Abdominal Sepsis and Complicated Intraabdominal Infections
Complicated intraabdominal infections (cIAI) are a common cause of morbidity and mortality in the intensive care unit. Uncomplicated infections do not involve perforation or disruption of the gastrointestinal tract whereas complicated infections are assoc
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Sara A. Buckman and John E. Mazuski
Case Presentation A 52 year-old male with a history of hypertension, obesity, and depression presented to the emergency room with increasing abdominal pain. In the emergency room he was found to be hypotensive, with a blood pressure of 80/40, tachycardic to 120, and febrile with a temperature of 38.9 F. He had evidence of peritonitis on physical exam. His abdomen was rigid and distended, with diffuse tenderness to palpation and involuntary guarding in his lower abdomen. Abnormal laboratory exam values included a white blood cell count of 18,000 cells/mm3, and a serum creatinine concentration of 1.4 mg/ dL. Cross-sectional imaging of his abdomen and pelvis is shown below (Fig. 79.1). Question How should this patient’s intraabdominal condition be managed? Answer This patient has an intraabdominal infection from a perforated transverse colon, as
S.A. Buckman • J.E. Mazuski (*) Department of Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, MO, USA e-mail: [email protected]
demonstrated by his physical exam findings, laboratory values and cross-sectional imaging. The patient should receive early goal-directed resuscitation based on the Surviving Sepsis Guidelines in the emergency room or the ICU [1]. Broad spectrum antibiotics to cover gram negative Enterobacteriaceae and enteric anaerobes should be initiated. He should be taken to the operating room expeditiously for exploratory laparotomy while undergoing ongoing resuscitation.
Principles of Management Diagnosis Intraabdominal infections should be suspected in patients with evidence of gastrointestinal symptoms such as nausea, anorexia, vomiting, diarrhea and abdominal pain. They may or may not have signs of inflammation including fever, tachycardia or tachypnea [2]. A history including recent abdominal operations may help identify the source of the intraabdominal infection. Physical exam is important but may be nonspecific in patients that are obtunded, intubated, sedated, elderly or on immunosuppressive therapy [2, 3]. Patients presenting with signs of peritonitis including abdominal rigidity, guarding and rebound tenderness should be considered for urgent laparotomy [4].
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_79
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S.A. Buckman and J.E. Mazuski
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Fig. 79.1 Perforated diverticulitis in the transverse colon
Basic laboratory tests including complete blood count, and electrolytes should be obtained. If a hepatobiliary or pancreatic source is suspected, liver enzymes and an amylase and lipase can be added [5]. Additional labs including those measuring end organ perfusion such as lactate and mixed venous oxygen saturation should be obtained if the patient is suspected of having severe sepsis or septic shock [1]. Further imaging studies should be obtained in patients with suspected intraabdominal infection, if feasible. Cross-sectional imaging with computed tomography (CT scan, Fig. 7
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