The CTV ICU

How the CTV ICU works

The CTV ICU is the hospital's dedicated cardiothoracic and vascular intensive care unit, in the newer critical care tower, staffed by intensivists who look after post-operative cardiac, thoracic and vascular patients every day. Your patients there have two teams, and the care goes well when each team knows what the other owns.

Most academic surgical ICUs run a closed or collaborative model. The ICU team (the intensivist, fellows or residents, advanced practice providers and the bedside nurses) manages the critical care. The vascular team remains the surgical owner: it makes the operative decisions, sets the operation-specific plan and targets, and owns the wounds, grafts, surgical drains and the antiplatelet and anticoagulation decisions. Neither team should ever be surprised by an order the other wrote.

Who goes to the CTV ICU

ICU admission after vascular surgery is driven by three things: the physiological insult of the operation, the need for drips, ventilation or invasive monitoring, and a risk that needs hourly eyes on the patient. Most vascular patients never need it.

Most uncomplicated carotid endarterectomies, standard EVARs, lower extremity bypasses and amputations go from the operating room to PACU and then to a step-down unit or the floor. The level of care is decided by the attending surgeon with anesthesia and the ICU team: before the day of surgery for elective cases, and again at the end of the case if something changed.

Getting a patient admitted

The ICU bed is part of the operative plan. For elective cases it is requested before the patient is in the room; for emergencies, the call to the ICU goes out as the decision to operate is made.

From the operating room

1. Decide the level of care. For elective open aortic and complex endovascular cases the attending decides before the day of surgery and the ICU bed is requested with the case. In the OR the decision changes when the case does: unexpected blood loss, a new pressor, a long cross-clamp, or a plan to stay intubated.
2. Request the bed and call the ICU. Place the bed request the way the hospital does it, then give the ICU team a heads-up call: the operation, the expected arrival time, and what is coming with the patient (ventilator, drips, a CSF drain, ongoing transfusion, an open abdomen). A call before the end of the case lets the nurse set up the room.
3. Transport with monitoring. Anesthesia usually transports with a member of the surgical team, on a transport monitor with the arterial line transduced, drips running on pumps, and oxygen or a transport ventilator. A CSF drain is clamped for the move.
4. Hand off at the bedside. Monitors and drips are connected first, then the structured handoff happens with everyone present. See the OR-to-ICU handoff.
5. Reconcile the admission orders. The ICU admission PowerPlan and the surgical post-operative orders must agree. Check that the vascular items are there (pulse checks, blood pressure range, drain orders, aspirin and statin, the antibiotic stop time), that home medications such as beta-blockers and anticoagulants are addressed, and that nothing is ordered twice. See admission orders.
6. Update the family. The surgeon usually speaks to the family after the case. Make sure they know the patient is going to the CTV ICU, when they can visit, and who will call them if something changes overnight.
7. Do the post-op check. A focused exam a few hours after arrival: perfusion compared with the end-of-case exam, the incisions, drains, urine output and the first set of labs. A template is on History, exam and charting.

Direct admissions from the ED or a consult

Some vascular patients reach the CTV ICU without passing through the operating room: an acute type B dissection that needs impulse control, a symptomatic aneurysm awaiting repair, a patient with acute limb ischemia on heparin who needs hourly checks, or a transfer from another hospital. The resident's job is to make the calls early and to make the plan explicit.

• Call the vascular attending, through your senior if that is the service norm, with a one-line summary, the vitals and the imaging, and agree on the plan and the targets.
• Call the CTV ICU team (the intensivist or fellow) to request the bed. Give the same summary, the drips that are running, and the targets you want, for example a heart rate and systolic pressure for a dissection.
• Start the time-critical treatment while the bed is found: impulse control and an arterial line for a dissection, heparin for acute limb ischemia, and analgesia, because pain drives heart rate and pressure.
• Write the note with the surgical plan and the call parameters, and make sure everyone knows which service is primary. Consult note templates are on History, exam and charting.

The OR-to-ICU handoff

The handoff is the moment information is most easily lost. A structured bedside handoff with the surgeon, anesthesia, the ICU nurse and the intensivist all present catches the omissions that cause harm overnight.

