07 BOHNEN MMMD 2011-12 Abdominal Sepsis
Transcript of 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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Overview Causes: 1 and 2 peritonitis
Anatomy: peritonitis, abscess
Diagnosis (1) typical Prognosis
- 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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Overview Causes: 1 and 2 peritonitis
Anatomy: peritonitis, abscess
Diagnosis (1) typical Prognosis
- Mana ement
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