Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_725_Библиотеки_им_академика_М_И_Перельмана
.pdf
Figure 7.1. “Doctor, try our new Gorillacillin. Here is a recent paper published in the
ZimbabweanJournalofSurgery…inastudyof75patients…itprovedpotentandsafe!”
Contrary to what is preached by drug companies ( Figure 7.1) and
their various beneficiaries or representatives — including certain
clinicianswhofunctionas ‘medicaladvisers’(wehaveanothername for
them…)—thechoiceofdrugsisstraightforward.Manysingledrugor
combinationregimensareavailableandequallyeffective;themost
recentandexpensivenotnecessarilybeingbetter.
Theexactregimenofantibiotictogivedependsonthepathology
you are dealing with. Operating on different organs and disease
processes you are likely to encounter different sets of bugs. Therefore,
when considering which empiric antimicrobial agents to administer you
shouldtakeintoaccount:
•
Thespecificpathology(perforatedcolonvs.incarceratedhernia).
•
Severity of disease (mild acute cholecystitis vs. emphysematous
cholecystitiswithseveresepsis).
•
Other factors: Did the pathology develop during hospitalization?
Was the patient already on antibiotics? Is the patient
immunocompromised? Any of these factors could suggest that
unusual, opportunistic micro-organisms (e.g. fungi) could be
involvedintheinfection.
In later chapters we will advise on which antibiotics to use when
treating the specificpathologies. But here letus bring thegut as an
example.
Thebacterialfloraofthe gutispredictable. When adrop of feces
leaks into the peritoneal cavity, it contains more than 400 different
speciesofbacteria;onlyahandfulof theseare involvedin anyensuing
infection. Thus, from the initial plethora of contaminating bacteria, the
inoculumisspontaneouslyreducedandsimplifiedtoincludeonlyafew
organismsthat surviveoutsidetheir naturalenvironment. These arethe
endotoxin-generatingfacultativeanaerobessuchasEscherichiacoliand
obligateanaerobes,suchasBacteroidesfragilis—whichactinsynergy.
Any agent or combination of agents that effectively kills these target
bacteriacanbeused.
The once-popular ‘triple regimen’ of the 1970s (ampicillin, an
aminoglycoside, and metronidazole or clindamycin) has become
obsolete. Enterococcus, frequently isolated in experimental and clinical
peritonitis, is clinically almost non-significant as a pathogen in the
peritoneal cavity and is not required to be ‘covered’ with ampicillin.
Aminoglycosides are markedly nephrotoxic (especially in critically ill
patients), are inefficient in the low pH of the infected peritoneal
environment,andarenolongerthefirstchoiceofantibioticsintheinitial
treatmentof intra-abdominalinfection. Surgeonstend tobe creaturesof
habit, desperately clinging to dogmas passed on by their mentors; the
triple regimen is one such dogma that has been carried into the 21st
century through ignorance. (You may however, work in an environment
wherethesehabitspersistorhavebeenreintroducedbydecree.Atleast
oneoftheeditorsdoes…Aregrettablesituation.)
Therearenumerousagentsonthemarket youcanchoosefrom.You
mayusewhicheveragent,as‘monotherapy’orincombination—aslong
asE.coliandB.fragilisarecovered.
Afewmoregeneralpoints:
•
In abdominal emergencies, we advise that the same agent
shouldbeusedforprophylaxisandtreatment.Aninitialdoseof
theappropriatedrugisgivenpre-operativelyand,ifindicatedbythe
intra-operative findings, can be continued following the operation
(see Chapter 44). The common (mal)practice of starting with a
‘weak’agent(e.g.cephazolin)beforetheoperationandconvertingto
a ‘stronger’ regimen is baseless. But wait a minute, you may be
hollering, what about the results of intra-operative cultures? Well,
after finishing this book you will understand that routine
microbiological cultures often have no practical clinicalvalue
— in many cases when the data on the cultured bacteria and its
sensitivitytoantibioticsareavailable,thepatientisathomeandoff
antibiotics. However, while cultures are useless in ‘routine cases’
(e.g. acute appendicitis) they should be obtained in selective
situationsasdiscussedin Chapter13.
