HHE Emergency care supplement 2018 - Page 17

2011 27 recommends that timing of intervention to control the source of sepsis, that is, surgery or equivalent (for example, radiological drainage) should be carried out in a time frame consistent with the severity of the clinical situation, so that, where relevant, source control should be undertaken immediately in patients with septic shock, within six hours in patients with organ dysfunction but without shock, and in less severely ill patients with uncomplicated sepsis within 18 hours. These targets were established prior to the most recent definitions of sepsis and it remains to be seen how they will be changed given more recent emphasis on qSOFA and NEWS2 scores as soon as possible. Early detection and timely therapeutic intervention can improve prognosis and overall clinical outcome in septic patients Radiological intervention Traditionally, drainage of collections has been achieved by surgical exploration. However, radiological drainage of abdominal abscesses using ultrasound was first described in 1974 28 and CT in 1977. 29 While surgical intervention is still required where drainage of an abscess alone cannot achieve source control (for example in free visceral perforation or where resection or debridement are required), where radiological drainage cannot be undertaken adequately or safely (for example, where there are multiple and /or interloop abscesses), in many cases radiological drainage is possible and here it is the standard of care. 29,30 Most authorities recommend draining all collections larger than 3cm in patients with systemic signs of infection. 29,31 A national study conducted in the USA has reported that the number of percutaneous drainage procedures for intra-abdominal sepsis more than doubled between 2001 and 2013, while the laparotomy rate fell by 21% over the same period. 30 Similar studies in patients with intra-abdominal abscesses due to Crohn’s disease noted that 29% could be managed by percutaneous drainage, whereas 32% still required surgery. 32 Interventional techniques can also be used to treat other foci of sepsis. A study comparing clinical efficacy and adverse events of percutaneous cholecystostomy (PC) and early cholecystectomy (EC) in a large group of severely ill patients with acalculous cholecystitis (AC) has shown PC to be a safe and cost-effective bridging treatment strategy, with perioperative outcomes superior to those of early open cholecystectomy. Compared with open or laparoscopic EC, PC was superior in terms of morbidity, intensive-care unit admissions, length of hospital stay, and cost. 33 Two studies have shown that PC is an effective procedure in seriously ill patients with AC and may be regarded as a definite treatment option in the majority of patients. 34,35 Percutaneous drainage of liver and splenic abscesses can also be undertaken safely as first-line treatment prior to/ instead of surgical intervention. A meta-analysis of five randomised, controlled trials comparing catheter drainage and repeated needle aspiration of liver abscesses has demonstrated catheter drainage to be more effective, with higher success and shorter time to achieve clinical improvement. 36 Drainage of retroperitoneal collections can be performed transgastrically where required. Drainage of pelvic collections can be challenging and in appropriate circumstances a transgluteal approach and endoscopically assisted ultrasound-guided drainage by transrectal, transperineal or transvaginal access is associated with a low risk of complications and should be considered for deep pelvic abscesses. 37 European consensus guidelines recommend catheters of 7 – 10F for the treatment of most abscesses, regardless of abscess dimensions. However, large catheters (>10F) may be required for complex abscesses with thick contents. 37 There are still no established guidelines for subsequent management of drains with regards to flushing the abscess, interval imaging and timing of removal. Regular, small-volume, gentle flushes should be used in such abscess cavities. Some centres advocate contrast-imaging prior to drain removal, 38 while others recommend that drains be removed 48 hours after output has stopped, following repeat imaging. 39 Surgical treatment Surgery will be required where radiological source control is not possible and where a patient needs a definitive procedure, for example, resection or debridement of necrotic tissue, management of complete anastomotic dehiscence, proximal diversion of the gastrointestinal tract etc. It may also be safer in some circumstances to transfer an unstable patient to an operating theatre than to the radiology department to establish source control. Timing and adequacy of surgical source control are vital. The third National Emergency Laparotomy Audit (NELA) reported on the outcome of approximately 4000 patients requiring laparotomy for peritonitis and found an average delay of eight hours to reach theatre after admission to hospital. 24 If the diagnosis has been ascertained, a tailored approach should be undertaken with regards to the optimum approach and technique. In dangerously unstable patients, a truncated ‘source/damage-control operation’ can be undertaken, in which abscesses are drained, bowel resected with the stapled ends left in situ and a planned re-laparotomy (RL) subsequently undertaken. 40 Kim et al showed that 22% of patients undergoing emergency surgery for intra- abdominal catastrophes, of whom at least 65% had sepsis, required a further unplanned laparotomy. Risk factors for RL were identified to be peripheral arterial disease, alcohol abuse, body mass index >29, ischaemic bowel and an Inadvertent enterotomy 17 HHE 2018 | hospitalhealthcare.com