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Postoperative intraabdominal abscesses: Percutaneous versus surgical treatment
Abstract
The optimal treatment of postoperative intraabdominal abscesses has not yet been defined and mortality and morbidity remain high. In this retrospective study 2.310 laparotomies were reviewed. The records of 39 patients with postoperative intraabdominal abscesses (1.6%) are reported and the results obtained in percutaneous drainage (PD, n = 27) versus surgical drainage (SD, n = 10) are compared. The choice of drainage was made after consultation with the interventional radiologist, and PD was preferred in single, well-defined abscesses. Two patients had prompt spontaneous resolution of the abscess. The two groups were homogeneous for age, sex and postoperative day of abscess diagnosis. There was no difference in severity of illness assessed by Acute Physiologic Score (APS) between PD and SD groups (7.9 vs 9.3). No significant difference was found in mortality (11% vs 20%), morbidity (11% vs 40%) and duration of drain tube (14 vs 15 days) between PD group and SD group. This study confirms the data of recent retrospective stratified series: PD and SD are equally efficacious to cure postoperative intraabdominal abscesses. However, PD should be the treatment of choice because of its lower invasiveness and cost.
... The basic treatment for abscess is drainage, and the first choice of drainage route is percutaneous [3,4,14]. Imaging-guided percutaneous abscess drainage has been shown to be effective, and has been a great milestone in the treatment of abscesses [3,[14][15][16][17][18]. The modalities used for this procedure have been mostly ultrasonography and computed tomography. ...
... The modalities used for this procedure have been mostly ultrasonography and computed tomography. Previous reports of percutaneous drainage for intra-abdominal abscess have documented success rates of between 60% and 92% [3,[15][16][17][18]. In series with high success rates, imaging-guided percutaneous abscess drainage was performed when an available access route could be secured. ...
... However, when the abscess cavity is deeply located in the body, it may be difficult to secure a drainage route due to the surrounding organs. Therefore, for such cases, surgical drainage has remained a standard [3,6,17], even though it is highly invasive [3]. With the growing number of elderly patients worldwide, who cannot tolerate highly invasive techniques, there has been a need to develop a less invasive method for drainage of deeply seated abscesses. ...
Background
An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route. Case presentationWe describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible. Conclusions
Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.
... 13 Percutaneous CT-guided drainage is considered the gold standard of care and is highly effective with low morbidity and mortality compared with surgical drainage. 14,15 For persistent drainage that may indicate an intestinal fistula, diagnosis with contrast-enhanced CT scan and treatment by transmural drainage with endoscopic ultrasound may be helpful. 16,17 Endoscopic drainage allows assessment of the collection, creation of an internal fistulous tract even in collections that do not protrude into the lumen, avoidance of intervening vessels, and placement of internal drainage stents. ...
... 18 If percutaneous or endoscopic drainage fails, surgical drainage by either an open or a laparoscopic method may be indicated. 8,14 Often, an abscess under the left half of the diaphragm is missed. Abscesses on the left are bounded by the spleen, stomach, and left lobe of the liver. ...
... Because of the availability of less toxic agents demonstrated to be at least equally effective, aminoglycosides are not recommended for routine use in adults with communityacquired intra-abdominal infection (B-II). 34. Empiric coverage of Enterococcus is not necessary in patients with community-acquired intra-abdominal infection (A-I). ...
... Well-localized fluid collections of appropriate density may be drained percutaneously with acceptable morbidity and mortality [47,[33][34][35]. Percutaneous drainage of appropriately selected infectious sources may result in significantly less physiologic alterations in patients and may eliminate or reduce the need for open techniques. ...
BACKGROUND
Antimicrobial resistance and inappropriate antibiotic regimen hamper a favorable outcome in intra-abdominal infections. Clinicians rely on the minimum inhibitory concentration (MIC) value to choose from the susceptible antimicrobials. However, the MIC values cannot be directly compared between the different antibiotics because their breakpoints are different. For that reason, efficacy ratio (ER), a ratio of susceptible MIC breakpoint and MIC of isolate, can be used to choose the most appropriate antimicrobial.
MATERIALS AND METHODS
A prospective, observational study conducted during 2015 and 2016 included 356 Escherichia coli and 158 Klebsiella spp. isolates obtained from the intra-abdominal specimens. MIC was determined by microbroth dilution method, and ER of each antibiotic was calculated for all the isolates.
RESULTS
For both E. coli and Klebsiella spp., ertapenem, amikacin, and piperacillin/tazobactam had the best activities among their respective antibiotic classes.
DISCUSSION
This is the first study calculating ER for deciding empiric treatment choices. ER also has a potential additional value in choosing the use of susceptible drugs as monotherapy or combination therapy. A shift in ERs over a period of time tracks rising MIC values and predicts antimicrobial resistance development.
CONCLUSION
Estimation of ER could be a meaningful addition for the interpretation of an antimicrobial susceptibility report, thus helping the physician to choose the best among susceptible antimicrobials for patient management.
... In these cases, PE is left-sided, given that the liver is on the right side and prevents herniation of adjacent organs. It occurs in patients with a strangulated diaphragmatic hernia [138]. PE may be an empyema. ...
