High Risk Children and Adults Steven Teich MD Daniel Cohen MD Ann Dietrich MD Osama ElAssal MD John Shultz MD Study Aims Aim 1 Describe the presentation of acute abdomen in medically fragile high risk children and adults to expedite the recognition of a surgical emergenc ID: 481484
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Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults
Steven Teich, M.D.
Daniel Cohen, M.D.
Ann Dietrich, M.D.
Osama El-Assal, M.D.
John Shultz, M.D.Slide2
Study Aims Aim 1:
Describe the presentation of acute abdomen in medically fragile, high risk children and adults to expedite the recognition of a surgical emergency
Aim 2:
Develop a diagnostic algorithm for
patients
with special care needs with possible intra-abdominal emergencySlide3
BackgroundThere are an estimated 9 million children and 23 million adults in the U.S. with special health care needs
Large subset of special health care needs patients at risk to develop acute surgical abdomen due to co-morbidities
Multiple abdominal surgeries
Indwelling abdominal devices
Chronic constipation
Nissen
fundoplicationSlide4
BackgroundAdhesive peritoneal bands occur in 93-100% of patients with prior abdominal surgery
Nissen fundoplication increases the risk of adhesive SBO up to 21% in children
Incidence of complications after VP shunt varies from 5-47%
-
CSF
pseudocyst
-Inguinal hernia
-SBO -Intestinal perforation
-CSF
ascites
-Intestinal entanglement
-Shunt displacementSlide5
BackgroundNonverbal children and adults with altered sensation often unable to communicate symptoms classically associated with acute abdomen and often present with subtle manifestations
Therefore, this patient population at greater risk for acute abdominal surgical emergencies and delayed or missed diagnoses with potentially catastrophic outcomesSlide6
Study DesignStudy conducted at Nationwide Children’s Hospital, Columbus, OH (#IRB09-00151)
Retrospective case-controlled study with patients serving as their own control
Review of hospital discharge data including ICD9 codes and surgical case records
Inclusion criteria: patients with neuro-developmental delay with diagnosis of acute surgical abdomen within 48 hours of hospital admission from the Emergency Department between May 2005 and October 2009Slide7
Study Design
Acute surgical abdomen defined as an abdominal surgical procedure demonstrating a pathological process or an IR procedure for abdominal pathology (e.g. drainage of CSF cyst)
Each subject had to have an index ED visit during which an acute surgical abdomen was diagnosed and a control ED visit which proved to be negative for an acute surgical emergency
The control visit required to have occurred within two years of the acute surgical abdomen visit but at least two months distant to avoid repeat presentation for the same illness Slide8
Study Definitions
Feeding intolerance
Decreased oral intake or vomiting in orally fed patient
Abdominal distention, discomfort, or increased gastrostomy tube output after oral or gastrostomy feeds
Pain
Described by patients able to communicate
Interpreted by caregivers as changes in behavior consistent with feeling abdominal pain such as grimaces or moaning with abdominal touch
Constipation
New onset or worseningSlide9
Results
169 patients with special needs had abdominal procedures over the study time period
24 patients met the selection criteria after screening for elective surgical procedures and lack of a qualifying ED control visitSlide10
Demographic Data
Variable
Number
Age (years)
14.37
+
9.58
(22, 31, and 43 year olds)
Gender
16
male/ 8 female
Residence
19 home/ 5 facility
Mode of Feeding
17 tube/ 10 mouth/ 3 combined
Implants/Surgical Procedures
11 VP shunt
17
gastrostomy tube
16 Nissen fundoplication
4 tracheostomy
1
central line
Number of ED visits/year
(Over past 3 years)
1.49
+
1.28
ED visit/admission ratio
2.06
+
