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Acute Abdominal Complications In The ICU
17 Plays6 years ago
Acute abdominal complications developing in critically ill patients in the ICU can be associated with significant morbidity and mortality.
In this episode of Critical Matters, we discuss a variety of acute abdominal complications such as abdominal compartment syndrome, acalculous cholecystitis, toxic megacolon and ischemic bowel.
Our guest is Dr. Samuel Tisherman. Dr. Tisherman is a surgical critical care physician at the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center and a Professor of Surgery at the University of Maryland School of Medicine.
Additional Resources:
World Society of Abdominal Compartment Syndrome (WSACS) consensus definitions and recommendations: https://bit.ly/2l9m6EQ
Acute Acalculous Cholecystitis: A Review. Huffman J, Schenker S. Clinical Gastroenterology and Hepatology: https://bit.ly/2nfssTL
Ogilvie’s Syndrome: Management and Outcomes. Haj, M et al. Medicine: https://bit.ly/2mKLVM5
Books Mentioned in this Episode:
Complications: A Surgeon’s Note on an Imperfect Science. By Atul Gawande: https://amzn.to/2laETzB
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
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And now your host, Dr. Sergio Zanotti.
ICU Abdominal Complications Overview
00:00:32
Speaker
Acute abdominal complications developing in critically ill patients in the ICU can be associated with significant morbidity and mortality.
00:00:40
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In patients admitted to the ICU with non-abdominal primary diagnosis, the development of an acute abdomen can be missed by the intensivist, leading to delays in treatment and worse outcomes.
00:00:50
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In today's episode of Critical Matters, we will discuss a variety of acute abdominal complications, such as abdominal compartment syndrome, acalculus claustis, megacolon, and ischemic bowel.
Guest Introduction: Dr. Samuel Tisherman
00:01:02
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Early recognition and timely surgical consultation are essential in these situations.
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Our guest is Dr. Samuel Tisherman.
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Dr. Tisherman is professor of surgery at the University of Maryland School of Medicine.
00:01:14
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He is a practicing surgical intensivist at the R. Adams Colley Shock Trauma Center, University of Maryland Medical Center, where he also serves as director for the Surgical Intensive Care Unit and director for the Center for Critical Care and Trauma Education.
00:01:27
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Dr. Tisherman is a renowned surgeon, medical educator, and researcher.
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He has received numerous awards for his teaching in surgical and multidisciplinary critical care.
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His research interests include hemorrhagic shock, cardiac arrest, therapeutic hypothermia, education, and surgical skills.
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He has an extensive list of publications, and we are truly honored to have him as our guest today.
00:01:47
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Sam, welcome to Critical Matters.
00:01:50
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Great.
00:01:50
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Thanks for having me.
00:01:51
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It's great to be here.
Challenges in ICU Abdominal Diagnosis
00:01:53
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So I think that we might start with just a general introduction to this topic, but we're trying to focus on
00:02:00
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are abdominal complications that may occur in patients who were admitted with a primary diagnosis that's not abdominal, most frequently to a mixed ICU or a medical ICU, who then during their critical illness develop complications that can lead to some problems.
00:02:16
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Could you just give us an overview of how you see these patients from a surgical critical care perspective?
00:02:22
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I think these patients can be very challenging because they're
00:02:27
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obviously quite sick from whatever the primary problem is that brought them to the ICU.
00:02:33
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And from an evaluation standpoint, the abdomen can become kind of this black box that you can't really easily get a handle on.
00:02:46
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In the usual situation of somebody coming into an emergency department with belly pain, you can talk to the patient, get a good history, do a nice physical exam, and then based on physical exam, you get a good idea of
00:02:57
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what's going on, but that doesn't work in the ICU.
00:03:02
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Patients have all kinds of tubes and lines and they're sick, they're sedated.
00:03:07
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So the usual history of physical kind of goes out the window.
00:03:11
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And I think that a compounded problem is our current practice.
00:03:16
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I think that more and more we're walking away from good physical exams and patients who are already in the hospital.
00:03:21
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I think a lot of people like to put a stethoscope here and there, pop it real quickly.
00:03:25
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But we often probably are doing our patients a disservice not by paying attention to the abdomen since some of these problems might first manifest with some subtle findings.
00:03:36
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Absolutely.
00:03:37
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So, I mean, even though I say that you can't really do physical exam, it doesn't help as much, I think you need to do that because it can help.
00:03:46
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The issue is that oftentimes it's hard to get a whole lot of specific sense of what's happening.
00:03:54
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from your exam because the patient's sedated and it looks like it bothers them when you move them around.
00:04:01
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But I think it's important to look at the belly.
00:04:03
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I mean, I've certainly seen plenty of times where it's pretty clear nobody's really examining somebody's abdomen for a little while.
00:04:08
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Now suddenly the guy's really sick and, yeah, it could be something in the
Approach to Abdominal Issues in ICU
00:04:12
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abdomen.
00:04:12
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It could be something else.
00:04:15
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And when these patients present, Sam, I guess usually they either have issues with tolerating tube feeds, abdominal distension,
00:04:24
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where all of a sudden the abdominal exam has changed, and sometimes that change might be quite dramatic, as you said.
00:04:30
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How do you think about differential diagnosis and how to approach these patients?
00:04:38
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So I think it's helpful to think about what kind of things can happen in the belly just because you're sick, which is quite different than somebody who's walking around needing a normal life and suddenly they get abdominal pain.
00:04:52
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Somebody is in the ICU, presumably intubated, might be getting antibiotics, maybe on pressures.
00:04:59
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There are a few things that really rise to the top of the list that are worrisome.
00:05:05
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Certainly, ischemic bowel can occur for a number of reasons in a critically ill patient.
00:05:12
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Perforation, particularly ulcerative,
00:05:15
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It's certainly much less common now than it was 20, 30 years ago because we give everybody prophylaxis, but it can still happen.
00:05:25
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Acute achiacus cholecystitis can occur.
00:05:28
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C. diff is the other.
00:05:30
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Big E, those are the ones that kind of probably the most common that we worry about.
00:05:35
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Certainly there are lesser things that can happen too, but like just bleeding or somebody rupturing in aneurysm suddenly while they're here in the hospital for something else.
00:05:46
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And if you got called for somebody in an ICU as a consult with maybe a rigid abdomen or a significant change in their abdominal exam, what would be the initial workup that you would expect the critical care team to have in place as you come in to see that patient?
00:06:03
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Well, certainly worth starting with some basic stuff like checking labs, the CBC, maybe liver enzymes, pancreatic enzymes, the lactate level.
00:06:14
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Although as an aside,
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It's not that uncommon that somebody is sick, maybe the sepsis from pneumonia or urinary tract infection and the lactate's up because of sepsis and somebody gets worried that, oh, lactate type could be the bowel.
00:06:32
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And that can be difficult to sort out, but it's worth at least keeping in mind that you can get really high lactates just from being septic and not having dead bowel or dead tissue somewhere.
00:06:42
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But that would start with basic labs.
00:06:43
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But I think if you're worried
00:06:47
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to something going on in the belly, I would get a surgeon involved quickly before you start doing a bunch of films.
00:06:56
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Because I think playing films in the ICU are generally not terribly helpful.
00:07:04
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They're helpful to maybe locate where tubes are, like an NG tube or drains or something, but not typically look for anything like free air because you're
00:07:14
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you're rarely going to see that on a supine plane film.
