SEPTIC ABDOMEN IN SPINA BIFIDA: USING CRITICAL THINKING TO PRIORITISE CARE Alison Duggan, RN, PGDip HealthSc Canterbury District Health Board Christchurch, NZ CONFLICT OF INTEREST / PERMISSION I have no conflicts of interest to declare. Permission was granted by the patient and his family to present this anonymous case study. *Patient s name has been changed. INTRODUCTION Spina Bifida was a common congenital abnormality 25 years ago. This case study is of a 10 year old boy with Spina Bifida who was recently transferred to our tertiary care hospital from a smaller hospital, with a septic abdomen. Staff were no longer very familiar with the issues associated with Spina Bifida. This child required numerous immediate interventions, which needed to be prioritised and attended to promptly. As the child's condition changed, reassessing and reprioritising was required using critical thinking skills. 1
SPINA BIFIDA: THEN AND NOW 1991 Australia incidence 1:800 live births (Spina Bifida Association of New South Wales, 1991) Poor maternal nutrition thought to contribute to incidence Common to have children with Spina Bifida (SB) on the ward, staff familiar No specialty trained paediatric surgeons 2016 New Zealand incidence: 1:3000 live births (NZ Ministry of Health, 2016) Maternal folic acid reduces incidence by around 70%. (Borman, 1999) MoH guidelines on folic acid supplementation Uncommon to have children with Spina Bifida on the ward, staff unfamiliar Paediatric surgery department WHAT IS SPINA BIFIDA? Spina Bifida results from the failure of the embryo s neural tube to develop properly. The vertebrae at one part of the spine are divided. The spinal cord and its coverings bulge out from the gap forming a myelomeningocele and causing the messages between the brain and areas of the body to be interrupted. (Spina Bifida Association New Zealand, 2013) Spina Bifida Association New Zealand (2013) COMMON SPINA BIFIDA PROBLEMS Chiari II malformation Hydrocephalus Neurogenic bowel Chronic constipation Encopresis Scoliosis Talipes Impaired mobility Learning disabilities Obesity Pressure injuries Latex allergy Neurogenic bladder Small capacity Urinary incontinence Recurrent infections (Spina Bifida Association New Zealand, 2013) 2
MEET HARRY Harry is a 10 year old male born with a myelomeningocele and hydrocephalus. As a neonate: surgical closure of the spinal defect ventriculoperitoneal shunt for hydrocephalus Age 5 years: antegrade continence enema (ACE) for constipation Age 7 years: bladder augmentation Harry presented to his local hospital with a 4 day history of lower abdominal pain, fever, vomiting and smelly urine with hematuria. Urosepsis was diagnosed and treated. HARRY, CONTINUED VP shunt was found to be disconnected, so removed. An external ventricular drain was inserted Harry deteriorated, developed signs of peritonitis CT scan: free fluid and free gas Transferred by air ambulance to Christchurch Hospital with septic abdomen of unknown origin VENTRICULOPERITONEAL (VP) SHUNT FOR HYDROCEPHALUS A VP shunt diverts cerebrospinal fluid (CSF) which is not circulating and absorbing normally, from the ventricles into the peritoneal cavity where it is absorbed. People with VP shunts are at risk of developing a shunt infection secondary to abdominal infection. (Hydrocephalus Association, 2012) 3
ANTEGRADE CONTINENCE ENEMA (ACE PROCEDURE) The appendix is used to create a passageway between a stoma on the skin and the large bowel for the purpose of enema solution administration. This allows colonic washout, which is effective as it washes out more of the colon than conventional rectal enemas. (Gill, 2013). BLADDER AUGMENTATION This surgery increases a small bladder capacity by incorporating a graft of the patient s own tissue (usually a section of the ileum) into the bladder. This increases the functional capacity and lowers the filling pressure of the bladder. (Sountoulides, Laguna & de la Rosette, 2009) SEPTIC ABDOMEN Septic abdomen is a presentation with abdominal distention, pain, peritonism and fever typically with high inflammatory markers Issues with septic abdomen: systemic response to sepsis (septic shock), cardiovascular compromise, poor perfusion, paralytic ileus Issues with SB: multiple abdominal issues and previous surgeries 4
