PITTFALLS ON ACUTE ABDOMEN - .Pitfalls on Acute Abdomen Cause of Acute Abdomen (1) Urgent...

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PITTFALLS ON ACUTE ABDOMEN

1st Surabaya Gastrointestinal and Emergency Surgery (SuGIES), Hotel Novotel Surabaya, 19 20 May 2017

Prof. Dr. P. Soetamto Wibowo, Sp.B-KBD Dep/SMF I. Bedah FK. Unair/RSUD Dr. Soetomo Surabaya

An error the breath of a single hair can lead one a thousand miles astray Chinese Proverb

WHY ?

Medicine : High Risk System with High Error Rate

Cross Industry Comparison of size, productivity and efficiency (the Advisory Board Company 2005 )

Complications and Adverse Events

in Surgery

10% of hospital admission suffer harm, half is preventable [1,2]

50% - 75% of hospital wide adverse events are attributable to surgical care.

Most errors occur in the OR [3]

[1] Thomas EJ, Clinical Risk Management Enhancing Patient Safety, BMJ Publ. 2001 : 31-44 [2] Vincent C. System Approaches to Surgical

Quality and Safety, Ann. Surg. 2004; 239 : 475-482 [3] Healey MA, Complications of Surgical Patients, Arch Surg. 2002; 137 : 611 618

Insurance Premium $ 30,000 - $ 300,000 / yr

Health Cost

Rising Cost of Health Care is just a symptom

WHAT IS THE REAL DISEASE ?

GREED and INCOMPETENCE ?

Do not count for double digit

(Thomas A Lee, HBR, Apr 2010)

Pitfalls on Acute Abdomen

The Paradox

Institute of Medicine (IOM) 1999 :

To Err is Human (1)

not an explanation accepted by the media, the public, the insurance companies, or lawyer.

(1) Institute of Medicine. To Err is Human. Washington DC. National Academies Press, 2000.

Pitfalls on Acute Abdomen

Taking Ownership

Leape and Berwick (1) 2004 :

We will not became safe until we chose to become safe Patients safety.

(1) Leape L, Berwick D. Five years after To Err is Human What we have learned ? JAMA 2005 : 293 : 2384 2390

Leadership

Performance

Pitfalls on Acute Abdomen

Errors in Human Performance

Errors Categories (1) :

Knowledge base

Lack of experience or knowledge or misintepretation of the problem

Rules based

Misperception or misapplication of the rule

Skill based = slips

Reason J. Human error. Cambridge, MA. Cambridge University Press 1992

Case 1

54 years old man with sudden right upper abdominal pain for 5 days

Fever + ED

PE : Abdomen RUQ

Rigidity +

Murphy signs +

General peritonitis

USG : Gallbladder stone +

Thicken wall

Double layer

Pericystic fluid

Perforated gallbladder ?

Rules Tokyo Guidelines Surgery ?

Evidence Based Golden Rules

Emergency Surgery

Usually doing less is betterbut

Occasionally doing more may be life saving

Acute Abdomen :Operate only when necessary and do the minimum possible

butDo not delay a necessary operation

and do the maximum when indicated

Pitfalls on Acute Abdomen

Errors Training

Whoever refuses to admit error may be a great scholarbut

He is not a great learnerJohann Wolfgang von Goethe 1749 1832

Fitts and Posner Model (1) :

If you commit any mistake there are 3 things to do :

Admit it

Learn from it

Dont repeat it

(1) Fitts P, Posner MI. Human Performance, Belmont, CA : Brooks / Cole Publ. 1969

Compassion

Pitfalls on Acute Abdomen

Acute Abdomen

Definition :

Pain of non traumatic origin with a maximum

duration of 5 days (1)

Account 7 10 % of all Emergency Department

(ED) (2)

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

(2) Hasting RS, Power s RD. Abdominal pain in the ED. A 35 years retrospective . Am.J. Emerg.Med 2011; 29 711 716.