00:07:18
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And before you send somebody out for a CAT scan, which kind of tends to be the next test, it's worth having the surgeon weigh in because, you know, there are patients that, you know, the setup is so obvious that this patient is at higher risk of ischemic bowel, the patient's got a rigid abdomen, there's septic shock, that patient doesn't need a CT scan, that patient needs an operation.
00:07:43
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So I think early surgical consultation is really helpful.
00:07:48
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And I think that perhaps if anything that people were to take home today, it would be the time-sensitive nature of these interventions and the studies that have looked at these acute abdomens in medical intensive care unit patients have shown over and over again that
00:08:03
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that probably the most important factor to survival is how quickly you intervene, which means getting surgery on board as early as possible probably is the best way to get that ball rolling.
00:08:15
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Right, because the surgeon can give a better sense of maybe honing down the differential before you start doing any imaging or wasting time with other things and working toward getting a patient to either the OR or for
00:08:32
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drainage of something.
00:08:33
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I mean, one of the important things about surgical infections in general is those are infections that require either drainage of pus or some fluid collection somewhere or an operation to remove something.
00:08:50
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And the timeliness of that is, I think, underrated.
00:08:56
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If you look at things like the surviving sepsis campaign that focuses on
00:09:00
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getting antibiotics on board quickly, getting fluid resuscitation going, getting pressure started.
00:09:04
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The notion of source control, which is really what you need for any surgical infection, it kind of seems to take a back seat, whereas it needs to be more upfront.
00:09:18
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You need to do all the other stuff too and do it quickly, but it shouldn't be put off till, oh, well, we'll schedule tomorrow his X lab for his possibly dead bowel.
00:09:28
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Yeah.
00:09:29
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And I think, like you mentioned, there are signs that immediately indicate the need for surgery, such as like a true rigid and acute abdomen on exam, free air that's not supposed to be there on an imaging, plain imaging, are things that quickly can get you to the OR.
00:09:48
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And like you said, having the surgeon involved early can obviate unnecessary tests that might just delay proper care and wouldn't add much to the decision making.
00:09:58
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Exactly.
00:10:00
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So let's start to dive maybe a little bit deeper into some of these situations or clinical scenarios that might appear or might be of interest for our patients.
Abdominal Compartment Syndrome Discussion
00:10:12
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And I wanted to start with one that you hadn't mentioned yet, but I think that is important for our non-surgical colleagues to review, which is abdominal compartment syndrome and abdominal hypertension situations, which historically
00:10:28
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we're really the purview of surgical patients, but with our emphasis or maybe with our overemphasis on fluoroacitation, a lot of medical patients has become more common, and hopefully as that pendulum shifts back again to more moderation, will decrease, but it's still something that happens very commonly in patients who are critically ill with non-surgical primary diagnoses.
00:10:55
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Well, yeah, I think it has become really,
00:10:59
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important issue and so important that there's a society dedicated to the abdominal compartment syndrome and I think is worth keeping in mind certainly most of the time it's going to be related to either trauma or a big operation in the abdomen and in both of those situations particularly if the surgeon is an acute care surgeon is somebody's focused on cervical care and trauma or
00:11:28
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or specifically a trauma patient, operatively people have gotten away from always trying to close the abdomen.
00:11:37
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So you kind of remove the potential of abdominal compartment syndrome if the abdomen has been closed.
00:11:44
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But it's definitely been more and more recognized as an issue, even if nobody has operated in the abdomen just because of massive fluid resuscitation.
00:11:57
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You see it with burn patients, you see it with patients that get a lot of fluids for other reasons.
00:12:02
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And hopefully we're moderating that massive fluid resuscitation a bit, but it can still happen.
00:12:14
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And it's a challenge to deal with because there's always a debate about what point does the patient need
00:12:27
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to have a decompressive laparotomy.
00:12:31
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Certainly, it's always important to think about is it really an abdominal compartment syndrome as opposed to intra-abdominal hypertension?
00:12:42
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So if you measure bladder pressure, which is for better or worse, the easiest way to get at some sort of measure of what's going on inside the abdomen, if it's higher than 12, that becomes
00:12:56
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what you could call intra-abinominal hypertension, and higher than 20, start really getting kind of worried about it.
00:13:02
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But it's not really a syndrome until you start seeing organ dysfunction because of it, whether it's acute kidney injury, increasing thoracic pressure, sort of the last thing that's going to be hypotension.
00:13:19
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Short of any of those things, probably not that much that a surgeon would
00:13:26
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do.
00:13:30
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But it's certainly helpful to think about what could easily be done to decrease that pressure short of a big operation.
00:13:39
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So things like sedation, even neuromuscular blockade, things like if there's a whole lot of fluid in there that's easily drained, draining the fluid can help.
00:13:52
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If there's a lot of
00:13:54
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gaseous extension of the stomach or the colon, you can decompress that.
00:14:00
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So there are some less invasive ways to help the problem if you think that's causing some organ dysfunctional problems for the patient.
00:14:12
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But then it comes down to the big question of, is it bad enough that the surgeon needs to do something about it?
00:14:20
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And occasionally we do.
00:14:22
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And in terms of making that decision for a surgical intervention, so decompressing the abdomen, is that something that you based on numbers, more on acute organ damage, on the failure of therapies, or all of the above?
00:14:37
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Yeah, it's a little bit of all the above.
00:14:40
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Certainly the number is probably the least useful.
00:14:44
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I mean, one thing to keep in mind is patients who are on the larger side,
00:14:51
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let's say, would not have the same resting intra-abdominal pressure that a thinner person might have.
00:15:00
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So the normal may be in the teens for a very obese patient.
00:15:06
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So now if it's higher in the teens or maybe low 20s, that may not be as important as it would be for somebody who's thinner and normally has a pressure that's in single digits.
00:15:18
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So numbers don't help as much as
00:15:21
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The physiology, is this really causing physiologic harm to the patient?
00:15:26
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And have we done everything else that we can do to treat the problem?
00:15:31
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Sedation, paralysis, drainage of anything that's drainable, minimizing fluids, getting fluids off.
00:15:37
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D-resuscitation is really an important thing to do is when the patient is able to do that.
00:15:44
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And what about the physical exam, Sam?
00:15:46
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I mean, does it tell you anything valuable or not really helpful in this situation?
00:15:53
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It helps.
00:15:56
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It can be hard, particularly in obese patients, to really get a sense of how tight the abdomen is.
00:16:01
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But I think if you feel the abdomen and it's not really tense, it's probably not an abdominal compartment syndrome.
00:16:12
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But certainly, you know, getting some numbers can kind of help with that.
00:16:16
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I guess that's why it is a syndrome, and it's kind of a complicated syndrome.
00:16:22
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So you got to take all these things into account when you're going to decide what to do.
00:16:27
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And just to remind our audience, what would be some of the clinical slash physiologic manifestations that you would really want to be tuned into as an intensivist?
00:16:40
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So we can start maybe going from the head down.
00:16:43
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I guess if you're in a neuro ICU, ICP would be the one thing you would be concerned about, right?
00:16:50
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Yeah, and actually coming out of this institution, there is a paper describing sort of a multi-compartment syndrome, a patient with head injuries and also intra-abdominal hypertension, even without trauma to the abdomen and help to decompress the abdomen.
00:17:10
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But that's, you know, somebody who has some kind of severe neurologic syndrome going on and you're monitoring ICP.
00:17:21
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What about at the lung level?
00:17:23
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What are the things that usually people should be aware of or looking for if they're concerned about increased pressures in the abdomen?
00:17:32
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So you'll see worsening lung compliance.
00:17:36
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Yeah.
00:17:37
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increased intrathoracic pressure, depending upon what kind of mode you're on a ventilator, if you're on a volume controlled mode, you'll see the pressures go up.
