< Back Guts on the Floor and Exposed Spine Patient #1 A 32-year-old male was involved in a head-on motor vehicle collision. He was ejected and pinned between two vehicles. He was brought in by EMS and on arrival to the trauma bay, he was covered with a sheet. When he was transferred to the gurney, it was clear that there was something unusual. He was eviscerated with a large wound in his right lower abdomen just above his inguinal ligament, and his intestines were entangled in his clothing. Patient #2 A patient was brought in by EMS following a motorcycle accident with a report of "exposed spine". Primary survey unremarkable, hemodynamically stable. FAST revealed fluid in the abdomen. A secondary survey revealed multiple extremity abrasions. When the patient was log rolled, he was noted to have a full-thickness degloving injury of the soft tissue and partial avulsion of the back musculature with exposed spinous processes. What are the management priorities? Prioritize primary and secondary survey, treat life-threatening injuries first. Secure airway. Evaluate for concomitant injuries, including thoracoabdominal injuries, requiring emergent surgical intervention. The challenge of Distracting injuries Remember- very painful or frightening injuries may distract from pressing clinical priorities. Regardless of how horrifying or novel an injury is, the goal of rapid evaluation and management of trauma patients is to identify and treat the most life-threatening injuries first. Remember to evaluate the airway, breathing, and circulation, and don't be concerned with the exposed intestine until you have ensured the patient doesn't have a pending loss of airway, tension pneumothorax, cardiac tamponade, etc. Control active arterial hemorrhage. Don't let the patient die from an unsecured airway while you are frantically attending to grass and flecks of wood and rock covering the exposed back muscle overlying the spine. Previous Next

What language are we speaking? Speaking Greek < Back What language are we speaking? Medicine has a language all its own. Sometimes we use formal words for common terms, like sputum or phlegm to refer to snot. But a lot of words are unique to the medical field. When speaking with patients and families, the most important thing is communicating effectively. Using a slew of foreign and formal words might sound impressive, but everyone will likely be more confused when you leave the room. After years of education and training, words and phrases in the medical dictionary become second nature. Our conversations with colleagues, consultants, and peers are frequently saturated with this unique lexicon. Sometimes this even spills into your conversations outside of work, and your family and friends might start to pick up some of your common work terms. Patients and their families are not fluent in the language of healthcare unless they are employed in healthcare or have experienced frequent interactions with the healthcare field, such as being a caregiver for an ill family member or suffering from a chronic illness. Once you learn something, it’s difficult to remember a time when you didn’t know. If you’ve worked in healthcare, it’s obvious that laparoscopic cholecystectomy means using tiny incisions and long instruments to remove the gallbladder through the belly button. But unless you’ve had one yourself or know someone who has had one, these words might have little meaning. This language barrier can be even more challenging in the stressful environment encountered in the ICU. Several factors create additional barriers to effective communication. 1. Patients in the ICU are sicker and the threat of death or serious disability is more apparent. This can create emotional distress that occupies or distracts families as they try to ask questions and get answers, impairing their ability to thoroughly understand, even if the healthcare team provides very detailed, comprehensive information. 2. When individuals receive bad news, they process/ remember very little after the initial shocking revelation. 