The initial in \202 ammatory stage lasts usually only for a few days. Blood vessels are co nstricted to minimize loss of blood; platelets and thromboplastin attend the affected area in an effort to form a clot. White cells then enter the area to clear it of organisms and d ebris. This process gen- erates heat and redness which can be seen and felt at the wound si te. Depending on the severity of the pressure sore, the next stage of proliferation lasts f or 3 weeks. Fibroblasts attend the area to make collagen. Collagen \200\230 \201 lls \200\231 in the wound and is assisted signi \201 cantly by the forma- tion of new blood ve ssels. The \201 nal stage of maturation and remodeling is the most protracted. It can tak e up to 2yrs to complete. A new form of collagen arrives and attempts to re-mold and streng then the wound site. Scar tissue develops which although visibly appears stronger is, in fa ct, only 75% as strong as normal tissue. There is a particular problem associated with chro nic wounds in that the scar tissue cells can become unrespon- sive to growth markers and cy tokines, thereby prolonging the above stages and delaying healing considerably. Frequent assessment and documentation of the pressure sore using this scale is mandatory in order to track wound progress. A pressure sore can be likened to an iceberg in that despit e the appearance of slight skin damage on the skin surface, the dermis and epidermis may ha ve considerable damage. Any area of redness is a cause for concern. Pressure sores can deve lop as a result of the use of equipment. Pressure sores developing on the bridge of patient \200\231s noses from CPAP masks is not uncommon, and have been the subject of successful l itigation. Ventilator tubing, abandoned ven \202 on bungs, drip and drain tubing, ECG dots and monitor wiring serve as other examples. Wound treatment ICU patients seem particularly vulnerable to developing pressure sores on t heir heels. If a pressure sore develops it will require treatment. Wound treatments exist t hat range from wound cleaning to surgical debridement. Grade 1 pressure sores seldom requir e pharmaceutical or surgical treatment, but for the other grades an expanse of creams, gels , pads, dressings and devices exist. Treatment is largely governed by the nature, location and type of pres- sure sore. In general: \200 Conclusion The following serve as an aide memoir to the successful management of pressure s ores: \200 \200 Do not use sheep skins, they do not work Do not leave pressure sores to nursing staff; you have a part to play Inspect skin areas frequently, particularly the sacrum and the heels. D ocument, and if necessary photograph, any pressure sores Ensure regular reviews of the pati ent \200\231s risk factors are performed Regularly inspect any pressure sores that develop Treat pressure sores appropriately; quality advice can be obtained from your local Tissue V iability Nurse. Dressings should not \200\230dry \200\231 the wound but maintain a moist environment. Do n ot use systemic antibiotics in an attempt to eradi- cate bacteria within the wound. Frequen t removal of dressings could disturb the wound- healing process \200\230Hard \200\231 dres sings or pads should not be used as they can exacerbate pressure. Handwashing and other inf ection control measures must be adopted to prevent wound contamination or bacte- rial sprea d. Dressings should remain in place as in accordance with the manufacturer \200\231s recomm endations. \200 Further reading Theaker C, Mannan M, Ives N, et al. Risk factors for pressure sores in the critically ill. Anesthesia 2000; 55: 221 \200\2234. A large \200\230custom and practice \200\231 culture exists around the treatment of pressu re sores. Expert advice from a tissue This page intentionally left blank 507 Chapter 30 Pain and post-operative intensive care Chapter contents Pain management in ICU 508 Intensive care for the high risk surgical patie nt 510 The acute surgical abdomen in the ITU 512 The medical patient with surgical problems 514 508 CS WALDMANN Pain management in ICU Introduction Relief from pain is not only indicated on humanitarian and ethical grounds alo ne, but has medical and possibly cost bene \201 ts. and their stay on ICU. In order to minimize this time, daily sedation holding is now a feat ure of the \200\230ventilator \200\231 bundle of care. The use of early percutaneous trach eostomy may also be a means of reducing weaning times. Before resorting to hypnotic-based r egimes for sedation, it is important that the patient is assessed regularly for pain and ad equately treated. Patients \200\231 requirements for strong anal- gesic drugs may be modi \201 ed or reduced by attention to: \200 \200 \200 \200 \200 Terminology \200 Oxford dictionary \200\224sensation of physical suffering or acute discomfort The Internati onal Association for the Study of Pain 1986 \200\224 an unpleasant sensory and emotional ex perience associ- ated with actual or potential tissue damage or described in terms of such damage Neuropathic pain \200\224seen in patients in the ICU due to nerve damage, herpes zos ter, GBS; does not respond to conventional analgesics but may require combinations of drugs such as amitryptylline, carbemazepine, sodium val- proate, gabapentin and ketamine. Reduce noise levels Change pulse oximeter \201 nger regularly Reduce \202 atulence, nau sea Immobilize fractures Establish sleep pattern Despite ICU staff believing that pain is adequately treated, many studies have shown that a t least 50% of ICU patients experienced moderate or severe pain during their ICU stay, and the CoBATRICE patient and relatives survey dem- onstrated that 76% of responders expected i ntensive care staff to do everything to control pain. The use of analgesia-based sedation w as described by Lane et al. in 2002, and has been responsible for a trend in the reduction of hypnotic-based regimes. There are concerns with hypnotic-based regimes particularly sinc e 1984 when it was discovered that etomidate was associated with ade- nal gland suppression and increased mortality in trauma patients. However, it is only recently in 2005 that the con- tinued use of etomidate has been questioned. There is literature to demonstrate that p ropofol in chil- dren and in adults with head injury can be associated with an excess morta lity. Causes of pain in ICU patients \200 \200 \200 \200 \200 \200 Post-surgery Trauma Organ dysfunction: gut ischaemia, DVT, cardiac Treatment: procedures on ICU, change of dressings Pre-existing pain: vascular, neuropathic, rheumatoid Pain of term inal disease. Adverse effects of pain \200 Respiratory: atelectasis \200 Cardiovascular: stress, MI \200 Gut: ileus, nausea, vomiting \200 Genitourinary: retention, agitation \200 Endocr ine: increased ADH, water retention \200 Hematological: venous stasis, DVT \200 Musculo skeletal: immobility, critical illness polyneuropa- thy and myopathy, pulse oximeter probe Neuropsychological: decreased sleep, agitation, delirium, post-traumatic stress disorder. Guidelines The Fundamentals of the Critical Care Support (FCCS) manual outlines the use of drugs such as lorazepam, mor- phine and fentanyl for analgesia and sedation, and empha- siz es the importance of not using these drugs as a method of restraint by staff (Federal Regul ation 42 CFR 482.13), but points out that where it is thought that pain is the cause of agi tation, then analgesia would be the appropriate initial therapy. The Intensive Care Society Guidelines state that: \200 All patients must be comfortable and painfree \200 Anxiety should be minimized \200 Patients sould be calm, cooperative and able to sleep \200 Pa tients should tolerate organ system support and be able to synchronize with ventilator Pati ents must not be paralyzed and awake Assessment of pain in ICU \200 \200 \200 Dif \201 cult if patient cannot communicate If in doubt assume they are in pain Use surrog ate markers such as stress response, but this will be affected by -blockers and inotropes , and anti- cholinergics. Balanced sedation in the ICU Traditionally, sedation as practiced in UK, European and US IC Us has been based on hypnotic regimes. However, as intubated patients on ICU are unable alw ays to communi- cate, it may be that they would bene \201 t from an analgesic- based regim e if pain is a feature of their disease and management whilst in ICU. There is an assumptio n amongst doctors, nurses and relatives that it is probably best that patients remember rel atively little of their ICU stay, hence the widespread use of hypnotic regimes. However, wh en patients are recovering from critical illness, the absence of memory of events in ICU ma y lead to lack of understand- ing of why they are exhausted and psychologically dis- turbed during their rehabilitation phase. The emphasis these days is on trying to ensure adequate analgesia in order to ensure comfort and reduce the need for hypnotic drugs which may prol ong the patient \200\231s time spent ventilated Thus both US and UK societies say the same thing, i.e. that analgesia and comfort must be t he \201 rst aim of sedating patients in intensive care. Methods of pain relief in ICU Non-steroidal anti-in \202 ammatory drugs (NSAIDs) In view o f important and frequent side effects, it seems prudent to avoid this class in the critical ly ill in the absence of any de \201 nite gain to be had. Paracetomol Now that it is available as an IV infusion 10mg/ml, this is becoming a popular choice for analgesia in intensive care practice. 