Although pleural effusion is a frequent finding in clinical practice, determining its etiology may be challenging, and up to 20% of cases remain undiagnosed. Pleural effusion may occur secondary to a non-malignant gastrointestinal disease. A gastrointestinal origin is confirmed based on a review of the medical history of the patient, and thorough physical examination and abdominal ultrasonography. In this process, it is crucial to correctly interpret findings on pleural fluid obtained by thoracentesis. In the absence of high clinical suspicion, identifying the etiology of this type of effusion may be difficult. Clinical symptoms will be determined by the gastrointestinal process causing PE. In this setting, correct diagnosis relies on the specialist's ability to associate pleural fluid appearance, test for the appropriate biochemical parameters, and determine whether it is necessary or not to send a specimen for culture. The established diagnosis will determine how pleural effusion is approached. Although this clinical condition is self-limited, many cases will require a multidisciplinary approach, as some effusions only resolved with specific therapies.
... Recent advances in radiological techniques and the development of percutaneous interventions have offered what is sometimes an equally effective and less invasive surgical alternative to source control. 88 Improvement in diagnostic modalities have also allowed for the early detection of clinically occult foci of infection. ...
There has been a significant evolution in the definition and management of sepsis over the last three decades. This is driven in part due to the advances made in our understanding of its pathophysiology. There is evidence to show that the manifestations of sepsis can no longer be attributed only to the infectious agent and the immune response it engenders, but also to significant alterations in coagulation, immunosuppression, and organ dysfunction. A revolutionary change in the way we manage sepsis has been the adoption of early goal-directed therapy. This involves the early identification of at-risk patients and prompt treatment with antibiotics, hemodynamic optimization, and appropriate supportive care. This has contributed significantly to the overall improved outcomes with sepsis. Investigation into clinically relevant biomarkers of sepsis are ongoing and have yet to yield effective results. Scoring systems such as the sequential organ failure assessment and Acute Physiology and Chronic Health Evaluation help risk-stratify patients with sepsis. Advances in precision medicine techniques and the development of targeted therapy directed at limiting the excesses of the inflammatory and coagulatory cascades offer potentially viable avenues for future research. This review summarizes the progress made in the diagnosis and management of sepsis over the past two decades and examines promising avenues for future research.
... Unless the patient has a posterior subphrenic abscess, percutaneous, less invasive approach is generally recommended. 40 The mortality of subphrenic abscess is high mostly because of delayed or missed diagnosis; this is the reason that the diagnosis must be considered in every patient with fever and pleural effusion if there is a recent abdominal surgery or trauma. ...
... Guidelines differ as to whether a partially resuscitated patient should be taken directly to surgery, 41 or whether intervention should follow successful resuscitation. 136 However, the data cited in support of these statements depend primarily on the risk of failure of source control if intervention is delayed beyond 24 hours, 12 137-139 or the management of necrotizing soft tissue infections, [140][141][142] respectively. To our knowledge, only a single study has directly assessed the optimal timing of surgery for secondary peritonitis. ...
Secondary peritonitis accounts for 1% of urgent or emergent hospital admissions and is the second leading cause of sepsis in patients in intensive care units globally. Overall mortality is 6%, but mortality rises to 35% in patients who develop severe sepsis. Despite the dramatic growth in the availability and use of imaging and laboratory tests, the rapid diagnosis and early management of peritonitis remains a challenge for physicians in emergency medicine, surgery, and critical care. In this article, we review the pathophysiology of peritonitis and its potential progression to sepsis, discuss the utility and limitations of the physical examination and laboratory and radiographic tests, and present a paradigm for the management of secondary peritonitis.
... In addition, well-localized fluid collections of appropriate density and consistency (i.e., lack of extensive loculations) may be drained percutaneously with acceptable morbidity and mortality [74][75][76][77][78]. ...
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
... Foci of infection readily amenable to source control measures include an intra-abdominal abscess or gastrointestinal perforation, cholangitis or pyelonephritis, intestinal ischemia or necrotizing soft tissue infection, and other deep space infection, such as an empyema or septic arthritis. Such infectious foci should be controlled as soon as possible following successful initial resuscitation (106)(107)(108), and intravascular access devices that are potentially the source of severe sepsis or septic shock should be removed promptly after establishing other sites for vascular access (109,110). ...
... Percutaneous drainage of a sub diaphragmatic abscess is an accepted method of treatment today. Percutaneous drainage offers lower invasiveness and cost and has equal efficacy in drainage [9]. However, we feel that once sub diaphragmatic collection develops than drainage under general anesthesia should be considered initially to avoid morbidity in such cases. ...
In the current era of minimally invasive surgery, Laparoscopic Cholecystectomy has become the gold standard for the surgical management of symptomatic gallstones. However, with the increase in the number of laparoscopic operations performed, there has also been a noticeable increase in the number of complications specific to these procedures. Known complications of laparoscopic Cholecystectomy include bowel and vascular injury, injury of the bile duct and complications of retained stones, in less than 5% procedures performed. Spillage of bile and stones in the abdominal cavity has been reported in 15%-40% of procedures performed, but these are believed to be innocuous. We report a patient who suffered a thoraco abdominal complication in form of right sub diaphragmatic abscess, may be due to bile spillage, three weeks after initial operation.