3. The higher acuity and sometimes the need for urgent intervention can add time constraints. This creates an additional barrier to effective communication- having to convey the information and potentially obtain consent for treatment and procedures while balancing the ever-present demands of multiple urgent procedures and critical patients to attend to. Families can get information from different members of the healthcare team. Sometimes the nature of the conversation demands the skills of the most experienced provider. However, young trainees sometimes converse with families as well. It’s easy to forget the process of learning how to effectively communicate with families in difficult situations. Listening to phone conversations between team members and family can be enlightening. As young trainees are becoming much more facile with the unique language of the ICU, it can start to infiltrate these discussions. For example, imagine you are caring for a patient who was just admitted to the ICU with a severe traumatic brain injury. When you’re reporting to the accepting team, you’ll use words like subdural hematoma, midline shift, cerebral edema, and severe TBI. When discussing the patient's current clinical status, you might mention that they are over-breathing the ventilator or that they don’t have brainstem reflexes. When developing a management plan, you might discuss the utility of ICP monitoring and debate the use of a bolt or an EVD, the benefits of hypertonic saline versus mannitol for hyperosmolar therapy, whether or not to hyperventilate the patient and the potential for a craniectomy. While these will be readily understood by your colleagues, these are likely foreign terms for most family members. So here are some tips for talking to family and friends, especially during initial conversations. 1. Avoid unfamiliar medical terminology (for example: severe TBI, hypertonic saline). Instead, opt for descriptors such as “bad head injury” or “medication to protect the brain”. 2. Avoid unnecessary details. Don’t ramble on about everything that has happened, especially while they are waiting to hear if their loved one is alive or dead. After you’ve told them their family member is alive, they aren’t likely to hear much else. 3. Avoid revealing that a patient has died over the phone, especially in your initial discussion with the family. 4. Avoid acronyms (for example: TBI, GCS) 5. DO give them a chance to ask questions. 6. DO encourage them to write down their questions as they think of them and reassure them that they can ask questions throughout the process. Previous Next

< Back Delirium...what's going on? A 29-year-old male with moderate traumatic brain injury (TBI) remains intubated in the surgical ICU (SICU) due to agitation/ delirium during daily spontaneous awakening and breathing trials (SAT/ SBT). What are the clinical priorities? Rule out acute processes that can cause agitation and delirium, such as anemia, acidosis, hypoxemia, infection, intra-cranial process, fever, and an adverse drug reaction. Other potential causes? Immobility, "lines and tubes." Isolation, disorientation, lack of normal sleep-wake patterns Endocrine or metabolic derangements Organ dysfunction (renal disease, liver disease, etc) Withdrawal from chronic home medications (benzodiazepines, alcohol, psychiatric medication, etc.). What are the treatment principles for agitation and delirium? Treat organic reversible causes (treat infection, minimize unnecessary medication, etc.) Implement non-pharmacology therapy (sleep-wake cycles, lights and stimulation during the day and darkness at night) Pharmacologic agents can be used once reversible causes are remedied and non-pharmacologic therapy has been instituted. After the optimization of non-pharmacologic therapy, the patient was successfully extubated. A few days later on rounds, the patient was sitting up in bed. During our conversation, I noticed that he was drinking a Mountain Dew. His mom told us that he drinks multiple Mountain Dews every day (read- 6 or more). I told her that I suspect this had a significant role in his altered mental status during attempts at ventilator liberation. Management of Agitation and Delirium Definition Agitation is a psychomotor disturbance characterized by excessive motor activity and a feeling of “inner tension”. Delirium is an altered consciousness with reduced focus/ cognitive function. It is abrupt in onset and can have a fluctuating presentation. High prevelance, often misdiagnosed. Classified as hypoactive (most common, worse prognosis, difficult to diagnose), hyperactive (better prognosis) or mixed. Etiologies Acute illness- sepsis , electrolyte/ metabolism disorders, hyperthermia, hypoxia, hypotension, EtOH withdrawal, organ dysfunction, polytrauma, emergency surgery Patient factors- elderly, history of depression/ stroke/ dementia, history of EtOH abuse, tobacco use. Hearing or vision impairment. Iatrogenic- noise, discomfort, pain, sedative/ analgesics, ventilator dyssynchrony. Exacerbated by pain, anxiety, discomfort. Diagnosis [see charts below] Assess consciousness with Richmond Agitation-Sedation Scale (RASS). 