Toxic Megacolon in Crohn’s Colitis
Savio George Barreto, Shailesh V. Shrikhande in Dilemmas in Abdominal Surgery, 2020
Toxic megacolon is a condition traditionally characterized by gross colonic distension in the setting of severe colitis culminating in septic shock. In the acute scenario, biopsies from flexible sigmoidoscopy often cannot distinguish between ulcerative colitis or Crohn's disease. Surgery remains the mainstay of managing toxic megacolon due to inflammatory bowel disease and is often a life-saving procedure. The initial management of a patient with suspected toxic megacolon begins with securing the airway, providing supplemental oxygen, assessing the hemodynamic stability and cognitive state. An erect chest X-ray, with the inclusion of both domes of the diaphragm, is warranted to confirm the same before proceeding to emergency surgery. The findings of erythema, granularity, loss of submucosal vessels with deep ulceration, and spontaneous bleeding with contact or air insufflation often portends the risk for surgery. Tertiary centers often have a subspecialist colorectal surgical unit that must be involved early, should the need for surgery arise from failed medical management.
Critical care and emergency surgery
Stephen Brennan in FRCS General Surgery Viva Topics and Revision Notes, 2017
Diagnostic laparoscopy is safe and effective when used in pregnancy. Several studies have shown that pregnant patients may undergo laparoscopic surgery safely during any trimester without any appreciated increased risk to the mother or foetus. Systemic inflammatory response syndrome differs from sepsis in that sepsis is SIRS with a documented infection. Septic shock is sepsis with refractory arterial hypotension and/or need for inotropes despite adequate fluid resuscitation. The physiological changes occurring in patients with severe sepsis and septic shock are myriad and include changes that are clearly detrimental such as decreased contractility of the left and right ventricle, increased venous capacitance, increased pulmonary vascular resistance, and capillary leak. A damage control laparotomy (DCL) is a laparotomy performed usually for trauma where the primary aim is to control haemorrhage and limit sepsis in the first instance. The central nervous system degeneration, trauma, or neoplasms may affect the hypothalamic regulatory centre.
Urology
Kelvin Yan in Surgical and Anaesthetic Instruments for OSCEs, 2021
Common investigative indications include urinary sample collection for microscopy, culture and sensitivity, and active monitoring of urine output in cases such as active bleeding and septic shock. Common therapeutic indications include acute urinary retention such as prostatism and chronic neurogenic bladder for intermittent decompression. Blood found at the urethral meatus, scrotal haematoma or a high-riding prostate should all raise alarm about a possible urethral tear. A retrograde urethrography should be performed in such cases to rule out any urethral injury. Common immediate complications include pain, trauma and failure of the procedure. Early complications include persistent pain and infection. Later complications may involve retrograde migration of bacteriuria leading to pyelonephritis, renal scarring and possible urethral strictures. The telescope comes with varying degrees of freedom to allow for optimised visualisation of different structures depending on anatomical locations. To minimise trauma, it is generally advised to start with the smallest cystoscope without compromise to visualisation.
Plasma levels of F-actin and F:G-actin ratio as potential new biomarkers in patients with septic shock
Published in Biomarkers, 2016
Justin B. Belsky, Daniel C. Morris, Ralph Bouchebl, Michael R. Filbin, Kevin R. Bobbitt, Anja K. Jaehne, Emanuel P. Rivers
Objective: To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shock, noninfectious systemic inflammatory response syndrome (SIRS) and healthy controls. Results: F-actin was significantly elevated in septic shock as compared with noninfectious SIRS and healthy controls. G-actin levels were greatest in the noninfectious SIRS group but significantly elevated in septic shock as compared with healthy controls. TB4 was not detectable in the septic shock or noninfectious SIRS group above the assay’s lowest detection range (78 ng/ml). Conclusions: F-actin is significantly elevated in patients with septic shock as compared with noninfectious SIRS. F-actin and the F:G-actin ratio are potential biomarkers for the diagnosis of septic shock.
Soluble TREM-1 as a diagnostic and prognostic biomarker in patients with septic shock: an observational clinical study
Published in Biomarkers, 2017
Thorsten Brenner, Florian Uhle, Thomas Fleming, Matthias Wieland, Thomas Schmoch, Felix Schmitt, Karsten Schmidt, Aleksandar R. Zivkovic, Thomas Bruckner, Markus A. Weigand, Stefan Hofer
Objectives: The impact of TREM-1-mediated inflammation was investigated in different inflammatory settings. Methods: Secondary analyses of an observational clinical pilot study, including 60 patients with septic shock, 30 postoperative controls and 30 healthy volunteers. Results: Plasma levels of sTREM-1 were found to identify patients with septic shock more effectively than procalcitonin and C-reactive protein. Moreover, sTREM-1 was identified to be an early predictor for survival in patients with septic shock. Conclusion: Due to its diagnostic as well as prognostic value in sepsis syndrome, implementation of sTREM-1 measurements in routine diagnostics should be taken into account.
Pharmacokinetics of anidulafungin in two critically ill patients with septic shock undergoing CVVH
Published in Journal of Chemotherapy, 2013
Francesco G. De Rosa, Silvia Corcione, Lorena Baietto, Daniela Pasero, Giovanni Di Perri, V. Marco Ranieri, Antonio D’Avolio
Candidemia is associated with high mortality rate especially in critically ill (ICU) patients with septic shock and echinocandins such as anidulafungin are recommended as first-line treatment. Available pharmacokinetic studies of anidulafungin in healthy volunteers and in patients with renal or hepatic impairment showed that no dose adjustment is needed even in patients receiving standard intermittent haemodialysis. However, few data are available with continuous veno-venous haemofiltration (CVVH). In this study, the pharmacokinetic of anidulafungin was studied in two ICU patients with candidemia and septic shock undergoing CVVH. Both patients had satisfactory parameters of Cmax (9·04 and 5·68 mg/l, respectively), area under the curve (AUC) (95·18 and 67·48 mg/l h) and Cmin (2·61 and 1·43 mg/l). AUC/MIC ratio and Cmax/MIC values were: 11887 and 8435; 1130·25 and 710, for patients 1 and 2, respectively. Our data confirm that in patients with septic shock anidulafungin presents only mild pharmacokinetic changes compared to data reported during CVVH alone.