KULIAH PRABEDAH PPDS I ILMU BEDAH FK UNUD/RSUP SANGLAH

TOPIK :1. Vascular trauma2. Limb Ischemia (ALI, PAD/ CLI )3. DVT4. DM-DF5. Trauma toraks6. Efusi pleura

Figure of diagnostic and treatment algorithm for extremity trauma

Type of vascular injury

• Complete transection• Transection and

thrombosis• Contusion and

thrombosis• Laceration• Dissection

Type of repair

• Reverse autogenous vein graft

• End to end anastomosis• Patch plasty• Lateral suturing• PTFE graft

Time lag of vascular trauma

the incidence of limb loss1 – 6 h : 10%12 – 18 h : 50%24 – 30 h : 80%

Treatment of vascular trauma general principle

assessed for presence other injuries life threatening injuries must be treated immediate control for hemorrhage : direct digital pressure,

packing and pressure dressing tourniquet should be discouraged interupt venous return &

collateral hemorrhagic shock corrected Antibiotics broad-spectrum open wound explored only in OT all resuscitative, diagnostic effort must be minimizing time lag

to definitive treatment ( best within 6-8 h )

Method of surgical repair

Ligation Lateral suture Vein patch Resection with

- End-to-end anastomosis - Autogenous vein graft - Prosthetic graft

Scoring systems to predict amputation and functional outcome

• Mangled Extremity Syndrome Index (MESI)• Mangled Extremity Severity Score (MESS)• Predictive Salvage Index (PSI)• Limb Salvage Index (LSI) • Prediction of amputation was sensitive and specific, but prediction of

functional outcome was universally poor.• The MESS score appears to be the most commonly used method and is

based on criteria that include (1) degree of skeletal/soft tissue injury, (2) limb ischemia, (3) shock, (4) patient age.

• no one system is universally accepted.

The Mangled Extremity Severity Score (MESS)

Objective criteria for amputation prediction after lower or upper extremity injury.

A MESS of >7 has been used as a cutoff point for amputation prediction.

A MESS of >7 does not always indicate that amputation is required; however, MESS is a better predictor for patients who do not require amputation when the score is <7.

The decision regarding whether or not to amputate should be made individually based on clinical signs and intraoperative findings of irreversible limb ischemia.

ACUTE LIMB ISCHEMIADiagnostic criteria

• TransAtlantic Inter Society Consensus (TASC)Working Group– Sudden decrease or worsening in limb perfusion causing a potential

threat limb viability

• Less than 14 days• Symtom & sign : 6P

– Pain– Paresthesia– Paralysis– Pallor – Poikilothermia– Pulselessness

Anaesthesia and paralysis are the key to diagnosing complete ischaemia that requires emergency surgical treatment

ACUTE LIMB ISCHEMIAAssessing limb viability

• SVS / ISCVS criteria for limb viability

Category Description / prognosis

Sensory loss Muscle weakness

Doppler arteril Doppler venous

I. Viable No threatened N one None Audible Audible

II. Threateneda. Marginalb. immediate

Salvable Salvable with immediate revascularitation

Minimal /noneRest pain

NoneMild, moderate

Inaudible (often)Inaudible (usuallly)

Audible Audible

III irreversible Major tissue lossNerve damage

Profound, anesthetic

Profound, paralysis

Inaudible Inaudible

ACUTE LIMB ISCHEMIAclinical assessment & management strategy

1. Limb viability ( I-III )2. Investigation : noninvasive and invasive imaging 3. Urgent revascularization ( class I – IIb )

Thrombolysis Embolectomy (fogarty catheter) Primary By-pass Angioplasty Fasciotomy if compartment syndrome

4. Primary amputation after demarcation ( class III )5. Anticoagulant 6. Reperfusion injury awarness and management

ACUTE LIMB ISCHEMIAAnticoagulant

• Earliest reduce proximal & distal thrombosis Heparin bolus, IV, 10.000 U, followed by 500-1500 U /h

• As Nonoperative management High dose heparin 10.000-20.000 U bolus ,followed 1000-4000 U /h

Peripheral Artery Disease (PAD)

