case study of abdominal surgery

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Home > Books > Abdominal Surgery - A Brief Overview

Postoperative Follow-Up and Recovery after Abdominal Surgery

Submitted: 23 November 2020 Reviewed: 15 April 2021 Published: 21 May 2021

DOI: 10.5772/intechopen.97739

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Abdominal Surgery - A Brief Overview

Edited by Ahmad Zaghal and Arwa El Rifai

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Postoperative patient care has several components: - surveillance, − prevention of complications associated with surgical disease or other preexisting comorbidities, − specific postoperative treatment of the surgical disease and its complications. While these distinctions are purely didactic, the postoperative care merges into an active surveillance with a higher level of standardization than it would seem at first glance. Computing, interpreting and integrating signs and symptoms with active search of proofs by lab tests or other paraclinical explorations highly depends on skills and dedication of the entire healthcare team. Those attributes gained through continuous theoretical preparation but validated by current practice bring added value, always in favor of the patients’ best interests. In this chapter, we propose to explore the main clinical and paraclinical means and tools that can improve the outcomes of surgical procedures for a faster and safer recovery. We will also discuss the need for different types of surgical bed drains placement and their management, the use of antibiotics and thrombotic event prophylaxis.

• postoperative
• complication
• prophylaxis

Author Information

Stelian stefanita mogoanta *.

• General Surgery Department, University of Medicine and Pharmacy of Craiova, Romania

Stefan Paitici

Carmen aurelia mogoanta.

• ENT Department, University of Medicine and Pharmacy of Craiova, Romania

*Address all correspondence to: [email protected]

1. Introduction

The surgical act, defined as the time that a surgeon effectively operates on the patient, remains the center of surgical therapy, however, it is increasingly clear that the preoperative and more importantly the postoperative care can enhance or unfortunately compromise the results of a technically successful surgery. For reducing the mortality and morbidity rates in the postoperative period, it is crucial to identify risk factors, prevent and treat as soon as possible any deviation of the patient state from the normal rehabilitation course. Timely interventions reduce the impact of the negative events in the patient’s recovery. Early recognition of signs and symptoms by close surveillance is the key and starting point for active surveillance. This allows targeted lab testing or imaging (if needed) to rapidly identify any undesired event in patient recovery and allow for specific and proper action.

To monitor the operated patient, we have at our disposal the clinical and paraclinical parameters. The patient’s temperature, despite being a general and non-specific parameter, is one of the most important and easy to monitor.

During the follow-up period of the surgical patient, the temperature is usually measured at least twice a day, in the morning and in the afternoon, and whenever there is a suspicion of fever. The determinations are included in the observation sheet completing the temperature graph whose oscillations become suggestive in a clinical context. A single febrile rise, below 38 degrees Celsius can often be caused by the resorption of blood degradation products from the operative wound or secondary to the excessive maintenance of a drainage tube, without major pathological significance [ 1 ]. However, the persistence of the fever with the configuration of “saw teeth” on the thermal chart suggests the development of a septic process. The first to be checked is the surgical site, then the lung and urinary system, as these are the most frequent sites of infection after surgery. Particular attention should be paid to the occult causes of fever such as endocarditis, phlebitis, lamellar atelectasis that should be systematically searched for in the context of an unjustified febrile syndrome with an apparently good evolution in the operative site. In a large cohort study [ 2 ], the most common causes of fever development were stratified a few days after surgery. On the day of surgery, cardiac pathology and specific myocardial infarction seem to be the most common, then pulmonary pathology – pneumonia and atelectasis seem to cause fever in days 1–3 postoperatively. Urinary infections usually occur in 2–3 days postoperatively but can also begin later. From day 4 to 30 postoperatively, superficial or profound surgical site infections become the main cause for fever development, while thrombosis can cause fever at any time between the day of surgery and postoperative day 30. When the febrile ascension appears suddenly on the fifth day after surgery, without signs of wound infection anastomosis dehiscence should be suspected, however, it can also be caused by thrombophlebitis. Therefore, we can conclude that fever is a general sign that should always be interpreted in accordance with other signs and symptoms but it is an alarming sign that should lead to careful and complete physical examination and laboratory tests or imaging studies evaluated on a case-by-case basis.

3. Supervision of the cardiovascular system

Cardiovascular system stability is crucial in the postoperative evolution of the patient. Complex surveillance is needed in many cases and the rehabilitation measures must be intensive and prompt, conducted in most cases by the intensive care specialist or cardiologist. However, the surgeon must be prepared to recognize cardiac risks and main syndromes and even manage the patient until one of the above mentioned specialists are available.

Heart rate is systematically monitored several times a day. Immediately postoperatively, the pulse rate is usually higher than normal with a decreased amplitude, may be justified by intra operative blood loss, which may remain insignificant in the overall economy of the patient’s healing, or by anesthetic drugs, the extent of surgical “aggressiveness”, pain, etc. As these factors are progressively corrected, the heart rate should return to normal. Additional oxygen administration can help achieve a faster normal rate as it improves tissue oxygenation [ 3 ]. It is very important to compare the pulse frequency with the values ​​noted preoperatively taking into account the patient’s underlying pathology (thyroid, heart, etc.). The pulse with increasing frequency from one determination to another, with a small amplitude that becomes progressively filiform, associated with hypotension in a sweaty and pale patient, may be caused by a bleeding at the operating site (which is not always in the drain tube or in the container); this may require analysis of reoperation for hemostatic purposes. Tachycardia with low pulse amplitude and a decrease in blood pressure that occurs on days 4–6 postoperatively, may indicate a septic complication or anastomosis dehiscence. On the other hand, bradycardia is however associated with increased cardiac, pulmonary, renal and pain-related morbidity at 3 and 5 days after surgery [ 4 ]. The discovery of arrhythmias whether extrasystolic or atrial fibrillation as a new event, requires rapid correction of ionic and hydric imbalances and the search for a septic process, the most likely causes in this context. Both bradycardia and arrythmias always require a postoperative cardiac consult [ 4 , 5 ].

Blood pressure is determined at least twice a day. The recorded values ​​are interpreted in a dynamic clinical context, always compared with the normal values ​​of the patient determined preoperatively. Low blood pressure levels ​can be found immediately postoperatively, in conditions of shock, dehydration, bleeding or heart failure, etc. All these causes of low blood pressure require immediate and accurate diagnosis and correction as they bring increased mortality [ 6 ]. Elevated blood pressure levels ​​occur especially in patients with a history of hypertension in the context of an exaggerated postoperative catecholamine reaction, fluid overload or inadequate pain control. When they exceed certain values, ​​beyond physiological variations, both increases and decreases in blood pressure values ​​must be promptly corrected to prevent cerebral or cardiac events or ischemia of a recent anastomosis [ 7 , 8 ]. Due to the high complexity of the measures required, it is recommended that an unstable cardiovascular patient be transferred to the intensive care unit and evaluated by a cardiologist [ 8 ].

4. Respiratory surveillance and care

The quality of respiratory function has a major impact on the patient’s postoperative recovery, especially after major surgery. Immediately postoperatively, the anesthetist cleans the oropharyngeal and orotracheal cavities by suction to evacuate excessive secretions; this should be done easily so as not to increase or trigger local inflammation and spasm. Additional oxygen administration (via facemask or nasal tube) is recommended to reduce the effort of the respiratory muscles. In patients with ventilatory deficit, a high back position of 30–40 degrees can be adopted [ 9 ]; this improves respiratory dynamics and promotes the drainage of secretions [ 10 ]. For this purpose, back percussion is usually performed several times a day with the patient in sitting position, followed by respiratory toilet. The patient is encouraged to take deep breaths in order to relax and open the alveolar spaces thus reducing the ventilation “dead spaces” [ 9 , 10 , 11 ]. Under conditions of tracheobronchial fluid overload with excessive secretions, expectorants and mucolytics may be administered [ 12 ]; this improves drainage and reduces the effort of coughing. In such conditions, the patient is encouraged to cough in a controlled and effective manner, with the protection of the abdomen [ 13 ] (the most common site of surgery) either by gentle external pressure exerted by patient, doctor or nurse (as appropriate), or by using means of abdominal restraint like girdles. Prolonged, inefficient coughing may result in undue strain and tension on the surgical wounds, increasing the risk of evisceration or eventration. Aerosol solutions can be very useful [ 14 ] administered 2–3 times a day by nebulization for 5–10 minutes helps to “dry” or “thin” of the secretions as needed. It should be noted that postoperative pneumonia is one of the most common causes of significant morbidity and mortality after major surgery [ 9 , 10 , 11 ]. Prophylactic or therapeutic antibiotic therapy may not protect the patient from such a complication if excessive secretions remain undrained in the tracheobronchial tree [ 15 ]. The impact of a deficient oxygenation is systemic [ 16 , 17 ], manifested at the level of the operative site (with the hypooxygenation of an anastomosis for example), at the cardiac level (decompensation of an ischemic heart disease), cerebral, etc. However supplemental oxygen should not be administered on a regular basis, but only when the oximetry drops under 90–92%, due to secondary risks of hyperoxia [ 18 , 19 ]. The presence of prolonged, productive cough, especially when associated with fever and altered general condition, becomes an indication for a chest X-ray in order to capture changes responsible for the occurrence of this symptomatology and take appropriate measures [ 20 , 21 ]. In this context, the findings suggest that pneumonia is a strong indication for antibiotic therapy. Irritant cough associated with sore throat and hoarseness, reported by the patient, are elements that draw attention to a digestive reflux with secondary aspiration in the airways and glottis irritation. The situation is not unusual in conditions of prolonged postoperative intestinal paresis. In such cases, the first goal is to combat gastric stasis and hyper pressure and the most rapid way is by placing a nasogastric decompression tube. If we already have a nasogastric tube in position, we need to ensure its permanent patency because the tube can be obstructed with cloths, fibrin deposits partially digested food or gastric mucosa. Otherwise, the tube becomes a reflux promoting factor by keeping the cardia open and incompetent [ 22 ]. Concurrently adopting a semi-sitting position (maintained also during sleep) to prevent or reduce reflux is an extremely useful element in combating Mendelson’s syndrome (aspiration of the digestive fluid with acid content in the patient airways).

5. Surveillance of the excretory system

It is usually done by tracking the quantity and quality of urine output over a given time and more importantly in 24 hours. All patients undergoing medium and major abdominal surgery usually have a urinary catheter placed under anesthesia [ 23 ]. Catheter placement should be performed under sterile conditions, usually in preanesthetic room or on-table [ 24 ] to avoid infection, bladder injury during surgery, and to accurately monitor renal function during surgery. There are numerous causes of acute kidney injury or otherwise low urine output in the perioperative period, the risk being reported up to 5–10% in surgical patients [ 25 ]. In the immediate postoperative setting, low flow and concentrated urine indicate a good renal function but poor hydration of the patient or a state of shock due to blood loss or impaired cardiovascular function. Decreased urinary flow that occurs under conditions of proper hydration and previously normal renal function may be an indicator of fluid retention in the setting of third spacing, abdominal compartment syndrome or blood transfusions adverse reactions [ 10 , 25 ]. If this event occurs within 4 to 6 days postoperatively, it is usually secondary to the development of fistular or suppurative complications at the site of surgery, alerting the surgeon and allowing a prompt diagnosis of the complication. Failure to recognize the causes and the attempt to obtain adequate diuresis can lead to overloading the patient with fluids; this impairs the function of all the systems up to acute pulmonary edema or cardiac decompensation by increased preload.

Hyperchromic urine also occurs in conditions of mechanical jaundice when the urine turns intensely yellow to brown due to the renal elimination of soluble bile pigments [ 26 ]. The presence of large amounts of urobilinogen in urine usually indicates the hemolytic or hepatocellular nature of jaundice. Hematuria is the evacuation of blood into the urine. Bleeding can be located at any level of the urinary tract from the kidneys to the urethra and usually denotes an intraoperative lesion or clotting disorder. Hematuria can be microscopic and constantly appears after pelvic or retroperitoneal surgery [ 27 ] or macroscopic - when the red color of the urine is obvious, sometimes with deposits and blood clots to the point of obvious blood (Gross hematuria). Usually, hematuria caused by minor intraoperative lesions or produced at the placement of the urethro-bladder catheter is self-limiting. Persistent hematuria requires a complete specialist diagnosis. Hemoglobinuria defines hyperchromic urine, purple to dark brown that occurs during major hemolysis after transfusion accidents [ 28 ]. Early recognition is extremely important because if undiagnosed and subsequently untreated, it can precipitate acute irreversible renal failure by blocking glomerular filtration.

The proper timing of catheter removal is debatable, numerous studies and metanalyses have addressed this question as the risk of urinary infections increases with the duration of catheterization. For abdominal surgery that does not involve the genitourinary systems or pelvic surgery it seems that the optimal timing of catheter removal is the first postoperative day [ 29 ] which in most cases coincides with the time when the patient becomes ambulatory. However, for major surgery (extensive dissection, usually for cancer) involving the pelvic organs or requiring a longer period of immobilization, the catheterization period can be extended to 3–6 days or even longer, adapted to the clinical needs [ 29 ]. For instance, whenever the bladder is sutured (after iatrogenic lesions or deliberated partial resection) the urinary catheter should be left in place for at least 10–14 days.

6. Digestive system surveillance

The digestive system is the most common surgical site in general surgery, hence the special attention paid to its care. Systematic clinical examination can provide valuable information about the patient’s progress, adapting postoperative measures for an eventless and rapid recovery.

Usually forgotten or neglected, oral cavity inspection provides information about the patient’s hydration level; dry oral mucosa, for instance, requires an increase in fluid intake. The presence of whitish deposits on the lingual mucosa may suggest candidiasis infection caused by prolonged antibiotic use, while red depapillated glossy mucosa suggests iron deficiency. Toileting of the oral cavity by brushing and washing with antiseptic solutions is almost as important as postoperative wound care, as germs ingested at this level colonize and contaminate the lower levels of the digestive tract accentuating dysmicrobism and promoting complications. Moreover, pathogens in the oral cavity can colonize the lung and lead to postoperative pneumonia with increased morbidity and mortality [ 30 ]. Until the patient is able to exercise basic hygiene, the task must be performed systematically by the medical personnel.

Pain therapy. Pain is one of the main factors that can delay the recovery of the operated patient. Pain delays the patient’s mobilization, limits the range of motion of the diaphragm, delays the resumption of intestinal transit, and psychologically stresses the patient. Postoperative pain therapy begins during surgery, avoiding excessive traction, tension in the sutures or unjustified extensive dissections outside anatomic planes. From this point of view, laparoscopic surgery and generally mini-invasive surgery, whenever possible, brings major advantages. Also, a very important role in combating pain is the positioning of the patient in bed after surgery. The patient should be positioned as comfortably as possible, avoiding tension on the muscles around the incision areas. The movement of the patient in bed after surgery should not be forbidden; on the contrary the patient should be encouraged to adopt the position in which the pain is minimal and to change his/her position periodically. Beds with semi-rigid elastic mattresses are preferable, which can provide the patient with effective support to achieve active movements and which evenly distribute the patient’s weight.

The abdomen should be examined at least twice a day. In the first 24 hours after surgery, the patient may complain of low to moderate pain in the abdomen, accentuated by active movements or coughing. The pain must be combated accordingly, in order to avoid the development of the “fear” of mobilization. Pain therapy must be adjusted to the extent of surgery and known mechanisms of pain. Multimodal postoperative analgesia appears to provide better outcomes [ 31 ]. Usually, the combination of acetaminophen with a non-steroidal anti-inflammatory drug is sufficient for most patients, but in some cases, local analgesia [ 32 ], or even patient-controlled epidural analgesia may be needed. In case of prolonged use of non-steroidal anti-inflammatory drugs (NSAID), prophylaxis of gastroduodenal disorders like erosions, hemorrhage or ulcers should be considered, especially if the patient’s oral feeding has been temporarily suspended. In those cases, proton pump inhibitors and E-prostaglandin analogs seem to be the most effective, then the histamine receptors antagonists, while barrier agents are mostly useless since they do not interfere with the pathogeny of NSAID-induced ulcer. However, proton pump inhibitors are to be diverted in patients with a current or recent history of antibiotherapy, since the two conditions act synergically favouring severe Clostridium difficile colitis [ 33 ]. The use of major opioid analgesics is not indicated because it contributes to the accentuation of intestinal paresis and favors the accumulation of tracheobronchial secretions [ 34 ]. There are combinations of painkillers (analgesics) that combine a non-steroidal anti-inflammatory and an opioid in low concentrations where the side effects are absent or negligible. In the context of intense pain that does not yield to milder painkillers, it is recommended to place an epidural catheter to ensure the effective analgesia administration with minimal effects on the intestinal smooth muscles [ 35 , 36 ].

The inspection of the abdomen helps in monitoring the degree of distension of the abdomen due to the accumulation of gases and fluids in the digestive tract lumen. This condition is mainly caused by the absence of peristalsis but also by the change of microbiome. Postoperative paresis, present after interventions involving or exposing the intestinal loops, must be actively prevented. Prevention can and should begin in the preoperative period and continue in the operating room and beyond. The very important measures are related to the optimum hydration and correction of the electrolyte imbalances. Because - Enhanced Recovery After Surgery - (ERAS) protocols have been progressively adopted, the patient is usually advised to avoid starving in the preoperative period and to have a light liquid diet in the evening, before scheduled operation. Clear fluid diet is allowed up to 2 hours preoperatively [ 37 ]. Specific medications – prokinetics - like anticholinesterases and parasympathomimetics may be prescribed in order to stimulate peristalsis [ 38 ]. Neostigmine, a synthetic anticholinesterase alkaloid, stimulates intestinal peristalsis with less extensive side effects on the cardiovascular and respiratory systems [ 39 ]. Local-acting intestinal peristaltic stimulants, such as castor oil may be administered orally or introduced through the nasogastric tube (NGT). Prolonged paresis requires the placement of an NG-tube for decompression of the digestive tract, prevention of vomiting and airway aspiration or Mendelson’s syndrome. We do not usually use nasogastric decompression tube, but only in emergency surgery and just in cases associated with high fluid and gas distension or in cases with expected prolonged ileus [ 40 ].

Various methods of reducing postoperative ileus have been studied. It seems that something as simple as abdominal massage after colonic surgery can reduce the postoperative pain and help resume intestinal transit [ 41 ]. Similarly, numerous studies including a metanalysis advocate for the use of chewing gum in order to reduce the ileus period [ 42 ] but the results have been contradicted by other studies [ 43 ]. Chewing gum is adopted by the Enhanced Recovery After Surgery (ERAS) protocols as a measure that could reduce ileus [ 37 ]; we recommend its selective use whenever applicable.

Commonly used opioids such as morphine and fentanyl can prolong the postoperative ileus, by acting like agonists on mu receptors; it is recommended to reduce their use at least in the postoperative settings. In contrast, some kappa agonists like fedotozine U-50, 488H, bremazocine or asimadoline appear to reduce ileus in animal models studies but have never entered clinical practice [ 44 , 45 ].

For the lower digestive tract surgery, the placement of a transanal gas tube may be used, in order to evacuate the increased pressures that may develop at this level [ 46 ]. The procedure is safe and very effective especially in low rectal anastomosis [ 47 ]. The transanal tube (TAT), usually 28–30 CH (Charrierre), is placed at the end of the procedure foiled in greased gauze and is primarily used for intraoperative leakage test. The tube is usually left in place for 48 hours or more, accordingly to the patient evolution. The TAT seems to reduce anastomotic leakage (AL), the need for re-interventions for AL, and it is proposed by some authors for the reduction of defunctioning stoma [ 48 ]. After interventions that do not involve the colon, an evacuation enema may be performed at 2–3 days postoperatively; this reduces stasis and microbial load at this level, and stimulate the resumption of normal peristalsis.

Close patient surveillance with abdominal palpation is required in order to take and adapt the appropriate postoperative measures. Palpation aims to detect possible areas of deep tenderness and infiltration in the abdomen, painful areas in which any discrete signs of peritoneal irritation draw attention to the occurrence of a complication. The jerky palpation may show flapping, a sign with great specificity for postoperative occlusive syndrome, especially when the patient has initially resumed intestinal transit. Percussion highlights diffuse tympanism during intestinal paresis, while persistent localized hypersonority in an area after hesitant resumption of intestinal transit may draw attention to a complication that may have developed at this level. Auscultating the abdomen can reveal a silent abdomen during the paretic period or vice versa- vivid noises, accompanied by whistling and crackling, an expression of the “struggle” of a loop to overcome a distal obstacle/obstruction. Anastomotic leakage is the most feared complication because it comes with significant morbidity and mortality in short but also in long term [ 49 ]. The earlier the recognition of an anastomotic leakage the better and prompter measures can be taken in order to limit or avoid major morbidity [ 50 ]. Postoperative peritonitis following an anastomotic leakage usually develops quietly and may remain undetected since the patient is on pain-killers and the peritoneal surface is less reactive after surgical aggression. CT scan can be falsely negative for anastomotic leakage in fairly large number of cases, therefore, in such cases, it is advisable to take action on first clinical signs of peritonism [ 51 ]. Measures may include various combinations of relaparotomy, percutaneous drainage, postoperative wound opening, antibiotics and complete parenteral nutrition. Earlier detection of the underlying pathology result in prompt intervention and therefore better outcomes [ 52 ]. In cases of diffuse peritonitis, relaparotomy is mandatory to remove the peritoneal contamination and try to gain control of its source. There is no ideal solution for controlling anastomotic leakage. In some cases, re-resection and anastomotic reconstruction can be an option depending on the local and general conditions. In some cases, the anastomosis may be suppressed, followed by closure of the distal end, while the proximal partner is exteriorized in a stoma. This seems to be the safest approach but it is not always feasible. In other cases, perianastomotic drainage might be enough [ 53 ], but usually a proximal diverting stoma is advisable in addition to local drainage. The decision is highly dependent on the surgeon’s experience who should always thoroughly evaluate the local and general condition of the patient; it also depends on ICU level, and the local feasibility of endoscopic stenting, interventional radiology, and other interventions.

Some cases may be managed conservatively with the main purpose being to transform the leak into an isolated enterocutaneous fistula [ 53 ]. Adequate drainage of the leak results in reduction of the general and local signs of sepsis and inflammation with resuming of intestinal transit, tolerance to dietary intake and improvement of the general condition of the patient. The use of a low-pressure drainage system [ 54 ] can help organize the fistular tract, avoiding extensive contamination or digestion (by the activated intestinal enzymes) of neighboring tissues. For the success of this method, we need to ensure that the lumen of the tube remains patent and the surrounding tissues are not being sucked into the holes of the draining tube. The normal evolution of the fistula is with progressive reduction of the flow (which must be noted every 24 hours). In 5–7 days after fistular organization (clinically documented and by contrast enhanced imaging) and the reduction of the flow, we can progressively mobilize the drain by 2 cm every 2–3 days. This allows the tissues to collapse and close the fistula. Sudden reduction of a fistula flow or the early and fast suppression (in a single gesture, not progressively mobilized) of a tube that drains the leak, can result in local abscess formation or even peritonitis. Usually, the fistula closes in 2–3 weeks for the colon and 1–3 month for the small bowel but the time is variable depending on the various factors like type of surgery, age, general performance status, nutrition, level of anastomosis and partners of anastomosis quality [ 55 ], but most importantly dependent on the functional status of the bowel. If there are no anatomic (adherences or strictures for instance) or functional obstacles (residual abscess, Crohn disease, etc.) distally, the fistula closure will be faster. Insufficient drainage of the fistula or abdominal sepsis will result in persistence of local inflammation with secondary impairment of the peristaltic movements, creating a vicious circle that will delay fistula closure.

7. Postoperative wound surveillance

The postoperative wound should be closely monitored on daily basis. In the immediate postoperative period, a sterile dressing covers the wound so we may not be able to directly inspect the sutures. In the first postoperative hours soaking of the dressing [ 56 ] with blood is the main sign to look for. The presence of the blood prompts the physician to look for a source of bleeding at the superficial or deeper level and perform adequate hemostasis. In most cases, it is a low-flow bleeding from a dermal vessel that can be controlled by as simple as a local pressure dressing, placing a mesh with hydrogen peroxide, fibrin glue, or a supplementary stitch under local analgesia. This may also have psychological consequences on the patient since the psychological impact of the presence of blood in sight of the patient may induce a state of anxiety and agitation. For deeper bleedings that tend to form hematomas between the wound layers or margins, the evacuation of cloths is mandatory otherwise impairing wound healing. We should not forget that digestive surgery is a contaminated one, because of the breach of gut mucosa, and that blood is the ideal culture medium for bacteria. Therefore, leaving a dead space filled with a hematoma between the margins of the postoperative wound is equivalent with initiating a germ culture. Left in place, in the following days, the cloth will become a more or less profound abscess. At this moment, even if we drain it, the damage has happened already, and short-term morbidity as well as long-term (such as incisional hernia) increase. In order to avoid those unfavorable outcomes, the most appropriate action seems to be the immediate opening of the postoperative wound, (more or less extensive, but usually 2–4 stitches in the area of the bleeding), evacuating the hematoma under sterile conditions, lavage of the wound with antiseptic solutions, targeted hemostasis and primary closure. If there is doubt on definitive hemostasis or sterility conditions the wound can be left open, covered with sterile dressing until granulation is obtained and secondary superficial suture can be accomplished.

Sometimes under the blood-soaked dressing, we may find a diffuse bleeding, accompanied by an ecchymotic aspect of the wound edges aspects that usually indicates poor coagulation. In this context, we must not forget that the superficial operative wound is a mirror of what is happening in depth, in the operative site, and the general measures for restoring the coagulation balance must be prompt and vigorous. Of course, an ecchymosis of the postoperative wound may seem a benign and maybe minor to negligible complication requiring no action or simply a bag of ice, but if the same happens at the level of the anastomosis deep in the abdomen, anastomotic leakage becomes plausible. In this context, we immediately adjust the anticoagulation treatment, postponing or even skipping a dose until we further investigate coagulation status of the patient. As long as the anticoagulation therapy is suspended, it is advisable to use alternative methods to prevent DVT in lower limbs such as intermittent compressive therapy [ 57 , 58 ] or at least compressive stockings.

In the following days, the normal surgical wound is usually uncovered, “in plain sight” or “exposed to the air”. There is no reason for covering with sterile dressing since the wound is already sealed by the fibrin that is organized between the two edges. Usually, this normal wound sealing process takes 24–48 hr. in clean or clean-contaminated wounds. Even if there is no strong evidence or consensus [ 54 , 56 ] on how long we should keep a sterile dressing, our current practice is to avoid dressing after 48 hr. The zonal erythema of the wound accompanied by a localized swelling, possibly centered on a slightly ecchymotic area, suggests the development of the suppurative complication. In this context, the wound must be explored with a stylus or a fine forceps inserted relatively easily in the respective area. The evacuation of a seroma or hematoma that has already turned purulent will prompt the removal of several stitches, with wide opening of the wound, followed by mechanical and antiseptic debridement [ 56 ]. Insufficient opening of the wound without adequate drainage will perpetuate the infection and allow the infection to spread to new spaces in the vicinity of the wound. In such instances a superficial infection can become profound and healing may be delayed and deficient, with wound granulomas, postoperative incisional hernias or even eviscerations. Of course, in extensive surgical site infections, local measures must be accompanied by systemic antibiotic therapy, initially with large spectrum according to the most plausible germs and then targeted when culture results become available [ 10 , 56 ].

8. Postoperative drainage monitoring

Drainage is one of the fundamental means of treatment and prophylaxis in general surgery. Intraoperatively, drainage can be established in various areas of the peritoneal or pleural cavity (in the case of interventions involving the opening of the pleura), at the level of segments of the digestive tract (stomach, intestine, bile ducts) or in remaining cavities following the evacuation of pathological processes (abscesses, hydatid cysts, on the soft parts after evacuation of abscesses, hematomas, tumors, etc.).

8.1 Drainages of the peritoneal cavity

They are usually placed after medium or major and contaminated abdominal surgical interventions that open the peritoneum. That said, there is no consensus in the literature around the need for drain(s) placement after abdominal surgeries [ 59 , 60 , 61 ]. It is advisable to use drains only when and where they are justified. Drains are then removed in due time after they have served their purposes [ 62 ].

In the first hours after surgery, peritoneal drains usually produce small amounts of serosanguinous fluid. Pure blood drainage usually indicates a hemostasis defect that can be minor in small vessels, often secondary to clotting disorders, or major by slipping of ligatures placed on relatively large vessels. Under these conditions, it is extremely important that the drainage be interpreted in the clinical context of the patient, the association with a hemodynamic instability raising the problem of an immediate reintervention to complete the hemostasis. It is advisable to check the condition of the drain tube and especially its permeability frequently, as it can be clogged with clotted blood [ 63 ]. In this case, the tube remains unproductive, “hidden” under a clean dressing on the surface, thus providing a false sense of surgical reassurance. Unclogging of the drain tube leads to the resumption of blood flow. If the hemorrhage is still active, the drainage will be with reddish coagulable blood, drop by drop, and will be a strong indication for relaparotomy or laparoscopy [ 64 ]. In some cases, not uncommonly, the source of bleeding can be identified in the parietal trajectory of the drainage tube that intercepted a more or less important blood vessel. Local anesthesia and targeted hemostasis can save the patient from an unnecessary laparotomy. Sometimes the drainage resumes with blackish, incoagulable blood, mixed with small partially lysed cloths. This aspect of drainage, which usually persists for several days, sometimes up to weeks, indicates the progressive evacuation of a clot or a large hematoma. Particular attention must be paid in these situations to dressing maneuvers as they can lead to germ contamination and the transformation of the hematoma into an abscess.

The normal evolution of the drainage in the following days is towards the diminution and progressive clearing up. This is the optimal moment to remove the drain. When the drainage is supposed to “protect” an anastomosis we remove the tube after 5–7 days, once the anastomosis has passed the critical period and the intestinal transit is resumed [ 60 ]. The tube does not prevent anastomotic dehiscence but may avoid relaparotomy to control an anastomotic dehiscence. If the drainage is to be maintained for a longer period, it is recommended to mobilize the tubes after several days, with their dislocation from the fibrin deposits that form around, a condition for the drainage to remain effective and to prevent pressure lesions that the tube can determine on certain structures such veins, nerves, ureters, etc.

