Complications of Small Intestinal Surgery Flashcards
Septic peritonitis can occur postoperatively after intestinal surgery for any of the three following reasons..?
Septic peritonitis was present preoperatively, but we did not recognise/address it
Septic peritonitis has developed due to intraoperative contamination
The intestinal wound has undergone dehiscence postoperatively.
What is the commonest reason for the development of postoperative peritonitis following intestinal surgery?
Intestinal wound dehiscence
Is the source of peritonitis important in determining the next step in managing the patient?
No
What is the issue of Jackson Pratt drains for septic peritonitis?
Omentum obstructs drain
Is it important to culture the peritoneal fluid in dogs that have septic peritonitis?
Yes/no- The infection will be with bacteria that live in the intestines, therefore we can choose antibiotics based on this knowledge. The patient requires antibiotics to be given immediately but bacterial culture and antibiotic sensitivity testing takes 2-4 days. We can’t wait until we receive these results before starting antibiotics.
= USEFUL but not essential if finances are restricted
Clinical signs of peritonitis?(7)
- Nausea
- Regurg
- V+
- Inappetence
- Abdo pain/discomfort
- Abdo distension
- Lethargy
Clinical signs of ileus? (7)
- Nausea
- Regurg
- V+
- Inappetence
- Abdo pain/discomfort
- Abdo distension
- Lethargy
What other post op complication can cause same signs as ileus/peritonitis?
Pancreatiitis
So, broadly speaking, can we postoperatively differentiate septic peritonitis from ileus by considering the following:
Onset time
Ileus onset time?
24 hours
Peritonitis onset time?
2-5 days
So how can we differentiate peritonitis from ileus?
U/S
How to diagnose septic peritonitis with U/S?
- Free fluid; collect - degenerative neutrophils.
(there should be minimal fluid 24 hours post op even with lavage)
How to confirm septic peritonitits with sampling of fluid + blood?
Glucose and lactate levels of the abdominal fluid cf to blood.
A higher lactate and lower glucose concentration within the peritoneal fluid compared to the blood are supportive of a diagnosis of septic peritonitis.
How to identify ileus on U/S (2)
Gaseous and fluid distension of the stomach and small intestines
An absence of peristalsis.
If degenerate neutrophils on abdo fluid sample was collected from the abdomen of a dog that was quiet, inappetent and pyretic 72 hours after having undergone enterotomy for foreign body retrieval how would you interpret this?
The predominance of degenerate neutrophils together with the history and clinical findings suggest that this dog has septic peritonitis due to intestinal wound dehiscence. (7)
Next steps for septic peritonititis Tx after confirming with U/S? (7)
- Haem + biocehm - guide intravenous fluid therapy;
- Start broad spectrum intravenous antibiotics;
- Reassess the patients cardiovascular status including blood pressure;
- Start aggressive intravenous fluid therapy;
- Give analgesia;
- Anaesthetise the dog and explore abdomen to identify source of septic peritonitis, lavage the abdomen prior to wound closure;
- Place a feeding tube prior to recovery from anaesthesia
Causes of ileus? (9)
- GA
- Obstruction
- Intestine inflamm
- Handling abdo organs
- Anorexia 24-48 hours
- Opiod
- Pain
- Stress
- Electrolyte abnormalities (esp K)
How to reduce ileus due to:
GA
Minimise time (unavoidable really)
How to reduce ileus due to:
Obstruct
- Sx - relieve
- Recognise promptly
How to reduce ileus due to:
intestine inflamm (3)
Gentle handling of the intestines at surgery
Protect intestines from desiccation by use of saline soaked swabs and saline lavage
Use of NSAIDs: controversial
How to reduce ileus due to:
Handling
Minimal!
How to reduce ileus due to:
Anorexia 24-48 hours
Start feeding early in post op
How to reduce ileus due to:
Opioid
Assess needs; pain scores, reduce dose/intervals where poss
How to reduce ileus due to:
Pain?
Analgesia based on score
How to reduce ileus due to:
Stress/anxiety? (2)
- calm/quiet environment
- TLC!
How to reduce electrolyte abnormalities causing ileus?
Measure electrolytes once daily; IVFT
What are the possible causes of hypokalaemia with SI dx? (3)
- Inappetence
- V+
- IVFT
What post op consideration need to be made re potassium?? (3)
- Continue intravenous fluid therapy to rehydrate the patient and allow them to correct acid-base disturbances;
- Ensure supplementation of potassium to intravenous fluids for patients that are hypokalaemic;
- Encourage early nutrition.
What meds all have prokinetic activity and can be used alone or together to treat ileus? (3)
Ranitidine
Metoclopramide
Erthromycin
Which patients are at a higher risk of developing ileus and benefit from early and aggressive use of prokinetic drugs?
- Obstructions
- Enterectomies
When to start prokinetics after surgery?
Immediately - in recovery
How is metoclopromide best given and why?
Very short duration of activity and is most effective if given as a constant rate infusion.
Good analgeisa post SI surgery?
- Opioid
- Paracetamol
What is the issue of giving lidocaine as an analgesic? + how is it given?
Given as a constant rate infusion (CRI); but unfortunately causes nausea; therefore making our patient and inappetent/dull - difficult to assess
It is good practice to regularly palpate the abdomen of patients that have undergone intestinal (or any abdominal) surgery.
Is this true or false?
False - Palpation of the abdomen of patients that have undergone abdominal/intestinal surgery is not recommended because it gives very little information and causes the patient discomfort.
When should food be offered following GI surgery?
ASAP - Within hours of Sx
What is the issue with the previous recommendation of offering food once a patient is drinking?
If the patient is receiving their maintenance fluid requirement intravenously they often won’t drink so you could wait a very long time for a patient receiving intravenous fluids to drink
How long before being fed full RER post surgery?
If the patient was eating normally until 24-48 hours before surgery, then they can immediately be fed their full calculated requirement
If inappetent for 48 hours or longer prior to surgery, feeding should be started by giving a third of their calculated requirements on day 1, two thirds on day 2 and full requirements on day 3.
Why are we not worried about a sequential weight gain over 24-48 hours after SI surgery?
This amount of weight could genuinely be due to body tissue gain.
- NB could also be due to dehydration pre op
How often should sick/hospitalized patients be weighed?
2 x daily
What are the late or chronic complications of intestinal surgery? (3)
- Adhesions
- Intestinal stricture
- Short bowel syndrome
Where do adhesions occur?
Structures within the abdomen adhere to one another
Factors known to increase adhesion formation include (4)
- Ischeaemia
- Infect
- Haemorrhage
- Foreign material in abdo
Why cats and dogs rarely suffer from adhesions?
A very active fibrinolytic system that breaks down fibrinous adhesions at the site of inflammation, haemorrhage, infection and ischaemia within the abdomen.
IF you find adhesion in surgery - what should you do?
They should not be disturbed unless they are causing problem. This is because they are likely to reform therefore nothing will have been achieved by disrupting them
What causes intestinal strictures?
Excessive scarring and fibrosis at the enterectomy site resulting in annular narrowing.
How to treat a stricture?
Enterectomy
What is short bowel syndrome characterised by (2)
Maldigestion
Malabsorption
What amount of SI is tolerated?
85%
