Appendicitis

Question 1

A 42-year-old male patient is undergoing an emergency procedure for
appendicitis. He is a smoker and a type 1 diabetic.

What added information would you like when approaching this case?

Answer 1

Patient factors:
* A detailed anaesthetic history focusing on previous anaesthetics, known comorbidities and an airway assessment.

• Specific diabetic history: when it was diagnosed, the patient’s compliance with treatment, and any micro and macro-vascular complications suggesting poor diabetic control. The patient’s normal blood sugar level, and the levels at which they feel unwell, can also indicate their compliance.
• Smoking history: pack years; when the patient last smoked; any history of asthma/COPD; previous infections and hospital admissions; ICU admissions; and current chest symptoms e.g. sputum production, cough.
• The patient’s starvation status, baseline observations, and relevant investigations should also be noted.

Surgical factors:
* The urgency of surgery, the availability of the surgeon and theatre team, and the proposed surgery and approach.

Question 2

The patient has a heart rate of 121 and a temperature of 39.2°C. He has a blood glucose level of 27 mmol/L with ketones present in his urine. Te surgeons would like to operate as soon as possible. How do you proceed?

Answer 2

• Senior help with an ABCDE approach.
• Large bore IV access, 100% oxygen with a non-rebreathe mask and a
  fluid bolus.
• Early consideration of ICU team input.
• Investigations: FBC, U+E, blood culture, ABG and ketones.
• Treatment for suspected diabetic ketoacidosis:
• Fixed rate insulin infusion (0.1 U/kg/hour).
• 0.9% sodium chloride fluid boluses with potassium replacement when appropriate.
• Commence a 10% dextrose infusion when blood glucose levels fall
  below 14 mmol/L.
• Monitor potassium and ketones carefully.
  Treat the underlying cause (likely appendicitis): proceed to theatre while continuing resuscitation.

Question 3

In general, what are the risk factors for surgical-site infections?

Answer 3

Patient factors:
* Comorbidities: diabetes mellitus, raised BMI, smoker, malnutrition, poor immune function.

• Smoker.
• Older age.

Surgical factors:
* Length of the procedure (increased risk with a longer duration).

• Site and type of surgery.
• Soiling of the surgical wound.
• Surgical technique.
• Emergency surgery.

Question 4

In this case, how can the risk of developing a postoperative surgical-site infection be reduced?

Answer 4

Preoperative:
* Optimal blood glucose control.

Intraoperative:
* Antibiotic prophylaxis within 30 minutes of induction, prior to wound incision.

• Appropriate antibiotics for the type of surgery – skin commensals and bowel contents.
• Perioperative haemostasis, optimal oxygenation, cardiovascular stability and normothermia.
• Asepsis of the theatre environment and surgical technique.

Postoperative:
* Further antibiotics as indicated (often directed by the surgical team) e.g. if abdominal soiling is present.

• Good blood sugar control: consider a variable rate insulin infusion until the patient is eating and drinking when ketoacidosis is resolved.
• Keep the wound clean and dry.
• Ensure early mobilisation postoperatively.

Question 5

The surgeon informs you that the appendix has ruptured and the patient has four-quadrant peritonitis. The procedure is converted into a laparotomy. What is your approach to pain management in this patient?

Answer 5

This patient requires a stepwise, multi-modal approach to analgesia.

• Regular paracetamol (IV until absorbing).
• NSAIDs unless contraindicated (note the patient’s renal function).
• Opioids: intraoperative fentanyl boluses, postoperative oral morphine.
• Patient controlled analgesia if oral route is not suitable (fentanyl/
  morphine).
• Intraoperative adjuncts e.g. magnesium and ketamine bolus.
• Regional anaesthesia e.g. rectus sheath catheters.