SA Sx - GDV 1

drraythe's version from 2017-09-13 18:43

GDV arriving

Question Answer
How is GDV characterized?Syndrome is characterized by accumulation of gas in the stomach & Malpositioning of the stomach w/ obstruction of eructation & pyloric outflow
What is Gastric dilatation w/o rotation like?No burping, belching or any other way to get rid of gas bc pylorus is obstructed
What does GDV stand for?Gastric dilatation - volvulus
Whats particularly awful about the "volvulus' part of GDV?Twisting of stomach twists vessels - cut off blood supply
You should be doing constant monitoring, esp to make sure...Heart, Lungs & Brain are perfused
How does Gastric dilatation w/o rotation happen?No burping, belching or any other way to get rid of gas bc pylorus is obstructed, or dog eats a TON of food at once...
How urgent is GDV?Considered a clinical-surgical emergency w/ a High mortality rate (15-28%, was 42%). Its physiopathology can involve all types of shock
Whats going on w/ the chronic form of GDV?Chronic form - goes on for a long time, dog tends to vomit & nothing comes out & survives but theres a lot of damage to the stomach that occurs, fibers of stomach may not go back to normal precision, recurrent episodes
Ideal situation for GDV is having them stabilized. What if you cant?Better if stabilized, try to optimize if you can, sometimes you cant even get that & you just gotta go into Sx
Which vessels should you be gaining IV access to if a dog comes in w/ GDV? Which vessels should you not use?USE external JUG! BIG VESSELS! If you ligate them theyll be ok. Cephalic if you must. DONT USE SAPHENOUS!! Stagnation of blood from diaphragm backwards, so useless.
You need a well-organized crash cart, as well as a funnel & a bucket-why?Funnel to lavage stomach, bucket to recover lavage fluids
Why cant you use the saphenous for venous access in a GDV?The swelling of the stomach from the trapped gas blocks venous flow from vena cava & portal vein, so blood flow of entire back of animal is compromised
Possible etiological czs of GVD?Etiology UNKNOWN. However, could be due to... delayed gastric emptying, laxity of ligaments (ones that connect stomach to wall as well as gastrosplenic), commercial diets
RISK FACTORS for GDV?Large/ Giants breeds
Deep/narrow chest
Single meal
Rapid ingestion/aerophagia
Exercise after eating
Can cats get GDV?Yes!
Why might there be altered cardiovascular & resp parameters?Stomach pressed against heart, great vessels, diaphragm
How might the spleen be affected by GDV?Splenomegaly, or altered position
What type of saliva might you see w/ GDV?Foamy mucus (can also have heavy salivating/drooling)
Gastric Dilatation → stomach distension czd by?Air, fluid, food & a frothy mucoid substrate
Why can gastric dilation w/ no volvulus still cz huge problems?Theres no twisting but theres a huge stomach pushing forward & causing pain >> ileus. Then, bacteria are starting to replicate from ileus (no peristalsis gives them a chance to stay in 1 place & replicate), normal peristalsis helps stop bact from establishing
What is Gastric Torsion? How often is this seen?When the stomach twists abruptly on the long axis & rotation is LESS THAN 180 degrees & there is no complete obstruction. This stage can be overlooked bc there is no complete closure of the gastro-esophageal jnxn
What is Gastric Volvulus?Twisting takes place over the long axis of the stomach & rotation of the gastro-esophageal jnxn is greater than 180°, w/ esophageal & pyloric obstruction
Torsion vs volvulusVolvulus >180°, torsion <180°,
How can you tell there is volvulus the moment you open the abdomen?Everything is covered in omentum
What are the 2 things that are necessary for GDV to occur?(1) Failure of normal eructation
(2) Acute pyloric outflow dysfnxn
What are the degrees the stomach rotates if it goes in a clockwise fashion? Counterclockwise? Which happens more often?Clockwise rotation is usually btwn 180° & 270°. Counterclockwise is 90°...almost always a clockwise rotation (the worse 1 of course)
Which would you rather have - clockwise or counterclockwise rotation?COUNTERclockwise bc only goes 90° (instead of 180-270) so less damage (counteract the awful w/ a counterclockwise turn)
If the stomach is covered in omentum, which way did it rotate?Clockwise (180-270°)
Why should you never rapidly rotate the stomach back once exposed?Reperfusion injury
You can't rotate the stomach right away due to reperfusion injury, but what can you do while you start to try to?Vessels are twist, caudal vena cava cant empty, lots of pressure against the heart & lungs after turning the stomach a quarter of the way, let blood flow through the liver a few times while animal is "stabilizing"
What can you do to help decompress the stomach quickly?Release air w/ a large bore needle
what is the problem that this picture is talking about
The gigantic rotated stomach is compressing the vena cava, so vessels not able to drain well.
