07 BOHNEN MMMD 2011-12 Abdominal Sepsis

8/10/2019 07 BOHNEN MMMD 2011-12 Abdominal Sepsis

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om na seps s

Departmentof Surgery


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Key points

GI leak inflammation death, disability ,

Difficult dx: Postop, old, immun, coma e ay x: mor a y, sa y

Rx: resuscitate, operate/drain, antibiotics


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Overview Causes: 1 and 2 peritonitis

Anatomy: peritonitis, abscess

Diagnosis (1) typical Prognosis

- Mana ement


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r mary per on s

Unimicrobial, associated with

Infected ascites Cirrhosis

Peritoneal dialysis catheter

TB


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Gut Duodenal ulcer (DU)rohns Disease,

infla,Cancer

sc em aMes artery embolus

v uTrauma


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cute appendicitis


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Acute diverticulitis


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Ischemic gut


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Acute Mesenteric Infarction

Wang NEJM 2011;364:1349


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Anatomy Peritonitis can be

Local (eg at appx)genera ze

Abscess can be

single, multiple

n raper onea , v scera ,

retro eritoneal


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Pathogenesis

Responses

Acute local inflammation

via lymphatics RE system uptake

cu e sys em c n amma on Culmination: resolution, ersistence

or death


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cute n ammat on 4 e ects

Kills microbes eeps m cro es n per oneum

localization so s stemic RE mono-phagocytes not overloaded

c va es cyo nes e c ma ng p s c


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its complicated

Contamination

inflammation absorptionRESOLUTION

coagulation abscesses systemic infla

fibrinlocalization

organ failure

DEATHPERSISTENCE


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Resolution, persistence or death?

Resolution: young, fit, mild bacterial

load, prompt treatment

Persistence: complex abdomen (eg,

ea : overw e m ng ac er a oa ; host defenses


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-

Pain, tenderness, rebound

Movement pain, lies still

ara y c eus: s ens on,

, S stemic: fever, chills, wbc


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Imaging free peritoneal air,

(perf DU #1 causeree a r

Paral tic ileus May see etiology

scess cav ty


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Terms youll hear (dont use)

acute abdomen usually means acuteabd ain sur eon mi ht o erate

surgical abdomen usually means,

Better: Pt has peritonitis and

, w u


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,not have 2 peritonitis:

Ruptured AAA

cute pancreatitis

r mary per on s


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Note 2 : des ite 2 eritonitisstable pt may not need operation:

Perforated DU Colonoscopic perforation


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rognos s n

per on s: - e


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com lications


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an , n some:

Renal failure u monary comp ca ons

more


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Which atients die or aredisabled?

prevent) Frail person (hard to prevent)


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Treatment delay

adverse

outcomes

Arch Surg 1983; 118:285


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eritonitis

Posto

Old Immune

Coma

diagnostic delay, sicker, more lethal


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yo man

In hospital 3 weeksimmunity from GI cancer

T 35 x 5 da s

Got short of breath

CXR:


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Posto

Old do not resent Immunetypically

CNS function


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air and ain

mean?

(all have free air

pain at 3 days)


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present as organ failure

Confusion; LOC

Hypotension

D srh thmia,

Jaundice Hyperglycemia

=

(or similar acronym MOF, etc)


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eritonitis Clinical

susp c on

or an

dysfunction

as a po n er


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Or an failure after abdominaloperation

rule out gut leak

anastomosis

inadvertent tear

m sse per ora on

P it iti


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Peritonitis

,

dysfunction

death


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- Mana ement


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agnose

rom tl

com lications

Resuscitate Antibiotics Control source Psychosocial

Fix abd wall


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Fluids, electrolytes

Nourish if NPO 7d

prevent aspiration


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contamination

laparoscopic)

Radiology)


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o on source contro

Colon-colon anastomosesoften leak

Hartmann resection used

upper end colostomy

anastomose later if healthy


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Challenges:

tight to close persistent abd wall infection

,incisional hernia


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1 fascial closure

Absorbable mesh fascial closure

y

Wound vacuum


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Primary closure with

advancement flaps


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asc a e ec an

s u a


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appy o e a ve


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Tem orar mesh


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Skin graft


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S aureus bacteremia from line


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S. aureus bacteremia from line

infectionepidural abscess


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Antibiotics for abdominal


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Antibiotics for abdominal

n ec on

over . co + . rag s

, ,

Patient still sick 4d: find sourcea , woun , ungs, nes, ur ne,

thrombo)

DO NOT JUST CHANGE OR ADD

Psychosocial asap:


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Psychosocial, asap:

Inform pt/family re:

stoma, edema, confusion,

,recover time, ro nosis

Depression common: call

Psych

Overview


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- Mana ement


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07 BOHNEN MMMD 2011-12 Abdominal Sepsis

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