Shaver Case Presentation Flashcards
1 year old MN beagle mix
Presents in primary care setting for vomiting x24 hours, mild lethargy.
Known to be an indiscriminate eater.
Received full puppy vaccine series.
No other significant history.
QAR, mucous membranes tacky, adequate skin turgor, Abdomen tense on palpation.
PL: Vomiting, lethargy, abdominal pain, dehydration.
Differentials?
Vomiting:
GI vs extra-GI
Top?
Gastroenteritis
Foreign body or intussusception
Pancreatitis
Diagnostic plan:
Abdominal Radiographs, CBC,CHEM, UA
Good idea: sc fluids, antacids, gastoprotectants..
controversial (anti-emetic, cerenia, ondansetron)… antibiotics and steroids?
Obstructive pattern on radiographs, intestinal FB.
What is an obstructive pattern on radiographs?
Two populations of bowel. Body of L5 >1.6x= distention >2x = likely obstruction Rib width normal SI <2 Not 100%.. correlate with history, PE, clinical signs..SI diameter >3x cranial endplate of L2- 70% confidence. Remember fluid filled loops. Radiographs inconclusive? Contrast study.. ultrasound.. hospitalize and monitor! Body
Surgery plan for patient with intestinal FB..
Single enterotomy to remove rock FB.
Surgery report: incision made in jeunum over rock, enterotomy closed with 3-0 vicryl.
Patient given buprenorphine in pre-med.
Discharged with rimadyl and clavamox
Intestinal surgery patient…
Told to recheck in a week.
Next day zion still wont eat, lethargic.. nauseated (told to give patient cerenia)..
Exam: dull mentation, unwilling to rise, walk, tacky mm, distended abdomen..
Septic peritonitis
Septic peritonitis
Post op time frame?
Diagnosis: intracellular bacteria on cytology.. free air on radiographs (not in this case),
Glucose ratio; difference greater than 20 mg/dl, peritoneal fluid <50 mg/dl
Lactate ratio (peritoneal fluid >2.5mmol/L, peritoneal fluid > peripheral.
Septic peritonitis
Why?
Lag phase
Inappropriate technique
Unhealthy intestine
7-16% dehiscence rate after surgery
Intestinal surgery patient…
Told to recheck in a week.
Next day zion still wont eat, lethargic.. nauseated (told to give patient cerenia)..
Exam: dull mentation, unwilling to rise, walk, tacky mm, distended abdomen..
At surgery..
Dehiscence of enterotomy Resection and anastomosis performed using 3-0 monocryl. Critical components of this surgery either not described or performed: -Full ex-lap? did you miss something. -Appearance of the tissue. -CULTURE -Lavage, lavage, lavage! -Drainage techniques!
View ex-lap incision (not good!)
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Treatment for septic peritonitis..
Fluids
Recovered from surgery and discharged..
-Additional dose of butorphanol
-Discharged with IVC in place
-Started on metronidazole
-Recheck in 24 hours nausea, dehydration, pain, lethargy, head tremors..
TX: IVF (crystalloid at maintenance + replacing 8% deficit over 24 hours)
-Unsyn
-Pantoprazole
-Fentanyl CRI
..
Next morning.. distended abdomen, fluid from incision.. vomiting and intracellular bacteria on cytology of peritoneal fluid..
Drainage using a Jackson pratt closed suction drain third surgery, feeding tube..
Serosanguinous peritoneal fluid, fibrin clots.
Septic peritonitis
Post op care
Crystalloid maintenance fluids
Colloid for oncotic support
Unasyn and Enrofloxacin for broad spectrum antibiotic coverage
Fentantyl CRI
pantoprazole and famotidine
Regularly checking BP, ECG, TPR, drain production (volume, fluid character, cytology)
Generate and prioritize differentials for acute vomiting..
?
Compare and contrast the risks and benefits for treatment strategies for acute vomiting..
?
Interpret abdominal x-rays for acute vomiting..
?
Understand the indications for exploratory lap in vomiting patients..
?
Complications with GI surgery?
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