Structured OR-to-ICU handoffs reduce missed information and early errors. The pattern most units use is equipment first, then a short protected period in which one person speaks at a time and nobody else works on the patient unless something is urgent, then questions, then a spoken summary of the plan and the targets.

• Monitors, lines and drips transferred first. ICU nurse and anesthesia Arterial line transduced on the ICU monitor, drips confirmed on ICU pumps, ventilator connected. Only then start talking.
• Anesthesia report. Anesthesia Airway and ventilation, lines, fluids and blood products, vasoactives, hemodynamic events, analgesia including any epidural, last antibiotic dose, and reversal agents given.
• Surgical report. Surgeon, often the resident The items in the template below: what was done, what was found, what worries you, the targets, and what the vascular team wants to be called for.
• Nursing questions and bedside checks. ICU nurse Drains identified and labeled, CSF drain and epidural told apart, dressings and skin checked, pulse sites marked, and the Doppler signals confirmed together at the bedside.
• Plan and read-back. Intensivist Summarizes the plan and the targets; the surgeon confirms or corrects; anyone with a concern says it now.
• Who to call. Surgeon The name and number of the vascular team member covering tonight.

Patient: ___  Age: __  Weight: __ kg  Allergies: ___
Operation: ________________________________
Indication and key findings: _______________
Complications or surprises: ________________

Aorta
  Cross-clamp level: [infrarenal / suprarenal / supraceliac]
  Cross-clamp time: ___ min   Renal ischemia: ___ min
  Visceral ischemia: ___ min
  Reimplanted or sacrificed: [IMA / renals / hypogastrics]

Blood and fluids
  EBL: ___ mL   Cell saver returned: ___ mL
  Crystalloid: ___ L   Other: ___
  Products: PRBC __  FFP __  Plt __  Cryo __
  Urine output: ___ mL total, last hour ___ mL

Anticoagulation in the OR
  Heparin: ___ units total, last at __:__
  Last ACT: ___ s   Protamine: [no / yes, ___ mg]

Hemodynamics
  Vasoactives now: ___________  Trend: [up / down / off]
  SBP goal: ___ to ___   MAP floor: ___

Limbs at end of case (and baseline before surgery)
  R: Fem ___ DP ___ PT ___ (baseline ___)
  L: Fem ___ DP ___ PT ___ (baseline ___)
  Doppler sites marked on skin: [yes / no]

Drains and catheters
  Surgical drains: [site, type]   Output so far: ___
  CSF drain: [no / yes]  Opening pressure: ___ mmHg
    CSF pressure goal: ___   Max drainage: ___ mL/h
  Epidural: [no / yes, level, infusion]

Plan
  Antiplatelet: ___   Statin: ___
  Anticoagulation: ___ (start when, any bolus)
  Antibiotic: ___ stop by __:__ (within 24 h)
  Diet / NG: ___   Labs or imaging due: ___
  Call vascular for: [loss of signal, bleeding,
    drain > ___ mL/h, SBP out of range, leg
    weakness, neck swelling, bloody stool, low UOP]
  Vascular contact tonight: ___

Admission orders: what the vascular team cares about

The ICU admission PowerPlan covers the critical care basics. Your job is to make sure the vascular items are in the orders, correct for this operation, and not duplicated by a second set.

Use the template as a check of the combined orders rather than a script. Most items follow ICU or hospital protocol; the bracketed ones are the surgeon's call for this patient. Who actually enters each order depends on the unit's model.

