acute abdomen 4.18.58 PM

acute abdomen 4.18.58 PM - Acute Abdomen in the ICU Patient...

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Unformatted text preview: Acute Abdomen in the ICU Patient ICU Simon Kimm and Edward Melkun December 11, 2006 Definition Definition Acute abdominal pathology that if Acute left untreated will increase patient M&M M&M Physiology Physiology Visceral and parietal peritoneum Peritoneal fluid normally <50ml Absorbed via lymphatics in Absorbed omentum and diaphragmatic peritoneum (30%) peritoneum Omentum acts as physiologic Omentum “patch” for perforation or infection infection Physiology Physiology Pain – somatic and visceral Somatic from direct irritation of Somatic parietal peritoneum, visceral follows embryologic origin or major splanchnic vessels major Refered pain – ex. Shoulder and Refered phrenic nerve phrenic Pathophysiology Pathophysiology Similar incidence of common Similar diseases as general population plus more unique processes more Post-surgical state Hypotension and low flow states Antibiotic therapy (Overgrowth ex. C. Antibiotic diff) diff) Narcotics Poor nutrition Co-morbidities Trauma Presentation Presentation Always start with ABCs, eyeball Always test, and adjuncts to ABCs test, H&P If possible review symptoms in If awake patient awake OLDCARTS History History Location gives Location clues to pathology pathology Character – Character crampy usually from hollow viscus viscus Progression Progression often more important in post op patients post Physical Physical Again difficult in non-awake Again patients patients Vitals Remember lines and wounds Inspect, auscultate, percuss, Inspect, palpate palpate Genital and rectal exam Labs Labs CBC – wbc trend, left shift, anemia UA – wbcs, LE, Nitrite LFTs – tbili can be elevated in biliary LFTs dz, sepsis, hemolysis, and cholestasis from TPN cholestasis Amylase/Lipase – amylase elevated Amylase/Lipase in pancreatitis, perfed ulcer, mesenteric ischemia, parotid injury or inflam, and ruptured ectopic or ABG – acidosis, hypoxia Imaging Imaging • Bedside films vs. in department • CXR – free air,PNA, effusions • Abd films – colonic volvulus, obstruction, stones, pneumobilia • US – biliary system • CT – little use in 1st post-op week for abscess • Angio – mesenteric ischemia, GI bleeds • Nuclear scans – tagged rbc Imaging Imaging Endoscopy – UGI bleed, colonic Endoscopy ischemia, ? Role in C. diff (1/3 negative toxin assays) negative Postoperative Considerations Postoperative Bleeding Anastamotic leak Fascial Dehiscence Bowel obstruction Abscess Abdominal Compartment Abdominal Syndrome Syndrome Bowel obstruction Bowel Diagnosis often Diagnosis confounded by normal post-op adynamic illeus adynamic Patients on Patients narcotic pain meds narcotic Management per Management standard protocol standard Complete Complete obstruction or nonresolving/ worsening PSBO requires reoperation reoperation Leak Leak In cases where leak controlled by In drainage with little or no peritoneal contamination, may not need early operative intervention operative Percutaneous drainage NPO, TPN, ? octreotide If peritoneal spillage or signs of If intraabdomial sepsis, need emergent reoperation reoperation Abscess Abscess Need approximately 7 Need post op days to organize an abscess organize Small may only require Small abx abx Larger or those with Larger continued enteric contamination (leak) require drainage require Percutaneous, Percutaneous, operative if not accessible accessible Cholecystitis Cholecystitis Acalculous – may see Acalculous sludge in GB in US or nonvisualization on HIDA (hepato-iminodiacetic acid) scan (hepato-iminodiacetic Can see these findings in nl Can patients maintained on TPN patients Percutaneous Percutaneous cholecystostomy tube for critically ill patients critically Ischemic Bowel Ischemic Low flow Embolic Abd films – pneumatosis, Abd pneumobilia, free air, double wall sign wall CTA Lactate levels ...
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