... These effects have never been analyzed before for the surgical patient with intestinal perforation. Interestingly, the guideline recommendation is based on literature mainly dealing with necrotisizing soft tissue infections [8][9][10]. Furthermore, the necrosectomy of peripancreatic necrosis is citated as one rationale for a conservative, delayed surgical intervention [11,12]. ...
Purposes:
An abdominal inflammatory focus is the second most often source of sepsis with a high risk of death in surgical intensive care units. By establishing evidence-based bundled strategies the surviving sepsis campaign provided an optimized rapid and continuous treatment of these emergency patients. Hereby the hospital mortality decreased from 35 to 30 %. Sepsis treatment is based on three major therapeutic elements: surgical treatment (source control), antiinfective treatment, and supportive care. The international guidelines of the surviving sepsis campaign were updated recently and recommend rapid diagnosis of the infection and source control within the first 12 h after the diagnosis (grade 1c). Interestingly this recommendation is mainly based on studies on soft tissue infections.
Methods:
In this retrospective analysis 76 septic patients with an intraabdominal inflammatory focus were included. All patients underwent surgery at different time-points after diagnosis.
Results:
With 80 % patients of the early intervention group had an improved overall survival (vs. 73 % in the late intervention group).
Conclusions:
Literature on the time dependency of early source control is rare and in part contradicting. Results of this pilot study reveal that immediate surgical intervention might be of advantage for septic emergency patients. Further multi-center approaches will be necessary to evaluate, whether the TTI has any impact on the outcome of septic patients with intestinal perforation.
... Therefore, we can conclude to some extent that there are several hardly-avoidable disadvantages for both PCD and SD. PCD can only be performed on well-localized and low-density abscesses [12,13] while SD may result in a remarkable physiologic alteration, prolonged hospitalization and decelerated recovery process [14,15]. ...
Intra-abdominal and pelvic abscesses are common and result from various illnesses. Percutaneous drainage applies limitedly to well-localized abscesses with appropriate density while surgical drainage usually causes significant physiological disturbance. We herein illustrated an innovative choice "sump drainage with trocar puncture" for the management of intra-abdominal abscesses and compare it with conventional percutaneous and surgical drainage in terms of clinical outcomes and prognosis.
Medical records of a total of 75 patients with abscesses were retrospectively retrieved and scrutinized. Data consisted of demographics, abscesses characteristics and treatment outcomes including postoperative complication, duration of hospitalization, postoperative recurrence of abscesses, subsequent surgery, ultimate stoma creation and survival rate. All enrolled patients were divided into trocar group (n = 30), percutaneous group (n = 20) and surgical group (n = 25) according to the therapeutic modalities. One-way ANOVA and t-test with Welch's correction were used in continuous variables, and Chi-squared test as well as Fisher's exact test for categorical variables. The cumulative incidence of subsequent surgery and ultimate stoma creation was also indicated by the Kaplan-Meier method and compared by log-rank test.
The risk of ultimate stoma creation (p = 0.0069) and duration of postoperative hospitalization (p = 0.0077) were significantly decreased in trocar group compared with the surgical group. Patients receiving trocar puncture also tended to be less likely to have subsequent surgery (p = 0.097). Patients in trocar group displayed a lower rate of postoperative complication than the percutaneous (p = 0.0317) and surgical groups (p = 0.0175). As for Kaplan-Meier analysis, the cumulative incidence of ultimate stoma creation of the patients using sump drainage was also significantly different among three groups during follow-up period (p = 0.011).
This novel technique "sump drainage by trocar puncture" could produce better clinical outcomes and prognosis than conventional percutaneous drainage and surgical intervention. It might become an optimal choice in the management of intra-abdominal abscesses in the future.
... La elección de las medidas de control del foco de infección serán las de máxima eficacia con el menor trastorno fisiológico (drenaje de absceso percutáneo en lugar de quirúrgico) 5,223 . ...
... Em abscesso intra-abdominal póscirúrgico, sugere-se drenagem percutânea em relação à cirúrgica, por ser menos invasiva e de menor custo, conforme demonstrado em estudo retrospectivo (B). (7) Neste estudo, não se observaram diferenças na redução da taxa de mortalidade ao comparar drenagem percutânea versus cirúrgica em pacientes no pós--operatório de abscessos intraabdominais, sendo ambos os procedimentos eficazes para tratamento. ...
Sepsis is a common and lethal condition that carries a substantial financial burden. In addition, it is the main cause of death in intensive care units. Early diagnosis and treatment of patients has been clearly shown to improve prognosis. Therefore, early diagnosis of the infecting agent, control of the primary infection site and the use of appropriate antibiotic therapy are fundamental to improving outcomes. This guideline reviews the available evidence in the literature concerning infection control and therapy strategies.
... The recommended timing to obtain source control has been changed from 6-to 12-h and the grade for sourcecontrol timing has been changed from a 1D to 1C. This grade change was based on a case-series of children with necrotizing fasciitis, a retrospective cohort of adults with necrotizing soft tissue infections, and an analysis of postoperative abscess formation434445. In the study by Boyer et al. [44], a more than 14-h delay in debridement of necrotizing tissue was associated with a significantly worse outcome. ...