Persistence of significant drainage, over 500 mL/24 hr. (sometimes 3 L/24 hr), with serous fluid, denotes ascites production, secondary to an advanced malignancy (ovarian, peritoneal or massive hepatic metastases), liver cirrhosis or associated hypoproteinemia. Most often these conditions are suspected based on preoperative work-up and then well-documented by the intraoperative exploration. Few recent studies advise to avoid drainage in cirrhotic patients after abdominal surgery [ 65 , 66 ]. If drainage is necessary, the same studies recommend discontinuing them as soon as possible. When suppressing the drain tube in these cases, a parietal restraint suture is often required to control the discharge of ascites that will otherwise persist through the parietal path of the tube. However, surgical suture dehiscence is frequent in such patients accounting between 20 and 45% [ 66 ], forced by the pressure exerted by the fluid and favored by hypoproteinemia and dysmetabolism. In those patients, we use a controlled-flow drainage tube or an abdominal decompression catheter left intraperitoneally until the wound is well healed and/or ascites production is therapeutically reduced. This management allow a controlled drainage of the ascites, in a closed system avoiding the infectious risk. Otherwise, if the tube is removed too early, intraabdominal pressure of the ascitic fluid will force the wound dehiscence and will leak uncontrollably.

After interventions involving an extended lymph node dissection, the initial drainage with serosanguinous appearance becomes sero-citrine after 2–3 days, but persistent, sometimes at flows between 50 and 300 ml / 24 h, consisting of lymph fluid rich in protein. Since there is not a consensus [ 67 ] our practice is to keep the tube in position until a significant decrease in the amount drained, otherwise there is a risk of developing lymphatic collections [ 68 ] (lymphocele), which can become secondarily infected.

Under the conditions of perianastomotic drainage, the resumption of a bloody drainage, cherry colored with low flow, sometimes gray to frank purulent with specific odor, associated or following a febrile episode is most often the sign of the onset of an anastomotic fistula. This moment usually coincides with the recurrence of the intestinal paresis, the alteration of the general condition of the patient, the increase of the digestive aspirate or vomiting. Muscle guarding may be present but the specific contracture of peritonitis is most often missing. Postoperatively, most signs of peritonism are less pronounced [ 69 ], especially in the elderly patients. Abdominal examination usually reveals localized but difficult to delineate tenderness, accompanied by a local dull pain which is accentuated on palpation. Frequently associated is the suppuration of the surgical wound that must be monitored and opened as early and as wide as needed, a unique gesture that has the ability to limit the extensive evolution in depth. Over the next few days, digestive content according to the level at which the anastomosis was performed, will be evacuated on the drain tube or directly through the surgical wound. Under the conditions of a favorable evolution, the drainage tube will be the “splint” on which an entero-cutaneous fistula forms, the inflammation then gradually decreases, the patient becomes afebrile, resumes his intestinal transit, tolerates diet, and the abdominal signs gradually subside. The development of signs of generalized peritonitis with the persistence of fever and the progressive alteration of the general condition means an insufficient drainage of the anastomotic dehiscence defining a grade C leakage [ 70 ] and forces to reintervention. Prompt diagnosis is the key for better outcomes and in this respect the CT exam seems to offer the best diagnostic chances [ 69 ]. Either conservative or interventional management is applied, in such conditions addition of antibiotherapy in curative course and a non-steroidal anti-inflammatory drug is always necessary.

8.2 The drainages of some segments of the digestive tract

The drainages of some segments of the digestive tract are generally established intraoperatively and aim at achieving temporary decompression of the organs they drain (stomach, common bile duct, etc.) As mentioned, their main role is to evacuate the secretions accumulated in the conditions of postoperative paresis and fight against intraluminal hyper pressures. The most common form is represented by the upper digestive aspiration through a nasogastric tube (NGT), in which the probe inserted trans-nasally and is conducted intraoperatively at the level of the drained segment - esophagus, stomach, duodenum, small intestine. In general, the probe is placed in the conditions of performing anastomoses or sutures at the level of these segments having as main role the protection of the suture. ( anastomotic dehiscence prophylaxis role ). The quality and quantity of the digestive aspirate must be systematically monitored and interpreted in the context of the general and local examination of the abdomen ( diagnostic tool role ). Occasionally the tube can be used to administer medications, to perform lavage or even enteral nutrition ( therapeutic role ) [ 71 ]. Congruently with literature reviews we do not systematically use the nasogastric tube [ 72 ] but only in cases with stasis, intense paresis or expected impaired temporary deglutition.

The normal evolution of the aspirate is towards “clarification” and progressive decrease in the context of the resumption of the intestinal transit and the reduction of the abdominal distension, aspects that mark the optimal moment of NGT suppression. The sudden decrease of the aspirate with the persistence or the accentuation of the distension denotes the clogging of the tube and the need to re-permeabilize it. It should not be forgotten that a significant amount of electrolytes is lost in the aspirated fluid, a loss that must be compensated by intravenous perfusion, correlated with the serum ionogram and the quality and quantity of the aspirate. Fluid loss through nasogastric tube must also be compensated by parenteral intake.

In some cases, the drainage of specific segments can be realized by tubes that are trans-parietally externalized, such as duodenostomies or jejunostomies. In the first 2–3 days postoperatively the main role of the tube is to decompress the bowel segments that they drain. The “prototype” for this use is lateral duodenostomy after total gastrectomy with “Roux en-Y” esojejunal anastomosis, in which the duodenum is partially excluded from digestive transit. After normal peristalsis resumption announced by the decreasing of the fluid output per tube over 24 hr., the drainage tube placed laterally in the duodenum can be used as a temporary feeding path [ 73 ] until the esojejunal anastomosis can support oral feeding. Although considered a “forgotten” method [ 73 , 74 , 75 ], the use of lateral duodenostomy gave us satisfaction (yet unpublished data), being the path that we use in order to achieve early enteral feeding, one of the main goals of ERAS protocol, especially in doubtful anastomosis or documented leakage.

External biliary drainage aims at decompressing the intra- and extrahepatic bile ducts after CBD exploration in the presence of a distal obstruction, or to obtain a controlled biliary fistula after major hydatid cyst resections or major hepatectomies [ 76 ]. The most common use is the “Kehr” drain with a “T” tube placed in the common bile duct (CBD) which will be suppressed in a controlled manner after resolving the distal obstruction or the proximal leakage. The indications for T tube decreased in the era of endoscopic retrograde colangio-pancreatography (ERCP), endoscopic drainage and stenting, etc. However, there are specific situations when the T tube remains a very good option. Usually the T tube is “guarded” by a subhepatic intraperitoneal drainage that in the first days after surgery will take over small amounts of bile that may leak around the T tube. In the following days the quantity and quality of bile drained by the T tube will be attentively monitored. Normal drainage should be clear bile with a flow of 3-400 ml/24 h and progressively decreasing. The persistence of a high flow clear yellow bile that sometimes can reach 1.5 l/day is a clear indication that the liver functions normally but the common bile duct is still obstructed. In those situations, the T tube becomes also a diagnostic tool, since it allows a rapid cholangiography that in most cases will clarify the diagnostic. Bile drainage containing floaters and deposits that persists for a few days raises the suspicions for intrahepatic acute cholangitis. In those cases, the T tube offers the possibility to collect seriated bile samples for bacteriology exam, culture and antibiogram, allowing thus a specific targeted antibiotherapy. In case that the drainage flow is low with a translucid uncolored fluid hepatic insufficiency should be suspected. Without becoming exhaustive in approaching an extremely complex subject, it should be mentioned that in conditions of abundant biliary drainage that persists for long periods, the imbalances induced in the body become major both by the complex loss of electrolytes, salts and bile acids but also by insufficient nutrient absorption from the digestive tract, generated by insufficient digestion. In such conditions, the reintroduction of the drained bile into the digestive tract by oral administration, via the naso-gastric tube or jejunostomy, should be considered especially in critical ill patients that do not support an internal diversion of the bile flow.

8.3 The drainage of residual cavities

The drainage of residual cavities after the evacuation of some pathological processes is generally a drainage with a long maintenance period (sometimes 1–2 month or more), time necessary for the repair processes to progressively reduce and eliminate the cavities (ex: infected hydatid cyst of the liver, pancreatic or peripancreatic abscess, etc.). The quality and quantity of drainage will be constantly monitored. Periodically the drain tube will be mobilized with dislocation of 1–2 cm in order to prevent its “anchoring” in the repair tissue, decubitus injuries on adjacent organs or structures, as well as to allow the progressive reduction of the depth of the cavity. If the drained process was a septic one, it is advisable to change periodically the drain tube since the germs tend to form biofilms on them. The profound tip of the drain will be sent for bacteriologic exam and cultures.

8.4 Drainage of the pleural cavity

Drainage of the pleural cavity is used after openings of the pleura, usually during esophageal interventions, a situation in which the drain is placed intraoperatively after re-expansion of the lung. The simplest drainage is with a transthoracic tube conducted in a half-loaded vessel with sterile saline solution, below the liquid level, to prevent pneumothorax. Mobile kits with unidirectional valves are available and considered better because they facilitate an easier and early mobilization of the patient. Normal drainage in the first days is serous, perhaps with a light serosanguinous color but with a low output, usually under 200 ml/24 h. Higher flows are reported after extended lymph node dissection (performed for esophageal carcinomas) or important bleeding [ 77 ]. The production of the bubbling phenomenon in the bottle usually denotes the existence of a “valve” through which air enters the pleural cavity - damage to the lung parenchyma or tracheobronchial-pleural fistula, another unrecognized pleural lesion (rupture), or lack of tightness of the drain tube in the parietal tract. If the intraoperative pleural lesions remain unrecognized, a situation sometimes encountered during at the esogastric junction interventions, especially in interventions for large hiatal hernias, postoperative dyspnea will require immediate clinical examination and chest X-ray which will evidence pneumothorax. In those cases, a pleural drain will be instituted under local analgesia. Pleural drainage will be removed when it becomes unproductive for gases and fluids and control X-ray will show normal pulmonary expansion, usually 5–10 days after surgery. During the removing maneuver the tube will be closed with a forceps and the parietal route will be closed with a suture and tight dressing for 24 h in order to avoid air aspiration in pleural cavity.

9. Postoperative nutrition

The postoperative diet should be strictly individualized. Current protocols recommend resuming oral feeding as early as possible [ 10 , 37 ]. In conjunction with minimally invasive surgery, less aggressive anesthesia with reduced side effects, patient mobilization as early as possible, multimodal analgesia, all of which are part of the ERAS (enhanced recovery after surgery) protocol or fast track surgery.

Postoperatively, oral feeding is usually resumed progressively, starting with fluids, sometimes even from the day of surgery. Fluids can initially be administered in small amounts of “testing” of tolerance. The quantities of ingested fluids can then be increased even in the presence of the digestive tract high anastomosis [ 78 ]. In addition to the cleansing effect of the digestive tract, the dilution of toxic products and digestive enzymes, there is a proven trophic effect on the digestive mucosa, especially for glucose rich fluids, which strongly support this type of approach. The resumption of normal peristaltic and intestinal transit for gas usually marks the moment when we switch to a semi-solid diet based on vegetable purees, cheese, eggs, etc., which gradually begin to bring protein capital to the organism. Meat based products are introduced in the diet usually 2–3 days postoperatively using easy to digest white meat like fish and poultry. In the immediate postoperative period we avoid uncooked food, especially raw fruits and vegetables since their fermentative potential and fiber content that make hem harder to digest and can cause distension. After transit resuming, a banana can be daily eaten for its potassium content and then small amounts of other fruits, but always taken during the meal.

Given that in some cases the enteral diet is impractical (ex: esophageal anastomosis dehiscence) the complex products of amino acids, lipids and vitamins will be added in parenteral nutrition. Because large amounts are required it is preferably to administer them on a central venous catheter. However, it should be noted that this type of nutrition can replace the normal oral diet only for a limited time. For patients who expect a long period of oral nutrition suspension, it is preferable to perform a feeding jejunostomy [ 79 ].

10. Postoperative antibiotic therapy

Postoperative antibiotic therapy is reserved for pathologies involving extensive infections, stray patients with major interventions involving prolonged septic time, soft tissue infections, associated urinary tract infections, infectious pneumonia or another well-documented infectious syndrome.

Prolonged postoperative “so-called prophylaxis” antibiotic therapy has no justification in another context [ 80 ]. It brings major disadvantages by selecting resistant bacteria, altering the normal intestinal flora, the strain of liver and/or kidney function. In localized infections as well as in wound suppurations, the healing process starts with the appropriate drainage and not the antibiotic therapy that will be useful but to limit extensive infections and prevent dissemination. In these situations, the antibiotic therapy will be initiated according to the clinical suspected pathogen and the bacteriological profile of the nosocomial infections in the respective service, and modified according to the antibiogram after culture results are available [ 56 ].

11. Prevention of deep vein thrombosis and pulmonary thromboembolism

To this end, anticoagulant therapy is usually started preoperatively with very broad indications for interventions exceeding 30 minutes, knowing that a large number of thrombotic events in the venous system of the lower limbs begin during surgery [ 81 ]. Fractionated (or low molecular weight - LMWH) heparins as well as low dose unfractioned heparin are currently used [ 82 ]. Anticoagulant therapy is continued postoperatively for several days after the patient’s usual mobilization, sometimes up to 3 weeks depending on the risks. After this period, as appropriate, anticoagulant therapy with HGMM will be replaced with oral anticoagulants - acenocoumarin derivatives, novel oral anticoagulants (NOACs) or antiaggregants. For each aspects of the anticoagulation therapy (when to start, which type, what dose, for how long, etc.) there are numerous predictive scores and tables, mostly used being the PADUA Score [ 83 ] and the Caprini Score.

In at risk patients, the calves should be inspected and palpated at least once a day. Immobilized patients are encouraged to perform active exercises in bed until complete mobilization. The appearance of a seemingly unjustified swelling or leg pain, a discrete unilateral edema of the leg, sometimes with a positive Homans sign (pain at the dorsiflexion of the foot) requires a Doppler ultrasound of the venous system of the lower limbs and the transition from prophylactic doses of anticoagulant to curative doses.

In patients with coagulation defects, with severe anemia (such as a gastrointestinal bleeding) often associated with coagulation disorders, in patients with unresectable gastrointestinal neoplasms, in polytraumatized patients with extensive hematomas at various levels or whenever heparin administration is considered risky, compressive therapy is recommended [ 84 ]. Compressive therapy can be passive, using pressure stockings, but desirable active using an intermittent compression system of the lower limbs, equipped with pneumatic cuffs that are progressively inflated and decompressed automatically, with computerized control of pressure and application times.

12. Prevention of bedsores and patient mobilization

The development of bedsores is an undesirable event that significantly influences the patient’s recovery with increasing morbidity, hospitalization, medication consumption, time and resources. Elderly, deproteinized patients, diabetics, stroke patients, patients with urinary or fecal incontinence, patients with fractures or immobilized for a long time are susceptible to the development of bedsores [ 85 ]. Whenever we treat such patients, we must take into account those risk factors for an early application of bedsores prophylaxis. The most common areas affected by the development of bedsores are the sacral region, buttocks, trochanters and shoulder blades. Prophylaxis includes intermittent inflated mattresses that periodically change the pressure on the support areas, powdering of wet areas, passive mobilization for immobilized patients. They are passively transferred to alternative positions (left lateral decubitus, right lateral, dorsal, ventral) at the shortest possible time intervals (2–3 hours) after a schedule established and strictly observed. The pressure areas must be massaged to promote the opening of blood circulation in the area.