Why must fluid levels be monitored super carefully & be changed even after the procedure?Worried about kidneys! Look out for urine output - if below 500mmhg, can get kidneys shutting down. So make sure kidneys are ok.
How should you derotate the stomach? Why?A quarter at a time to try to minimize reperfusion injury & let them re-stabilize a little at a time
How/when will peristalsis restart?Once you derotate the PTx when you pinch the intestines they will slowly recover the peristalsis
When do most GDVs present?NIGHT is most common time (68.7%) followed by afternoon, followed by morning
What are 3 methods for gastric decompression? (Do you put the animal under for each?)Orogastric intubation (awake/ sedation narcosis). Gastrocentesis (awake or not) Gastrostomy (local ANx?)
If you are going to try orogastric intubation, what should you do before you start & what should you be careful of?Mark tube outside of body apprx where you wanna be so you know where you are when you are shoving a tube down there (8th-9th IC space). (Use marker, not tape that can loosen) DO NOT USE forceful pushing of tube to pass → it can perforate bueno
What is Gastrocentesis?Stick a needle/trochar into stomach through abdominal wall
What is/what do you do in Gastrostomy?Temporarily (flank approach/incision) creation of new opening - stomach exposed. But you do it in any position the stomach is in... Will need to put stomach back into normal position
Downside of gastrostomy?When you get ready for Sx, need to close the stomach whole, then reposition the stomach, then do Sx. takes too much time
How should you prepare the tube for orogastric intubation & how can you prevent biting & occlusion?(Dont forget to mark length beforehand) make sure to lube! Put 2-3 additional holes so there is not occlusion & you can place a roll of tape btwn their incisors & pass it through the core to keep them from biting down
Where is the esophageal hiatus?8th-9th intercostal space (where you want your tube to be)
When you are trimming extra holes into the orogastric tube, what rules should you keep in mind?Only 2 or 3max holes, make sure they arent more than 20% of circumference
If you successfully pass the orogastric tube, you will hear & smell...Hear a hissing sound & the air will smell like concentrated acid
After you successfully pass the orogastric tube, what do you do?Get your funnel & your bucket - angle dog up w/ head up at 45° angle & lavage stomach w/ water (he recc cold water to numb a bit & reduce chances of vomiting)...then lie them back down on the table & place bucket at end of tube hanging down, have assistant squeeze dog from behind to help get fluids out into bucket
If you get thick saliva & brown coffee-ground looking fluid in your bucket after lavaging the PTxs stomach, what do you think it means?Mucosa sloughed off - denuded mucosa of stomach
When do you remove the orogastric tube?Not till after Sx
Do you do orogastric tube or gastrocentesis 1st?Gastrocentesis is PLAN B - do when you cant pass the tube
With what tools do you perform a gastrocentesis?LARGE BORE catheter (that are LONG 14/16g (like horse caths) NOT a trochar.
What should you be very aware of & percuss to try to locate when doing a gastrocentesis?DO NOT HIT THE SPLEEN! Percuss abdomen for most tympanic area look out for dull sounds, could be spleen
Explain how to do the gastrocentesisSterile procedure - clip+ scrub! Insert cath, percuss, remove stylette, hear hiss & smell the acidy smell...then push abdominal wall gently & *hold cath as you do so (pushing it along with the belly)*
How do you make sure that the catheter you use for the gastrocentesis doesnt get occluded?Cut in extra holes (shouldnt not be larger than 30% of circumference)!!! Bc otherwise can BREAK in the dog
Gastrostomy is the last ditch effort if you cant do anything else (no good but described in literature) what technique would you use?Grid paracostal approach
CSs of PTxs at Risk?Dyspnea w/ abdominal component
Debilitated, decreasing consciousness
Dec HR
Inc resp rate followed by a reduction
Hackles raised
If you see a dog w/ GDV suddenly raise their hackles, arch back, stretch out legs... what should you be prepared for?CPR - usually do this right before they die. **DONT FORGET TO TURN OFF ANESTHETIC GAS
What kinda priority do you have w/ taking radiographs of a GDV PTx?Do not delay therapy for an X-ray!!! radiographs are used to distinguish gastric dilatation from gastric dilatation volvulus - which means obtaining radiographs is not therapeutic, the PTx must be stabilized 1st…(dont do rads 1st!)
