Peritonitis - Treatment

Question 1

What types of shock are the septic peritonitis patients facing?

Answer 1

Hypovolaemic
Distributive

Question 2

What is the main risk in septic patients?

Answer 2

Anaesthetic!
Stabilise patient as much as possible

Question 3

What should be provided to patients with increased RR?

Answer 3

Oxygen!

Question 4

What may be the cause for increased RR/effort?

Answer 4

Ascites
Pulmonary Dx
Pleural effusion

Question 5

How should the patient be prepared for surgery if severe ascites?

Answer 5

Tilted table to prevent resp compression

Question 6

What type of antibiotic is indicated?

Answer 6

Bactericidal - effective against +ve and -ve

Question 7

What are good empirical antibiotic choices?

Answer 7

2nd gen cephalosporin
metronidazole (10mg/kg IV q12hr)
Clavulanic amoxicillin (20mg/kg IV q6hr)

Question 8

How many patients currently receive appropriate empirical ABx?

Answer 8

52.6%

Question 9

When has it been found poor ABx choices have been made for sx? (2)

Answer 9

Previous ABx administered
Recent abdo surgery performed

Question 10

Which ABx should be avoided - why?

Answer 10

FLUOROQUINOLONES
Increase resistance and less than 52% of isolated in peritonitis are sens

Question 11

What period of time should ABx be used for?

Answer 11

5-7 days

Question 12

When should ABx be used for a prolonged course of 2-3 weeks? (2)

Answer 12

S. Auereus present
Pancreatic necrosis

Question 13

What are the pre-op goals? (7)

Answer 13

• Client education/informed consent
• understanding viscera involved
• Smooth rapid induction of anaesthesia
• Understanding co-morbidities
• Aseptic prep
• Understand anatomy
• Stabilise cardiovasc/resp

Question 14

What are the surgical goals? (5)

Answer 14

• Reduce bacteria load, foreign material and inflamm mediators
• elimination of contam/infection
• prevent leak
• halstead principles
• provision of post op nutrition support (feeding tube if needed)

Question 15

What are post operative goals? (2)

Answer 15

• Thorough post op evaluation
• monitor for complications

Question 16

What incision will be made?

Answer 16

Xiphoid to pubis

Question 17

What campaign have WHO released to reduce surgeon error?

Answer 17

“Safe surgery saves lives”

Question 18

How do you extend incision in male dog?

Answer 18

Continue incision paramedian to one side of prepuce
Preputial muscle and vessels identified and reflect laterally to expose linea alba.

Question 19

What must be placed on wound edges of incision?

Answer 19

Moist lab swabs

Question 20

What happens to falciform fat on entry?

Answer 20

Removed to improve visualisation (dithermy or suturing of cranial vasc)

Question 21

What can be dissected to visualise oesophagus as it enters cardia?

Answer 21

Triagnular lig

Question 22

General approach to ex lap

Answer 22

Liver
Oesophagus
Diaphragm
Pylorus
Duodenum
Pancreas
Portal vein
hepatic artery
Gall Bladder
R adrenal gland and kidney
Greater omenturm
Spleen
L kidney and adrenal gland
Small intestine
Mesenteric LN
Colon
Rectum (gentle traction on descend colon)
Sublumb LN
Bladder - + ureter
Vas deferens in male
Prostate
Internal surface of abdo wall
LAVAGE, SWAB COUNT, SUCTION

Question 23

How do you visualise R adrenal gland?

Answer 23

Cut Nephroheptaic ligaement

Question 24

How to identify ileum?

Answer 24

Antimesenteric vessel

Question 25

What are basic essential requrements for septic peritonitis surgery? (4)

Answer 25

Retractors Suction Diathermy Body temp saline/hartmanns

Question 26

Should we lap surgery septic peritonitis?

Answer 26

No

Question 27

What should we do with any excised tissue?

Answer 27

Histo C+S

Question 28

Canine jejunum leak test (10cm site): 1. Volume in digital occlusion 2. Volume in Doyen occlusion 3. acheive what pressure?

