Title: Ischemic bowel after open heart surgery
1Ischemic bowel after open heart surgery
2Introduction
- Acute mesenteric ischemia is a rare but severe
complication after open heart surgery. - Incidence 0.2-0.4
- Mortality rates 70-100.
- In 0.94 abdominal complication following cardiac
surgery, GI bleeding33 and mesenteric
ischemia27
3Risk factor
- Emergency cardiac surgery
- The use of IABP
- Failed angioplasty requiring emergency surgery
- Prolonged pump time
- Advanced age
Allen KB. et al. Acute mesenteric ischemia after
cardiopulmonary bypass. Journal of Vascular
Surgery. 16(3)391-5 discussion 395-6, 1992 Sep.
4 5Cause
- Arterial emboli
- Arterial thrombosis
- Nonocclusive ischemia
6Nonocclusive ischemia(I)
- Low cardiac output state?? blood flow in
mesenteric vessel? mesenteric vasoconstriction
and redistribution of blood flow - Nonpulsatile blood flow during CPB angiotensin
II release Huddy SPJ. et al.Gastrointestinal
complication in 4473 patients who underwent
cardiopulmonary bypass surgery.Br J Surg
199178293-6
7Nonocclusive ischemia(II)
- Catecholamines use in early postoperative phase
- Changes in microcirculation because of ?blood
viscosity via fluid restriction and diuretic
therapy
8Diagnosis
- Ventilator support and heavy sedation, making
communication and PE difficult. - Delay in diagnosis of 9.5 days Allen KB. et al.
Acute mesenteric ischemia after cardiopulmonary
bypass. Journal of Vascular Surgery. 16(3)391-5
discussion 395-6, 1992 Sep. - Angiography is the golden standard of diagnosis.
Other methods were not reliable.
9Presentation
- Abdominal pain with tenderness
- Diffuse abdomen pain with flatulence and absence
of bowel sounds - Abdominal guardingperitonitis
- Renal insufficiency
- Hemodynamic instability
10Laboratory
- Hyperamylasemia
- Metabolic acidosis
- Hyperkalemia
- Leukocytosis
- Fever
- no single lab test is both sensitive and specific
- Leukocytosis--91.7
- Metabolic acidosis--83.3
- Lactate ?--100
- Cre.?--100
- Osmolality ?--100
- sodium?--75
- Lactate acidosis type A with hyperosmotic
dehydration was revealed in 100
Allen KB. et al. Acute mesenteric ischemia after
cardiopulmonary bypass. Journal of Vascular
Surgery. 16(3)391-5 discussion 395-6, 1992 Sep.
Schutz A. et al.Acute mesenteric ischemia after
open heart surgery. Angiology. 49(4)267-73, 1998
Apr.
11Angiography
- The gold standard
- Whenpt with one or more risk criteria,
suspicious abd. symptoms, leukocytosis, lactate
acidosis, severe hyperosmotic dehydration. - Whatnonocclusive(58.3) and occlusive proximal
mesenteric artery(41.7) Schutz A. et al.Acute
mesenteric ischemia after open heart surgery.
Angiology. 49(4)267-73, 1998 Apr. - Howballoon angioplasty(PTA), infusion of
Papaverine(60 survival)
12Conservative treatment with local vasodilation(I)
- Typical sign
- narrow and spastic branches,
- irregular spasm(string of sausage sign)
- impaired filling of arcades and intramural
vessels - Method intraarterial perfusion of
Papaverin(30mg/h)
Niederhauser U. Mesenteric ischemia after a
cardiac operation conservative treatment with
local vasodilation. Annals of Thoracic Surgery.
61(6)1817-9, 1996 Jun.
13Conservative treatment with local vasodilation(II)
- Angiography 16 hrs later ?vasospasm
- Local application of vasodilators
- ?mortality(60-90 to 40-50),
- ?extent of bowel resection if laparotomy
14Laparotomy
- Laparotomy should not be delayed
- Missed intestinal infarction 100 mortality rate
- Grossly infarction bowel should be resected
15Conclusion
- Occurrence of typical symptoms angiogrphy and
laparotomy must be done very urgently. - Prognosis of mesenteric gangrene very poor,
despite extensive bowel resection. - Preventive measure in high-risk pt
perioperative hyperosmotic dehydration should be
avoided.
16Thank you very much!