Operative management of peritonitis in ICU patients

[leviathan]

Just curious to hear how your hospital's surgeons manage peritonitis in ICU patients?

I have a young guy who had perforated + feculent peritonitis from diverticulitis. He had a hartmann's and washout and weeks later still on low dose pressors with ongoing fevers, sepsis, CRP in the 400s etc. All the surgeons feel there's no point in going back as it's unlikely to help, would be high risk, and would be challenging due to adhesions.

The rationale sounds reasonable, but I do wonder if it's a local culture and if you guys have seen it done differently at your hospital. It's frustrating as I see cases like this a few times a year and they ultimately always die, which I suspect will be the outcome for the guy I have right now. I should mention his repeat CTs show no organized collection or abscess, and if it the recommendation is always to get IR to put in perc drains, which never seem to work well.

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[jdh71]

Just curious to hear how your hospital's surgeons manage peritonitis in ICU patients?

I have a young guy who had perforated + feculent peritonitis from diverticulitis. He had a hartmann's and washout and weeks later still on low dose pressors with ongoing fevers, sepsis, CRP in the 400s etc. All the surgeons feel there's no point in going back as it's unlikely to help, would be high risk, and would be challenging due to adhesions.

The rationale sounds reasonable, but I do wonder if it's a local culture and if you guys have seen it done differently at your hospital. It's frustrating as I see cases like this a few times a year and they ultimately always die, which I suspect will be the outcome for the guy I have right now. I should mention his repeat CTs show no organized collection or abscess, and if it the recommendation is always to get IR to put in perc drains, which never seem to work well.

My surgeons tend to leave these patients open for a few dats with a wound vac in place and two or three washouts before closing them back up. Seems to decrease the badness that can occur with these kinds of cases.

 

[MediMike]

Agree with above. Pretty sure the surgeons around here own stock in Abthera...

 

[chocomorsel]

Just curious to hear how your hospital's surgeons manage peritonitis in ICU patients?

I have a young guy who had perforated + feculent peritonitis from diverticulitis. He had a hartmann's and washout and weeks later still on low dose pressors with ongoing fevers, sepsis, CRP in the 400s etc. All the surgeons feel there's no point in going back as it's unlikely to help, would be high risk, and would be challenging due to adhesions.

The rationale sounds reasonable, but I do wonder if it's a local culture and if you guys have seen it done differently at your hospital. It's frustrating as I see cases like this a few times a year and they ultimately always die, which I suspect will be the outcome for the guy I have right now. I should mention his repeat CTs show no organized collection or abscess, and if it the recommendation is always to get IR to put in perc drains, which never seem to work well.

How many total washouts? Just one?

 

[SurfingDoctor]

Can’t treat sepsis without source control...

 

[CCM-MD]

Can’t treat sepsis without source control...

Of course you can! I see it all the time. Just doesn't work very well.

 

[SurfingDoctor]

Of course you can! I see it all the time. Just doesn't work very well.

Kinda of the point of the question posed no?

 

[leviathan]

How many total washouts? Just one?

Yep just one. Have never seen an abthera at this hospital.

 

[ShockIndex]

Yep just one. Have never seen an abthera at this hospital.

That seems a little odd although the evidence behind open vs closed approach is lacking outside of damage control surgery for trauma. Every SICU I’ve seen has adopted an open approach (<8 days) for operative peritonitis despite a lack of robust prospective data. I’m going to go out on a limb that your surgeons are outside of the mainstream but within the standard of care provided that they are staying on top pitfalls like ACS.

 

[Radetzky]

Hartmanns and ongoing sepsis afterwards equals rectal stump leak (assuming he hasn’t developed some nosocomial sepsis in the meantime) and should go back for inspection/washout and repair.

 

[MoMoGesiologist]

It may be worth posting this in the surgeons forum. May get a lot of insight there

 

[chocomorsel]

Yep just one. Have never seen an abthera at this hospital.

Just one washout? That doesn’t seem like enough if he’s still spiking. Those things are nasty and from what I have seen go back to OR a few times.
But I ain’t no cutter.

 

[Beeftenderloin]

Just curious to hear how your hospital's surgeons manage peritonitis in ICU patients?

I have a young guy who had perforated + feculent peritonitis from diverticulitis. He had a hartmann's and washout and weeks later still on low dose pressors with ongoing fevers, sepsis, CRP in the 400s etc. All the surgeons feel there's no point in going back as it's unlikely to help, would be high risk, and would be challenging due to adhesions.

