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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC