AcuteAbdomenPerioperativeCare

inAcuteSetting.

J.Iswanto.

1st SuGIESConferenceforGPMay19th 2017HotelNovotelSURABAYA

AcuteAbdomen

• Referstoabdominalpainofshortdurationthatrequiresadecisionregardingwhetheranurgentinterventionisnecessary.

• ThemostcommoncauseforsurgeontobecalledtoprovideasurgicalconsultationintheER.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.17.

Managementoptions

• Immediateoperation(surgerynow)• Pre-operativepreparationandoperation(surgerytomorrowmorning)• Conservativetreatment.(activeobservation,ivfluids,Antibiotics.• Dischargehome.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.19..

Clinicalpatterns

• Abdominalpainandshock• Generalizedperitonitis• Localizedperitonitis(confinedtoonequadrantoftheabdomen)• IntestinalObstruction.• Medicalillness:e.g inferiorwallischemic,basalpneumonia,leukemia.

Schein’sCommonSense EmergencyAbdominalSurgery,2nd Ed.p.19..

Case27-12-2016.B/F/51year.

• BP100/60mmHg• 128/bpm• RR24x/min.• Temp.37.8oC.• BW65Kg.• GCS456

CRANIAL

CAUDAL

X-RAY

Laboratorium 28/12/2016

Hb 13,4g/dL.

WBC 7.860/mm3

HCT 40,1

PLT 364.000/mm3

BUN/SC 55/3,47mg/dL

SGOT/SGPT 54/21mg/dL.

GDA/Albumin 77/2,71mg/dL

Na/K/Cl 139/4,6/110

BGA 28-12-2016

pH 7,06

PaO2 55

PaCO2 49

HCO3- 13.9

BE -16.4

Sa02 92%

P/Fratio 275

Thebestmanagement

• Old-establishedprinciples.(don’tre-inventthewheel)• Modernscientificunderstandingofinflammationandinfection.• Evidence–basedsurgery.• Personalexperience.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed. 2005,p.6.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.2005,p.4

THINKASANINFANTRYSOLDIER.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.2005,p.23.

AcuteAbdomen

ConsultSurgeonDigestiveSurgeon

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.2005,p.7.

PerioperativeCareIn

Acutesetting(EmergencyRoom)

Optimizingthepatient

Optimizingthepatient.

• Whypre-operativeoptimization?• Whatarethegoalsofoptimization?• Whoneedsoptimization?• Howtodoit.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.55.

O2

METABOLISMEAEROBE

Lacticacid

METABOLISMEANAEROBE

Rupii,Kollegium Ilmu Bedah IndonesiaPerioperativeCareCourseModul

Why?

• Volume-depletedpatientsdonottolerateanesthesiaandoperation.• InductionofGAandmusclerelaxationcausessystemicvasodilatation.• Openingabdomen,IAPsuddenlydeclines• Poolingofbloodinthevenoussystem• Decreasesvenousreturn,decreasesCardiacOutput.• Anemergencylaparotomyinanunder-resuscitatedpatientmayresultincardiacarrest,evenbeforetheoperationisstarted.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.55.

Whatarethegoals?

• Thechiefgoalofpreoperativeoptimizationistoimprovethedeliveryofoxygentothecells.Reasons:

• Patientinhypovolemicstateorsepsisandsepticshock.• Bothconditionpatientsinunder-perfusionofthetissuesandcells.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.56.

Pathophysiology

Hypovolemicstate:• Severedehydration• ECthirdspacefluidsequestration.• Patientsinunder-perfusionofthetissuesandcells.• Cellularhypoxia,• Anaerobicmetabolism,hyperlactatemia,lacticacidosis.• Cellulardysfunction,SIRS,MODS-MOF,adverseoutcome.

