E2- Peritonitis Flashcards by Crimson Cuppernell

Perinoneal circulation: focal contaimation can do what?

QUICKLY inoculate entire peritoneum

caudal to cranial flow

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***Primary classification of peritonitis****

spontaneous inflam in the absence of intraperitoneal source

corona virus→ FIP (cats)

hematogenous/lymphogenous bact spread, transmural bacterial migration from GI tract, or bact spread from oviducts

Gram + organisms more common and usually MONOBACTERIAL

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***Secondary classification of peritonitis****

consequence of an underlying primary dz process

bowel leakage/translocation, urine/bile/blood extravasation, neoplastic invasion, pancreatitis

Gram - organisms more common and usually POLYMICROBIAL

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_____ peritonitis- infectious etiologies present (usually bacterial)

septic

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Why is it important to differentirate b/t primary Vs secondary peritonitis?

Surgery is NOT routinely indicated for primary but is requisite for secondary

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Septic peritonitis from GI origin causes

cause= 38-75% of cases

mecahnical perforation (FB), trauma, ruptured neoplasia, vascular disruption leading to ischemia/necrosis (GDV), surgical dehiscence after R&A, drug induced

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Septic peritonitis from GI origin: location of perforation dictates ____

bacterial demographics

aboral = higher total bacterial counts, increased anaerobes, increased mortality

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Septic peritonitis from GI origin: two main offenders from the bowel?

E. Coli (57-74% of cases) = alpha hemolysin endotoxin

Bacteroides fragilus (anaerobic)- enhances lethal potential of E. Coli

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Septic peritonitis from **hepatobiliary** causes

Ruptured gall bladder mucocele

necrotizing cholecystitis

abscess (+/- tumor)

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Serptic peritonitis from **Urogenital** causes

pyometra

prostatic abscess

ovarian cyst

pyelonephritis/renal abscess

retained testicle

ruptured bladder

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Other causes of septic peritonitis?

pancreatic

splenic

penetrating trauma- bite wounds

lymph node

iatrogenic

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Peritonitis pathophysiology: local manifestations

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Peritonitis Pathophysiology: Systemic manifestations

trickle down effect

***have a good understanding of this***

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What are the terminal effects of peritonitis?

DIC- disseminated intravascular coagulation

SIRS- systemic inflam response syndrome

MODS- multiple organ dysfunction syndrome

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Clinical signs of peritonitis

variable- depend on etiology, duration, signalment and severity

classic= painful, vomit, fever, distended abdomen +/- shock (acute abdomen)

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Two phases of shock in peritonitis?

Hyperdynamic
- vasomotor dysfunction, cytokine-induced peripheral vasodilation, tachycardia, hyperemic (brick red) MM’s w/ rapid CRT, bounding pulses and hyperthermia
Hypodynamic
- decreased contractility and CO = pale MM w/ CRT >2sec, weak peripheral pulses, hypothermic, increased RR,HR, dehydration, dull mentation

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Septic peritonitis in cats

NO pain on abdominal palpation

relative BRADYCARDIA = <140bpm

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Diagnostic imaging of peritonitis

Abdominal US- pneumoperitoneum and ID pathology

Radiographs- pneumoperitoneum and loss of serosal detail

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How long can residual free air remain after abdominal surgery?

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up to 30 days

Preferred diagnostic technique for peritonitis in people?

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CT imaging

differentiating surgical vs non surgical

What is the GOLD standard dx for peritonitis?

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CYTOLOGY

US guided- aFAST (focused assessment w/ sonography for trauma)

blind 4 quadrent abdominocentesis

diagnostic peritoneal lavage (DPL)

What is seen on cytology that is diagnostic for peritonitis?

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degenerative neutrophils w/ intracellular bacteria***

How accurate is cytology?

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only 57-87% accurate****

In dogs with septic effusion, peritoneal fluid glucose concentration will ALWAYS be _____ than the blood glucose concentration

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LOWER

**In dogs, Glucose is _____ points lower in belly fluid than blood**

20 points bc glucose is used up by bacteria and phagocytic cells

**In dogs, Lactate is ____ points higher in belly fluid than blood**

2 points anaerobic metabolism and lactic acid production by bacteria in peritoneum

How does glucose sensitivity compare to cats vs dogs

cats only 86% sensitive, dogs 100% sensitive so we rely more on lactate for cats

Diagnosis of fluid analysis for peritonitis: uroperitoneum

Urogenital source- peritoneal fluid creatinine conc \> serum creatinine conc = dx for uroperitoneum

Diagnosis of fluid analysis for peritonitis: Bile peritonitis

peritoneal fluid bilirubin conc \*\*\*\***_\>2.5X\*\*\*_** serum bilirubin conc is 100% dx for bile peritonitis in dogs and cats

Treatment of peritonitis

provide hemdynamic support: fluids, blood products, antibiotics, analgesia **emergency surgery!!!** * **reduce amount of contamination** * **prevent further contamination by controlling source** * **provide postop abdominal drainage**

Antimicrobial selection for peritonitis

increased rate of bact resistance with ampicillin, cefazolin, fluoroquinolones lower rates of resistance with aminoglycosides and 3rd gen cephalosporins combo therapy to start: **FOUR QUADRANT**: - iv ampicillin/aminoglycoside/metro, careful w/ P that have poor perfusion = can lead to acute renal failure - iv ampicillin/baytril/metro -classic "go to" choice

For peritonitis surgery- you must repair or remove the \_\_\_\_

inciting cause= intestinal resection and anastomosis, cholecystectomy, liver lobectomy, partial cystectomy, nephrectomy

What is important in peritonitis surgery?

LAVAGE w/ warm isotonic saline suction

Do NOT overlook the need for ____ with peritonitis sx

PO enteral nutrition- these animal need feeding tubes!!

PO ___ critical with peritonitis sx

drainage

\_\_\_\_ closure- if source of infection has been isolated and completely controlled in peritoneal sx

primary

Two types of open peritoneal drainage

gravity dependent- dressing packed w/in open incision vacuum assisted closure

Two types of closed peritoneal drainage

**passive**- multi luminal, penrose or column disk catheters \*\***active**\*\*- closed suction (jackson pratt)- requires external vacuum to create neg pressure w/in cavity

Pros of open peritoneal drainage

most effecient way to drain limits anaerobic bacterial growth

Cons of open peritoneal drainage

labor intensive bandage management risk of nosocomial contamination anemia, hypoproteinemia and electrolyte imbalances 2nd sx procedure to close abdomen

Pros of closed peritoneal drainage

lower risk of nosocomial bact contamination decrease potential for evisceration less intensive PO bandage care no additional sx to close abd

Cons of closed peritoneal drainage

occlusion (omentum/clots) ascending bacterial contamination

Open Vs Closed peritoneal drainage: which one is significantly better?

NO SIGNIFICANT difference

Open Vs Closed peritoneal drainage: which requires more intensive care?

OPEN blood, plasma, enteral nutrition

Open Vs Closed peritoneal drainage: which one requires a longer hospital stay?

6 days- open 3.5 days closed

Cav's choice for abdominal drainage?

closed suction- Jackson pratt

E2- Peritonitis Flashcards

(46 cards)