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1、Source control in the management of severe sepsis and septic shock:An evidence-based review1Abstractn nSource control represents a key component of success in therapy of sepsis.n n It includes drainage of infected fluids,debridement of infected soft tissues,removal of infected devices or foreign bod
2、ies,and finally,definite measures to correct anatomic derangement resulting in ongoing microbial contamination and to restore optimal function.2Drainagen nQuestion:What is the optimal approach to abscess Question:What is the optimal approach to abscess drainage in the patient with severe sepsis or s
3、eptic drainage in the patient with severe sepsis or septic shock?shock?n nRecommendationRecommendation:As a general principle,the:As a general principle,the optimal method of drainage is that which optimal method of drainage is that which accomplishes full drainage of the collection with accomplishe
4、s full drainage of the collection with the least degreethe least degree of anatomic and physical trauma of anatomic and physical trauma to the patient;not only does such an approach to the patient;not only does such an approach minimize the immediate morbidity associated with minimize the immediate
5、morbidity associated with drainage,it also ensures the broadest range of drainage,it also ensures the broadest range of options for subsequent reconstructive options for subsequent reconstructive surgery.(Grade E)surgery.(Grade E)3Drainagen nDrainage is most likely to be successful when the Drainage
6、 is most likely to be successful when the abscess occurs as a postoperative complication,abscess occurs as a postoperative complication,whereas failure is most common with whereas failure is most common with very small very small abscesses,pancreatic abscesses,and abscesses abscesses,pancreatic absc
7、esses,and abscesses from which fungi are isolated from which fungi are isolated n nLaparoscopic drainage of abdominal abscesses has Laparoscopic drainage of abdominal abscesses has been reported,although it is been reported,although it is unclearunclear whether whether laparoscopic techniques have a
8、ny significant laparoscopic techniques have any significant advantage over open surgery or percutaneous advantage over open surgery or percutaneous radiographic drainage.radiographic drainage.4Debridementn nIn patients with necrotizing soft-tissue infections,In patients with necrotizing soft-tissue
9、infections,the extension of tissue necrosis is the extension of tissue necrosis is rapidrapid,and,and because the necrotic tissues are exposed,control because the necrotic tissues are exposed,control of areas of bleeding can be readily accomplished of areas of bleeding can be readily accomplished us
10、ing using electrocauteryelectrocautery.n nEarly aggressive debridementEarly aggressive debridement is associated with is associated with an improved clinical outcome an improved clinical outcome n nfor patients with retroperitoneal necrosis for patients with retroperitoneal necrosis secondary to pan
11、creatitis,extension of tissue secondary to pancreatitis,extension of tissue necrosis is more gradual,whereas necrosis is more gradual,whereas injudicious injudicious exploration can result in bleedingexploration can result in bleeding from from retroperitoneal vessels that are not readily retroperit
12、oneal vessels that are not readily controlled.controlled.5Debridementn nAt the time of laparotomy for peritonitis,At the time of laparotomy for peritonitis,neitherneither irrigation of the peritoneal cavity irrigation of the peritoneal cavity nor nor the careful the careful removal of fibrinous exud
13、ates adherent to loops of removal of fibrinous exudates adherent to loops of bowel have been shown to bowel have been shown to improve outcome or improve outcome or decrease rates of recurrence.decrease rates of recurrence.n nIn summary,then,the In summary,then,the optimal timingoptimal timing of of
14、 debridement is a tradeoff between the infectious debridement is a tradeoff between the infectious process and the morbidity associated with process and the morbidity associated with intervention intervention n nAlthough early therapy is desirable,the benefits Although early therapy is desirable,the
15、 benefits must be weighed against the must be weighed against the risks of hemorrhagerisks of hemorrhage in tissues that are not readily amenable to surgical in tissues that are not readily amenable to surgical control.control.6Foreign bodyn nfor example,a colonized intravascular catheter or for exa
16、mple,a colonized intravascular catheter or infected prosthetic heart valve)can serve as an infected prosthetic heart valve)can serve as an ongoing reservoir of microorganisms that trigger a ongoing reservoir of microorganisms that trigger a systemic inflammatory response.systemic inflammatory respon
17、se.n nQuestion:Can an infected vascular catheter be Question:Can an infected vascular catheter be safely exchanged over a guidewire?safely exchanged over a guidewire?n nRecommendationRecommendation:An infected intravascular:An infected intravascular catheter can be safely exchanged over a guidewire,