Operation: ____________   Attending: ________   POD 0

Vascular checks
  Pulse / Doppler checks [sites] q__h x __ h, then q__h
  Doppler sites marked; call for loss or change of signal
  Incision, groin or neck checks with each vital set
  Compartment checks [which legs] q__h if reperfused

Neuro
  Neuro checks q1h [carotid: face, speech, grip]
  Leg motor and sensory checks q1h [cord at risk]
  Sedation light enough to examine, per ICU

Cardiovascular
  SBP goal ___ to ___ mmHg; call if out of range
  MAP floor ___ mmHg [cord at risk: about 80-90+]
  Telemetry; ECG and troponin per protocol
  Continue home beta-blocker, with hold parameters
  Vasoactives per ICU, titrated to the goals above

Respiratory
  Ventilator and extubation per ICU
  Incentive spirometry once extubated

Renal, fluids and labs
  Foley, strict I/O; UOP goal >= 0.5 mL/kg/h
  Bladder pressure q__h [rupture, open abdomen]
  On arrival: CBC, BMP, Mg, ionized Ca, PT/INR,
    PTT, fibrinogen, lactate, ABG if ventilated
  Then: CBC and BMP q__h; lactate until normal
  CK q__h [revascularized limb]
  Active type and screen

GI
  NPO [ice chips?]; NG to low suction [yes / no]
  Stress ulcer prophylaxis if indicated, per ICU
  Bowel regimen when appropriate

Antithrombotics and VTE
  Aspirin ___ mg daily (continue unless told)
  P2Y12 inhibitor [stents, TCAR]: ___
  Statin, high intensity, daily
  Therapeutic heparin: [no / start ___, bolus?]
  VTE prophylaxis: [SQ heparin / LMWH] start ___
    (timing with CSF drain or epidural per protocol)
  SCDs [which legs]

Infection
  [Cefazolin] last dose __:__; stop within 24 h
  Drains are not a reason to continue antibiotics

Endocrine
  Glucose goal 140-180 mg/dL; insulin per protocol

Pain
  Epidural / PCA / multimodal per anesthesia, ICU
  [Avoid motor block if legs need neuro checks]

Drains
  [Site]: record q__h; call if > ___ mL/h
  CSF drain: per CSF drain protocol and orders

Activity
  [Bed rest / HOB __ / flat __ h after sheath out]
  Out of bed POD __ if stable

Call vascular for
  Loss or change of a pulse or Doppler signal
  New neuro deficit (face, arm, speech or legs)
  Neck swelling, bleeding, drain > ___ mL/h
  Hgb drop > ___, UOP < ___ for 2 h, bloody stool
  Bladder pressure > ___, tense compartments

• Aspirin and statin continue. Nearly every vascular patient stays on aspirin and a statin through surgery; stopping them raises perioperative cardiovascular events. Patients with a recent stent or a TCAR also need their P2Y12 inhibitor, and only the surgeon stops it.
• Beta-blockers continue, they do not start. Continue a beta-blocker the patient already takes, with hold parameters for bradycardia and hypotension. Do not start one on the day of surgery.
• VTE prophylaxis starts when hemostasis is secure, usually within about 24 hours and on the surgeon's word. Around a CSF drain or epidural catheter, the timing of each dose follows the neuraxial protocol. Mechanical prophylaxis goes on legs without fresh incisions, fasciotomies or ischemia.
• Stress ulcer prophylaxis is for patients with risk factors, such as mechanical ventilation, coagulopathy or shock, per ICU practice, and stops when they resolve.
• Perioperative antibiotics stop within 24 hours. Longer courses do not prevent graft or wound infection and add resistance and C. difficile. Treat a real infection as a real infection, with cultures.
• Glucose goal is about 140 to 180 mg/dL. Tighter control in ICU patients caused more hypoglycemia without benefit. Insulin infusions run per ICU protocol.

What to watch, by operation High yield

Each operation has its own first-night failure modes. Know the list for your patient's operation before the patient arrives, and say it out loud at the handoff so the ICU team watches for the same things you are.

Open AAA repair

The operation is described in Open operations. The first 48 hours are about blood, kidneys, gut, legs and heart.