10 point scale, ranging from combative to unarousable. Assess for delirium with Confusion Assessment Method for the ICU (CAM-ICU). 1-2 min test, 98% accurate in diagnosing delirium. Assess over 24 hrs to capture nocturnal symptoms. Non-Pharmacologic Treatment of Delirium Diagnose and manage underlying acute illness - Treat sepsis as appropriate- antibiotics, source control, etc. - Correct hypoxia, metabolic disturbances, dehydration, hyperthermia Non-pharmacologic interventions for anxiety/ discomfort[1] Periodic reorientation and reassurance from nursing staff Cognitive stimulation Correction of sensory deficits Management of environment (reassess need for invasive devices) Normalize sleep/wake cycles Minimize iatrogenic factors (sedation) Pharmacologic Therapy for Delirium Typical anti-psychotic- Haloperidol. MIND and HOPE-ICU trial- no difference in duration of delirium.[2,3] AID-ICU trial- no difference in mortality.[4] Atypical anti-psychotic- Quetiapine, Ziprasidone MIND-USA trial- no difference in delirium duration with either agent [5] Dexmedetomidine MENDS and SEDCOM trials- ↓ mechanical ventilation and ↓ delirium vs benzos [6,7] MIDEX and Prodex trial- non-inferior compared to benzos/ Propofol [8] DahLIA trial- quicker and more sustained resolution of delirium vs placebo [9] SPICE III Trial- similar mortality and similar number of delirium-free days [10] MENDS II Trial- similar number of delirium-free days vs Propofol.[11] Melatonin Pro-MEDIC Trial- prophylactic melatonin didn't decrease delirium prevalence[12] Assessment for Caffeine Withdrawal Obtaining a detailed patient history, or even a focused history of the most pertinent diagnoses or medication (blood thinners, cardiac disease) is often challenging in traumatically injured parents who may have decreased mental status due to injury or intoxication. Documenting daily caffeine intake is not typically a key component in a surgical history. However, caffeine is readily available and is the most commonly used drug in the world.[13] Unfortunately, it has significant systemic effects. Along with nicotine, it is gaining more attention as a potential etiology of altered mental status or other symptoms that would typically prompt extensive work-up. If a patient has persistent altered mental status after evaluating typical causes, consider the possibility that the patient could be missing their usual caffeine fix. "Withdrawal symptoms caused by people abruptly stopping smoking or drinking tea and coffee can include nausea, vomiting, headaches, and delirium and can last for up to two weeks."[14] References Faustino TN et al. Effectiveness of combined non-pharmacological interventions in the prevention of delirium in critically ill patients: A randomized clinical trial. J Crit Care. 2022;68:114-120. MIND Trial. Girard TD et al. Feasibility, efficacy, and safety of antipsychotics for intensive care unit delirium: The MIND randomized, placebo-controlled trial. Crit Care Med. 2010;38(2):428-437. HOPE-ICU Trial. Page VJ et al. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Resp Med. 2013;1(7):515-523. AID-ICU Trial. Andersen-Ranberg NC et al. Haloperidol for the Treatment of Delirium in ICU Patients. N Engl J Med. Published online October 26, 2022. MIND-USA Trial. Girard TD et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. N Engl J Med. 2018;379(26):2506-2516. MENDS Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. SEDCOM Trial. Riker RR et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial. JAMA. 2009;301(5):489. MIDEX and PRODEX Trials. Jakob SM et al. Dexmedetomidine vs Midazolam or Propofol for Sedation During Prolonged Mechanical Ventilation: Two Randomized Controlled Trials. JAMA. 2012;307(11):1151. DahLIA Trial. Reade MC et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA. 2016;315(14):1460. SPICE III Trial. Shehabi