Postoperative mobilization as early as possible is an extremely important factor in the patient’s recovery since it promotes the resumption of intestinal motility, reduces the risk of decubitus pneumonia and postoperative pneumonia by promoting normal respiratory dynamics, requires and stimulates the adaptation of the cardiovascular system, reduces the risk of deep vein thrombosis and thromboembolic events, prevents the appearance and development of bedsores. Thus, the patient must be passively mobilized on the edge of the bed from the first postoperative day and encouraged to repeat the maneuver several times during the day. The next day the patient will be accompanied for a few steps in the room and will later become independent at distances of 20–50 m. Of course, this mobilization program will have to be adapted to each case depending on the particularities (age, type of surgery, comorbidities, etc).

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Chapter 3-1:  Approach to the Patient with Abdominal Pain - Case 1

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Chief complaint, constructing a differential diagnosis.

• RANKING THE DIFFERENTIAL DIAGNOSIS
• MAKING A DIAGNOSIS
• CASE RESOLUTION
• Full Chapter
• Supplementary Content

Mr. C is a 22-year-old man who complains of diffuse abdominal pain.

Figure 3-1.

The differential diagnosis of abdominal pain by location.

Abdominal pain is the most common cause for hospital admission in the United States. Diagnoses range from benign entities (eg, irritable bowel syndrome [IBS]) to life-threatening diseases (eg, ruptured abdominal aortic aneurysms [AAAs]). The first pivotal step in diagnosing abdominal pain is to identify the location of the pain. The differential diagnosis can then be limited to a subset of conditions that cause pain in that particular quadrant of the abdomen ( Figure 3-1 ).

Several other pivotal points can help narrow the differential diagnosis including (1) the time course of the pain, (2) peritoneal findings on exam, (3) unexplained hypotension, and (4) abdominal distention. Each of these is reviewed below.

The time course of the pain is a pivotal feature. Some diseases present subacutely/chronically over weeks to months or years (eg, IBS) whereas others present acutely, within hours to days of onset (eg, appendicitis). In patients with their first episode of acute severe abdominal pain, a variety of life-threatening, must not miss diagnoses must be considered (eg, AAA). Many of these diseases that cause acute abdominal pain cannot recur because patients are either treated or die of complications (eg, AAA, acute appendicitis, splenic rupture.) Since prior episodes are incompatible with many of these diagnoses, a history of such prior episodes narrows the differential diagnosis. Therefore, the differential diagnosis of abdominal pain can be organized based on whether patients are presenting with their (1) first episode of acute abdominal pain, (2) a recurrent episode of acute abdominal pain, or (3) chronic/subacute abdominal pain. Table 3-1 outlines the typical time course associated with different diseases causing abdominal pain. See Table 3-2 for a summary of abdominal pain organized by location, time course, and clinical clues.

AAA, abdominal aortic aneurysm; DKA, diabetic ketoacidosis; IBD, inflammatory bowel disease; IBS, irritable bowel syndrome; PID, pelvic inflammatory disease; PUD, peptic ulcer disease.

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Introduction

A 35-year-old woman is referred to the surgical assessment unit with acute abdominal pain . Work through the case to reach a diagnosis.

UK Medical Licensing Assessment (UKMLA)

This clinical case maps to the following UKMLA presentations :

• Acute abdominal pain

Presenting complaint

“My stomach is killing me.”

History of presenting complaint

Where is the pain?

“ At first it was everywhere, but now it is in my lower tummy on the right-hand side ”

When did the pain start?

“ Around two days ago ”

Did it come on suddenly?

How would you describe the pain?

“ A sharp pain ”

How bad is the pain out of 10?

“ 8/10 at the moment ”

Does the pain go anywhere else?

Does the pain follow any pattern?

“ No, it’s just constant and there all the time ”

Does anything help the pain?

“ Not moving! I took some paracetamol and that helped a little ”

Does anything make the pain worse?

“ Moving around ”

Have you had any nausea or vomiting?

“ Mainly nausea, but I did vomit a couple of times when the pain started ”

How is your appetite?

“ Yes, I’ve not really eaten since it started ”

Any change in weight?

Have you had a fever?

“ Not really, I think the highest I’ve measured has been 37.8C ”

Have you had a change in bowel habit?

Have you noticed any blood in your stools?

Any change in the amount you are passing urine?

Is it painful to pass urine?

Have you had any illnesses recently?

“ I had a cold last week ”

Have you been feeling more tired than usual?

Have you noticed any skin changes?

Have you noticed any abnormal vaginal bleeding?

Have you noticed any abnormal vaginal discharge?

When was your last menstrual period?

“ It started 2 weeks ago and lasted 4 days ”

Clinical examination

• Basic observations
• Abdominal examination
• Vaginal examination

Examination findings

Basic observations :

• HR 108, RR 20, BP 106/62, Oxygen saturation 96% on air, Temperature 37.9 o C

Abdominal examination :

• Generally tender abdomen, maximal tenderness in the right iliac fossa (RIF)
• Voluntary guarding present
• Bowel sounds normal
• No organomegaly

Vaginal examination :

• Vulva appears normal
• No evidence of vaginal prolapse
• Cervix appears normal
• No cervical motion tenderness
• Uterus is of normal size and is anteverted
• No palpable masses
• Rovsing’s sign : palpation of the left iliac fossa (LIF) causes RIF pain
• Psoas sign : extension of the right thigh, in the left lateral position, causes RIF pain
• Obturator sign : internal rotation of the flexed right thigh causes pain
• Hop test : hopping or jumping causes abdominal pain

Investigations

A urine pregnancy test is one of the most important initial investigations in a woman of childbearing age presenting with abdominal pain.

• Blood glucose
• Full blood count
• Urea and electrolytes
• Coagulation profile : in case surgery is needed
• Group and save : in case a blood transfusion is needed

V ascular: mesenteric ischaemia, upper gastrointestinal bleed , ovarian torsion

I nflammatory & infectious: acute appendicitis , gastroenteritis, urinary tract infection , pelvic inflammatory disease, ruptured ovarian cyst

N eoplastic: intra-abdominal malignancy

D egenerative: diverticulitis

I diopathic:

C ongenital:

A utoimmune: inflammatory bowel disease

T raumatic:

E ndocrine: ectopic pregnancy , endometriosis , diabetic ketoacidosis

Investigation results

Some of the results of the patient’s investigations are shown below.

Bedside tests :

• Urine pregnancy test: negative
• Urinalysis : negative for blood, nitrites, and leukocytes
• Blood glucose : 4.7 mmol/L

Blood tests :

• WCC 12.7 x 10 9 /L
• Platelets 234 x 10 9 /L
• Na+ 138 mmol/L
• K+ 4.2 mmol/L
• Urea 8.2 mmol/L
• Creatinine 84 μmol/ L
• CRP 48 mg/L

The most likely diagnosis in this patient is acute appendicitis .

They have presented with typical symptoms of migratory abdominal pain (beginning generally and localising to the RIF), nausea and vomiting, and anorexia. The combination of RIF pain, nausea and vomiting, and low-grade fever is known as Murphy’s triad and is commonly seen in appendicitis.

• Intravenous fluids
• Antiemetics
• Antipyretics

Laparoscopic appendicectomy

This operation removes the inflamed appendix carried out under general anaesthetic . Generally, a laparoscopic approach is preferred. However, an open procedure may be required if the appendix has burst, the patient has a history of abdominal surgery or has from peritonitis.

• Group and save (+/- crossmatch)
• Ensure the patient is nil by mouth
• Consent patient for surgery
• Anaesthetic assessment
• Prescribe any regular medications
• Venous thromboembolism (VTE) risk assessment
• Prescribe VTE prophylaxis
• Inform theatres

Complications

• Perforation: leading to generalised peritonitis
• Abscess formation: generally requiring drainage

Dr Jess Speller

• Patient UK.  Abdominal Pain . January 2023. Available from: [ LINK ]
• Patient UK.  Acute Abdomen . August 2019. Available from: [ LINK ]
• Tavakkoli A, Szasz P. Acute appendicitis. BMJ Best Practice. 2020. Available from: [ LINK ]
• NICE CKS.  Appendicitis. May 2021.  Available from: [ LINK ]

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CASE STUDY 1

Patient A is a man 37 years of age who arrives in the PACU following surgical removal of his gallbladder. Surgical intervention using the laparoscopic approach is successful.

Patient A's airway and ability to maintain respiratory stability are evaluated immediately. His respiration is 16 breaths per minute, and his heart rate is 78 beats per minute. Oxygen is being administered at 2 liters via nasal cannula. A pulse oximeter is placed on his left forefinger, and his oxygen saturation is measured at 95%. The patient is arousable but easily drifts off to sleep.

A transfer of care report on the patient is received from the operating room staff. His operative course was unremarkable. Patient history obtained during the preoperative phase of care showed that he was a 2 pack per day smoker, and he denies taking any prescribed or over-the-counter medications. Patient A's weight is documented as 110 kg.

Further assessment of the patient demonstrates normal skin perfusion with good capillary refill in all extremities. He has a drain in his abdomen with a small amount of yellowish discharge. The wound site and sutures are clean and dry without bleeding or discharge. No Foley catheter is in place; when questioned, he denies the need to void. Completing a head-to-toe assessment shows no other alterations from Patient A's baseline.

Patient A wakes when the second set of vital signs is obtained. He reports that his pain is 6 on a 10-point scale. He states that he has pain in his shoulder and pressure in his abdomen. Morphine (5 mg) is ordered for the pain, and 4 mg is administered IV. His wife is in the waiting room, and she comes into the unit to visit and sits by his bed reading while the patient dozes off.

Repeat vital signs are obtained every 15 minutes for the first hour. At 45 minutes after admission, the patient's oxygen saturation is noted to be 90%. PACU staff suction secretions from the patient's throat, and he is instructed on how to use the incentive spirometer. His oxygen flow is increased to 4 liters/minute by nasal cannula. No change in the patient's oxygen saturation is noted over the next 15 minutes despite compliance with the respiratory exercises.

At one hour after admission, the patient's oxygen saturation remains at 89% to 90%, his respiratory rate is 16 breaths per minute, and he is more difficult to arouse. The nurse notifies the physician of the changes in Patient A's status. Oxygen delivery is changed again to a face mask at 4 liters/minute without improvement in the oxygen saturation level. All other parameters remain stable, demonstrating a readiness for discharge.

Despite the improvement in the patient's status, the oxygenation issue remains worrisome. The patient is admitted for an overnight hospital stay, and respiratory exercises are continued, eventually demonstrating an improvement in oxygen saturation to a high of 94%. The next morning, the patient is discharged home.

The assessment of Patient A was thorough and well-organized. The ABCs were evaluated upon admission to ensure the stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged on the same day.

The patient's history of smoking may be the cause of the respiratory insufficiency. Whether the patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms subsided prior to having surgery. When patients underreport or are dishonest during the preoperative phase of care, the staff caring for the patient in the postoperative phase is put at a disadvantage.

CASE STUDY 2

Patient B, a woman 31 years of age, is admitted to phase I PACU after undergoing an abdominal hysterectomy. During the preoperative assessment, the patient noted that she is a nonsmoker, has a history of motion sickness, and is quite anxious concerning the surgery and her future prospects, as she will be "sterile" upon recovery. The report from the operating room is that the patient received inhalation anesthesia and a neuromuscular blocking agent during the procedure. Prior to discontinuing the anesthesia, the patient was administered 4 mg of ondansetron for PONV prophylaxis. Also noted was a period of hypotension caused by a significant amount of blood loss requiring the intraoperative infusion of two units of whole blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and is not yet oriented to place and time. When questioned, Patient B states that her pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV per order. The narcotic appears to begin to take effect, and when questioned, Patient B's pain is now reported as a score of 4. However, she is now complaining of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the physician who orders another dose of ondansetron, which is administered. Thirty minutes after medication administration, the patient's complaints of nausea have not subsided and the nurse again requests an order for an antiemetic. At this point, the physician orders a scopolamine patch be placed on the patient. Subsequent to patch placement, Patient B notes that her nausea is resolving.

Case Study Discussion

Preoperative management of Patient B's nausea was handled well. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.

There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance the effectiveness of the serotonin antagonist.

During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea. However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume-depleted into the PACU, and no note of this was made.

The physician ordered the second PACU dose of ondansetron, which was administered without benefit. The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room. It is critical to gather as much information as possible to reduce these types of delays in patient management.

CASE STUDY 3

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO 2 ) of 110 mm Hg, and a partial pressure of carbon dioxide (PaCO 2 ) of 55 mm Hg. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.

The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case.

Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment.

The long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.

CASE STUDY 4

Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior. The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length. During the procedure, the patient has one short episode of hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen saturation is 93%, and the patient is more alert. However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care. The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. When obtaining the next set of vital signs, the nurse notices that the oxygen saturation has again dropped to 91%; however, as the patient's respiratory effort appears to be adequate, the nurse assumes this low saturation is a consequence of his smoking history. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further. The patient is left sleeping while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory arrest. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated. However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient. When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing laryngospasm. Succinylcholine is administered, and high positive-pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs. He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital.

Patient D is a typical postoperative patient. He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged. Fortunately, he survived without long-term sequelae.

The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance.

When Patient D sustained the respiratory arrest, the initial cause was unknown. He had numerous risk factors; the arrest may have been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent. However, upon intubation he was noted to have developed laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation.

Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort. In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care. Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE.

Patient D should be educated prior to discharge regarding the development of this side effect. If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise.

CASE STUDY 5

Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left femoral artery. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16 breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The patient was extubated prior to arrival in the PACU. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon. The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his body temperature is now 36°C. At this point, he complains of pain in both lower extremities. Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone. After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation. As the patient had been heparinized in the operating room, no further anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.

This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression devices in addition to anticoagulation [50] . It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable.

The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.

CASE STUDY 6

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four hours. She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional analgesia. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of 10. The physician is again contacted by telephone, and additional pain medications are ordered. Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities.

This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury. This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.

Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier. In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.

This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.

This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken. It is a sad outcome, especially as it was a preventable complication.

CASE STUDY 7

Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was 160 mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control. With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time. He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to 10. He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following a myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered. Prior to instituting further management, the patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, to which he complied. His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening before surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently. His wife also noted that he had complied with the bowel prep cleansing as instructed.

The patient is administered additional intravenous fluids at a rate of 75 mL/hour. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward. On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3 with a blood pressure of 102/86 mm Hg.

This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.

Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise.

In addition, the patient took his normal blood pressure control medications prior to surgery. While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted.

Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure. The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved.

The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are several reasons for postoperative confusion in the elderly; those reasons should be identified and treated. In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided.

Managing an elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging. Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period.

CASE STUDY 8

Patient H, a man 34 years of age, is admitted to the PACU following abdominal surgery for colitis. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and core temperature 35°C. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of 100 mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg. Although this is below baseline, it does show improvement. However, urine output remains the same; there is no recognizable response to this fluid challenge. The ostomy drainage does increase and is measured at 100 mL of very light yellow liquid.

Two hours after admission, the patient remains in the PACU. His core body temperature remains low, and his blood pressure is below baseline. Little urine output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones are heard as high-pitched squeaks. Additionally, the patient remains significantly sleepy and slow to respond to commands.

After three hours, the patient is transferred to the surgical inpatient unit. His blood pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient is arousable but sleeping when not stimulated.