00:17:45
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If you're on a pressure controlled mode, the volumes may be down.
00:17:52
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So it's something to think about if those things are happening and you don't see anything new on a chest x-ray, like suddenly the patient has a pneumothorax or something like that, and you examine the belly and the belly seems pretty tight, then...
00:18:07
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Thanks, I guess, for thinking about that interaction.
00:18:11
Speaker
And at the cardiovascular level?
00:18:14
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That's usually one of the last things that happen, that the intra-abdominal pressure decreases venous return, and that's going to lead to decreased cardiac output and then hypotension.
00:18:27
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That's typically not going to happen until all the other things are happening, but it does, and so...
00:18:38
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is worth, you know, if you start seeing that and you don't have another obvious reason for it, along with some of these other findings like increasing intrathoracic pressure, then you can start thinking more seriously about intra-abdominal hypertension and abdominal compartment syndrome.
00:18:54
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And I think that the, perhaps, I mean, the organs, I mean, that are most prone to having problems from high intra-abdominal pressures are rightfully so in the abdomen and both at a
00:19:06
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intestinal and gut level, but also the kidney obviously is very susceptible to increases in pressures.
00:19:12
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And I know that even increases in intra-abdominal pressure without causing compartment syndrome can lead to allegoria and impaired venous return to the kidney with decrease of chlamyloidrate.
00:19:27
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And ultimately, with severe increases, you can have etotololoneuria.
00:19:32
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But the reason why I bring this up is I think that
00:19:34
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The first response usually in these patients is to give more fluids.
00:19:38
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And you can get caught in a very vicious cycle unless you start thinking about, well, could this be a problem?
00:19:44
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Should I stop measure and try to figure out, am I headed here in the wrong direction?
00:19:49
Speaker
Any comments on that?
00:19:51
Speaker
Yeah, I would certainly agree that if it's not clear why somebody's urine op is dropping off, the kidney function is getting worse,
00:20:03
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and your exam the admin suggests there's some tension there, you need to start thinking about it.
00:20:09
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And that's where it's really helpful to get a better sense of the patient's hemodynamic status in a more global sense.
00:20:17
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And we do a lot of echoes can kind of help us with where does the patient stand from volume and cardiac function and all of that.
00:20:26
Speaker
So that can help.
00:20:28
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It doesn't take a whole lot to decrease your urine output.
00:20:30
Speaker
I mean, one of the things that was
00:20:32
Speaker
recognized as laparoscopy became more and more common is that just inflating the admin with CO2 to do laparoscopy, because you get pressures up in the 15 range, the urine apple would drop off.
00:20:47
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And anesthesiologists had to recognize this early because they would say, oh, the urine apple's dropped off.
00:20:52
Speaker
I got to give the patient more fluid.
00:20:54
Speaker
Then you get these patients that have too much fluid.
00:20:56
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So I think the response to oliguria
00:20:59
Speaker
needs to be thoughtful about.
00:21:01
Speaker
Is it really a fluid problem or something else going on?
00:21:04
Speaker
And are there any tips or caveats that you would share with us regarding measuring the endophthalmic pressure via the bladder?
00:21:13
Speaker
Yeah, you need to fully.
00:21:17
Speaker
I don't know you need to go as far as getting the devices that are marketed to measure this because you can
00:21:28
Speaker
All you need to do is hook into a side port on the tubing and then clamp this to all that and you can inflate the fully with or instill, I should say, like 50 c's of saline and you can then just measure the pressure through your normal monitoring devices and there's no great reason to do it continuously.
00:21:57
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You can do it intermittently pretty easily, so it's not too difficult to do.
00:22:02
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And it's worth thinking about.
00:22:03
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If you're possibly going down this route, it's easy enough to at least measure the pressure and then use that as one more factor in deciding what to do next.
00:22:13
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And I think, like you mentioned earlier, having an early consultation with our surgical colleagues just so they can follow and give their input early is probably preferable for the patient, but also I'm sure
00:22:24
Speaker
for the surgeon as opposed to being called in the middle of the night when the pressure is greater than 25 and everything is going to hell.
00:22:31
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Right.
00:22:32
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No, it's definitely better to get people on board in daytime.
00:22:35
Speaker
Excellent.
00:22:36
Speaker
Let's move on to another topic, Sam, and there's something that you did mention earlier when we were talking about the differential diagnosis, which refers to the gallbladder and the development of acalculus colostitis in the critically ill patients, which is something that, I mean, has been described, and I think that most of our
00:22:54
Speaker
listeners have encountered.
Understanding Acalculous Cholecystitis
00:22:56
Speaker
And maybe you could just start by telling us what are the risk factors and the pathogenesis for developing a calculus colostostitis before we go into the management and clinical manifestations.
00:23:08
Speaker
Well, I think our best understanding of this is that it's mostly related to blood flow to the gallbladder.
00:23:16
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So the people that are high risk are people who have peripheral vascular disease or diabetics.
00:23:22
Speaker
And then you add on top of that
00:23:24
Speaker
that they're sick for something else, whether it's cardiogenic shock or septic shock, some form of hypotension, hypovolemia on pressors.
00:23:36
Speaker
So you have a gallbladder that now is not getting blood flow that it normally gets.
00:23:43
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And then on top of that, the patient is not being fed.
00:23:47
Speaker
So the gallbladder will tend to get distended.
00:23:50
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So when it's distended,
00:23:53
Speaker
and does not have good blood supply with the tension in the wall from this tension, basically the wall will get ischemic and eventually can die.
00:24:03
Speaker
But this ischemia alone will allow the bacteria to get in the wall, even air getting in the wall, you can get an emphysematis and gallbladder, or it can totally necrose.
00:24:16
Speaker
So that's the pathogenesis.
00:24:17
Speaker
Somebody that's sick, which is part of the challenge of how to deal with it,
00:24:23
Speaker
And is this something that usually develops as people get sick days into the presentation as opposed to something that might be the cause of their sepsis that they're coming up to the hospital for that?
00:24:35
Speaker
Well, it is possible for people to come in with a cataclysm cholecystitis.
00:24:40
Speaker
This is not terribly common.
00:24:43
Speaker
And it's not all that common to even develop it in the ICU, but it's something to think about for somebody who's got intolerance to tube feeds,
00:24:52
Speaker
or maybe they just haven't been fed, the abdomen is distended, and you may get some sense on exam that there's tenderness in the right upper quadrant.
00:25:04
Speaker
Okay.
00:25:05
Speaker
And I think that what's important, again, is that despite not being as common, when it does occur, if it goes undiagnosed, it can have a very high mortality, so it needs to be taken care of.
00:25:19
Speaker
Right, and it's one of those things to think about when, if you've got somebody that's sick.
00:25:24
Speaker
How would you evaluate somebody for a Kekoskosastitis?
00:25:27
Speaker
So maybe on exam, like you mentioned, they have right upper quadrant tenderness, and maybe they might be intubated and sedated, they can't really tell you.
00:25:36
Speaker
So, yeah, I mean, sometimes it comes up as one of those things where, all right, the patient looks septic, but I don't have a good source, and there's maybe some vague sense that
00:25:48
Speaker
the abdomen isn't quite right, that they're not tolerating tube feeds, there's a little bit of tenderness.
00:25:54
Speaker
That's where you want to think about it.
00:25:55
Speaker
So like with any of these patients, you start with some labs.
00:26:00
Speaker
One important thing to keep in mind is that if you just have inflammation of the gallbladder, your liver enzymes are going to be normal.