Y et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. N Engl J Med. 2019;380(26):2506-2517. MENDS II Trial. Hughes CG et al. Dexmedetomidine or Propofol for Sedation in Mechanically Ventilated Adults with Sepsis. N Engl J Med. 2021;384(15):1424-1436. Pro-MEDIC Trial. Wibrow B et al. Prophylactic melatonin for delirium in intensive care (Pro-MEDIC): a randomized controlled trial. Intensive Care Med. 2022;48(4):414-425. Caffeine: The chemistry behind the world’s most popular drug Stephenson J. Nicotine and caffeine withdrawal may affect ICU patients. Nursing Times. June 2019 . RASS for Agitation Assessment CAM-ICU For Delirium Assessment Previous Next

< Back Electrolytes...pending Electrolyte Management Previous Next

5 Critical Care References ICU Rounds A-F Bundle .pdf Download PDF • 33KB Pharmacology Med Doses .pdf Download PDF • 56KB Neurologic RASS .pdf Download PDF • 281KB CAM-ICU .pdf Download PDF • 127KB CPOT .pdf Download PDF • 76KB EtOH Withdrawal .pdf Download PDF • 1.02MB Cardiac Arrhythmias .pdf Download PDF • 1.55MB Pulmonary Cuff Leak .pdf Download PDF • 15KB Fluids, Electrolytes and Nutrition Fluids .pdf Download PDF • 29KB Na and pH .pdf Download PDF • 53KB Endocrine and Nutrition Types of Insulin .pdf Download PDF • 85KB TPN .pdf Download PDF • 221KB Steroids .pdf Download PDF • 36KB Hematology Anticoag .pdf Download PDF • 44KB Anticoag Reversal .pdf Download PDF • 334KB Organ Donation Hormone Therapy .pdf Download PDF • 13KB

1 A Field Guide to Lies Critical Thinking in the Information Age - Explains common misuses of statistics and misrepresentation of probability. Use common sense as the first line of defense. This impacts advertising, criminal trials (what is the likelihood that the defendant is guilty based on the blood found at the scene vs whats the possibility that any other individual is guilty based on the blood found at the scene). - Post hoc ergo propter hoc- After this, therefore because of this. Because this event followed another event, the subsequent event must have been caused by the first event. We link events that might be temporarily related but aren't actually cause and effect. - Likelihood of two unrelated events both happening= probability of event 1 x probability of event 2→ lower than the probability of each event independently. Likelihood of flipping one head on a coin followed by flipping another head. - Likelihood of two related events- for example, the likelihood of freezing weather tonight and tomorrow night→ higher given the occurrence of freezing weather the first night. - Vaccines lead to autism? People look at the increased percentage of autism diagnoses. Autism was more frequently diagnosed because it became more understood. Autism is commonly diagnosed between 18-24 months and the MMR vaccine is given around 12 months. - Was 9/11 an inside job? Why did the towers collapse vertically? Easy to overwhelm with questions and theories designed to cast doubt on the events. But structural engineers never found anything suspicious about it. - Breast cancer. Pretest probability- occurrence in the population. 1/8 women develop BrCA. Mammograms can over-call diagnoses (false positive). - Positive test + confirmed diagnosis= true positive - Negative test + confirmed absence of diagnosis= true negative - Positive test + confirmed absence of diagnosis= false positive (low FP= high specificity) - Negative test + confirmed diagnosis= false negative (low FN= high sensitivity) Previous Next

< Back C dificle Colitis...pending Management of Clostridium Difficle Colitis Previous Next

< Back Just Cellulitis...or something worse.... A 42-year-old female presents to the ED with one week of painful swelling of her left medial upper thigh. Her past medical history is remarkable for diabetes, morbid obesity, and rheumatoid arthritis, for which she takes immunomodulator therapy. She had been seen by a PCM earlier in the week and was started on antibiotics. She returned to her PCM when she continued to have pain and swelling and she was then sent to the ER for evaluation. She was concerned because the redness was extending to her groin and lower abdomen. On exam, she had redness and edema to her left lower abdominal wall extending midway down her thigh. Initial x-ray image What are the signs and symptoms suggestive of NSTI? Symptoms- fevers, painful skin lesion (redness, swelling, warmth) Signs- tachycardia, potentially hypotension. Skin warmth, edema, foul-smelling drainage, blistered or sloughing skin, crepitus. *Pain out of proportion to exam is a concerning finding. What workup should be performed? Labs- CBC, electrolytes, lactate Imaging- x-ray, ultrasound to rule out abscess, CT An ultrasound was performed, but it was non-diagnostic. There was no obvious underlying abscess. Why is ultrasound difficult with NSTI present? Soft tissue air obscures the ultrasound images. Evidence of artifact on the ultrasound can be suggestive of NSTI. What is the initial treatment of NSTI? Like any septic patient, antibiotics, resuscitation, and rapid source control are paramount. For necrotizing soft tissue infections, source control requires expeditious surgical exploration and debridement. Representative image from CT scan- upper thigh Representative image from CT scan- lower abdominal wall After starting broad-spectrum antibiotics and fluid resuscitation, the patient was taken to the operating room. Upon exploration, the tissue planes were easily dissected and there was copious grey-tinged malodorous fluid. The fluid was cultured to allow tailoring of antibiotic therapy. All necrotic tissue was excised and the wound was left open with gauze packing. She required low-dose norepinephrine during the case and had an elevated lactate. She remained intubated and was taken to the ICU. She returned each of the following 3 days until there was no more evidence of necrotic tissue or undrained infection. At that time a wound vac was placed and she returned for wound vac changes every 3 days. Management of Necrotizing Soft Tissue Infection (NSTI) Risk factors- diabetes, immunosuppression, malnutrition, obesity, IV drug use. Bacteriology- often polymicrobial (Type 1), 20% are monomicrobial (Group A strep or S aureus). Culture with Gram + rods= Clostridia (Type III). Diagnosis [1] Patients may present with sepsis and multi-system organ failure. Physical Exam- erythema or discolored skin, edema, pain out of proportion to exam, bullae, crepitus (late finding). Fever, hypotension. Imaging- CT is more reliable than plain films. MRI is most effective but may delay care. Plain films- gas in soft tissues MRI- fascial thickening CT- soft tissue air, muscle edema, fluid collections, thickened non-enhancing fascia Labs- leukocytosis, elevated lactate. Blood cultures. LRINEC score- ≥6 is suspicious, ≥8 is strongly predictive. Low sensitivity, not reliable to rule-out NSTI.[1,2] CRP ≥150= 4 points WBC 15-25= 1 point, >25= 2 points Hgb 11-13.5= 1 point, <11= 2 points Sodium <135= 2 points Cr >1.4= 2 points Glucose >180= 1 point Intraoperative findings: dishwater-like fluid is frequently encountered. Tissue planes easily separate, including the soft tissue separating from the underlying fascia. Management Rapid resuscitation, antibiotics, and surgical excision. If there is a high clinical suspicion, don't delay surgery to await imaging. Obtain tissue culture intraoperatively. Antibiotics Broad-spectrum until cultures available- vanco OR linezolid + pip/tazo OR carbapenem OR ceftriaxone/metronidazole S aureus- nafcillin, cefazolin, vancomycin, clindamycin Group A strep OR Clostridium- clindamycin and penicillin. Adjuvant Therapies IV immunoglobulin- neutralize Strep or clostridia toxin. Hyperbarics- no clear benefit. Immunomodulators? There are comprehensive reviews of the current practices regarding diagnosis and treatment of NSTI in Lancet and the New England Journal of Medicine.[3,4] References Fernando SM. Necrotizing Soft Tissue Infection: Diagnostic Accuracy of Physical Examination, Imaging, and LRINEC Score: A Systematic Review and Meta-Analysis. Ann Surg. 2019 Jan;269(1):58-65. Wong CH et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32 (7):1535-1541. Hua C et al. Necrotising soft-tissue infections. Lancet Infect Dis. 2023 Mar;23(3):e81-e94. Stevens DL et al. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017;377(23):2253-2265. Previous Next

