- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Acute Abdominal Distension |
38 |
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Mohd. Talha Noor and Rakesh Kochhar |
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A 75-year-old male patient presented with respiratory distress after a road traffic accident. On examination, he was dyspneic. Computed tomography (CT) revealed features suggestive of massive hemothorax. He underwent urgent open thoracotomy following which his condition improved. On the third day of hospitalization, he developed acute onset abdominal distension. The percussion note over the abdomen was tympanic, and bowel sounds were sluggish. Abdominal X-ray revealed dilated bowel loops with multiple air-fluid levels. The serum sodium level was 139 mEq/L, and the serum potassium level was 2.6 mEq/L.
Abdominal distension in the ICU patients occurs due to many reasons. Acute colonic pseudo-obstruction is not an uncommon cause of acute abdominal distension in this setting. This is characterized by clinical features of large bowel obstruction but without any mechanical cause. Early recognition and appropriate management are critical in minimizing the morbidity and mortality from complications.
Step 1: Initial resuscitation and assessment
•After initial resuscitation (Chap. 78), a detailed history should be obtained, and the patient should be carefully examined.
•The bowel frequency, stool character, bowel sounds, abdominal distension and abdominal girth, and intra-abdominal pressure should be monitored (see the chapter 39).
M.T. Noor, M.D., D.M. (*) • R. Kochhar, M.D., D.M.
Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
e-mail: dr_kochhar@hotmail.com
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
305 |
DOI 10.1007/978-81-322-0535-7_38, © Springer India 2012 |
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306 |
M.T. Noor and R. Kochhar |
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•Crampy abdominal pain and exaggerated bowel sound suggest the presence of mechanical obstruction.
•Ileus presents with abdominal distention and abdominal pain that is typically mild and poorly localized. Other features include hypoactive or absent bowel sounds, lack of passage of flatus and stool, intolerance of oral intake, and nausea and emesis. Physical examination reveals a distended, tympanitic abdomen; hypoactive bowel sounds; and mild, diffuse abdominal tenderness. The patient may exhibit signs of dehydration, such as tachycardia, orthostatic hypotension, poor skin turgor, and dry mucous membranes.
•In critically ill patients, the possibility of a fecolith causing fecal impaction and obstruction should be kept in mind. Rectal examination should be performed with digital disimpaction if hard fecal matter is present.
•Send for the following investigations immediately:
– Erect and supine abdominal X-ray
•Abdominal X-ray shows a cutoff point in mechanical obstruction. Free air under the diaphragm must be looked for perforation. Gas seen till the rectum rules out distal bowel obstruction.
•Stool for occult blood and C. difficile toxin.
•Serum electrolytes.
Step 2: Make a diagnosis
The following conditions commonly present with acute abdominal distension in the
ICU:
•Acute colonic pseudo-obstruction (ACPO)
•Mechanical obstruction
•Intestinal perforation
•Ischemic bowel
•Toxic megacolon
–Inflammatory bowel disease
–C. difficile colitis
ACPO can be associated with a number of medical conditions (Table 38.1), which should be looked for and corrected if present.
•Correct important conditions:
–Medications such as calcium channel blockers and narcotics can lead to paralytic ileus. These medications should be stopped or their dose should be reduced.
–The presence of sepsis should be investigated, and samples for culture should be sent.
–In elderly patients with risk factors such as hyperlipidemia, atrial fibrillation, and the presence of coronary artery disease, mesenteric ischemia should be excluded.
–Rarely, endocrine disorders such as adrenal insufficiency, hypothyroidism and hypoparathyroidism can also lead to paralytic ileus.
