Resident Readiness General Surgery (31 page)

COMPREHENSION QUESTIONS

1.
A 16-year-old male with a 3-week history of right lower quadrant pain presents to the emergency department. An abdominopelvic CT shows a 6-cm phlegmon adjacent to an inflamed appendix with small pockets of free air. He is febrile, mildly tachycardic, and normotensive without peritoneal signs. The next step of management should be which of the following?

A. Begin intravenous piperacillin–tazobactam.

B. Appendectomy.

C. Arrange for image-guided percutaneous drain placement.

D. Colonoscopy.

2.
A 32-year-old woman with Crohn disease has been receiving inpatient intravenous steroids and antibiotics for 2 weeks. She suddenly develops fever and worsening abdominal pain. CT reveals a 6-cm rim-enhancing fluid collection adjacent to a thickened, inflamed terminal ileum. The next step of management should be which of the following?

A. Continue antibiotics and observe.

B. Terminal ileal resection and operative abscess drainage.

C. Arrange for image-guided percutaneous drain placement.

D. Start acetaminophen for fever and β-blocker for tachycardia.

3.
A 55-year-old male presents to the emergency department with a 5-day history of worsening left lower quadrant pain. He is tachycardic and febrile with intense left lower quadrant tenderness. CT reveals a 7-cm left lower quadrant fluid and air collection adjacent to a segment of thickened sigmoid colon with multiple diver-ticula. After resuscitation and IV antibiotics his blood pressure is 85/60 mm Hg and he has left lower quadrant guarding. The next management step should be which of the following?

A. Sigmoid colectomy.

B. Broaden antibiotics to cover tertiary abscesses.

C. Arrange for image-guided percutaneous drain placement.

D. Repeat CT scan.

Answers

1.
A
. A chronic phlegmon without sepsis or peritonitis should be managed first with antibiotics and close observation. A chronic phlegmon may be hostile
(difficult and dangerous to operate on), and surgery is reserved for sepsis or failure of medical therapy. A phlegmon typically contains no drainable fluid and is not amenable to percutaneous drainage. Colonoscopy may eventually be necessary to evaluate for inflammatory bowel disease, but is not necessary acutely.

2.
C
. Image-guided drain placement would be ideal for the stable patient with a drainable abscess. This patient is worsening despite 2 weeks of antibiotics and continued antibiotic therapy alone will not help. In this high-risk patient, operation would be reserved for failure of percutaneous drainage, sepsis, or peritonitis. Acetaminophen and β-blockers may only mask symptoms and will not treat the patient’s underlying pathology.

3.
A
. This patient requires abscess drainage. He is hypotensive, which determines the means by which you should drain the abscess. Hypotension makes image-guided drainage a risky procedure and is generally considered a contraindication. Instead, he should undergo prompt resuscitation and an emergent operation. Antibiotics play only an adjunctive role for a large drainable abscess. Short-interval re-imaging is wasteful, dangerous, and unhelpful in this hypotensive patient.

Section III.
Handling Inpatients

A 75-year-old Man With Postoperative Pain

Ezra N. Teitelbaum, MD

A 75-year-old, otherwise healthy man undergoes an elective right hemicolectomy for colon cancer. The case was converted from laparoscopic to open due to dense adhesions from a prior laparotomy. Six hours after the operation, you are paged by the patient’s nurse because he is complaining of 8 out of 10 abdominal pain and his next dose of “prn” morphine is not available for another 2 hours.

When you arrive at the bedside, the patient is alert and answers all questions appropriately. He complains of a sharp pain along the length of his incision that was improved from 10 out of 10 to 6 out of 10 after receiving a dose of morphine 4 hours ago. In the past hour, however, the pain has been gradually increasing and is once again 10 out of 10. He is not nauseated and has not vomited.

His vital signs are: temperature 37.2°C, heart rate 85, blood pressure 150/90, and respiratory rate 12. His abdomen is soft with localized and appropriate tenderness along the length of the midline incision dressing. He is making 100 mL/h of clear yellow urine and, except for the pain, has been recovering well.

You review his medications and find he is ordered for “morphine 2 mg IV q6h prn pain.” He has received a single dose since arriving to the surgical ward 4 hours ago.

1.
Why did you have to come see the patient and not simply provide a new order over the phone?

2.
How would you change the order for his pain medications?

3.
Name 3 common side effects of opioids.

4.
Name 2 nonopiate medications that can be used in the immediate postoperative period (ie, when the patient is NPO).

5.
When and how should this patient be transitioned to oral pain medications?

POSTOPERATIVE PAIN MANAGEMENT

Answers

1.
When evaluating a patient complaining of an unusual amount of pain, or pain that is persistent despite the administration of medication, your first thought should always be that the pain might be the result of a surgical complication. While the most common cause of pain in the immediate postoperative period is inadequate analgesia, this should always be considered a diagnosis of exclusion. Therefore, patients with refractory pain need to be evaluated
in person
, and orders to increase the dose of narcotics should never be given over the phone. On
your way to evaluate this patient you should be thinking of the possibility that bleeding, an anastomotic leak, or a missed bowel injury is responsible for his pain.

