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Part 2 : MANAGEMENT

Part 2 : MANAGEMENT. A C U T E A B D O M E N. You have made your diagnose of an Acute Abdomen and patient needs operation such as ? - Bowel obstruction,

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Part 2 : MANAGEMENT

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  1. Part 2 : MANAGEMENT A C U T E A B D O M E N

  2. You have made your diagnose of an Acute Abdomen and patient needs operation such as ? - Bowel obstruction, - Strangulation of bowel, like in an inguinal hernia! - Perforated ulcer What TO DO FIRST..........?

  3. Management A.A 1) Resuscitation !! then.... 2) Operate.... or.....Transfer

  4. Difficulties in diagnosing What to do if notsureabout Acute Abdomen..? • Resuscitate for 4 hours and observe patient - Ifno improvement:Decide.... - Operate or - Transfer

  5. What do you do in resuscitation ? • iv line and iv fluids why? • naso gastric tube - aspirate regularly why? • indwelling catheter why? • oxygen in serious cases • peri op: antibiotics, if indicated. Colon: aerobic/anaerobic bacilli LIKE: - a Cefalosporine or - Chloramfenicol 500 mg iv 6 hourly - Gentamycine - Metronidazol 7.5 mg/kg iv 8 hourly

  6. What kind of iv fluids do you have in your hospital? 1) Saline 2) Ringers lactate 3) Dextrose 5% 4) Half – and Full strenght Darrow What is that? Half or Full? • Half is 17mmol K/liter • Full is 34 mmol K/liter

  7. How much IV fluids? The right answer is : DEPENDS ONDEHYDRATION other names: HYPOVOLAEMIA or DEFICIT

  8. How much iv fluid is needed? Rough guidelines for person of 60 kg • Mildlydehydrated: signs? • - lips and tongue dry • - 4 liters iv • Moderatlydehydrated: signs? • - also sunken eyes, loss of skin elasticity: • - 6 liters iv • Severilydehydrated: signs? • - also oliguria/anuria, hypotension, clammy extremities: • - 8 liters iv . Start 4 liters in 1 hour • - also weak and desorientated: • - More than 8 liters, Danger of so much fluid iv ?

  9. More about iv fluids in resuscitation • What kind of fluidsdo you give? - First half of deficit: Ringers lactate or Saline - Second half: 5% dextrose Why dextrose? • Which electrolyte needs to be replaced in a vomiting patient? Potassium • How to replace that most simply? - By full or half strength Darrow solution - Every second bottle.... afterthe deficit

  10. Still about Resuscitation • How do you know you give enough iv fluids? - if he is passing urine • How much urine before going to theatre? - at least 35 - 60 cc/hr - ideally ? 150 cc • Maintenance iv fluid: - at least 3 liters iv daily (1 l saline, 2 dextrose) fluid loss: skin: 1000 cc, lungs: 500 cc, urine: 1500cc Make sure: urine production 3 p.o. day: at least 1500cc

  11. Decided: operation is needed.......To transfer or not to transfer ? General rule: • Transfer for operation, but after resuscitation! • If you can’t transfer do a laparotomy • Inform patient

  12. No…… I want to have a CO as my surgeon who attended the training in Malawi………

  13. Remember .....what is the most likely diagnose of BOWEL Obstruction? • External hernia (73%) • Sigmoid volvulus (13%) • Intussusception (4%) • Bands and adhesions (4%) • Malignant diseases, adult pyloric obstruction and congenital anomalies (1%) So make preparations before starting operation

  14. Be prepared in bowel obstruction to find • Distended and Necrotic bowel so.... ask the theatre nurse BEFORE operation starts for .......? 1. decompressor (or a urine catheter) 2. bowel clamps, bowel sutures (chrcatg, vicryl) 3. saline for cleaning abdominal cavity • What kind of anaesthesia? - General • What is the major risk in general anaesthesia in bowel obstruction? - Aspiration. So what do you do to prevent aspiration?

  15. ABSOLUTE OPERATIVE treatment ? • 1) In all clinical signs of Perforations - Symptoms of a perforation? - Examples? - perforated peptic ulcer - perforated typhoid ulcer • 2) In all symptoms of Strangulation OPERATE, unless the patient is moribunt

  16. Operation indications

  17. When notto operate..... LOCALISED INFLAMMATORY MASS - Appendicitis unless/until ? - PID unless/until ? - Tb peritonitis • But how to treat ?? - by CONSERVATIV treatment FIRST What is that? - suck and drip - for how long ? • What are signs of improvement in conservativ treatment?

  18. Acute abdomen due to BOWEL OBSTRUCTION Some information about OPERATIONS

  19. Operative treatment • Incisions • Finding the cause • What to do next ? • Post operative care

  20. ANATOMY

  21. Incisions

  22. After opening abdomen: finding the cause

  23. HOW to DECOMPRESS? Insmall bowel by SUCTION? 1) via naso gastric tube and maneuver (C) is the preferred method, why? 2) metal decompressor or 3) urine catheter, large size

  24. Finding the cause • Is Gut dead or viable? Signs?

  25. If a bowel resection is needed What kind of ANASTOMOSIS ? • end/end • end/side • side/side 1 layer, preferrably vicryl

  26. What to do in : • 1) Necrotic SMALL bowel? - Resect and do: - preferrably an end/end anastomosis • 2) NecroticLARGE bowel? Resect and do: - Hartmann procedure (preferred ) - Exterization - Colon anastomosis + proximal colostomy In general: NOT SURE of the anastomosis in LARGE Bowel ALWAYS a proximal colostomy! and transfer later for further management

  27. What to do in • COLON ILEUS due to Cancer? - Proximal colostomy and REFER to surgeon • In a PEPTIC ULCER PERFORATION? - Close the perforation - Wash out

  28. What is the diagnose in the nextpatient? • An adult man • Complains of diffullty in passing flatus • Increasing abdominal distention (tympanic like a drum) • Not very painful • General condition is usually good, can drink, • Not dehydrated LIKELY DIAGNOSE? ............... • How to confirm? • X ray: erect abdominal. Look for the ?....... - Reversed U • Management?: deflation with scope and pass a rectal tube (36 Ch or 12 mm) • Prepare for operation

  29. The reversed U sign(FrimannDahls sign)

  30. Position

  31. Operative management in Sigmoid Volvulus • Loop necrotic RESECT: 3 choices - Primary anastomosis with prox colostomy - or Hartman procedure - or Exteriorization • Loop notnecrotic: - untwist, deflate, fIX sigmoid (PROSC) (non absorbable suture material)

  32. Do not operate yourself Refer to surgeon Central Hospital 3 months later Closing Hartmann

  33. Other findings at operation: Intussusception What to do? - Manual reduction and inspection of the bowel - check if bowel is vital (how?) - if bowel is necrotic or in doubt: resection and anastomosis

  34. STOMACOMPLICATIONS

  35. What to do in bands and adhesions?

  36. Direct Post op Care: DAILY visits • Continue NG tube when to remove ? …..flatus, peristalsis, less stomach fluid • How much fluid / 24 hrs? …..3 liters fluid iv: - 1 liter 0.9 % Saline, 2 liters 5% dextrose • Continue urine catheter and measuring urine output - on the third day it should be about: 1500 cc / 24hrs • After 2nd/3rd day: Potassium need: 40 – 80 mmol/24 hrs - give half strength/ full strength Darrow • Start oral feeding: when? - bowel sounds and flatus - start thin porridge

  37. The END of the Acute Abdomen Thank you

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