•
Think about the dose. In the course of fluid resuscitation of
hypovolemic patients, antimicrobialsmay be ‘diluted’, reducing the
availability of antimicrobial drugs at sites of contamination or
infection. In these cases, especially in the trauma patient, higher
initialdosesshouldbeused:“soonerandmoreisbetterthanless
andlonger.”Don’tforgetthatfatpeopleneedhigherdoses!
•
One might expect that the bacteriology of postoperative
infectionsatspecificsitesmightbepredicatble.Often,however,
this is not so. For example, the biliary system is typically
contaminated with Gram-negative bacteria but the postcholecystectomy wound infection is commonly caused by typical
skinbacteria—Staphylococcusaureusorevenmethicillin-resistant
Staphylococcusaureus(MRSA).
Tosumitup
Start antibiotics prior to any emergency laparotomy/laparoscopy;
whetheryou continueadministrationafter theoperation dependsonthe
operativefindings(see Chapter44).Knowthetargetflora,understand
the host, be aware of exceptions, and use the cheapest and simplest
regimen.Thebacteriacannotbeconfused,norshouldyoube!
P.S.: Try to familiarise yourself with one or more of the many
guidelines on antimicrobial therapy for intra-abdominal infections
availableonline. Choosethe oneswith anauthors’listwhich isshorter
thanthenarrative.Avoidtheoneswithan‘appendix’whichreadslikethe
phonedirectoryofManhattan.Andremember:guidelinesare written
byhumans—useyourcommonsense.
“Patientscangetwellwithoutantibiotics.”
MarkM.Ravitch
Chapter8
Family,ethics,informedconsentandmedicolegal
issues
JamesC.Rucinski
Doctor,mydoctor,whatdoyousay…?
PhilipRoth
Stoplying!Youknow,andIknow,thatIamdying.Sodoat
leaststoplyingaboutit!
LevTolstoy
(Tounderstand the ‘dyingman’you have toread Tolstoy’s
TheDeathofIvanIlyich.)
The wind whistles through the cracks in your on-call room window
when the emergency department (ED) calls and suddenly you find
yourselfinthemaelstromofthatenvironment,speakingtoasmallgroup
of extremely anxious strangers — having to explain that an immediate
operationwillberequiredtosavetheirbelovedone.Theoperatingroom
isready.
Obtaining informed consent is a practical combination of
salesmanship,ethicalproblemsolvingandpsychologicalnurturing.
Itinvolvestherapidmarketingofone’sownskillsandplanfortreatment.
It requires therecruitment of the patient and the family as allies in the
decision-making process. More than a legal requirement, however,
informed consent requires an ethical commitment to the patient, your
peersandtoyourself.
Salesmanship
Begin by explaining the problem and your proposed treatment using
thesamewordsandlanguagethatyoumightuse inspeakingto oneof
your non-medical relatives. Describe the expected benefits of
operation and what the consequences of alternative treatment
approachesmightbe.(Whathappensifwedonothing…).
Offerseveral scenarios;takeacase ofobstructingcarcinomaof
the sigmoid colon, for example. At one end of the spectrum is non-
operative management, which almostcertainly will result ina slow and
difficult death. At the other end of the spectrum is rapid recovery from
operationwithlong-termcureofthedisease.Inbetweenliethepotential
difficulties of peri-operative complications or death, recovery with
disabilityorrecurrentdisease.
Itiscrucialthatyoubelieveintheplanoftreatmentthatyoupropose.If
thisisnotthecase,andtheplanisnotacceptabletoyoubutdictatedto
youfromabove,thenlettheresponsiblesurgeon(yourboss)conducthis
ownpre-operative‘negotiations’withthepatientand/orhisfamily.
