vcu death and complications conference. complication necrosis of ileostomy procedure parastomal...
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VCUDEATH AND COMPLICATIONS CONFERENCE
Complication Necrosis of ileostomy
Procedure 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 developed a very large
parastomal hernia
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?– Yes, hypotension could have been avoided with
perioperative steroid administration to prevent adrenal insufficiency
• Would avoiding the complication change the outcome for the patient?– 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 studies315 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