Pitfalls on Acute Abdomen

Acute Abdominal Pain (AAP)

Great caution Problem

AAP can be caused by variety of diseases from mild self limiting live threatening diseases

Early accurate diagnosis better outcomes

Diagnostic practice varies within hospitals and within specialities

Despite substantial improvement in diagnostic approach, pitfalls remain misdiagnosis error

Medicolegal Litigation

Pitfalls on Acute Abdomen

Cause of Acute Abdomen (1)

Urgent Treatment within 24 hours

Non Urgent Not requiring treatment within 24 hours

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

Pitfalls on Acute Abdomen

Diagnostic Pathway

Step 1 :

Medical History

Physical Examination

Laboratory : CRP > 100 mg/dl

WBC > 15x109/L

Correct Diagnosis in 46% - 48% (1,2)

Higher sensitivity for differentiating urgent from non urgent than for specific diagnosis (EL A2) (1,2)

(1) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

(2) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

Pitfalls on Acute Abdomen

Medical History History History

Previous similar pain

Previous abdominal surgery

Previous major illness

Gynecologic history

Drug history

nset sudden chronicrovocative Progress What make it better worse

no change movement uality Colicky sharp burning egion General localized

radiated migrated reverseverity Mild moderate - severe ime begin - duration

O

P

QR

S

T

Pitfalls on Acute Abdomen

Medical History

Case 1

9 yrs old boy abdominal discomfort

+ diarrhoea ED : Dx gastroenteritis

The clinical notes did not cerroberate

4 days no better ED : ongoing GE

Overnight the boy deteriorated ED

ED Dx : burst appendix abscess surgery

2 weeks discharge

claim out of court settlement

Pitfalls on Acute Abdomen

Medical History

Case 2

70 yrs old woman with sudden abdominal pain for one day + fever + vomiting

ED : there was no written note to support the doctor in charge contention that the abdomen was examined.

Lab : WBC 13x109/L Blood sugar 250 gm/dl

Consult internist : urine shutdown, s.creatinine 2.5 gm/dl

Consult Nephrologist resuscitation ICU

Day 1 GCS Consult Neurologist

Day 2 her condition deteriorated ?

Abd X-ray : Free air : positive surgeon : perforated peptic ulcer

Pitfalls on Acute Abdomen

Diagnostic Pathway

Step 2

Urgent condition imaging :

1. Conventional Radiography

Plain chest x-ray

Plain abdomen : upright position

supine

left lateral decubitus

Diagnostic accuracy 47% - 56% (ELA2) (1,2)

No added value on top of clinical assessment

in discriminating urgent or non urgent causes (ELA2 (1,2)

Only for bowel obstruction

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

http://127.0.0.1:1818/chaps/48FF20http://127.0.0.1:1818/chaps/48FF20

Pitfalls on Acute Abdomen

Diagnostic Pathway

2. Ultrasound (US)

Advantages : widely available

no risk of radiation

no risk of nephropathy

Downside : operator dependent

Clinical + USG dx accuracy 53% - 83% (ELA2 (1,2)

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

Pitfalls on Acute Abdomen

Diagnostic Pathway

3. Computed Tomography (CT)

Clinical + Radiography + CT accuracy final diagnosis 61.6% - 96%

(ELA2) (1,2)

Prefer i.v. contrast eGFR > 45 ml/min/1.73m2 (3)

Recom (1,2) :

USG CT (conditional)

Laparoscopy : No Research (1,2)

MRI : No place yet (1,2) non urgent

Pregnant woman

(1) Lameris W, von Randen A, von ES HW et al. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain;

diagnostic accuracy study. BMJ 2009; 339 : 62431

(2) Gans SL, Pols MA, stoker J. et al. Guidelines for the diagnostic pathway in patients with acute abdominal pain . Dig. Surg. 2015; 32 : 23 31

(3) Katzberg RW, New house JH : Intravenous contrast medium induced nephro toxicity is the medical risk really as great as we have come to

believe ? Radiology 2010 ; 256 : 21 28.

inconclusive

Pitfalls on Acute Abdomen

Cause of AAP Evidence

n %

Nonspecific Abdominal Pain (NSAP) 1.680 31.46

Renal Colic 1.665 31.18

Biliary 411 7.70

Appendicitis 203 3.80

Diverticulitis 194 3.63

Urologic 147 2.75