Should you restrain a GDV dog?No...just added stress
What does GDV look like on a lateral view? How about the DV/VD<-which one, why? : LATERAL = Popeyes arm, smurfs hat.
Want DV & not a VD bc VD adds extra pressure & weight onto the lungs
VD = Looks like "double bubble"/compartmentalization (usually extends beyond 8th IC space)
Question Answer
Once you've decompressed the stomach... what next?When decompressed, HR, RR, BP improve...then you need to do Sx!! Explain to owner this is a syndrome. If only decompression, can reoccur (even in a few hours), or end up w/ chronic torsion
Sx management of GDV has what 3 primary OBJECTIVES?(1) Reposition the stomach (stomach tubing?)
(2) Assess the severity of ischemic injury to the stomach & spleen & “resect” any devitalized tissue
(3) Perform a permanent gastropexy to prevent recurrence
When lavaging & then draining the stomach, what should you be cautious of?Make sure dogs head is DOWN so they don't aspirate any liquid
Do you wanna give ABx to a GDV PTx?YES! Ileus → bacterial translocation
If there is mucosal sloughing that you find upon lavageing, what are some things you can do to help this?Use mucosal protectants if there is mucosal sloughing & proton inhibitors & special food (basically like ulcers)
Which vessels should you check when you have a GDV PTx?Check SHORT GASTRIC VESSELS
Which 2 organs should you DEF check if the dog gets GDV?Check SPLEEN & PANCREAS
What is MDF? How does it relate to GDV?"Myocardial depressant factor" is a polypeptide the pancreas can make if it's too pissed off which can be detrimental to the heart
What will gastropexy not fix?Can still dilate
If there is splenic torsion, what should you do?Remove spleen w/o untwisting or see if its still viable
How should you open abdomen for GDV Sx?(Remember to prepare entire area bc you dont know how much space youll need or what procedure youll need)
Make sure stab incision through linea alba....can start at level of umbilicus & then use grooved director to avoid hurting underlying organs
The 1st objective of surgical management of GDV is?If the repositioning is correct, the pylorus should be back on the right & the gastroesophageal jnxn should not be twisted
How much fluid do you want to leave in the stomach after the lavage?NONE! The emptier the better for Sx procedures
Why is it so important to get any fluids out of the abdomen?Lots of serosanguineous fluid, esp if vasculature has ruptured. Lavage & clean this - blood is a great medium for bact to grow.
Why do you want to make sure bladder is catheterized?Bladder should be cath so know there is normal urine production (which is 1-2ml/kg/hr)
What is the 2nd objective of surgical management of GDV?Stomach is assessed using the standard criteria of color, presence of pulsating vessels, peristalsis & bleeding from the cut surface. Another useful technique is to palpate the thickness of the stomach wall → devitalized areas will feel thinner than adjacent viable tissue
Why do you not want to leave devitalized areas in?They can rupture?
Which colors of tissue are ok to leave in, which arent?Red to violet ok, green to black, prolly need to remove.
What can you do to possibly revive some of the color of the stomach? How do you check if tissue is viable?Moist lap sponge w/ moist warm saline to help recover color. Scrape surface gently w/ scalpel & see what comes out - if dark & sluggish, no bueno. Want good bleeding/ something reddish
If you see a "String of pearls" near the spleen, what do you think it means?Spleen not working well (hemorrhagic lesions bc congestion & rupture of vessels - string of pearls-clots w/i vascular supply, hemorrhagic spleen)
What should & shouldnt you do if the spleen is twisted?DONT untwist - will release tons of free radicals. Knick it & see if the tissue is still viable
How can you assess the intestines?Pinch test
Assess peristalsis
Where would you look to see if there was a pulse in the intestines?Mesenteric side
How commonly are gastrostomies done now?Not used anymore bc increases morbidity & mortality. but approach can be used for gastropexy
If the stomach is greatly expanded, might be hard to grab linea alba - what do then?May have to go by umbilicus to make incision bc linea alba can be hard to grasp & then use grooved director. Intestines can splooge out. Omentum covering stomach indicates clockwise rotation. Look at serosa & muscularis of stomach color.
Normal urine production is?1-2 ml/kg/hr
Why might the spleen be super big?Engorged w/ backed up blood