HHE Emergency care supplement 2018 - Page 16

reliably exclude bacterial infection as a cause of sepsis. 20,21 Computed tomography (CT) with oral contrast remains the commonly used diagnostic modality to identify abdominal and pelvic sepsis, and is able to do so with high sensitivity and specificity in the hands of an experienced radiologist. However, safely moving a haemodynamically unstable patient out of the critical care environment into a CT scanner is never desirable and, on some occasions, might not be possible. The use of bedside diagnostic laparoscopy in such instances may reduce the risk involved in transferring unwell patients to a radiology department and also avoid the adverse consequences of negative laparotomy. 22,23 Specifically, mortality after a negative bedside laparoscopy (18.3%) was also statistically lower than the percentage of patients who died after a negative exploratory laparotomy (38.9%) and the mean operating time in those patients who underwent laparotomy after bedside laparoscopy was lower, possibly because a β€˜tailored laparotomy’ could then be undertaken. 23 Antimicrobial therapy NICE guidelines emphasise rapid commencement of empirical antimicrobial therapy based on data showing a direct and strong relationship between the timeliness of appropriate therapy and survival. 14 While early administration of appropriate antibiotics is, therefore paramount in the management of sepsis, audits of clinical practice in this area suggest there may be considerable room for improvement. The third patient report of the National Emergency Laparotomy Audit 24 has examined patients with peritonitis and reported that <25% patients received their first dose of antibiotics within 1 hour and approximately 25% wait •€ψ؁‘½ΥΙΜ)™Ι½΄…‘΅₯ΝΝ₯½ΈΙ•ΝΑ•Ρ₯Ω•±δΈQ‘”MΥΙΩ₯Ω₯Ήœ)M•ΑΝ₯́ …΅Α…₯Έ€ΰΙ•Α½ΙΡ•Ρ‘…Ё•…ɱ䁅ΉΡ₯‰₯½Ρ₯Œ)…‘΅₯Ή₯ΝΡΙ…Ρ₯½Έέ₯Ρ‘₯ΈΡ‘Ι•”‘½ΥΊ݅Μ)₯Ή‘•Α•Ή‘•ΉΡ±δ…ΝΝ½₯…Ρ•έ₯Ρ ΝΥΙΩ₯Ω…°°‰ΥΠ)Ρ‘₯́݅́…‘₯•Ω•₯Έ½Ή±δ€Ψά”½˜…Ν•ΜΈ€ΔȁQ‘”)Ι•½΅΅•Ή‘…Ρ₯½Έ‘…́Ν₯Ή”‰••Έ‘…Ή•ΡΌ)‘•±₯Ω•Ι䁽˜…ΉΡ₯‰₯½Ρ₯Μέ₯Ρ‘₯Έ½Ή”‘½Υȁ½˜)‘₯…Ή½Ν₯́½˜Ν•ΑΝ₯Μ€Δȁ‰ΥЁ₯Ё͕•΅Μ•Ω•Έ±•Ν́±₯­•±δ)Ρ‘…Ёё₯́έ₯±°‰”…‘₯•Ω•ΥΉ±•Ν́ё•Ι”₯́„Ν•„)‘…Ή”₯Έ±₯Ή₯…°Α•Ι™½Ι΅…Ή”Έ9!LΉ±…Ή)‘…Ω”…₯΅•ΡΌ‘ΌΡ‘₯́‰δ₯Ή½ΙΑ½Ι…Ρ₯ΉœΡ…ɝ•ΡΜ)™½ΘΡ₯΅•±δ…ΉΡ₯‰₯½Ρ₯ŒΡΙ•…Ρ΅•ΉΠ…ΉΙ•Ω₯•ά₯ΉΡΌ)Ρ‘” EU%8€‘ ½΅΅₯ΝΝ₯½Ή₯Ήœ™½ΘEΥ…±₯Ρ䁅Ή)%ΉΉ½Ω…Ρ₯½Έ€Α…ε΅•ΉΡ́™Ι…΅•έ½Ι¬™½ΘΡ‘”…Ι”½˜)Α…Ρ₯•ΉΡ́₯ΈΉ±…Ή°±•…‘₯ΉœΡΌΑ½έ•Ι™Υ°™₯Ή…Ή₯…°)₯Ή•ΉΡ₯ٕ́™½ΘΡ‘”‘•±₯Ω•Ι䁽˜½ΑΡ₯΅Υ΄…Ι”Έ)%ΈΝ•ΑΝ₯Μ΅₯Ή‘Ս•‘εΑ½Ρ•ΉΝ₯½Έ°€άΤ”½˜Α…Ρ₯•ΉΡΜ)ΝΥΙΩ₯Ω”έ₯Ρ ΑΙ½΅ΑЁɕ½Ή₯Ρ₯½Έ…Ή)΅…Ή…•΅•ΉΠ‰ΥЁέ₯Ρ •Ω•Ι䁑½Υˊé‘•±…δΡ‘₯Μ)™₯ΥΙ”™…±±Μ‰δ€ψά”°₯΅Α±ε₯ΉœΡ‘…Ёё”΅½ΙΡ…±₯Ρδ)ΡεΑ₯…±±δ₯ΉΙ•…͕́‰δ…ΑΑΙ½α₯΅…Ρ•±δ€Μΐ”Έ€ΔΔ)1½Ή•Θ΅Ρ•Ι΄ΝΡΥ‘₯•ΜΝ‘½ά±…ѕȁ‘•…Ρ Ι…Ρ•Μ°½Ή”)啅ȁ…™Ρ•Θ„‰½ΥЁ½˜Ν•ΑΡ₯ŒΝ‘½¬ΡΌ•α••€Τΐ”€Δΰ)…Ή™Ι•ΕΥ•ΉΠ™ΥΉΡ₯½Ή…°₯΅Α…₯Ι΅•ΉΠ•Ω•Έ₯Έ)Ρ‘½Ν”έ‘ΌΝΥΙΩ₯Ω”Έ€Δδ)₯…Ή½Ν₯Μ)…Ι±δ₯‘•ΉΡ₯™₯…Ρ₯½Έ½˜Ν•ΑΝ₯́ɕ΅…₯ΉΜ„Ν₯Ή₯™₯…ΉΠ)‘…±±•Ή”₯ΈΙ₯Ρ₯…±±δ₯±°Α…Ρ₯•ΉΡΜΈI•Ν•…ɍ ₯Έ)‰₯½΅…Ι­•Ί½˜Ν•ΑΝ₯́ΝՍ ΑΙ½…±₯Ρ½Ή₯Έ°) ΅Ι•…Ρ₯Ω”ΑΙ½Ρ•₯Έ…ΉεΡ½­₯Ή•Μ€‘%0΄Ψ°%0΄Δΐ€₯Μ)‰•₯ΉœΥΉ‘•ΙΡ…­•ΈΡΌ…₯•…Ι±δ₯‘•ΉΡ₯™₯…Ρ₯½Έ½˜)Ν•ΑΝ₯́…Ή₯Ρ́…ΝΝ½₯…Ρ₯½Έέ₯Ρ Ω…Ι₯½ΎΑ…Ρ‘½•ΉΜ)…Ή™½€½˜₯Ή™•Ρ₯½ΈΈ) ±½½Υ±ΡΥɕ́…Ι”Ι½ΥΡ₯Ή•±δΑ•Ι™½Ι΅•₯Έ΅½ΝΠ)Α…Ρ₯•ΉΡ́έ₯Ρ Ν•ΑΝ₯́…Ή₯Ή‘••°Ρ‘•δ™½Ι΄Α…ΙЁ½˜)Ν•ΑΝ₯Μ€Ψ½!½Υȴā‰ΥΉ‘±”Έ€Δ؁!½έ•Ω•Θ°™…±Ν”Ή•…Ρ₯Ω”)Ι•ΝΥ±Ρ́…Ι”•αΡΙ•΅•±δ½΅΅½Έ°•ΝΑ•₯…±±δ₯˜)…ΉΡ₯‰₯½Ρ₯Μ‘…Ω”…±Ι•…‘䁉••Έ…‘΅₯Ή₯ΝΡ•Ι•ΈQ‘•Ι”)₯́…±ΝΌΥΝΥ…±±δ„‘•±…䁽˜€ΠγŠLάȁ‘½ΥΊ‰•™½Ι”)Ι•ΝΥ±Ρ́½˜ΝΡ…Ή‘…ɐ‰±½½Υ±ΡΥɕ́…Ή)΅₯Ι½‰₯½±½₯…°Ν•ΉΝ₯Ρ₯Ω₯Ρ₯•Μ‰•½΅”…Ω…₯±…‰±”ΡΌ)Ρ‘”ΡΙ•…Ρ₯Ήœ±₯Ή₯₯…ΈΈ5½±•Υ±…ȁ…ΝΝ…έё…ЁΥΝ”)Α½±ε΅•Ι…Ν”‘…₯ΈΙ•…Ρ₯½ΈΡΌΡ…ɝ•ΠΡ‘”Ι₯‰½Ν½΅…°)9Ν•ΕΥ•Ή•Μ½˜½΅΅½ΈΑ…Ρ‘½•ΉΜ‘…Ω”‰••Έ)‘•Ω•±½Α•™½Θ±₯Ή₯…°…ΑΑ±₯…Ρ₯½Έ°…́ё”…‰₯±₯ΡδΡΌ)‘•Ρ•Π‰…Ρ•Ι₯…°9‘½•ΜΉ½ΠΙ•ΕΥ₯Ι”Ρ‘”)ΑΙ•Ν•Ή”½˜±₯Ω”‰…Ρ•Ι₯„₯ΈΡ‘”‰±½½ΝΡΙ•…΄Έ)]‘₯±”Ρ‘•Ν”Ρ•‘Ή₯ΕՕ́΅…䁅±±½άΙ…Α₯)₯‘•ΉΡ₯™₯…Ρ₯½Έ½˜‰…Ρ•Ι₯…°Α…Ρ‘½•ΉΜΡ‘•δ…ΑΑ•…Θ)ΡΌ±…¬…‘•ΕΥ…Ρ”Ν•ΉΝ₯Ρ₯Ω₯ΡδΡΌ…±±½ά±₯Ή₯₯…ΉΜΡΌ)M½Υɍ”₯‘•ΉΡ₯™₯…Ρ₯½Έ…Ή½ΉΡΙ½°)…ɱ䁑•Ρ•Ρ₯½Έ…ΉΡ₯΅•±δΡ‘•Ι…Α•ΥΡ₯Œ)₯ΉΡ•ΙΩ•ΉΡ₯½Έ…Έ₯΅ΑΙ½Ω”ΑΙ½Ή½Ν₯́…Ή½Ω•Ι…±°)±₯Ή₯…°½Υэ½΅”₯ΈΝ•ΑΡ₯ŒΑ…Ρ₯•ΉΡΜΈA…Ρ₯•ΉΡ́έ₯Ρ )Ν•Ω•Ι”Ν•ΑΝ₯́…Ι”…ЁΙ•…Ρ•ΝЁΙ₯Ν¬½˜‘•Ω•±½Α₯Ήœ)Ν•ΑΡ₯ŒΝ‘½¬ΈQ‘•Ι”₯́ΉΌ‘₯Ι•Π•Ω₯‘•Ή”ΡΌ)½Ή™₯Ι΄Ρ‘…Ё‘•±…啐Ν½Υɍ”½ΉΡΙ½°έ½ΙΝ•ΉΜ)½Υэ½΅”‰ΥЁ₯Ё͕•΅Μ½‰Ω₯½Ύё…Ё₯Ёέ₯±°ΈQ‘•Ι”)…Ι”½‰Ω₯½Ύ…‘Ω…ΉΡ…•ΜΡΌΑ‘εΝ₯…±±δ•ΝΡ…‰±₯Ν‘₯Ήœ)½ΉΡΙ½°½˜„Ν½Υɍ”½˜₯Ή™•Ρ₯½Έ‰•™½Ι”ΑΙ½Ι•ΝΝ₯½Έ)ΡΌΝ•ΑΡ₯ŒΝ‘½¬½ΥΙΜ°₯Ω•ΈΡ‘”…ΝΝ½₯…Ρ•(׊LΔΐ΅™½±Ι₯Ν”₯Έ΅½ΙΡ…±₯Ρδέ‘₯ ½ΥΊ…́ё”)Α…Ρ₯•ΉΠ‘•Ρ•Ι₯½Ι…Ρ•ΜΈ€ΘΤ°ΘΨ)Υ₯‘…Ή”½ΈΝ½Υɍ”½ΉΡΙ½°ΑΥ‰±₯Ν‘•₯Έ(ΔΨ)!!€ΘΐΔΰπ‘½ΝΑ₯Ρ…±‘•…±Ρ‘…Ι”Ή½΄