theatre and surgery
Recent developments in surgical sepsis
Every surgical operation is an experiment in bacteriology – Moynihan
Ramya Kalaiselvan MBBS MPhil FRCS
Gordon Carlson BSc ( Hons ) MB ChB ( Hons ) MD FRCS FRCSGen FRCSEd ( Ad Hom ) Department of General and Colorectal Surgery , Salford Royal NHS Foundation Trust , Manchester , UK
It is almost a century since Moynihan famously noted that , “ every surgical operation is an experiment in bacteriology .” 1 While the basic components of that experiment ( the host , the bacterial flora and the factors which alter the balance between bacterial capacity for invasion and host resistance ) have not changed , the outcome of surgical procedure , even when complicated by infection , has improved markedly . The last century has seen overwhelming advances in reducing the incidence of surgical ( and other ) infections , as well as an ability to treat them more effectively . These have resulted from ( inter alia ), better nutrition and overall public health , a better understanding of factors which contribute to infection such as temperature maintenance , oxygenation , blood glucose control , and aseptic technique , and of course the development of powerful antibiotics for both prophylaxis and treatment of infection complicating surgical care . However , despite these measures , infection remains a common and life-threatening problem and the sepsis , which results from this infection , continues to be a significant cause of avoidable mortality , morbidity and health expenditure . Some of the most devastating adverse consequences of infection result not from the direct pathogenic effects of the invading bacteria but from the immunological consequences of the host response . While a coordinated pro- and anti-inflammatory response is essential for localisation , bacterial killing , and resolution , infection can trigger an overwhelming host inflammatory response , resulting in shock , multi-organ dysfunction , and death .
The definitions of sepsis , septic shock , and organ dysfunction were based on an international consensus conference , 2 which focused on the then-prevalent view that sepsis developed as part of a host systemic inflammatory response syndrome ( SIRS ), triggered by an infectious insult , noting that sepsis could arise in response to multiple infectious causes and that ‘ septicaemia ’ was neither a necessary condition nor a helpful term . It was proposed that sepsis complicated by organ dysfunction was termed severe sepsis , which could progress to septic shock , defined as “ sepsis-induced hypotension ”, persisting despite adequate fluid resuscitation or by hyperlactataemia . In 2001 , a second consensus panel endorsed most of these concepts , with the caveat that signs of a systemic inflammatory response , notably tachycardia or an elevated
204 HHE 2018 | hospitalhealthcare . com white-cell count , also occur in many noninfectious conditions and therefore are not helpful in distinguishing sepsis from other conditions . 3 In addition , severe sepsis and sepsis were sometimes used interchangeably to describe the syndrome of infection complicated by acute organ dysfunction . Attempts to take account of the fact that critical illness might arise as a consequence of infection , without the requirement for the patient necessarily to exhibit the fever , tachypnoea , tachycardia and leukocytosis required of SIRS led to a third International consensus for sepsis and septic shock , at which sepsis was defined as lifethreatening organ dysfunction caused by a dysregulated host response to infection . 4
This new definition also recommended using