That same evening, approximately seven hours after surgery, the patient is awake and complaining of severe abdominal pain. His abdomen is distended; ostomy drainage now measures an additional 300 mL, and urine output is 150 mL. The surgeon is notified, and the patient is evaluated. At this point, the surgeon speculates that there may be leakage at the stoma site. The patient is prepped for the operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a significant amount of gas into the ostomy bag. The amount of drainage remains high, but with the passing of the gas the distension begins to resolve and the patient notes that his pain has diminished. It is determined that the surgery will be delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another four days. He receives instructions on how to manage his stoma and ostomy. His stoma drainage remains high for the first two days. He tries solid foods on day 3 but develops severe abdominal cramping and distension yet again. His diet is changed to soft foods, and over the course of the next week, he is eventually able to tolerate a normal diet.

This patient was admitted following an extensive abdominal procedure. Upon arrival in the PACU, his core body temperature was low; however, this is common in patients undergoing an open abdominal procedure of extended length. The only error in care was the delay in beginning to warm the patient. Rewarming measures, using forced air warming, should be the standard of practice for this type of patient.

The patient developed hypovolemia, as evidenced by his low blood pressure. This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. The fluid challenge of 100 mL was ordered without awareness of the ostomy output. This output should be included in the volume assessment of the patient prior to reporting his vital signs. Most likely, a large fluid challenge would have benefited the patient and could have helped to prevent the ileus formation.

When the patient complained of severe pain while in the nursing unit, it was appropriate to consider the risk of failure of the stoma sutures. This is not an uncommon complication in this type of surgery, especially with the distended abdomen. However, the patient required a more detailed evaluation prior to being prepped for surgery. Ileus formation was not considered because the patient had audible bowel tones. While most patients with postoperative ileus do not exhibit bowel tones, these tones are not uncommon for patients with a stoma and significant changes in their GI tract. One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. However, with the concern of disruption of the sutures, this was not an appropriate course of action for Patient H and was not performed.

While the patient did exhibit postoperative complications, the development was not unexpected. The assessment of the patient could have been better; assessing the intake and output beginning before surgery may have alerted the staff to the hypovolemic state. If this had been recognized and treated earlier, the ileus formation may have been averted. However, it is not uncommon for this patient type to develop an ileus, so it is difficult to determine whether it was a controllable complication. The patient's ultimate outcome was not affected by these complications, but his recovery period could have been more comfortable and without risk had certain assessment parameters been monitored more closely.

CASE STUDY 9

Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a congenital cleft lip and palate. She is small for her age and has had multiple difficulties with food intake. During the first year of life, it was nearly impossible for her to suck either at the nipple or on a bottle due to the shape and size of the defect. Despite multiple attempts and alternative methods of feeding, her growth has been slowed due to malnourishment. As she became able to ingest solid foods, she had difficulty with swallowing and had multiple bouts of sinus infections due to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in her mother's arms and shying away from the caregivers. She does not want an IV line started and throws a tantrum when this is attempted. Despite her young age, she is well aware of the multitude of interventions that occur in a hospital setting and she is determined to maintain some control over these developments. Her mother comforts her and does not appear to have much control over Patient I's behavior.

The corrective repair progresses without complication, although the surgery is long, more than six hours in length. When Patient I is transferred to the PACU, she is intubated and asleep. The surgeons do not want her to awaken abruptly and risk dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital signs are stable compared to those obtained during the preoperative phase of care. She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her and sit at the bedside. The mother is instructed to watch the patient and notify the nurses if she starts to awaken and reach for the tubes. The mother is overwhelmed by the change in her daughter's appearance, something she has dreamed about for the last five years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain closed but she appears to be awakening and somewhat agitated. The orders are to administer narcotics to the patient for pain; however, the patient is unable to use any type of pain scale due to the decrease in cognition. The mother is holding the child's hand when the child pulls her hand away and starts to reach for her mouth. The nurse sees this happening and is able to grasp the child's wrist and prevent her from reaching the tube and surgical site. Wrist restraints are applied to ensure that the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to side. She is pulling against the restraints and trying to sit up so she can reach the endotracheal tube to remove it. The nurse instructs the patient that she must lie still and that the tube must remain in place. The nurse attempts to use an illustrated pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue to rise and blood is noted on the dressing around her mouth. It is imperative that something be done to reduce the risk of damage; the nurse decides to medicate the patient with the narcotic ordered to help control the agitation and allow the child to relax and perhaps fall asleep. This objective is achieved, and the patient falls asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient. While touching the patient's dressing, the patient's eyes open; she grasps the hand of the surgeon and tries to grasp the endotracheal tube. She is shaking her head violently from side to side, and the dressing on her face begins to loosen. The physician yells for assistance, and the nurse holds the head of the child still so the tube and dressing can be re-stabilized and secured. The look in the eyes of the child is one of pure terror. By now the only way the patient is able to lash out is to kick her legs, and she is thrashing about in the bed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure the safety of the tube and surgical site. After administration, the child does calm down and is no longer struggling; however, she does not appear to fall asleep. She continues to have a very scared look in her eyes, and she does not appear to be fully aware of what is going on around her. Within 20 minutes, the child is dozing quietly and appears to be much more comfortable.

Two hours after surgery, the patient again awakens and is calm and cooperative. She is responding to her mother and is receiving comfort from her mother's presence. She is again instructed as to the need for the restraints and is not pulling against them. She tries to talk and begins coughing against the endotracheal tube. The surgeon has ordered that the patient remain intubated for at least the first 48 hours post-surgery to ensure adequate time for the wound healing to begin. This is going to be a challenge with this patient as she is trying continually to either remove or talk around the tube.

The patient is stable at three hours and is transferred to the ICU, as she remains intubated. Report is given to the staff. While the patient is being moved to the ICU bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately, she is prevented from removing the tube, although the tube is checked to ensure proper placement. At 48 hours, she is extubated and transferred to the pediatric floor. Within four days she is discharged home without further complication.

This child presents a number of challenges to the PACU staff. Airway management is always the first step in stabilizing a patient who has arrived from the operating suite, and this patient did have a secure airway at the time of transfer. The concern developed when the patient began to awaken and tried to remove the tube. Had she been successful at pulling the tube, this could have been a life-threatening complication. Attempting to mask ventilate the child would be challenging with the surgical repair site preventing the achievement of a good seal with the mask. Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair.

The child was initially stable, and the recovery appeared to be without incident. However, after the child started to awaken she demonstrated many of the signs of emergence delirium, which is more common in children than adults. She was thrashing about, pulling on her restraints, and uncooperative with instructions. Her mother did not appear to be able to calm her, indicating the possibility that she was disoriented and confused.

While the nurse was aware of the need to protect the child, she chose to administer the narcotics as ordered rather than receive an order for a different medication. It may have been that the narcotic was the right choice; the patient could have been in pain, although this was not assessed due to her behavior. On the other hand, the narcotic could have caused the second bout of combativeness noted upon the surgeon's arrival. When the patient was able to grasp the endotracheal tube, it was determined that the mother had released the restraint while holding her daughter's hand. This could have been another life-threatening complication; the nurse needed to not only ensure that the mother understood the need for the restraints but also check for proper placement of the restraints when her vital signs were obtained.

Midazolam was the drug that was able to allow the child to fall asleep and awaken in a more controlled state. Although midazolam may be a cause of emergence delirium and confusion in children, it is also one of the first drugs considered in its management. For this patient, it was the right drug, although the right time may have been during the first episode of combativeness. Not all children must be medicated; however, with the risks of tube dislodgement and surgical site disruption being quite high in this child, the administration of midazolam in the earlier phase of care may have been a better choice.

This case demonstrates the multitude of issues in dealing with pediatric patients. Although patients are educated prior to the surgical intervention, this education is not fully understood and the child may not follow instructions as directed. The mother was an excellent source of comfort to her child but also put her child at huge risk by untying the restraints. Parents should have continual reminders of their place in the care of their child.

The risk of postextubation croup was not addressed but could have presented a significant challenge to this patient either in the ICU or once on the pediatric unit. The risk of this form of croup increases when the patient has remained intubated for a length of time and/or when the child fights against the tube, both risk factors in this case. Fortunately, this did not occur and the patient was eventually discharged without further incident.

Children present challenges regularly in the PACU. Their risk of compromise is greater, and the complications are different. Astute care will allow for safe recovery during this period.

CASE STUDY 10

Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip. He was living at home independently when he slipped and fell in the bathroom, fracturing his right femoral neck. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. Emergency service personnel were called. They found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Patient J had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic, cardiology, and neurology specialists. His history is reviewed and reveals a previous open-heart procedure eight years prior to admission, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor; he has multiple bruises in varying stages of healing. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and foul smelling, indicating a poor hygienic state. He has a list of medications in his wallet, which identifies the following drugs: digoxin, simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his current state of confusion, the accuracy of this list and the last time the patient took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anesthesia. The orthopedic surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the operating room, has a cardiac monitor on and a Foley catheter in place, and his hip is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is noted in the Foley catheter. The greatest initial concern is the lower oxygen saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters per minute. Within 15 minutes of switching the oxygen delivery device, the oxygen saturation increases to 91%.

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital signs are stable; however, his body temperature remains at 35°C despite forced air warming. He is not moving nor does he appear to be in any discomfort. His skin condition does not appear to have improved. His lower extremities are cool to touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without success, and the physician in charge pronounces the patient dead.

This patient is representative of the typical postoperative geriatric patient. He has multiple health issues and takes many medications. His physical status is compromised by his nutritional status, in this case, obesity. He was living independently prior to this event; he did not have family close by, and his history was only ascertained by the information that his neighbor and the first care responders were able to locate. Even with that, the accuracy of this information was questioned. Prior to the fall, the patient had been happily living his life, which was subsequently lost after the surgery.

After the patient was pronounced dead, it was speculated that he had developed a clot that occluded his pulmonary vasculature. If this was indeed the case, the outcome would not have changed despite the resuscitation efforts. However, due to his advanced age and condition, a postmortem exam was not performed and the cause of death was never confirmed.

The patient's condition was compromised by numerous factors. He had a positive cardiac and smoking history and may have sustained a neurologic event at the time of the fall, or a neurologic event may have precipitated the fall. His obesity presented a number of issues. His skin condition was quite poor, and his apparent lack of hygiene would increase his risk of postoperative infection. While he was considered to be independent, his current health state was definitely not optimal.

Had this patient survived, in all likelihood, he would not have been able to return to an independent living environment. He would have required care in a rehabilitation facility to learn to ambulate post-surgery. Whether he would be strong enough to recover to a fully independent state was questionable.

This case demonstrates the many issues and challenges in managing the elderly patient. The lack of concrete information in the preoperative stage can impact the decisions that are made in the operating suite. Patient J's poor health status put him at increased risk for complication development. Even if the patient had survived, his long-term outcome would have been significantly different than the lifestyle he had prior to the injury. Preparing the patient and family for these less-than-optimum outcomes should be considered part of the preoperative care measures.

CASE STUDY 11

Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of 62 and is scheduled to undergo a restrictive bariatric procedure. Her history is positive for hypertension, diabetes controlled with two to three insulin injections daily, gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band placed, creating a small pouch. She is transferred to the PACU having been extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg, pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature 35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She maintained a saturation of 94% during the procedure but the postoperative saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4 liters/minute. The nurse caring for the patient is unsuccessful at awakening her for more than a few seconds. The oxygen delivery system is changed to a face mask with a liter flow of 6 liters/minute. Little improvement in the patient's status is seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit. Elevating the head of the bed may help her oxygenation but does little to increase her oxygen saturation values. Arterial blood gas analysis is obtained; the results are pH of 7.34, PaO 2 of 74, and PaCO 2 of 47. With these results it is obvious that the patient is hypoventilating, most likely secondary to pressure on the diaphragm limiting her respiratory excursion effort.

The patient remains somnolent for the next four hours. Her oxygen saturation values remain around 91% despite the efforts of the staff. After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. She remains hypoxic until the following afternoon.

The patient in this case study demonstrated one of the more common complications following bariatric surgery: hypoventilation. The upward displacement of Patient K's diaphragm prevented full expansion of her lungs, causing carbon dioxide levels to rise while oxygenation values remained low. Although the levels were low, they were not to the point of being life-threatening.

One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. As this patient remained somnolent for a lengthy period, efforts at obtaining her cooperation were unsuccessful. It is not uncommon for obese patients to experience a delay in awakening following anesthesia. The drugs are absorbed into the fatty tissue, and release occurs over an extended period. One measure that may have been successful in arousing the patient more quickly is a fluid challenge. This extra fluid can often help circulate the remaining anesthetic and speed the metabolism of the medication, allowing the patient to awaken more quickly. While this may not always be the answer to delayed awakening, it is often successful in obese patients.

Fortunately, this patient did not experience any of the other postoperative complications that are common following bariatric surgery. After her respiratory status improved, she was able to meet the criteria for discharge and was sent home the next day.

In follow-up with this patient, she lost more than 100 pounds in the first year following surgery. She started an exercise regimen and is determined to continue with her weight loss. While 100 pounds is quite a bit of weight to lose, her weight is now 330 pounds; therefore, she remains at risk for the complications of obesity. Her diabetes has not resolved, yet she remains hopeful that with continued weight loss, she will one day be free of insulin injections. Morbidly obese patients have a long and often arduous path ahead of them and should not expect miracles to happen overnight.

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A Case Study of Abdominal Aortic Aneurysm Detection and Critical Vascular Surgery

Mamta kamboj.

1 Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND

Arghadip Das

2 Internal Medicine, Nil Ratan Sircar Medical College and Hospital, Kolkata, IND

Hadeeqa Idris

3 Internal Medicine, Shifa International Hospital Islamabad, Islamabad, PAK

4 Internal Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND

Sachin M Chaudhary

5 Internal Medicine, Gujarat Cancer Society (GCS) Medical College, Hospital and Research Centre, Ahmedabad, IND

Mohitha C Mallipeddi

6 Internal Medicine, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, IND

Abdominal aortic aneurysm, characterized by a persistent dilation exceeding 3 cm or 50% of the aortic diameter, poses a substantial risk, particularly in males over 65. Despite its potentially asymptomatic nature, early detection is imperative due to the elevated mortality rates, reaching 90% following rupture. The presented case involves a 60-year-old male with progressively worsening abdominal pain, a history of cardiovascular disease, hypertension, and smoking. Initial examinations were inconclusive, requiring advanced imaging that revealed a large aneurysmal dilation. Therapeutic measures included endovascular aneurysm repair (EVAR), highlighting the significance of timely intervention. Despite elective surgery risks, mortality rates decrease significantly when the aneurysm diameter surpasses 43 mm. This report stresses the need for primary care physicians to conduct thorough screenings, recognize risk factors, and facilitate prompt referrals for advanced imaging. The case's pivotal lesson lies in the comprehensive management of abdominal aortic aneurysm, showcasing the potential for life-saving interventions and the critical role of early detection in mitigating the severe consequences associated with its rupture.

Introduction

A persistent dilatation of the abdominal aorta with a diameter greater than 3 cm or greater than 50% of the aortic diameter at the diaphragmatic level is indicative of an abdominal aortic aneurysm (AAA) [ 1 ]. Usually located inferiorly to the renal arteries in 88-89% of cases, an AAA results from gradual vascular wall deterioration that causes dilating and weakening if left untreated [ 2 ]. Atherosclerosis, smoking, male gender, advancing age, Caucasian ethnicity, having a family history of AAA, hypertension, high cholesterol, and an existing history of aortic dissection are the main risk factors [ 3 ].

