Intra-abdominal Catastrophe Patient Hot Case

GENERAL APPROACH

• Cause
• Treatment (source control) — complete or ongoing?
• Nutrition — NBM? route? nutritional status?
• Complications – ACS, fungal sepsis?
• How to move forward?

Important causes

• intra-abdominal sepsis
• pancreatitis
• abdominal trauma
• perforation (e.g. ulcer, appendicitis, diverticulitis, tumor, obstruction, anastomotic leak)
• obstruction or pseudo-obstruction
• GI haemorrhage

INTRODUCTION

CUBICLE

•  infectious warnings (MDRO)
• isolation

INFUSIONS

• vasoactive drugs
• fluid boluses
• antibiotic infusions (may suggest likely organisms, e.g. MDROs)
• TPN (failed gastric feeding or GI fistulae)
• transpyloric feeding (failed gastric feeding or pancreatitis)
• blood products
• octreotide infusion (variceal bleeding)
• omeprazole
• terlipressin infusion for (hepatorenal syndrome or variceal bleeding)

VENTILATOR

• mode
• level of support
• level of oxygenation: FiO2, PEEP: ARDS, aspiration, nosocomial pneumonia
• ARDS specific questions: plateau pressure, PaCO2

MONITOR

• ECG: SIRS
• temperature: SIRS
• CVP: number, waveform
• arterial trace: MAP, swing, pulsus paradoxus, pulse pressure

EQUIPMENT

• surgical drains: number, location, nature of material being drained, suction, irrigation tubes
• stoma: location, mucosal integrity, nature of losses, feeding jejunostomy in necrotizing pancreatitis
• surgical scars
• intra-abdominal pressure
• rectal tubes: diarrhoea, malena, blood, mucus
• CRRT
• Minnesota tube
• RIJ puncture from TIPS procedure
• large bore cannulae if recent massive transfusion

QUESTION SPECIFIC EXAMINATION

• hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> general: jaundice
-> cardiovascular:
-> respiratory: effusions, aspiration, APO
-> abdominal: distension, GI failure, liver laceration, Cullen’s or Grey Turners sign, open abdomen, stigmata of chronic liver disease/alcoholism

• neurological (if hypothermic, comment that will effect neurological assessment)

-> paralysed
-> quick
-> unconscious
-> conscious

• findings on laparotomy
• urine output over last 12 hours

RELEVANT INVESTIGATIONS

• amylase/lipase
• FBC: WCC, Hb, platelets
• LFTs: jaundice (conjugated/unconjugated) -> U/S
• CXR
• cultures from drainage fluid/surgical samples
• cultures from blood (including fungal)
• recent CT abdomen
• other organ failures
• ABG: gas exchange, metabolic state

OPENING STATEMENT

• Cause
• Treatment (source control)
• Nutrition
• Complications – ACS, fungal sepsis
• How to move forward?

DISCUSSION

• Abdominal Compartment Syndrome
• Intolerance to Enteral Nutrition
• Pancreatitis
• GI haemorrhage
• Mesenteric Ischaemia
• Enteral Nutrition versus Parenteral Nutrition
• TPN