00:26:09
Speaker
So that doesn't help in terms of ruling it out.
00:26:12
Speaker
So unless the inflammation is
00:26:15
Speaker
gets into the cystic duct and then can cause inflammation of the common hepatic duct, which will lead to some obstruction and then increased LFTs.
00:26:23
Speaker
Or sometimes just the inflammation of the gallbladder sitting under the liver causes some elevation of some enzymes.
00:26:29
Speaker
But normal LFTs don't rule us out at all.
00:26:33
Speaker
So if you think about it, then you need to do some imaging.
00:26:38
Speaker
And ultrasound is still the best first test because
00:26:43
Speaker
It's easy.
00:26:44
Speaker
You don't move the patient and can certainly readily make the diagnosis.
00:26:49
Speaker
So that's where I would start with imaging.
00:26:52
Speaker
And what would you see on ultrasound that would lead you in that direction?
00:26:58
Speaker
So you see thickening of the wall of the gallbladder and pericholecystic fluid.
00:27:04
Speaker
Now the part that can make it more complicated is if the patient has
00:27:11
Speaker
just general ascites for some reason, you're going to see some fluid there.
00:27:17
Speaker
So it might, you can have a false positive in that kind of situation.
00:27:22
Speaker
But if it seems like that's where the inflammation is, the thickening of the wall, you can even see if it's really bad, air on the wall by ultrasound.
00:27:31
Speaker
So ultrasound is the place to start.
00:27:33
Speaker
If that's equivocal, then a CT is probably the next.
00:27:41
Speaker
best imaging to do, which will also help make sure it's not something else.
00:27:46
Speaker
And a CT, in terms of, like you said, offers the advantage of ruling out other potential problems, but you have to move the patient, which in some cases might not be ideal.
00:27:58
Speaker
But the finding would be similar.
00:28:00
Speaker
You're looking for thickening of the gallbladder wall, dilation of the gallbladder overall, and fluid around it, right?
00:28:08
Speaker
Right, the same kind of findings, just the CT rather than ultrasound.
00:28:13
Speaker
And it'll help that you don't see anything else that seems to be a source of problems.
00:28:19
Speaker
Now, the only other, sorry, the only other, I mean, the HIDA scans can be done.
00:28:25
Speaker
If you give the HIDA agent and you see it get into the liver and the biliary tree and the small bowel, but never see the gallbladder, that's suggestive of it.
00:28:37
Speaker
MRCP has now become popular, but that's even worse than a CT scan in terms of transporting the patient and a longer time in the magnet and in a place where nobody can actually touch the patient readily, so it's a little more complicated.
00:28:55
Speaker
So really, in terms of ultimately, there is really no kind of gold standard in terms of diagnosis that tells you this is ACC.
00:29:05
Speaker
It's really
00:29:06
Speaker
a combination of images that are consistent within the right context.
00:29:10
Speaker
And that's where I guess having early consultation and discussions of which direction the patient is going really helps in terms of deciding what the next step is.
00:29:19
Speaker
Right.
00:29:20
Speaker
I agree.
00:29:21
Speaker
Now, Sam, I'm just going to ask you to repeat something because I think that we had a little bit of internet issues when you were talking about the LFTs.
00:29:29
Speaker
But what I understood is that a lot of these patients might have a high bilirubin
00:29:35
Speaker
abnormal LFTs, but also you could have ACC with totally normal LFTs, and that's why you shouldn't rule it out just based on the LFTs.
00:29:43
Speaker
Is that correct?
00:29:44
Speaker
Right.
00:29:45
Speaker
I mean, I would say the norm would be that the LFTs and the enzymes and the bilirubin are normal.
00:29:53
Speaker
So you can get an elevation in bilirubin just from any kind of sepsis affecting the liver.
00:29:59
Speaker
The only way to get elevation of
00:30:05
Speaker
the canalicular enzymes like alkyl and phosphatase would be if you have something obstructing the common hepatic duct or the common bile duct.
00:30:15
Speaker
And that generally only happens if you have a stone down there.
00:30:18
Speaker
So you don't see it with achycocytoscholositis.
00:30:21
Speaker
And then the only other thing is just because the gallbladder is sitting under the liver and the gallbladder is very inflamed, it'll cause some inflammation of the parts of the liver that's right there.
00:30:30
Speaker
So you can get some mild
00:30:33
Speaker
elevations of transaminases.
00:30:35
Speaker
So you can get some elevations, but in general, you won't.
00:30:39
Speaker
So you probably, you want to get some MLTs, but don't think that it's a normal, oh, it's not the gallbladder.
00:30:46
Speaker
We're going to move on to something else.
00:30:48
Speaker
Okay, perfect.
00:30:49
Speaker
And once you've decided that this might be contributing to the patient's clinical problems or might be actually a source of their clinical deterioration, how would you approach this from a therapeutic standpoint?
00:31:04
Speaker
So I would start with saying that the gold standard for dealing with acute cholecystitis is to do a cholecystectomy.
00:31:14
Speaker
Having said that, since this is often occurring in patients that are very sick for other reasons, it could be somebody that just had an acute myocardial infarction and maybe is on some inotropes or even on a balloon pump or something like that, or is in septic shock from something else.
00:31:32
Speaker
That's not the kind of patient that you want to take to the operating room and give them a general anesthetic to take the gallbladder out.
00:31:38
Speaker
So we basically, as the next step, would start with draining the gallbladder percutaneously and have radiologists placing drain in it, which will work the majority of the time.
00:31:53
Speaker
So it's worth doing that.
00:31:55
Speaker
It's a relatively low-risk procedure.
00:31:59
Speaker
It can be done.
00:32:01
Speaker
at the bedside or down in the radiology department.
00:32:05
Speaker
But it's usually worth doing that in a really sick patient when you think this is what's going on.
00:32:13
Speaker
And if that is done appropriately and this is what's driving the clinical issues, what do you expect to happen?
00:32:21
Speaker
When do you expect the patient to show some improvement?
00:32:24
Speaker
Well, I think one way to look at it is
00:32:27
Speaker
anybody that's sick from an abscess anywhere in the body, and so now the abscess is the gallbladder itself.
00:32:34
Speaker
So you drain it, you have a patient on antibiotics, and it still may take a day or two to see significant improvement, but they ought to improve.
00:32:47
Speaker
But I'll add that there are failures of this, and particularly if the gallbladder wall itself is necrotic,
00:32:56
Speaker
it'll fall apart.
00:32:57
Speaker
And so putting a drain in there won't solve the problem.
00:33:00
Speaker
So they may need something in addition to that drain.
00:33:05
Speaker
So what would be indications?
00:33:07
Speaker
You mentioned one of them, the necrotic gallbladder wall.
00:33:12
Speaker
What would be other indications to escalate to surgery or go primarily to surgery because the tube wouldn't solve these issues?
00:33:20
Speaker
Well, I think if
00:33:25
Speaker
the patient's not responding relatively promptly.
00:33:29
Speaker
So within a couple of days, the patient's not looking better and the patient's sick enough that the surgeon is worried up front that maybe the gallbladder is necrotic or then sometimes you can get some evidence on your CT, the ultrasound, then people would have to start thinking about taking the patient to the OR for a cholecystectomy.
00:33:51
Speaker
Now, there are some
00:33:55
Speaker
less drastic approaches.
00:33:58
Speaker
People have described, you know, if there is some leakage from the gallbladder, that can be contained with another drain, that that can help.
00:34:09
Speaker
So if you have an abscess or a collection outside of the gallbladder drain, that may do the trick and get the patient through this.