Answer 28

1. 16.3-19ml 2. 12.1-14.8ml 3. 34cm (that of peristalsis)

Question 29

What needle gauge for leak test?

Answer 29

23g or 35g

Question 30

What if a leak if found?

Answer 30

Simple interrupted with monofil absorb material

Question 31

General leak test vol: Digitial? Doyen?

Answer 31

20ml 15ml

Question 32

Why is serosal patching prudent?

Answer 32

pro-op sepsis --> increase wound dehis

Question 33

Following full thickness organ surgery, what should be done to aid blood supply?

Answer 33

Omentalisation

Question 34

How much fluid to lavage post?

Answer 34

200-300ml/kg (body temp)

Question 35

What are the acceptable abdo closure methods following septic peritonitis?

Answer 35

Primary routine closure Abdo closure and active suction drain (Jackson Pratt) Open abdo drain Vacuum assisted open abdo drainage

Question 36

Where >10% blood loss in anticipated, what should be calculated? (4)

Answer 36

Total circulating blood vol 10% blood loss 20% blood loss 30% blood loss

Question 37

What should be done if there if contamin/infect of intra abdo neoplasia?

Answer 37

Kit change

Question 38

When is primary routine closure okay?

Answer 38

If peritonitis source acceptable, addressed and abdo lavaged. Low residual bacteria

Question 39

Benefit of primary routine closure? (1)

Answer 39

Straightforward Post op wound

Question 40

Disadvantages of primary routine closure? (2)

Answer 40

- Inability to repeat lavage or evacuate abdomen - Inability to regularly access abdo fluid production

Question 41

What are the survival rates following primary routine abdo closure?

Answer 41

54-67%

Question 42

Where is wound failure most likely to happen? How can this be prevented?

Answer 42

At the knot - tight square knot needed!

Question 43

How should knots be placed to ensure no increase in hernia developement?

Answer 43

Tight and square At least 5mm of external rectus fascia

Question 44

Which muscle can be reconstructed on abdo closure to void lateral penis deviation?

Answer 44

Preputialis muscle

Question 45

Which drains are unacceptable?

Answer 45

Passive -penrose.

Question 46

Which drain is used? How is it placed?

Answer 46

Active -Jackson Pratt. Paramedian adbo incision

Question 47

What are the advantages of placing a drain? (2)

Answer 47

- Monitor abdo fluid production regularly - Minimise fluid accumulation

Question 48

Disadvantages of placing a drain? (3)

Answer 48

- poss ascending infections - Omentum blocking drain - Hypoproteinaemia

Question 49

Drains should be removed when a patient is showing...? (3)

Answer 49

- Clinical improvement - No intracellular bacteria on abdo cytology - Reduction in abdo fluid production

Question 50

What is the median number of days a drain is removed?

Answer 50

6 (2-11) days

Question 51

Should we biochem post op abdo fluid?

Answer 51

No - not clinically useful

Question 52

When is open abdominal drain required? (2)

Answer 52

- cannot definitively address source - gross contamination/necrotic after

Question 53

Advantages of open abdominal drainage? (3)

Answer 53

- Decreased anaerobic bacteria proliferation - minimal fluid accumulation - potential for fluid lavage before definite closure

Question 54

Disadvantages of open abdominal drainage? (3)

Answer 54

Intensive post op management Hosp acquired infect Hypoprotein

Question 55

Survival rates of open abdominal drainage? (referral only)

Answer 55

52-89%

Question 56

Which infection associated with GI perforation carries a grave prognosis?

Answer 56

Candidal fungal

Question 57

Mortality rate for dogs having more than 1 surgery for septic peritonitis is higher than that reported for single? T or F

Answer 57

False

Question 58

What is increase mortality associated with?

Answer 58

- Increase: Lactate, bilirubin, ALP - Age - Decreased PCV and albulim - Hypotension and need for vasopressors

Question 59

Which patients are more likely to develop post op septic peritonitis? (3)

Answer 59

- pre op septic peritonitis - hypoalbumin - hypoprotein

Question 60

What analgesia (along with opioid) improves survival?

Answer 60

Lidocaine CRI