Colic II - Exploratory Celiotomy and Post-Op Complications

Question 1

Two forms you’d want completed before the surgery?

Answer 1

1. Written / Signed consent from owner/agent

2. Signed estimate

Question 2

Minimum Pre-Op Bloodwork:

1. \_\_/\_\_\_
2.
3.
4.
5.
6. \_\_\_/\_\_\_

Answer 2

1. PCV/TP
2. Lactate
3. CBC with differential
4. Fibrinogen
5. Glucose
6. BUN / Creatinine

Question 3

4 surgical approach options?well

1.
2.
3.
4.

Which one is the best? Why?

Answer 3

1. Ventral Paramedian
2. Inguinal
3. Ventral Midline
4. Flank (paralumbar and transverse)

Ventral Midline is the best because you can exteriorize 75% of the GIT with minimal hemorrhage, and close

Question 4

Things you are unable to exteriorize during a ventral midline approach?

1.
2.
3.
4.
5.
6.
7.

Answer 4

1. Stomach
2. Duodenum
3. Distal ileum
4. Base of cecum
5. Distal RDC
6. Transverse colon
7. Terminal small colon

Question 5

Ventral Midline Approach:

1. Incision through the linea alba cuts through what three layers?
2. Average length of incision?
3. Begin incision where? Why?

Answer 5

1. EAO, IAO, and transverse abdominal muscle
2. 30 cm+
3. Umbilicus - linea is thickest here

Question 6

A bad sign during exploratory celiotomy is loss of (negative/positive) pressure

Answer 6

Negative

Question 7

Describe the step-by-step exploration:

1. Begins at ____
2. Follow ___ to the ____
3. Follow ___ to the ____
4. Run ___ from __ to ___

Answer 7

1. Cecum
2. Follow lateral band to the cecocolic band to the RVC
3. Follow dorsal band to the ileocecal fold to the antimesenteric band of ileum
4. Run SI from Ileum to duodenum

Question 8

How can you decompress the SI during exploration?

Answer 8

Manually milk contents to the cecum

Question 9

Duodenum Exploration:

1. Fixed to ____ + ____ by the ____
2. How it runs in the body?
3. Be sure to palpate what closely associated structure?

Answer 9

1. Dorsal body wall and Transverse colon by the duodenocolic ligament
2. from L to R behind the root of mesentery to the ascending duodenum
3. Cranial mesenteric artery

Question 10

What is the next step of an Exploratory Celiotomy after the initial exploration?

Answer 10

Colonic evaluation

Question 11

Where do you begin the colonic evaluation stage of the exporatory celiotomy?

Answer 11

at the lateral band of the cecum to the RVC

Question 12

Describe the steps of the colonic evaluation:

Starting from the RVC:

1. from ___ to ____

3.

6.

Answer 12

1. From cecum cranially to the sternal flexure
2. Caudally down the LVC to the pelvic flexure
3. Cranially as the LDC
4. To the diaphragmatic flexure
5. To the RDC
6. To the Transverse colon

Question 13

If a horse in desperate need of a correcting surgery for a small intestine colic is <2 from surgical facility, you can consider giving _____

Answer 13

hypertonic saline

Question 14

Methods to determine tissue viability:

1. ____ - Gold Standard!

2.

3.

4.

5.

6.

Answer 14

1. Histopathology
2. Gross clinical assessment
3. Fluorescein Dye given IV
4. Doppler U/S
5. Luminal Pressure
6. Surface Oximetry

Question 15

Post-Op Supportive Care Includes:

1.
2.
3.
4.
5.
6.

Answer 15

1. CV support
2. Pain Management
3. Anti-Endotoxin therapy
4. Prevent/treat infection
5. Restore GI function
6. Manage complications

Question 16

Post-Op Fluid Therapy:

1. Most important aspect is the (volume/rate) of fluids given
2. Daily maintenance = ___ ml/kg/day
3. Common electrolyte imbalances you’d try to correct?

Answer 16

1. Volume
2. 50 ml/kg/day
3. Hypocalcemia, hypomagnesemia

Question 17

Causes of Hypokalemia Post-op?

Answer 17

1. Lack of intake
2. Diuresis
3. GI loss through diarrhea

Question 18

Potassium Supplementation:

1. When to supplement?
2. No greater than __mEq/kg/hr **
3. Usually add ___mEd/5L bag

Answer 18

1, lack of intake > 24 hours or when youve given IV fluids > 24 hours

2. .5 mEq/kg/hr
3. 80mEq/5L bag

Question 19

Why is it difficult to maintain vascular volume post therapy?

