Treatment Of Abdominal Sepsis Research Articles

Extracorporeal Methods of Hemocorrection in Patients with Abdominal Sepsis

BACKGROUND. Theoretical data convincingly support the use of extracorporeal hemocorrection (ECHC) methods in the treatment of sepsis. However, a large number of researchers have still not been able to convincingly prove the advantage of ECHC methods; there is no unanimity of opinion. We tried to analyze our own experience in using ECHC methods in the treatment of abdominal sepsis over the past 3 years. AIM OF STUDY. To analyze the use of ECHC methods in the early stages of treatment of abdominal sepsis, to determine whether their use had an advantage for survival. STUDY DESIGN. Prospective cohort. DESCRIPTION OF THE METHOD. In 50 cases (group 1), ECHC was performed early after surgery. The median time from admission to the intensive care unit after surgery to the start of ECHC was 25.3 (17.7; 36.5) hours. When determining the ECHC modality, we were guided by the individual approach and clinical experience of the ECHC specialist. Apheresis methods alone were performed in 8 % of patients (4/50), a combination of apheresis methods and renal replacement therapy was performed in 40 % (20/50), renal replacement therapy (RRT) methods were performed in 98 % (46/50), plasmapheresis/plasma exchange/selective plasma filtration were performed in 30 % (15/50), selective hemosorption of cytokines was performed in 4 % (2/50), selective hemosorption lipopolysaccharides was performed in 24 % (12/50). We analyzed outcomes, assessments of the severity of functional disorders and sepsis-associated organ dysfunction according to the APACHE scales II and SOFA and their dynamics, probabilities of outcomes depending on the scores on the indices (logistic regression); life times, cumulative survival rate (Kaplan-Meier method). SAMPLE CHARACTERISTICS. There were 113 patients after emergency laparotomy due to widespread peritonitis, abdominal sepsis, aged from 23 to 90 years. 67 men, 46 women. In 50 cases of observation (group 1), ECHC was performed in the early stages ; in 63 cases, methods of active hemocorrection were not used (group 2). In group 1 there were 35 patients with septic shock and 15 patients with stable hemodynamics (subgroup 1/shock and subgroup 1/sepsis). In group 2 there were 20 patients with shock and 43 with stable hemodynamics (subgroup 2/shock and subgroup 2/sepsis). RESEARCH RESULTS ECHC. Methods allowed survival of patients with more severe APACHE scores II and SOFA: in survivors in subgroup 1/shock Me 29 (24; 31) versus 23 (14; 26) in the subgroup 2/shock and 8 (4; 10) versus 4 (2; 6) points, p=0.048 and p = 0.010; with stable hemodynamics in survivors in subgroup 1/sepsis Me 20 (17; 22) versus 15 (11; 19) in subgroup 2/sepsis, p=0.016. ECHC changed the survival threshold in favor of more severe patients from 29 to 33 points; reduced the likelihood of an unfavorable outcome 1.2-fold for each point on the APACHE scale II and 1,276 times over the entire range of estimates; prolonged survival time in hemodynamically unstable patients at a significance level of p = 0.083, shifting the first quartile of survival from 1 to 12 days, the median from 12 to 20, the third quartile from 27 to 45 days. When performing ECHC, the cumulative survival rate was higher throughout the entire hospital observation period: 0.886 (95 % CI 0.780–0.939) in 2 days versus 0.700 (95 % CI 0.499–0.802); 0.800 (95 % CI 0.667–0.868) in 10 days versus 0.545 (95 % CI 0.325–0.658); 0.653 (95 % CI 0.494–0.734) in 14 days versus 0.416 (95 % CI 1.185–0.533). Overall mortality from all causes was 35.4 % (40/113), 67.3 (37/55) with shock, 5.2 % (3/58) with stable hemodynamics. The maximum risk of an unfavorable outcome occurred in the early stages: 30 % (12/40) of all deaths occurred in the first 4 days after surgery, 20 % (8/40) in the first 24 hours. In shock patients, 10-day mortality was lower when performing ECHC: 20.0 % (7/35) versus 45.0 % (9/20), p = 0.050, 1st stage. Fisher’s test, P = 0.38 insufficient. Hospital mortality in the shock subgroups was equal, all the advantages of ECHC achieved in the early stages were lost; although in most late outcomes the peritonitis was relieved; which was confirmed during the section. CONCLUSIONS. The power of the study was sufficient to identify statistically significant advantages of extracorporeal hemocorrection in the treatment of abdominal sepsis based on APACHE index estimates II and SOFA. For the Kaplan–Meier method, differences were obtained for shock patients at a significance level of 0.083; the number of observations must be doubled to detect statistically significant differences. The final results of hospital mortality require additional in-depth analysis, since in the later stages many deaths were not associated with abdominal sepsis and occurred with already resolved peritonitis. It is necessary to understand to what extent they were associated with experienced sepsis, and to what extent with comorbid pathology; whether there was an association with methods of extracorporeal hemocorrection.