< Back Chronic Upper Abdominal Pain A 65-year-old female with chronic non-specific abdominal pain develops acute severe pain in her epigastrium. She presents to the ED for evaluation. What's on the differential diagnosis? Perforated hollow viscus Gastritis Peptic ulcer disease Pancreatitis Biliary pathology- cholecystitis, choledocholithiasis, hepatitis Pneumonia Myocardial ischemia What are the relevant clinical questions and what is included in a focused physical exam? Further details about the abdominal pain- prior similar episodes, onset/ duration, aggravating/ alleviating factors, constant or intermittent, radiating pain, severity, quality of pain (burning, stabbing, cramps). Associated symptoms- systemic symptoms. Fevers/ chills. Nausea/ vomiting. Change in color of urine or stool? Any prior medical or surgical history? Any medications? Smoker? Exam- abdominal palpation- identify tenderness and presence of peritonitis. The pain is stabbing and constant, and she's never had this pain before. She occasionally has right shoulder pain. She reports nausea and loss of appetite, but denies fevers/ chills/ vomiting. She had tea-colored urine and pale white stool a couple days ago. She has no medical or surgical history and is a non-smoker. On exam, she is afebrile, heart rate in the 90s. She is tender in the right upper quadrant with minimal palpation. What is the initial diagnostic workup? Labs: CBC, amylase/ lipase, hepatic enzymes, bilirubin Right upper quadrant ultrasound Possible computed tomography What ultrasound findings are consistent with cholelithiasis? Masses in the gallbladder that are echogenic (reflect on the anterior surface) with a posterior shadow and mobile/ dependent (move with changes in patient position). What ultrasound findings are consistent with acute calculous cholecystitis? Gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. What radiographic and laboratory findings are consistent with choledocholithiasis? Dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. What clinical/ radiologic/ laboratory findings are consistent with acute calculous cholecystitis? Criteria are based on Tokyo guidelines.[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis- one local sign + one systemic sign + imaging findings An ultrasound reveals gallstones, gallbladder wall thickening, and a dilated common bile duct. Her bilirubin is 2. Diagnosis? Cholecystitis with high risk for choledocholithiasis. Right Upper Quadrant Ultrasound- Gallstones Case courtesy of Maulik S Patel, Radiopaedia.org . From the case rID: 20542 Right Upper Quadrant Ultrasound- Gallbladder Wall Thickening Case courtesy of RMH Core Conditions, Radiopaedia.org . From the case rID: 3802 Patient was taken to the OR and underwent uncomplicated laparoscopic cholecystectomy. Intraoperative cholangiogram revealed multiple stones in the distal common bile duct. Despite multiple attempts, stone retrieval was unsuccessful. She underwent a postoperative endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction. SAGES Guidelines on Diagnosis and Management of Choledocholithiasis Cholelithiasis, Predicting Likelihood of Choledocholithiasis Choledocholithiasis Management Algorithm Evaluation and Management of Acute Cholecystitis Diagnosis History- right upper quadrant/ epigastric pain, nausea/ vomiting. Labs- CBC, renal panel, LFTs. Radiology- right upper quadrant ultrasound. - Cholelithiasis: echogenic masses in the gallbladder with a posterior shadow that are mobile (move with changes in patient position). - Acute calculous cholecystitis: gallstones + gallbladder wall thickening + pericholecystic fluid +/- positive sonographic Murphys sign. Diagnostic Criteria for Acute Cholecystitis- Tokyo 2018 Guidelines[1] Local signs of inflammation- Murphy’s sign, RUQ mass/pain/tenderness Systemic signs of inflammation- fever, elevated CRP, elevated WBC count Imaging findings characteristic of acute cholecystitis Suspected diagnosis- one local sign + one systemic sign Definite diagnosis - one local sign + one systemic sign + imaging findings Management Cholecystitis is managed with early laparoscopic cholecystectomy unless the patient is too ill to tolerate surgery.[2] A percutaneous cholecystostomy is a minimally-invasive option for high-risk patients, avoiding the risk of general anesthesia. However, in a recent study of high-risk patients, cholecystectomy was associated with fewer complications than percutaneous cholecystostomy.[3] Evaluation and Management of Choledocholithiasis Diagnosis- dilated common bile duct, stones visualized in the common bile duct, elevated bilirubin. Management- common bile duct stones are managed with endoscopic or operative stone extraction.[4,5] References Yokoe M et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):41-54. Okamoto K et al. Tokyo Guidelines 2018: Flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25(1):55-72. Loozen CS et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018;363:k3965 . Manning A et al. Protocol-Driven Management of Suspected Common Duct Stones. J Am Coll Surg. 2017;224(4):645-649. Clinical Spotlight Review: Management of Choledocholithiasis - A SAGES Publication. SAGES. Accessed July 13, 2022. Previous Next