Answer 19

Because increased capillary permeability d/t mucosal damage creates fluid and protein loss into interstitum

Question 20

1. Goal of Post Op Fluid Therapy?

2. Reasonable indicators that you are successful?

Answer 20

1. Maintain enough vasc. volume to sustain CO

2. HR < 80, PCV < 50%, TP > 4.1

Question 21

Post Op-Monitoring:

How often should you:

1. Take a PCV/TP?
2. Perform gastric decompression?
3. Complete PE?
4. Take a CBC/Fibrinogen/Lactate/Electrolytes?

Answer 21

1. Q6 HRs
2. Q2-3 Hr
3. Q1-3 Hrs
4. One day post op, and 3 days post op

Question 22

Post op medications:

1.
2.
3.
4.
5.
\+/-
6.
7.

Answer 22

1. Fluids
2. Antibiotics (broad spectrum)
3. NSAIDs
4. Gastric protectants
5. Anti-endotoxin drugs

+/-

6. Colloids
7. Prokinetics

Question 23

When to discontinue Post-op Meds?

1.
2.
3.

Answer 23

1. Eating
2. Afebrile
3. Normal CBC

Question 24

Post-Op Pain Management:

Etiology?

1.
2.
3.

Answer 24

1. Peritoneal inflammation
2. Abdominal incision
3. Intestinal distension

Question 25

Post-Op Pain Management Options: 1. ____ - Beneficial effects? 2. _____ - Dosage regimen?

Answer 25

1. Pain + Anti-Endotoxin | 2. Loading dose followed by CRI

Question 26

Post-Op Endotoxemia: 1. (common/rare)? 2. Describe some clinical signs

Answer 26

1. common! | 2. tachycardia, abnormal mm, pain, edema, hypomotility, GI distension, NG net reflux, thrombosis/coag disorders

Question 27

Post-Op Endotoxemia Management: ``` 1. 2. 3. 4. 5. 6. ```

Answer 27

1. FLUIDS! FLUIIIIIDDDDSSS 2 Flunixin meglumine low dose 3. Meds to chelate endotoxins like DTO 4. Drugs to bind endotoxin like POlymyxin B 5. Plasma 6. Heparin therapy (if DIC)

Question 28

Post-Op Ileus (POI) 1. (Common/rare)? 2. Some risk factors (there are a lot!)

Answer 28

1. common ``` 2. > 10 years old, PCV > 45% at presentation, Hight TP and alb, Hyperglycemia, Anesthesia > 2.5 hr, Surgery > 2 hours, R/A, SI lesions, Ischemic small intestine ```

Question 29

Post-Op Ileus (POI) 1. Incidence rate: __-__% 2. Most common lesion that leads to POI? 3. Prognosis?

Answer 29

1. 10-21% 2. Strangulating SI 3. Favorable

Question 30

Clinical Signs of POI: 1. Behavior? 2. 3. 4. Lab results?

Answer 30

1. Colicky, depressed 2. Decreased/no borborygmi 3. Elevated Hr 4. Increased PCV/TP, electrolyte derangement

Question 31

Dx of POI: 1. 2. 3.

Answer 31

1. Rectal exam 2. U/S 3. Gastric reflux 12-48 hours post op

Question 32

T/F: The best way to treat POI is via supportive therapy

Answer 32

T

Question 33

Supportive therapy options for POI: 1. 2. 3. 4.

Answer 33

1. NG decompression 2. FLUIDS 3. Address any electrolyte imbalances 4. +/- Antibiotics

Question 34

Prokinetic options for POI: 1. 2. 3.

Answer 34

1. Lidocaine 2. Metoclopramide 3. Erythromycin

Question 35

Lidocaine CRI : 1. Decreases _____ 2. Suppresses _____ activity 3. Directly stimulates ____ 4. Inhibits: a) b) c)

Answer 35

1. catecholamines 2. 1st degree afferent neuron activity 3. smooth muscle 4. a) prostaglandin = decreased inflam in gut wall b) granulocyte migration/lysosomal enzyme release c) free radical production

Question 36

Lidocaine CRI: 1. Loading Dose? 2. CRI dose?

