10/13/2016 FISTULAS. Outcomes

Transcription

1 October 28, 2016 FISTULAS Having the guts to care for them Presenter: Dorothy P. Goodman BSN RN CWOCN Margaret Hiler MSN RN CWOCN 1 Outcomes 1. State four aspects of fistula assessment 2. Name three goals of fistula site care 3. Discuss how to assemble a multidiscplinary team to care for a patient with a fistula 1

2 The Path of Least Resistance Abnormal connection between two locations Named by direction of flow ECF Entero Cutaneous EAF Entero Atmospheric Classifications Organ Involvement Simple: short, direct tract Complex: I: abscess with multiple organs II: opens into base of wound Output amount High: >500mL/24hrs Medium: Low: <200 Organ of origin I: Abdomen/esop/gastro II: Small bowel III: Large bowel IV: EAF Morbidity & Mortality Sepsis Malnutrition +/ Fluid & Lyte Albumin >3.5mg/dL Infection High Output Age 2

3 CAUSES Iatrogenic 75-85% Technical error; injury of bowel bad bowel Vascular Tension Breakdown of anastomosis SPONTANEOUS IBD, malignancy, perf divertic; appendicitis, ischemia FRIENDS? Foreign Body Radiation Rx IBD/Ischemia Epithelialization Neoplasms Distal Obstruction Sepsis 3

4 Disaster Management Stabilize the patient Nutrition Assess anatomical mapping Plan the treatment 4

5 STABILIZE Sepsis Management Catabolic state decreases nutrition and immune response significantly decreasing closure rates Limits surgical/radiologic closure techniques Identify source d/c antibiotics ASAP NUTRITION Closure rates are twice as high in patients receiving adequate supplemental nutrition Anatomical Mapping CT Early evaluation, pathology May not detect small For known: can determine cause FISTULOGRAPHY MRI Ultrasound (fluid collections but not diagnosis) 5

6 Plan the Treatment Medicine Surgery Radiology Nursing Medical Management Vigilant nutritional, fluid&lyte balance PPIs/H2Chanel Blockers Antacids sucralfate Somatostatin (consider renal clearance) Decreases output, increases rate spontaneous closure Does NOT decrease mortality Anti-diarrheals Effluent Management High Output NPWT: mmHg 46% spontaneous closure 98% controlled output 40% had no output within 7 days 57% decreased to less than 500mL 41% no improvement in amount but effluent was managed 6

7 Spontaneous Closure 30% without any invasive intervention 60 70% within 4 7weeks (Non surgical, conservative tx) Esophageal Long, narrow Gastric High flow SB, duodenum/ileum d Maturation/granulation Short, wide Treatments Fibrin seal Fistula Plug External opening in open wound or externally exposed bowel Infliximab i Electrical stimulation HBO Surgery No sooner than 6-8 weeks Purulence or fecal contamination Delay No anastomosis ONLY hope for closure distal obstruction; foreign body in tract; epithelialized lined tract; previous irradiation; Crohn s; large abscess 7

8 the RIGHT surgery at the RIGHT time Entire bowel must be mobilized (decreases reoccurrence from 34-18%) 6-8 hr minimum Diversion increases success 8

9 INTERVENTIONAL RADIOLOGY Once you find it, drain it Initial stabilization Diagnosis Fluroscopy guided tubing; fistulography Treatment Once you find it, drain it Repeated evals; decreasing catheter size Go through healthy skin Presentation Fever Localized erythema Induration Progressive local discomfort Progressive, local discomfort Lyte imbalance AMS 9

10 Nursing Considerations Goals of Care Protect the skin Contain the drainage Qualify & quantify Control the odor Involve Patient and Family in care Ease of Care-prepare for discharge Costs Containment t Educate Patient and Family Fistula Assessment Location- Internal or External; Proximity to tubes, stomas, incisions Size/Description- Length, width, depth mature, within wound, not visible Condition of surrounding skin- Intact, macerated, denuded, bleeding, weeping Description of the surrounding tissue- firm/induration, soft, folds and creases, wound! Effluent Assessment Volume: (high >500ml/day or low output) Effluent: bile, fecal, urine, purulent Consistency and Content: liquid, semi-formed, undigested food, medication tablets 10

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13 Car accident New fistula after minor car accident Asked the question: Why would you develop? Congenital defect requiring multiple surgeries- had no fascia NEVER stop at pouching this helps to stabilize, but need to get root of problem These patients need to be in hospitals that have teams capable of caring for all their REFERENCES 1. Gribovskaja-Rupp, I., & Melton, G. (2016). Enterocutaneous Fistula: Proven strategies and updates. Clinics in Colon and Rectal Surgery, 29(02), doi: /s Hoeflok, J., Jaramillo, M., Li, T., & Baxter, N. (2015). Health-related quality of life in community-dwelling persons living with Enterocutaneous Fistulas. Journal of Wound, Ostomy and Continence Nursing, 42(6), doi: /won Kumar, P. (2015). Enterocutaneous Fistula: Different surgical intervention techniques for closure along with comparative evaluation of aluminum paint, Karaya gum (Hollister) and gum acacia for Peristomal skin care. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH, 9(12), doi: /jcdr/2015/ Rahman, F. N., & Stavas, J. M. (2015). Interventional Radiologic management and treatment of Enterocutaneous Fistulae. Journal of Vascular and Interventional Radiology, 26(1), doi: /j.jvir Willcutts, K., Mercer, D., & Ziegler, J. (2015). Fistuloclysis. Journal of Wound, Ostomy and Continence Nursing, 42(5), doi: /won