• Bleeding. Falling hemoglobin, tachycardia, a rising pressor requirement or a distending abdomen. Check platelets, fibrinogen, coagulation studies, temperature and ionized calcium, correct what is abnormal, and call early; ongoing transfusion despite corrected coagulation means a conversation about returning to the OR.
• Urine output and the kidneys. Aim for at least 0.5 mL/kg/h. Oliguria has a differential: hypovolemia or bleeding, renal ischemia from a suprarenal clamp or embolization, a blocked or kinked Foley, rising abdominal pressure, low cardiac output, and rarely a ureteral injury. Flush the Foley before giving fluid blindly.
• Abdominal compartment syndrome. Suspect it when the abdomen is tight, airway pressures rise, urine output falls or the patient needed large-volume resuscitation, and measure a bladder pressure. Intra-abdominal hypertension is a sustained pressure of 12 mmHg or more; abdominal compartment syndrome is a sustained pressure over 20 mmHg with new organ dysfunction. The definitive treatment is decompressive laparotomy, so call at once.
• Colon ischemia. The left colon and sigmoid depend on the inferior mesenteric artery and internal iliac collaterals. Bloody stool, or any early diarrhea, unexplained acidosis, a rising lactate, fever, leukocytosis, distension or a growing fluid requirement should prompt a bedside flexible sigmoidoscopy without delay. Mucosal ischemia is managed with bowel rest, fluids, antibiotics and a repeat scope; transmural necrosis needs resection, which is why early diagnosis matters.
• Lower limb ischemia and trash foot. Compare the feet with the end-of-case exam. A lost signal suggests limb thrombosis or a problem at the distal anastomosis; mottled, painful toes with palpable pulses suggest distal microembolization (trash foot). Either way, call.
• Myocardial infarction. It remains the leading cause of death after open aneurysm repair and is often silent under sedation and an epidural. Watch the rhythm, the ST segments and the hemodynamics, and check troponin per protocol. New atrial fibrillation is common.
• Ileus. Expected after a transperitoneal repair and less marked after a retroperitoneal one. Keep the patient NPO with an NG tube if the surgeon wants one, and advance the diet on the surgeon's word.
• Hyperkalemia and acidosis. From reperfusion of the pelvis and legs, transfusion and kidney injury. Check potassium on arrival and repeat it.

Ruptured AAA Highest risk

Everything that can go wrong after an elective repair is more likely after a rupture, whether the repair was open or endovascular. Three problems dominate the first 48 hours.

• The effects of massive transfusion. Patients arrive cold, acidotic and coagulopathic. Keep warming, replace calcium (citrate in stored blood binds it), and guide further products with labs or viscoelastic testing per protocol. Ongoing bleeding once coagulation is corrected means the OR.
• Abdominal compartment syndrome. Common after both open repair and EVAR for rupture: the retroperitoneal hematoma stays in place after EVAR, resuscitation swells the bowel, and an open repair may be closed under tension or left open by plan. Bladder pressures are measured on a schedule (commonly every 4 to 6 hours for the first day or two, per protocol) and whenever airway pressures rise or urine output falls.
• Colon ischemia. Several times more common than after elective repair. Most teams have a low threshold for sigmoidoscopy, and some scope every ruptured patient in the first day or two.
• Organ failure. Acute kidney injury (sometimes needing dialysis), prolonged ventilation and multiorgan failure are common, and many of these patients have long ICU stays.
• After EVAR specifically. Check the large-bore access sites and both legs. A falling hemoglobin may be access-site bleeding or continued filling of the sac through a type I or III endoleak; call rather than simply transfusing.

TEVAR and complex EVAR

The devices and steps are in Open operations and Endovascular.

• Spinal cord ischemia. Risk rises with the length of thoracic aorta covered, prior aortic repair, coverage of the left subclavian artery without revascularization, occluded internal iliac arteries, and perioperative hypotension. It can appear on waking or hours to days later, often after a hypotensive episode. Hourly leg checks and a MAP floor are the defense; the rescue is in CSF drains and spinal cord protection.
• Stroke. From wire and device manipulation in the arch, or posterior circulation ischemia after left subclavian coverage. Check the full neuro exam, not only the legs, and compare the arm pulses and pressures.
• Access complications. Large femoral or iliac sheaths cause groin hematoma, pseudoaneurysm, limb ischemia from dissection or thrombosis, and retroperitoneal bleeding (back or flank pain, falling hemoglobin, hypotension with an unimpressive groin). Brachial or axillary access, common for branched cases, can bleed into the arm and compress the median nerve; new hand numbness or weakness after arm access needs the surgeon urgently.
• Target vessels after fenestrated or branched repair. A renal or visceral stent can occlude. Watch urine output, creatinine, lactate and abdominal pain, and the contrast load on the kidneys.
• Post-implantation syndrome. Fever, leukocytosis and a raised CRP in the first days without infection, an inflammatory response to the graft. It is self-limited but a diagnosis of exclusion: look for infection and ischemia first.