With the 2012 Surviving Sepsis Campaign Guidelines, clinicians have access to evidence based guidelines for the treatment of adults with severe sepsis. Some of the important changes include: new recommendations for screening of adults with sepsis for organ dysfunction (grade 1C); lactate normalization as a therapeutic target in early resuscitation (grade 2C); colloids no longer recommended for initial resuscitation (grade 1B); a minimum of 30 mL/kg for initial fluid resuscitation (grade 1C); norepinephrine as the initial vasopressor of choice (dopamine allowed only under specific circumstances) (grade 1B); removal of recombinant human activated protein C for the treatment of severe sepsis (ungraded); removal of permissive hypercapnea as a recommendation (ungraded); and a change of the target blood glucose level to <180 mg/dL (previously 150 mg/dL) (grade 1A). In this article, we review the evidence base for these and other guideline changes for the early treatment of severe sepsis in adults.
... Nonetheless, the approach to drainage cannot be based solely on the underlying disease, as other radiologic and clinical considerations are of equal or greater importance. Complicating this decision is the fact that these two modalities have only been compared retrospectively [14, [48][49][50][51][52][53], and never in a randomized, controlled fashion. The studies to date using case controls or attempting to account for severity of patient illness have shown no clear advantage of one method over. ...
Infection of the peritoneal cavity can be divided into acute peritonitis and chronic abscess formation. While acute peritonitis is easier to diagnose and treatment is often straightforward, the diagnosis of an intra-abdominal abscess can be subtle and treatment can involve multiple diagnostic and therapeutic modalities. The advent of high-quality computed tomography and ultrasonography has revolutionized the care of these patients, and has allowed for the definitive management of these infections without open operation. We review the current techniques for the diagnosis, localization, and treatment of these serious infections, discuss important factors influencing the decision between percutaneous and operative approaches, and examine several other controversies in this challenging area.
... Source control failure is more likely to occur in patients with delayed (124 h) procedural intervention, higher severity of illness (APACHE II score 15), advanced age (170 years), preexisting chronic medical conditions, poor nutritional status, and a higher degree of peritoneal involvement and is heralded by persistent or recurrent intra-abdominal infection, anastomotic failure, or fistula formation2829303132. Well-localized fluid collections of appropriate density may be drained percutaneously with acceptable morbidity and mortality [47,333435. Percutaneous drainage of appropriately selected infectious sources may result in significantly less physiologic alterations in patients and may eliminate or reduce the need for open techniques. ...
Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical
Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published
in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for
them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The
panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management
differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.
... World Journal of Emergency Surgery 2011, 6:40 http://www.wjes.org/content/6/1/40 WORLD JOURNAL OF EMERGENCY SURGERY Ultrasound-and CT-guided percutaneous drainage of abdominal and extra-peritoneal abscesses have proven to be safe and effective in select patients56789101112. Surgery is the most important therapeutic recourse for controlling intra-abdominal infections. ...
Complicated intra-abdominal infections are frequently associated with poor prognoses and high morbidity and mortality rates.
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.
In order to describe the clinical, microbiological, and management-related profiles of both community-acquired and healthcare-acquired complicated intra-abdominal infections (IAIs), the World Society of Emergency Surgery (WSES), in collaboration with the Surgical Infections Society of Europe (SIS-E) and other prominent European surgical societies, has designed the CIAO study.
The CIAO study is a multicenter, observational study and will be carried out in various surgical departments throughout Europe. The study will include patients undergoing surgery or interventional drainage for complicated IAI.
... 2 Bufalari found that percutaneous drainage and surgical drainage are equally effi cacious treatments for postoperative intraabdominal abscesses in terms of mortality, morbidity and duration of drain tube placement. 3 However, percutaneous drainage should be the treatment of choice because it is less invasive and more cost effective. The results are very good for simple, unilocular abscesses but less so for complex ones. ...
Biopsies provide histologic, cellular, genetic, and molecular information. Percutaneous biopsy and diagnostic fluid aspiration are defined as the placement of a needle into an organ, mass, or fluid collection to obtain tissue or fluid sample. Image-guided percutaneous biopsy has been widely accepted for its clinical effectiveness and safety and has largely replaced surgical biopsy. Successful percutaneous needle biopsy has been applied in most organ systems with excellent results and few complications (Cardella et al. J Vasc Interv Radiol 4(9):S227–30, 2003). Similarly, therapeutic image-guided percutaneous aspiration or drainage of abnormal fluid collections has resulted in reduced morbidity and mortality, as well as lower hospital length of stay and healthcare costs (Bufalari et al. Acta Chir Belg 96(5):197–200, 1996; Ferraioli et al. Dig Liver Dis 40(8):690–6, 2008). Percutaneous drainage in conjunction with antibiotic therapy often provides definitive treatment for abscesses or can serve as a minimally invasive alternative to allow for eventual single-stage rather than double-stage surgery (Siewert et al. Am J Roentgenol 186(3):680–6, 2006). This chapter reviews clinical significance, periprocedural management, relative organ-specific anatomy and pathophysiology, and the technical aspects of image-guided percutaneous biopsy and drainage procedures.
