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Nigerian Journal of Surgical Research, Vol. 8, No. 3-4, Jul-Dec, 2006, pp. 185-187 LETTER TO THE EDITOR Re: Surgery in refractory metabolic derangements Dr. Ahmed Adamu Consultant Surgeon, Division of General Surgery ,Department of Surgery, Ahmadu Bello University Teaching Hospital,Zaria, Nigeria Code Number: sr06047 I have read with interest the paper by Anele A.A et al 1 on surgery in refractory metabolic derangements. At the time of presentation, their patient was unconscious, febrile, pale and jaundiced. He also had severe fluid and electrolytes derangement, hypoglycemia and hypoprotenaemia. Despite instituting appropriate resuscitative measures for 20 hours his biochemical status deteriorated with worsening hypokalaemia, hypoglycaemia and anaemia. The patient had emergency laparotomy which was considered to be safer than continuing unrewarding resuscitation. In our institution, patients with acute abdomen present late2, 3 with severe fluid and electrolytes and other metabolic derangements that resist correction on conventional resuscitative measures. Five such patients were seen in our unit between 2004 and 2006. Typhoid ileal perforation was the primary diagnosis in 3 patients (table 1). Biochemical abnormalities at the time of presentation and during the course of resuscitation are shown in table 2. In two patients the American society of anaesthesiologist (ASA) score changed from ASA IIE at presentation to IIIE at commencement of operation. During resuscitation, pulse rate, blood pressure, fluid input and urinary output were recorded hourly. In addition to hourly cardiovascular and respiratory observations, 12-hourly measurements of serum concentrations of electrolytes, urea, creatinine and glucose were made. Intraoperative blood glucose assessment was performed in 1 patient. Three had intraoperative ECG monitoring. Two patients were managed in the ICU postoperatively. As in the patient reported by Anele et al 1, our patients were febrile, pale and jaundiced and had severe metabolic abnormalities (table 2). In these patients, overwhelming sepsis resulting from the primary surgical condition perpetuated the metabolic abnormalities. Therefore, prolonged delay in operative intervention was associated with deterioration in the clinical and metabolic state of the patients. Several studies have shown that serum electrolytes abnormalities in patients presenting for emergency surgery is not uncommon3, 4. This may persist in the postoperative period4. Impairment of cardiac and neuromuscular function can result from electrolytes disorder especially sodium, potassium, calcium and magnesium. However, advances in perioperative practice and introduction of minimally invasive surgical approaches have enabled very sick patients to be eligible for surgery. In acute abdomen hypokalaemia is usually due to intracellular translocation of potassium. Although assaying plasma potassium concentration is the only practical means of assessing hypokalaemia, enormous deficit can be present with only a small decrease in plasma concentration. An example is in acute surgical emergencies which are likely to cause rapid deterioration in diabetic control with diabetic ketoacidosis and dehydration. A period of 6-8 hours of rapid fluids, potassium and insulin infusion is sufficient to improve the metabolic situation so that the patient can safely undergo emergency surgery. It is usually futile to delay such surgery for too long while attempting to completely eliminate ketosis since the underlying acute progressive surgical condition if uncorrected would lead to further deterioration. Indeed, the confidential inquiry into perioperative death (NCEPOD) defined resuscitation to include total or partial correction of fluid, electrolytes and other metabolic abnormalities5. In our setting, attempts were made to achieve optimum metabolic status before operation. As reported by others1, 3, timed surgical intervention was carried out in order to arrest the progressing metabolic abnormalities. Close monitoring of the patient during operation with intra operative ECG monitoring, pulse-oximetery, frequent blood glucose assessment and appropriate choice of anaesthetic agents were associated with satisfactory outcome. In addition, aggressive management in the postoperative period with regard to fluid and electrolytes management, monitoring and pharmacological therapy in the patient is also important. In conclusion, severe metabolic abnormalities that fail to correct on conventional resuscitation are not uncommon in our patients. While the risk of surgical intervention in patients with persisting metabolic derangements is high, the risk of prolonged delay may be higher since the primary disease if uncorrected would lead to rapid deterioration of the clinical and metabolic condition of the patient. Timely operative intervention should be performed under close monitoring and appropriate choice of anaesthetic agents. Close monitoring and correction of metabolic abnormalities should continue in the postoperative period. Acknowledgment I am grateful to Dr Anuma M for reviewing the manuscript and to other consultants for including their patients in this study References
Copyright 2006 - Nigerian Journal of Surgical Research The following images related to this document are available:Photo images[sr06047t1.jpg] [sr06047t2.jpg] |
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