Answer 36

1. 1.3ml/kg IV | 2. .05mg/kg/min in fluids

Question 37

Lidocaine CRI: 1. Toxicity can cause: ___, ___, ____ 2. DO NOT GIVE AS ____

Answer 37

1. muscle fasiculation, ataxia, SEIZURE | 2. Bolus

Question 38

Metoclopramide: Effects: 1. Mechanism? 2. End result?

Answer 38

1. Increases ACH release via Da1 and DA2 antagonism, and serotonin modification 2. Stimulates smooth muscle in stomach and small intestine

Question 39

Toxic effects of Metoclopramide? 1. 2. 3. 4.

Answer 39

1. Excitement 2. Restlessness 3. Sweating 4. Seizure

Question 40

Erythromycin: 1. Mechanism? 2. Effect? 3. Reports of ____ with use, can also have what two side effects?

Answer 40

1. Motilin agonist 2. Stimulates stomach and small intestine motility 3. Severe colitis, Cramping, colic

Question 41

Possible incisional complications: 1. 2. 3. 4.

Answer 41

1. Infection 2. Hernia 3. Suture sinus formation 4. Acute incisional dehiscence

Question 42

Incisional Infection: 1. Usually occurs how long post-op? 2. CxS?

Answer 42

1. > 3 days | 2. Febrile, pain, edema

Question 43

Incisional Infection: Treatment options: 1. 2. 3. 4.

Answer 43

1. Drainage 2. Culture 3. Antibiotics (depending) 4. Abdominal support to minimize hernia / dehiscence

Question 44

Incidence of incisional infection can be decreased by: 1. 2. 3. 4.

Answer 44

1. Rapid surgery 2. Appropriate draping 3. Isolating enterotomy incision 4. Good technique

Question 45

Most common complication from incisional infection? Factors that increase likelihood of this complication?

Answer 45

Incisional Hernia Violent recovery, severe post-op pain, prolonged surgery time

Question 46

Acute Total Dehiscence: 1. (common/rare)? 2. (mild/severe)?

Answer 46

1. rare | 2. Severe, often fatal

Question 47

Acute Total Dehiscence: Predisposing factors: 1. 2. 3. 4.

Answer 47

1. Violent recovery 2. Severe post-op pain 3. Prolonged surgery time 4. Continuous suture pattern

Question 48

2nd most common reason for a repeat surgery? More common in (foals/adults)?

Answer 48

1. Adhesions | 2. Foals > adults

Question 49

Ways to prevent post-op adhesions (pre/intra-op) 1. 2. 3. 4.

Answer 49

1. Maintain intact mesothelial layer 2. Minimize trauma via good technique (keep bowel moist, remove talc from gloves, hemostasis, minimal exposure of suture) 3. Decide on surgery in a timely manner 4. Peri-op NSAIDs and antibiotics

Question 50

Adhesion Prevention (post-op) ``` 1. 2. 3. 4. 5. 6. ```

Answer 50

1. DMSO 2. Heparin 3. CMC 3% 4. HA 5. NSAIDs / Antibiotics 6. Omentectomy 7. Peritoneal Lavage

Question 51

Peritonitis: 1. Mortality rate - __% 2. Damage via: a) b) c)

Answer 51

1. 56% 2. a) Bowel necrosis b) Anastomotic / enterotomy leakage c) contamination

Question 52

Clinical Signs of Peritonitis: ``` 1. 2. 3. 4. 5. 6. ```

Answer 52

1. Colic, depression 2. Anorexia 3. Ileus 4. Diarrhea 5. Fever 6. Elevated HR and Rr

Question 53

T/F: 200,000 cells/uL, TP 6 g/dL is normal after a colic surgery

Answer 53

T

Question 54

What would you look for on cytologic eval of of abdominal fluid to dx peritonitis?

Answer 54

Toxic PMNs, bacteria

Question 55

Peritonitis Dx: 1. pH? 2. Glucose?

Answer 55

1. Serum peritoneal glucose difference > 50 mg/dL | 2. Peritoneal pH < 7.2 with peritoneal glucose < 30 mg/dL

Question 56

Treatment of Perionitits: ``` 1. 2. 3. 4. 5. ```

Answer 56

1. Stabilize with fluids/electrolytes/plasma 2. NSAIDs 3. Antibiotics 4. Possible repeat laparotomy 5. Closed drains

Question 57

What is the best way to prevent post-op laminitis?

Answer 57

By minimizing risk of post-op endotoxemia