1
|
Lagazzi E, Yi A, Nzenwa IC, Panossian VS, Rafaqat W, Abiad M, Hoekman AH, Arnold S, Luckhurst CM, Parks JJ, Velmahos GC, Kaafarani HMA, Hwabejire JO. First do no harm: Predicting futility of intervention in geriatric emergency general surgery. Am J Surg 2024; 236:115841. [PMID: 39024721 DOI: 10.1016/j.amjsurg.2024.115841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/28/2024] [Accepted: 07/09/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. METHODS We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. RESULTS Of 41,029 patients, 5589 (13.6 %) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 % CI,3.5-26.8, p < 0.001), septic shock (aOR 4.9, 95 % CI,4.5-5.4, p < 0.001), and dialysis (aOR 2.1, 95 % CI,1.8-2.4, p < 0.001). Without risk factors, mortality rates were 11.9 % after colectomy and 10.2 % after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 % and 100 % following colectomy and small bowel resection, respectively. CONCLUSIONS In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.
Collapse
Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Department of Surgery, Humanitas Research Hospital, Rozzano, Italy
| | - Alisha Yi
- Harvard Medical School, Boston, MA, United States
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Anne H Hoekman
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Suzanne Arnold
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Casey M Luckhurst
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Jonathan J Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
2
|
Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate? POSTEP HIG MED DOSW 2022. [DOI: 10.2478/ahem-2022-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Abstract
The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.
Collapse
|
3
|
Crapnell RD, Dempsey-Hibbert NC, Peeters M, Tridente A, Banks CE. Molecularly imprinted polymer based electrochemical biosensors: Overcoming the challenges of detecting vital biomarkers and speeding up diagnosis. TALANTA OPEN 2020. [DOI: 10.1016/j.talo.2020.100018] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
4
|
Burdick H, Pino E, Gabel-Comeau D, Gu C, Roberts J, Le S, Slote J, Saber N, Pellegrini E, Green-Saxena A, Hoffman J, Das R. Validation of a machine learning algorithm for early severe sepsis prediction: a retrospective study predicting severe sepsis up to 48 h in advance using a diverse dataset from 461 US hospitals. BMC Med Inform Decis Mak 2020; 20:276. [PMID: 33109167 PMCID: PMC7590695 DOI: 10.1186/s12911-020-01284-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 10/08/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Severe sepsis and septic shock are among the leading causes of death in the United States and sepsis remains one of the most expensive conditions to diagnose and treat. Accurate early diagnosis and treatment can reduce the risk of adverse patient outcomes, but the efficacy of traditional rule-based screening methods is limited. The purpose of this study was to develop and validate a machine learning algorithm (MLA) for severe sepsis prediction up to 48 h before onset using a diverse patient dataset. METHODS Retrospective analysis was performed on datasets composed of de-identified electronic health records collected between 2001 and 2017, including 510,497 inpatient and emergency encounters from 461 health centers collected between 2001 and 2015, and 20,647 inpatient and emergency encounters collected in 2017 from a community hospital. MLA performance was compared to commonly used disease severity scoring systems and was evaluated at 0, 4, 6, 12, 24, and 48 h prior to severe sepsis onset. RESULTS 270,438 patients were included in analysis. At time of onset, the MLA demonstrated an AUROC of 0.931 (95% CI 0.914, 0.948) and a diagnostic odds ratio (DOR) of 53.105 on a testing dataset, exceeding MEWS (0.725, P < .001; DOR 4.358), SOFA (0.716; P < .001; DOR 3.720), and SIRS (0.655; P < .001; DOR 3.290). For prediction 48 h prior to onset, the MLA achieved an AUROC of 0.827 (95% CI 0.806, 0.848) on a testing dataset. On an external validation dataset, the MLA achieved an AUROC of 0.948 (95% CI 0.942, 0.954) at the time of onset, and 0.752 at 48 h prior to onset. CONCLUSIONS The MLA accurately predicts severe sepsis onset up to 48 h in advance using only readily available vital signs extracted from the existing patient electronic health records. Relevant implications for clinical practice include improved patient outcomes from early severe sepsis detection and treatment.
