Deficiencies with Short Bowel Syndrome

General

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  use of perioperative B-blockers recommended for patients with CV risk factors or known disease; however, its use is probably not as helpful in low-risk patients / risk of postoperative cardiovascular complications does not appear influenced by stable HTN, elevated cholesterol, obesity, cigarette smoking or BBB
  

Post-Operative Fever

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  atalectesis – occurs early – low temp
  
• 
  wound infection (Abx, drainage)
  
  • 
    early: Streptococcus (common), Clostridium (uncommon)
    
  • 
    late: staphylococcus / includes IV site infections
    

• 
  intra-abdominal sepsis/abscess – 5-7 days (get CT abdomen)
  

1/07 current recommendation is to stop Lovenox either night before surgery (12 hrs or some now are saying full 24 hrs before to allow anticoagulation effect to fully wear off)

DVT prophylaxis (in general)

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  reduces risk of DVT by 50% and PE 60%
  
• 
  relative risk increase of severe bleeding episodes 1.3
  

Current recommendation for elective surgery for abdominal cancer is 4 weeks Lovenox

Prevertebral emphysema [pic]

Trauma/Burns
Trauma
Airway

Breathing

Circulation
IV access: 2 large-bore (Q = l/r⁴ / volume status: check urine output

O₂: give oxygen to increase O₂ sat and dissolved O₂

Plain Films: chest (1^st), cervical, pelvis

Labs: CBC, H/H, UA, drug screen, amylase?
must keep spine immobilized (can r/o cervical spine trauma in awake/alert patient)

thoracic spine / cord transection / – rectal exam (feel for prostate/rectal tone)

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  spleen (1^st), liver, kidney, mesentery, pancreas, Jejunum more likely to rupture
  

• 
  bladder (then spleen, liver) most commonly injured intra-abdominal organ from blunt trauma
  

diagnostic peritoneal lavage (DPL)

decompress stomach and bladder

open laparotomy if high RBC (over 10,000)

if high-prostrate or frank blood in urine  don’t put a Foley / get retrograde urethrogram

Myocardial contusion (10% with shock or arrhythmias)

Widened mediastinum (10% with aortic rupture)

Pulmonary contusion

Within 12 hrs of injury – worsens for 48 hrs – then gets better – or progresses to ARDS
Tip: r/o esophageal rupture with barium contrast when suspecting oral-pleural communication because water-soluble contrast creates an ARDS-like picture
Eye Trauma
1 million cases/yr / get optho consult within 24 hrs with acid/base burns, decreased visual acuity, severe conjunctival swelling, corneal clouding

Foreign body (25% of eye trauma)  consult with any intraocular foreign body (even without physical exam findings) / Wood’s lamp (fluorescein dye given now and serially every day) / antibiotics

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  Fe, steel, Cu  inflammatory reaction
  
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  Glass, lead, stone  decreased inflammatory reaction
  
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  Vegetable  purulent endopthalmitis
  

DO NOT examine a ruptured globe / patch and refer to optho STAT

eyelid laceration can be repaired after ruling out lid margin and lacrimal apparatus involvement
Burns
Rule of 9’s / palm = 1%

Get CO-Hgb levels

give ½ of total in first 8 hrs, next ½ in next 16 hrs (based from time of injury)

Placement of arterial lines [video]

ALG (antibodies?) decreases T-cell numbers

Steroids moves lymphocytes into RES and decreases Il-2 production

Radiation

Azathioprine (Immuran) decreases DNA synthesis

Cyclosporine (Sandimmune) blocks IL-2 / decreases T-cell numbers

vasculitis, thrombosis, necrosis – antibodies to MHC, ABO blood groups

Repeated attacks

Eventual fibrosis

Cystitis (with Cytoxan)

Oral mucositis, alopecia (common)

Venoocclusive disease of liver (from hypercoagulable state; peak incidence ~day 16)

Total body irradiation: cataract formation, thyroid dysfunction

Cognitive dysfunction: reasons not entirely clear

Neutropenic Fever

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  Neutropenia: neutrophil count < 500 cells/mm³ or < 1000 cells/mm³ with predicted decrease to < 500 cells/mm³
  
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  Fever: single oral ≥ 38.3 C (101 F) or ≥ 38.0 (100.4 F) for ≥ 1 hour
  
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  Nadir of WBCs 10-14 days after chemotherapy / risk of infection increases with duration/severity of neutropenia (>7-10 days)
  
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  5-10% of cancer patients die from neutropenia-associated infections
  
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  elderly and immunosuppressed may not mount febrile response: cellulitis may not be obvious, pneumonia without infiltrate on CXR, meningitis without typical CSF findings, UTI without pyuria, etc.
  
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  necrotizing enterocolitis (typhlitis): cecum > large bowel/ileum / may result in bowel perforation or infarction
  

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  remove (non-tunneled) lines/catheters; talk to ID about more permanent/tunneled lines in case there is a need to attempt to treat through it)
  
  • 
    S. aureus and S. epidermidis (coagulase negative) are most common (more likely to be able to treat through line infection with coagulase negative Staph; most other organisms (fungus, gram negative, etc.) or if patient is septic/hemodynamically compromised, line will almost certainly require removal
    

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  pip/tazo or cefepime
  
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  consider adding cipro or tobramycin for double coverage of Pseudomonas (e.g. if pneumonia suspected)
  
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  add vancomycin if suspect gram positive or (+) lines
  
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  if PCN allergic  tobra/cipro/metro
  
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  if fever persists 3-5 days, can add amphotericin B and/or vancomycin empirically
  

1. 
   if pt has history of febrile neutropenia with previous round of chemotherapy
   
2. 
   if pt has 40% of becoming neutropenic
   

GCSF has been shown to reduces hospitalization and duration of neutropenia following chemotherapy (no overall change in mortality demonstrated as of time of this notation 8/04)

Note: use of G-CSF once patient already neutropenic controversial 8/04
Erythropoietin can be used to increase red blood cell count but it takes weeks to work, and will probably not work if patients own erythropoietin levels already > 100 mU/mL

Emergency Medicine (not in other places)

Rapid rewarming in bath 37-40 / give analgesics / can lower temperature if too painful

No medications proven to improve outcome as of 1/07

Usu. best to defer decision about amputation until viable tissue margins become demarcated

Long term complications: neuronal injury with abnormal sympathetic tone, cutaneous carcinomas, nail deformities, epiphyseal damage (in children)
Methemoglobinemia (see other)
Environmental / poisonings / ingestions / etc

Other Topics

ARR (absolute risk reduction)

NNT (number needed to treat) = 1/ARR
Randomization using volunteers eliminates lead time, selection, and length bias (overdiagnosis)

Does not eliminate generalizability error

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  Trials using volunteers  efficacy studies
  
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  Population-based subjects  effectiveness studies