The rationale sounds reasonable, but I do wonder if it's a local culture and if you guys have seen it done differently at your hospital. It's frustrating as I see cases like this a few times a year and they ultimately always die, which I suspect will be the outcome for the guy I have right now. I should mention his repeat CTs show no organized collection or abscess, and if it the recommendation is always to get IR to put in perc drains, which never seem to work well.

We have a patient well known to the anesthesia dept at my hospital. HIPEC/Hartmans/TAHBSO complicated by anastamotic leak/abscess with multiple re-operations. Every 2-3 weeks the patient starts getting SIRSy with soft BPs and white count spiking so they take her back for another washout/reexploration. This has been going on for the better part of a year.

 

[chocomorsel]

We have a patient well known to the anesthesia dept at my hospital. HIPEC/Hartmans/TAHBSO complicated by anastamotic leak/abscess with multiple re-operations. Every 2-3 weeks the patient starts getting SIRSy with soft BPs and white count spiking so they take her back for another washout/reexploration. This has been going on for the better part of a year.

Well that ain’t good. Could be other sources besides the gut,
What’s HIPEC?

 

[Beeftenderloin]

Well that ain’t good. Could be other sources besides the gut,
What’s HIPEC?

The problem is every time they wash her out she improves (albeit transiently).

HIPEC = Hyperthermic Intraperitoneal Chemotherapy. From what I’ve seen, reserved for more advanced gastric, colorectal and ovarian cancer. Do as much debulking as they can then dump hot chemo in the abdomen and slosh it around for a while. Think burn physiology but intraperitoneal. They third space fluid like crazy. Most get 8-10 liters of crystalloid intra-op. Our ICU runs 250-500cc/hr maintenance rates in the immediate post-op period.

 

[psychbender]

What’s HIPEC?

The infamous "Shake and Bake." They take all damn day long, and come out looking like ass, but generally turn around overnight, and come off pressors by morning, or afternoon POD1, usually.

 

[deleted547339]

We have a patient well known to the anesthesia dept at my hospital. HIPEC/Hartmans/TAHBSO complicated by anastamotic leak/abscess with multiple re-operations. Every 2-3 weeks the patient starts getting SIRSy with soft BPs and white count spiking so they take her back for another washout/reexploration. This has been going on for the better part of a year.

They have palliative at your hospital, no?

 

[MoMoGesiologist]

The problem is every time they wash her out she improves (albeit transiently).

HIPEC = Hyperthermic Intraperitoneal Chemotherapy. From what I’ve seen, reserved for more advanced gastric, colorectal and ovarian cancer. Do as much debulking as they can then dump hot chemo in the abdomen and slosh it around for a while. Think burn physiology but intraperitoneal. They third space fluid like crazy. Most get 8-10 liters of crystalloid intra-op. Our ICU runs 250-500cc/hr maintenance rates in the immediate post-op period.

May be a silly question, but when they “third space” this fluid and get 10L IVF, where does all the fluid go? Do they look like balloons the next day in ICU and get diuresed? Or are these open abdominal cases and the large volume given is simply replacing insensible losses?

 

[chocomorsel]

The problem is every time they wash her out she improves (albeit transiently).

HIPEC = Hyperthermic Intraperitoneal Chemotherapy. From what I’ve seen, reserved for more advanced gastric, colorectal and ovarian cancer. Do as much debulking as they can then dump hot chemo in the abdomen and slosh it around for a while. Think burn physiology but intraperitoneal. They third space fluid like crazy. Most get 8-10 liters of crystalloid intra-op. Our ICU runs 250-500cc/hr maintenance rates in the immediate post-op period.

Wow. Guess I am used to working in smaller community hospitals. Never heard of this. Even when I was doing fellowship in a major academic center where they were doing all kind of crazy stuff. Including bowel transplants.

 

[CCM-MD]

They have palliative at your hospital, no?

No, I believe all of the patients are “fighters”.

 

[Beeftenderloin]

May be a silly question, but when they “third space” this fluid and get 10L IVF, where does all the fluid go? Do they look like balloons the next day in ICU and get diuresed? Or are these open abdominal cases and the large volume given is simply replacing insensible losses?

8-10 hours with an open belly so insensible losses are definitely a big part of the equation, but they get pretty swollen. The healthier ones auto-diurese a few days post-op. Some need a little help pharmacologically.