Collapse
Affiliation(s)
- Hoyt Burdick
- Cabell Huntington Hospital, Huntington, WV, USA
- Marshall University School of Medicine, Huntington, WV, USA
| | - Eduardo Pino
- Cabell Huntington Hospital, Huntington, WV, USA
- Marshall University School of Medicine, Huntington, WV, USA
| | | | - Carol Gu
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| | | | - Sidney Le
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| | - Joseph Slote
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| | - Nicholas Saber
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| | | | | | - Jana Hoffman
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| | - Ritankar Das
- Dascena, Inc., P.O. Box 156572, San Francisco, CA, 94115, USA
| |
Collapse
|
5
|
Anirudhan A, Paramasivam P, Murugesan R, Ahmed SSSJ. Temporal changes of NF-κB signaling pathway genes in bacterial stimulated whole blood- a host mechanism associated with sepsis. Microb Pathog 2020; 147:104415. [PMID: 32738283 DOI: 10.1016/j.micpath.2020.104415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 05/05/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
Bacterial sepsis affects both neonates and adults worldwide. There is no specific anti-sepsis treatment. Disease management mainly depends on early diagnosis. The gold standard blood culturing method is routinely practiced; it requires 24-48 h for confirmation. Understanding the disease mechanism may help in the early detection of sepsis. We studied the temporal change in NF-kB pathway genes in adult whole blood upon bacterial stimulations across time intervals (2-6 h). Four experimental conditions were investigated (1: Gram-positive, 2: Gram-negative, 3: Gram-positive + Gram-negative stimulated and compared with 4: un-stimulated group) to show host selection of canonical or non-canonical pathway against invading pathogens. Gene expression analysis showed significant variations (p < 0.5) in TLR2, TLR4, TRAF6, NIK, RelA, and RelB upon bacterial stimulants. Further, the correlation analysis showed the coherent behaviour of genes in selecting the canonical or non-canonical pathway. TLR2 sensed by gram-positive bacteria that immediately activates the canonical pathway through RelA, whereas other bacterial stimulants activate the non-canonical pathway via TLR4, NIK, and RelB. In addition, the inflammatory markers showed a significant increase in response to bacterial stimulants, suggesting the immediate activation of innate immunity. Overall, our results show the bacterial specific and time-dependent activation of the NF-kB pathway, which through a light towards the early detection of bacterial sepsis.
Collapse
Affiliation(s)
- Athira Anirudhan
- Multi-omics and Drug Discovery Lab, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Kelambakkam, 603103, Tamil Nadu, India
| | - Prabu Paramasivam
- Department of Cell& Molecular Biology, Madras Diabetes Research Foundation, Tamil Nadu, India
| | - Ram Murugesan
- Multi-omics and Drug Discovery Lab, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Kelambakkam, 603103, Tamil Nadu, India
| | - Shiek S S J Ahmed
- Multi-omics and Drug Discovery Lab, Faculty of Allied Health Sciences, Chettinad Academy of Research and Education, Kelambakkam, 603103, Tamil Nadu, India.
| |
Collapse
|
6
|
The Combined SIRS + qSOFA (qSIRS) Score is More Accurate Than qSOFA Alone in Predicting Mortality in Patients with Surgical Sepsis in an LMIC Emergency Department. World J Surg 2020; 44:21-29. [PMID: 31641836 DOI: 10.1007/s00268-019-05181-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND qSOFA has been proposed as a prognostic tool in patients with sepsis. This study set out to assess the sensitivity of several scores, namely: the pre-ICU qSOFA, the qSOFA with lactate (qSOFA L), SIRS score, qSOFA + SIRS score (qSIRS) and qSIRS with lactate (qSIRS L) in predicting in-hospital mortality in patients with surgical sepsis as well as the sensitivity of these scores in predicting high-grade sepsis. The secondary aim was to determine which of these scores is best suited to predict high-grade surgical sepsis. METHODS This was a retrospective cohort study that was conducted between December 2012 and August 2017 in a public metropolitan surgical service. Data from patients aged > 13 years, who were admitted to the hospital and who had an emergency surgical procedure for source control were retrieved from a prospectively maintained hybrid electronic database. The qSOFA, qSOFA plus lactate (qSOFA L), SIRS and qSOFA + SIRS (qSIRS), as well as the qSIRS plus lactate (qSIRS L), were calculated for each patient. A