Emergency Laparotomy
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1 Emergency Laparotomy 15 th June 2018 Rural SIG Meeting, Ayers Rock Jeremy Fernando Anaesthetist and Intensive Care Specialist Rockhampton Hospital, QLD
2 Conflicts
3 Conflicts Nil
4
5
6 Overview
7 Resuscitation
8 Resuscitation Risk Assessment
9 Resuscitation Risk Assessment Anaesthesia
10 Resuscitation Risk Assessment Anaesthesia Surgery
11 Resuscitation Risk Assessment Anaesthesia Surgery Recovery
12 Resuscitation
13 Definition of Sepsis
14 Old Sepsis Definitions (1992, 2001) SIRS = 2 or more of the following: Temp > 38 or < 36ºC Heart rate > 90 Resp rate > 20 or PaCO2 < 30 mmhg WCC > 12 or < 4 Sepsis = SIRS with identified organism Severe sepsis = sepsis with organ dysfunction - hypoperfusion lactate >4 or impaired mentation - hypotension SBP < 90, MAP < 65, drop of 40mmHg from baseline Septic shock = sepsis with hypotension after adequate fluid resuscitation
15 Old Sepsis Definitions (1992, 2001) SIRS = 2 or more of the following: Temp > 38 or < 36ºC Heart rate > 90 Resp rate > 20 or PaCO2 < 30 mmhg WCC > 12 or < 4 Sepsis = SIRS with identified organism Severe sepsis = sepsis with organ dysfunction - hypoperfusion lactate >4 or impaired mentation - hypotension SBP < 90, MAP < 65, drop of 40mmHg from baseline Septic shock = sepsis with hypotension after adequate fluid resuscitation
16 Old Sepsis Definitions (1992, 2001) SIRS = 2 or more of the following: Temp > 38 or < 36ºC Heart rate > 90 Resp rate > 20 or PaCO2 < 30 mmhg WCC > 12 or < 4 Sepsis = SIRS with identified organism Severe sepsis = sepsis with organ dysfunction - hypoperfusion lactate >4 or impaired mentation - hypotension SBP < 90, MAP < 65, drop of 40mmHg from baseline Septic shock = sepsis with hypotension after adequate fluid resuscitation
17 New Sepsis Definitions (2016) Sepsis = life threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction quantified by Sequential Organ Failure Assessment (SOFA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) Singer et al, JAMA 2016;315(8):
18 Sepsis Quick SOFA Score (qsofa) 2 or more: Hospital Mortality = 10% RR 22/min Altered mentation SBP 100mmHg The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) Singer et al, JAMA 2016;315(8):
19 Septic Shock Vasopressor requirement post fluid resuscitation Hospital Mortality = 40% Lactate > 2mmol/L The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) Singer et al, JAMA 2016;315(8):
20 More specific Clinically more helpful Doesn t require lab tests Facilitates earlier recognition Greater consistency with research and trials qsofa does not replace SIRS in the definition of sepsis Vincent et al, Critical Care :210
21 IV antibiotics when?
22 Well + qsofa score < 2: sample first? qsofa 2 or Septic Shock: within 1 hour
23 Well + qsofa score < 2: sample first? qsofa 2 or Septic Shock: within 1 hour
24 For every hour a patient with septic shock is without appropriate antibiotic therapy, their mortality rate increases by 7.6% Duration of hypotension before the initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock Kumar et al, Critical Care Medicine 2006 Jun;34(6):