• Diagnosa – Leg symptoms (Fontain or Rutherford

classification)– Risk factors– Ankle Brachial Index (ABI) < 0,9

Fontaine Classification Rutherford Classification

StageClinical

Description Grade CategoryClinical

Description

I Asymptomatic 0 0 Asymptomatic

IIa Mild claudication I 1 Mild claudication

IIb Moderate-to-severe

claudication

I I 2 3 Moderate claudication

Severe claudication

III Rest pain II 4 Rest painIV Ulceration or

gangreneIII IV 5 6 Minor tissue loss

ulceration or gangrene

Table. Classification of PAD: Fontaine’s Stages and Rutherford’s Categories

Circulation 2007; 116: 2203-2215

Lower Extremity PAD : treatment

1. Cardiovascular Risk Reduction2. Claudication 3. CLI and Treatment for Limb Salvage

SURVUE-5

REVASCULARIZATION• Indications : salvage and pain-free extremity.

• Contraindications : patients not fit for revascularization; revascularization not technically possible (unreconstructable vascular disease), benefit cannot be expected (i.e. widespread ulceration gangrene, persistent infection

• The treatment chosen depends : risk of intervention based on co-morbid, expected patency and durability of the reconstruction, location and morphology of the disease

• Adequate inflow must be established prior to improvement in the outflow.

Clinical characteristics (Well’s criteria):

• Active cancer

• Paralysis or plaster immobilization

• Bedridden ≥ 3 d; major surgery in 3 mo

• Entire leg swollen

• Calf swelling > 3cm

• Pitting edema in affected leg

• Collateral non-varicose superficial veins

• Localized tenderness along deep veins

• Previous DVT

• Alternative dx more likely

Pre-test Probability - DVT

[Wells PS. NEJM 2003;349:1227-35]

1

1

1

1

1

1

1

1

1

-2

• score < 2: DVT unlikely

• score ≥ 2: DVT likely

Treatment of DVT : dose,duration, and monitoring

Drug Dose Duration Monitoring

UFH

Loading dose 5000 units iv or 100-150 IU/kg, followed 20.000 - 40.000 IU every 24 hrs the dose can be adjusted based on aPTT /INR

for at least 5 days with warfarin started simultaneously on the first treatment day and discontinuation of heparin when the INR is stable and >2.0.

aPTT/INR twice daily, then once daily after aPTT has stabilized ) full anticoagulation, defined as aPTT 1.5 to 2.5 times or INR 2-3

Patients with renal failure are best treated with UFH.

LMWH

1.5 mg/kg sc once/day or 1 mg/kg sc q 12 h to a maximum of 200 mg/day

for at least 5 days with warfarin started simultaneously on the first treatment day and discontinuation of LMWH when the INR is stable and >2.0.

Monitoring is unnecessary because do not significantly prolong (aPTT),, and there is no clear relationship between LMWH overdose and bleeding.

Warfarin

5 to 10 mg loading dose, maintenance dose depending on INR

Therapeutic goal is INR 2-3. Againts high-VKA-intensity therapy (INR>3) or low-VKA-intensity therapy (INR<2)

except pregnant women (recommend LMWH or UFH) Duration 3 to 12 mo

INR is monitored daily from day-2 until R/ range, then 2-3 times weekly for first 2 week, once weekly for the first 1 to 2 mo , once monthly therafter

Thrombolytic

Streptokinase :loading dose 250.000 U over 30-60 mnt, maintenance dose 100.000 U/h , rt-PA 1-5 mg/h

for 24-48 hrs or longer

Hallet et al. Comprehensive Vasc & endovasc surgery. 2004 ; 625-661 . ACCP guidelines. Büller H et al. Chest 2004;126:401S-428S , Greenfield LJ. Vascular surgery. 1994; 852-864

Surgery in DVT• Rarely needed (Grade C) , not widely accepted invasive, thrombolysys / minimaly invasive preferred choice long-term uncertain, short-term superior to anticoagulant• Most focus to prevent PE, extent thrombus, reccurent. Less sequelae.! New

data on inflamatory response to DVTremove thrombus as early and quickly as possible

• Indication :– Iliofemoral DVT, not candidate for thrombolysis– Phlegmasia alba or cerulea dolens – Unresponsive to thrombolytics to try to prevent limb gangrene.