‘Sell’yourselftothepatientandfamilyasascientificexpertwho
recognizes the needs of another person, and is participatingwith
them in solving a difficult problem. Include a description, with
approximate probabilities, of the most common ‘problems’
(complications)fortheproposedprocedureinyourparticularpatient.You
willneedtomakeanestimatebasedongeneralandspecificinformation.
For example, the risk of mortality for elective colon resection may be
negligible but in an elderly patient with acute colonic obstruction and
hypoalbuminemiathe odds of dying may be one in four ( Chapter6).
Discuss general potential postoperative complications such as
infection,hemorrhage (and risk of transfusion),poorhealing and death.
Thenmentiontheuniquecomplicationsspecifictotheprocedureyou
areproposingtoundertake,suchascommonbileductinjuryorbileleak
inlaparoscopiccholecystectomy.
Anadjunctivemethodofassessingpre-operativeriskisnowavailable
throughtheAmericanCollegeofSurgeonsNSQIP(NationalSurgical
Quality Improvement Program) Risk Calculator. It utilizes outcome
datatoallowastatisticalpredictionofvariousoutcomesassociatedwith
thecharacteristicsofyourpatient.Thetoolisavailablewithoutchargeat:
www.riskcalculator.facs.org.
Itiscrucialthatbeforeanymajoremergencyabdominaloperation
youemphasizethatareoperationmaybenecessarybasedonyour
operative finding or if a problem subsequently develops. This will
drasticallyfacilitatethe‘confrontation’withthefamilywhenareoperation
is indeed indicated; they will understand that the reoperation
represents a ‘continued management effort’ rather than a
‘complication’.Minorcomplications,suchasphlebitisarisingfromperi-
operative intravenous therapy, may contribute to information overload
andprobablyshouldbeomitted.
Try to conduct the above ‘script’ in a relatively quiet setting —
awayfromtheusualchaosoftheER,SICUorthe OR;findaquite
corner and let everyone, including yourself, sit down! Use simple
language and repeatyourselfad infinitum; stressed members of the
familymayhavedifficultyingraspingwhatyousay.Offertheopportunity
toask questions andassesswhether thereisan understanding ofyour
discussion.Themoretheyunderstandinitially,thefewer‘problems’you’ll
haveifcomplicationssubsequentlydevelop.
Be ‘human’, friendly, empathetic but professional. A good trick isto
remindyourselffromtimetotimethatthefamilyyouaretalkingto
couldbeyours.Finally,alwaysleaveopenthepossibiltythatwhatyou
think the problem to be is not correct. Similarly, if you are asked to
provideaprognosisalwaysallowfortheunexpected,bothgoodandbad,
sothatifadisasteroramiracleshouldoccurthiswillnotbeousidethe
boundsof thepossibilities yououtlined earlier.Nevermentionspecific
times;forexample,ifyousay“3to6monthsorso”theonlything
that will beremembered is thatyou said “6 months”. Then,when
thepatient dies thefollowingdayof an MI…orisstill alive ayear
later…
Illustratetheproblem
Whendiscussingtheprospectsofanoperationwithapatientora
family we find that illustrating the problem and the planned
procedure on a blank piece of paper greatly enhances the
communication.Draw,schematically,theobstructedcolon:“hereisthe
colon,thisis theobstructinglesionandhereisthe segmentwewantto
remove; we hope to be able to join this piece of bowel to that one; a
colostomymay,however,be needed;this is the place it willbebrought
out.”Belowthedrawingwritethediagnosisandthenameoftheplanned
operation.At the end of the consultationyou’llbe surprised to see how
carefullymembers ofthefamily restudythe pieceofpaper youleftwith
them,explainingtoeachotherthediagnosisandplannedoperation.Very
oftenpatientsandtheirrelativesareveryenthusiasticaboutkeepingany
drawingsyoumakeforthem.
Thefamily
Whenitcomestoanoperation,youadvisethepatientand
hisfamilyandtheydecide…
Thepatient’sfamilyisyourgreatestallyinpromotingyourplanof
action. By involving them at an early point in the decision-making
processyoumaybeabletomakethempartnersintherelationshipthat
you share with the patient. By avoiding the family you may alienate
potentialalliesorworsenanalready‘difficult’group.