TREATMENT OF ABDOMINAL SEPSIS WITH LEVAMISOLE AND PERITONEAL LAVAGE IN RATS

Introduction: Intra-abdominal sepsis is one of the most difficult situations in surgery and usually presents as a peritonitis. It is a systemic inflammatory response to infection that is often associated with hypoperfusion followed by tissue injury and organ failure. Given that its the sequelae reflect the increasing severity of the systemic response to infection, a correct and early treatment needs to be established. In this sense, the study analyzes the effect of peritoneal lavage and the use of the isomers immunomodulator in the treatment of abdominal sepsis in rats. Methods: The animals were randomly assigned to three groups A (control), B (peritoneal lavage), C (levamisole). All groups underwent laparotomy, anesthesia and cecal ligation/puncture. A ten-parameter clinical score was analyzed, which allowed the classification of sepsis degree, peritoneal fluid cultures, and cytokine dosage. Results: Group C had better scores on the clinical score and also lower growth of bacterial colonies in cultures. A lower dosage of TNF-alpha, IL-Ib, IL-6 and PCR in group C was observed, compared to groups A and B. Conclusion: Levamisole positively influenced the treatment in the parameters analyzed compared to the peritoneal lavage group and the control group.

MANAGEMENT OF POSTOPERATIVE PERITONITIS IN LOW-RESOURCES SERVICES

Background. Postoperative peritonitis (PP) reminds one of the most difficult complications in abdominal surgery with mortality rate 22.3 – 90 %. Methods. In Ivano-Frankivsk Regional (tertiary level) Clinical Hospital (Ivano-Frankivsk, Ukraine) during 2010–2017 were operated 8762 patients with acute and chronic diseases of digestive system (appendicitis, pancreatitis, cholecystitis, bowel obstruction, complicated ulcer of upper gastrointestinal truck, mesenteric vessels thrombosis, abdominal adhesion diseases, hernia, Chron’s diseases, abdominal trauma), among them in 209 (2.4 %) patients developed PP. Local PP (abscess of abdominal cavity) had 142 (67.9 %), diffuse PP – 67 (42.1 %) patients. Results. Clear local symptoms of peritonitis were absent in 178 (85.1 %) of 209 patients. General complication, such as acute respiratory failure had 95 (45.5 %), cardiovascular insufficiency – 68 (32.5 %), hepato-renal dysfunction - 46 (22 %) patients with PP. 129 (61.7 %) patients were treated by minimally invasive approach: 24 patients had laparoscopic lavage with drain of abdominal cavity abscess and 105 - ultrasound guided drain of abscess with catheter. 80 (38.3 %) patients had re-laparotomy (RL): 61 (91 %) from 67 with diffuse PP, 19 (13.4 %) from 142 patients – with local PP. 46 (57.5 %) patients underwent one RL, 26 (32.5 %) – two, 8 (10 %) patients – three RL. With increasing numbers of RL, increase mortality rate: after first RL died 7 (15.2 %) of 46 patients, after second RL – 12 (63.2 %) of 19, after third RL 6 (75 %) of 8 patients. Conclusions. Together with standard surgical methods and precise technique were used lavage of abdominal cavity with 8 – 12 litres of antiseptic solutions, solution for peritoneal dialysis intraabdominally, nasointestinal drain tube, what was favourable for faster treatment of abdominal sepsis, reducing number of RL and postoperative mortality.