AAA is the ninth most common cause of death for men over 65 [ 4 ]. The size of the aneurysm determines the rupture risk, and rupture results in a mortality rate higher than 80% [ 5 ]. The most common clinical indication of AAA is a pulsatile, painless abdominal mass, but it can also stay asymptomatic despite its potential severity [ 6 ]. Because AAA is usually quiet in its early stages and rupture can have serious implications, early detection and care are critical. We describe a fissured aortic aneurysm case to highlight the critical importance of screening, referral for vascular surgery, and life-saving measures.

Case presentation

A 60-year-old man presented to the emergency department with a complaint of progressively increasing abdominal pain and distension over the past four months. His medical history was notable for known cardiovascular disease, hypertension, and a history of smoking. Upon presentation, the patient's vital signs were stable, with a blood pressure of 130/90, a pulse rate of 58/min, a respiratory rate of 17/min, an oxygen saturation of 98% on room air, and a temperature of 36.5°C. The patient's body mass index measured 26.29 kg/m 2 . Physical examination findings revealed clear lungs, a regular heart rate and rhythm, and an obese abdomen characterized by softness and mild distension. Palpation did not detect any AAA or hepatosplenomegaly. However, the patient experienced significant discomfort during light palpation of the abdomen.

The laboratory findings were generally within normal limits. Notably, the patient's anticoagulation was below the therapeutic range, with an international normalized ratio of 1.9 (Table ​ (Table1 1 ).

WBC: white blood cell

The electrocardiogram results revealed a normal sinus rhythm without acute ST changes. An abdominal Doppler ultrasound revealed a saccular lesion measuring 9 cm with a circumferential parietal thrombus communicating with the aorta through a 32-mm-wide neck (Figure ​ (Figure1). 1 ). Subsequent abdominal multi-detector row computed tomography (MDCT) was conducted for a more comprehensive assessment, disclosing a large saccular aneurysmal dilation originating from the posterior of the abdominal aorta below the renal arteries, connected by a 30-mm-wide neck with circumferential parietal thrombosis respecting the arterial lumen (Figure ​ (Figure2). 2 ). Upon further investigation, it was revealed that the patient's sibling had previously experienced an AAA a few years ago, ultimately succumbing to the consequences of AAA rupture.

AAA: abdominal aortic aneurysm

The patient returned a few days later with intensified abdominal pain and in a hemodynamically unstable condition. An emergency abdominal-pelvic CT scan revealed an extensive saccular aneurysmal dilation of the infra-renal abdominal aorta, peritoneal effusion, mesenteric infiltration, and parietal hyperdensity, confirming an aneurysmal fissure (Figure ​ (Figure3 3 ).

Therapeutic intervention commenced with the establishment of appropriate intravenous access, judicious administration of intravenous fluids, and pain management. Endovascular aneurysm repair (EVAR) was performed, and the patient was prescribed a treatment regimen comprising angiotensin 2 receptor blockers, acetylsalicylic acid, and clopidogrel. The patient's condition and vital signs showed improvement, and a follow-up was advised.

It is estimated that approximately 0.6 million individuals in India were affected by AAA in 2016, with a prevalence of 0.4% [ 7 ]. Patients with a ruptured AAA face alarmingly high mortality rates, reaching up to 90%. Conversely, mortality rates for those undergoing elective AAA repair are typically under 10% [ 8 ]. Therefore, early AAA diagnosis is crucial to prevent rupture. Common risk factors for AAA include male gender, age over 65, a history of tobacco use, and a familial predisposition [ 2 ]. Approximately 4-8% of men and 0.5-2% of women above 60 years old are estimated to have AAA. If left untreated, AAAs tend to progressively enlarge, with larger aneurysms carrying a higher risk of rupture [ 9 ]. Moreover, larger aneurysms exhibit a faster rate of expansion compared to smaller ones. AAA repair stands out as a relatively safe and effective method to mitigate the risk of rupture-associated death. Primary care physicians play a crucial role in ordering appropriate AAA screenings and should possess knowledge about when to refer patients to vascular surgeons, optimize pre-surgery comorbidities, understand potential complications, and be aware of post-repair surveillance requirements.

In instances where symptoms manifest, the typical grievances include lower back pain and abdominal discomfort. Recognizing these signs, symptoms, and associated risk factors is crucial due to the frequently inconspicuous nature of the diagnosis, leading to misdiagnosis in 20-30% of cases [ 10 ]. In addition to back or abdominal pain, patients can additionally experience pain in the hip, flank, groin, or buttock. Patients may describe this pain as severe or piercing, but it is generally nonspecific if the AAA compresses a nearby structure such as a vertebral endplate [ 11 ]. Sudden ischemia, painful cyanotic toes, and palpable pedal pulses are examples of leg symptoms that might come from distal embolization or aortic occlusion caused by thrombosis [ 12 ]. More intense pain with an abrupt beginning is caused by rupture or dissection, which occurs when bleeding into the media of the vessel separates its layers [ 13 ]. The patient in this case experienced low back pain radiating into the leg but did not exhibit the thrombosis-related signs.

One significant risk factor is smoking, defined as consuming more than 100 cigarettes over the course of a lifetime [ 14 ]. Interestingly, the only controllable factor associated with the growth of AAA is quitting smoking. In this specific case, the patient aligns with the risk factors related to age, gender, and a smoking history.

Individuals who are close blood relatives, especially male family members, of a person already diagnosed with an aneurysm face an elevated risk [ 15 ]. In our case, the patient's sibling had earlier succumbed to the rupture of AAA. Another correlation observed with AAA is the presence of atherosclerotic disease, encompassing conditions like coronary heart disease and claudication, as seen in the instance of our patient. However, the diagnosis of AAA cannot be conclusively determined by a single risk factor or characteristic, as it is a complex disorder influenced by various genetic and environmental factors.

The clinical examination has restricted effectiveness in identifying AAA. Nonetheless, the researchers emphasize the significance of abdominal palpation and auscultation, particularly when there is a suspicion of non-mechanical or abdominal issues causing low back pain or when patients show resistance to treatment [ 16 ]. Another scenario justifying clinical examination is when the patient's clinical history raises concerns about AAA. In this particular case, abdominal palpation was conducted during the initial examination, even though the patient did not exhibit symptoms at that time.

The patient's abdominal circumference and the aneurysm's size have an impact on the detection of AAA [ 17 ]. It becomes extremely uncommon for AAAs to be palpable in patients whose girths are more than 100 cm. However, the chance of a clinical diagnosis also rises with the size of the aneurysm. This suggests that among obese patients, a referral for ultrasonography evaluation may be prudent if the medical history discloses enough indications and risk factors. This obese patient had a large AAA, but it was difficult to palpate and detect. Ultrasound is a more reliable screening method for male AAA than abdominal palpation, although it is less accurate for female patients. Research has demonstrated that offering a baseline screening test to males over 65 can cut the population's AAA-related mortality in half [ 18 ]. An ultrasonography examination was used to confirm the aneurysm's presence in this patient.

Nonetheless, there are risks associated with elective surgical repair of AAA. Operative death rates range from 1.4% to 5.8%, with a 32.4% complication rate [ 2 ]. As a result, aneurysms are usually left untreated surgically until they have a diameter of at least 43 mm; some research even advises against doing surgery until the aneurysm is larger than 50-55 mm [ 19 ]. Age alone does not determine operating eligibility; however, patients with concomitant morbidity and those awaiting treatment for AAA have the highest death rates [ 20 ].

Conclusions

Our case underscores the importance of appropriately screening for AAA, referring patients to vascular surgery, and taking into account a high level of suspicion and potentially life-saving measures. There are distinct risk factors and unique symptoms associated with AAA. Despite the relatively low sensitivity of such evaluations, a clinical assessment is necessary when identified indicators of risk are visible. For any male patient 50 years of age or older with low back pain, it should be part of the differential diagnosis. It is advised to promptly refer the patient for advanced imaging if there is any suspicion.

The authors have declared that no competing interests exist.

Author Contributions

Concept and design:   Mamta Kamboj, Hadeeqa Idris, Ajay Singh, Sachin M. Chaudhary, Mohitha C. Mallipeddi

Acquisition, analysis, or interpretation of data:   Mamta Kamboj, Arghadip Das, Sachin M. Chaudhary

Drafting of the manuscript:   Mamta Kamboj, Hadeeqa Idris, Sachin M. Chaudhary

Critical review of the manuscript for important intellectual content:   Mamta Kamboj, Arghadip Das, Ajay Singh, Mohitha C. Mallipeddi

Supervision:   Mamta Kamboj, Sachin M. Chaudhary, Mohitha C. Mallipeddi

Human Ethics

Consent was obtained or waived by all participants in this study

• Open access
• Published: 09 September 2024

Fournier’s Gangrene: clinical case review and analysis of risk factors for mortality

• Qingyun You 1   na1 ,
• Jing Guan 1   na1 ,
• Bensheng Wu 2 ,
• Yangyang Miao 3 ,
• Xinxin Bai 1 ,
• Yuhua Ma 1 ,
• Shuguang Zhen 2 &
• Zongqi He   ORCID: orcid.org/0000-0002-1721-0018 4  

BMC Surgery volume  24 , Article number:  251 ( 2024 ) Cite this article

Metrics details

Fournier’s Gangrene is a severe surgical infectious disease, and various risk factors can increase its mortality rate. The purpose of this study is to retrospectively analyze the clinical characteristics and laboratory data of Fournier’s Gangrene patients, followed by an analysis of mortality-related risk factors. This study has no secondary objectives.

This study included 46 hospitalized patients diagnosed with Fournier’s Gangrene at Suzhou Traditional Chinese Medicine Hospital from December 2013 to March 2024. Clinical data for all patients were extracted from the electronic medical records system. The collected data included gender, age, duration of illness, length of hospital stay, sites of infection involvement, comorbidities, white blood cell count, hematocrit, albumin, blood glucose, creatinine, serum sodium, serum potassium upon admission, microbial culture results, and patient outcomes (survival/death). The Simplified Fournier Gangrene Severe Index (SFGSI) was used to score all patients. Patients were categorized into survival and death groups based on clinical outcomes. Differences between categorical variables were compared using the χ² test or Fisher’s exact test. Differences between numerical variables were compared using Student’s t-test or the Mann-Whitney U test. Binary logistic regression was employed to analyze the risk factors for mortality in Fournier’s Gangrene.

Among the 46 Fournier’s Gangrene patients, 39 were male (84.8%) and 7 were female (15.2%). The age ranged from 17 to 86 years, with a median age of 61 years. Fourteen cases (30.4%) were confined to the perianal area, 26 cases (56.5%) had fascial necrosis involving the perianal, perineal, and genital regions, while 6 cases (13.0%) extended to the abdominal wall. At a 3-month postoperative follow-up, 43 patients (93.5%) survived, while 3 patients (6.5%) died shortly after admission due to severe illness. Based on the outcome, patients were divided into survival and death groups with 43 and 3 cases, respectively. Significant differences were observed between the two groups in terms of age ( P <0.05), extension to the abdominal wall ( P <0.01), hematocrit ( P <0.01), albumin ( P <0.01), SFGSI ( P <0.01), and SFGSI>2 ( P <0.01). Binary logistic regression analysis indicated that decreased hematocrit was an independent risk factor for mortality in Fournier’s Gangrene patients.

This study provides a detailed analysis of the clinical characteristics and risk factors for mortality in Fournier’s Gangrene patients. The primary outcome of this study is that a decreased hematocrit is an independent risk factor for predicting mortality in FG patients. These findings offer valuable prognostic insights for clinicians, underscoring the importance of early identification and correction of reduced hematocrit to improve patient outcomes and survival rates.

Peer Review reports

Introduction

Necrotizing fasciitis is a severe and rapidly progressing soft tissue infection, known for its highly invasive nature and high mortality rates [ 1 , 2 ]. The hallmark of this disease is extensive fascial necrosis caused by microbial infection, rapidly leading to tissue destruction and toxic shock, posing a grave threat to the patient’s life [ 1 , 2 , 3 ]. Severe inflammation and the infectious process spread rapidly along the fascial plane, affecting adjacent soft tissues [ 2 , 3 ]. The spread of inflammation and infection can lead to vascular thrombosis, subsequently causing ischemia and necrosis of adjacent soft tissues and fascia [ 4 ]. Therefore, the disease may initially go unnoticed or unrecognized, as there may be minimal or no skin manifestations in its early stages.

Necrotizing fasciitis occurring in the scrotum, perianal, and perineal regions is also known as Fournier’s Gangrene [ 1 , 5 ]. Necrotizing fasciitis results from a synergistic infection of the fascia and subcutaneous tissues by both aerobic and anaerobic microorganisms [ 2 , 6 ]. Literature reports that Gram-positive bacteria, such as Group A Streptococcus and Staphylococcus aureus, and Gram-negative bacteria, like Escherichia coli and Pseudomonas aeruginosa, are the most common bacteria isolated from wound cultures in Fournier’s Gangrene patients [ 7 , 8 , 9 ]. These bacteria can infect through various routes, including the urinary tract, gastrointestinal tract, or skin. The infectious and inflammatory processes spread rapidly along the Dartos, Colles, and Scarpa fasciae, early involving the abdominal wall [ 7 , 10 , 11 ]. Trauma, postoperative conditions, urinary tract infections, and other perineal infections like perianal abscesses often serve as the initial points of infection [ 1 , 12 ]. Fournier’s Gangrene most commonly affects males over 50 years of age with diabetes mellitus [ 4 , 7 ]. Fournier’s Gangrene is a surgical emergency often requiring urgent and multiple surgical debridements, antibiotic therapy, and supportive measures [ 5 , 12 ].

Due to the rapid progression and high lethality of necrotizing fasciitis, prompt diagnosis and treatment are key to improving outcomes. Therefore, early identification and management of factors associated with mortality are crucial. Risk factors primarily involve host factors, pathogens, and environmental factors, including but not limited to diabetes, immunosuppressive states, history of trauma or surgery, and prolonged use of non-steroidal anti-inflammatory drugs [ 12 , 13 ]. Understanding these risk factors aids in identifying high-risk populations and providing them with more targeted prevention and management strategies.

This study aims to conduct a retrospective analysis of clinical characteristics and laboratory data of Fournier’s Gangrene patients managed by the authors’ institution. We aim to analyze factors associated with mortality to enhance the clinical team’s understanding and comprehension of this disease. By doing so, we aim to provide robust evidence for the early identification of high-risk Fournier’s Gangrene patients, thereby reducing the harm to patients’ health and improving treatment success rates and survival rates.

Materials and methods

Study subjects.

This is a retrospective, descriptive study that received approval from the Ethics Committee of Suzhou Traditional Chinese Medicine (TCM) Hospital (2024 Ethics Approval 004). We included 46 hospitalized patients diagnosed with Fournier’s Gangrene (FG) who were treated at Suzhou TCM Hospital from December 2013 to March 2024.

Inclusion criteria: Patients diagnosed with Fournier’s Gangrene who meet the following conditions: clinical presentation of localized cellulitis with significant systemic toxicity symptoms (high fever, significantly elevated white blood cell count, severe cases with altered mental status, rapid breathing, tachycardia); rapid progression of the condition, with the affected area showing quick swelling, crepitus, blackened and necrotic tissue, and significant pain; infection originating from the skin, urethra, or rectum [ 3 ].