lactate level that was greater than 2mmol/L was deemed to be a positive finding. Any score ≥2 was deemed to be a positive score. The outcome measure was in-hospital mortality. The prognostic value of qSOFA, qSOFA L, SIRS, qSIRS and qSIRS L was studied. Receiver operating characteristic analyses were performed to determine the area under the curve (AUC), sensitivity, specificity and positive and negative likelihood ratios for positive qSOFA, qSOFA L, SIRS, qSIRS, and qSIRS L. Contingency tables were used to calculate the sensitivity, specificity, PPV and NPV for predicting severe or high-grade surgical sepsis. RESULTS There were a total number of 1884 patients in the sample group of whom 855 were female (45.4%). The median patient age was 36 years (IQR 23-56). A total of 1489 patients (79%) were deemed to have high-grade sepsis based on an advanced EGS AAST grading, whilst 395 patients (21%) had low-grade sepsis. A total of 71 patients died (3.8%). Of these patients who died, 67 (94.4%) had high-grade sepsis and 4 (5.6%) had low-grade sepsis. The mortality rate in the high-grade sepsis group was 4.5%, whilst the mortality rate in the low-grade sepsis group was 1%. The scores with the greatest accuracy in predicting mortality were qSIRS (AUROC 0.731, 95% CI 0.68-0.78), followed by SIRS (AUROC 0.70, 95% CI 0.65-0.75). The qSOFA and qSOFA L were the least accurate in predicting mortality (AUROC 0.684, 95% CI 0.63-0.74 for both). The addition of lactate had no significant effect on the accuracy of the five scores in predicting mortality. Patients with a qSOFA ≥ 2 have an increased risk of dying (OR 5.8), as do patients with a SIRS score ≥2 (OR 2.7). qSIRS L had the highest sensitivity (69%) in predicting the presence of high-grade surgical sepsis, followed by qSIRS (65.5% sensitivity). qSOFA showed a very low sensitivity of only 4.5% and a high specificity of 99.2%. The addition of lactate to the score marginally improved the sensitivity. Lactate of 2mmol/L or more was also an independent predictor of high-grade sepsis. CONCLUSION The qSIRS score is most accurate in predicting mortality in surgical sepsis. The qSOFA score is inferior to both the SIRS and the qSIRS scores in predicting mortality. The qSIRS score with the addition of lactate to the qSIRS score made it the most sensitive score in predicting high-grade surgical sepsis.
Collapse
|
7
|
Burdick H, Pino E, Gabel-Comeau D, McCoy A, Gu C, Roberts J, Le S, Slote J, Pellegrini E, Green-Saxena A, Hoffman J, Das R. Effect of a sepsis prediction algorithm on patient mortality, length of stay and readmission: a prospective multicentre clinical outcomes evaluation of real-world patient data from US hospitals. BMJ Health Care Inform 2020; 27:e100109. [PMID: 32354696 PMCID: PMC7245419 DOI: 10.1136/bmjhci-2019-100109] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/25/2019] [Accepted: 02/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe sepsis and septic shock are among the leading causes of death in the USA. While early prediction of severe sepsis can reduce adverse patient outcomes, sepsis remains one of the most expensive conditions to diagnose and treat. OBJECTIVE The purpose of this study was to evaluate the effect of a machine learning algorithm for severe sepsis prediction on in-hospital mortality, hospital length of stay and 30-day readmission. DESIGN Prospective clinical outcomes evaluation. SETTING Evaluation was performed on a multiyear, multicentre clinical data set of real-world data containing 75 147 patient encounters from nine hospitals across the continental USA, ranging from community hospitals to large academic medical centres. PARTICIPANTS Analyses were performed for 17 758 adult patients who met two or more systemic inflammatory response syndrome criteria at any point during their stay ('sepsis-related' patients). INTERVENTIONS Machine learning algorithm for severe sepsis prediction. OUTCOME MEASURES In-hospital mortality, length of stay and 30-day readmission rates. RESULTS Hospitals saw an average 39.5% reduction of in-hospital mortality, a 32.3% reduction in hospital length of stay and a 22.7% reduction in 30-day readmission rate for sepsis-related patient stays when using the machine learning algorithm in clinical outcomes analysis. CONCLUSIONS Reductions of in-hospital mortality, hospital length of stay and 30-day readmissions were observed in real-world clinical use of the machine learning-based algorithm. The predictive algorithm may be successfully used to improve sepsis-related outcomes in live clinical settings. TRIAL REGISTRATION NUMBER NCT03960203.
