Colic 3: Post Op Management/complications Flashcards
What is one of the most important things to manage Post op?
Fluid therapy
VOLUME of fluids most important Dehydration/electrolyte imbalance Daily maintenance 50ml/kg/day Add losses to maintenance Electrolytes add to fluids
What 2 electrolytes imbalances are common post op (exploratory celiotomy) in a horse?
Hypocalcemia
Hypomagnesemia
What are the supplements post op that should be considered after a horse has an exploratory celiotomy?
K+, Ca, Mg
What is the Daily maintenance for a horse?
50ml/kg/day
What are the common causes of Hypokalemia in the horse?
1) lack of intake (only get it from their diet)
2) Diuresis
3) GI loss through diarrhea
When should you supplement K+ in a horse?
1) lack of intake >24hrs and/or IV fluids >24hrs
* **Remember not greater than 0.5meq/Kg/hr
Usually add 80mEq/5L bag!!!
What is the maximum K+ a horse can receive?
0.5mEq/kg/hr!!!!!
What is the goal of post op fluid therapy in a horse?
Maintain vascular volume to sustained cardiovascular output
Mucosal damage—> increased capillary permeability—> fluid/protein loss into interstitial = difficult to maintain vascular volume
Indicators:
HR <80, PCV <50%, TP >4.1
Post op monitoring: (Refluxing colic and foals)
PCV/TP
Gastric decompression
Exam
CBC/fibrinogen/lactate/electrolyte
PCV/TP q6hrs
Gastric decompression q2-3hrs (if needed)
Exam q1-3
CBC etc… one day post op and 3 days post op
Following exploratory surgery on a horse when do you discontinue meds?
- EAT
- afebrile
- normal CBC
What can be given to a horse post op to manage pain and anti-endotoxins effects?
Banamine
What is lidocaine CRI prescribed for post op in horses?
- Anti-inflammatory properties
- post op ileus (POI)
What are the clinical signs of Endotoxemia?
- tachycardia
- Abnormal mm (hyperemic, cyanotic)
- Pain
- edema
- hypomotility
- GI distention
- NG net reflux
- Thrombosis/coag disorders
How do you manage endotoxemia in a horse?
Maintain circulatory volume:
1)FLUIDS!!!!
2)NSAIDS (low does Banamine BID-QID)
3)Anti-endotoxin therapy:
—>Di-tri-octahedral (DTO) smectite (Biosponge)
bind endotoxins, bind clostridium enterotoxin
—>Polymyxin B (bind endotoxins, Lipid A, neutralizes endotoxin)
—>Plasma (colloidal, provides abs)
In cases of DIC —-> Heparin therapy
What are the 3 risks to look for with Endotoxemia?
1) hypovolemia/endotoxemia (GI stasis, reflux, cap. Prep.)
2) Protein loss (albumin)
—>edema formation (2ndary to protein loss)
3) laminitis
What are the risk factors for Post op ileus. (POI) in the horse?
BAsically some kinda small intestinal lesion at surgery!
-old horse
-abnormal CBC:
—-PCV>45%
—-High TP and ALbumin
—-Hypergylcemia
- anesthesia >2.5hrs
- Surgery >2hr
- R/A
- SI lesions
- Ischemic small intestine
What is the incidence of POI in the horse?
10-21%
Up to 40% of all post op deaths in horses treated for colic
What is the most common lesion leading to POI in horses?
-What is the prognosis for POI
Strangulating small intestine
Prognosis = favorable but $$$$
What are the clinical signs of a horse with POI?
- Colic, depression
- decreased/no borborygmi
- elevated HR
- increased PCV/TP, electrolyte derangement
How do you diagnose POI in the horse?
Dx:
Rectal Palpatine
U/S
Gastric reflux 12-48hrs post op!
How do you treat POI in the horse?
1) supportive therapy:
- NG decompression
- Fluids
- electrolytes
- antibiotics
2) pro kinetic agents
- Lidocaine (anti inflammatory, free radical scavenger)
- Metoclopromide
- erythromycin (we do not use this very much causes pain)
How does Lidocaine CRI help with POI?
1) decreases catecholamines
2) supremes primary afforestation neuron activity
3) directly stimulates smooth muscle
4) inhibits:
- prostaglandin = decreases inflammation in gut wall
- granulocyte migration/lysosomal enzyme release
- free radical production
What is important to remember about the administration of Lidocaine CRI?
Toxicity
Can cause muscle fasciculations, ataxia, SEIZURES
DO NOT BOLUS!!!!!!!!!!! Give it slow over 5 mins
What is metoclopramide used for? And how does it work? What should you be careful of?
Stimulate gut motility in POI!
1) increases ACH release
2) stimulations smooth muscle in stomach and small intestine!!!
- Toxicity/ Extrapyramidal effects ()
- excitement, restlessness, sweating, SEIZURES
What is the occurrence of incisional complications?
10-37% Not uncommon
-increases with additional surgeries
What is the number one cause of incisional complication?
1) INFECTION!!
2) Hernia 13-16%
3) suture sinus formation
4) Acute incisional dehiscence 2-3%
When would you see an incisional infection?
And what must you do?
>= 3 days post op Febrile Pain/edema Drainage Culture
Needs abdominal support - minimize hernia/dehiscence
Why would you potentially not use antibiotics in a horse presenting with incisional infection?
Drainage
Resistance
What is the most common complication from incisional infection?
Incisional hernia????
Should you repair an incisional hernia, secondary to incisional infection immediately?
No, do not repair for a minimum of 3 months:
- Want to make sure the infection resolves first
- allow the incision (body wall) site to heal more,because it has weak granulation tissue that wont hold sutures
- need fibrous ring to form, so we have tissue to hold to close that up
What type of repair should eventually be used for incisional hernia treatment?
Primary !!!!!
We don’t really like mesh
How common does Acute total dehiscence of an incision site occur post op?
-What are the predisposing factors?
RARE
- Violent recovery
- severe post op pain
- prolonged surgery time
- continuous suture pattern!!!!
What is the second most common reasons for repeat surgery?
-who is it more common in?
Adhesions
Foals > Adults
How can you prevent Adhesions Post op?
1) maintain intact mesothelial layer
2) minimize trauma-good technique (wet bowel, hemostasis, minimal suture exposure)
3) decide on surgery in a timely manner
4) Peri-op NSAIDs and antibiotics
Peritoneal lavage, HA (everyone one should get a shot), CMC 3% (belly jelly, physical barrier lubricant), omentectomy, DMSO (free radical scavenger, anti edema)
In a horse with Post op peritonitis, why is it important to do a cytological evaluation?
Bacteria
Neutrophilic
Degenerate
What is a good indicator of septic peritonitis in a horse?
pH and Glucose
Serum: peritoneal glucose difference >50mg/dL
Or
Peritoneal pH <7.2 + peritoneal glucose <30mg/dL = septic
What else can be used to diagnose septic peritonitis?
Other than glucose and ph
-culture /sensitivity. (Peritoneal fluid)
-CBC/Fibrionogen:
—->left shift
—->thrombocytopenia
—->hypoproteinemia
How do you treat Septic peritonitis?
Fluids Electrolytes Plasma NSAIDs Antibiotics Possible repeat laparotomy Closed drains
WHat is a huge post op complication of an Endotoxemia horse?
LAMINITIS
5x higher risk in horses with endotoxemia
