Chapter 77. Developing an Anesthetic Plan for a Critically Ill Patient

1. Critically ill patients often need surgery to correct the underlying cause of their illness or to deal with the complications of their illness.

2. Advanced planning and open communication between the anesthesiologists, surgeons, the critical care team, and the patient and the patient's family is crucial to understanding the goals and priorities of treatment.

3. Critically ill patients may have impaired function of multiple organ systems. Preoperative evaluation of the degree of organ dysfunction and optimization of the patient's condition ensures that the patient is in the best possible condition to undergo the additional stresses associated with surgery and anesthesia.

4. The simplest surgical procedure resulting in the least physiologic upset is generally the best option for the critically ill patient.

5. Planning for transport to the operating room is essential because patients are at high risk for adverse events during transport.

6. The anesthesiologist must decide which monitors are needed to assess the assessment of the patient's condition.

7. Although general anesthesia is most often necessary for surgery in the critically ill patient, regional anesthesia can play a valuable role helping achieve patient comfort and reduce physiologic stress.

8. There should be specific goals and end points defined in the management of the critically ill patient to optimize hemodynamics and minimize further end-organ damage.

More than 5 million patients are admitted annually to intensive care units (ICUs) across the United States. Many of these patients undergo a surgical procedure during their hospitalization either to correct the underlying cause of their illness or to deal with its complications. Similar to the healthy patient, the anesthesia plan for the critically ill patient should include a clear delineation of the goals of management, an assessment of the priorities of care, and a consideration of alternative strategies to avoid or treat complications.

Many studies indicate that the patient's outcome depends on the interaction of several factors, including the type and extent of the procedure, the physiologic reserves of the patient, the presence of chronic health problems, and the nature of the acute physiologic derangements.1 The number of complications attributable to anesthesia is 8 times greater for patients with American Society of Anesthesiologists (ASA) Physical Status grades P3 and P4 rather than for patients with ASA grade P1 or P2.2 One study reports that the presence of an anesthesiologist intraoperatively and certain characteristics of intraoperative and postoperative care were associated with a decreased risk of severe postoperative morbidity and mortality.2 Thus the plan for a critically ill patient should include preoperative optimization of the patient's condition, a chronological plan for intraoperative management, a plan to ensure that adequate support personnel and equipment are available, and a plan for postoperative care.

The critically ill patient often has many caregivers from various medical and surgical specialties. There should be open communication regarding the likely outcomes and realistic goals of treatment between the anesthesiologists, surgeons, critical care team, and the patient and the patient's family. Preoperatively, one person or ...