Exclusion criteria: Patients with simple perianal, perineal, urethral, and scrotal abscesses without evidence of fascial necrosis; and patients with missing or incomplete data [ 1 ].

Among the included patients, 42 cases originated from the Department of Anorectal Surgery, indicating FG originating from perianal and perirectal abscesses. Four cases of FG originating from scrotal infections were from the Department of Urology.

Data collection

Clinical data for all patients, including medical history, physical examination, laboratory tests, imaging studies, and surgical records, were extracted from the electronic medical record system. The Fournier’s Gangrene Severity Index (FGSI) score is commonly used to evaluate the severity of FG [ 9 , 11 , 14 ]. This is one of the most widely used scoring systems and includes eight parameters: temperature, heart rate, respiratory rate, sodium, potassium, creatinine, white blood cell count, and hematocrit. The higher the score, the worse the prognosis. Scoring is done by assigning each parameter a score from 0 to 4 based on the degree of abnormality. The total score is the sum of all parameter scores. Patients with a total score greater than 9 typically have a severe condition and a poor prognosis. The simplified Fournier’s Gangrene Severity Index (SFGSI) is currently the most widely used [ 11 , 14 ]. In addition, the age-adjusted Charlson Comorbidity Index (aCCI) is a widely used comorbidity scoring system. It quantifies comorbidities based on the number and severity of a patient’s disease and can be used to predict the risk of disease mortality [ 15 ]. The collected data included gender, age, duration of illness, length of hospital stay, sites of infection, comorbidities, white blood cell count, hematocrit, albumin, blood glucose, creatinine, serum sodium, serum potassium upon admission, microbial culture results, and patient outcomes (survival/death), among others. All patients were scored using the SFGSI and aCCI.

Treatment strategies

Based on the increasing understanding of FG, a high-level response was initiated for all FG patients upon admission to complete laboratory tests and CT scans as quickly as possible to assess the severity of the condition [ 16 ]. All FG patients underwent initial emergency surgical debridement and drainage under spinal or general anesthesia within 24 h of admission. The initial debridement and drainage were conducted under a multi-disciplinary team (MDT) approach. Depending on the affected areas, colorectal surgeons, urologists, and general surgeons performed debridement and drainage of the perianal, perineal, genital, and abdominal wall regions. Swab samples were collected from the wound edges for culture. Debridement was performed to remove necrotic tissue until fresh bleeding surfaces were exposed, typically requiring at least one debridement of necrotic tissue. Once diagnosed with FG, all patients received broad-spectrum antibiotic treatment. After microbial culture results were available, antibiotics were selected based on sensitivity testing [ 6 ]. Our experience suggests early and adequate use of imipenem/cilastatin. For patients with severe conditions, they were transferred to the intensive care unit (ICU) for mechanical ventilation and hemodynamic support after the initial debridement. None of the included patients underwent colostomy or cystostomy procedures.

After the initial thorough debridement, dressing changes were performed daily. The wounds were cleaned with povidone-iodine, saline, and 2% hydrogen peroxide, and then covered with povidone-iodine dressings [ 4 ]. During dressing changes, the progression of wound infection was observed. Depending on the progression of the infection, one or more additional debridements might be needed, which could typically be completed in the ward.

Statistical analysis

Statistical analysis was performed using IBM SPSS 26.0 software. Categorical variables were described using frequencies (n) and percentages (%). Numerical variables were expressed as mean ± standard deviation (SD) or median with interquartile range after the Kolmogorov-Smirnov normality test. Differences between categorical variables were compared using the χ² test or Fisher’s exact test. Differences between numerical variables were compared using the student’s t-test or Mann-Whitney U test. Binary logistic regression was used for analyzing risk factors associated with mortality [ 11 , 17 ]. A p -value < 0.05 was considered statistically significant.

Clinical characteristics of FG patients

As shown in Table  1 , among the 46 FG patients, there were 39 males (84.8%) and 7 females (15.2%). The age ranged from 17 to 86 years with a median age of 61 years. The shortest duration of illness was 3 days, the longest was 30 days, and the median duration was 7 days. The shortest length of hospital stay was 2 days, the longest was 30 days, and the median stay was 14 days. Regarding the sites of necrotic lesions, 14 cases (30.4%) were localized to the perianal area, 26 cases (56.5%) had fascial necrosis involving the perianal, perineal, and genital regions, and 6 cases (13.0%) had fascial necrosis extending to the abdominal wall. There were 17 patients (37.0%) with hypertension and 17 patients (37.0%) with diabetes. Nine patients (19.6%) had both hypertension and diabetes, while one patient (2.2%) had both a hematologic disorder and diabetes. Twenty patients (43.5%) had no comorbidities. During a 3-month follow-up after surgery, 43 patients (93.5%) survived, while 3 patients (6.5%) died shortly after admission due to the severity of their condition. It is noteworthy that the three deceased patients had very short hospital stays, lasting 2 days, 3 days, and 5 days respectively.

Analysis of laboratory data in FG patients

As shown in Table  2 , after normality testing, the blood glucose and creatinine levels of the 46 included patients did not follow a normal distribution. The white blood cell count ranged from 6.63 × 10^9/L to 38.57 × 10^9/L, with an average of 16.5 ± 6.3 × 10^9/L. The hematocrit ranged from 20.3 to 47.8%, with an average of (37.0 ± 6.0) %. Albumin levels ranged from 21.0 g/L to 43.7 g/L, with an average of 32.5 ± 5.6 g/L. Serum sodium levels ranged from 126.6 mmol/L to 144.5 mmol/L, with an average of 135.8 ± 4.6 mmol/L. Serum potassium levels ranged from 2.96 mmol/L to 5.1 mmol/L, with an average of 3.8 ± 0.6 mmol/L. Blood glucose levels ranged from 4.48 mmol/L to 32.55 mmol/L, with a median of 7.91 mmol/L. Creatinine levels ranged from 47.0 umol/L to 294.3 umol/L, with a median of 80.1 umol/L. Bacterial cultures were performed on necrotic tissues from 38 patients (82.6%), with 28 cases (60.9%) yielding positive results. Among the cultured microorganisms, Escherichia coli was the most common, found in 19 cases (41.3%), followed by Klebsiella pneumoniae in 4 cases (8.7%).

Comparison of clinical and laboratory data based on patient outcomes

Based on outcomes (survival/death), the 46 patients were divided into two groups: the survival group with 43 cases and the death group with 3 cases. As shown in Table  3 , after comparison, significant differences were found between the two groups in terms of age ( P <0.05), length of hospital stay ( P <0.001), extension to the abdominal wall ( P <0.01), hematocrit ( P <0.01), albumin ( P <0.01), SFGSI ( P <0.01), and SFGSI>2 ( P <0.01). These results suggest that older age, extension to the abdominal wall, lower hematocrit, and higher SFGSI are risk factors for mortality in FG patients. Because the three patients in the death group died shortly after admission due to the severity of their condition, a short hospitalization duration cannot be proven as an independent risk factor associated with mortality. No significant differences were observed in the remaining variables.

Binary logistic regression analysis

For the variables showing differences in Table  3 , binary logistic regression was employed to further analyze the risk factors related to FG mortality. Initially, a univariate regression analysis was conducted using age, length of hospital stay, involvement of the abdominal wall, hematocrit, albumin, and SFGSI>2 as independent variables, and mortality as the dependent variable. This was followed by a multivariate regression analysis where the variables showing statistical differences in the univariate analysis were used as independent variables to explore the independent risk factors affecting mortality after adjusting for confounding factors. As shown in Table  4 , The binary logistic regression analysis showed that hematocrit was the variable with a significant difference. The univariate regression analysis found a 95% confidence interval (CI) for hematocrit of 0.597–0.953, with an odds ratio (OR) of 0.754 and a p -value of 0.018, which is less than 0.05. The multivariate regression analysis found a 95% CI for hematocrit of 0.556–0.987, with an adjusted odds ratio (AOR) of 0.740 and a p -value of 0.040, which is also less than 0.05. According to Table  4 , for every unit increase in hematocrit, there was a significant 24.6% decrease in the likelihood of mortality in FG patients. None of the other factors showed statistical significance as predictors of mortality. Even after adjusting for age as a confounding factor, the relationship between hematocrit and mortality remained significant. Specifically, for every unit increase in hematocrit, there was a significant 26% decrease in the likelihood of mortality in FG patients.

We divided the 46 patients into two groups based on whether their hematocrit levels were below 30 (%) and compared the survival rates between the two groups. Statistical analysis indicated a significant difference in survival rates between the groups ( P  = 0.001). Similarly, we divided the 46 patients into two groups based on whether their hematocrit levels were below 35 (%) and compared their survival rates. The analysis showed a difference in survival rates between the groups ( P  = 0.037). These results further support the robustness of our conclusion that decreased hematocrit is an independent risk factor for mortality in FG patients (Supplementary Tables 1 , 2 ).

Fournier’s gangrene is a severe surgical infection that is relatively rare. Over an 11-year period, our hospital treated 46 cases of FG. The disease predominantly affects males, with our results showing that males accounted for 84.8% of FG patients, consistent with existing literature [ 10 , 11 ]. Early diagnosis, proper management of predisposing factors, and aggressive surgical debridement can improve clinical outcomes [ 18 ]. Previous studies have reported varying mortality rates for this disease, ranging from 20 to 80% [ 18 ]. With increased attention to the disease and advancements in treatment, the reported mortality rate for FG now ranges between 7.5% and 16% [ 12 ]. Our study found a mortality rate of 6.5% for FG, consistent with the most recent literature.

Several studies have identified the main risk factors for the occurrence of FG, including diabetes, alcohol abuse, obesity, immunosuppression, hypertension, hematological diseases, perianal and rectal abscesses, perineal infections, and trauma [ 12 , 13 , 19 ]. Our study found that 37.0% of patients had hypertension, and 37.0% had diabetes. Additionally, 19.6% of the patients had both hypertension and diabetes. Among the 46 FG patients in our study, 91.3% originated from perianal abscesses, while 8.7% were from scrotal infections. These clinical data are consistent with what is described in the literature.

Studies have reported that risk factors associated with mortality in FG include advanced age, diabetes, infection extending to the abdominal wall, low hematocrit, abnormal serum potassium levels, and elevated creatinine levels [ 11 , 17 ]. Due to the high mortality rate of FG, several assessment scales have been used to evaluate the severity of the disease and prognosis in patients. Currently, used clinical assessment scales include FGSI, ACCI, LRINEC, and UFGSI, among which FGSI is the most commonly used [ 11 , 14 , 20 ]. Research has shown that the sensitivity and specificity of FGSI in predicting mortality are both between 65% and 100% [ 14 ]. In 2014, Lin et al. developed the SFGSI based on the FGSI scale, incorporating three laboratory parameters: serum potassium, creatinine, and hematocrit. They compared it with other assessment scales and found that SFGSI is user-friendly with good sensitivity (87%) and specificity (77%) in predicting mortality, effectively identifying patients with poor prognosis [ 14 ]. Our results show that higher age, involvement of the abdominal wall, lower hematocrit, lower serum albumin, and higher SFGSI scores were observed in the non-survival group. Elderly patients experience a gradual decline in physiological function and a weakening of the immune system, which may increase the risk of infection and reduce their ability to fight off infections. Additionally, older patients often have multiple chronic conditions, such as diabetes and hypertension, which could exacerbate the severity and prognosis of Fournier’s gangrene. Abdominal wall involvement often indicates a large extent of the lesion that has spread to deeper tissues, resulting in more severe tissue necrosis and infection, and a poor prognosis. The involvement of the abdominal wall as a predictive factor for mortality has been described in related studies [ 13 , 21 ]. Hypoalbuminemia was correlated with mortality in FG. Lin et al. reported significant differences in admission hematocrit and serum albumin levels between the survival and non-survival groups in FG patients [ 20 ]. The C-reactive protein/albumin ratio (CAR) has been shown to correlate with the severity of infection and serves as an effective inflammatory marker to predict prognosis [ 22 ]. Özgül et al.‘s study demonstrated that the CRP/albumin ratio can be used to predict FG-related mortality [ 23 ]. SFGSI is an important tool for assessing the severity and prognosis of patients with Fournier’s gangrene [ 11 , 14 ]. In our study, SFGSI showed a higher trend in the mortality group, with all deceased patients having an SFGSI > 2, reflecting a severe decline in the patient’s overall condition. However, our results showed no significant differences in creatinine and serum potassium levels between the two groups. The mean and p -value (0.083) for serum potassium suggest a tendency toward statistical difference between the groups. Although the median creatinine level in the mortality group was noticeably higher than that in the survival group, the p -value (0.276) > 0.05. We believe that the lack of significant differences in serum potassium and creatinine between the two groups may be due to the small sample size and resulting bias in the study results.

The results of both univariate and multivariate regression analyses in this study showed that a decreased hematocrit level is a risk factor for mortality in FG patients. The statistical analysis demonstrated that lower hematocrit levels were significantly associated with increased mortality risk in Fournier’s Gangrene (univariate regression: OR 0.754, 95% CI: 0.597–0.953, p  = 0.018; multivariate regression: AOR 0.740, 95% CI: 0.556–0.987, p  = 0.040). Both univariate and multivariate regression analyses for the variable hematocrit showed p -values less than 0.05. This finding underscores the importance of monitoring and managing hematocrit levels in these patients to improve survival outcomes. Regardless of whether it’s FGSI or SFGSI, hematocrit remains an important laboratory parameter for predicting the prognosis of FG [ 12 , 14 ]. Cen et al. conducted a retrospective analysis of 111 cases of necrotizing soft tissue infections to investigate the risk factors associated with mortality and amputation in these patients. Their study showed that high LRINEC scores, elevated WBC counts, low hematocrit (HCT), and multiple surgeries were associated with increased mortality rates [ 10 ]. Similar results have been corroborated in other studies [ 13 , 17 , 24 , 25 ].

This study has several limitations. First, we recruited a relatively small sample of 46 FG patients over an 11-year period, which might introduce potential biases into our results. Second, this was a retrospective study conducted at a single center. The small sample size and single-center design limit the generalizability of our findings. The small sample size may affect the representativeness and accuracy of the results. Small sample data often fails to meet the traditional statistical test hypothesis, and special statistical methods are required for analysis, increasing the research’s complexity and uncertainty. In addition, single-center studies may have a single sample source and lack of diversity, further increasing the difficulty of statistical inference. Therefore, large-scale multicenter studies are needed to minimize potential biases as much as possible and validate these results in the future. Our findings are based on our clinical experience in managing FG patients, so we cannot generalize our findings to other populations. However, our experience and findings can serve as a valuable reference for other clinical teams tasked with managing FG.

Conclusions

This study provides a comprehensive analysis of the clinical characteristics and mortality risk factors in FG patients. The primary outcome of this study is that a decreased hematocrit level is an independent risk factor for predicting mortality in FG patients. These findings offer crucial prognostic guidance for clinicians, underscoring the importance of early identification and correction of decreased hematocrit levels. Timely correction of low hematocrit levels may improve patient outcomes and survival rates. Of course, this requires large-scale, multicenter studies to further validate the findings. Future research endeavors should delve deeper into investigating the correlation between hematocrit levels and prognosis in FG, while also striving to identify more efficacious interventions aimed at improving the quality of life and survival rates of affected individuals.