25 IV cannula in Blood cultures out Appropriate empiric antibiotics in
26 IV cannula in All in one motion Blood cultures out Appropriate empiric antibiotics in
27 IV antibiotics what?
28 IV antibiotics what? Triples
29 Ampicillin + Gentamicin + Metronidazole OR Piperacillin-Tazobactam (Pip-taz) OR Ticarcillin+clavulanate (Timentin) Penicillin allergic (mild reaction/rash) Ceftriaxone/Cefuroxime + Metronidazole Penicillin allergic (anaphylaxis) Gentamicin + Clindamycin
30 Ampicillin + Gentamicin + Metronidazole OR Piperacillin-Tazobactam (Pip-taz) OR Not a Cephalosporin Ticarcillin+clavulanate (Timentin) Penicillin allergic (mild reaction/rash) Ceftriaxone/Cefuroxime + Metronidazole Penicillin allergic (anaphylaxis) Gentamicin + Clindamycin
31 Emergency Laparotomy Microbiology Most common organisms E coli B fragilis C perfringes Enterococcus faecalis Microflora of Abdominal Sepsis by Locus of Infection Walker, A.P., et al, Journal of Clinical Microbiology, 1994 Feb:
32 Emergency Laparotomy Microbiology Most common organisms E coli B fragilis C perfringes Enterococcus faecalis Microflora of Abdominal Sepsis by Locus of Infection Walker, A.P., et al, Journal of Clinical Microbiology, 1994 Feb:
33 Cephalosporins don t cover Enterococcus Risk Factors Prolonged antibiotics exposure In-hospital > 48 hours Infective endocarditis risk Immunosuppressed
34 Intravenous Venous Fluid
35 SAFE SPLIT CHEST FEAST FIRST SALT-ED SMART Literature Summary
36 SAFE SPLIT CHEST FEAST FIRST SALT-ED SMART Literature Summary Saline: safe
37 SAFE SPLIT CHEST FEAST FIRST SALT-ED SMART Literature Summary Saline: safe Hartmans + Plasmalyte: safe but no better than Saline
38 SAFE SPLIT CHEST FEAST FIRST SALT-ED SMART Literature Summary Saline: safe Hartmans + Plasmalyte: safe but no better than Saline Starches: renal dysfunction
39 SAFE SPLIT CHEST FEAST FIRST SALT-ED SMART Literature Summary Saline: safe Hartmans + Plasmalyte: safe but no better than Saline Starches: renal dysfunction Albumin: can use, but not in head injury,?sepsis Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures Bampoe, S. et al (2017) Cochrane Database of Systematic Reviews, Issue 9. Art. No,: CD004089
40 n = 3,000 Urgent/Time critical surgery excluded Liberal fluid vs Restrictive fluid No change in disability free survival at 1 year AKI + RRT Surgical site infection
41 n = 3,000 Urgent/Time critical surgery excluded Liberal fluid vs Restrictive fluid No change in disability free survival at 1 year AKI + RRT Surgical site infection
42 n = 3,000 Urgent/Time critical surgery excluded Liberal fluid vs Restrictive fluid No change in disability free survival at 1 year AKI + RRT Surgical site infection
43 n = 3,000 Urgent/Time critical surgery excluded Liberal fluid vs Restrictive fluid No change in disability free survival at 1 year Liberal Fluids 1L intraoperatively 200mL/hr Hartmans AKI + RRT Surgical site infection
44 Urgent CT scan with contrast
45 RANZCR guidelines have changed in 2016 egfr > 60
46 RANZCR guidelines have changed in 2016 egfr > 60
47 RANZCR guidelines have changed in 2016 egfr > 60 > 30
48 Resuscitation Risk Assessment
49 Risk Assessment
50 Elderly + MOF + Emergency Surgery
51 Elderly + MOF + Emergency Surgery
52 Risk Assessment Patient Family Primary care Comorbidity assessment, IHD, heart failure, COPD Frailty Exercise capacity Mobility Independence P-POSSUM NSQIP NELA
53 Risk Assessment Patient Family Primary care Comorbidity assessment, IHD, heart failure, COPD Frailty Exercise capacity Mobility Independence P-POSSUM NSQIP NELA
54 Frailty = a state of increased vulnerability to stressors Walston, J et al. (2006) - Research agenda for frailty in older adults: toward a better understanding of physiology and etiology - J Am Geriatr Soc, vol. 54, pg
55 Function Predicting Performance Status 1 Year After Critical Illness in Patients 80 Years or Older: Development of a Multivariable Clinical Prediction Model Heyland, D et al (2016) Critical Care Medicine, Vol 44, Issue 9, page