IMMUNE IMBALANCE IN THE PATHOGENESIS OF ABDOMINAL SEPSIS IN THE PATIENTS WITH THE PRIMARY AND SECONDARY LIVER ABSCESSES.FEATURES OF THE DIAGNOSTICS AND OPTIMIZATION OF COMPLEX TREATMENT

The purpose ofourworkwas to identify markers of immune imbalance in the patients with abdominal sepsis due toprimary and secondary liver abscesses, to study methods of the correction of the infraction in the organism and a volume of the infusion. There were analyzed the results of treatment of 64 patients with primary and secondary liver abscesses.The results of analysis indicate a pronounced immune imbalance and the formation of secondary immune deficiency at the T-suppressor type. The main stage of the treatment of abdominal sepsis due to primary and secondary abscesses is draining the source of infection with antibacterial, hepatoprotective and detoxification therapy.

IMMUNE IMBALANCE IN THE PATHOGENESIS OF ABDOMINAL SEPSIS IN THE PATIENTS WITH THE PRIMARY AND SECONDARY LIVER ABSCESSES.FEATURES OF THE DIAGNOSTICS AND OPTIMIZATION OF COMPLEX TREATMENT

The purpose ofourworkwas to identify markers of immune imbalance in the patients with abdominal sepsis due toprimary and secondary liver abscesses, to study methods of the correction of the infraction in the organism and a volume of the infusion. There were analyzed the results of treatment of 64 patients with primary and secondary liver abscesses.The results of analysis indicate a pronounced immune imbalance and the formation of secondary immune deficiency at the T-suppressor type. The main stage of the treatment of abdominal sepsis due to primary and secondary abscesses is draining the source of infection with antibacterial, hepatoprotective and detoxification therapy.

Abdominal Sepsis: An Update.

Despite the significant development and advancement in antibiotic therapy, life-threatening complication of infective diseases cause hundreds of thousands of deaths world. This paper updates some of the issues regarding the etiology and treatment of abdominal sepsis and summaries the latest guidelines as recommended by the Intra-abdominal Infection (IAI) Consensus (2017). Prognostic scores are currently used to assess the course of peritonitis. Irrespective of the initial cause, there are several measures universally accepted as contributing to an improved survival rate, with the early recognition of IAI being the critical matter in this respect. Immediate correction of fluid balance should be undertaken with the use of vasoactive agents being prescribed, if necessary, to augment and assist fluid resuscitation. The WISS study showed that mortality was significantly affected by sepsis irrespective of any medical and surgical measures. A significant issue is the prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in the clinical setting, and the reported prevalence of ESBLs intra-abdominal infections has steadily increased in Asia. Europe, Latin America, Middle East, North America, and South Pacific. Abdominal cavity pathology is second only to sepsis occurring in a pulmonary site. Following IAI (2017) guidelines, antibiotic therapy should be initiated as soon as possible after a diagnosis has been verified.

