Improving Analgesia in Emergency Departments: Optimising Use of Pethidine
FISTULA SURGERYFISTULA SURGERY OPTIMUM PRE AND POST-OP CARE. No robust studies (RCTs) ... Pethidine...
Transcript of FISTULA SURGERYFISTULA SURGERY OPTIMUM PRE AND POST-OP CARE. No robust studies (RCTs) ... Pethidine...
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FISTULA SURGERYFISTULA SURGERY
OPTIMUM PRE AND POST-OPOPTIMUM PRE AND POST-OP
CARECARE
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No robust studies (RCTs)
Recommendations are from
“Accepted Practice”
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First VisitFirst Visit
Careful history and
examination
Respecting the dignity of each
woman
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Rehabilitation
(A most important outcome)
Begins at first visit
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SOME STARK FACTSSOME STARK FACTS
850 Million people will go to bed hungry tonight
1 Billion today lack access to safe drinking water
10 Million children will die this year before their5th birthday
0.5 Million mothers (1 per min) will die inchildbirth (<1/2 of 1% of these will be inDeveloped World) while many suffer seriousmorbidity - all because appropriate emergencyobstetric care is not available (nor accessible) tothose who require it.
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Pregnancy historyPregnancy history
How many childrenalive?
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Gentle vaginal examination
(1 finger)
Exaggerated left lat. (Sims’) to
view VVF
Gentle P.R. – leakage may not
be volunteered
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Bladder stones felt
with metal catheter
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Counselling / ExplanationCounselling / Explanation
Removal of stones interval
weeks later, repair
Why advise colostomy?
Counselling re HIV
Advisability of any diversion
procedure
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Pre- OpPre- Op
Water: drinking (boiled), other
fluids, washing
Soap: washing pre and post-op
Soap powder for clothes
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Keep AmbulatedKeep Ambulated
Foot drop
Prevent / treat pressure
sores
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EnemaEnema 24 hours before surgery24 hours before surgery
Soiling during surgery seems
increased with ‘late’ enemas
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RVFRVF
If no colostomy, have enema
Fluids (oral only) for 2 to 3
days
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Anaesthesia guidelines agreed
by the team, with advice from
anaesthesiologist, about
what to do when certain
problems arise.
(Someone capable of intubation).
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Beware, that in treatinga maternal morbiditywe do not end with a
mortality
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Post-opPost-op
Nurse on alternate sides,
change 4 hourly and always
look towards drainage receptacle(s)
Encourage fluids
No food for RVF till day 5
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AnalgesiaAnalgesia
Pethidine 50 mg I.M.
4 hourly
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KEEP
PATIENT
CLEAN
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Drainage of BladderDrainage of Bladder
Balloon no more than 10 ml.
No kinks in catheter or
tubing
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Bag or receptacle at lower
level than bladder
‘Water flows down,
not up, hill’
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Beware waist belt or cord
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Avoid ‘trousers’ pre and post-op
Aim to get as much air as
possible to vulva
Maintain dignity with long
wide skirt
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Closed or open
drainage system ?
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Prophylactic antibioticsProphylactic antibiotics
No satisfactory RCTs in
fistula surgery
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If given, give appropriate
antibiotics
I.V. at induction of anaesthesia
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Specific problemsSpecific problems
No or little urine
Blood stained urine
Ureteric catheters
Rectal tube
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‘‘EarlyEarly’’ closure closure
Numerically not a significant problemin developing world – many seek
treatment after years
Spontaneous healing
Check catheter position
Most studies at 2 months – not early
Where fail, success ratesubsequently decreased
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The best time
to cure fistula
is at the
first attempt
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PreventionPrevention
isis
Best TreatmentBest Treatment
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Catheter DrainageCatheter Drainage
Early – tip: not in vagina
balloon not keeping fistula open
Early and late – not more than 10ml
balloon
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Waiting period 2-3 monthsWaiting period 2-3 months
Tissues become healthier and less
friable
Infection can be eradicated
Waiting hostel
Physiotherapy
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Other Clinical ProblemsOther Clinical Problems
Severe anaemia
Severe malnutrition
HIV infection
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Involved in prevention and
treatment strategies
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Clinicians can learn so
much from collaboration
with, and guidance from,
colleague(s) in
Public Health and
Epidemiology
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We owe it to the poor women
who suffer, to obtain robust
scientific evidence so that we
may inform correct,
appropriate health care
policies at regional, national
and international levels
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