Colic II Flashcards by Corinne Perra

You come across a 14yr old QU gelding with..

Temp 100.8
HR 80 bpm 
RR: unable to assess 
MM: “muddy” 
CRT 3 sec

GI neg in all quadrants
Self induced trauma over the head/eyes

What do you do first?

NG tube

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You come across a 14yr old QU gelding with..

Temp 100.8
HR 80 bpm 
RR: unable to assess 
MM: “muddy” 
CRT 3 sec

GI neg in all quadrants
Self induced trauma over the head/eyes

What additional diagnostics do you do?

Rectal
US
Abdominocentesis

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You come across a 14yr old QU gelding with..

Temp 100.8
HR 80 bpm 
RR: unable to assess 
MM: “muddy” 
CRT 3 sec 
GI neg in all quadrants 
Self induced trauma over the head/eyes

NG tube — 10L of foul reflux
Rectal — multiple loops of distended from SI
US— stacked loops of thick SI
Abdominocentesis — serosanuinous, TP 3.4, cells 5000

Top DDX?

Strangulating lesion of small intestine due to severe colic signs, large amounts of reflux and distended SI loops

Most likely a strangulating lipoma due to age

Others:
Volvulus
Herniation
Intussusception

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You are referring a patient for colic surgery. The center is 3 hours away form you. How should you prepare your patient for transport ?

Indwelling gNG tube

Hypertonic saline (4ml/kg) — provides CV support

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For every 1L of hypertonic solution you give a horse, it should be followed up with ______ L of __________

10L of crystalloids

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Minimum pre-op blood work for colic surgery?

PCV/TP 
Lactate 
CBC with differential 
Fibrinogen 
Glucose 
BUN/CREA

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What is the best overall approach for colic surgery?

Ventral midline
— can exteriorize 75% of GIT
— minimal hemorrhage
—strong closure

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What are you unable to exteriorize with a ventral midline approach?

Stomach 
Duodenum 
Distal ileum 
Base of cecum 
Distal RDC 
Transverse colon 
Terminal small colon

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What are poor prognostic indicators for exploratory celiotomy?

Loss of negative pressure

Foul smell

Excessive/abnormal fluid

Excessive gas/abnormal bowel position

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How do you work through the intestine when doing exploratory celiotomy?

Begin at cecum

Follow lateral band to cecocolic bank to RVC

Follow dorsal band to ileocecal fold to antimesenteric band of ileum

Run SI from ileum to duodenum

Exteriorize pelvic flexure

RVC from cecum cranial to sternal flexure caudally down LVC to pelvic flexure, cranially to LDC to diaphragmatic flexure to RDC to transverse colon

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How do you decompress the SI?

Manual “milking” of contents to the cecum

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Where do you find the duodenum?

Fixed to dorsal body wall and transverse colon by duodenocolic ligament

Runs from L to R behind root of mesentery to the ascending duodenum

Palpate cranial mesenteric artery
Follow duodenum to pylorus/stomach

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Transverse colon runs in what direction?

Right to left

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How do you close a ventral midline incision in the horse?

Large synthetic absorbable
— vicryl
—PDS

Short burst simple continuous (most common)
Cruciate
Simple interrupted

8-10throws at each end

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Potential post op complications from colic surgery?

POI
Endotoxemia
Leakage from anastomosis site/peritonitis

Hemorrhage
Stricture at anastomosis site

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When would you expect to see reflux from post op ileus?

In 12-24 hours post op

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You have a 8yr warmblood mare that is violently colicky

Hx of 
Foaling 8 weeks ago 
This is her 3rd foal 
Current of vax and deworming 
On spring pasture

Owner gave 10ml banamine before calling

Top ddx??

Colon torsion

Based on foaling history this is most likely

How do you want to stabilize the following patient prior to surgery?

8yr old warmblood mare with suspected colonic torsion

HR 60
RR elevated
MM brick red with toxic line
Cool extremities

Severe pain

IV fluids — bolus

NSAIDS

AB :K + pen and gentocin

Tetanus prophylaxis

How are you going to assess tissue viability in a case of colonic torsion?