Extracorporeal Detoxification in Abdominal Sepsis in Cancer Patients

The purpose is to evaluate the detoxification effects of the polymyxin sorption columns and filtration detoxification using polymethyl methacrylate membranes in abdominal sepsis in cancer patients. Materials and Methods . We examined 226 patients with oncological diseases of abdominal organs complicated by abdominal sepsis postsurgery. In 50 cases, septic shock was reported. In 173 patients an acute renal injury (ARI) was diagnosed in the structure of organ failures, of which a combination with acute respiratory distress syndrome (ARDS) was diagnosed in 61 patients. The severity was 26.3±3.3 points (APACHE-II scale), 10.2±2.5 points (SOFA scale), and 4.3±1.8 points (qSOFA scale). Microbiological identification was obtained in 155 (68.6%) cases. The polymyxin column sorption was used in 86 patients 2–6 hours after sepsis was diagnosed with the EAA greater than 0.5. The blood flow rate was 80–150 mL/min; the duration was 120–240 min; the sorption frequency was 2–3 sessions at a 24-hour interval. If ARI and ARDS were developed, detoxification by filtration using a dialyzer with a BK-1.6F polymethylmethacrylate membrane was included in the complex treatment of 144 patients. The detoxification was carried out for 8–12 hours changing the dialyzer every 4 hours. Results . A statistically significant decreases of hyperthermia, leukocytosis, neutrophilia, procalcitonin, and the EAA test values were revealed after the completion of the sorption treatment. Normalization of hemodynamic parameters, increase of the oxygenation index, and SOFA scoring decrease by 5.6±2.1 points (P<0.05) were found. PCT and IL-6 blood levels decreased from 6.7±2.7 ng/mL to 2.3±0.6 ng/mL and from 7300±7700 pg/mL to 860±180 pg/mL, respectively, as determined 60 minutes after completion of filtration detoxification procedure (P<0.05). The SOFA index decreased by 4.1±1.1 points (P<0.05). Conclusion . The use of polymyxin column sorption and filtration detoxification using a polymethyl metacrylate membrane improves the results of treatment of abdominal sepsis in cancer patients.

Effect of Peritoneal Lavage with Coconut Water in Healing of Colon Anastomosis in Rat Abdominal Sepsis Model

Purpose: The objective of this study was to evaluate the efficacy of peritoneal lavage with coconut water in the healing of colonic anastomoses in a model of abdominal sepsis in rats. Methods: Twelve Wistar rats were used. The animals were randomly selected and distributed in 2 groups, with six rats each. Group 1: rats with sepsis + peritoneal lavage with 0.9% saline solution and Group 2: rats with sepsis + peritoneal lavage with coconut water. Induction of abdominal sepsis was performed through the exteriorization of the cecum and ligature. After ligation, 4 perforations and gentle pressure were made in the cecum, allowing the small amount of stool to escape. The cecum was then replaced in the abdominal cavity and the abdominal incision sutured. Six hours after induction of sepsis, under anesthesia in all animals, 2 cm of colon resection and anastomosis were performed. The peritoneal lavage therapy was repeated 3 times, each wash with 5 ml of solution, which remained in the peritoneal cavity for 1 minute and then removed with sterile dry gauze. Coconut water was obtained from Cocus nucifera L specimens, with sterile technique for administration to the animals. Results: In group 2 the bursting pressure of anastomosis was 196.3±17.47 mmHg, significantly higher (p=0.001) than in the saline group, (152.8±12.31 mm/Hg). The peritoneal lavage group with coconut water presented histological scores with a significantly (p&lt;0.001) lower inflammatory process (score 14.8±3.13) compared to the saline group (score 31.7±4.92). The count of colony forming units (CFU) in the peritoneal fluid was significantly lower (p=0.001) in the coconut water group (16.0±7.32 CFU) than in the saline group (83.5±8.62 CFU). Conclusion: The treatment of abdominal sepsis with peritoneal lavage using coconut water positively afluenced the healing of colon anastomosis in rats. It favored the bursting pressure, the reduction of inflammatory process, and bacterial colonization.

Abdominal sepsis.

To summarize the recent evidence on the treatment of abdominal sepsis with a specific emphasis on the surgical treatment. A multitude of surgical approaches towards abdominal sepsis are practised. Recent evidence shows that immediate closure of the abdomen has a better outcome. A short course of antibiotics has a similar effect as a long course of antibiotics in patients with intra-abdominal infection without severe sepsis. Management of abdominal sepsis requires a multidisciplinary approach. Closing the abdomen permanently after source control and only reopening it in case of deterioration of the patient without other (percutaneous) options is the preferred strategy. There is no convincing evidence that damage control surgery is beneficial in patients with abdominal sepsis. If primary closure of the abdomen is impossible because of excessive visceral edema, delayed closure using negative pressure therapy with continuous mesh-mediated fascial traction shows the best results.