CEA and TCAR

Most carotid patients recover in PACU and a step-down bed. Those in the ICU are usually there for blood pressure or a neuro change. The operation is in Open operations.

• Blood pressure. The surgeon sets the range, commonly a systolic under about 140 to 160 mmHg with a floor around 100, and tighter when the risk of hyperperfusion is high (a very tight stenosis, a contralateral occlusion, a recent stroke). Hypertension is more common after endarterectomy; hypotension and bradycardia from carotid sinus stretch are more common after stenting, including TCAR, and are treated with atropine or glycopyrrolate and a pressor if needed.
• Neck hematoma. An expanding hematoma can compromise the airway within minutes, through compression and venous and laryngeal edema. See the red flag below.
• Cranial nerve injuries. Hypoglossal (tongue deviates toward the side of injury), vagus or recurrent laryngeal (hoarseness, weak cough, aspiration risk), marginal mandibular branch of the facial nerve (drooping corner of the mouth), superior laryngeal (voice fatigue, loss of high pitch), and glossopharyngeal with a high dissection (dysphagia). Most are stretch injuries that recover. Document the exam on arrival, and get a swallow evaluation before feeding a hoarse patient.
• Stroke. A new deficit on waking or in the first hours suggests thrombosis at the operative site, a flap or an embolus. Call the surgeon immediately; the answer is often an immediate return to the OR or urgent imaging, and minutes count.
• Hyperperfusion syndrome. Ipsilateral headache, then seizures, focal deficits or intracerebral hemorrhage, usually within the first days to a week, as a hemisphere that has lost autoregulation receives restored flow. Prevention and treatment are strict blood pressure control and a CT head for symptoms. Labetalol and clonidine are common choices; many surgeons avoid cerebral vasodilators such as nitroglycerin, nitroprusside and hydralazine in this setting.
• TCAR specifics. Check the small incision above the clavicle and the femoral vein sheath site used for flow reversal. Dual antiplatelet therapy is required after any carotid stent; do not hold it without the surgeon.

Aortic dissection, medical management

The dissections the vascular team manages medically are type B; type A goes to cardiac surgery emergently. Background is in Presentations.

• Impulse control, beta-blocker first. An IV beta-blocker (esmolol or labetalol) brings the heart rate down before any vasodilator; then add a vasodilator (nicardipine, clevidipine or nitroprusside) if the systolic is still high. The 2022 ACC/AHA targets are a heart rate of 60 to 80 and a systolic under 120 mmHg, or the lowest pressure that keeps the brain, kidneys and gut perfused. Older guidance and ESC teaching use a heart rate under 60, so ask which target your attending wants and write it in the orders. If beta-blockers are contraindicated, a nondihydropyridine calcium-channel blocker (diltiazem or verapamil) controls the rate.
• Treat the pain. Pain drives heart rate and pressure. Pain that persists or returns despite controlled hemodynamics suggests extension or impending rupture.
• Measure pressure in the right arm. Check pressures in both arms; subclavian involvement can make one arm read falsely low, so the arterial line goes in the arm with the higher pressure.
• Check every bed for malperfusion, every exam. Brain (mental status, focal deficits), spinal cord (leg strength), both arms (pulses and pressures), gut (abdominal pain, distension, lactate), kidneys (urine output, creatinine) and legs (pulses, motor and sensory function).
• Transition to oral agents once the targets are stable on the drips, so the patient can leave the ICU on a regimen that holds them.