 

[Hork Bajir]

Even more fun than HIPEC is HITEC. Not many places doing that these days because the outcomes are so dismal, as I understand it, but man those patients get sick as dogs postop. File it under “just because we can, doesn’t mean we should...”

 

[DoctwoB]

Just curious to hear how your hospital's surgeons manage peritonitis in ICU patients?

I have a young guy who had perforated + feculent peritonitis from diverticulitis. He had a hartmann's and washout and weeks later still on low dose pressors with ongoing fevers, sepsis, CRP in the 400s etc. All the surgeons feel there's no point in going back as it's unlikely to help, would be high risk, and would be challenging due to adhesions.

The rationale sounds reasonable, but I do wonder if it's a local culture and if you guys have seen it done differently at your hospital. It's frustrating as I see cases like this a few times a year and they ultimately always die, which I suspect will be the outcome for the guy I have right now. I should mention his repeat CTs show no organized collection or abscess, and if it the recommendation is always to get IR to put in perc drains, which never seem to work well.

Surgeon (though not a general surgeon) here. In the absence of compelling data I don't think there is a "correct" number of washouts. The "correct" number is what is needed for source control and this patient is telling you he has inadequate source control. It is also true that going back in now could be a cluster 2 weeks post-peritonitis, everything will be sticky, planes gone, risk of bowel injury very high. The real screw up here was waiting two weeks. When he was still showing signs of sepsis on day 2 after his first procedure they should have been back in there.

 

[Dr.LeoSpaceman]

General surgeon (+ surg onc) here. I came for the COVID thread, found this.

Agree with DoctwoB. Going back in two weeks out without a defined problem that can only be managed with a laparotomy is not a great idea due to the risk of creating more problems. There are very few situations that can't be managed with perc drains and supportive care, and it's going to be very hard to convince someone to go back in "just to take a look". The two situations I could think of are an uncontrolled leak/enterotomy (including a stump leak) that can't be managed with a perc drain or ischemic gut.

Other issues mentioned in this thread:
- Damage control/planned takebacks. There is no literature supporting this strategy outside of trauma. There are a few times it may make sense, though. 1)if I'm addressing ischemic gut, and it's unclear what's going to live or die. When that happens, a planned takeback to allow things to declare themselves is appropriate. 2) Necrotizing pancreatitis that has progressed.through the "step up" approach. 3) Someone whom is so incredibly unstable that the you have to simply get source control and get them off the table for resuscitation prior to closure. 4) Abdomen is too tight. More frequent in ruptured AAA, or people whom have gotten massive crystal resuscitation prior to OR.

But run of the mill feculent peritonitis, they're generally getting their definitive operation the first time. Unfortunately I've observed that planned reoperation is being used more at some places in the era of ACS services and shift work. Not because it has defined benefit for the patient, but because it can be a matter of convenience.

-Rectal stump leak: Agreed this would be high on the differential. However it doesn't (necessarily) require a takeback. I'd start with a gastrograffin enema +/- CT to evaluate. If it's contained in the pelvis, it could potentially be managed with drainage (some combination of transrectal and perc) and antibiotics, especially considering it's two weeks out. Getting back into that pelvis is going to be a nightmare. Even if you had a high index of suspicion early, reop isn't mandatory in a stable patient.

Edit to add:
Here are some recent articles on damage control laparotomy: Damage Control Laparotomy - The Eastern Association for the Surgery of Trauma

Admittedly it had been a year or two since I looked at this specifically. However it was good to see that there are some newer studies documenting the prevailing antecdotal evidence (and previous lack of evidence defining benefit) that damage control for nontrauma patients isn't beneficial. And the most recent from JTrauma also suggested that use of temporary closure was associated with ACS services and night-time operations.

 

[ACSurgeon]

Late to the discussion. anyways I agree with above post. I’ll add:

- At the two week mark post-op the abdomen will be difficult to access, which also means a leak is likely to be contained to one corner in the abdomen, which is easier to control with a drain. This is different than the initial perforation with free leakage and diffuse peritonitis that can be controlled readily through surgery and no so much with drains.

- re: ABTHERA. It’s a bail out option. Anyone doing acute care or trauma ALWAYS has a “bail out” plan. This should not be the first option, but sometimes should be done. Some surgeons over use it. Just like anything there are different approaches to things and this is based on experience, skill, style, recent complications, etc.

I’ll admit, as a young surgeon if I’m doing a difficult case in the middle of the night, an ABTHERA is a good way to keep the patient alive until I can have more help in a day or two.