Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

Slide presentation from the AHRQ 2011 conference.

Slide 1

Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults

Steven Teich, M.D.
Daniel Cohen, M.D.
Ann Deitrich, M.D.
Osama El-Assal, M.D.
John Shultz, M.D.

On the bottom of every slide it has the logo and name "Nationwide Children's", Ohio State.

Slide 2

Study Aims

Study Aims

  • Aim 1: Describe the presentation of acute abdomen in medically fragile, high risk children and adults to expedite the recognition of a surgical emergency.
  • Aim 2: Develop a diagnostic algorithm for patients with special care needs with possible intra-abdominal emergency.

Slide 3

Background

Background

  • There are an estimated 9 million children and 23 million adults in the U.S. with special health care needs.
  • Large subset of special health care needs patients at risk to develop acute surgical abdomen due to co-morbidities:
    • Multiple abdominal surgeries.
    • Indwelling abdominal devices.
    • Chronic constipation.
    • Nissen fundoplication.

Slide 4

Background

Background

  • Adhesive peritoneal bands occur in 93-100% of patients with prior abdominal surgery.
  • Nissen fundoplication increases the risk of adhesive SBO up to 21% in children.
  • Incidence of complications after VP shunt varies from 5-47%:
    • CSF pseudocyst.
    • SBO.
    • CSF ascites.
    • Shunt displacement.
    • Inguinal hernia.
    • Intestinal Perforation.
    • Intestinal entanglement.

Slide 5

Background

Background

  • Nonverbal children and adults with altered sensation often unable to communicate symptoms classically associated with acute abdomen and often present with subtle manifestations.
  • Therefore, this patient population at greater risk for acute abdominal surgical emergencies and delayed or missed diagnoses with potentially catastrophic outcomes.

Slide 6

Study Design

Study Design

  • Study conducted at Nationwide Children's Hospital, Columbus, OH (#IRB09-00151).
  • Retrospective case-controlled study with patients serving as their own control.
  • Review of hospital discharge data including ICD9 codes and surgical case records.
  • Inclusion criteria: patients with neuro-developmental delay with diagnosis of acute surgical abdomen within 48 hours of hospital admission from the Emergency Department between May 2005 and October 2009.

Slide 7

Study Design

Study Design

  • Acute surgical abdomen defined as an abdominal surgical procedure demonstrating a pathological process or an IR procedure for abdominal pathology (e.g. drainage of CSF cyst).
  • Each subject had to have an index ED visit during which an acute surgical abdomen was diagnosed and a control ED visit which proved to be negative for an acute surgical emergency.
  • The control visit required to have occurred within two years of the acute surgical abdomen visit but at least two months distant to avoid repeat presentation for the same illness.

Slide 8

Study Definitions

Study Definitions

  • Feeding intolerance:
    • Decreased oral intake or vomiting in orally fed patient.
    • Abdominal distention, discomfort, or increased gastrostomy tube output after oral or gastrostomy feeds.
  • Pain:
    • Described by patients able to communicate.
    • Interpreted by caregivers as changes in behavior consistent with feeling abdominal pain such as grimaces or moaning with abdominal touch.
  • Constipation:
    • New onset or worsening.

Slide 9

Results

Results

  • 169 patients with special needs had abdominal procedures over the study time period.
  • 24 patients met the selection criteria after screening for elective surgical procedures and lack of a qualifying ED control visit.

Slide 10

Demographic Data

Demographic Data

VariableNumber
Age (years)14.37 ± 9.58
(22, 31, and 43 year olds)
Gender16 male/ 8 female
Residence19 home/ 5 facility
Mode of Feeding17 tube/ 10 mouth/ 3 combined
Implants/Surgical Procedures11 VP shunt
17 gastrostomy tube
16 Nissen fundoplication
4 tracheostomy
1 central line
Number of ED visits/year
(Over past 3 years)
1.49 ± 1.28
ED visit/admission ratio2.06 ± 2.35

 

Slide 11

ED Index Visit (Surgery)

ED Index Visit (Surgery)

EtiologyNumber (%)
Adhesive SBO11 (45.8%)
Shunt-related CSF cyst5 (20.8%)
Volvulus3 (12.5%)
Malrotation2 (8.3%)
Hiatal Hernia1 (4.1%)
VP-tube related intestinal entanglement1 (4.1%)
Peritonitis1 (4.1%)
Total24 (100%)

Slide 12

ED Control Visit (No Surgery)

ED Control Visit (No Surgery)

EtiologyNumber (%)
Ileus6 (20.8%)
Gastroenteritis4 (16.6%)
Unknown3 (12.5%)
UTI2 (8.3%)
URI2 (8.3%)
Colitis1 (4.1%)
Sepsis1 (4.1%)
Pancreatitis1 (4.1%)
Feeding intolerance1 (4.1%)
Pneumonia1 (4.1%)
SMA Syndrome1 (4.1%)
Cyclic vomiting1 (4.1%)
Total24 (100%)

