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Surgical Complications of Typhoid Fever 105
Management
1. Correction of fluid and electrolyte deficits: Care needs to be
taken to achieve adequate correction. A common cause of death is
inadequate replacement of fluid and electrolyte deficits. Four to six
hours may be needed to achieve adequate correction.
• Dextrose: Intravenous dextrose in 0.18-0.45% N saline is used in
children younger than 5 years of age (the amount of saline used
will depend on the serum level of Na ). In older children, dextrose
+
in 0.9% N saline is used. Large volumes of fluid may be required:
20 ml/kg by bolus infusion is given initially in severely dehydrated
patients and those presenting in shock. Ten ml/kg may be repeated
after 1 hour if urine output is not satisfactory (never give bolus
infusion of any potassium-containing fluid). Thereafter, adjust
infusion to maintain a urine output of 1.5–2 ml/kg/hr.
+
• Potassium (K ): Once the child is making adequate urine, give at
+
least a daily requirement of K (1–2 mmol/kg/day) until a serum
biochemistry result is available. Thereafter, any calculated defi-
cit is added to the daily requirement. The amount of potassium
required is added to the intravenous fluid and administered over
18 to 24 hours (do not give more than 10 mmol of K in an hour
+
unless the child is in the intensive care unit (ICU) and is being
monitored using an electrocardiogram (ECG)).
2. Nasogastric decompression: An appropriate size nasogastric tube
is inserted and the stomach decompressed by low pressure suction or
intermittent aspiration. This will also help in reducing the pressure on
the diaphragm and improve respiration.
Figure 17.3: Large pneumoperitoneum from typhoid perforation. 3. Urethral catheter: An indwelling urethral catheter is left in place
to ensure adequate monitoring of urine output.
• Full abdomen (erect and supine): The intestines may show dilata- 4. Reversal of hypoxia: Hypoxia is a common problem that may
tion and oedematous walls. Frequently, all that can be seen is a affect the integrity of intestinal anastomosis as well as survival.
diffuse opacity in most of the abdomen, particularly in those pre- Respiration may be impaired by abdominal distention, peritonitis, and
senting late with intraperitoneal collection. Patients who are too presence of a large pneumoperitoneum. If the pneumoperitoneum is
sick for erect film should have a lateral decubitus film to identify large (see Figure 17.3), insert a size 16G–18G intravenous cannula
pneumoperitoneum (Figure 17.3). The shadow of a distended gall- in the right or left upper quadrant (depending on the site of maximal
bladder may be obvious, suggesting cholecystitis. air collection) to vent the collected gas (avoid the lower border
of the liver, if enlarged). The cannula is removed after adequate
3. Abdominal ultrasonography: This is to be done only in patients
who do not need urgent surgery and in whom the diagnosis is doubtful; venting. This manoeuvre often helps to improve respiration and reduce
it should identify the following , if present: intraperitoneal abscesses hypoxia. Administer 100% oxygen by nasal catheter until surgery.
and cholecystitis. The usual evidence of cholecystitis in these patients Oxygen administration may need to be continued for up to 6 hours
is mainly dilatation, presence of pericholecystic fluid, and oedematous postoperatively in very ill children.
wall. Other intraabdominal conditions can be excluded. 5. Blood transfusion: This is necessary to correct anaemia if the
4. Microbiological cultures: Blood and urine, as well as an haemogram is <8 gm/dl (packed cell volume of <24%). Anaemia is
operative specimen of intraperitoneal fluid/pus, are cultured to identify always corrected before surgery to minimise hypoxia. A rough estimate
the Salmonella organism and any superimposed infections. In one for blood transfusion is 20 ml/kg body weight to attempt to correct the
report of children younger than 5 years of age with TIP, Salmonella anaemia before surgery.
3
typhi was cultured from the peritoneal fluid in 46%, urine in 36%, 6. Correction of coagulopathy: A vitamin K injection, 10 mg daily,
and stool in 32%. In patients in whom intraoperative diagnosis of is given and maintained for at least 5 days.
cholecystitis (and its complication) is made, a sample of gallbladder 7. Antibiotic therapy: Intravenous, broad-spectrum antibiotics are
contents is also cultured. commenced immediately when the diagnosis of typhoid is suspected.
5. Complete blood count: A haemogram is done to identify anaemia. The antibiotics may need to be changed later if there is no improvement
The platelet count is ascertained, particularly in patients with evidence and culture results become available. A commonly used effective
of coagulopathy. Although leucopaenia is a more common finding in antibiotic combination is one of the following:
patients with uncomplicated typhoid fever, leucocytosis and neutrophilia • Chloramphenicol (50–75 mg/kg/24 hours in 6-hour dosing) + gen-
are more common in those with intestinal perforation or cholecystitis. tamicin (3–5 mg/kg/24 hours in 8-hour dosing) + metronidazole
6. Blood grouping and cross matching: These procedures are (7.5 mg/kg/dose given in 8-hour dosing).
necessary in most patients for correction of anaemia or intraoperative use. • Amoxicillin [50–75 mg/kg/24 hours in 8-hour dosing (or ampicil-
7. Widal’s test: Although found to be positive in one report, this lin, 50–75 mg/kg/24 hours in 6-hour dosing)] + gentamicin (3–5
3
test is rather nonspecific and frequently misinterpreted. It has limited mg/kg/24 hours in 8-hour dosing) + metronidazole (7.5 mg/kg/
use in the management of these patients. dose given in 8-hour dosing).
8. Further investigations: These will depend on other complications
that are suspected. Note that resuscitation takes precedence over these • Third-generation cephalosporin + metronidazole.
investigations, which should not delay intervention after resuscitation • A quinolone such as ciprofloxacin 10,11 + metronidazole (IV peri-
is complete.