Surgical Challenges
in the treatment of cIAI
(complicated Intraabdominal Infection)
Reno Rudiman
Hasan Sadikin General Hospital, Bandung, Indonesia
Definition
Infections that spread beyond the hollow viscus of origin
into the peritoneal space and are associated with:
Abscess formation or
Peritonitis
Peritonitis
Primary = spontaneous bacterial peritonitis
arises without a breach in the peritoneal cavity or GI tract
Secondary
spillage of gut organisms through a physical hole in the GI
tract or through a necrotic gut wall
community acquired or healthcare associated
Tertiary
peritonitis in a critically ill patient which persists or recurs at
least 48 h after apparently adequate management of primary
or secondary peritonitis
Microbiology:
Abscesses or secondary peritonitis
Health care associated intra-abdominal infection
Community acquired infections
Infections derived from stomach, duodenum, biliary system and proximal small bowel:
Gram positive and Gram negative aerobic and facultative bacteria
Distal small bowel:
Gram negative facultative and aerobic bacteria
Anaerobes
Large bowel:
Facultative and obligate anaerobic bacteria
Streptococi and enterococci commonly present
Clinical features of cIAI
Difficult to diagnose in the critically ill patient because
history is usually unobtainable and physical signs
usually masked by decreased conscious level
Clinical features of cIAI
Consider diagnosis in the appropriate clinical setting in patients
with otherwise unexplained signs of sepsis or organ
dysfunction:
recent abdominal surgery
source of arterial emboli
peripheral vascular disease
thrombotic disorder
recent arteriography
history of reduced splanchnic blood flow
(eg use of vasopressors or prolonged shock)
Clinical features of cIAI
Suspicion of intra-abdominal infection
Unexpected shortness of breath
supraventricular tachycardia occurring 3-4 days
after an abdominal operation
new onset renal dysfunction
elevated bilirubin or transaminases
Investigations
Microbiological
Blood cultures
often negative
polymicrobial or anaerobic bacteraemia should raise
possibility of anaerobic infection
Community acquired infections: Gram stain of no
value
Healthcare associated infections: Gram stain may be
valuable in S.aureus or Enterococcus spp. infections
AXR
Ultrasound
CT abdomen
Invasive Investigations in
ICU
Probing of surgical wounds with sterile culture swab or gloved
finger can often identify collections of infected material immediately
adjacent to incision
Diagnostic peritoneal lavage
may reveal bacteria, white cells, bile or intestinal contents
bloody lavage return suggests acute intestinal ischaemia
Bedside laparoscopy
difficult
experience in critically ill patients largely anecdotal
Management of cIAI
Physiological resuscitation
Systemic antibiotics
Source control
Physiologic resuscitation: Early Goal Directed Therapy
What is Source Control?
All those physical measures that are undertaken
To eliminate a focus of infection
To control ongoing contamination
To restore premorbid anatomy & function
What is Source Control?
Not always surgical procedures, also include
Radiologically directed drainage of abscess
Removal of colonized urinary or vascular catheter
Removal of devitalized tissue by frequent dressing
changes
Term
Definition
Source control
All physical measures undertaken to eliminate a source of
infection, control ongoing contamination, and restore
premorbid anatomy and function
Sinus
Abnormal communication to an epithelial cell-lined surface
Fistula
Abnormal communication between two epithelial cell-lined
surfaces
Abcess
Fluid-filled collection of tissue fluid, tissue debris,
neutrophis, and bacteria contained within a fibrous capsule
Drainage
Debridement
Creation of a controlled sinus or fistula
Removal of devitalized tissue, foreign bodies, or other
areas advantageous to bacterial growth
Principles of Source Control
Drainage of abscess
Debridement of nonviable of infected tissue
Definitive management of the anatomic abnormality
responsible for ongoing microbial contamination &
restoring normal function and anatomy
Drainage
•
Converting a contained collection to a controlled fistula (to
exterior) or sinus
•
Drain must permit free flow of the abscess
•
Minimum risk and physiologic derangement: percutaneous
drainage
•
Modern imaging: all collections can be visualized
preoperatively
•
In unstable and ill patient – surgery for controlled
sinus/fistula & removal of dead tissue only
Drainage
CT guided abcess drainage
Debridement
•
The process of removing nonviable tissue
•
Directed against solid components that promote
bacterial growth
•
Demarcation between viable and nonviable tissue
maybe not absolute at early stage
•
Gentle debridement - use wet to dry saline dressing
Debridement
•
Remove all necrotic tissue but minimize the
resulting defects for easier reconstruction
•
Bleeding from viable tissue is better than fail to
debride necrotic material
Debridement
Necrotic bowel
•
Excision for necrotic bowel is more complex
•
The benefits of resection must be weighed
against the consequences of loss of bowel length
•
The dilemma is usually best resolved by a
planned second-look laparotomy
Debridement
Retroperitoneum
•
Peripancreatic retroperitoneal necrosis is well
tolerated
•
Blind exploration of retroperitoneum - risk of
uncontrollable hemorrhage
•
Delayed debridement is preferred for suspected
infected necrosis
Debridement
Foreign body
•
Risks are minimal when urinary or vascular
catheter is infected
•
Risks are high when aortic graft or heart valve is
infected
Definitive management
•
The ultimate aim of therapy:
•
•
to restore function with the least risk
To correct the abnormality that created the infection
Extent of Surgical Therapy
•
The more extensive the initial intervention, the
greater is the challenge of subsequent
reconstruction
•
The optimal intervention is that which
accomplishes the source control objectives in the
simplest manner
Failed Source Control
•
Failure of source control is more important than
antibiotic failure
•
Cause of failure:
•
•
•
•
Poor choice of operation
Correct operation performed poorly
Poor timing
Consequences of failure:
•
•
•
Nosocomial infections
Nutritional and metabolic disorders
Multiple organ dysfunction syndrome
Diffuse Peritonitis
•
•
Aggressive initial surgical source control :
intraoperative lavage
If source control not possible
• Continuous lavage
• Laparostomy
• Planned reexploration
• Or combination of above
Complications of Source Control
•
Complications from
•
•
Technical error
Local factors that impair healing
Source Control
Should be individualized based on:
Diagnostic uncertainty
Physiologic stability
Premorbid health status
Previous surgical interventions
Surgeon’s experience & skill
Available surgical facilities
Antibiotics
High risk patients should be given antibacterials with a
wider spectrum of activity
Risk factors:
higher APACHE II
poor nutritional status
significant cardiovascular disease
inability to obtain adequate source control
immunosuppression
Antibiotics
Should be active against enteric Gram negative
aerobic and facultative bacilli and ß-lactam
susceptible Gram positive cocci
For distal small bowel and colon-derived infections
antibacterials should cover anaerobes
Same recommendation also applies to more proximal
GI perforations when obstruction is present
Antibiotics
Suitable regimes include:
imipenem/cilastin, meropenem, doripenem
3rd or 4th generation cephalosporin plus
metronidazole
ciprofloxacin plus metronidazole
aztreonam plus metronidazole
piperacillin/tazobactam
Risk Factors for Treatment
Failure
Patient factors
• Age, comorbidity, malnutrition
• Prolonged hospital stay, Antibiotic resistance
• Severity of illness
Surgical factors
• Inadequate source control
Ineffective antibiotic therapy
Modifiable
Risk
Factors
Surg Inf 2002(3):175-233
Conclusion
Management of cIAI includes: physiologic
resuscitations, systemic antibiotics and source control
The key to success when treating surgical infections is
timely intervention to stop the delivery of bacteria and
adjuvants of inflammation/infection into the peritoneal
cavity
All others are useless if source control failed