• Timing : < 6 days the onset of symptom, longer adherent, difficult removal, rethrombosis. Floating thrombus or segmental iliac or femoral thrombose, up to 4 weeks

• Type : Thrombectomy +/- AV fitula, femoral crossover bypass, ligation

TRAUMA TORAKS

• DIAGNOSTIK– FISIK– PLEURAL TAPING– IMAGING : CXR, CT SCAN, CT ANGIO, AORTOGRAFI, ECHO– EKG

• MANAGEMENT– MRS– PAIN MANAGEMENT– THORACOSTOMI-WSD– AIRWAY MANAGEMENT (TRAKEOSTOMI, BRONKOSKOPI )– VENTILATOR SUPPORT– SUBXIPHOID PERIKARDIOSTOMI– TORAKOTOMI EXPLORASI / RESUSITASI– TORAKOTOMI & RIB FRACTURE STABILIZATION (SHAPP CLIP)

Indikasi stabilisai interna( SHAPP Clip Costae )

• Nyeri berlebihan dan berkepanjangan (intractable pain)

• Distres nafas• Atelektasis• Kontusio paru• Fraktur multipel, flail chest• Pneumotorak/hematotorak persisten

Chest radiographic findings suggesting aortic injury

• mediastinal widening > 8cm• loss of the aortic knob• displacement of the nasogastric tube to the right of the T4 spinous process• left apical pleural cap• widened paraspinal lines• widened right paratracheal stripe > 5mm• loss of descending aorta line.

Thoracostomy-WSD

• Site• Direction• Function : Bubling, undulation

• Follow-up : CXR, No clamp, < 100 ml/d

DM-DF

Wagner Grading

• 0 lesi preulserasi, kulit intak• I ulkus superfisial• II Ulkus dalam s/d tendo-tulang• III Abses +/- osteomielitis• IV Gangren jari / kaki distal• V Gangren seluruh kaki

PENANGANAN1. Debridement2. Off Loading3. Antibiotik4. Perawatan luka5. Revaskularisasi

Ulkus DM dengan infeksi

Infeksi ringan Infeksi berat

Radilogi, Ya MRS Debridement osteomielitis Antibiotika, IV Evaluasi osteomielitis

Tidak

Rawat jalan Osteomielitis ada Tidak ada

Tidak Reseksi tulang Ya AntibiotikaPerbaikan dlm 48 jam Revaskularisasi 2 minggu

Ya Tidak 7-14 hr Antibiotika Antibiotika evaluasi ulang osteomielitis 6 - 8 minggu

Gambar 3. Managemen ulkus diabetikum dengan infeksi

Pedoman penggunaan antibiotika

1. Faktor lokal2. Terapi awal :

empiris broad spectrum

streptokok dan stafilokok kombinasi

3. Cara pemberian4. Durasi

5. Terapi definitif sesuai kultur respon klinik

Efusi Pleura

Transudate Eksudate

Tes Rivalta (-) (+)Protein < 3 g/dl > 3 g/dlPleural fluid / serum protein ratio * < 0,5 ≥ 0,5Berat jenis < 1016 > 1016LDH < 200 IU > 200 IUPleural fluid / serum LDH ratio * < 0,6 ≥ 0,6Type of cellular > 50 % > 50 %

Limfosit MN Limfosit PMN

Number of cellular normal increasepH > 7,3 < 7,3Glukosa = glukosa darah < glukosa darah (< 40)

MANAGEMENT OF PLEURAL EFFUSION 1. Identification

– Transudate vs exudate – Malignant pleural effusion

Fluid should routinely be sent for 1. chemical analysis 2. cytology3. microbiology stains and culture

2. Treatment - Causative / underlying process treatment- Complete removal of effusion

1. thoracocentesis2. tube thoracostomy (standard)3. open drainage / VATS with decortication (if loculation or

extensive fibrosis and adhesion)4. pleurodesis ( if recurrent or malignancy)5. pleurectomy (if all above failed)6. pleuroperitoneal shunt ( if all above failed )

Malignant Pleural Effusion

• Definition : malignant cells in pleural fluid or pleural tissue• Pathogenesis :

– Direct extension and Haematogenous invasion of tumor to pleura Lymphatic channel and lymphnode blocked impaired lymphatic clearance of

protein and fluid Inflamatory response to pleural tumor invasion ↑ microvascular permeabelity

• Pleural fluid characteristics :– Serous(lymphatic obstruction) , serosanguineous, hemorrhagic (direct

pleural involvement)– Exudate

• Management :– Investigation source of malignancy– Treatment of primary tumor– Drainage : tube thoracostomy + pleurodesis (w/ talc, tetracycline)