GANGGUANPERFUSI

Rupii,Kollegium Ilmu Bedah IndonesiaPerioperativeCareCourseModul

DAMPAKHIPOPERFUSIGLOBAL1. Hipoksia →metabolisme anaerob →laktat ↑.2. Gangguan fungsi organ:

a. Disfungsi jantung.b. Disfungsi paru.c. Disfungsi ginjal.d. Disfungsi saluran cerna.e. Disfungsi ginjal.f. DICg. ……dll

MOF

Rupii,Kollegium Ilmu Bedah IndonesiaPerioperativeCareCourseModul

O2HIPOKSIA

MODS/MOF(gawat)

Rupii,Kollegium Ilmu Bedah IndonesiaPerioperativeCareCourseModul

Laboratorymanifestation

• Hemoconcentration :• Highhemoglobinandhematocrit.• Urineanalysis:• Highspecificgravity(>1.039)• Electrolyteimbalance• Prerenalazotemia(BUNtoCreatinineratioof>20:1).• ABGanalysis:• Metabolicacidosiscausedoflacticacidosis.• Baseexcess(BE)<-6:significantmetabolicacidosismeans:• Poorprognosis,needforaggressiveresuscitation.

Whoneedsoptimization?

• PatientsdiagnosiswithAcut Abdomenassociatedwithsuchclinicalmanifestationandlaboratoryparameterabove.

Procedures

• Oxygenation• Restorationofvolume• Gastricdecompression• Indwellingurinarycatheter• DecompressionofACS.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.59-63.

Oxygenation

• Bagandmask• 8– 10l/min.• Airwayintubationandmechanicalventilationasindicated.

CARAdan DOSISTERAPIOKSIGEN

METHOD GASFLOW FiO2Nasal cannula 1 – 2 L / men 24– 28%

3 – 4 30 – 355 – 6 38 – 44

Simplemask 5 – 6 406 – 7 507 – 8 60

Nonrebreathingmask 6 607 708 80

9 – 10 90 – 99Venturi mask 4 – 8 24 – 35Oxygentent 8 – 10 40

OxygenDelivery

DO2 =COxCaO2

DO2 =(HRxSV)x(1,34xHb xSaO2+0,003xPaO2(5L/min)x(200cc/L)

=1000cc/min

Dalam keadaan basal,tubuh menggunakan 250cc/min

RESUSITASI RUMATAN

NUTRISIKristaloid

Mengganti kehilanganakut (hemorrhage,

GI loss, rongga ke-3)

1. Kebutuhan normal(IWL + urin+ feses)

2. Dukungan nutrisi

Terapi Cairan

Koloid Elektrolit

RESUSITASI

Agar volume intra vaskuler tetap cukup,sehingga preload cukup → stroke volume cukup →

diharapkan perfusi cukup.

RUMATAN

Yaitu memenuhi kebutuhan tubuh karena fungsisaluran cerna terganggu, (sehingga tidak bisa

mencukupi kebutuhan tubuh).

DistributionofInfusedSolutions

0% 20% 40% 60% 80% 100%

Interstitial fluid Intracellular fluidPlasma

Colloids0.9% NaCl

5% Dextrose

OXYGENCASCADE

SaO2 =97%

SvsO2 =70%

SmvO2 =65%

ER=25%Rupii,Kollegium Ilmu Bedah IndonesiaPerioperativeCareCourseModul

Volumereplacement

• Crystalloid:100– 200ml/hour.• Addition:Bolus250– 500mLgivenover15– 30minutes.

Schein’sCommonSenseEmergencyAbdominalSurgery,2nd Ed.p.63.

Monitoring

• Vitalsigns• Levelofconsciousness• Urineoutput• Oxygensaturation,• BGAandBE.• Lactateconcentration• CVPasindicated.• Sittingbythepatient:repeatedexamination.

Summary

• AcuteAbdomenneedaquickdecisionbyadoctorondutywhetherthereisinterventionornot.

• Mostacuteabdomencasesneedconsultationtosurgeon/digestivesurgeon.

• Acuteabdomenpatientfrequentlyinsevereinflammationandorgandysfunction.

• Optimizingthepatientbeforesurgeryisessential.

THANKYOU