Purulent or infected fluid collection in the gap between diaphragm and liver or spleen is called as subphrenic abscess. Intraperitoneal perforations such as duodenal ulcer, diverticulitis, appendicitis, amoebic liver abscess are common reasons of this pathology. Other reasons in the etiology are surgical interventions, critical diseases and abdominal traumas. In about half of the cases, subphrenic abscess is seen on the right side, while 1/4 in the left side and 1/4 simultaneous bilateral. Main symptoms of subphrenic abscess pathology are fever, chills and abdominal pain on the side of the abscess. Also cough and respiratory distress may seen. In the treatment of subphrenic abscesses; draining the abscess and using appropriate antibiotics are needed. In general, the rate of cure for the subphrenic collections is between 79 and 85%. Empyema and sepsis complications are seen with a incidence of 2%. Subphrenic abscesses continue to be associated with high mortality, despite wide spectrum antibiotics and surgical techniques. Overall mortality rate is 31%.
Postoperative abdominal infections are an important and heterogeneous health challenge in intensive care units (ICU) and encompass postoperative infectious processes developing within the abdominal cavity that may be caused by either bacterial or fungal pathogens. In this narrative review, we discuss postoperative bacterial and fungal abdominal infections, covering also multidrug-resistant (MDR) pathogens. We also cover clinically preeminent aspects such as the definition of postoperative abdominal infections, which still remains difficult owing to their heterogeneity in patient characteristics, clinical presentation, ecology and antimicrobial treatment. With regard to treatment, modifiable factors such as source control and antimicrobial therapy play a key role in influencing the prognosis of postoperative abdominal infections, but several conditions may hamper their correct application; thus efforts should necessarily be devoted towards improving their appropriateness and timing. Hot topics regarding the characteristics and management of postoperative abdominal infections are discussed in this narrative review.
Objective:
Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis.
Data sources:
We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection.
Study selection:
We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics.
Results:
By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci.
Conclusions:
This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.
Die abdominelle Sepsis ist die schwerste Verlaufsform einer abdominellen Infektion, bei der es aufgrund einer Fehlregulation der Antwort des Wirtsorganismus auf die Infektion zu einem lebensbedrohlichen Organversagen bis hin zu einem septischen Schock kommt, der eine Letalität von >40 % hat. Der vorliegende Artikel gibt eine Übersicht über die Evidenz zum strategischen Vorgehen bei der Behandlung von Patienten mit abdomineller Sepsis und septischem Schock. Der Fokus liegt dabei auf den zeitkritischen Elementen Diagnose, antiinfektive Therapie und hämodynamische Stabilisierung.
Recent literature continues to refine which components of the early goal-directed therapy (EGDT) algorithm are necessary. Given it utilizes central venous pressure, continuous central venous oxygen saturation, routine blood transfusions, and inotropic medications, this algorithm can be timely, invasive, costly, and potentially harmful. New trials highlight early recognition, early fluid resuscitation, appropriate antibiotic treatment, source control, and the application of a multidisciplinary evidence-based approach as essential components of current sepsis management. This article discusses the landmark sepsis trials that have been published over the past several decades and offers recommendations on what should currently be considered ‘usual care’.
Source control is defined as all those physical measures necessary to eradicate a focus of infection as well as to control factors that maintain infection, promote microbial growth or impair host antimicrobial defences [1]. Sepsis is defined as infection plus systemic manifestations of infection. Severe sepsis is defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion [2, 3]. The term source control was first used in the early twentieth century but regained attention over the past 10 years when a panel of experts was asked to provide guidelines for treating severe sepsis and septic shock during the Surviving Sepsis Campaign project. The campaign was promoted by the European Society of Intensive Care Medicine (ESICM), the International Sepsis Forum (ISF) and the Society of Critical Care Medicine (SCCM) to increase awareness of and improve outcomes in severe sepsis [4]. The last updated guidelines were published in 2008 [5]. Recently, the campaign provided “bundles” to help improve guideline outcomes. Bundles help to simplify the complex processes of a septic patient’s care. A bundle is a simple principle of care resulting from evidence-based practice guidelines that, when implemented as a group, have a significant effect on outcomes beyond implementing the individual elements alone. Each hospital can elaborate a sepsis protocol, but it must meet the standards created by the bundle [6].
Effusions and collections that form in the peritoneal cavity and in the infra-peritoneal spaces are usually secondary to pathological processes of the intra-peritoneal organs and only rarely do they represent the extension of collections of juxta- and retroperitoneal compartments. They can be formed by transudates, exudates, blood, pus, bile, lymph, urine, pancreatic enzymes or food, and are caused by a wide range of inflammatory, vascular, traumatic, neoplastic or dys-metabolic processes, by hepatic, renal or cardiac failure, and by surgery.