Your bedside history and physical exam should therefore focus on ruling out these serious complications. The fact that the patient’s pain is localized to his incision, rather than the site of the anastomosis (likely the RUQ or RLQ) or diffusely over the entire abdomen, is reassuring, as is the fact that the pain is partially relieved by medication. The patient’s vital signs are also within normal limits except for mild hypertension. Any fever, tachycardia, hypotension, or tachypnea in the immediate postoperative period is concerning and may be the result of hypovolemia (due to bleeding) or an inflammatory response (due to infection, anastomotic leak, or another complication). Hypertension in isolation is a common result of pain itself and is not immediately concerning (see Chapter 36 on postoperative hypertension for criteria for when you
should
be concerned).

The abdominal exam (or other surgery site–specific exam) is an essential component to differentiating between pain from inadequate analgesia and pain secondary to a complication. Patients with poorly controlled but uncomplicated pain should still have abdomens that are soft to palpation, especially away from the area of the incision. Your exam should thus start laterally (if you are examining a patient with a midline laparotomy) and proceed medially toward the incision. If the patient has an abdominal drain, then its output should be closely examined for bile, succus, stool, or frank blood.

If you are confronted with a patient with poorly controlled pain and any of these “warning signs,” you should notify your senior resident or the attending immediately. While it’s always good to come up with a plan for investigating potential complications (eg, checking a CBC to rule out bleeding) before making that call, such a workup should never be initiated on your own without keeping everyone “in the loop” about what is going on with a potentially sick patient.

2.
After you have reassured yourself that this patient’s pain is not due to a surgical complication, the next step is to look at the existing pain orders and the medication administration record (MAR) to see how you can best address the inadequate analgesia. In this case, the patient’s morphine order has too low a dose and too long an interval between doses. For treating pain in an average patient after a laparotomy or other major surgery, an order of morphine 4 mg IV q3h or q4h is a good place to start. Keep in mind that younger adult patients and patients taking opioids chronically at home will typically require higher doses of narcotics. Conversely, elderly patients or those with renal insufficiency should be started on lower doses.

In this patient, starting a patient-controlled analgesia (PCA) pump is an even better solution than simply increasing the dose and frequency of his morphine order. A PCA allows patients to control the administration of intravenous opioids themselves by pressing a button attached to the PCA pump. The physician indicates in the PCA order the dose that is given with each button press and a
“lockout” interval that is required to elapse between presses before the pump will administer a second dose.

PCAs are ideal for pain management in the immediate postoperative period for several reasons. The patient is in control of his or her own medication administration, and thus the time between when the patient begins to experience pain and when he or she finally receives medication is greatly reduced. Second, by providing small, frequent doses, a PCA allows for better medication titration to the required level, helping to avoid the “peaks and valleys” of pain often caused when a q3h or q4h prn opioid schedule is used. Lastly, PCAs limit the risk of opioid overdose, as the patient must be alert enough to press the pump button in order to administer another dose. A good starting PCA dose for a standard patient is morphine 1 mg, with a lockout interval of 8 minutes. Hydromorphone (trade name Dilaudid) is the other most popular IV opioid and is approximately 7 times as potent as morphine. A standard PCA order would be Dilaudid 0.1 or 0.2 mg with the same lockout interval of 8 minutes.

So far we have only discussed the use of “prn” or “breakthrough” pain medication that is administered when requested by the patient (via either the patient’s nurse or a PCA). The other, complementary, dosing option is a “standing” or “basal rate” in which patients receive the medication at a set time interval or continuously, regardless of whether they are in pain. In general, opioids should not usually be ordered in such a fashion due to the risk of narcotic overdose. Likewise, a basal administration rate on a PCA (by which patients get a set dose of narcotics every hour regardless of whether they press the pump button) should not be used except in special circumstances.

3.
Opioids act on the central nervous system to depress consciousness and, ultimately, respiratory drive. Other than depressed mental status, the primary finding of opioid toxicity on physical exam is pinpoint and sluggishly reactive pupils. Opioid overdose is treated with IV naloxone; however, keep in mind that any narcotic overdose resulting in unresponsiveness or respiratory depression is a life-threatening emergency. Under no circumstance should you attempt to treat it on your own and if an inpatient is found in such a condition, a medical “code” should be called so that help arrives immediately.

Opioids can also cause delirium, especially in elderly patients. This can result in paradoxical agitation, confusion, and aggressive behavior. In older inpatients these side effects are often falsely attributed to dementia, even when the patient was not previously diagnosed with this condition. This is why it is extremely important to determine what the patient’s baseline mental status was when evaluating abnormal behavior in the hospital.

Another opioid side effect of critical importance in general surgery is the slowing of bowel peristalsis, resulting in ileus and/or constipation. For this reason, the total amount of opioids used should be limited whenever possible, especially after a bowel resection. Additionally, patients who are receiving opioids and can take oral medications should be placed on a prophylactic stool
softener (ie, “bowel regimen”), such as docusate (trade name Colace) 100 mg PO BID. Another option is the relatively new medication alvimopan (trade name Entereg), an opioid antagonist that acts selectively in the enteric nervous system and has been shown to reduce the length of ileus after colon resections.