History

病史Enterotomy

4

days

ago(foreign

body)四年前因異物做腸切開術(shù)A

bit

lethargic

since有些嗜睡Physical

examination

體檢T=39.3°CGrossly

normal

abdominalpalpation

(no

pain)大體腹部觸診（無痛）Investigations檢查Bloods血27,000

WBC/mm3PCV=32%Glucose=173

mg/dlAlbumin=2.3

g/dlInvestigationsInvestigationsraysP

operito

氣腹No

obvious

effusion無積液Loss

of

serosal

detail

無漿膜細(xì)節(jié)InvestigationUltrasoundB超Ileus梗阻Little

effusion少量滲出What

to

think

about...考慮是什么?氣腹P

operitoEffusion?滲出Ileus?梗阻What

next?下一步？Samplethe

effusion!滲出樣本！Abdominocentesis腹腔穿刺Diagnostic

Peritoneal

Lavage性腹腔Abdominal

effusion腹腔滲出11,000

cells/μl33

g/l

total

proteins總蛋白Glucose=128

mg/dl葡萄糖Classification

ofeffusions滲出分類滲出液改變的滲出液洗出液總蛋白細(xì)胞計(jì)數(shù)Effusion

cellularity滲出液細(xì)胞質(zhì)Nucleated

cells成核細(xì)胞>13,000

cells/μl86%

sensitive

86％敏感100%

specific

for

septic

effusion對(duì)于化膿性滲出有100％特異性100%

sensitive100％敏感性100%

specific

for

septic

effusion對(duì)于化膿性滲出有100％特異性Bonczynski

et

al.

Vet

Surg

2003Effusion

glucose滲出液糖含量Blood-to-effusion血-to-滲出液difference

in

glucose

>

0.20g/l糖含量不同>0.2g/l100%sensitive100%敏感100%

specific

for

septic

effusion化膿性滲出有100％特異性86%sensitive86％敏感100%

specific

for

septic

effusion化膿性滲出有100％特異性Bonczynski

et

al.

Vet

Surg

2003Definitive

diagnosis

確診Septic

peritonitis化膿性腹膜炎Treatment治療Treat

the

patient,not

just

its

abdomen!治療病患，不僅僅是他的腹腔！Patient

optimisation改善病患Perioperative

goals手術(shù)期目標(biāo)–Albumin>

20

g/l–PCV

>

25%Patient

optimisation改善病患Septic

shock

(distributive)化膿性休克Fluid

therapy(colloids)液體治療（膠體）O2

supplementation,

O2

carrying

capacity吸氧，O2攜帶能力IV

antibiotics

(Gram+,

Gram-,

anaerobes)Escherichia

coli,

Bacteroides

fragilis靜脈抗生素gesia鎮(zhèn)痛Steroids?No!不能用激素！Patient

optimisation改善病患No

overt

shock無明顯休克HEA

5ml/kgCefazolin

(20mg/kg

IV

q8h)頭孢唑林Metronidazole

(10-15

mg/kg

q12h)甲硝唑Methadone

(0.2

mg/kg

q6-8h)Caprofen

(4mg/kg

q24h)卡布酚Treatment

fundamentals

治療原理Control

the

source控制病原Repair

the

damage修復(fù)損傷Control

the

source控制病原Explorative

coeliotomy開腹探查Repair

the

damage修復(fù)損傷Peritoneal

lavage腹腔Peritoneal

lavage腹腔Peritoneal

lavage腹腔Purported

benefits優(yōu)點(diǎn)Mechanical

removal

of

necrotic

tissue,debris

and

chemicals機(jī)械移除壞死組織，碎片和化學(xué)物質(zhì)Dilution

of

bacteria

and

endotoxin稀釋細(xì)菌和內(nèi)毒素(Warming

the

patient)升高動(dòng)物體溫To

close

ornot

to

close?閉合還是不閉合？To

close

or

not

to

close?Options:選項(xiàng)Primary

closure基本閉合Planned

re-exploration計(jì)劃再次探查Abdominal

drainage腹腔Open

peritoneal

drainage開放式To

close

or

not

to

close?Choice

depends

on

case

&

resources選擇取決于病例&資源Primary

closure基本閉合Re‐exploration二次探查/Closed

drainage閉合Open

peritonealdrainage開放Risk風(fēng)險(xiǎn)DrainageOpen

peritoneal

drainage腹腔開放Successive

lavages連續(xù)Better

drainage/dialysis

及透析更好compartment

syndrome隔室綜合征↗O2

tension張力Hypoproteinaemia,

anaemia低蛋白血癥，貧血ial

infections院內(nèi)Early

enteral

nutrition早期腸道營養(yǎng)Early

enteral

nutrition早期腸道營養(yǎng)Feed

the

gut!喂腸道！心Preserves

function維持功能心Gut

barrier腸道屏障,↘bacterialtranslocation細(xì)菌易位心Easier,

safer,

che

r簡單，安全，便宜守Potential

complications潛在并發(fā)癥Conclusion結(jié)論P(yáng)ostoperative

septic