509 CHAPTER 30.1 Pain management in ICU date demonstrate that with a remifentanil-based sedative regime patients can be extubated m ore quickly and leave ICU when compared with conventional regimes. Cost- benefit analyzes t o date make analgosedation with a remifentanil regime an attractive proposition. Epidural Epidural pain relief is especially useful for post-operative surgical management a nd for \200\230 \202 ail \200\231 chest injuries, but ideally patients need to be coopera tive as there is controversy about the safe placement of epidural catheters in sedated pati ents and there are concerns about catheter placement in the presence of coagulopathy and se psis. Summary \200 \200 \200 \200 \200 Opioids the most common method for analgesia Hypnotics associated with many unwanted effect s Remember neuropathic pain Involve pain team if complicated. Regional techniques can impro ve outcome in high risk surgical patients Avoid NSAIDs Remifentanil shows promise and wides pread use already in Neuro and Cardiac ICU Acupuncture, aromatherapy These and other alternative methods may have a role. Opioid analgesic drugs These remain the mainstay of analgesia in the ICU. The minimum effec tive analgesic concentration for each patient will vary widely. In the frequent presence of organ dysfunc- tion, pharmacokinetic considerations play the most impor- tant role in the choice of agent. \200 The ideal agent This has the following properties: \200 \200 \200 \200 \200 \200 \200 \200 \200 Further reading Annane D. ICU Physicians should abandon the use of etomidate! rapid onset predictable no active metabolites wears off quickly no cardiorespiratory depres sion no nausea, vomiting not addictive, no tolerance not affected by renal or hepatic disea se wide therapeutic index Intensive Care Med 2005: 31: 325 \200\2236. Bakker J, Mulder P. Remifentanil shortens duration of mechanical ventilation and ICU stay. Intensive Care Med 2006; 32(Suppl 13): S86. Cohen A. http://www.ics.ac.uk/downloads/Sedation. pdf 2001 Cremer O, Moons K, Bouman E, et al. Long-term propofol infusion and cardiac failure in adul t head-injured patients. Lancet 2001; 357: 117 \200\2238. Jacobi J, Fraser GL, Coursin DB, et al; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Healt h- System Pharmacists (ASHP), American College of Chest Physicians. Clinical practice guide lines for the sustained use of sedatives and analgesics in the critically ill adult. Crit C are Med 2002; 30: 119 \200\22341. Remifentanil This opioid has the properties above of an ideal agent, and is increasingly \201 nding a role for sedation in UK intensive care practice. Many intensivists feel that i t allows patients to be comfortable and cooperative. It has a license for use up to 72h so may not be ideal for long-stay patients. Its rapid breakdown to remifentanil acid (with onl y 1/1460 potency of remifentanil) by non-speci \201 c esterases means that it cannot accum ulate in the bloodstream; this is not the case with morphine, fentanyl or alfentanil. Studi es to Lane M, Cadman B and Park G. Sedation and analgesia in the criti- cally ill patient using r emifentanil \200\224frequently asked questions and their answers. Care Crit Ill 2002; 18: 1 46 \200\2237. Parke J, Stevens J, Rice A, Greenaway C, et al. Fatal myocardial fail- ure, metabolic acidosis. BMJ 1992; 305: 613 \200\2236. www.cobatrice.org 510 R PEARSE Intensive care for the high risk surgical patient Introduction The majority of in-patient surgical procedures culminate in a good outcome, bu t low overall surgical mortality rates (<2% in the UK) disguise the presence of an importan t subpopulation of patients at signi \201 cantly greater risk of complications and death. Up to 15% of in-patient surgical procedures may be classi \201 ed as high risk, accounting for >80% of post-operative deaths. Around 10 \200\22315% of high risk patients die followi ng surgery, and as many as 70% develop complications. The key features of the typical high risk sur- gical patient are listed in Table 30.2.1. Early identi \201 cation and optimal c are of the high risk patient may result in a substantial reduction in risk. This chapter de scribes a basic approach to the care of such patients. care should be complemented by treatment approaches which are now considered standard in th e ICU. These include appropriate antibiotic therapy, low tidal volume ventilation, restrict ive red blood cell transfusion (maintain hemoglobin \211 8g/dl), maintenance of normotherm ia and tight glycaemic control. Recent developments in intraop- erative \202 uid therapy may also offer an opportunity to improve outcome. Most high risk