00:34:17
Speaker
And the main thing is to get adequate drainage, and that's the basic surgical principle here.
00:34:22
Speaker
If you can get adequate drainage with percutaneous drains and the patient can get better, then that can be way better than putting the patient into a bigger operation.
00:34:31
Speaker
There are also smaller operations you can do from a surgical standpoint.
00:34:34
Speaker
You can just make a small incision and do better drainage of the gallbladder and the fluid around it than what's happened with the percutaneous drain, short of trying to do a full cholecystectomy, which is
00:34:50
Speaker
often is circumstances very difficult to do because of all the inflammation.
00:34:55
Speaker
So there are a few other things in between, but all those decisions need to be made in concert with the surgical team.
00:35:03
Speaker
Absolutely.
00:35:04
Speaker
And does the presence of air or emphysematous acocystitis mandate surgery, or that can also be treated with a percutaneous tube initially?
00:35:14
Speaker
It doesn't mandate it, but
00:35:17
Speaker
People need to have a lower threshold to recognize that the percutaneous drainage isn't working, that now the patient needs something more.
00:35:26
Speaker
And sometimes, you know, surgeons get forced in doing this sort of a partial cholecystectomy, take out whatever they can easily get out without causing harm, putting some bigger drains in there, and then just getting out.
00:35:40
Speaker
So I have a question actually related to those patients who do well.
00:35:44
Speaker
leave the ICU.
00:35:45
Speaker
So I've had a couple in my practice that have left the ICU and they leave the ICU with their tubes.
00:35:52
Speaker
What happens to them afterwards?
00:35:54
Speaker
Just out of curiosity for follow-up.
00:35:57
Speaker
That's a good question because nobody's really studied that very well.
00:36:02
Speaker
Typically people want to keep the tube in for a good four or six weeks just so that you have a safe track for removing it.
00:36:12
Speaker
And then
00:36:14
Speaker
one can debate about should you take the gallbladder out now or not.
00:36:19
Speaker
There have been some studies suggesting that after all this inflammation and drainage, that at the end of all that, assuming the patient's doing well, the gallbladder is now shrunken down, scarred down, and it's almost impossible for it to actually cause trouble again.
00:36:39
Speaker
So I think people have kind of gotten away from routinely saying, oh,
00:36:43
Speaker
Patient with colitisitis when he was really sick after his MI, I got to bring him back in a couple of months to take his gallbladder out.
00:36:49
Speaker
You know, if there aren't stones there, you know, probably, probably not.
00:36:55
Speaker
And certainly people will study the gallbladder through the drain to be sure that there's nothing left that's causing any trouble before taking the drain out.
00:37:06
Speaker
No, I think the reason why I'm asking is because a patient had asked me once and I really didn't know the answer.
00:37:12
Speaker
And I think it's like, it's interesting.
00:37:15
Speaker
And obviously for those who are well enough to leave the ICU with a tube, when the ICU team knows what the natural course is, I think it always helps also with communicating to patients, decreasing their anxiety and them understanding also and hearing the same kind of story from multiple team members of
00:37:34
Speaker
what's going to happen next.
00:37:35
Speaker
But I think it's an interesting just kind of fact that a lot of these patients don't get their gallbladders ultimately removed because it probably at that point is not needed anymore.
00:37:47
Speaker
Yeah.
00:37:47
Speaker
And just look at the risk-benefit ratio.
00:37:49
Speaker
Trying to take out a hard, scarred-in gallbladder is going to be difficult.
00:37:56
Speaker
The likelihood of causing more harm
00:38:00
Speaker
is greater than the potential benefit because it's probably not going to cause trouble again.
00:38:06
Speaker
Yeah.
00:38:07
Speaker
And in your practice, is there, like you said, a lot of these patients might be being treated already, but obviously you mentioned earlier that there's a high risk of bacterial translocation and infection or super infection, although this is not originally an infectious problem.
00:38:22
Speaker
Any comments on your antibiotic of choice or how do you approach these?
00:38:27
Speaker
Well, the...
00:38:29
Speaker
Dan, at the beginning, usually there aren't very resistant organisms.
00:38:33
Speaker
So just like anything else, most other things in the abdomen, if you use something that covers gram negatives, maybe streps, you'll get good coverage.
00:38:47
Speaker
And if the gallbladder isn't going to have a ton of anaerobes, that's not as big of an issue as covering the colon and pretty much...
00:38:58
Speaker
fungal infection is usually not part of it either.
00:39:00
Speaker
So, you know, simple things like Piptasa or even Amcelbactam is probably okay.
00:39:09
Speaker
People sometimes use quinolones, but you don't need big gun antibiotics.
00:39:17
Speaker
Excellent.
00:39:18
Speaker
So I think a good, a good, it would be a good segue to talk about the
Preventing ICU Megacolon
00:39:21
Speaker
colon now.
00:39:21
Speaker
And one of the things that we sometimes get called on, you know,
00:39:27
Speaker
x-rays or a patient who might not be tolerating two feet, who's intubated for several days, and they call us from radiologists saying that the colon is significantly dilated.
00:39:38
Speaker
Can we talk a little bit about these megacolons and what are the differential diagnosis and what are some of the things that we should be concerned about in the ICU?
00:39:46
Speaker
Yeah, I think it's a pretty common problem.
00:39:50
Speaker
It's often related to immobility, to
00:39:57
Speaker
deep sedation to narcotic use, that can certainly lead to this problem.
00:40:05
Speaker
And I think it's important to keep on top of somebody's bowel function.
00:40:13
Speaker
We don't always ask, did the patient have a bowel movement today?
00:40:16
Speaker
And suddenly you have somebody who the nurses say, oh, I think his last one was last Monday.
00:40:20
Speaker
And you're then way behind.
00:40:24
Speaker
So it's important to make sure people
00:40:27
Speaker
continue to have bowel function as you're feeding the gut in the ICU.
00:40:34
Speaker
If you do get into this distended colon, the question becomes, is it just sort of a pseudo obstruction kind of picture, like, oh, we'll be from immobility and narcotics, or we always worry about C. diff.
00:40:50
Speaker
And that has other implications.
00:40:57
Speaker
not always easy just by seeing the stentive colon to figure out what's going on.
00:41:04
Speaker
It's important to look at the rest of the patient.
00:41:06
Speaker
Does the patient have a fever?
00:41:07
Speaker
Does the patient have a high white count?
00:41:08
Speaker
Does the patient have diarrhea?
00:41:11
Speaker
You can certainly have bad C. diff without diarrhea and then put all that together to figure out what you think is going on.
00:41:20
Speaker
And what would be some of the
00:41:23
Speaker
differential in terms of maybe imaging or other than clinical you mentioned, but between UGLIVs or non-obstructive pseudobstruction and a toxic megacolon from C. diff?
00:41:35
Speaker
Are there any things that help you differentiate?
00:41:40
Speaker
Well, up front, if the patient isn't systemically that ill from this, and again, this brings up the challenge of dealing with
00:41:51
Speaker
an acute abdominal problem in the ICU because the patient could have fever or white count for a lot of reasons.
00:41:59
Speaker
Certainly C. diff, you'll typically get an impressive leukocytosis.
00:42:04
Speaker
I think certainly if the patient doesn't have a fever, doesn't have a white count, the risk of C. diff is relatively low and
00:42:17
Speaker
One of the challenges with that, too, is that there are people who are carriers of it.
00:42:22
Speaker
So at least at our institution, the infectious disease people have now set up within the electronic health record that there has to be an attending sign-off to get a C. diff sent on a patient.