Collapse
Affiliation(s)
- Hoyt Burdick
- Cabell Huntington Hospital, Huntington, West Virginia, USA
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | - Eduardo Pino
- Cabell Huntington Hospital, Huntington, West Virginia, USA
- Marshall University School of Medicine, Huntington, West Virginia, USA
| | | | - Andrea McCoy
- Cape May Regional Medical Center, Cape May Court House, New Jersey, USA
| | - Carol Gu
- Dascena Inc, Oakland, California, USA
| | | | - Sidney Le
- Dascena Inc, Oakland, California, USA
| | | | | | | | | | | |
Collapse
|
8
|
Abstract
Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.
Collapse
|
9
|
DeWane MP, Davis KA, Schuster KM, Maung AA, Becher RD. Rethinking our definition of operative success: predicting early mortality after emergency general surgery colon resection. Trauma Surg Acute Care Open 2019; 4:e000244. [PMID: 31245613 PMCID: PMC6560481 DOI: 10.1136/tsaco-2018-000244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 03/08/2019] [Accepted: 03/23/2019] [Indexed: 11/03/2022] Open
Abstract
Background The postoperative outcomes of emergency general surgery patients can be fraught with uncertainty. Although surgical risk calculators exist to predict 30-day mortality, they are often of limited utility in preparing patients and families for immediate perioperative complications. Examination of trends in mortality after emergent colectomy may help inform complex perioperative decision-making. We hypothesized that risk factors could be identified to predict early mortality (before postoperative day 5) to inform operative decisions. Methods This analysis was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database (2012-2014). Patients were stratified into three groups: early death (postoperative day 0-4), late death (postoperative day 5-30), and those who survived. Multivariable logistic regression was used to explore characteristics associated with early death. Kaplan-Meier models and Cox regression were used to further characterize their impact. Results A total of 18 803 patients were analyzed. Overall 30-day mortality was 12.5% (3316); of these, 37.1% (899) were early deaths. The preoperative factors most predictive of early death were septic shock (OR 3.62, p<0.001), ventilator dependence (OR 2.81, p<0.001), and ascites (OR 1.63, p<0.001). Postoperative complications associated with early death included pulmonary embolism (OR 5.78, p<0.001), presence of new-onset or ongoing postoperative septic shock (OR 4.45, p<0.001) and new-onset renal failure (OR 1.89, p<0.001). Patients with both preoperative and postoperative shock had an overall mortality rate of 47% with over half of all deaths occurring in the early period. Conclusions Nearly 40% of patients who die after emergent colon resection do so before postoperative day 5. Early mortality is heavily influenced by the presence of both preoperative and new or persistent postoperative septic shock. These results demonstrate important temporal trends of mortality, which may inform perioperative patient and family discussions and complex management decisions. Level of evidence Level III. Study type: Prognostic.
Collapse
Affiliation(s)
- Michael P DeWane
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly A Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adrian A Maung
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert D Becher
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
10
|
Mugazov M, Turgunov Y, Kaliyeva D, Matyushko D, Koishibayev Z, Omertayeva D, Nurbekov A, Koishibayeva L, Alibekov A. The Role of Presepsin in Patients with Acute Surgical Diseases. Open Access Maced J Med Sci 2019; 7:1282-1286. [PMID: 31110570 PMCID: PMC6514349 DOI: 10.3889/oamjms.2019.292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/21/2022] Open
Abstract
AIM The purpose of this study was to determine the level of significance of markers in the development of intra-abdominal hypertension in patients with acute surgical diseases of the abdominal cavity. METHODS The authors surveyed 100 patients who were monitored at the Regional Clinical Hospital, Karaganda. The criterion for inclusion in the study was the informed consent of patients to participate in the study, the presence of acute surgical pathology, and the monitoring of intra-abdominal pressure over time. The exclusion criteria for patients from the study is the presence of sub and decompensation of associated diseases: trauma (hematoma of the bladder), bladder tumour and impaired integrity of the pelvic ring. The design of the study was by the legislation of the Republic of Kazakhstan, international ethical norms and normative documents of research organizations, approved by the ethics committee of the Karaganda State Medical University. RESULTS According to the world scientific literature, there are 4 indicators that change their value in response to increases in pressure in the abdominal cavity: fibrinogen and prothrombin index (the main indicators of the coagulogram); marker of blood clots D-dimer; early marker of translocation of bacterial flora into the bloodstream sCD14 (presepsin). CONCLUSION The authors concluded that the obtained data indicate that an increase in intra-abdominal pressure in acute surgical diseases of the abdominal cavity causes hypercoagulation and an increase in presepsin. Monitoring IAP with simultaneous measurement of the level of presepsin significantly improves the stratification of critical patients in need of emergency surgery.