Extracorporeal Treatments for Abdominal Sepsis

In spite of considerable progress in the intensive treatment of abdominal sepsis, mortality from this disease remains very high. A systemic inflammatory response to infection is characterized by the blood flow release of endotoxin and inflammatory mediators, which cause circulatory disorders and multiple organ dysfunctions. High frequency Doppler ultrasound allows dynamic estimation of tissue perfusion during efferent treatment. Objective: to give an account of current approaches to extracorporeal treatment for abdominal sepsis in the light of urgent views on the pathogenesis of bacterial translocation and a systemic inflammatory response, as well as macrohemodynamic disorders and tissue perfusion failure.

Sildenafil as a vasodilatatory madiator in the treatment of abdominal sepsis

Sildenafil as a vasodilatatory madiator in the treatment of abdominal sepsis

Effects of pentoxifylline in the treatment of abdominal sepsis in rats

Objective: To evaluate the effects of pentoxifylline in the treatment of abdominal sepsis in rats submitted to cecal ligation and puncture (CLP). Methods: We used 18 Wistar male rats three months old, randomly divided into control group C (n = 6); CLP (n = 6) for the rats submitted to CLP; Group CLP + PTX (n = 6) whose rats were treated with pentoxifylline and submitted to CLP. Pentoxifylline (40mg/Kg) was injected intraperitoneal 2 hours before and 8 hours after the induction of peritonitis. Histopathology of the lung, liver and kidney as well as analysis of renal function, markers of liver injury and cytokines were studied. The results were compared through ANOVA, and post hoc by Bonferroni test, considering p &lt;0.05 as significant. Results: The control group rats showed lower levels of all cytokines, compared to CLP group (p &lt;0.05). The CLP+PTX rats showed significantly lower amounts of TNF-α and IL-1 β when compared to the CLP group, but similar to group C. The levels of IL-6 in Group CLP+PTX, were higher than that found in group C and lower than that found in Group CLP (p &lt;0.05). Reduction of urea and creatinine occurred after administration of pentoxifylline. The values of AST and ALT were slightly lower in the experimental group, and no significant difference was observed comparing with the control group. The microscopic findings of kidney, liver and lung revealed less inflammatory reaction associated with the reduction of pathological changes in animals treated with pentoxifylline. Conclusion: The pentoxifylline attenuated the pathophysiological events of sepsis, reducing the expression of pro-inflammatory cytokines, preserving renal function and tissue injury in an experimental model of polymicrobial sepsis.

Active Detoxification in the Treatment of Abdominal Sepsis

Objective: to evaluate the efficiency of extracorporeal detoxification techniques in patients with abdominal sepsis. Subjects and methods. Three hundred and seventy-nine patients with acute generalized peritonitis were examined. Extracorporeal detoxifying techniques were used during conventional therapy in Group 1 (n=319); the other patients received only traditional therapy (a control group). The time course of changes in the parameters of toxemia, a hemostasiogram, and an immunogram were examined. Results. The study indicated significantly reduced endotoxemia and better blood aggregation resulting from the use of plasmapheresis, cryoplasmasorption, and plasmasorption, as well as stimulated immunity when the above techniques were combined with autoblood photomodification and extracorporeal immunopharmacotherapy in patients with abdominal sepsis. In severe abdominal sepsis and infectious-toxic shock, there was regression of multiple organ dysfunction and lower mortality when venovenous hemofiltration was applied. Conclusion. A differential approach to using active detoxifying techniques is needed, by taking into account the severity of the disease. Key words: abdominal sepsis, detoxifying techniques.