00:42:40
Speaker
Because if a patient just has some diarrhea and somebody has a knee jerk of sending off,
00:42:46
Speaker
the C. diff, without a fever, without a white count, without any abdominal complaints, without anything, you may get a false positive that's not going to be very helpful.
00:42:58
Speaker
So it's important to think about those other things.
00:42:59
Speaker
And the other side is if you're thinking that it's an Ogilvy's or pseudo-obtruction kind of picture, if that's the only issue, then the patient should not really have a fever or white count unless they are now
00:43:15
Speaker
either perforated or the bowel wall is ischemic from the distension.
00:43:22
Speaker
So the worrisome thing up front is certainly, does the patient look sick?
00:43:26
Speaker
Does the patient have fever, white count?
00:43:28
Speaker
Belly tenderness, that's not just some distension, but actual peritonitis, that definitely is way more worrisome than now.
00:43:37
Speaker
Either the pseudo obstruction is bad enough that the bowel is in trouble, or it's something else like C. diff.
00:43:46
Speaker
So I guess, I mean, if you're going down the direction, the patient truly, I mean, is toxic and there might be indications of, like you said, a severe complication caused by one of these.
00:43:57
Speaker
You obviously are going to go down probably a much more aggressive route very, very quickly.
00:44:01
Speaker
It might end up, I mean, in the operating room.
00:44:04
Speaker
But let's talk about the other case where you have Augliebius syndrome.
00:44:08
Speaker
and just have a dilated colon.
00:44:09
Speaker
And a lot of times I think these can be quite dramatic, and especially, I think, and people have not seen a lot of them, it can become very difficult to understand what to do.
00:44:18
Speaker
How would you approach these patients who are not toxic, who have Ogilvie syndrome and have a dilated colon?
00:44:24
Speaker
And what do you mean by dilated colon in terms of numbers as well, just to give people some reference?
00:44:29
Speaker
Well, people look at the cecum and when it gets...
00:44:37
Speaker
to be, I mean, there are various numbers around, so pick 10 centimeters is something worrisome.
00:44:42
Speaker
But everybody's a little different in terms of how big it can get and how much trouble it can cause.
00:44:49
Speaker
But certainly simple things up front are making sure the patient's well hydrated and perfusing everything well, minimize narcotics, get the patient moving around,
00:45:02
Speaker
start trying to decompress the colon from below, whether starting with simple things like suppositories or enemas, and then if that's not working, thinking about how getting GI to scope the patient to decompress them if it's not getting better.
00:45:20
Speaker
There are pharmacologic things like neostigmine you can give to get the bowel to function, but that should be
00:45:32
Speaker
And when you get to that kind of stage, you've tried simple things like stopping narcotics and minimizing narcotics, getting the patient moving around.
00:45:39
Speaker
You've tried suppository enemas, and now you're thinking about something else.
00:45:51
Speaker
Then it's important to either have a surgeon involved or GI involved to assist with that decision making.
00:45:59
Speaker
And in terms of my experience, Sam, with Ogilvy has been that usually you can avoid surgery, obviously, right?
00:46:06
Speaker
I mean, unless they have a perforation or a complication.
00:46:09
Speaker
And I have utilized in conjunction, obviously, with our consultants, like you mentioned, from the surgical and the GI teams, neostigmine infrequently, but have had experience with it.
00:46:22
Speaker
And usually I think that what's important, and I'll still remind the audience, is that neostigmine
00:46:28
Speaker
It can have serious cardiovascular complications.
00:46:32
Speaker
Obviously, it can cause bradycardia, hypotension, blocks.
00:46:35
Speaker
So you should have some atropine at the bedside and also can cause bronchoconstriction in some patients.
00:46:42
Speaker
So these patients need to be monitored in ICU.
00:46:45
Speaker
It's not something you would give in a non-monitoring setting.
00:46:49
Speaker
But can you talk a little bit about...
00:46:52
Speaker
when we do colonic decompression via endoscopes or via colonoscopes.
00:46:59
Speaker
Is that something that is commonly done?
00:47:00
Speaker
I have not had a lot of experience with that.
00:47:03
Speaker
No, it's not common.
00:47:07
Speaker
Well, because I don't go over to the medical ICU here, I haven't seen it done.
00:47:15
Speaker
Previously, it was something done very rarely for these kind of refractory cases.
00:47:23
Speaker
certainly methyl naltrexone is another drug you could give so it certainly it could be easier to start with the simple stuff before going to that because putting a scope up there has its risks too you know if you've got a distended colon now you put a little more air in it now there's a risk of perforation so and then simple rectal tubes can help too even just
00:47:52
Speaker
you know, blindly inserting erectile tubes of various sorts that have been around for years can help if the air is down that far.
00:48:04
Speaker
And it sounds like Ogilvy's is more of a, almost like a board question that usually is asked.
00:48:10
Speaker
I mean, and they want you to recognize it and talk about pharmacological therapy, it seems like.
00:48:15
Speaker
But clearly, I mean, recognize that when it's dilated and the patient is not toxic,
00:48:22
Speaker
That's probably what's going on and that maybe ruling out mechanical obstruction might be useful sometimes, but ultimately some basic principles like hydration, movement, decompression from above and below with NG tubes and rectal tubes and maybe decreasing of the narcotics are good first steps, getting surgery and GI involved.
00:48:45
Speaker
And for those that have a higher risk of perforation, which I presume is based on the diameter,
00:48:51
Speaker
So you mentioned 10 centimeters.
00:48:52
Speaker
The literature also talks of 12 centimeters as being kind of a cut point of increased danger.
00:48:59
Speaker
Do the neostigmatic, if that doesn't work, colonoscopy.
00:49:03
Speaker
And as an ultimate resort, I mean, you would really do something surgical.
00:49:08
Speaker
Is that correct?
00:49:10
Speaker
If it really came down to it, but you really want to try to avoid surgery because you can maybe get away with just a
00:49:21
Speaker
a stoma somewhere, but typically people will operate because they're worried that the bowel is now in jeopardy, that it's ischemic or it's perforated, and short of that, try not to operate.
00:49:38
Speaker
And what about in the other case that you mentioned was a toxic megacolon related to severe C. diff infection?
00:49:45
Speaker
Obviously, you would be treating the C. diff
00:49:47
Speaker
with stopping the fending antibiotics, giving the proper antibiotics for C. diff.
00:49:52
Speaker
But at what point do you consider taking somebody to the operating room for a toxic megacolon from severe C. diff?
00:50:01
Speaker
That's a really important point because oftentimes what seems to happen is that the patient has C. diff and gets started on enterovancomycin, maybe IV metronidazole, and
00:50:17
Speaker
It's not until a couple of days later and the patient's now more floridly septic that the surgical team gets involved.
00:50:24
Speaker
So like pretty much all the other topics we talked about, early surgical consultation is very important.
00:50:31
Speaker
When to take the patient to the operating room can be a difficult decision.
00:50:38
Speaker
It's certainly you don't want to wait till clearly the medical therapy has failed.
00:50:41
Speaker
Now the patient's on death's doorstep.
00:50:45
Speaker
But on the other hand, you're talking about a big operation for the most part.
00:50:52
Speaker
You don't want to take that too lightly either.
00:50:55
Speaker
So usually it's when the patient's in septic shock and not responding to the antibiotics.
00:51:04
Speaker
The other piece of the surgical side of this is the loop ileostomy idea.
00:51:13
Speaker
So the traditional surgical approach is to do a subtotal colectomy, which means taking out all the colon that's in the abdomen and basically leave the rectum because the rectum is not typically part of C. diff.