Gastrointestinal surgery is often high-risk surgery. Yet, despite the high risk, it is not given a position of prominence in many anesthesia textbooks. It seems to be assumed that knowledge of providing anesthesia care for the high-risk gastrointestinal surgical patient will be gleaned purely from experience gained in managing other patients. In other words, anesthesia for gastrointestinal surgery is just “general anesthesia”. Paradoxically, certain rare conditions encountered in surgery in the abdomen (such as carcinoid or pheochromocytoma) are well covered in standard textbooks. Similarly, management of conditions such as acute pancreatitis, although surgical, are not commonly operated upon in most centers and are well covered in intensive care unit (ICU) textbooks. These conditions will not be discussed in this chapter. Gastrointestinal surgery – very high-risk surgery The general public (and many physicians) would undoubtedly consider surgery such as open heart surgery as being amongst the riskiest of surgical procedures in terms of 30-day operative mortality. In fact, certain relatively common gastrointestinal operations are arguably amongst the highest-risk procedures performed. Many of these expected mortality rates will be increased if the operations are performed on an emergency basis. The lessons to be learned are: gastrointestinal surgery is high-risk surgery and warrants careful consideration of the patient's preoperative status and pre-existing medical conditions, the surgical procedure proposed, and the postoperative disposition; with the expected mortality, palliation may be better for some patients than attempting a cure; patients and their families need to be aware of the high-risk nature of the surgery.
Subphrenic abscess after caesarean section is rare. We report the case of a 27-year-old patient who underwent caesarean section for foetal distress. Seven days after the operation, she was re-admitted for abdominal pain, dyspnoea and fever. Abdominal ultrasound revealed left subphrenic abscess. Broad-spectrum antimicrobial therapy and surgical drainage by laparotomy permitted the resolution of the abscess. Escherichia coli were identified in the culture of purulent fluid. Although it is rare, subphrenic abscess should be suspected when the patient presents signs of intra-abdominal infection after caesarean section.
Objective
To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004.
Severe sepsis and septic shock are common health care problem with high mortality. In 2001, Early goal directed therapy was introduced, early appropriate therapy impact on the outcome. In 2012, the “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012” was updated. Since then, several landmark studies recently demonstrated that modified guidelines. We review the treatment guidelines of severe sepsis and septic shock.
Objective:
To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.
Design:
A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
Methods:
The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.
Results:
Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).
Conclusions:
Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Purpose
To identify differences in hospital course and hospitalization cost when comparing image-guided percutaneous drainage with surgical repair for gastrointestinal anastomotic leaks.
Materials and methods
A retrospective IRB-approved search using key words “leak” and/or “anastomotic” was performed on all adult CT reports from 2002 to 2011. CT examinations were reviewed for evidence of a postoperative gastrointestinal leak and assigned a confidence score of 1–5 (1 = no leak, 5 = definite leak). Patients with an average confidence score
Sepsis is among the most common reasons for admission to ICUs throughout the world, and it is believed to be the third most common cause of death in the United States. The pathogenetic mechanism and physiologic changes associated with sepsis are exceedingly complex, but our understanding is evolving rapidly. The major pathophysiologic changes in patients with septic shock include vasoplegic shock (distributive shock), myocardial depression, altered microvascular flow, and a diffuse endothelial injury. These pathophysiologic changes play a central role in the management of sepsis. The early management of patients with severe sepsis and septic shock centers on the administration of antibiotics, IV fluids, and vasoactive agents, followed by source control. However, the specific approach to the resuscitation of patients with septic shock remains highly controversial. This review provides a practical and physiologic-based approach to the early management of sepsis and explores the controversies surrounding the management of this complex condition.
Since the initial studies published in the 1980s, percutaneous radiologic drainage is considered the first-line treatment of infected post-operative collections and is successful in over 80% of patients. Mortality due to undrained abscesses is estimated between 45 and 100%. Radiology-guided percutaneous drainage can be performed either with curative intent or to improve patient status prior to re-operation under better conditions. Cross-sectional imaging, using either ultrasound or computed tomography (CT), has changed the management of post-operative complications. Percutaneous drainage is most often performed by interventional radiologists and imaging is essential for road-mapping and guiding the puncture and drainage of intra-abdominal collections. Indeed, such imaging allows both identification of adjacent anatomical structures and determination of the best tract and the safest route. Cooperation between the surgeon and the interventional radiologist is essential to optimize the management and to avoid, if possible, surgery, which is so often difficult in this setting.
A possible complication after surgery is infection. An abscess is an infection localized in the surgical site. We present the case of a patient who was diagnosed with bilateral abscesses in the lymphadenectomy area, around the iliac vessels. Administration of wide spectrum intravenous antibiotics produced no response and image-guided aspiration was performed. This technique proved successful in the treatment of our patient, avoiding the need for open surgery.The major advances achieved in imaging techniques have aided progress in interventional radiology. The combination of gynecology and radiology could provide effective and relatively non-invasive treatments, which were unthinkable until a few years ago.
Since the initial studies published in the eighties, percutaneous radiologic drainage, is considered the first-line treatment of infected post-operative collections and is successful in over 80% of patients. Mortality due to undrained abscesses is estimated between 45 and 100%. Radiology-guided percutaneous drainage can be performed either with curative intent or to improve patient status prior to re-operation under better conditions. Cross-sectional imaging, using either ultrasound or computed tomography (CT), has changed the management of post-operative complications. Percutaneous drainage is most often performed by interventional radiologists and imaging is essential for road-mapping and guiding the puncture and drainage of intra-abdominal collections. Indeed, such imaging allows both identification of adjacent anatomical structures and determination of the best tract and the safest route. Cooperation between the surgeon and the interventional radiologist is essential to optimize the management and to avoid, if possible, surgery, which is so often difficult in this setting.