patients will develop some degree of circulatory dysfunction during or after sur- gery. Reduced \202 uid intake, he morrhage and insensible losses will result in a variable degree of hypovolaemia. The result ing circulatory dysfunction may be further exacer- bated by cardiac failure and sepsis. Opt imal \202 uid therapy will require careful consideration of the risks associated with bot h inadequate and excessive IV \202 uid administration. However, precise estimation of \202 uid de \201 cit may be dif \201 cult, particularly with patients undergoing GI surge ry. Fluid therapy may be more effective when measurements of car- diac output and stroke vo lume are used as end-points. In this respect, the use of oesophageal Doppler monitoring may improve outcomes following cardiac, orthopedic and abdominal surgery. Pre-operative assessment and care Although the characteristics of the high risk patient are well described, many do not receive an appropriate level of perioperative care. New approa ches to risk assessment may help to stratify patients to an appropriate level of care. An i mportant example is the increasing use of submaximal exercise testing to measure anaerobic threshold. Where this is not possible, subjective evaluation of exercise toler- ance will s till provide a useful indication of cardiorespira- tory reserve. Post-operative intensive care Close liaison with critical care unit staff is required to en sure a seamless transition into post-operative care. In the \201 rst few hours after surg ery, a strong emphasis should be placed on maintaining the balance between oxygen con- sump tion and oxygen delivery. Even brief admission to a critical care unit will allow the optim ization of analgesia, body temperature and a gradual decrease in sedation (oxy- gen consump tion factors). as well as adequate \202 uid, ino- trope and vasopressor therapy (oxygen d elivery factors). This approach may substantially decrease the risk of cardi- orespiratory failure following extubation. In some institu- tions, overnight intensive recovery units fa cilitate this approach without the expense and complexity of a full- scale ICU. Table 30.2.1 Factors associated with an increased risk of post-operative complications and death Patient factors Ischaemic heart disease Chronic obstructive pulmonary disease Diabetes Adva nced age Poor exercise tolerance Poor nutritional status Surgical factors Emergency surgery Major or complex surgery Body cavity surgery Large blood or insensible \202 uid loss Prolonged duration of surgery Post-operative ventilation Major surgery under general anesthesia will result in a signi \201 cant degree of respiratory compromise as a result of reductions in functional residual capacity which cause atel- ectasis and a reduction in minute volume. Post-operative pain m ay prevent full inspiration, preventing any correction of this process. Along with increase s in oxygen consump- Perioperative care factors Inadequate critical care facilities Insuf \201 cient patient mo nitoring Inadequate analgesia Lack of early intervention as complications develop 15 1.5 P o s t - o p e r a t i v e m o r t a l i t y ) s n o i l l i 10 1.0 m ( Many high risk patients present on an emergency basis, leaving little time to adjust basic medical treatments. However, wherever possible, medical therapies should be optimized prior to surgery, particularly in the case of COPD, asthma, hypertension, ischaemic heart diseas e and diabetes. For those patients considered to be at high risk of perioperative myocardia l ischaemia, prophylactic -block- ade may also prove bene \201 cial. e z i s n o i t a l u p o P 5 0.5 ( % ) 0 0.0 Standard High-risk Overall Size Mortality Management during surgery Critical care of the high risk patient should commence in the ope rating theater. Standard anesthetic and surgical Fig. 30.2.1 Mortality rates for standard and high risk surgical procedures in the UK. 511 CHAPTER 30.2 Intensive care for the high risk surgical patient tion due to agitation, pain or shivering, these factors will predispose the high risk patie nt to respiratory failure and pneumonia. Early extubation after surgery may ease pres- sure on critical care resources, but for high risk patients it is preferable to wean sedation a nd invasive ventilation over a period of a few hours. This approach is an effective part of the routine care of cardiac surgical patients. CPAP or NIV may also be used to maintain an d improve respiratory function in the hours after surgery. This approach can reduce the inc idence of respiratory failure and subsequent re-intubation. patient will have a number of predisposing factors for venous thromboembolism. LMWH should usually be administered on a prophylactic basis. Other aspects of treatment which may poten tially have an impact on out- come following high risk surgery include analgesia and early mobilization. Summary Post-operative complications and death are commonplace in the high risk surgical po pulation. Perioperative critical care may substantially improve both short- and long-term o utcomes for such patients. The most effective way of achieving this may be through the use of treatment proto- cols to standardize care during and immediately after sur- gery. Furthe r reading Cullinane M, Gray AJ, Hargraves CM, et al. The 2003 Report of the National Confid ential Enquiry into Peri-Operative Deaths. London: NCEPOD. 