00:51:26
Speaker
And so that's obviously a big operation.
00:51:29
Speaker
The patient will have an ileostomy and may or may not get reversed down the road.
00:51:34
Speaker
The alternative that was started by my former colleagues at the University of Pittsburgh was to consider the fact that
00:51:43
Speaker
The reason people get sick with C. diff is because of the toxin, not so much that it's invading tissues like other surgical infections and you don't have pus somewhere.
00:51:53
Speaker
So if you could just wash the colon out, you could get rid of the toxin and the patient can get better.
00:52:00
Speaker
So you do this loop ileostomy, which gives you access to put a tube in the distal part of the loop and just irrigate the colon with just
00:52:12
Speaker
Saline, add vancomycin.
00:52:14
Speaker
There's a protocol they came up with of just washout along with some vancomycin, and you put in a rectal tube so you can just drain out on the other end, and you basically wash the colon out with a relatively minor operation.
00:52:31
Speaker
I mean, it still requires a general anesthetic, but it's a quick little procedure to do.
00:52:37
Speaker
And in their hands, a lot of people who are really sick, even in septic shock,
00:52:42
Speaker
responded well to that.
00:52:45
Speaker
It's not universally embraced by general surgeons, so people often will still do the subtotal colectomy.
00:52:55
Speaker
Here I've seen both done more of the colectomy, but it's like a lot of things where the patient needs to be sick enough that it's worth putting them through a big operation, but not so sick that they're going to die no matter what you do.
00:53:11
Speaker
And I think that's something that we also can talk at the end in terms of the fact that the patient has one of these extreme or acute abdomen problems doesn't always mean that surgery is the right choice because, like you said, they're not going to survive the surgery and there's a lot of other things going on.
00:53:28
Speaker
It might require a different conversation.
00:53:32
Speaker
But even so, that's why we need the surgical team on board early to be part of all those conversations.
00:53:38
Speaker
Right.
00:53:38
Speaker
I think the important thing is never –
00:53:40
Speaker
Never assume that either the patient needs an operation or that an operation won't help the patient.
00:53:46
Speaker
That's why you have to have the consultation.
00:53:50
Speaker
Absolutely.
00:53:51
Speaker
So the last topic I wanted to touch about was related to bowel ischemia.
00:53:56
Speaker
We talked a little bit about that at the beginning, but non-occlusive esoteric ischemia is one of the types of esoteric ischemia, but I think it's the one that is more commonly associated just with being critically ill from
00:54:10
Speaker
other causes.
Non-Occlusive Mesenteric Ischemia Insights
00:54:11
Speaker
Can you talk a little bit about how that presents and who are the patients who are at risk?
00:54:18
Speaker
The call from the medical ICU about some of the possible ischemic bowel is the nightmare for general surgeons because there's no easy test to either rule it in or rule it out.
00:54:32
Speaker
So non-ischemic, I mean, non-occlusive ischemia
00:54:39
Speaker
can certainly happen in anybody that's on high doses of pressors, or more often, it's not so much pressors as people with really bad heart failure.
00:54:54
Speaker
One of the challenges in dealing with patients in septic shock is you might give them fluids, and they're also vasodialists, you put them on vasopressors.
00:55:04
Speaker
And usually, the overwhelming majority of the time,
00:55:07
Speaker
If your volume is resuscitated inadequately as you're putting them on pressers, you're not going to cause that much distal ischemia to like fingers or toes or bowel or other things because particularly when you're talking about bowel or kidneys or liver, those organs need a perfusion pressure.
00:55:27
Speaker
So you got to give them the pressure to get the pressure up.
00:55:29
Speaker
So it's possible.
00:55:34
Speaker
But the organs do need that perfusion pressure.
00:55:38
Speaker
So you just don't want to give them the vasopressors without giving them a reasonable amount of fluid at the same time.
00:55:45
Speaker
So this then is more of an issue with patients who have really bad heart failure and just don't have enough pump flow to adequately perfuse organs.
00:55:59
Speaker
That's where you get into trouble.
00:56:02
Speaker
The challenge is that there's no simple test.
00:56:07
Speaker
The patient looks sick.
00:56:09
Speaker
You may or may not get something on exam that suggests that the patient's having pain or tenderness.
00:56:15
Speaker
You'll have elevated white count, elevated lactate, which can be really high without bowel ischemia, just from being septic, or you can have
00:56:29
Speaker
small parts of the bowel that are actually infarcted and the lactate is not terribly above normal.
00:56:34
Speaker
So you want to check those things.
00:56:37
Speaker
The one other lab that can confuse people a bit is looking at amylase because we typically get amylase and or lipase looking at the pancreas.
00:56:51
Speaker
But in fact, if you have ischemic bowel or perfed bowel, you can get a mild elevation of amylase just because it's in the
00:56:59
Speaker
GI tract, and now the bowel wall is falling apart or it's perforated, so you leak some of the amylase and it gets reabsorbed.
00:57:08
Speaker
And so in my mind, if I saw somebody with belly pain, distension, intolerance of two feeds, and the amylase is like 300 or something like that, I'm actually more worried that the patient has a surgical abdomen than if the amylase is 3,000, because the only way you get to 3,000 is tancartitis.
00:57:30
Speaker
So the labs can kind of help, but they aren't the be-all and end-all.
00:57:37
Speaker
And that's why this becomes a nightmare from a surgical perspective, because even if you send the patient for a CT scan, it can be falsely negative.
00:57:51
Speaker
What are you looking for on the CT scan?
00:57:52
Speaker
You're looking for, well, if you see free air, that's easy, but thickening of the bowel wall,
00:57:59
Speaker
can be suggestive of ischemia, some fluid around that bowel wall suggesting inflammation.
00:58:07
Speaker
More obvious would be if there's pneumatosis, there's actually air in the bowel wall, and that would prompt the need for an operation.
00:58:17
Speaker
And the free air or the perforation in ischemic bowel, that's a very late, late phenomenon, right?
00:58:24
Speaker
That's the problem.
00:58:25
Speaker
That's the problem, right.
00:58:28
Speaker
And you could have bowel that is in the process of dying and making the patient sick, and the CT may not show it to you.
00:58:38
Speaker
So that's why it can be very challenging from a surgical perspective, because if you think about it long enough and you haven't clearly ruled it out by finding something that seems more obvious for causing the problem, you may end up
00:58:54
Speaker
being stuck with, oh, the only way to really roll it out is to operate on the patient, take a look around.
00:59:00
Speaker
So that becomes an issue.
00:59:02
Speaker
And that's a challenge because you got a sick patient that you're putting through a general anesthetic and a big operation.
00:59:10
Speaker
And I think that also part of the important aspect that I encounter sometimes with families is if the patient has ischemic bowel and not a candidate for surgery, they're really not a candidate
00:59:24
Speaker
for a lot of other critical care interventions at that point, because without that surgery, it's unlikely that if they have true ischemic bowel and necrotic bowel that they would survive, right?
00:59:34
Speaker
Yeah, I think that, and that's, that adds to the risks involved in making this kind of decisions, because if that's the case, then you know the patient's not going to make it without an operation.
00:59:48
Speaker
But that doesn't always mean that
00:59:51
Speaker
the right thing to do is in operation because the patient may have so many comorbidities and be so sick that even if you do operate and resect some dead bowel, the patient's not going to survive.
01:00:02
Speaker
So that becomes a difficult conversation.
01:00:05
Speaker
Absolutely.
01:00:06
Speaker
Is there any role, Sam, for interventional radiology for angiography in these patients?