Objective:
To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008.
Design:
A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
Methods:
The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations.
Results:
Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C).
Conclusions:
Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
OBJECTIVE:: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN:: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS:: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS:: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS:: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high. The World Society of Emergency Surgery (WSES) has designed the CIAOW study in order to describe the clinical, microbiological, and management-related profiles of both community- and healthcare-acquired complicated intra-abdominal infections in a worldwide context. The CIAOW study (Complicated Intra-Abdominal infection Observational Worldwide Study) is a multicenter observational study currently underway in 57 medical institutions worldwide. The study includes patients undergoing surgery or interventional drainage to address complicated intra-abdominal infections. This preliminary report includes all data from almost the first two months of the six-month study period. Patients who met inclusion criteria with either community-acquired or healthcare-associated complicated intra-abdominal infections (IAIs) were included in the study. 702 patients with a mean age of 49.2 years (range 18–98) were enrolled in the study. 272 patients (38.7%) were women and 430 (62.3%) were men. Among these patients, 615 (87.6%) were affected by community-acquired IAIs while the remaining 87 (12.4%) suffered from healthcare-associated infections. Generalized peritonitis was observed in 304 patients (43.3%), whereas localized peritonitis or abscesses was registered in 398 (57.7%) patients.
The overall mortality rate was 10.1% (71/702). The final results of the CIAOW Study will be published following the conclusion of the study period in March 2013.
Sepsis is among the most common reasons for admission to ICUs throughout the world. Over the last two decades, the incidence
of sepsis in the United States has tripled and is now the 10th leading cause of death.1,2 Advances in medical technologies, the increasing use of immunosuppressive agents, and the aging of the population have contributed
to the exponential increase in the incidence of sepsis. In the United States alone, approximately 750,000 cases of sepsis
occur each year, at least 225,000 of which are fatal.1,2 Septic patients are generally hospitalized for extended periods, rarely leaving the ICU before 2–3 weeks. Despite the use
of anti-microbial agents and advanced life support, the case fatality rate for patients with sepsis has remained between 20
and 30% over the last two decades.1,2
In den klassischen Lehrbüchern bzw. Operationslehren der Chirurgie des 20. Jahrhunderts (Kirschner-Nordmann; Bier-Braun-Kümmell;
Garrè-Borchard-Stich-Bauer) wurden die unterschiedlichen »intraabdominelle Abszesse« jeweils am Schluss eines Kapitels unter
dem Abschnitt »Komplikationen« der Grunderkrankung bzw. der chirurgischen Therapie abgehandelt. Erst seit der Einführung interventioneller
Methoden werden die verschiedenen intraabdominell gelegenen »Abszesse« zunehmend als klinische Entität erkannt, da trotz ihrer
sehr unterschiedlicher Pathogenese gemeinsame Therapieprinzipien aufgestellt werden konnten.
Während früher der Grundsatz »ubi pus ibi evacua« bei Vorliegen eines intraabdominell gelegenen Abszesses oft nur durch eine
Laparotomie in Allgemeinnarkose befolgt werden konnte, kann dies heute in vielen Fällen weniger invasiv durch interventionelle
perkutane Punktions- und Drainagemethoden in Lokalanästhesie erreicht werden.
Dieses neue Denken in der Medizin ist bereits früh in der belletristischen Literatur [Oreibasios 1858] karikiert worden: »There
is no body cavity that cannot be reached with a #14 needle and a good strong arm.«
Historically, major bleeding was a significant problem associated with radical retropubic prostatectomy and cystectomy, TUR,
and nephrectomy. Nowadays, major life-threatening hemorrhage after urologic open and endoscopic surgery by expert surgeons
is a rare event. In some cases, the patient typically becomes hemody-namically unstable soon after arrival in the recovery
room. On the other hand, sometimes hemorrhage arises a few hours or days following the initial procedure. The surgeon must
make a decision whether to return immediately to the operating room or treat the patient conservatively with blood and volume
replacement (Kaufman and Lepor 2005). Reasons for a significant major bleeding later on in the postoperative period may be slipped ligatures or clips (e.g.,
from the renal pedicle or other major blood vessels) or in case of partial nephrectomy, ruptured kidney. Also, removal of
drains days after surgery may induce significant bleeding, if the drains have been put primarily through a major blood vessel
(e.g., epigastric). Reasons for early revisions may be insufficient ligatures or hemostasis.
Die »Peritonitis« (abgeleitet aus dem Griechischen περιτόν±¹¿ν, «das Herumgespannte»; Suffix -ιτησ, Ausdruck der Ähnlichkeit, medizinisch:
Entzündungen) ist auch heute noch eine Erkrankung von großer klinischer Problematik, da die Letalität von Patienten mit Bauchfellentzündung
trotz Fortschritten in der chirurgischen Behandlung und in der Intensivmedizin, abhängig von Ätiologie und Erkrankungsstadium,
zwischen 10 und 40% beträgt. Da es sich bei dem klinischen Syndrom »Peritonitis« nur um einen Sammelbegriff für ätiologisch,
pathophysiologisch und morphologisch unterschiedliche Erkrankungen handelt, ist es bisher in der Literatur nicht gelungen,
eine allgemein akzeptierte, einheitliche und klinisch praktikable Klassifikation der verschiedenen Peritonitisformen aufzustellen.