The‘difficult’familyis notuncommon.Longsubmergedconflicts and feelingsofguilttend
tosurfacewhenamemberofthegroupbecomesill.Recruitthemasalliesbyofferingthema
chance to participate, by ‘reading’the nuances of their relationships and by confidently and
continuously selling yourself as a knowledgeable and compassionate advisor. Use your first
meetingwiththefamilytomakeagoodimpressionandgaintheirtrustsothatyouwillcontinue
to be trusted when a complication arises or when further therapy becomes necessary.
Rememberthatifthingsturnoutbadlyitwillbethesurvivingfamilymembersthatwillwantto
know“whatwentwrong?”
Ethicalproblemsolving
In order to sell aparticular product or idea onemust believein it.In
other words, based on your knowledge and experience, the operation
youoffershould appearethicaltoyou.Itisethicalifitisexpected to
saveorprolongthepatient’slifeorpalliatehissymptoms,andcan
achieve this goal withareasonable risk-benefit ratio.At thesame
time you must also be convinced that there are no non-operative
treatmentmodalitiesthataresaferoraseffectiveasyourproposed
operation.Theburdenofproofisonyou!
Medicolegalconsiderations
Surgeryisthemostdangerousactivityoflegalsociety.
P.O.Nyström
The medicolegal dangers associated with emergency abdominal
surgery greatly depend on where you practice. In some countries
surgeons can get away with almost anything; in other countries
emergency surgery is a legal minefield. There are a few simple but
well-proventacticstopreventlawsuitsagainstyou:
•
Havethepatientandfamily‘onyourside’(asmentionedabove)
by being empathetic,caring, honest, open, informative, and at the
sametimeprofessional.Youngsurgeonstendtobeover-optimistic,
tryingtocheerupthefamily.Acommonscenariofindsthesurgeon
emergingfromtheoperatingroom,assuminga‘tiredhero’poseand
announcing: “It was smooth and easy, I removed the cancer from
thecolon,relievingtheobstruction.Iwasabletojointheendsofthe
boweltogether,avoidingacolostomy.Yes,yourfatheris stable,he
tooktheoperationverywell,let’shopehe’llbehomenextweekfor
Easter… (or Passover or Ramadan).” Such a script is somewhat
misguided in that it may raise high hopes and expectations, with
subsequentanger andresentmentif complicationsshoulddevelop.
The better script might be: “The operation was difficult, but we
managedtoachieveourgoals.Thecancerisoutandweavoideda
colostomy.Consideringyourfather’sageandotherillnesseshetook
it well. Let us hope for thebest but you must understandthat the
road to recovery is long and, as I mentioned before the operation,
therearestillmanypotentialproblemsahead.”
•
Detailed informedconsent ( Figure 8.1). This should be much
morethanthestandard,‘shablonic’sheet—listinginsmallprintall
possible complications ever described in abdominal surgery. The
chart has to include evidence that you have met with the
patient before the operation and discussed with them the
plannedprocedureanditsinherentrisks—andalternativesof
management.
•
Documentation.Thisiscrucial,aswhathasnotbeendocumented
in writing did not actually take place. Your notes can be brief but
mustencompass theessentials. Priorto anemergency laparotomy
for colonic obstruction we would write: “78 YO male patient with
hypertension, diabetes and COPD. Three days of abdominal pain
plusdistension.AbdominalX-ray—suggestingadistallargebowel
obstruction—confirmedonGastrografin® study. APACHEII score
on admission 17 — making him a high risk. Therapeutic options,
risksandpotentialcomplications,includinganastomoticleak,wound
infection, respiratory failure, explained in detail to the patient and
family who accept the need for an emergency laparotomy. They
understand that a colostomy may be needed and that further
operationsmaybenecessary.”Ayearorsolater,whenyouhave
todefendalawsuit,thisshortnotewillproveinvaluable!
Соседние файлы в папке Библиотека им академика М.И. Перельмана