Data availability

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

Abbreviations

• Fournier’s Gangrene

Traditional Chinese medicine

• Simplified Fournier Gangrene severe index

Fournier Gangrene severe index

Age-adjusted Charlson comorbidity index

Multi-Disciplinary team

Intensive care unit

Confidence interval

Adjusted odds ratio

Laboratory risk indicator for necrotizing fasciitis

Uludag Fournier’s Gangrene severity index

C-Reactive protein/albumin ratio

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Qingyun You and Jing Guan contributed equally to this work.

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Nanjing University of Chinese Medicine, Nanjing, 210046, Jiangsu, PR China

Qingyun You, Jing Guan, Xinxin Bai & Yuhua Ma

Department of Anorectal Surgery, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, Jiangsu Province, PR China

Bensheng Wu, Jun Du & Shuguang Zhen

Clinical Laboratory, Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, 215009, PR China

Yangyang Miao

Department of Anorectal Surgery, Kunshan Hospital Affiliated to Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu Province, PR China

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Zongqi He, Shuguang Zhen, and Bensheng Wu conceived and designed the study. Qingyun You, Jing Guan, Jun Du, and Yangyang Miao collected all clinical and laboratory data and were responsible for the literature review. Zongqi He, Xinxin Bai, and Yuhua Ma conducted the statistical analysis. All authors contributed significantly to drafting and revising the manuscript. All authors gave final approval for the manuscript to be published.

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Correspondence to Shuguang Zhen or Zongqi He .

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You, Q., Guan, J., Wu, B. et al. Fournier’s Gangrene: clinical case review and analysis of risk factors for mortality. BMC Surg 24 , 251 (2024). https://doi.org/10.1186/s12893-024-02547-4

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Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war

• Igor Lurin 1 , 2 ,
• Eduard Khoroshun 3 , 4 ,
• Vitalii Makarov 3 , 4 ,
• Volodymyr Negoduiko 3 , 4 ,
• Serhii Shypilov 3 , 4 ,
• Yurii Bunin 3 ,
• Maksym Gorobeiko 1 , 5 , 6 &
• Andrii Dinets 1 , 5 , 7  

International Journal of Emergency Medicine volume  17 , Article number:  113 ( 2024 ) Cite this article

Metrics details

Russo-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90–100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava.

Case presentation

A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars’ explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the “golden hour” principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent second-look surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava.

Conclusions

Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies.

Introduction

Vascular injuries are common in warfare, demonstrating five times more frequent incidence in modern wars because of the application of high-energy weapons, causing severe damage to tissues [ 1 , 2 , 3 , 4 , 5 , 6 ]. Also, one out of five (20%) combat wounds are diagnosed with bleeding from unspecified sources, associated with significant blood loss. Vascular injury is considered one of the most severe injuries. It is associated with significant damage of soft tissues, thoracoabdominal gunshot injuries, limb amputations, or lethal outcomes [ 1 , 3 , 7 ]. The high-energy weapon is associated with severe damage to military personnel, including vascular injury, as shown in clinical and experimental studies [ 4 , 5 , 7 , 8 , 9 , 10 ]. Vascular trauma is frequent in combat casualties, constituting up to 12% in Operation Iraqi Freedom and Operation Enduring Freedom, which is higher by 1–3% as compared to WWII, the Vietnam War, and the war in Korea. The frequency of gunshot injuries to the major abdominal vessels is 1.7–7.8% during the ATO/OOC (i.e. hybrid period of Russo-Ukrainian war 2014–2022) [ 11 ].

Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90–100% in the case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding [ 12 , 13 ]. The possible clinical outcomes in patients after the gunshot injury to the aorta are aortocaval fistula or aortic pseudoaneurysm formation, which should be considered in the patients’ follow up. There are different options for the management of aortic gunshot injuries such as open surgery or peripheral balloon embolization. In almost all cases, urgent surgical treatment is indicated to prevent immediate death. Patients wounded by small-caliber, low-velocity bullets with hemorrhage in the aortic wall almost always survive.

Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. The overall incidence of IVC injuries ranges from 0.5 to 5% of penetrating injuries and 0.6–1% of blunt injuries. Approximately 30–50% of patients will die before reaching the hospital due to exsanguination or associated injuries. Of those who survived at admission, 20–57% patients die during operations due to severe blood loss or during postoperative period due to shock [ 14 ]. In previous publications, we have reported features of a vascular gunshot injury, however, little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management [ 3 , 4 , 15 ]. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava.

A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars’ explosive shelling. The patient got first medical aid at the place of injury within 10 min (according to the principle “platinum minute”) and within one hour (principle “golden hour”) was transported to the Forward Surgical Team, which is in line with the Military Medical Doctrine of Ukraine [ 16 ]. At the Forward Surgical Team, the patient’s condition was extreme, he had undergone laparotomy and revision of abdominal and retroperitoneal cavities, followed by right hemicolectomy, suturing of defects of the small intestine, obstructive resection of jejunum, retroperitoneal hematoma evacuation (300 ml), lavage and drainage of the abdominal cavity. Intra-abdominal packing with laparotomy pads was performed for the right abdominal flank to temporarily control hemorrhage. The patient was also undergone for primary surgical debridement for wounds of the upper and lower limbs as well as fasciotomy of the right femoral area. The time of operation was 90 min at the stage of management by the Forward Surgical Team. Considering the severity, the patient was transported to the higher level of medical care, which is the Military Medical Clinical Center of Northern Region (i.e. Role 3 hospital) of Command of Medical Forces of Armed Forces of Ukraine located in Kharkiv city within 4 h. At admission, the patient’s severity status was judged as moderate. At Role 3 hospital, the patient was evaluated by ultrasonography using FAST-protocol for the abdomen and chest (Sonosite Micromaxx, 2017) showing an absence of free fluid in both the abdomen and chest. The blood test included routine clinical chemistry, biochemical analyses, coagulation analyses, and blood typing. A whole-body multispiral computed tomography (CT) scan was used with a 0.5 mm slice image (Toshiba Activion 16 machine, Japan). The arterial phase of the CT scan showed a foreign body of metal density (i.e. metal projectile), located in the aortic wall at the level of aortic bifurcation, but without signs of blood extravasation (Fig.  1 ).

CT scan image at admission to the Role 3 hospital illustrating metal fragment in the retroperitoneal space in area of aortic bifurcation, free air in the abdomen, abdominal packing with laparotomy pads in right abdomen, two drainage tubes, closes laparostomy: in axial projection (A) , coronal projection (B) , 3D modeling of arterial phase of a CT scan (C) , 3D modeling of venous phase of a CT scan

24 h after the admission to the Role 3 hospital, the patient underwent second-look surgery. At revision, no active bleeding was observed, and the surgical pads were removed. Further revision showed a metal projectile within the aorta wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the IVC. The operation ended with an ileostomy and drains to the abdomen were placed.

48 h after the injury, the patients underwent third-look surgery in order to revise the abdominal cavity, the right parts of the extraperitoneal space, to remove surgical pads. At third look revision, liver, spleen, stomach, and duodenum were identified in normal state. Resected parts of the jejunum and transverse colon were without pathological changes. The revision of the area of aortic bifurcation showed hematoma without sign of tension. The possible presence of the metal shell was suspected and revision of that hematoma was performed by using a multifunctional surgical magnetic tool using previously described protocols. In brief, the metal fragment is usually identified by X-ray or CT-scan. During the operation, if available, we use C-arc and insert magnetic tool to the area of the metal fragment location. The choice for the specific magnetic tool shape depends on the metal fragment contours and locations. Frequently, the metal fragment is fixed and rotated by the endoscopic forceps for reliable catching by the magnetic tool and its subsequent removal from the body [ 17 , 18 ]. At the revision of the hematoma, the metal fragment was identified and removed. After the removal of small metal shell, the active aortic bleeding started and we stopped it by proximal and distal application of surgical clamps. We hypothesize that hematoma caused compression to the defect in the aorta, which prevented the bleeding in first place.

Further revision showed perforations of both the aorta and IVC in the area proximal to the aortic bifurcation. These defects were sutured. The blood loss was 300 ml. The time of operation was 90 min and stages of operation are illustrated in Fig.  2 .

Illustration of the surgical stages: A – removal of the metal fragment from aortic wall with application of surgical magnetic tool followed by pressure of the aortic defect by digit; B – photgraph of the removed metal projectile; C – application of the Satinsky clamp to inferior vena cava (IVC); D – photgraph illustrating preformation in the IVC; E – photgraph illustrating suturing of the IVC; F – view of the operation filed of the sutured aorta and IVC without signs of bleeding

In 2 days after the restoring of aorta wall integrity, the fourth look revision was performed for the abdomen, right retroperitoneal space, removal of gauze packings, application of ileotransverse anastomosis. Sanitation and redraining of the abdominal cavity. At revision of the aorta and IVC defect areas we observed no pathological changes (Fig.  3 ).

Intraoperative view of the aorta and inferior vena without signs of bleeding in the area of gunshot defects indicating consistency of the sutures at the 4th postoperative day

In the postoperative period, intestinal motility was restored on the 4th day after the operation. The draining tubes from the abdominal cavity were removed on the 5th day and sutures on the 14th day. During the treatment at Role 3 hospital, the patient was administered antibiotic therapy, infusion therapy, anticoagulants, and painkillers. The patient was discharged from the in-patient department on the 21st day after the surgery and continued rehabilitation at Role 5 hospital.

Abdominal gunshot wounds with simultaneous damage to both the aorta and IVC are very uncommon in wars, whereas separate injuries to those vessels are more common with frequent lethal outcomes [ 11 , 19 , 20 , 21 ]. This case report is consistent with our previous publications and another example of possibilities to apply highly-specialized surgical care nearby to the battlefield line (Role 3 hospital) in Kharkiv city, which is close to the border with Russia. In this case report we also emphasized the importance of damage control surgery and application of surgical magnets to treat our patient with severe gunshot injury as we also showed in our previous reports [ 3 , 17 , 22 ]. It is also another example of what kind of trauma Ukraine’s war surgeons deal with and how we can achieve excellent outcomes in the management of severe gunshot injuries at the high risk of artillery strikes on medical facilities by the russian army. It is also important to inform global surgical community about the achievement in combat trauma, which might help to other military doctors and may as well be included in possible investigations by artificial intelligence [ 23 ].

MEDEVAC is the suggested standard for medical evacuation worldwide [ 24 ]. However, there is a high risk for medical evacuation in the Roles 1–2 hospital in Ukraine due to the high activity of Russian air forces, attempting to shut down any vehicles, including sanitary transport with attacks on both combat and civil medical facilities [ 3 , 4 , 9 , 15 , 22 , 25 , 26 , 27 , 28 , 29 , 30 ].

Pocivavsek et al. demonstrated a case of a thoracoabdominal gunshot wound with trans-diaphragmatic trajectory features of the projectile. The authors also applied the FAST protocol and simultaneous laparotomy and thoracotomy were also performed. Similar to our situation, manual bleeding control was applied followed by clamp application and suturing of aortic defect [ 31 ].

Baldwin et al. presented the case of intubated patient who was admitted to the tertiary center 6 h after the injury. The authors also applied drainage to the chest followed by the application of endovascular repair surgery [ 12 ]. Branco et al. showed an investigation of early trauma deaths among 25,428 cases, which was associated with a high rate at the trauma care civil hospitals. However, a decreased mortality rate was associated with the application of endo-vascular procedures, which might be considered in gunshot injury to the aorta in civil conditions [ 21 ]. The authors discussed the advantages and disadvantages of using open surgery vs. endovascular repair of gunshot aortic injuries [ 21 ]. To our best knowledge, endovascular repair has not been yet introduced in combat conditions. However, other advanced technologies such as minimally invasive surgery or hemodialysis might likely be also considered at a hospital of Role 3 or even Role 2 in the Russo-Ukrainian war, considering that this warfare is associated with unexpected challenges such as complicated evaluation of the patients to the appropriate level of medical care. However possible costs for such an equipment should be considered in Ukraine which is a country with limited medical resources as well as bad planning for medical provision [ 4 , 15 , 22 , 23 , 26 , 32 ]. Another possible alternative for the management of gunshot injury to the aorta is resuscitative endovascular balloon occlusion of the aorta (REBOA), which was presented by Northern et al. in the study of combat injury [ 33 ]. The authors showed the high utility of REBOA, which is improved damage control resuscitation (DCR) [ 33 ]. In contrast to our study, but in line with Northern et al., Campbell et al. presented a study of vascular injuries with the application of resuscitative thoracotomy, resuscitative endovascular REBOA, and whole blood emergency donor panels [ 34 ].

In line with other authors, DCR plays an important role in saving patients in the Russo-Ukrainian war [ 34 ]. The application of REBOA seems appropriate for our patients, and it might be introduced at Role 3 hospitals in Ukraine. Similar to others and based on our experience, we have applied damage control surgery and damage control resuscitation to also manage severe vascular trauma. Damage control surgery allows to achieve better results of the management at Role 2 hospital as well as to prepare the patient for the management at the higher level of medical care (Role 3 and 4 hospitals) [ 16 , 20 , 30 , 35 , 36 , 37 , 38 ]. As we have shown previously, the application of the surgical magnetic tool (designed and manufactured in Ukraine) is associated with the distinct removal of metal fragments in patients with gunshot injuries [ 17 , 18 , 22 , 26 ]. Similar to others and based on our experience, we have applied surgical magnets to treat the patient due to their high effectiveness in removing ferromagnetic shells [ 18 , 22 ]. In line with Jaha et al., we also conducted a revisions (second, third, fourth looks) surgery and observed hematoma in the area of aorta injury [ 39 ]. However, in contrast to that study, we used a surgical magnetic tool to remove the projectile. Our results show the utility of surgical magnetic tool application to significantly minimize surgical trauma and shorten the time of surgical intervention.

Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies allows for minimized operative trauma and reduces the time of identification of the foreign body.

Data availability

No datasets were generated or analysed during the current study.

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Igor Lurin, Maksym Gorobeiko & Andrii Dinets

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Department of Thoraco-Abdominal Surgery, Military Medical Teaching Center of the Northern Region of Ministry of Defense of Ukraine, Kharkiv, Ukraine

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Eduard Khoroshun, Vitalii Makarov, Volodymyr Negoduiko & Serhii Shypilov

Department of Healthcare, Faculty of Postgraduate Education, Kyiv Agrarian University, Kyiv, Ukraine

Maksym Gorobeiko & Andrii Dinets

Department of Surgery, Lancet Clinic and Lab, Kyiv, Ukraine

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IL – designed the study, drafted manuscript, literature search, and analyses. EK - study conception and design, collected the data; VM – study conception and design, collected the data; VN – designed the study, acquisition of data, drafted manuscript, literature search, and analyses; SS – study conception and design, collected the data, preparation of figures; YB – drafted the manuscript; MG – literature search and analyses; AD – analysis, and interpretation of data, critical revision and supervision; final approval, submission of the manuscript. All authors read and approved the final manuscript.

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Lurin, I., Khoroshun, E., Makarov, V. et al. Management of gunshot injury to the abdominal aorta and inferior vena cava: a case report of a combat patient wounded in the Russo-Ukrainian war. Int J Emerg Med 17 , 113 (2024). https://doi.org/10.1186/s12245-024-00690-6

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Received : 29 May 2024

Accepted : 26 August 2024

Published : 05 September 2024

DOI : https://doi.org/10.1186/s12245-024-00690-6

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