01:00:17
Speaker
Not usually.
01:00:18
Speaker
I mean, if somebody came in
01:00:20
Speaker
that maybe has some evidence of chronic mesenderic ischemia or even it's kind of acute but they're not that ill, then you potentially could just try to revascularize either it's interventional radiology or now a lot of vascular surgeons are doing all these things from an endovascular approach.
01:00:46
Speaker
If there's concern that the bowel is
01:00:50
Speaker
in trouble, then the only way to know that is to operate and then be prepared to figure out how to revascularize.
01:01:00
Speaker
So you go in there and if the bowel just looks kind of dusky but still potentially viable, then you get the vascular surgeons or the general surgeons that might do some of those kind of procedures to open up the vessels and try to restore perfusion.
01:01:21
Speaker
The non-occlusive mesothereic ischemia patients are complicated, and that's where optimizing their hemodynamics is really the most important thing until they show evidence that maybe there's actually dead bowel now.
01:01:37
Speaker
But people can certainly have elevation of lactate and some belly pain when they're horrible heart failure.
01:01:45
Speaker
You improve their hemodynamics,
01:01:50
Speaker
in one way or another, and the belly pain goes away.
01:01:53
Speaker
That's something that certainly people see in cardiac surgery ICUs.
01:01:59
Speaker
Yeah, I think like you said, I mean, it's commonly seen in patients in low flow states and these heart failure patients that's more commonly encountered.
01:02:10
Speaker
Sam, this has been, I think, a great conversation about things that are not daily occurrences, but I think that are important for us to recognize when they do occur.
01:02:19
Speaker
And perhaps the two overriding messages I heard over and over again relate to just being vigilant and think about all these potential abdominal complications early, but also to make sure that we have our surgical colleagues on board in consultation early so that the proper decisions in terms of triage to the OR or not and appropriate support can take place in a timely fashion.
01:02:44
Speaker
Right.
01:02:45
Speaker
Exactly right.
01:02:47
Speaker
If it's okay with you, we'd like to end the podcast with some questions that are not related to the topic but that tap into the wisdom of our guests.
01:02:55
Speaker
Would that be okay?
01:02:57
Speaker
Sure.
01:02:57
Speaker
I don't know how much wisdom I have, but I'll see what I can say.
01:03:02
Speaker
So the first question relates to, are there any book or books that have influenced you tremendously or that you have gifted very often to others?
01:03:12
Speaker
The one that came to mind is...
01:03:16
Speaker
Atul Gawande's book on complications.
01:03:19
Speaker
I think it really kind of makes you think about all the things we do to patients and what their implications are.
01:03:26
Speaker
And certainly as surgeons, we think about complications all the time, and we have morbidity and mortality conferences, but all of us in medicine are doing things to patients, whether it's prescribing medications or supporting them in the ICU or doing procedures on them and
01:03:45
Speaker
They all have implications, so I think it gives a good perspective on how what we do can affect our patients.
01:03:53
Speaker
Yeah, and I think that it also talks, I mean, to how we think about complications, and sometimes I think complications that are very vivid in terms of maybe procedural complications I think are very present in physicians' minds, but then again, we sometimes don't think about starting heparin, and that could kill somebody.
01:04:15
Speaker
or giving them a medication that leads to an allergic reaction that could give them an aphylactic shock.
01:04:20
Speaker
And everything that we do, no matter how trivial, sometimes, I mean, can have a very severe complication.
01:04:26
Speaker
And always, I think, being aware of that is very, very valuable.
01:04:31
Speaker
Right.
01:04:32
Speaker
That's why I think it's a useful book to read for any of us.
01:04:35
Speaker
So we'll definitely put that in the – link that in the show notes.
01:04:39
Speaker
And I do think it's a great read.
01:04:41
Speaker
And I think it's his first book, actually, one of the first books that he wrote that really –
01:04:45
Speaker
started his writing career, but it is a tremendous read.
01:04:51
Speaker
The second question relates to beliefs and whether it's something that you believe to be true in medicine or in life that most other people don't believe or act as if they don't believe.
01:05:02
Speaker
Yeah, I thought about that for a little bit.
01:05:08
Speaker
I guess the first thing that came to my mind, though, was that there are no magic bullets.
01:05:14
Speaker
We all kind of
01:05:16
Speaker
try to find quick answers to the problems that we face in medicine and outside of medicine.
01:05:25
Speaker
And there usually aren't easy answers.
01:05:29
Speaker
There's nothing that magically changes whatever the problem is that we're trying to fix.
01:05:35
Speaker
And the other piece of that in medicine in particular is a lot of things that come along that seem really exciting
01:05:46
Speaker
We also are giving a certain drug that's going to fix sepsis.
01:05:50
Speaker
And then some subsequent studies show that it didn't really work.
01:05:55
Speaker
So that was the first thing that came to my mind is searching for quick answers or magic bullets has generally not been very fruitful.
01:06:06
Speaker
Not that we shouldn't keep looking for answers to problems, but it's not going to be simple.
01:06:12
Speaker
But I think it's a great point.
01:06:13
Speaker
I mean, if it's too good to be true, it probably isn't true, right?
01:06:16
Speaker
Exactly.
01:06:17
Speaker
Exactly.
01:06:17
Speaker
And I think the other thing that comes to mind is that there's no easy answers, just tough questions.
01:06:23
Speaker
That's right.
01:06:23
Speaker
And we keep coming up with new questions.
01:06:27
Speaker
But I think that's a great point.
01:06:29
Speaker
And the last question really relates to, is there anything that you want to make sure that everyone who listens to this podcast knows or something you want to share with the audience before we leave?
01:06:40
Speaker
Well, I think from an intensive standpoint, actually my thought stems from my comment just now about no magic bullets and having done all this for a while now, I think what helps our patients more than anything is fixing the physiology as quickly as possible.
01:07:02
Speaker
And it's maybe simplistic, but I think it really is true in terms of what's changed, what we do in medicine and in the ICU.
01:07:11
Speaker
over the past 20 plus years.
01:07:13
Speaker
We've learned that if you have a cardiac arrest, the sooner you can shock somebody and get their own rhythm back, the sooner you can do good CPR on them, the better the chances of surviving.
01:07:24
Speaker
If they have sepsis, early goal-directed therapy, fixing their physiology makes a difference.
01:07:30
Speaker
For us that manage surgical problems and particularly trauma, if somebody's bleeding, it seems simple and obvious, but
01:07:39
Speaker
stopping the bleeding and giving them blood is what's going to make them better.
01:07:43
Speaker
So I think working on fixing the physiology and not overdoing it, because that's the other piece of this that we've found that doing too much isn't good either.
01:07:56
Speaker
Sometimes less is more.
01:07:58
Speaker
So I focus on quickly getting this patient's physiology back to normal.
01:08:02
Speaker
That's going to be the best way to get the patients through whatever their acute illness is.
01:08:08
Speaker
And I think that's a great place to stop, Sam.
01:08:10
Speaker
I really want to thank you for your time and sharing your expertise with us.
01:08:13
Speaker
It was a phenomenal conversation and that we look forward to having you back on the podcast maybe in the future.
01:08:18
Speaker
Sure.
01:08:19
Speaker
Happy to do it.
01:08:19
Speaker
A lot of fun.
01:08:22
Speaker
Thanks.
01:08:23
Speaker
Thank you.
01:08:25
Speaker
Thank you for listening to Critical Matters, a sound critical care podcast.
01:08:29
Speaker
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01:08:35
Speaker
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01:08:41
Speaker
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