NMS. Casos Clínicos

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Part I ♦ Foundations In this case, the patient’s serum electrolytes should be restudied preoperatively because diuretic therapy can cause abnormalities. If possible, the patient’s nutrition status should be improved . In addition, improvement in liver status will improve his chance for a successful outcome. Lastly, the patient has a very abnormal PT , which should be normal- ized with vitamin K, if possible, prior to surgery. Q: What factors might prompt a delay in the patient’s surgery? A: A high MELD status, classification in Child’s group C , and presence of acute alcoholic hepatitis make patients generally poor operative candidates. Time and alcohol abstinence allow alcoholic hepatitis to resolve. If surgery can be delayed, efforts to improve a patient’s liver status can also be instituted. You decide to delay the surgery and begin efforts to improve the ascites and normalize his PT. Q: How would your proposed management change in each of the following situations? Case Variation 1.7.1. The patient has a small ulcerated area on the hernia. ◆ ◆ The skin over an umbilical hernia can ulcerate due to pressure necrosis, thus increasing the risk of rupture , which has a mortality rate of 11%–43%. This hernia should be repaired in an expedient manner after proper inpatient management of ascites. Case Variation 1.7.2. The patient returns to the emergency department in a confused, disoriented, and mildly lethargic state. ◆ ◆ Evaluation for mental status change is necessary. Possible causes include electrolyte ab- normalities, gastrointestinal (GI) bleeding, sepsis, and an intracranial event (e.g., subdural hematoma or hepatic encephalopathy) related to liver failure. Development of spontaneous bacterial peritonitis or peritonitis related to cellulitis or infection on the umbilical hernia skin is also possible. The ascites should be tapped, and the patient should be treated with antibiotics if there are more than 250 white blood cells (WBCs)/mm 3 . Case Variation 1.7.3. The patient returns to the emergency department with serous fluid leaking from a small ulcer on the hernia. ◆ ◆ Ascitic fluid leaking from the umbilical hernia leads to an increased risk of bacterial peri- tonitis. The mortality rate is high, primarily due to infection. The serous fluid should be sent for cell count and culture, and IV antibiotics should be initiated before culture results return. The hernia should be repaired urgently . Case Variation 1.7.4. You smell alcohol on the patient in the office. ◆ ◆ The surgery should be delayed until the patient has abstained from alcohol and undergone withdrawal. Alcohol withdrawal during the postoperative period is associated with high morbidity and mortality. Case Variation 1.7.5. The patient tells you that there are severe hemorrhoids that need to be removed. Examination confirms several moderate-sized internal hemorrhoids. ◆ ◆ Hemorrhoid removal requires great caution in patients with cirrhosis and possible portal hypertension . Uncontrollable hemorrhage during surgical repair may occur as a result of portal hypertension. SAMPLE