Today we welcome back Samuel Tisherman, MD, Professor of Surgery and Director of the Center for Critical Care and Trauma Education and the Director of the Surgical ICU of the University of Maryland Medical Center. Dr. Tisherman recently joined UMMC directly from The University of Pittsburgh, where he was the Director of the Multidisciplinary Critical Care Training Program and program director for the Surgical Critical Care Fellowship. In his 20 years at the University of Pittsburgh he held several other titles, including Associate Director of the Safar Center for Resuscitation Research, Professor in the Departments of Critical Care Medicine and Surgery, and Director of the Neurotrauma Intensive Care Unit. Today we are fortunate to have Dr. Tisherman speak on what he know’s best: the cursed surgical abdomen. Over the next 60 minutes he navigates this unstable mine-field and leaves you with a better understanding of the thought process used before opening someone’s abdomen!
Clinical Pearls: Assisted by Dr. Cameron Kyle-Sidell
- General Evaluation
- Exam:
- Difficult due to patient clinical status
- Helpful if you can determine focality of pain
- Bad: pain with tapping of abdomen and/or movement of bed (peritoneal signs)
- Labs:
- CBC w/ diff, LFTs, pancreatic enzymes, lactate
- Imaging:
- Plain films: What to look for?
- Free air – Rigler sign – air on both side of bowel walls
- Extra-luminal air fluid levels
- Obstruction – large vs. small
- Where are the tubes?
- CT
- Consider other imaging: ultrasound, MRCP, HIDA, Contrast studies w/ fluoro
- Plain films: What to look for?
- Exam:
- General management
- Classification of peritonitis
- Primary: SBP – Gram +, E.Coli
- Secondary: Perforation – Gram negatives, anaerobes
- Tertiary: Mult laparotomies – Fungal, enterococcus, Pseudomonas, resistant GNR
- Antibiotics
- Conver GNR + anaerobes
- Community acquired:
- Mild/Moderate: Cefotoxin, Fluoroquinolones, Flagyl + early gen Cephalosporins
- Severe: Carbepenems, Zosyn, Flagyl + later gen Cephalosporins
- NOT RECOMMENDED: Unasyn (resistant E. Coli), cefotetan or clindamycin (increasing resistance), empiric antifungals, empiric aminoglycosides (toxic, similar efficacy to other drugs
- Heath care associated:
- Cover Fungi, Enteroccocus, MRSA
- Duration of therapy:
- Generally 4 days after source control
- Landmark study: STOP IT (Study to Optimize Peritoneal Infection Therapy) – no difference between 4 days s/p source control and stopping based on clinical criteria
- Never forget to resuscitate the septic patients!
- Classification of peritonitis
- Source control
- Case 1: Mesenteric ischemia
- CT scan:
- Portal venous gas at liver periphery (as compared to biliary gas which is central)
- Pneumatosis: Air behind liquid/solid materials
- Mild elevation in lipase and amylase possible with ischemia without pancreatitis
- Diff to diagnose and manage due to multiple co-morbidities and clinical instability
- CT scan:
- Case 2: Perforated ulcer
- Consider operative vs. nonoperative management
- Non-operative: Stable, no peritoneal signs, not severely septic, minimal pneumoperitoneum, no extravasation
- Consider operative vs. nonoperative management
- Case 3: Loculated abscess (diverticulitis)
- Consider percutaneous drainage
- Case 4: C. Diff Colitis
- Management: Antibiotics (metro, enteral vanco, fidaxomicin) vs. Surgery (total abdominal Colectomy, loop Ileostomy)
- Case 5: Acalculus cholecystitis
- Usually normal LFTs + pancreatic enzymes
- Management: Abx w/ or w/o cholecystectomy (risk assessment)
- Case 6: PEG tube malpositioning
- Always consider post-procedure complications first
- Case 7: Pancreatitis
- Imaging: Ultrasound to r/o gallstones, MRCP if concern for CBD stone, CT to rule out other diagnosis and look for complication
- Management: Enteral nutrition, no antibiotics, selective ERCP, drain fluid collections
- Case 8: AAA
- Post-op complications: bowel ischemia, bleeding, infection, vascular injury, distal ischemia, endoleak, cardiac events, respiratory failure, acute kidney injury, ischemic colitis, spinal cord ischemia (rare)
- Case 1: Mesenteric ischemia
- Abdominal Compartment Syndrome
- Bladder pressures:
- >12 ⇒ intraabdominal hypertension
- >20 + end-organ dysfunction ⇒ abdominal compartment syndrome
- Classification
- Primary – Intraabdominal
- Secondary – Extraabdominal
- Tertiary – Recurrent
- Organs effected
- Kidneys – Decrease RBF
- Pulmonary – Increased intra-thoracic pressure, may benefit from PEEP
- Cardiac – Decreased VR – IAP > 15, increased afterload, can increase CVP
- Splanchnic – Decreased blood flow
- Liver – Decreased Portal flow
- Neuro – Multiple compartment syndrome
- Risk factors
- Massive crystalloid fluid resuscitation (> 5 L in 24 h)
- Multiple transfusions (> 10U in 24 hrs)
- Hypothermia (Core temp < 33)
- Acidosis (PH < 7.2)
- Body mass index (>30)
- To decrease risk
- Avoid crystalloids
- Burn resusc w/ plasma or colloids
- Open abdomen (damage control approach)
- Landmark study: J Trauma Acute Care Surg. 2014 showed decreasing crystalloids decreased abdominal compartment syndrome
- Avoid crystalloids
- Nonoperative management
- Sedation and paralysis to relax the abdominal wall
- Evacuation of intraluminal contents
- Evacuation of large abdominal fluid collections
- Optimize abdominal perfusion pressure
- Correct a positive fluid balance
- Keep abdominal perfusion pressure: MAP – IAP > 50mmHG
- Operative Approach
- Decompressive laparotomy
- Bladder pressures:
- Drains
- Can’t drain entire abdomen!
- Used
- Post-op
- Abscess
- Controlled fistula
- Risks
- Erosion
- Retro contamination
- Neg pressure VAC
- Decreases edema, inflammatory response, bacterial burden
- Increases blood flow
Suggested Reading
- Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ, O’Neill PJ, Chow AW, Dellinger EP, Eachempati SR, Gorbach S, Hilfiker M, May AK, Nathens AB, Sawyer RG, Bartlett JG. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010 Jan 15;50(2):133-64. [Pubmed Link]
- Montravers P, Blot S, Dimopoulos G, Eckmann C, Eggimann P, Guirao X, Paiva JA, Sganga G, De Waele J. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med. 2016 Aug;42(8):1234-47. [Pubmed Link]
- Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015; 372: 1996-2005. [Pubmed Link]
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