Severe Intra-abdominal Sepsis Research Articles

Intra-abdominal sepsis and adrenergic receptor response.

This study measured the adrenergic receptor response of 13 patients with severe intra-abdominal sepsis, who required laparotomy and an open abdominal closure with Marlex mesh. The source of the sepsis was gram-negative organisms of intestinal origin. There were seven survivors and six nonsurvivors. When the patients were stratified into survivors and nonsurvivors, the Septic Severity Score, the APACHE II score, the Acute Physiological Score, and the Glasgow Coma Scale score results were not significantly different between groups. The alpha-2 and beta-1 adrenergic receptor responses were measured in the adipose tissue of the abdominal wall and the small bowel mesentery on day 1 of admission to the intensive care unit. The results demonstrated that the alpha-2 and beta-1 receptors of the nonsurvivors had a significantly decreased receptor response with desensitization and down regulation. The alpha-2 and beta-1 receptors of the survivors had an increased response with hypersensitization and up regulation. This study indicates that the adrenergic receptor pattern is distinctly different between survivors and nonsurvivors with severe abdominal gram-negative sepsis. The pattern differences occurred early (within 24 hours) when the patients had similar physiologic profiles. It is concluded that adrenergic receptor response may be a biologic indicator of the magnitude of the septic injury and a predictor of outcome.

Treatment of severe intra-abdominal sepsis and/or necrotic foci by an 'open-abdomen' approach. Zipper and zipper-mesh techniques.

Undrained necrotic tissue or septic foci contribute to continued "activation" of host processes that in turn lead to multiple organ failure and death. We hypothesized that if wide-open drainage of the abdominal cavity is provided, thus not allowing intra-abdominal collections to form, mortality in these patients can be reduced. Since 1982 we have treated 49 patients with necrotic pancreatitis and related infections and 15 patients with severe intra-abdominal sepsis from intestinal perforations. The surgical treatment was based on the provision for daily laparotomies in the intensive care unit with the patient under epidural anesthesia by using an "open-abdomen" technique (zipper alone or a zipper-mesh combination). The APACHE II score and the functional classification were used to derive expected mortalities. The patients with intraabdominal sepsis had a mean APACHE II score of 25 and an expected mortality of 45%, vs the 26.5% mortality that we observed. The lowest mortality in the necrotic pancreatitis group was associated with noninfected pancreatic necrosis (6%) and single abscess (9%) vs 22% mortality rate in the patients with infected pancreatic necrosis. The mean expected mortality in this group was 47%, vs the observed 22%. We attributed this result to the daily abdominal explorations that achieved a complete excision of infected or necrotic tissue.

Open Management of the Septic Abdomen

The mortality rate of severe intra-abdominal infections is still very high. The open management of the abdomen is a method of treatment which has gained popularity over the past few years. Its advantages include a better drainage of the peritoneal cavity, a greater protection of the parietes, an improved perfusion of the abdominal viscera and a decrease in postoperative pulmonary complications. It is indicated in patients with severe intra-abdominal sepsis, especially when multiple re-explorations of the abdomen are likely. A variety of techniques, including the use of Marlex mesh have been devised to contend with possible complications: spontaneous fistulas, exogenous bacterial contamination, evisceration and massive fluid losses. The open method of management has not made the treatment of septic abdomen much easier; it requires intensive care support and repeated assessment of the peritoneal cavity. The closure of the abdomen is a problem which must be addressed when the sepsis has subsided. The value of this technique is still difficult to assess in the absence of controlled randomized trials.

The septic abdomen: open management with Marlex mesh with a zipper.

