The mnemonic ABCDE is used as an aide-memoire for this systematic approach to the initial phase of critical care management, ‘immediate assessment and treatment’. By the end of this phase some common steps should have occurred:

Table 3.1 The ABCDE approach to the ill patient

It is essential to reassess the patient regularly to ensure that some measure of improvement has occurred and that time has been bought for a more thorough ‘full assessment’.

Full assessment

This will depend upon the clinical scenario – the longer the patient has been in hospital the greater the amount of available information. Relative/carer history is of paramount importance in the newly-admitted patient whereas identification of trends (from charts, clinical notes and/or blood results) is often rewarding in identifying what is going on in a previously ‘stable’ ward patient.

Knowledge of the patients’ pre-existing conditions and functional performance is essential to guide treatment. There may be poor cardiac/respiratory and/or renal reserve; not only are those patients more likely to become critically ill from a lesser degree of severity of illness, therapeutic measures (and even the investigations) may also place the patient at further danger. Large fluid boluses may overload the failing heart and intravenous contrast can provoke renal failure.

Definitive treatment