38 Acute Abdominal Distension |
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307 |
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Table 38.1 Common conditions associated with ACPO |
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Cardiovascular |
Metabolic |
Neoplastic |
Posttraumatic |
Heart failure |
Alcohol |
Disseminated |
Femur fracture |
Myocardial infarction |
Electrolyte imbalance |
Leukemia |
Pelvic trauma |
|
Liver/kidney failure |
Retroperitoneal |
Spinal cord injury |
Drugs |
Inflammation |
Neurologic |
Postsurgical |
Antidepressants |
Acute cholecystitis |
Alzheimer’s |
Cesarean |
Antiparkinsonian |
Acute pancreatitis |
Multiple sclerosis (MS) |
Hip surgery |
Opiates |
Pelvic abscess |
Parkinsonian |
Knee replacement |
Phenothiazines |
Sepsis |
Spinal cord disease |
Spinal cord injury |
Respiratory problems |
|
|
|
Mechanical vent |
|
|
|
Pneumonia |
|
|
|
Step 3: Do appropriate imaging with proper interpretation
•Postoperative ileus must be differentiated from small bowel obstruction. Plain abdominal roentgenogram in ileus reveals pronounced small bowel dilatation but may reveal less pronounced large bowel dilatation.
•Additional imaging, such as abdominal CT, may be necessary to exclude mechanical obstruction. Abdominal CT is up to 90% specific and sensitive in excluding bowel obstruction.
Step 4: Initial treatment (Fig. 38.1)
•Continuous nasogastric decompression.
•Correction of fluid and electrolyte disturbance.
•Underlying conditions should be identified and aggressively treated.
•Discontinuation of drugs that promote an ileus.
•Metabolic disorders like diabetic ketoacidosis, if present, should be treated properly.
Step 5: Pharmacotherapy (Fig. 38.1)
The role of pharmacotherapy in the management of paralytic ileus is limited. However, the following drugs have shown some benefit:
•Metoclopramide—cholinergic agonist and dopamine antagonist—induces phase 3 of interdigestive migrating motor complex. Dose should be 0.5 mg/kg/24 h intravenously or intramuscularly.
•Alvimopan—selective mu-receptor opiate antagonist—antagonizes the gastrointestinal effects of nonselective opiates without affecting its central analgesic properties and enhances recovery of bowel function. Dose should be 6 mg orally.
•Neostigmine—reversible acetylcholine esterase inhibitor—enhances the activity of the neurotransmitter acetylcholine at the muscarinic receptors. It is the firstline treatment for colonic ileus. It is used in dosages of 2.0 mg infused over
308 |
M.T. Noor and R. Kochhar |
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|
Acute massive colon dilatation
Exclude mechanical obstruction assess for ischemia/perforation
Conservative management for 24–48 hours Identify and treat reversible causes
No improvement Or
Cecum > 12 cm Distention > 6 days
IV neostigmine |
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Resolution |
No improvement—Repeat dose |
|
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Colonoscopy with decompression tube |
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Yes |
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Percutaneous cecostomy |
improvement |
|
No |
||
or surgery |
Fig. 38.1 Algorithmic approach to ACPO
3–5 min. Atropine should be kept ready when it is done. EKG should be constantly monitored during infusion. Vital signs should be monitored for about 30 min after infusion. The patient should be kept in supine or semisupine position, and a bedpan should be provided. Randomized controlled trials (RCTs) have shown benefit.
Step 6: Colonoscopic decompression
•Colonoscopy is required in some patients to rule out distal obstructive lesions, but its role for colonic decompression is controversial.
•Its use has decreased after neostigmine has been accepted for treatment. Now it is resorted to if neostigmine fails.
•This is done without any preparation, and attempt has to be made to use minimum insufflation and reach cecum.
•Some centers use a decompression tube, which is kept inside to constantly decompress.
•This is initially successful in 70–90% of patients, but 10–20% may recur. In such patients, the second decompression can be tried.
Step 7: Surgery
•Surgery is rarely required in patients with persistent colonic dilatation in spite of colonoscopic decompression and in patients with peritonitis.
•Surgery recommended in such cases is cecostomy or loop colostomy. If there is any nonviable bowel, it is resected. In patients who are unfit for surgery, percutaneous cecostomy just like percutaneous endoscopic gastrostomy is performed.