56
57
58
59 NELA Score
60
61
62 Mortality at 30 days Critical Care Bed Consultant present
63 We ve done the risk assessment. Now what?
64 Surgery ED ICU/Anaesthesia
65 I can operate
66 I can operate I can resuscitate
67 I can operate I can resuscitate I can oxygenate and ventilate
68 ICU/Anaesthesia Surgeons EL ED
69 emdt ICU/Anaesthesia Surgeons EL ED
70 Post Risk Assessment Options (1) Operate (2) Operate with limitations (3) Not operate + conservative/symptom management
71 Sometimes the hardest decision is when not to operate
72 My 1 st Line I totally support a decision to not operate on this patient
73 We are going to operate!
74 Advance Resuscitation Planning ICU full support (+/- transfer) ICU limited support Ward based care (like #NOF patient)
75 Sometimes the hardest decision is to limit care
76 My 2 nd Line We are going to try to get you through this operation/illness, however, if you begin to take steps backwards and your organs begin to shut down, we will move to keeping you comfortable
77
78
79 emdt ICU/Anaesthesia Surgeons NELA risk of death at 30 days = 14% EL ED
80
81 ICU intubated Quick family meeting (ICU/Surgery) Extubated
82
83 Quality of Death = Quality of Life
84 Anaesthesia
85 Anaesthesia ETT + IV ETT + IV + Artline + CVL + Epidural +/- RCS +/- Q monitoring +/- PCA
86
87 Positioning Pain Sepsis Haemodynamics
88 Rectus Sheath Catheters Tudor, ECG, et al (2015) Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery Ann R Coll Surg Engl97: Wilkinson, K.M et al (2014) Thoracic Epidural analgesia vs Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery programme (TERSC): study protocol for a RCT Trials, 15:400 Mostafa, A.R, et al (2016) Postoperative analgesia of ultrasound guided rectus sheath catheters vs continuous wound catheters for colorectal surgery: A RCT Egyptian Journal of Anaesthesia, 32: Malchow, R. et al (2011) Rectus Sheath Catheters for Continuous Analgesia after Laparotomy without postoperative opioid usé Pain Medicine, 12: Cornish P, Deacon A, (2007) Rectus sheath catheters for continuous analgesia after upper abdominal surgery ANZ J Surg, 77:84
89
90 Cornish, P, Deacon, A (2007) Rectus sheath catheters for continuous analgesia after upper abdominal surgery ANZ J Surg, Jan-Feb; 77 (1-2):84
91 Rectus Sheath Catheters pain (somatic) opioid use mobility safety as less complex than an epidural
92 Lignocaine Infusion
93 Lignocaine infusion pain opioid use LOS ileus chronic post-surgical pain - cancer modulation Bailey, M. et al (2017) Lidocaine infusions: The golden ticket in postoperative recovery? ANZCA Blue Book, page
94 Lignocaine infusion Bolus 1-3mg/kg Infusion 1-4mg/kg/hr Length of duration; intraop, PACU,?24hrs Telemetry Stop when dosing Rectus Sheath Catheters Bailey, M. et al (2017) Lidocaine infusions: The golden ticket in postoperative recovery? ANZCA Blue Book, page
95 Surgery
96 Surgery (from an Anaesthetist- Intensivist perspective)
97 Surgery Damage control surgery Ostomy vs Anastomosis
98 Recovery
99 Recovery ERAS Marwah, S et al Enhanced Recovery after Surgery (ERAS) in Emergency Laparotomy EC Gastroenterology and Digestive System 3.3 (2017): 81-82
100 Recovery Ileus is major problem (R>L) - Distension - Vomiting - Aspiration - Pain - Respiratory failure - Inability to wean from MV - Nutrition CHASM data - NSW Marwah, S et al Enhanced Recovery after Surgery (ERAS) in Emergency Laparotomy EC Gastroenterology and Digestive System 3.3 (2017): Yuan, L. et al (2018) Prospective comparison of return of bowel function after left versus right colectomy ANZ Journal of Surgery 88: E
101 One final point
102
103 Take home messages
104 (1) Early, appropriate antibiotics
105 (2) Risk Assessment
106 (3) emdt
107 (4) Ileus
108 (5) Analgesic Options
109 (6) Quality of Death = Quality of Life
110 Thank you
111 Thank you
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