2.35Slide11
ED Index Visit (Surgery)
Etiology
Number (%)
Adhesive SBO
11 (45.8%)
Shunt-related CSF cyst
5 (20.8%)
Volvulus
3 (12.5%)
Malrotation
2
(8.3%)
Hiatal Hernia
1 (4.1%)
VP-tube
related intestinal entanglement
1 (4.1%)
Peritonitis
1 (4.1%)
Total
24 (100%)Slide12
ED Control Visit (No Surgery)
Etiology
Number (%)
Ileus
6 (20.8%)
Gastroenteritis
4
(1
6.6%)
Unknown
3 (12.5%)
UTI
2 (8.3%)
URI
2 (8.3%)
Colitis
1 (4.1%)
Sepsis
1 (4.1%)
Pancreatitis
1 (4.1%)
Feeding intolerance
1 (4.1%)
Pneumonia
1 (4.1%)
SMA Syndrome
1 (4.1%)
Cyclic vomiting
1 (4.1%)
Total
24
(100%)Slide13
Symptoms at Presentation
Variable
Surgical Abdomen
Control Visit
p Value
Respiratory distress
Yes 11
No 13
Yes 9
No 15
0.47
Fever
Yes 8
No 16
Yes 12
No 12
0.20
Vomiting
Yes 18
No 6
Yes 10
No 14
0.008 *
Feeding intolerance
Yes 9
No 15Yes 4No 200.059ConstipationYes 8No 16Yes 4No 200.20DiarrheaYes 3No 21Yes 10No 140.019 *Abdominal painYes 19No 3Yes 11No 130.011 *Abdominal distentionYes 17No 7Yes 10No 140.034 * Behavior changesYes 18No 6Yes 13No 110.13
* p < 0.05 Slide14
Physical Findings at Presentation
Variable
Surgical Abdomen
Control Visit
P Value
Tachypnea (>98%ile)
Yes 13
No 11
Yes 11
No 13
0.50
Tachycardia (>98%ile)
Yes 15
No 9
Yes 14
No 10
0.99
MAP
83.67 + 15.2
(N=23)
80.34 + 20.53 (N=22)
0.55
Dehydration
Yes 18
No 5
Yes 12No 110.031 *Abdominal DistentionYes 17No 7Yes 9No 150.007 *Abdominal TendernessYes 18No 6Yes 5No 190.006 ** p < 0.05 Slide15
Laboratory Results and Diagnosis of Acute Surgical Abdomen
Variable
Surgical
Abdomen
Control Visit
p Value
WBC
13,900
+
7,100
9,900
+
4,000
0.008*
Segs
61.5
+
22.4
57.8
+
23.2
0.036*
Bands
13.2 + 16.612.6 + 16.60.66Bicarbonate25.9 + 7.926.0 + 6.10.091Sodium140.9 + 5.5138.3 + 3.60.013*Potassium4.3 + 0.83.8 + 0.480.59Chloride99.2 + 19.798.5 + 19.30.022*Glucose149.2 + 50.8122.8 + 44.80.002*BUN22.8 + 20.614.6 + 6.90.044*Creatinine
0.8 + 0.600.55
+
0.29
0.047*
* p < 0.05 Slide16
Early ED Management and Diagnosis of Acute Surgical Abdomen
Variable
Surgical
Abdomen
Control Visit
p Value
O
2
requirement
Yes 4
No 20
Yes 6
No 18
0.50
Fluid resuscitation
Yes 18
No 6
Yes 12
No 12
0.031*
Number of fluid
boluses
1.30
+
1.100.78 + 0.950.036** p < 0.05 Slide17
Radiology Testing
Variable
Sensitivity
Specificity
Negative Predictive Value
Positive Predictive Value
AAS
0.57
1.0
0.62
1.0
Abdominal CT
0.94
1.0
0.92
1.0Slide18
Patient #1Slide19
Patient #1Slide20
Patient #2Slide21
Patient #2Slide22
Predictive Variables For Surgical Abdomen
Variable
p Value
Abdominal distention
0.027
Abdominal pain
0.009
Vomiting/ Increased gastrostomy output
0.001
No diarrhea
0.017
Abdominal tenderness
0.001
Elevated WBC
0.006
Number of fluid boluses
0.041Slide23
Yes
Abdominal ultrasound
Positive
Negative
Observe and reassess every 2 hours
No
Acute abdominal series
Positive
Negative
High Risk Patient with Clinical Suspicion or ≥ 2 of :
Vomiting/Increased G tube output
Abdominal pain, Tenderness, Dehydration, Absence of diarrhea, or Elevated WBC:
V-P shunt
Abdominal CT with contrast
Positive
Negative
Definitive treatment
Definitive treatmentSlide24
ConclusionsFirst study on high-risk patients with suspicion for acute surgical abdomen
P
resence of abdominal pain, abdominal distention, increased gastrostomy tube output or vomiting, abdominal tenderness, and signs of dehydration are significant predictors of need for emergency
surgery in high
risk,
medically fragile patients Slide25
ConclusionsWe propose abdominal ultrasound as the initial modality for patients with VP shunts when presenting with a possible acute surgical abdomen
Positive AAS is reliable finding but negative AAS can be misleading and a further confirmatory test is indicated
Abdominal CT is most reliable imaging modality
Our pathway for atypical, medically fragile patients at high risk for an acute surgical abdomen needs to be
validated
by
a prospective study with a larger cohortSlide26
Questions?