5 Team of Teams New Rules of Engagement for a Complex World - From retired General Stanley McChrystal. Guidance on developing an adaptable, agile, and unified organization. - Changes in the nature of war necessarily lead to changes in leadership and team dynamics. - Given the dynamic nature of current combat, the prevalence of unknown unknowns, and the rapid pace of information dispersion, it is unreasonable for every leadership level to approve every maneuver. - Teams need to be competent and well-trained. But in this current environment, it would be prohibitively cumbersome to require the commander's involvement in every decision while remaining agile and quickly responding to constant changes. In contrast, developing a strong team and providing a common goal, an overarching mission, allows teams to execute, react, and adjust to shifting battlefields. The end state serves as a guide, and the group draws from their training to accomplish the mission. Previous Next

< Back GI Dysmotility...pending GI Dysfunction Previous Next

< Back Diverticulitis...pending A 52-year-old female developed left lower quadrant abdominal pain, which she thought it was gas pain or indigestion. Unfortunately, the pain worsened and became so severe that she presented to the ER for evaluation. Associated symptoms include nausea, vomiting, lower grade fever and constipation. CBC revealed WBC of 13.5, renal panel was unremarkable. A CT of the abdomen/ pelvis with oral and IV contrast was obtained. CT Scan of Diverticulitis There was minimal thickening and inflammatory changes in the sigmoid colon. She was diagnosed with diverticulitis and discharged with a course of oral antibiotics. Over the next several months, she continued to have pain, with increasingly frequent and intense episodes. She was admitted to the surgery service several months later for a particularly severe episode. She was treated with IV antibiotics and then had resolution of her symptoms and was discharged home. What is the next step? Schedule for colonoscopy to rule underlying pathology. Discuss elective sigmoid colectomy for recurrent episodes of diverticulitis. The plan was to schedule a colonoscopy, but unfortunately, she never had a symptom-free interval. She returned several days later with recurrent pain. She was presented with the option of surgical intervention to remove the inflamed part of her colon. She underwent an uncomplicated laparoscopic sigmoid colectomy with primary anastomosis. Management of Diverticulitis Previously, antibiotics were recommended for the management of diverticulitis, regardless of severity. Two studies (AVOD, DIABOLO) have demonstrated no difference in outcomes for patients with uncomplicated diverticulitis that were managed with or without antibiotics.[1,2] Patients who have an episode of complicated diverticulitis (episode associated with free colon perforation, fistula, abscess, stricture, or obstruction) require an endoscopy to evaluate for underlying malignancy. Indications for Surgery Emergent surgery- acute episode with perforation or peritonitis. Semi-urgent surgery- failure of non-operative management (ie symptoms persist despite bowel rest and antibiotics). Elective colectomy - Resolved episode of diverticulitis associated with abscess/ fistula/ stricture/ obstruction. - Recurrent episodes of uncomplicated diverticulitis that interfere with the patient's lifestyle (frequent episodes, repeated hospital admissions, etc). For More Information on the Management of Diverticulitis ASCRS Patient Information: Diverticular Disease AVOD Trial. Chabok A et al; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532–539 . Diabolo Trial. Daniels L et al; Dutch Diverticular Disease (3D) Collaborative Study Group. Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg. 2017;104:52–61. Previous Next