Collapse
Affiliation(s)
- Miras Mugazov
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Yermek Turgunov
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Dinar Kaliyeva
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Dmitriy Matyushko
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Zhandos Koishibayev
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Dinara Omertayeva
- Department of Biochemistry, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Aidyn Nurbekov
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Leyla Koishibayeva
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| | - Asylkhan Alibekov
- Department of Surgical Diseases, Non-commercial Joint-stock Company, Karaganda Medical University, Karaganda, Kazakhstan
| |
Collapse
|
11
|
Hiong A, Thursky KA, Venn G, Teh BW, Haeusler GM, Crane M, Slavin MA, Worth LJ. Impact of a hospital-wide sepsis pathway on improved quality of care and clinical outcomes in surgical patients at a comprehensive cancer centre. Eur J Cancer Care (Engl) 2019; 28:e13018. [PMID: 30761632 DOI: 10.1111/ecc.13018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 09/12/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023]
Abstract
PURPOSE Sepsis is a significant complication following cancer surgery. Although standardised care bundles improve sepsis outcomes in other populations, the benefits in cancer patients are unclear. The objectives of this study were to describe the epidemiology of sepsis in cancer patients post-surgery, and to evaluate the impact of a clinical sepsis pathway on management and clinical outcomes. METHODS A standardised hospital-wide sepsis pathway was developed in 2013, and all cases of sepsis at the Peter MacCallum Cancer Centre in 2014 were retrospectively evaluated. Inclusion criteria were sepsis onset during the 100-day period following a surgical procedure for cancer diagnosis. Patients were identified using ICD-10-AM sepsis discharge codes, audit documentation and the hospital's antimicrobial approval system. Sepsis episodes were classified as managed on- or off-pathway. RESULTS A total of 119 sepsis episodes were identified. Of these, 71 (59.7%) were managed on the sepsis pathway. Episodes managed on-pathway resulted more frequently in administration of appropriate antibiotics compared to those off-pathway (94.4% vs. 66.7%, p < 0.001), and had shorter time to first-dose antibiotics (median 85 vs. 315 min, p < 0.001). Pathway utilisation was associated with significant reductions in need for inotropes (7% vs. 13%, p = 0.023), ventilation (3% vs. 10%, p = 0.006) and length of hospitalisation (median 15 vs. 30 days, p = 0.008). The most frequent source of infection was organ-space surgical site infection (24.4% of instances). CONCLUSIONS A dedicated hospital-wide sepsis pathway had significant impact on the quality of care and clinical outcomes of sepsis in cancer surgery patients. Cost-benefit analysis of sepsis pathways for cancer patients is required.
Collapse
Affiliation(s)
- Alison Hiong
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Karin A Thursky
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia.,National Health and Medical Research Council Centre for Research Excellence, National Centre for Antimicrobial Stewardship, Doherty Institute, Melbourne, Victoria, Australia
| | - Georgina Venn
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Benjamin W Teh
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Gabrielle M Haeusler
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan Crane
- The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia
| | - Leon J Worth
- Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, University of Melbourne, Melbourne, Victoria, Australia.,Victorian Healthcare Associated Infection Surveillance System (VICNISS), Doherty Institute, Melbourne, Victoria, Australia
| |
Collapse
|
12
|
Richman A, Burlew CC. Lessons from Trauma Care: Abdominal Compartment Syndrome and Damage Control Laparotomy in the Patient with Gastrointestinal Disease. J Gastrointest Surg 2019; 23:417-424. [PMID: 30276590 DOI: 10.1007/s11605-018-3988-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/20/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Aaron Richman
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA
| | - Clay Cothren Burlew
- Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO, 80204, USA.