Die Therapie der primären Peritonitis (spontane bakterielle Peritonitis, CAPDPeritonitis) ist konservativ (Antibiotika), der
viel häufigeren sekundären Peritonitis aber grundsätzlich chirurgisch (Beseitigung der Ursache, Spülung der Bauchhöhle).
A series of 241 patients with subphrenic abscess was analysed to seek reasons for the continuing mortality.
Aspects of pathology, clinical presentation, special investigations and management were affected by therapy with broad spectrum antibiotics to make diagnosis more difficult, particularly in relation to left subphrenic abscesses. When transperitoneal exploration and drainage were employed, high morbidity and mortality resulted.
Satisfactory results followed extraserous drainage. The introduction of parenteral hyperalimentation promised control of fistulas associated with abscesses, a situation hitherto associated with a poor prognosis.
The encouraging results of percutaneous abscess drainage (PAD) in simple intra-abdominal abscesses have led us to employ this method in patients with more complex abdominal inflammatory disease, such as those with multiple enteric communicating or multilocular abscesses and patients in whom the percutaneous approach requires puncture routes traversing uninvolved organs. Cure was achieved in 74 per cent of all patients (83 of 112 patients) who underwent PAD, but in only 50 per cent of patients with multiple intra-abdominal abscesses (n = 16), 50 per cent of patients with complex pancreatic inflammatory disease (n = 8) and 57 per cent of patients with complex intraparenchymal abscesses (n = 7). PAD contributed to cure in eight of nine patients with enteric communicating abscesses. The transhepatic route to perihepatic abscesses proved to be safe. Complications occurred in nine patients (8 per cent). No relationship was noted between the severity or number of complications and the indication for PAD. Of the 29 failures of PAD, 17 patients were cured by either surgical intervention (14 patients) or a second PAD (1 patient) or a combination of the two methods (2 patients). Twelve patients (11 per cent) died, eight from sepsis due to inadequate drainage. Frequent reassessment by ultrasonography and computerized tomography (CT) in patients with prolonged sepsis after PAD is mandatory. These results justify a place for PAD in the management of the often critically ill patient with complex abdominal inflammatory disease.
Over an 18 month period, 130 patients were sent to the radiology department for diagnostic CT scans to localize intraabdominal abscesses. Of these patients, 71 (55 percent) were diagnosed as having intraabdominal abscesses. Fifty-one surgical procedures and 17 radiologic drainage procedures were done. The cure rate of patients undergoing an operative procedure was 88 percent, and the major complication rate was 23 percent. The cure rate of patients undergoing CT guided catheter drainage was 47 percent and the complication rate was 6 percent. CT guided catheter drainage may be the initial treatment of choice in institutions that specialize in invasive procedures performed by radiologists. However, in institutions that have not concentrated their efforts on this problem, the results may not be as good, and it may not be wise to assume these data have general applicability. Greater cooperative efforts between departments of radiology and surgery should lead to better results in treatment of intraabdominal abscesses and better understanding of the best methods of treating them.
The experience in treating 44 intraabdominal abscesses in 30 patients using percutaneous or surgical drainage was analyzed. Ultrasonography or computerized tomography-guided percutaneous drainage was highly satisfactory for the definitive treatment of single, accessible collections. Complex, multilocular, and phlegmonous lesions can also be treated by percutaneous drainage as a temporizing measure. Abscesses that are inaccessible, contain large amounts of necrotic material or are ill-defined, as well as those that have not responded to percutaneous drainage, require surgical exploration. Using these principles, there was only one death from sepsis in this series and three significant complications.
Twenty-two major intraabdominal abscesses in 19 postoperative patients were drained percutaneously using cross-sectional imaging techniques (computed tomography and sonography) for localization. Sixteen lesions were cured in 14 patients without reexploration. All patients were palliated by the percutaneous drainage procedure. All 22 abscess cavities were entered without complication or compromise of adjacent normal organs. Percutaneous abscess drainage is recommended as a safe, effective method of treating a major intraabdominal abscess in the postoperative patient.
Forty-two abscess collections in the abdomen, pelvis and mediastinum were drained in 40 patients. Thirty-two were drained completely and required no operative treatment. The high success rate combined with the low morbidity rate and low mortality suggest that, if possible, percutaneous drainage of abscesses is preferable to operative drainage.
About 19 observations, authors analyse a method for treating post-operative sub-phrenic abscesses: transpleurodiaphragmatic drainage. This study is showing the efficiency of the technic which is a real flattening of the abscess. It is showing as well its inocuosness as mortality and morbidity are none in spite of the field this treatment is used on. On the other hand this method prescribes very definite conditions: the real sub-phrenic abscess must be single and quite localized in postero-lateral position.