2003. Post-operative haemodynamic therapy Occult circulatory disturbances often persist after sur gery. Minimally invasive cardiac output monitoring may also be used to guide haemodynamic t herapy in the early post- operative period. This approach may be extended to include low do se inotropic agents in addition to \202 uid ther- apy. This technique, which is sometimes termed goal- directed haemodynamic therapy, improves tissue oxygen delivery, leading to a reduction in post-operative complica- tions as well as duration of hospital stay. Pearse RM, Harrison DA, James P, et al. Identi \201 cation and charac- terisation of the h igh-risk surgical population in the United Kingdom. Crit Care 2006; 10: R81. Bersten A, Soni N, Oh T. Oh \200\231s intensive care manualn 5th edn. Other important aspects of post-operative care It is often preferable to commence enteral n utrition early (within 24h of surgery) via an NG tube, provided that any contraindications have been carefully excluded. Following surgery for bowel obstruction or perforation, for e xample, a more cautious approach may be preferable because of the risk of paralytic ileus. The typical high risk surgical London: Butterworth-Heinemann. 2003. 512 S MUDAN The acute surgical abdomen in the ITU evidence of infection and abscess formation. Intervention at that time might be surgical or by radiological drainage if the collection appears to be predominantly lique \201 ed. Assessing the acute abdomen remains an art. The causes of the acute abdomen or intra-abdomi nal catastrophe are bleeds, infarctions, obstructions, leaks and in \202 ammations. Clinic al assessment is more dif \201 cult in ICU because of dis- tractions such as sedation, ven tilation or other organ sup- port. There is heavy reliance on the history, imaging, measura ble physiological parameters and, most impor- tantly, changes thereof. An intra-abdominal p roblem increases the probability of mortality as predicted by the APACHE II score, in part because of delays in obtaining surgical assessment . Early manifestations include pain and distension, and changes in measured in \202 ammatory markers, acidosis, res- piratory and renal function. A serially rising lactate in an apparently unremarkable abdomen, for exampl e, is a seri- ously worrying feature of an impending problem. These signs and symptoms are non-speci \201 c and often occur with- out associated significant intra-abdominal patholog y. Access to good quality imaging such as ultrasound is essen- tial but, with the exception of biliary system pathology, CT scan is the imaging modality of choice. Ideally the same s urgical team should re-evaluate the patient. Causation is often re \202 ected in the recen t history, such as recent abdominal surgery and the development of an intestinal leak or su rgical bleed. The medical patient is also prone to secondary events giving rise to intra-ab dominal problems, and the pattern of signs and symptoms is likely to be similar. Satisfacto ry outcome requires control of the initiating event, control of the intra-abdominal patholo gy and then management of the consequences of the systemic response to the intra-abdominal catastrophe. Leaks Peritonitis secondary to intestinal tends to present slowly and insidiously. The leak might not begin until a day or two after operation, with gradual onset of physiological di stur- bance. Drains may indicate bile or other \202 uids. Pancreatic ef \202 uent has a characteristic prune juice color and can be con \201 rmed by \202 uid amylase estimation , which in a leak is likely to be in the 10s of thousands but at least 5-fold greater than the serum amylase. A raised urea in the setting of normal cardiovascular and renal paramete rs should alert one to the possibility of a urinary leak if the surgical episode has involv ed bladder surgery. The negative predic- tive value of a drain is poor. Typical manifestati ons of sec- ondary peritonitis are likely to be unaccountable elevation in in \202 ammator y parameters such as CRP. Unexplained tachycardia and more diffuse