Mesenteric revascularization

Whether by embolectomy, bypass or stent, the question after revascularization is whether the bowel is surviving. See Presentations.

• Lactate and acidosis. Trend the lactate until it normalizes. A falling value is reassuring; a rising one means ongoing ischemia, reperfusion injury or another source, and the team needs to know. A normal lactate does not exclude dead bowel.
• The abdominal exam. Serial exams, ideally by the same examiner: worsening pain, peritonitis, distension or GI bleeding.
• The second look. Marginal bowel is often reassessed at a planned second-look operation at 24 to 48 hours, sometimes with the abdomen left open under a temporary closure. Know whether one is planned and when; it goes ahead because it was planned, not because the labs look bad.
• Hemodynamics. Avoid hypovolemia, and use the least vasoconstrictor that maintains perfusion, because vasoconstrictors reduce splanchnic flow. Discuss the choice of agent with the ICU team.
• Antithrombotics. Heparin usually continues after embolectomy or thrombosis, and is the treatment for mesenteric venous thrombosis, unless bleeding prevents it. Stents need antiplatelet therapy.
• The longer view. Recurrent pain or a new rise in lactate can mean graft or stent occlusion. Prolonged NPO status and any bowel resection make early nutrition planning part of the plan.

Acute limb ischemia after revascularization

Restoring flow to muscle that has been ischemic for hours releases potassium, acid and myoglobin into the circulation. Background is in Presentations and Fasciotomy.

• Hyperkalemia. Check potassium on arrival and repeatedly over the first day, watch the ECG, and treat promptly.
• Acidosis. Trend lactate and blood gases.
• Myoglobinuria and kidney injury. Dark urine and a rising CK. Isotonic fluids to a high urine output (often about 200 to 300 mL/h in adults, guided by the ICU) while watching for volume overload; bicarbonate and mannitol have no proven benefit.
• Compartment syndrome. Pain out of proportion and pain on passive stretch come first, then tense compartments and paresthesia; pulses are often still present. A measured compartment pressure over about 30 mmHg, or a diastolic pressure minus compartment pressure under 30 mmHg, supports the diagnosis, and pressures are especially useful in a sedated patient whose exam is unreliable. The threshold for four-compartment fasciotomy is low, and many surgeons do it at the time of revascularization after prolonged ischemia or for a category IIb limb.
• After fasciotomy. The wounds belong to the vascular team: bleeding (the patient is often on heparin), muscle viability, the dressing or wound vac, and the plan for return to the OR for closure or debridement.
• Pulses and the source. Recheck pulses for rethrombosis, keep heparin running unless bleeding prevents it, and look for the embolic source with telemetry for atrial fibrillation and an echocardiogram.

CSF drains and spinal cord protection

A lumbar CSF drain protects the spinal cord after extensive thoracic and thoracoabdominal aortic repair by lowering the pressure around the cord. It is also the most protocol-driven device in the CTV ICU, so learn your unit's protocol and treat every number below as typical, not local.

Why it works

Spinal cord perfusion pressure is roughly the mean arterial pressure minus the CSF pressure (or minus the central venous pressure, if that is higher). When an aortic repair covers or sacrifices intercostal and lumbar arteries, the cord depends on a collateral network that stays pressure-dependent for days. You can raise perfusion pressure from either side: raise the MAP, or lower the CSF pressure.

Drains are usually placed by anesthesia before the operation, for open thoracoabdominal repair and for TEVAR or fenestrated and branched repair when the spinal cord risk is high: long coverage, prior aortic repair, or left subclavian or internal iliac arteries that are covered or occluded. Some centers place them selectively, or only as a rescue once a deficit appears.