Color (serosa/mucosa)
Thickness
Pulse quality
Peristalsis

Fluorescein dye — IV
Surface oximetry
Doppler US
Luminal pressure

Histopath — gold standard

Common post op colic surgery electrolyte derangement?

Hypo Ca and Hypo Mg —> most common

K+ also (only get from diet and loss from diuresis or diarrhea)

What is the max rate of K+ administration?

0.5mEq/kg/L

Usually add 80mEq/ 5L bag

What are reasonable indicators that you are maintaining vascular volume post op?

HR <80
PCV <50%
TP >4.1

How often are you monitoring your patient post op?

And what tests are you doing?

Exam q1-3h

PCV/TP q6h
Gastric decompression q2-3hrs
CBC/Fibronogen/lactate/electrolyte one day post op and 3 days post op

Common post op medications for colic surgery?

Fluids (crytalloids) 
Antibiotics 
NSAIDS 
Lidocaine 
Gastric protectants 
\+/- colloids (plasma, hetastarch) 
Anti-endotoxin medications 
\+/- prokinetics

When can you discontinue post op medication?

When patient is eating, afebrile, normal CBC

Common post colic surgery complications?

``` Pain Endotoxemia Post-op ileus Colitis Incisional complications Adhesions Peritonitis Hemorrhage Laminitis ```

Clinical signs of post-op endotoxemia?

``` Tachycardia Abnormal mm (hyperemic, cyanotic) Pain Edema Hypomotility GI distention NG net reflux Thrombosis/coag disorders ```

How do you manage post-op endotoxemia?

Fluids Flunixin meglumine Antiendotoxin therapy — di-tri-octahedral (DTO) smectite (biosponge) —> binds endotoxin Polymixin B — binds lipid A Plasma Heparin therapy in cases of DIC

Risk factors for POI?

<10years old PCV > 45% High TP and albumin Hyperglycemia ``` Anesthesia >2.5hrs Surgery >2hrs R/A SI lesions Ischemic small intestine ```

What is the most common lesion leading to post op ileus?

Strangulating SI lesions

Clinical sings of post op ileus?

``` Colic, depression Decrease/no borborygmi Elevated HR Increased PCV/TP Electrolyte derangement ```

Treatment for post op ileus?

``` Supportive therapy —NG decompression —fluids —electrolytes +/-antibiotics ``` Prokinetics agents — lidocaine — metoclopramide —erythromycin (can cause pain and colitis)

What function does lidocaine have in treatment of post op ileus?

Decrease catecholamines Suppress primary afferent neuron activity Directly stimulates smooth muscle Inhibits prostaglandins —> decrease gut wall inflammation, granulocyte migration/lysosomal enzyme release, free radical production

What happens when you give a bolus of lidocaine ?

Toxicity! Muscle fasciculation Ataxia Seizure

How does metoclopramide help treat post op ileus?

Increase ACH release | Stimulate smooth muscle in stomach and small intestine

What complications can arise from the incison site?

Infection Hernia Suture sinus formation Acute incisional dehiscence

What is the most common complication from incisional infection?

Incision hernias

When do you want to repair an incisional hernia and why?

3 months after initial surgery This allows boy wall to heal and fibrous tissue to form

Predisposing factors to acute total dehiscence?

Violent recovery Severe post op pain Prolonged surgery time Continuous suture pattern

How can you prevent adhesions ?

Maintain intact mesothelial layer Minimize trauma — good technique Keep bowel wet Hemostasis Minimal suture exposure Decide on surgery in timely manner Peri-op NSAIDs and antibiotics ``` DMSO Heparin CMC 3% HA Omentectomy Peritoneal lavage ```

Causes of peritonitis?

Bowel necrosis Anastomotic or enterotomy leakage Contamination

How can you diagnose peritonitis?

Abdominocentesis Toxic PMNs, bacteria PH glucose —serum: peritoneal glucose difference >50mg/dL — peritoneal pH <7.2 with glucose <30mg/dl CBC/fibrinogen Left shift, thrombocytopenia, hypoproteinemia