Peritonitis, Haemoabdomen, Uroabdomen

Cards (14)

  • Peritonitis - general diagnostics
    POCUS - any patients with abdominal discomfort should have POCUS performed.
    Free fluid -> tap it!
    Physical appearance of the fluid - Can’t tell if its septic or non-septic from looking at it, will find bacteria in it if it is septic.
  • Peritonitis - diagnostics haemotology and biochemistry.

    In the short term - look for products of the bacteria rather than the bacteria itself. If the bacteria is dividing needs energy and therefore glucose is being used up. Can use the glucometer to do a very quick check.
    Primarily doing anaerobic respiration so can measure the lactate of the fluid compared to the blood. Animals probably have hyperlactataemic anyway so make sure to compare properly.
  • Peritonitis diagnostics - cytology, lavage
    Cytology - diff quick, takes time so don’t tend to do cytology in the immediate short term.
    Lavage - if the fluid pockets you see on POCUS are quite small and are struggling to obtain a sample then can use diagnostics peritoneal lavage. Obtain this sample for cytology or culture and sensitivity.
  • Peritonitis - treatment source
    Source control is key!
    Depends on the source:
    • Surgical removal if it can be excised (e.g. perforated intestine)
    • Abdominal drain +/- Lavage if the source is non-removable.
    Stabilise the patient first - e.g. treat distributive shock and the associated complications such as arrythmias.
    Antibiotics if septic
  • Peritonitis - treatment escalation vs de-escalation
    Escalate - start with no antibiotics (or a single antibiotics) and wait for culture and sensitivity results or patient deterioration before adding others in. Every hour you delay the antibiotic you need them the death rate increases quite a lot.
    De-escalate - Start with double or triple combination antibiotics (e.g. amoxi-clav, metronidazole and marbofloxacin) and then reduce depending on the culture and sensitivity results.
  • Haemoabdomen - monitoring and treatment
    Monitoring - hypovolaemic shock.
    Loss of RBC’s = loss of O2 carrying capacity -> cerebral hypoxia (dull mentation).
    Transfusion dependant or not.
    Blood pressure - MAP >60mmHg (minimum, ideal >70).
    Lactate - <2.0mmol/l
    Baseline parameters then fluid bolus (10ml/kg, isotonic crystalloid) and reassess.
  • Haemoabdomen - neoplastic bleeds
    If response to fluid bolus is poor -> transfusion.
    Auto-transfusion vs whole blood vs pRBC + plasma.
    Definitive treatment:
    • Surgery +/- chemotherapy/ radiotherapy.
    • Euthanasia - remember to do a met check.
  • Haemoabdomen - blunt trauma
    Usually caused by RTAs.
    If response to fluid bolus is poor -> transfusion.
    Auto-transfusion vs whole blood vs pRBC + plasma.
    Definitive treatment is not always definitive, as is likely to be bleeding from multiple sources, so X-lap is not recommended.
    Conservative management:
    • Tranexamic acid - anti-fibrinolytic; maintains clot stability.
    • Repeat transfusion.
  • Haemoabdomen - penetrating trauma.
    If response to fluid bolus is poor -> transfusion.
    Auto-transfusion vs whole blood vs pRBC + plasma.
    Definitive treatment:
    • Operate - stabilise and cut, don’t wait.
    • Consider a staged approach - pack it and close.
    • Tranexamic Acid - anti-fibrotic, maintains clots stability.
  • Haemoabdomen - coagulopathy
    If response to fluid bolus is poor -> transfusion
    Auto-transfusion vs whole blood vs pRBC + plasma.
    Definitive treatment:
    • Depends on the cause.
    • Clotting factors - fresh frozen plasma
    • Thrombocytopaenia - platelet rich plasma (PRP).
    • Rat poison - vitamin K (+FFP).
    • Treat the underlying disease.
  • Uroabdomen - diagnostics

    History:
    • Urinary signs (stranguria/dysuria)
    • Previosu surgery (cystotomy)
    • Trauma (RTA)
    Clinical signs:
    • Abdo pain
    • Reduced mentation
    • Inappropriately low heart rate.
    POCUS
    Radiography.
  • Uroabdomen - stabilisation
    Inappropriately low heart rate
    Cardiogenic shock - ECG monitoring
    POCUS - if see free fluid tap it.
    Free fluid analysis to confirm uroabdomen
    • Creatinine >2x blood value
    • Potassium >1,4 blood (dogs)>1.9x blood (cats).
    Hyperkalaemia can be life threatening
    • >8.0mmol/l - risk of atrial standstill.
  • Uroabdomen - hyperkalaemia
    Inappropriately low heart rate.
    Protect the cardiac action potential:
    • Calcium gluconate - slow IV (can cause arrythmia itself) - give as a bolus over 30 minutes, helps the cardiac action potential to work more effectively.
    Source control:
    • Urinary catheter - buys you time. Urine will preferentially drain via the catheter (least resistance) - you can now lay surgery or refer if out of your comfort zone.
    • Abdominal Lavage
    • Surgery to repair leakage.
  • Uroabdomen - fixing hyperkalaemia
    Functional pancreas (perfusion needs to be decent), sodium and glucose pushed into cells which stimulates insulin release, then sodium and potassium will be equalised via sodium/potassium pump, therefore taking potassium out of the cells. If the glucose is not working, then just give insulin, this will give them a hyperglycaemic so need to also give them glucose CRI to manage this.