• 10 to 12 mmHgTypical CSF pressure goal; some protocols use 10 or lower, and lower during a rescue
• MAP 80 to 90+Typical MAP floor while the cord is at risk
• 10 to 15 mL/hCommon hourly drainage cap; more than the cap means clamp and call
• Every hourLeg motor and sensory checks while the drain is in
• 48 to 72 hTypical time before a clamp trial and removal

Bedside rules

• Level and zero. The transducer and drip chamber are leveled at the reference point the protocol names, commonly the tragus, and re-leveled whenever the head of the bed or the patient's position changes. Some protocols use a different reference, so check.
• Clamp for every move. Clamp the drain for transport, repositioning and head-of-bed changes, then re-level and unclamp. An open drain that suddenly ends up below the patient drains fast.
• Record every hour: CSF pressure, the volume drained, and the color of the CSF.
• Check the legs every hour. Hip flexion, knee extension, ankle dorsiflexion and plantar flexion on each side, graded the same way each time, plus sensation. Compare with the last check and with the baseline.
• Never let the MAP fall below the floor, including during sedation, dialysis, transport or antihypertensive dosing.
• Know which catheter is which. A patient may have both an epidural and a CSF drain in the back. Both are labeled, and nothing is injected into a CSF drain.
• Watch for the epidural confounder. A local-anesthetic epidural can itself cause leg weakness, which is why many protocols use dilute or opioid-only infusions in these patients. New weakness is treated as cord ischemia until proven otherwise.

New leg weakness: the rescue Emergency

Delayed spinal cord ischemia can improve, sometimes completely, if treated within hours. Every step below happens at once, not in sequence over an afternoon.

1. Call immediately. Call the vascular team and the ICU team with the time of onset and the exact exam. Do not wait for the next scheduled check to confirm it.
2. Raise the MAP. Fluids and vasopressors to a higher target, commonly 90 to 100 mmHg or more, per protocol and the team. Stop any antihypertensive.
3. Drain CSF. Open the drain and lower the pressure goal (often to about 8 to 10 mmHg) within the protocol's volume limits. If no drain is in, the team will discuss placing one urgently.
4. Optimize oxygen delivery. Many protocols transfuse to a hemoglobin of about 10 g/dL in a rescue, alongside good oxygenation and adequate cardiac output.
5. Look for other causes. Stop a local-anesthetic epidural infusion. Consider a spinal or epidural hematoma, especially after drain insertion or manipulation or with anticoagulation, which needs urgent imaging. Consider a stroke if the deficit is not confined to the legs.
6. Reassess and document. Recheck the legs frequently and record the response to each step; the team decides how long to hold the higher targets.

Complications of the drain

Overdrainage and intracranial bleeding

Draining too much CSF too fast can tear bridging veins and cause a subdural or other intracranial hemorrhage. Headache, falling consciousness or new focal signs mean clamp the drain, call, and expect a CT head.

Headache

A positional, post-dural puncture headache is common and usually managed conservatively. A severe or changing headache needs the overdrainage questions above.

Bloody CSF

New blood-tinged or frankly bloody CSF can signal intracranial or spinal bleeding. Clamp, call, check the neuro exam and coagulation, and let the team decide on imaging.

Spinal or epidural hematoma

Rare but devastating, usually around insertion or removal or with anticoagulation. It mimics cord ischemia: new leg weakness or numbness, sometimes back pain. Urgent MRI and spine surgery evaluation.

Infection

Meningitis risk rises with time, which is one reason drains come out promptly. Fever, neck stiffness, confusion or cloudy CSF.

Catheter problems

Occlusion, dislodgement, disconnection (clamp, cover, call) and catheter fracture at removal. Whoever removes the drain confirms and documents that the tip is intact.

Removal

Drains typically stay 48 to 72 hours. If the legs are intact, the drain is clamped for a trial period (often 12 to 24 hours) with neuro checks continuing, and removed if no deficit appears. Before removal the protocol checks coagulation and platelets and the timing of every anticoagulant dose, usually based on ASRA neuraxial guidance: prophylactic and therapeutic heparin, LMWH and P2Y12 inhibitors all have rules, while aspirin alone usually does not. Neuro checks continue for a period after removal, because a hematoma at removal causes new weakness too.

Rounding on vascular patients in the ICU

Two teams round on the same patient. The vascular team's job each morning is to examine what only it owns, set the surgical plan, and make sure the ICU team hears that plan before the day's orders go in.