features such as abdomin al distension and ileus may be present. Whether a leak is dealed with by re-operation or no t depends on many factors and requires early involvement of the surgical team and close ser ial assessment. As a general principle, if the leak is apparent early in the post-operative period and where it is safe to do so, re-operation is preferred to perform toilet and eith er repair the anastomosis or divert \202 ow by defunc- tioning the stoma at or proximal t o the anastomosis. However, when the leak manifests late or where repair or diversion are n ot feasible, e.g. in a leaking pancreatic or high bile duct anastomosis, then achieving a c ontrolled \201 s- tula is more appropriate. This might still require operation to perform toilet and drainage, but radiological drainage should also be considered especially for ve ry \202 uid leaks such as bile. The natural history of \201 stulae is to close unless t here is a distant obstruction, malignant or radiotherapy-treated tis- sues are involved or there is persistent local sepsis. There is some evidence that the use of octreotide to redu ce secretions might reduce the time to closure of pancreatic, biliary and small bowel \201 stulae but not the rate of closure. A substantial systemic in \202 ammatory response is often exhibited. Unless and sometimes even despite early con- trol of leakage, multi-sys tem failure supervenes and sys- tems support will be required. Attention should be paid to infection, including yeasts, BMS and nutrition. Enteral feed- ing is usually possible in mo st cases, even in upper GI tract problems. Care of the skin is essential in these patients as the \201 stula contents are corrosive. Colorectal anastomoses represent an area of pot ential concern. Some surgeons prefer to \200\230defunction \200\231 their vul- nerable ana stomoses such as after low rectal surgery. Then, even if there is a leak, a clinically thre atening situation should not ensue. Signs and symptoms of an intraperito- neal leak from a colorectal anastomosis are likely to be fever and rise in in \202 ammatory markers. There may be uri- nary frequency and diarrhea. Depending on the extent of contamination, there ma y be little in the way of abdominal signs until the collection is substantial. Suspicion an d early evaluation are essential. CT scan will be required and, if the leak is detected ear ly after operation, the surgeon might consider re-operation and lavage and drainage, or div ersion by defunctioning the stoma or conversion to end stoma. Complications of abdominal surgery Post-operative hemorrhage and intestinal leaks are the m ost common complications following abdominal surgery. Hemorrhage Distension and a precipitous fall in the hemoglobin and haematocrit. Fluid repla cement, drugs and epidural analge- sia may confuse the picture, and substantial blood loss can occur before being recognized. Drainage tubes should never be relied upon as a negative indicator for blood loss. Blood in the peritoneal space and especially in the retro- perit oneum gives rise to pain and ileus. If bleeding is con- tinuing, urgent surgical action to control the source or, if non-speci \201 c, such as following major retroperitoneal or pel vic resection, then packing of cavities and possibly the use of clotting factors locally an d systemically might be required. Radiological embolization is rarely appropriate. For pers istent or unusual bleeding response, a search should be made for inherited disorders of coa gulation such as von Willebrand disease, and so on. If bleeding stops spontanously A small amount of intra-abdominal blood will cause a tran- s ient peritonitis and prolongation of the post-operative ileus. Intra-abdominal haematoma pr edisposes to infection, especially if there has been contamination with intestinal contents . If ultrasound or CT demonstrate substantial hae- matoma, early evacuation is preferable, but radiological drainage of haematoma is usually fruitless as the clot is too thick to pas s through even the largest radiological drain. A smaller haematoma might be observed and fo llowed for 513 CHAPTER 30.3 The acute surgical abdomen in the ITU Further reading Crandall M, West MA. Evaluation of the abdomen in the critically ill patien t: opening the black box. Curr Opin Crit Care 2006; 12: 333 \200\2239. Evenson AR, Fischer JE. Evenson AR, et al. Current management of Leaks discovered later, after 7 days, are more problematic as the hazards of re-operation are high, and in this setting drainage through the rectum or percutaneously might rep- rese nt the best option. Previously, secondary sepsis from intestinal perforation or anastomotic failure was often managed by serial re-laparot- omy and surgical toilet