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Industry: Email Alert RSS FeedThe role of surgery in the management of septic shock—extra-abdominal causes of sepsis
AORN Journal, Jan, 2007 by George H. Sakorafas, Adelais G. Tsiotou, Maria Pananaki, George Peros
* SEPTIC SHOCK IS A SEVERE inflammatory response to one or more pathogenic microorganisms. When a person's immune response is excessively intense, a cascade of phenomena may be activated that ultimately is harmful.
* APPROPRIATE MANAGEMENT of septic shock may include surgical intervention to remove or neutralize the septic focus in an effort to treat the inflammatory response cascade.
* THIS IS THE FIRST OF TWO articles presenting current information on the role of surgery in the management of a patient with septic shock. This article describes extra-abdominal sources of sepsis.
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An invasion of microorganisms into the human body normally activates the immune system, which ensures the body's appropriate protective response to harmful stimuli. When a person's immune response is excessively intense, however, a cascade of phenomena may be activated that ultimately is harmful. The severity of this syndrome varies and is determined by the intensity of the body's response rather than by the noxious stimulus itself. (1-5) The more severe the clinical presentation is, the more powerful the systemic inflammatory response will be. Septic shock is a severe form of the inflammatory response to one or more pathogenic microorganisms.
Appropriate management of septic shock entails aggressive support of the patient's organic systems, including
* admission to an intensive care unit (ICU),
* nutritional support,
* appropriate antibiotic therapy, and
* surgical intervention, when indicated.
The goal of surgical intervention is to remove or neutralize the septic focus to treat the inflammatory response cascade. Unfortunately, despite significant advances in the management of critically ill patients in ICUs and the discovery of powerful antibiotics, the development of septic shock signifies a worsening prognosis. (6) This article presents current information regarding the role of surgery in the management of a patient with septic shock caused by an extra-abdominal source.
IDENTIFYING THE SOURCE OF SEPSIS
When assessing a patient who has sepsis, the first step should be to identify the most likely source of the sepsis. Unfortunately, this is not always easy. Clinical examination remains important in diagnostically evaluating a patient who has sepsis; however, in critically ill patients it is not always reliable for many reasons (eg, decreased levels of consciousness as a result of medications, severe underlying disease). Chest x-rays and blood, sputum, and urine cultures are necessary components in the diagnostic evaluation of patients who have sepsis. Clinicians also should use all available diagnostic modalities, such as
* ultrasonography,
* computed tomography (CT), and
* magnetic resonance imaging (MRI) to localize the source of sepsis.
Most infections in the thorax involve pneumonia; however, other possibilities include empyema of the thorax, endocarditis, pericarditis, and mediastinitis. Bronchoscopy may be required for patients in whom mucus plugging is occurring or in patients for whom precise sputum cultures are needed. (1,7)
Perirectal abscesses ate another potential source of sepsis. Infections in the extremities, such as abscesses or septic phlebitis, and severe necrotizing soft-tissue infections (eg, necrotizing fasciitis, Fournier's disease) may trigger the inflammatory cascade leading to clinical septic shock syndrome. Central venous catheter-related infection is another possibility that should be considered in a patient who has sepsis.
SOURCE CONTROL
The term source control is used to describe clinical interventions that endeavor to remove or neutralize (ie, control) the source that is responsible for the development of sepsis. (8) This intervention can be
* surgical in nature, such as
** meticulous surgical debridement of necrosed infected tissues or
** diversion, repair, or excision of ongoing contamination from a perforated hollow viscus;
* a less invasive procedure, such as
** removal of an infected intravascular catheter or
** introduction of a chest tube to drain a thoracic empyema; or
* some other minimally invasive procedure to drain infected fluid collections, such as
** ultrasound-directed percutaneous cholecystostomy in severe acute cholecystitis,
** CT-guided drainage of intra-abdominal abscesses, or
** endoscopic sphincterotomy for acute suppurative cholangitis.
These newer, minimally invasive therapeutic interventions and the shift of interest from open surgery to less invasive methods are largely a result of recent significant advances in interventional radiology. (1,7) Modern radiological techniques allow newer, minimally invasive procedures to be performed in situations in which open, surgical interventions were inevitable in the past. This approach has simplified the source control in a patient who has sepsis. Given the critical situation of patients with septic shock, image-guided therapeutic methods are associated with minimal morbidity and mortality, and should be preferred over open (ie, classical) procedures as long as effective drainage can be achieved. Certainly, open surgery will continue to be required in a significant percentage of patients who have sepsis, such as those with infected necrotic tissues (eg, infected pancreatic necrosis, necrotic soft-tissue infections) and for the drainage of some abscesses (eg, abscesses with thick, purulent material or with septi within the cavity).
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