Maedeh Dahaghin History A female patient named FEf aged 86 from Tehran and has 3 offsprings housewife and has no spesial habits Complaints Constant and non positional abdominal ID: 1045468
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1. Case of Perforated DiverticulitisMaedeh Dahaghin
2. HistoryA female patient named F.Ef aged 86 from Tehran and has 3 offsprings, housewife and has no spesial habits.
3. ComplaintsConstant and non -positional abdominal painConstipateInsomniaAnorexiaNausia and Vomiting
4. History of the present illness The constipation started 4 days before admission abdominal pain that is constant and non-positional. the EKG led to AF and the reason of spO2=83% is Pulmonary edema.GCS 15/15SpO2:83%PR:73%BP:100/70Vital signs:
5. Past historyPMHHemorrhoid ConstipationangiographyOther active problems:Pulmonary edemaUnilateral renal atrophyAFPDHNitroglycerinAtorvastatinASAHydrochlorothiazideCarvedilol
6. ExaminationWe need CT but We have a problemDue to GFR=25 , the patient is at high risk of receiving a contrast agent but is necessary so following check up is crucial:✔Check of BUN, Na, k daily until 72h after CT✔Use the least amount of contrast agent
7. Diagnosis after CT scan Perforated Diverticulitis
8. Diverticula • Small (0.5 - 1.0 cm) pouches protruding from bowel wall • Most pseudo diverticula: mucosa and submucosa only- muscle layer not present • True diverticula: all layers of the bowel wall involved • Up to 60% of people living in industrialized countries will develop colonic diverticula.
9. Pathophysiology Diverticular Disease• Increased intraluminal pressure • Caused by low fiber, constipation • Sigmoid colon most commonly involved (95%) • Smallest diameter • Laplace’s law: generates highest pressure • Incidence of diverticular disease increases with age: • 30% at age 60 • 60-80% at age 80
10. Risk factorsLow fiber Diet SmokingConstipationObesityKidney DiseaseCoronary Heart DiseaseHyperlipidemiaHypothyroidismDiabetes Mellitus
11. Clinical ClassificationUncomplicated vs. Complicated • Uncomplicated : Pericolic soft-tissue stranding colonic wall thickening phlegmon • Complicated: Acute diverticulitis + Abscess Obstruction Perforation Fistula
12.
13. Presentation• Symptoms • LLQ Pain, Fever, Diarrhea or constipation, Urinary symptoms if inflammation adjacent to the bladder •Classic Triad :Fever, Leukocytosis, LLQ tenderness Free perforation: peritonitis, sepsis
14. ManagementComplicated Diverticulitis: Free perforation • 1% to 2% of cases • Mortality between 20% - 30% • Hinchey Stage III - Purulent peritonitis • Hinchey Stage IV - free perforation with fecal peritonitis
15. According to current ASCRS guidelines, HP recommended Emergent Surgical Intervention for Management of Hinchey III & IV disease
16. Surgical Intervention the patient was anesthetized with Etomidate and intubated.Injection of Norepinephrine to prevent hypotension, and NaHco3 to correct metabolic acidosis.PH:7.27, PCO2:39.2, HCO3:17The patient came to ICU intubated with drip of norepinephrine.
17. Patient Management (ICU)In the ICU Heparin was started in the early hours due to EKG changes and elevated troponin. Cardiac troponin is specific and sensitive biomarker of cardiac injury(MI).Heparin 500-600 u/h
18. Troponin changes
19. ManagementCO was between 0.5- 1 increase the preload.What can we do? increase the volume.hypotonic fluids such as saline half, dextrose 5% and 1/3 2/3 Isotonic solutions such as Ringer, lactate ringer and NaCl 0.9% or hypertonic solutions such as Albumin 20% and 5% sodium chloride are suitable.
20. Sepsis, a recurring eventoccurs in hospitalized or who have recently been hospitalized. People in an intensive care unit sensitive to sepsis. Any infection, however, could lead to sepsis.
21. Antibiotic therapy
22. In this case:RR=15SBP=95GCS:3/15
23. Septic shockWith a mortality rate about 50% .Intervention should be performed in the first hour , otherwise organ damages will be increased.
24. Sepsis managementSepsis management bundle to be implemented within 1 hour of onset of sepsis:Consider intravenous fluid resuscitation.Administer intravenous antibiotics.Consider intravenous fluid resuscitation.Use Norepinephrine and if CO Norepinephrine + epinephrine
25. Vitamin C1-Prevention of Sepsis Associated Encephalopathy ( SAE)2-Endothelial stabilization3-Reduce the required dose of vasopressors4-Antioxidant effects
26. Cardiogenic shockDue to the lost of myocardial tissue, the CO and the vascular resistanceThe extent of damage to the heart tissue is unpredictable .
27. Treatment of cardiogenic shockManagement :1-inotropes: Insulin + Dextrose(D50W)+K or MilrinoneMilrinone to patients with hypotension But inotropes are desirable, especially in this case It is a choise because PCWP is high and CO is low.This is an example of patients with chronic respiratory disease and heart failure who have high pulmonary arterial pressure.Also for those who have pulmonary edema Milrinone is a good medicine.
28. Treatment of cardiogenic shock2- Vasopressors :Norepinephrine, EpinephrineThe patient could not tolerate cessation of norepinephrine for several days.3-diuretic: LasixThe best diuretic in heart failure is spironolactone, and oral or injectable ferrosamide is the worst drug.We do not give it because activates the RAS system. We use injectable ferrosomide only in cases where the patient has congestion such as this case.
29. A widely used combination in ICUK+ Insulin+Dextrose(D50W)It is a inotropic and combination of insulin, dextrose and potassium affects potassium channels and carries sugar into heart cells.And helps produce intracellular ATP
30. Erythropoietin (Eprex®) 1-Activation of the inflammatory process in critical ill patient hepcidin Over expression 2-Inflammation Erythropoietin synthesisiron absorption
31. Management of acidosisPH=7.25, PCO2=33.3, HCO3=14.9First stage: eliminate the cause and establish ventilation.second stage: giving bicarbonateSome acidosis is allowed in the ICU
32. Finally The patient expired…
33. References 1- Cirocchi R, Arezzo A, Vettoretto N, et al. Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy. Medicine (Baltimore) 2014; 93:e184. 2- Tartaglia D, Costa G, Camillò A, et al. Damage control surgery for perforated diverticulitis with diffuse peritonitis: saves lives and reduces ostomy. World J Emerg Surg 2019; 14:19. 3-Sohn M, Iesalnieks I, Agha A, et al. Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a "Damage Control Strategy". World J Surg 2018; 42:3189. 4-Maggard MA, Zingmond D, O'Connell JB, Ko CY. What proportion of patients with an ostomy (for diverticulitis) get reversed? Am Surg 2004; 70:928. 5- Vermeulen J, Coene PP, Van Hout NM, et al. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11:619. 6- Banerjee S, Leather AJ, Rennie JA, et al. Feasibility and morbidity of reversal of Hartmann's. Colorectal Dis 2005; 7:454