18、catheter can be safely exchanged over a guidewire,provided there is no significant evidence of soft-provided there is no significant evidence of soft-tissue infection at the exit site.(Grade B)tissue infection at the exit site.(Grade B)7Foreign bodyn nRationaleRationale:A systematic review of 12 ran
19、domized:A systematic review of 12 randomized trials comparing catheter changes over a guidewire trials comparing catheter changes over a guidewire with catheter replacement at a separate site in with catheter replacement at a separate site in patients with central venous catheter infections patients
20、 with central venous catheter infections found that found that guidewire exchangeguidewire exchange was associated was associated with with fewer mechanical complicationsfewer mechanical complications(relative (relative risk,1.72;95%confidence interval,0.893.33)risk,1.72;95%confidence interval,0.893
21、.33)and a and a modestly increased rate of catheter exit-site modestly increased rate of catheter exit-site infectioninfection(relative risk,1.52;95%confidence (relative risk,1.52;95%confidence interval,0.346.73).interval,0.346.73).8Question:How is the need for abdominal source control best establis
22、hed?n nRecommendationRecommendation:The need for abdominal:The need for abdominal source control measures is typically suggested by source control measures is typically suggested by the the history and physical examinationhistory and physical examination;radiographic examinationradiographic examinat
23、ion should be performed to should be performed to establish or confirm the diagnosis in the majority establish or confirm the diagnosis in the majority of cases and to aid in deciding on the optimal of cases and to aid in deciding on the optimal source control method.Radiographic definition of sourc
24、e control method.Radiographic definition of an intraabdominal infection facilitates operative an intraabdominal infection facilitates operative planning if surgery is contemplated and is a planning if surgery is contemplated and is a prerequisite for the use of percutaneous drainage.prerequisite for
25、 the use of percutaneous drainage.n nGrade EGrade E9Abdominal source controln nRationaleRationale:Abdominal painAbdominal pain is the cardinal is the cardinal symptom;its location and characteristics generally symptom;its location and characteristics generally provide insight into its cause.Addition
26、al historical provide insight into its cause.Additional historical features may point to specific causesa history of features may point to specific causesa history of peptic ulcer disease suggesting a perforated ulcerpeptic ulcer disease suggesting a perforated ulcer;a history of a history of periph
27、eral vascular disease,atrial peripheral vascular disease,atrial fibrillation,or acute myocardial infarction fibrillation,or acute myocardial infarction suggesting the possibility of intestinal ischemiasuggesting the possibility of intestinal ischemia;or;or a history of a history of abdominal surgery
28、 raising the abdominal surgery raising the possibility of strangulating intestinal obstructionpossibility of strangulating intestinal obstruction.10Question:What is the optimal approach to source control when sepsis results from a perforation of the gastrointestinal tract?n nRecommendationRecommenda
29、tion:The therapeutic objective in:The therapeutic objective in managing a perforation at any level of the managing a perforation at any level of the gastrointestinal tract is to eliminate ongoing gastrointestinal tract is to eliminate ongoing leakage of luminal contents through removal of leakage of
30、 luminal contents through removal of the perforation or through the creation of a the perforation or through the creation of a controlled sinus or fistula.How this objective is controlled sinus or fistula.How this objective is best accomplished depends on the best accomplished depends on the anatomi
31、c site anatomic site and extent of the perforation,the degree of and extent of the perforation,the degree of localization,and the physiologic stability of the localization,and the physiologic stability of the patient.patient.n nGrade E;except Grade C for gastrointestinal Grade E;except Grade C for g
32、astrointestinal perforations secondary to diverticulitisperforations secondary to diverticulitis11GI perforation secondary to diverticulitisn nThe The sigmoid colonsigmoid colon is the most common site of is the most common site of intestinal perforation,usually as a result of intestinal perforation
33、,usually as a result of underlying underlying diverticular diseasediverticular diseasen nSeveral therapeutic options are available.For the Several therapeutic options are available.For the patient with a walled-off perforation resulting in a patient with a walled-off perforation resulting in a perid