| |
Collapse
|
13
|
Harmankaya M, Oreskov JO, Burcharth J, Gögenur I. The impact of timing of antibiotics on in-hospital outcomes after major emergency abdominal surgery. Eur J Trauma Emerg Surg 2018; 46:221-227. [PMID: 30310958 DOI: 10.1007/s00068-018-1026-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/06/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients undergoing major open emergency abdominal surgery experience high morbidity and mortality rates and often have sepsis at admission. The purpose of this study was to evaluate the association between antibiotic timing and in-hospital outcomes such as complications, need for reoperation, length of stay, and 30-day mortality. METHODS This retrospective observational cohort study was conducted between January 2010 and December 2015 including patients that were triaged through the emergency department for subsequent major open abdominal surgery. All relevant perioperative data were extracted from medical records. The outcomes of interest were development of in-hospital postoperative complications, reoperations, length of stay, and 30-day mortality, all in association with antibiotic timing, categorized according to 0-6, 6-12, or > 12 h from triage. Multivariate logistic regression was performed to evaluate adjusted outcomes associated with antibiotic timing. RESULTS A total of 408 patients were included, of whom 107 (26.2%) underwent at least one reoperation and 55.4% had at least one postoperative complication. These complications consisted of 26% surgical complications and 74% medical complications. Of the surgical complications, 73% were Clavien-Dindo ≥ 3. The median length of stay was 9 days and the overall 30-day mortality was 17.9%. The data showed that the development of complications, need for reoperation, 30-day mortality, and the length of stay were significantly correlated to delayed antibiotic administration of more than 12 h from admission. CONCLUSIONS Antibiotic administration more than 12 h from triage was associated with a significantly increased risk of postoperative complications, need for reoperation, 30-day mortality, and a prolonged length of stay, when compared to patients that received antibiotic treatment 0-6 h and 6-12 h after triage. Our data suggest that prophylactic antibiotics should be administered to all patients undergoing major open emergency abdominal surgery; however, the dose and duration cannot be concluded on the basis of our data and should be further examined.
Collapse
Affiliation(s)
- Mücahit Harmankaya
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark.
| | - Jakob Ohm Oreskov
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
| | - Jakob Burcharth
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
| | - Ismail Gögenur
- Department of Surgery, Zealand University Hospital, Lykkebaekvej 1, 4600, Køge, Denmark
| |
Collapse
|
14
|
Wang Y, Wang X, Liu W, Zhang L. Role of the Rho/ROCK signaling pathway in the protective effects of fasudil against acute lung injury in septic rats. Mol Med Rep 2018; 18:4486-4498. [PMID: 30221694 PMCID: PMC6172402 DOI: 10.3892/mmr.2018.9446] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/13/2018] [Indexed: 01/13/2023] Open
Abstract
Fasudil, which is primarily prescribed to treat cerebral vasospasm, may also inhibit systemic inflammation and prevent sepsis-induced acute lung injury (ALI) in rats, although the mechanisms remain elusive. The purpose of the present study was to investigate the role of the rhodopsin (Rho)/Rho-associated protein kinase (ROCK) signaling pathway in the protective effects of fasudil on ALI in septic rats. A total of 60 Wistar rats were pretreated with fasudil (30 mg/kg) through intraperitoneal injections 1 h prior to cecal ligation and puncture. Administration of fasudil led to reductions in polymorphonuclear neutrophil counts, and the protein concentrations of tumor necrosis factor-α, interleukin (IL)-1β and IL-6 in the bronchoalveolar lavage fluid of rats with sepsis-induced ALI. The results demonstrated that fasudil decreased sepsis-induced bacteremia. In addition, fasudil effectively reduced the Evans blue content, wet/dry lung weight ratio, lung injury score, and expression levels of malondialdehyde and myeloperoxidase. However, the superoxide dismutase activity in the lung tissue of the rats was increased. Activated caspase-3 activity in lung tissue was reduced to 29% by fasudil. Furthermore, the expression of Rho and ROCK1 was significantly downregulated, and the phosphorylation of myosin phosphatase-targeting subunit 1 in lung tissues was markedly decreased, whereas the protein expression levels of zonula occludens 1 were increased in fasudil-treated rats (P<0.05). In the in vitro experiments, vascular endothelial growth factor, intracellular adhesion molecule 1 and vascular cell adhesion molecule 1 secreted from human pulmonary microvascular endothelial cells treated with lipopolysaccharide (LPS) were attenuated by fasudil. Fasudil also reduced the fluorescence intensity of filamentous actin induced by LPS. Taken together, the results of the present study demonstrated that fasudil was able to improve endothelial permeability and inhibit inflammation, oxidative stress and cellular apoptosis in order to alleviate ALI in septic rats through inhibition of the Rho/ROCK signaling pathway.