every 2 or 3 days, but more recently the trend is for re-laparotomy on demand, only if there is evidence of s urgically amenable collection or deterioration in general condition. enterocutaneous \201 stula. J Gastrointest Surg 2006; 10: 455 \200\22364. Frileux P, Attal E, Sarkis R, et al. Anastomic dehiscence and severe peritonitis. Infection 1999; 27: 67 \200\22370. Fujii Y, Shimada H, Endo I, et al. Management of massive arterial hemorrhage after pancreat obiliary surgery: does embolotherapy contribute to successful outcome? J Gastrointest Surg 2007; 11: 432 \200\2238. Hutchins RR, Gunning MP, Lucas DN, et al. Relaparotomy for sus- pected intraperitoneal seps is after abdominal surgery. World J Surg 2004; 28: 137 \200\22341. Summary In summary, where a GI anastomosis has been carried out, and the patient appears no t to be progressing as expected, has excessive \202 uid requirement, tachycardia or fever and unexplained or rising lactic acidosis, always suspect a leak until proven otherwise. F ailure to show anastomotic con- tents leakage in the drains is not suf \201 cient to rule out a leak. The patient should be considered for re-operation. Gaining control of the leak by exteriorization through drains or a diverting stoma is essential. Routine re-laparot- om y is not advocated, but rather is a selective approach. Careful attention to all aspects an d especially nutrition is key to the successful management of these patients. Lamme B, Boermeester MA, Belt EJ, et al. Mortality and morbidity of planned relaparotomy ve rsus relaparotomy on demand for secondary peritonitis. Br J Surg 2004; 91: 1046 \200\22354. van Ruler O, Lamme B, Gouma DJ, et al. Variables associated with positive \201 ndings at relaparotomy in patients with secondary peri- tonitis. Crit Care Med 2007; 35: 468 \200\223 76. 514 S MUDAN The medical patient with surgical problems mentation should be avoided as it may cause bacteraemia, hemorrhage or perforation. CT exam ination is most help- ful in the diagnosis, and shows large bowel dilatation, bowel wall th ickening and sometimes pneumotosis. Any part of the colon can be involved, but more typical ly the right colon and terminal ileum. Treatment is supportive with \202 u- ids and antib iosis, and surgery is rarely helpful. Early intro- duction of G-CSF to hasten haemopoietic cell recovery can be helpful. The patient may progress slowly to a palpa- ble mass, but som etimes rapidly to a picture of sepsis and MOF. The differential diagnosis in these patients is usually between Clostridium dif \201 cile and CMV colitis. Rare causes of abdominal pa in such as porphyria cause great diagnostic dif \201 culty, and the nature of the disease is such that occasionally these will surface on the ITU per- haps masquerading as an acute epileptic \201 t. Spontaneous retroperitoneal haematoma in the anticoagu- lated patient i s a rare but potentially life-threatening event for the patient in the ITU. The initial eve nt is a fall in the hemoglobin, but compartment syndrome caused by the expansion of the hae matoma and complications thereof require radiological evaluation and sometimes interven- ti on. Radiological drainage is likely not to be effective, and open retroperitoneal drainage might be required. However, this tends to be a high morbidity procedure and potentially con taminates a sterile \201 eld, resulting in retroperitoneal abscess formation. In medical patients the incidence of a GI problem compli- cating an ITU admission is though t to be between 1 and 7%. This also applies to patients admitted following a non- abdominal major operation such as cardiac bypass or neu- rological surgery. The mortality hazard pre dicted by the admission severity risk scores is increased, and an abdomi- nal complication is a substantial contributor to ITU mortal- ity. Delays in diagnosis and surgical referral contribute to a deleterious outcome. High clinical suspicion and early reporting of abdomin al signs or unaccountable deteriora- tion in physiological parameters are fundamental to ma n- agement of the critically ill patient in the ITU. The background reason for admission, e .g. diabetic compli- cation, respiratory failure, cardiovascular disease or treat- ment-rel ated neutropenia, may determine the type of surgical problem that follows. Complications in clude GI bleed, perforation, cholecystitis, pancreatitis and intestinal ischaemia, the mort ality for the latter being close to 100%. Severe metabolic derangement such as uraemia and use of mechanical ventiliation and pressors quickly lead to erosive changes in the intestin al and gastric mucosa. Such patients are especially prone to GI hemorrhage and should have pharmacological prophylaxis. The bleeding is likely