VCU DEATH AND COMPLICATIONS CONFERENCE Complication Necrosis Procedure of ileostomy Parastomal hernia repair, revision of ileostomy Primary Diagnosis Crohn’s colitis, parastomal hernia Clinical History 43yo F h/o Crohn’s colitis s/p total.
Download ReportTranscript VCU DEATH AND COMPLICATIONS CONFERENCE Complication Necrosis Procedure of ileostomy Parastomal hernia repair, revision of ileostomy Primary Diagnosis Crohn’s colitis, parastomal hernia Clinical History 43yo F h/o Crohn’s colitis s/p total.
VCU DEATH AND COMPLICATIONS CONFERENCE Complication Necrosis Procedure of ileostomy Parastomal hernia repair, revision of ileostomy Primary Diagnosis Crohn’s colitis, parastomal hernia Clinical History 43yo F h/o Crohn’s colitis s/p total proctocolectomy with end ileostomy at OSH in 2002 Subsequently hernia developed a very large parastomal Clinical History PMH Crohn’s colitis Pyoderma gangrenosum HTN Morbid obesity Depression PSH: Total proctocolectomy with end ileostomy 2002 Lap gastric band Medications Cellcept Humira Prednisone 20mg every other day Lisinopril HCTZ Celexa Allergies PCN Clinical History Clinical History 5/31 Repair of parastomal hernia with Proceed mesh underlay Revision of ileostomy, relocation to left side of abdomen POD 1-3 Hypotension, fluid resuscitation, persistently low UOP, ARF Steroid taper started POD 3 Required CVVH and 2 episodes of intermittent HD Improvement in UOP and creatinine returned to normal POD 7-13 Resolving ileus, tolerating diet Ileostomy noted to be dark, but productive Clinical History POD 7-13 Resolving ileus, tolerating diet Ileostomy noted to be dark, but productive POD 15 Pt c/o new pain at ostomy site and left flank Ostomy noted to have lateral muco-cutaneous separation WBC 15 POD 16 New erythema along left flank WBC 32 Taken to OR for re-exploration, found to have perforation of ileostomy at level of the fascia, 10cm of distal ileum resected, ileostomy moved to midline, necrotic soft tissue debrided Analysis of Complication • Was the complication potentially avoidable? – • Would avoiding the complication change the outcome for the patient? – • Yes, hypotension could have been avoided with perioperative steroid administration to prevent adrenal insufficiency Yes, avoidance of ARF, necrosis of ostomy, reoperation What factors contributed the complication? • Hypotension, lack of perioperative steroid administration, pt’s body habitus to a lesser extent Steroids and Adrenal Insufficiency Approximately 34 million prescriptions written for steroids every year Fraser, et al 1952 First described a steroid-dependent pt who died of intractable hypotension postoperatively after orthopedic procedure Since then, stress doses of steroids have become a regular part of perioperative management. Chronic steroid use suppresses the hypothalamic-pituitary-adrenal axis Pts unable to mount appropriate response to stress of a surgical procedure Most severe result is hypotension and cardiovascular collapse Recommended stress dose 100mg hydrocortisone perioperatively, followed by… 50mg hydrocortisone x 24 hours then taper dose by ½ per day until maintenance dose is reached Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12) Review of 2 RCTs and 7 cohort studies 315 patients undergoing 389 procedures Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12) In 2 RCTs (37 pts) No difference in hemodynamic profile between pts receiving stress doses of steroids compared to pts receiving only their usual daily dose 7 cohort studies (278 pts) Pts that continued to receive usual daily dose of steroid without addition of stress dose No pts developed unexplained hypotension Pts who had steroids stopped 36-48 hours prior to surgery 2 pts developed unexplained hypotension Both responded to administration of hydrocortisone and fluids Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12) Conclusion Suggests that in pts receiving long-term corticosteroid therapy, stress doses of steroids are not required However, pts should still continue to receive their usual daily dose Small sample size