Collapse
Affiliation(s)
- Yu Wang
- Emergency Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning 110004, P.R. China
| | - Xiaofeng Wang
- Emergency Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning 110004, P.R. China
| | - Wei Liu
- Emergency Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning 110004, P.R. China
| | - Lichun Zhang
- Emergency Department, Shengjing Hospital Affiliated to China Medical University, Shenyang, Liaoning 110004, P.R. China
| |
Collapse
|
15
|
Combined quantification of procalcitonin and HLA-DR improves sepsis detection in surgical patients. Sci Rep 2018; 8:11999. [PMID: 30097607 PMCID: PMC6086887 DOI: 10.1038/s41598-018-30505-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 07/31/2018] [Indexed: 01/09/2023] Open
Abstract
Early recognition of sepsis is a key factor to improve survival to this disease in surgical patients, since it allows prompt control of the infectious source. Combining pro-inflammatory and immunosupression biomarkers could represent a good strategy to improve sepsis detection. Here we evaluated the combination of procalcitonin (PCT) with gene expression levels of HLA-DRA to detect sepsis in a cohort of 154 surgical patients (101 with sepsis and 53 with no infection). HLA-DRA expression was quantified using droplet digital PCR, a next-generation PCR technology. Area under the receiver operating curve analysis (AUROC) showed that the PCT/HLA-DRA ratio outperformed PCT to detect sepsis (AUROC [CI95%], p): PCT: 0.80 [0.73–0.88], <0.001; PCT/HLA-DRA: 0.85 [0.78–0.91], <0.001. In the multivariate analysis, the ratio showed a superior ability to predict sepsis compared to that of PCT (OR [CI 95%], p): PCT/HLA-DRA: 7.66 [1.82–32.29], 0.006; PCT: 4.21 [1.15–15.43] 0.030. Multivariate analysis was confirmed using a new surgical cohort with 74 sepsis patients and 21 controls: PCT/HLA-DRA: 34.86 [1.22–995.08], 0.038; PCT: 5.52 [0.40–75.78], 0.201. In conclusion, the combination of PCT with HLA-DRA is a promising strategy for improving sepsis detection in surgical patients.
Collapse
|
16
|
Becher RD, Peitzman AB, Sperry JL, Gallaher JR, Neff LP, Sun Y, Miller PR, Chang MC. Damage control operations in non-trauma patients: defining criteria for the staged rapid source control laparotomy in emergency general surgery. World J Emerg Surg 2016; 11:10. [PMID: 26913055 PMCID: PMC4765073 DOI: 10.1186/s13017-016-0067-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 02/15/2016] [Indexed: 01/20/2023] Open
Abstract
Background The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients. Methods All EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined. Results 215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died. Conclusions The acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.
Collapse
Affiliation(s)
- Robert D Becher
- Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery, Yale School of Medicine, 330 Cedar Street, BB 310, New Haven, CT 06510 USA
| | - Andrew B Peitzman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - Lucas P Neff
- Department of Surgery, David Grant Medical Center, Travis Air Force Base, Fairfield, CA USA
| | - Yankai Sun
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Preston R Miller
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
| | - Michael C Chang
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC USA
| |
Collapse
|
17
|
Paternoster G, Guarracino F. Sepsis After Cardiac Surgery: From Pathophysiology to Management. J Cardiothorac Vasc Anesth 2015; 30:773-80. [PMID: 26947713 DOI: 10.1053/j.jvca.2015.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Gianluca Paternoster
- U.O.C. Cardiac Anaesthesia and Cardiac-Intensive Care, San Carlo Hospital, Potenza, Italy.
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| |
Collapse
|
18
|
Goerlich CE, Wade CE, McCarthy JJ, Holcomb JB, Moore LJ. Validation of sepsis screening tool using StO2 in emergency department patients. J Surg Res 2014; 190:270-5. [PMID: 24713469 DOI: 10.1016/j.jss.2014.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 02/24/2014] [Accepted: 03/05/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sepsis is a deleterious systemic response to an infection with a high incidence of morbidity and mortality, affecting more than a million patients a year in the US. The purpose of this study was to develop a screening tool for the early identification of sepsis in emergency department patients using readily available information at triage. MATERIALS AND METHODS This prospective, observational study took place at an academic tertiary referral hospital. Over a period of 10 wk, all patients who were seen at triage were screened for study enrollment. Inclusion criteria were adult (age≥18 y) nontrauma patients and exclusion criteria were prisoners and pregnant women. Using a Spot Check StO2 device to measure StO2 value, heart rate, respiratory rate, and temperature, these values were used to generate a cumulative screening score indicating whether a patient may have sepsis. RESULTS A total of 500 patients were screened. The incidence of sepsis in the present study population was 8.4%. The screening tool yielded a sensitivity of 85.7%, a specificity of 78.4%, a positive predictive value of 26.7%, and a negative predictive value of 98.4%. CONCLUSIONS Heart rate, respiratory rate, and temperature have good diagnostic potential for the early identification of sepsis among emergency department triage personnel. Additionally, early evidence suggests StO2 may play a complementary and synergistic role in the early identification of sepsis by triage personnel.
