GI Perforation
- Site of perforation: gastric/duodenal (peptic ulcer — H. pylori, NSAIDs, steroids), colonic (diverticulitis, tumor, ischemia, Ogilvie’s), small bowel (typhoid, Crohn’s)
- Boerhaave syndrome: esophageal perforation after forceful vomiting — mediastinitis, subcutaneous emphysema
- Severity/contamination: localized (walled-off) vs generalized peritonitis → ผล mortality ต่างกันมาก
- Hemodynamic status: septic shock = emergency OR; ให้ resuscitate concurrently ไม่ใช่ delay surgery
- Hinchey classification (colonic): I=paracolic abscess, II=pelvic abscess, III=purulent peritonitis, IV=fecal peritonitis
- CXR free air (pneumoperitoneum): subdiaphragmatic lucency — sensitivity ~70% in erect CXR; CT more sensitive
🕐 One-Day Orders
🔬 Investigation
- CXR erect (stat) — free air under diaphragm
- CT abdomen-pelvis with contrast — site + extent of perforation, free fluid/gas, abscess
- CBC, CRP — leukocytosis (may be low initially in severe shock)
- BUN, Cr, electrolytes — renal function, electrolyte derangement
- Lactate stat — tissue hypoperfusion
- PT/INR, aPTT, platelet — coagulopathy (DIC risk in septic peritonitis)
- Blood group + crossmatch — เตรียม OR
- ABG ถ้า hemodynamically unstable
💊 Medication
- NPO stat + NGT decompression
- IV NSS/LR resuscitation 30 mL/kg ถ้า septic shock; goal MAP >65, UO >0.5 mL/kg/hr
- Broad-spectrum IV ATB (ก่อน/พร้อม OR):
- Pip-Tazo 4.5 g IV q6h หรือ Meropenem 1 g IV q8h (ถ้า community-acquired severe/MDR risk)
- Fluconazole ถ้า Candida risk (GI surgery prior, prolonged ATB)
- Morphine/Fentanyl IV — analgesia (ไม่ delay surgery)
- Foley catheter — monitor UO
- Emergency surgical referral — exploratory laparotomy (กรณี generalized peritonitis = surgical emergency)
🔁 Continuous Orders
🔬 Investigation
- CBC, BUN/Cr, electrolytes, lactate daily post-op
- Drain output monitoring — สี, ปริมาณ (anastomotic leak = bile-colored)
- CXR/CT ถ้า clinical deterioration (abscess, anastomotic leak)
💊 Medication
- IV ATB ต่อ 3-5 วัน post-op (source control adequate); total 5-7 วัน
- [Anastomotic leak/persistent sepsis]: CT-guided drainage หรือ re-operation
- TPN/EN: early enteral feeding day 1-2 ถ้า bowel function returning; TPN ถ้า GI ใช้ไม่ได้
- DVT prophylaxis: LMWH เริ่มหลัง hemostasis ยืนยัน + pneumatic compression