The "open" abdomen has gained popularity in the management of severe intraabdominal sepsis. Drawbacks include evisceration, need for ventilator support, and recurrent abdominal sepsis. We have applied a more aggressive and effective technique consisting of abdominal "closure" with a Marlex mesh sheet containing a zipper. Manual exploration and lavage is performed daily through the zipper in the surgical intensive care unit. Ten patients with severe abdominal sepsis were treated for the following: fecal peritonitis (three patients), radiation enteritis with fistula (one patient), diverticular abscess and dehiscence (one patient), diffuse postoperative abdominal sepsis (two patients), and necrotizing pancreatitis (three patients). Thirteen meshes were inserted, four at first operation and nine at the second to sixth operations. Eight patients survived (80%). Only three patients required respirators; two died. Two patients underwent drainage of three defined abscesses in the surgical intensive care unit. Three patients underwent five major operations through the zipper. Intestinal stomas were present adjacent to the mesh in six patients and were not a management problem. No fistulas resulted from this technique. The Marlex/zipper was removed when all septic signs abated and adhesions were allowed to form (average of 10 to 12 days). Daily aggressive manual lavage of the abdomen through a Marlex mesh/zipper is rapid, simple, and well tolerated. It has permitted effective management of severe septic peritonitis and easier wound care. This technique merits further controlled trials to ascertain its ultimate benefit in survival.

The Hubbard Tank as an Adjunct to Drainage in Overwhelming Intra-abdominal Sepsis

Open drainage of the peritoneal cavity for severe intra-abdominal sepsis has been gaining popularity. We had a patient whose overwhelming intra-abdominal infection did not respond to open drainage but was controlled by frequent immersion in a Hubbard tank. Use of the Hubbard tank should be considered in patients with uncontrolled intra-abdominal infection refractory to standard therapy.

Blood concentration and disappearance of injected alanine and beta-hydroxybutyrate in surgical patients.

The blood concentrations and the disappearance of injected beta-hydroxybutyrate (beta-OHB) and alanine were measured in 12 health subjects who had fasted overnight and in 25 surgical patients. Ten of the patients had had uncomplicated abdominal surgery two of five days before, six patients had moderate sepsis e.g. wound sepsis and nine patients had severe intra-abdominal sepsis. Separated bolus injections of beta-OHB and alanine were given intravenously and the blood concentration of the corresponding metabolite was measured over the following 40 mins. The disappearance of the injected metabolite was logarithmic, and the half-life (t 1/2) and clearance rate of the injected metabolite were calculated. The basal ketone concentration (beta-hydroxybutyrate and acetoacetate) were higher in the post operative group than in healthy subjects whereas the severely septic group had the same ketone concentration as the healthy subjects. Alanine concentration was significantly lower in the post-operative group. The t 1/2 and clearance rate of the injected metabolites were similar in all the groups for both beta-hydroxybutyrate and alanine. It is suggested that if the bolus is handled like the endogenously produced metabolite then the differences in concentration of beta-OHB and alanine in post-surgical and septic patients are likely to be due to changes in production rate.

Anastomotic failure complicating total gastrectomy and esophagogastrectomy for cancer of the stomach

Anastomotic failure complicated the postoperative course of 11 per cent of 350 gastric cancer patients who underwent total gastrectomy and esophagogastrectomy and was responsible for 33 per cent of all operative deaths. The extent of disease and the presence of tumor at the margin of resection did not prove to be significant factors in regard to the incidence of anastomotic failure. Gastrectomy combined with resection of other organs was associated with a significantly higher risk of failure. End-to-end esophagogastrectomy and esophagoduodenostomy appeared to be prone to failure, while Roux-en-Y, jejunal pouch, and jejunal loop reconstructions were safer. Patients with severe intraabdominal or intrathoracic sepsis had a poor prognosis, and their management with surgical or conservative methods was ineffective. On the basis of these findings, alternatives to manual methods of visceral suturing should be considered.

Pseudomonas aeruginosa and the general hospital: a six-year survey.

The incidence of infections caused by Pseudomonas aeruginosa did not increase significantly among general surgical and medical patients between 1967 and 1972, and the majority of such infections were trivial. Serious infections were virtually confined to the intensive care unit and the renal transplant unit, and were usually associated with major trauma, surgical mishap or immunosuppression. The majority of these patients had received prior antibiotic therapy. Persistent isolation of Ps. aeruginosa from surgical wounds was often associated with severe intra-abdominal sepsis, and antibacterial therapy was commonly ineffective in these cases. Apparently susceptible patients did not necessarily acquire infection, though the organism was present in their environment. It is suggested that this may reflect a variation of virulence among environmental strains of Ps. aeruginosa, and that further study of this aspect may contribute to improved control of infection.