Collapse
Affiliation(s)
- Corbin E Goerlich
- Department of Surgery, University of Texas Medical School at Houston, Center for Translational Injury Research (CeTIR), Houston, Texas
| | - Charles E Wade
- Department of Surgery, University of Texas Medical School at Houston, Center for Translational Injury Research (CeTIR), Houston, Texas
| | - James J McCarthy
- Department of Emergency Medicine, University of Texas Medical School at Houston, Center for Translational Injury Research (CeTIR), Houston, Texas
| | - John B Holcomb
- Department of Surgery, University of Texas Medical School at Houston, Center for Translational Injury Research (CeTIR), Houston, Texas
| | - Laura J Moore
- Department of Surgery, University of Texas Medical School at Houston, Center for Translational Injury Research (CeTIR), Houston, Texas.
| |
Collapse
|
19
|
Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surg 2013; 101:e109-18. [PMID: 24273018 DOI: 10.1002/bjs.9360] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Damage control surgery is a management sequence initiated to reduce the risk of death in severely injured patients presenting with physiological derangement. Damage control principles have emerged as an approach in non-trauma abdominal emergencies in order to reduce mortality compared with primary definitive surgery. METHODS A PubMed/MEDLINE literature review was conducted of data available over the past decade (up to August 2013) to gain information on current understanding of damage control surgery for abdominal surgical emergencies. Future directions for research are discussed. RESULTS Damage control surgery facilitates a strategy for life-saving intervention for critically ill patients by abbreviated laparotomy with subsequent reoperation for delayed definitive repair after physiological resuscitation. The six-phase strategy (including damage control resuscitation in phase 0) is similar to that for severely injured patients, although non-trauma indications include shock from uncontrolled haemorrhage or sepsis. Minimal evidence exists to validate the benefit of damage control surgery in general surgical abdominal emergencies. The collective published experience over the past decade is limited to 16 studies including a total of 455 (range 3-99) patients, of which the majority are retrospective case series. However, the concept has widespread acceptance by emergency surgeons, and appears a logical extension from pathophysiological principles in trauma to haemorrhage and sepsis. The benefits of this strategy depend on careful patient selection. Damage control surgery has been performed for a wide range of indications, but most frequently for uncontrolled bleeding during elective surgery, haemorrhage from complicated gastroduodenal ulcer disease, generalized peritonitis, acute mesenteric ischaemia and other sources of intra-abdominal sepsis. CONCLUSION Damage control surgery is employed in a wide range of abdominal emergencies and is an increasingly recognized life-saving tactic in emergency surgery performed on physiologically deranged patients.
Collapse
Affiliation(s)
- D G Weber
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | | | | |
Collapse
|
20
|
Hecker A, Uhle F, Schwandner T, Padberg W, Weigand MA. Diagnostics, therapy and outcome prediction in abdominal sepsis: current standards and future perspectives. Langenbecks Arch Surg 2013; 399:11-22. [PMID: 24186147 DOI: 10.1007/s00423-013-1132-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE In the perioperative phase, sepsis and sepsis-associated death are the most important problems for both the surgeon and the intensivist. Critically ill patients profit from an early identification and implementation of an interdisciplinary therapy. The purpose of this review on septic peritonitis is to give an update on the diagnosis and its evidence-based treatment. RESULTS Rapid diagnosis of sepsis is essential for patient´s survival. A bundle of studies was performed on early recognition and on new diagnostic tools for abdominal sepsis. Although surgical intervention is considered as an essential therapeutic step in sepsis therapy the time-point of source control is still controversially discussed in the literature. Furthermore, the Surviving Sepsis Campaign (SSC) guidelines were updated in 2012 to facilitate evidence-based medicine for septic patients. CONCLUSION Despite many efforts, the mortality of surgical septic patients remains unacceptably high. Permanent clinical education and further surgical trials are necessary to improve the outcome of critically ill patients.
Collapse
Affiliation(s)
- A Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany,
| | | | | | | | | |
Collapse
|