The Patient with an Intra-abdominal Catastrophe
16/4/11
Examinations Book
GENERAL APPROACH
Cause
Treatment (source control)
Nutrition
Complications – ACS, fungal sepsis
How to move forward?
INTRODUCTION
CUBICLE
- infectious warnings (MDRO)
- isolation
INFUSIONS
- vasoactives
- fluid boluses
- antibiotic infusions
- TPN
- tranpyloric feeding (failed gastric feeding or pancreatitis)
- blood products
- octreotide infusion (variceal bleeding)
- omeprazole
- terlipressin infusion for hepatorenal syndrome
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?
Jeremy Fernando (2011)