to be upper GI rather than lower GI, wi th a 2:1 ratio. Fresh red blood or blood clots passed rectally can be either a lower GI tra ct bleed or a brisk upper GI tract bleed. Melaena can only come from the upper GI tract (pr oximal to the liga- ment of Treitz) where the blood has been exposed to enzymic and acid ac tion. The patient should be resusci- tated, commenced on acid blockade and an upper GI endo scopy carried out. Bleeding from a gastric or duode- nal ulcer may be seen and treated via the endoscope by injection. A more \202 orid picture of a bleeding pan-gastritis is somet imes seen in the uraemic patient, and no local ther- apy is effective. For bleeding lesions not controlled by endoscopic means, the alternatives lie with surgery or with radiological embolization. The extensive blood supply of the stomach sometimes makes control of gastric bleeding by radiological embolization dif \201 cult. More dif \201 cult diag- noses such as gastro-oesophageal varices or a DieuLafoy abnormality obviously require the appropriate specialist input, as will unexpected \201 ndings such as a clinically occult cancer. Ble eding from the small intestine is very dif \201 cult to diagnose, and radiology by either CT or visceral angiogra- phy is often helpful here if it is active bleeding. Low volume ble eding might require deployment of wireless capsule endoscopy. Diverticular disease and the colitides cause bleeding from the colon, and the former usually presents with a substantial bleed of fresh blood that usually settles and does not re-bleed. Pancolitis tends to have a picture of small amounts of blood clot mixed with mucus, and is more dif \201 cult to se ttle. Colonoscopy should be considered and surgery for colectomy might be required. Neutrop enic colitis, a syndrome of non-speci \201 c nausea, abdominal swelling and pain, is seen 7 days after adminis- tration of cytotoxic chemotherapy. Bleeding is not a fea- ture. Feve r may be absent and blood count shows leucopenia and a neutrophil count typically below 1.5 \227 109/l. This problem is seen in patients having high dose chemotherapy such as for he matological malignancy, and is less common in chemotherapy for solid tumors. The chemistry shows a rising lactate and, in severe cases, liver and renal dysfunction. The colon is very soft, and instru- Obstructions Acute colonic pseudo-obstruction (Ogilvie \200\231s syndrome) is seen in the c hronically hospitalized or seriously ill patient. Spinal surgery and retroperitoneal bleedi ng or other space- occupying lesions are recognized causes. The syndrome consists of massiv e colonic dilatation in the absence of a mechanical obstruction, and is probably due to aut onomic failure. The abdomen is distended and bowel sounds are tinkling. Imaging shows a mas sive dilatation of the colon with preservation of haustral markings and a thin wall, in con tra- distinction from dilatation of colitis. Unprepared enema with gastrograffin should be carried out to rule out a mechanical problem and is on its own sometimes therapeu- tic in r elieving the problem. Ischaemia or spontaneous per- forations occur in 3% of cases, and in these the mortality is 40%. Other causes of non-obstructed colonic dilatation such as C. dif \201 cile or CMV-related colitis should be excluded. Initial treatment consists of cor rection of electrolyte abnor- malities, nasogastric aspiration and prokinetic therapy with erythromycin or sometimes neostigmine. Serial plain AXR is used to follow the patient, and a failure to settle on con- servative therapies requires intervention; the patient should h ave decompression by colonoscopy. Repeat colonoscopy is required in some patients. Caecal d ilatation of >10cm car- ries a risk of perforation, and surgery might be required if decomp ressive colonoscopy has failed. True mechanical obstructions in the ITU patient are not com mon. Previously undetected pathology such as a bowel tumor or complications of existing dis ease such as diver- ticulitis or intestinal adhesions are the common causes. In the elderly patient, one should be aware of incarceration of hernia, and the groin and surgical wounds should be inspected carefully. After initial conservative treatment, the solution usually lies with surgical intervention, the exact nature of which 515 CHAPTER 30.4 The medical patient with surgical problems will depend on the site of obstruction. The more recent advent of colonic stents can avoid operation in some colon obstructions involving the left colon, but are more dif \201 cult to place in the more proximal colon. De \201 nitive surgical solution is usually required at some time. air can be seen in the gallbladder. Surgery is always required to salvage the situation.