VCUDEATH AND COMPLICATIONS CONFERENCE

Complication Necrosis of ileostomy

Procedure Parastomal hernia repair, revision

of ileostomy Primary Diagnosis

Crohn’s colitis, parastomal hernia

Clinical History

43yo F h/o Crohn’s colitis s/p total proctocolectomy with end ileostomy at OSH in 2002 Subsequently developed a very large

parastomal hernia

Clinical History

PMH Crohn’s colitis Pyoderma

gangrenosum HTN Morbid obesity Depression

PSH: Total proctocolectomy

with end ileostomy 2002

Lap gastric band

Medications Cellcept Humira Prednisone 20mg every

other day Lisinopril HCTZ Celexa

Allergies PCN

Clinical History

Clinical History

5/31 Repair of parastomal hernia with Proceed mesh underlay Revision of ileostomy, relocation to left side of abdomen

POD 1-3 Hypotension, fluid resuscitation, persistently low UOP, ARF Steroid taper started POD 3

Required CVVH and 2 episodes of intermittent HD Improvement in UOP and creatinine returned to normal

POD 7-13 Resolving ileus, tolerating diet Ileostomy noted to be dark, but productive

Clinical History

POD 7-13 Resolving ileus, tolerating diet Ileostomy noted to be dark, but productive

POD 15 Pt c/o new pain at ostomy site and left flank Ostomy noted to have lateral muco-cutaneous separation WBC 15

POD 16 New erythema along left flank WBC 32 Taken to OR for re-exploration, found to have perforation of

ileostomy at level of the fascia, 10cm of distal ileum resected, ileostomy moved to midline, necrotic soft tissue debrided

Analysis of Complication

• Was the complication potentially avoidable?– Yes, hypotension could have been avoided with

perioperative steroid administration to prevent adrenal insufficiency

• Would avoiding the complication change the outcome for the patient?– Yes, avoidance of ARF, necrosis of ostomy,

reoperation

• What factors contributed the complication?• Hypotension, lack of perioperative steroid

administration, pt’s body habitus to a lesser extent

Steroids and Adrenal Insufficiency

Approximately 34 million prescriptions written for steroids every year

Fraser, et al 1952 First described a steroid-dependent pt who died of intractable

hypotension postoperatively after orthopedic procedure Since then, stress doses of steroids have become a regular part of

perioperative management.

Chronic steroid use suppresses the hypothalamic-pituitary-adrenal axis Pts unable to mount appropriate response to stress of a surgical

procedure Most severe result is hypotension and cardiovascular collapse

Recommended stress dose 100mg hydrocortisone perioperatively, followed by… 50mg hydrocortisone x 24 hours then taper dose by ½ per day until

maintenance dose is reached

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12)

Review of 2 RCTs and 7 cohort studies315 patients undergoing 389 procedures

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12)

In 2 RCTs (37 pts) No difference in hemodynamic profile between pts

receiving stress doses of steroids compared to pts receiving only their usual daily dose

7 cohort studies (278 pts) Pts that continued to receive usual daily dose of

steroid without addition of stress dose No pts developed unexplained hypotension

Pts who had steroids stopped 36-48 hours prior to surgery 2 pts developed unexplained hypotension Both responded to administration of hydrocortisone and

fluids

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12)

Conclusion Suggests that in pts receiving long-term corticosteroid

therapy, stress doses of steroids are not required However, pts should still continue to receive their

usual daily dose

Small sample size