CRITICAL THINKING Critical thinking in nursing aims to raise questions on all aspects of a clinical situation without assumptions: to identify and analyze the problems and risks, and prioritize and critique the solutions. (Simpson & Courtney, 2002) It is important to understand both the underlying condition and the current physical status. (Leack, 2013) PROBLEMS raised intracranial pressure distention pain stress/fear risk of neuro-sepsis dehydrated, tachycardic nausea, bilious vomit needed preparation for surgery need for peritoneal tap paralytic ileus, no NGT drainage nutrition deficit parental concern no urine drainage uncertain diagnosis risk of cross infection bowel decompression oedema sepsis electrolyte derangement need for CVAD pressure injury prevention latex allergy scoliosis PRIORITISING CARE The Advanced Pediatric Life Support Structured approach to the seriously ill child: ABCDE. Primary assessment of Airway, Breathing, Circulation, Disability Exposure Secondary assessment : history, examination, investigations, and treatment (APLS, 2005) 5
PHARMACOLOGICAL TREATMENT Dehydration/ septic shock: IV fluids: 0.9% saline bolus, then maintenance fluids with additional ml for ml nasogastric loss replacement Sepsis: IV high dose antibiotics: cefuroxime and metronidazole Pain: IV morphine infusion, changed to Patient Controlled Analgesia (PCA) fentanyl, IV paracetamol (acetaminophen) Nausea: IV ondansetron Malnutrition, electrolyte imbalance, low albumin: tailored parenteral nutrition with additional electrolyte supplementation SO WHAT HAPPENED? This child had an adhesion between his ileal donor site, and bladder graft. This had ulcerated, become necrotic and perforated through the bladder graft The free fluid in his abdomen was urine, and inflammatory products He was stabilized and surgery was performed several days later Due to sepsis, his VP shunt was not replaced: a third ventriculostomy was performed Once recovered, Harry was discharged with a suprapubic catheter, with a further elective repair scheduled further in the future once all inflammation had settled completely Spina Bifida is no longer as common as it was 25 years ago SUMMARY When a complex seriously unwell child presents, a critical thinking process should be used A systematic framework should be used to prioritize approaches to the seriously unwell child The right tube needs to be in the right place at the right time, and these need to be assessed and be functional In summary: critically thought out and prioritized care can promote recovery and minimize complications in the seriously unwell child. 6
REFERENCES Advanced Life Support Group. (2005). Advanced Paediatric Life Support: the Practical Approach. Wiley-Blackwell, West Sussex. Borman, B. (1999). Folate, Folic Acid, and Health. Retrieved from http://www.health.govt.nz Gill, F. (2013).In Brown, N.; Flannigan, L.; McComiskey, C. & Pieper, P. (eds.) Nursing Care of the Pediatric Surgical Patient.(3 rd ed.) Jones Bartlett Learning, Burlington, MA. Hydrocephalus Association. (2012). Fact Sheet: Shunt Systems for the Management of Hydrocephalus. Retrieved from: http://www.hydroassoc.org Leack, K. (2013). Perioperative preparation of the child and family. In Brown, N.; Flannigan, L.; McComiskey, C. & Pieper, P. (eds.). Nursing Care of the Pediatric Surgical Patient.(3 rd ed.) Jones Bartlett Learning, Burlington, MA. REFERENCES Ministry of Health. (2016). How common are neural tube defects in New Zealand? Retrieved from: http://www.health.govt.nz Simpson, E.; Courtney, M. (2002).Critical thinking in nursing education: literature review. International Journal of Nursing Practice. 2002;8:89 98. Sountoulides, P.; Laguna, M. & de la Rosette, J. (2009). Complications following augmentation cystoplasty; prevention and management. Central European Journal of Urology, 2009/62/4. Spina Bifida Association of New South Wales. (1991) (Incomplete historic reference.) Spina Bifida Association New Zealand. http://spinabifida.org.nz/ 7