Slide 13

Symptoms at Presentation

Symptoms at Presentation

VariableSurgical AbdomenControl Visitp Value
Respiratory distressYes 11
No 13
Yes 9
No 15
0.47
FeverYes 8
No 16
Yes 12
No 12
0.20
VomitingYes 18
No 6
Yes 10
No 14
0.008*
Feeding intoleranceYes 9
No 15
Yes 4
No 20
0.059
ConstipationYes 8
No 16
Yes 4
No 20
0.20
DiarrheaYes 3
No 21
Yes 10
No 14
0.019*
Abdominal painYes 19
No 3
Yes 11
No 13
0.011*
Abdominal distentionYes 17
No 7
Yes 10
No 14
0.034*
Behavior changesYes 18
No 6
Yes 13
No 11
0.13

*p <0.05.

Slide 14

Physical Findings at Presentation

Physical Findings at Presentation

VariableSurgical AbdomenControl VisitP Value
Tachypnea (>98%ile)Yes 13
No 11
Yes 11
No 13
0.50
Tachycardia (>98%ile)Yes 15
No 9
Yes 14
No 10
0.99
MAP83.67 + 15.2
(N=23)
80.34 + 20.53
(N=22)
0.55
DehydrationYes 18
No 5
Yes 12
No 11
0.031*
Abdominal DistentionYes 17
No 7
Yes 9
No 15
0.007*
Abdominal TendernessYes 18
No 6
Yes 5
No 19
0.006*

*p <0.05.

Slide 15

Laboratory Results and Diagnosis of Acute Surgical Abdomen

Laboratory Results and Diagnosis of Acute Surgical Abdomen

VariableSurgical AbdomenControl Visitp Value
WBC13,900 ± 7,1009,900 ± 4,0000.008*
Segs61.5 ± 22.457.8 ± 23.20.036*
Bands13.2 ± 16.612.6 ± 16.60.66
Bicarbonate25.9 ± 7.926.0 ± 6.10.091
Sodium140.9 ± 5.5138.3 ± 3.60.013*
Potassium4.3 ± 0.83.8 ± 0.480.59
Chloride99.2 ± 19.798.5 ± 19.30.022*
Glucose149.2 ± 50.8122.8 ± 44.80.002*
BUN22.8 ± 20.614.6 ± 6.90.044*
Creatinine0.8 ± 0.600.55 ± 0.290.047*

*p <0.05.

Slide 16

Early ED Management and Diagnosis of Acute Surgical Abdomen

Early ED Management and Diagnosis of Acute Surgical Abdomen

VariableSurgical AbdomenControl Visitp Value
O2 requirementYes 4
No 20
Yes 6
No 18
0.50
Fluid resuscitationYes 18
No 6
Yes 12
No 12
0.031*
Number of fluid boluses1.30 ± 1.100.78 ± 0.950.036*

*p <0.05.

Slide 17

Radiology Testing

Radiology Testing

VariableSensitivitySpecificityNegative Predictive ValuePositive Predictive Value
AAS0.571.00.621.0
Abdominal CT0.941.00.921.0

 

Slide 18

Patient #1

Patient #1

Image: An x-ray of the patient's torso is shown.

Slide 19

Patient #1

Patient #1

Image: An MRI of the patient's abdomen are shown.

Slide 20

Patient #2

Patient #2

Image: An x-ray of the patient's torso is shown.

Slide 21

Patient #2

Patient #2

Image: An MRI of the patient's abdomen are shown.

Slide 22

Predictive Variables For Surgical Abdomen

Predictive Variables For Surgical Abdomen

Variablep Value
Abdominal distention0.027
Abdominal pain0.009
Vomiting/ Increased gastrostomy output0.001
No diarrhea0.017
Abdominal tenderness0.001
Elevated WBC0.006
Number of fluid boluses0.041

Slide 23

A decision flow chart for management of high-risk patients

Image: A decision flow chart for management of high-risk patients with suspicion of vomiting, abdominal pain, tenderness, dehydration, and other symptoms is shown.

Slide 24

Conclusions

Conclusions

  • First study on high-risk patients with suspicion for acute surgical abdomen.
  • Presence of abdominal pain, abdominal distention, increased gastrostomy tube output or vomiting, abdominal tenderness, and signs of dehydration are significant predictors of need for emergency surgery in high risk, medically fragile patients.

Slide 25

Conclusions

Conclusions

  • We propose abdominal ultrasound as the initial modality for patients with VP shunts when presenting with a possible acute surgical abdomen.
  • Positive AAS is reliable finding but negative AAS can be misleading and a further confirmatory test is indicated.
  • Abdominal CT is most reliable imaging modality.
  • Our pathway for atypical, medically fragile patients at high risk for an acute surgical abdomen needs to be validated by a prospective study with a larger cohort.

Slide 26

Questions?

Questions?

Current as of December 2011
Internet Citation: Identifying Intra-Abdominal Surgical Emergencies in Medically Fragile, High Risk Children and Adults. December 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/teich/index.html