What the vascular team checks every day

Perfusion

Pulses and Doppler signals at each level, compared with the end-of-case baseline; a graft pulse if it is palpable; the color and temperature of the feet.

Incisions and wounds

The abdomen, groins, neck and fasciotomy wounds, under the dressing when it matters, and the seal and output of any wound vac.

Drains

Volume and character (bloody, serous, milky, the color of the CSF) and the plan for removal.

The operation-specific neuro exam

Face, speech and grip after carotid work; leg strength while the cord is at risk.

The gut

Abdominal exam, distension, flatus or stool and any blood, and the bladder pressure trend if it is being measured.

Kidneys and potassium

Urine output, creatinine and potassium, and CK after a reperfused limb.

Antithrombotics

Aspirin, statin, any P2Y12 inhibitor, the heparin plan, and anything held for a procedure or for drain or epidural removal.

The surgical plan

Imaging due, return to the OR, diet, activity, and readiness for step-down.

Communicating the plan

• Talk to the ICU team, not just the chart. After you round, or by joining ICU rounds for your patients, give the ICU resident, fellow or intensivist the vascular plan in a few sentences: the targets, what to call for, and what changes today.
• Write the plan as targets. "SBP 100 to 140, MAP at least 85 until the drain is out, Doppler checks every hour, call for loss of the DP signal" is actionable. "BP control" is not. Progress note templates are on History, exam and charting.
• One owner per order. In a closed or collaborative unit, do not place orders for drips, fluids, electrolytes or the ventilator; ask the ICU team. When a vascular order needs to change, such as starting heparin, agree who enters it. Duplicate heparin orders, two sets of blood pressure parameters, and a VTE prophylaxis dose that collides with a planned drain removal are the classic errors.
• Tell the bedside nurse. The nurse does the hourly checks, so the nurse needs the baseline, the targets and the call parameters.
• Close the loop on overnight events. Read the ICU note, and if a pulse or neuro check was called overnight, examine the patient yourself.
• Agree who updates the family, so they hear one consistent story from both teams.

Transfer to step-down or floor

Leaving the ICU is a handoff in the other direction, and it is where vascular details get lost: the Doppler baseline, the antiplatelet plan, the blood pressure targets.

Typical readiness criteria

• Off vasoactive drips. Or on a dose the receiving unit can manage under local policy, with blood pressure in range on oral agents.
• Breathing comfortably. Extubated, with oxygen needs the floor can meet.
• Stable hemoglobin. No ongoing transfusion and no sign of active bleeding.
• Adequate urine output. Creatinine stable or improving, potassium controlled.
• Lactate normal and abdomen settled. Bladder pressures no longer needed.
• Drains out or stable. CSF drain removed with the post-removal neuro checks complete and the legs unchanged; surgical drains removed or with low, stable output.
• Neuro exam stable. Especially after carotid surgery and when the spinal cord was at risk.
• Pain controlled. On a regimen the receiving unit can deliver.
• Checks the unit can do. Pulse and neuro checks needed no more often than the receiving unit's nurses can perform them.

What to update in the transfer note

Write a fresh exam, not the one from the post-op check three days ago. The receiving team needs the operation, the ICU course in a few lines, today's perfusion exam against the baseline, and the plan in targets.

Operation and date: ____________   POD __
Key intraop facts: clamp ___, EBL ___, issues ___
ICU course: [drips, transfusion, complications]

Exam today vs baseline
  Pulses / Doppler: R ___  L ___ (baseline ___)
  Incisions, wounds, fasciotomies: ___
  Neuro: ___

Lines and drains: [removed / remaining, plan]
Antiplatelet: ___   Statin: ___
Anticoagulation: ___ (start, hold, monitoring)
VTE prophylaxis: ___
BP goal: ___   Beta-blocker: ___
Diet: ___   Bowel function: ___
Activity: ___   PT/OT: ___
Floor checks: pulses q__h, neuro q__h
Pending: [imaging, labs, repeat scope, etc.]
Call vascular for: ___
Disposition plan: ___

Night calls about these patients once they reach the floor are covered on On call and cross-cover, and discharge planning on History, exam and charting.