Damage control surgery by keeping the abdomen open during pregnancy: favorable outcome, a case report

BackgroundAcute abdomen in advanced pregnancy is one of the most challenging surgical situations. In life-threatening situations, despite optimal management, foetus distress and preterm delivery may occur. Although laparostomy is a useful treatment of abdominal sepsis, its successful management has not been reported previously in pregnant women.Case30-year-old woman at 23 week of pregnancy was investigated for non-specific abdominal pain. Surgical exploration revealed extensive ischemic bowel necrosis. Multiple segmental resections were performed and abdomen was left open with vacuum assisted dressing, maintained for 48 hours. At the third surgical look the continuity was restored and abdominal wall closed. The foetal condition stayed unperturbed under pharmacologic tocolysis. Pregnancy was carried to full term delivery.ConclusionOpen abdomen strategy can be successfully applied in pregnant woman.

A Differential Approach to Choosing Extracorporeal Detoxification Methods for Abdominal Sepsis

A differential approach to choosing the methods of extracorporeal detoxification in the complex treatment of abdominal sepsis in the context of endogenous intoxication in order to enhance the efficiency of medical measures was pathogeneti-cally substantiated. In 51 patients diagnosed as having abdominal sepsis, the latter was characterized as the endogenous intoxication syndrome in relation to the accumulation of low and medium molecular-weight substances (plasma and red blood cells) in the body and their physiological elimination with urine. An original formula was used to calculate the integral marker – the endogenous intoxication index correlating with the routine severity rating scales APACHE II and SOFA and reflecting the severity of endotoxicosis. According to the values of the endogenous intoxication index and to the sum of scores by the APACHE II and SOFA scales, the patients were divided into 3 groups of the clinicopathogenetic types of endogenous intoxication. According to the type of endogenous intoxication, the authors proposed a differential approach to choosing the modes of efferent therapy for abdominal sepsis: high-volume plasmapheresis in the subcompensated type and prolonged venovenous hemofiltration, which improved the results of treatment and reduced mortality rates.

Disturbances of protein c activity in abdominal sepsis: Diagnostic and predictive importance

Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, more than one third of patients still die of severe secondary peritonitis. Clinical difficulties in the treatment of abdominal sepsis were related to inherent problems of limited clinical signs and the rapid spread of infection. An inflammatory process is often well under way before the presence of clinical signs and symptoms of sepsis. The aim of this prospective study was to assess diagnostic and prognostic significance of protein C in abdominal sepsis. Twenty-two patients with severe intraabdominal infections with sepsis syndrome were treated surgically as compared to 15 patients with hernia repair (control group). During the study, the following parameters were analyzed daily: protein C, AT III, plasminogen, alfa-2 antiplasmin, HMWK, C5a and C5-B9 complement, C1-inhibitor, CRP. RESULTS. The mean APACHE II score was 17 points, with actual mortality rate of 23%. Each parameter evaluated in the abdominal sepsis group differed from the one evaluated in the control group to a great extent (p = 0.001). The results and multivariate regression statystical analysis confirmed the following parameters as sensitive biological markers of septic cascade (p < 0.0001-0.026): protein C, AT III, HMWK, C1-inhibitor and C5-B9 complement. According to the results the low level of protein C consistently correlated with disease severity and suggested the development of septic shock and poor outcome. Early diagnosis of plasma proteolytic disturbances was very important, from the diagnostic and predictive point of view, in abdominal sepsis. According to the results protein C was the most significant marker of sepsis and early predictor of the outcome of septic complications during severe intraabdominal infections (r = 0.761; p = 0.0001).

Cefoxitin in abdominal sepsis

A study of 34 patients was undertaken to determine the efficacy of a new antibiotic, cefoxitin sodium, in the treatment of abdominal sepsis. The most common infection was appendicitis associated with peritonitis. Thirty of the 34 patients were cured by cefoxitin therapy accompanied, when indicated, by surgical drainage. None of the patients developed adverse reactions to the antibiotic, but local pain related to i.v. injection was a common complaint.