General surgery


General surgery


Anatole V Wiik


Outline





Thromboprophylaxis


All patients admitted to hospital require a VTE prophylaxis assessment.








Nicole’s Risk Factors and Bleeding Risk



Nicole has no bleeding risk factors. Therefore, in addition to mechanical VTE prophylaxis, heparin prophylaxis is required as her VTE risk is high.




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Figure 8.1



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Figure 8.2


Note that the patient will need to be fasted preoperatively. Policy for this will vary between units. Once a time for surgery is settled, the patient, for instance, would not be allowed water or oral medications for 4 hours preoperatively. Therefore, oral medications would not be allowed in this time window.




Station 8.2: Acute pancreatitis


You are the surgical junior doctor in the emergency department. A 42-year-old obese female with a background of gallstones presents with severe epigastric pain radiating to the back. She has vomited on multiple occasions and feels that she is becoming more breathless. Please assess her and commence appropriate management.








Initial Assessment








Initial Investigations



ent Arterial blood gas: A metabolic acidosis is characterized by a low pH and bicarbonate with an increasingly negative base excess and elevated lactate. She may be compensating her pH by hyperventilating; a low CO2 would confirm this


ent Baseline bloods: FBC, U&E, CRP, LFT, amylase, LDH, calcium, coagulation profile and blood sugar. A raised amylase, 3 times its upper limit, is highly sensitive for acute pancreatitis. Assess her LFTs, raised ALP and bilirubin may be due to a stone in her common bile duct, and this could be causing pancreatitis. A CRP is a good surrogate to assess inflammation, the greater the more aggressive the inflammatory process. A raised WCC count may indicate infection (sometimes upper abdominal pain can be caused by a lower lobe pneumonia, or abdominal sepsis) but may be raised purely due to pancreatitis. A dropping Hb may be a sign of retroperitoneal haemorrhage. Additional bloods listed are used for severity scoring


ent Imaging: A CXR is extremely important to assess any element of ARDS. Diffuse bilateral pulmonary infiltrates are indicative of severe pancreatitis and that respiratory support may be pending. No free air under the diaphragm reduces the likelihood of perforation. An ultrasound is important; this will determine the aetiology and severity of the pancreatitis, 40% of pancreatitis is due to gallstones. The presence of stones and a dilated CBD is a good indicator of its origin. A non-dilated CBD does not exclude gallstones as the cause of pancreatitis



‘ABG shows a pH of 7.32, PaCO24 kPa, PaO210 kPa, HCO318 mmol/L, lactate 3 mmol/L and BE is−4 mmol/L. Hb 135 g/L, CRP 250 mg/L, WCC 18×109/L, amylase 477 IU/L, bilirubin 50 µmol/L, ALT 45 IU/L, ALP 200 IU/L, potassium 4 mmol/L, sodium 138 mmol/L, creatinine 175 µmol/L and urea 16.5 mmol/L (eGFR 36 mL/min). Initial Imrie score is 2 (WCC and urea). CXR shows mild bilateral pulmonary infiltrates, no free air under the diaphragm. USS shows multiple gallstones with a CBD diameter of 12 mm. The pancreas is markedly inflamed, but no obvious collections.’



Initial Management [2]



ent Get help early: ITU team and senior surgical team members


ent Airway and breathing support: High-flow oxygen with a non-rebreather mask, maintain oxygen saturation>94%


ent Analgesia: Opioids early to prevent any splinting of diaphragm due to pain. Patients generally require a PCA to control the pain; the ITU team will help you with this, but you can start with a regular oral morphine preparation


ent Fluid support: Monitor intravascular fluid volume with serial creatinine and urine output. Patients with severe pancreatitis normally need>5 L within the first 24 hours due to third space loss (the space between tissues where fluid does not normally collect). May require central access for blood pressure monitoring and accurate fluid balance


ent Nutrition: Acute pancreatitis is a catabolic event and promotes nutritional deterioration. Early feeding plays an important role in accelerating recovery. Start with oral fluids and avoid fatty foods. NG/NJ feeds may be required if unable to tolerate oral feeds. TPN is used for specific indications such as a paralytic ileus


ent Supportive: VTE prophylaxis as guided by trust guidelines, both mechanical and pharmacological


ent Gastric protection: A lot of patients will get started on proton pump inhibitors since they present with epigastric pain initially, which could be caused by a gastric ulcer. It would be reasonable to start one in this case. However, they are not indicated routinely in pancreatitis, particularly if it is mild


ent The patient should be placed nil by mouth given the severe pain and vomiting. Oral medications (plus fluid and diet) can be restarted as soon as the patient can tolerate them. This could be after as little as a day if the pancreatitis is mild, but may be several weeks.


Nov 18, 2017 | Posted by in PHARMACY | Comments Off on General surgery
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