34、iverticular abscess,percutaneous CT-guided peridiverticular abscess,percutaneous CT-guided drainage converts the abscess to a controlled drainage converts the abscess to a controlled colocutaneous fistula and so permits resolution of colocutaneous fistula and so permits resolution of the acute infla
35、mmatory process;resection of the the acute inflammatory process;resection of the involved colon can then be undertaken electively involved colon can then be undertaken electively at a later date at a later date 12Question:What is the optimal mode of source control when sepsis results from the biliar
36、y tract?n nRecommendationRecommendation:The objective of therapy when sepsis:The objective of therapy when sepsis arises from obstruction of the gall bladder or biliary tree is arises from obstruction of the gall bladder or biliary tree is the relief of intraluminal pressure through the creation of
37、a the relief of intraluminal pressure through the creation of a controlled fistula with the skin or intestinal tract.controlled fistula with the skin or intestinal tract.Timely Timely intervention after stabilization of the patient is indicated.intervention after stabilization of the patient is indi
38、cated.For the patient with gangrenous acute cholecystitis or For the patient with gangrenous acute cholecystitis or acalculous cholecystitis,source control options include acalculous cholecystitis,source control options include PTCD or operative cholecystectomy.Cholangitis PTCD or operative cholecys
39、tectomy.Cholangitis necessitates decompression of the biliary tree by ERCP necessitates decompression of the biliary tree by ERCP with papillotomy or nasobiliary drainage,transhepatic with papillotomy or nasobiliary drainage,transhepatic decompression,or operative exploration of the common decompres
40、sion,or operative exploration of the common bile duct.bile duct.n nGrade DGrade D13Question:What is the optimal mode of source control when sepsis results from intestinal ischemia or infarction?n nRecommendationRecommendation:Intestinal infarction is a Intestinal infarction is a surgical emergencysu
41、rgical emergency because gangrenous intestine because gangrenous intestine produces rapid physiologic decompensation,and produces rapid physiologic decompensation,and in the absence of surgical resection,is almost in the absence of surgical resection,is almost invariably invariably lethal.lethal.On
42、the other hand,On the other hand,intestinal intestinal ischemia in the absence of infarction is potentially ischemia in the absence of infarction is potentially reversiblereversible with hemodynamic support and with hemodynamic support and correction of the circumstances that produced the correction
43、 of the circumstances that produced the ischemia.Thus,ischemia.Thus,early diagnosis and timely early diagnosis and timely surgical interventionsurgical intervention are critical to a successful are critical to a successful outcome for patients with severe sepsis secondary outcome for patients with s
44、evere sepsis secondary to intestinal ischemia.(Grade E)to intestinal ischemia.(Grade E)14Question:What is the optimal source control approach for patients with infected pancreatic necrosis?n nRecommendationRecommendation:Infection of necrotic pancreas:Infection of necrotic pancreas or retroperitonea
45、l fat is a common complication of or retroperitoneal fat is a common complication of severe acute pancreatitis.When the process is severe acute pancreatitis.When the process is limited to infection of a collection of pancreatic limited to infection of a collection of pancreatic fluid,fluid,percutane
46、ous drainage alonepercutaneous drainage alone may be may be sufficient.More typically,however,variable sufficient.More typically,however,variable amounts of infected necrotic tissue must be amounts of infected necrotic tissue must be debrided to achieve adequate source control.Data debrided to achie
47、ve adequate source control.Data from case series and a single randomized trial from case series and a single randomized trial suggest that suggest that delaying surgical debridement for at delaying surgical debridement for at least 23 wksleast 23 wks results in fewer procedure-related results in few
48、er procedure-related complications and improved clinical plications and improved clinical outcome.n nGrade CGrade C15Infective pancreatic necrosisn nMost authorities recommend operative Most authorities recommend operative debridement only for patients with debridement only for patients with infecte
49、d infected pancreatic necrosispancreatic necrosis and prefer to manage and prefer to manage noninfected necrosis expectantlynoninfected necrosis expectantlyn nIn contrast,infected necrosis is an indication for In contrast,infected necrosis is an indication for intervention,although intervention,alth
50、ough successful nonoperative successful nonoperative managementmanagement of infected necrosis has been of infected necrosis has been reported reported n nDelayed surgery permits better Delayed surgery permits better demarcation of demarcation of planesplanes between viable and nonviable between via