Management of Intra-Abdominal Sepsis

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Management of Intra-Abdominal Sepsis

• Claude Fahrer

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The Basics

• History
• Pain
• Time course
• Nausea/ vomiting
• Diarrhoea/ constipation
• Distension
• Determination of fluid status
• Co-morbidities/ medications

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The Basics

• Examination
• Vital signs
• Cardiorespiratory
• Abdominal
• Pain
• Guarding/ rigidity
• Distension
• Masses
• PR

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Initial resuscitation

• Airway O2/ oximetry
• Breathing NGT
• Circulation 2x large bore iv
• fluids
• IDC
• Consider CVC
• Aim for UO and decreasing heart rate

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Investigations

• FBE, UECr, CrP, COAGS, GH
• Other bloods guided by symptoms and signs AxR,
  CxR
• Consider US if hepatobiliary pathology suspected
• Consider CT double contrast

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Initial resuscitation

• Drugs
• Analgesia
• Antibiotic
• Anti-DVT

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Primary peritonitis

• End stage hepatic failure (SBP)
• E.coli (GNB, Strep. Pneumoniae)
• Cefotaxime or ceftriaxone.
• CAPD
• Staph. Epidermidis
• Cephalothin or cefazolin via PD fluid
• PID
• Pneumococci
• Antibiotic choices are modified by culture
  results

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Secondary Peritonitis

• Perforated/disrupted viscus (eg. PUD)
• Ischaemic gut with bacterial translocation
• Superinfection of necrotic tissue (eg.
  Pancreatitis)
• Mixed flora
• Localised or generalised
• (Tertiary peritonitis - Overwhelming sepsis,
  usually irretrievable Staph. epi., Pseudomonas
  spp., Candida. )

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Antibiotic Regimens

• Amoxicillin/metronidazole/gentamycin
• Piperacillin tazobactam
• Ticarcillin clavulanate
• Ceftriaxone or cefotaxime/metronidazole
• E. coli, Bacteroides spp. most common isolates

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Definitive Management

• Abscess CT/ US guided drainage
• Generalised Laparotomy

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Principles of laparotomy

• Environment
• A warm patient bleeds less
• A warm patient is less acidotic

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Principles of laparotomy

• Midline laparotomy for access (usually)
• Control source Oversew
• Excision of segment
• Low threshold for stoma
• Lavage for decontamination (4-10L warm saline)
• Mass closure

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Second look laparotomy/laparostomy

• If gross contamination or continuing necrosis,
  may need two or more operations
• If more than two operations, leave abdomen open

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Controversies

• To drain or not to drain
• Irrigation through drain tubes
• IVIG
• Abdominal compartment syndrome
• Respiratory compromise
• Low urine output
• Measured via IDC

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• Sabiston Textbook of surgery, 2001
• Oxford textbook of surgery, 2000
• Antibiotic Guidelines, 12th ed. 2003
• Management of Intra-abdominal Sepsis in Surgical
  clinics of North AmericaDec 1991,1175-1185
• Surgical management of severe secondary
  peritonitis, BJS 1999, 1371-1377
• Intravenous immunoglobulin for treating sepsis
  and septic shock. Cochrane review Issue 2, 2004
• Abdominal compartment syndrome in severe burns.
  Abstract TR04 ANZJSurg. May suppl. 2004