Alex Yartsev, March 19 th 2012 Metabolic Mayhem Anaesthetic considerations in the abdominal catastrophe
Uncharted territory. No handy all-encompassing review article. Artwork will be used to distract from lack of content
Abdominocalypse • “Abdominal catastrophe” • • Peritonitis from a visceral source Mesenteric ischaemia Perforated viscus Abdominal compartment syndrome Septic shock Metabolic acidosis Multi-organ system failure
Abdominocalypse Table of Contents: • Preoperative considerations • Choice of induction and maintenance agents • Neuromuscular blockade and its reversal • Ventilation • Fluid management • Vasopressors • Systemic and regional analgesia
Preoperative considerations - Treat the shock - Treat the sepsis - Get central access - Hope for the best with the severe acidosis - Correct coagulopathy Correct anaemia Aim for normothermia Organize ICU bed
Preoperative considerations Cui bono? They may still die Mesenteric infarction mortality: • Without surgery: – 87% to 99% • With surgery – 32% to 77% • Cause of death: MOSF in 75%. • Age increases risk of death • In the over-85 age group, mortality is very similar with and without surgery • Delay of 6 hours = increase in mortality by 30% Schoots et al (2004), Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg, 91: 17– 27. doi: 10. 1002/bjs. 4459 Woosup M. et al Contemporary management of acute mesenteric ischemia: Factors associated with survival Journal of Vascular Surgery Volume 35, Issue 3 , Pages 445 -452, March 2002
Preoperative considerations Treating the sepsis while you wait • Each hour without antibiotics increases mortality by 1% • Management of septic shock – Surviving Sepsis campaign – Goal-directed therapy D. Eissa, E. G. Carton and D. J. Buggy Anaesthetic management of patients with severe sepsis Br. J. Anaesth. (2010) 105 (6): 734 -743.
Preoperative considerations Aggressive management of sepsis: Goals in the first 6 hours: • • • MAP > 65 CVP 8 -12 Urine output > 5 ml/kg/hr Sv. O 2 > 75% BSL < 8. 0 • Think about steroids…. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008.
Choice of anaesthetic agents Propofol vs volatile agents • Both decrease mesenteric arterial blood flow • Its decreased to an equal degree by both • Decrease in cardiac output is the main cause • Thankfully, severe sepsis decreases MAC. Zwijsen, J. H. M. J. , Bovill, J. G. , Geelkerken, R. H. , Delahunt, T. A. , Van Bockel, J. H. and Hermans, J. (1996), Comparison of sufentanil/propofol versus isoflurane/nitrous oxide anaesthesia on mesenteric artery blood flow. Anaesthesia, 51: 1060– 1063. doi: 10. 1111/j. 1365 -2044. 1996. tb 15006. x. Allaouchiche B, Duflo F, Tournadre JP, Debon R, Chassard D. Influence of sepsis on sevoflurane minimum alveolar concentration in a porcine model. Br J Anaesth 2001; 86: 8326. Lundeen G. Manohar M. Parks C. Systemic distribution of blood flow in swine while awake and during 1. 0 and 1. 5 MAC isoflurane anesthesia with or without 50% nitrous oxide. Anesthesia & Analgesia. 62(5): 499 -512, 1983 May.
Choice of anaesthetic agents Which gas? • Desflurane is slightly more likely to vasoconstrict splanchnic circulation • With or without nitrous, doesn’t seem to matter. • Less volatile agent = less hemodynamic instability • Dead kidneys = cant excrete those fluoride ions (not that it matters) Muller M. Schindler E. Roth S. Schurholz A. Vollerthun M. Hempelmann G. Effects of desflurane and isoflurane on intestinal tissue oxygen pressure during colorectal surgery. Anaesthesia. 57(2): 110 -5, 2002 Feb. Kerstin D. Röhm, MD*, Andinet Mengistu, MD*, Joachim Boldt, MD*, Jochen Mayer, MD*, Grietje Beck, MD† and Swen N. Piper, MD* Renal Integrity in Sevoflurane Sedation in the Intensive Care Unit with the Anesthetic-Conserving Device: A Comparison with Intravenous Propofol Sedation A & A June 2009 vol. 108 no. 6 18481854
Neuromuscular blockade No organs to metabolise with Suxamethonium? Severe sepsis = reduced plasma cholinesterase activity - hepatic dysfunction; half-life = 8 hrs, significant when less than 25% is left Aminoglycosides in therapeutic doses (~ 4 mg/kg) = inhibition of Ach release = sensitization to NMJ blockade Cisatracurium is the natural choice. …Does it matter? Going to ICU Sladen, Robert N Anesthetic Concerns for the Patient with Renal or Hepatic Disease ASA Refresher Courses in Anesthesiology: 2001 - Volume 29 - Issue 1 - pp 213 -228 Blanloeil Y, Delaroche O. [Decrease in plasmatic cholinesterase activity in severe bacterial infections: comparison with the decrease observed in severe liver cirrhosis]. Ann Fr Anesth Reanim. 1996; 15(2): 220 -2. Zohar A. Dotan, MD*, Rene Hana, MD†, Daniel Simon, MD†, Daniel Geva, MD‡, Reuven A. Pfeffermann, MD† and Tiberiu Ezri, MD§ The Effect of Vecuronium Is Enhanced by a Large Rather than a Modest Dose of Gentamicin as Compared with No Preoperative Gentamicin A & A March 2003 vol. 96 no. 3 750 -754 Al-Kassab, A. S. / Vijayakumar, E. Profile of Serum Cholinesterase in Systemic Sepsis Syndrome (Septic Shock) in Intensive Care Unit Patients. Clinical Chemistry and Laboratory Medicine. Volume 33, Issue 1, Pages 11– 14
Neuromuscular blockade Reversal • Neostigmine increases gut motility • In at least one old series, this increased the rates of anastomotic breakdown (from 4% to 36%) • No recent data • No data regarding influence from anticholinergics • But now, we have sugammadex • And anyway, …Does it matter? Going to ICU Bell CM. Lewis CB. Effect of neostigmine on integrity of ileorectal anastomoses. British Medical Journal. 3(5618): 587 -8, 1968 Sep 7.
Ventilation Oxygenation • Sepsis microarteriovenous shunt tissue hypoxia • Sepsis impaired mitochondrial oxygen utilization • Sepsis SIRS ALI and ARDS • In summary, high Fi. O 2 is beneficial, or at least not harmful. Ince, Can Ph. D; Sinaasappel, Michiel Ph. Db Microcirculatory oxygenation and shunting in sepsis and shock Critical Care Medicine: July 1999 - Volume 27 - Issue 7 - pp 1369 -1377 Richard S. Hotchkiss, MD; Irene E. Karl, Ph. D Reevaluation of the Role of Cellular Hypoxia and Bioenergetic Failure in Sepsis JAMA. 1992; 267(11): 1503 -1510 Glòria Garrabou 1, Constanza Morén 1, Sònia López 1, Ester Tobías 1, Francesc Cardellach 1, Òscar Miró 1 and Jordi Casademont 2 The Effects of Sepsis on Mitochondria J Infect Dis. (2012) 205 (3): 392 -400.
Ventilation • ARDS decreased compliance • Low tidal volume ventilation strategy improves survival • There is no greater risk of atelectasis (CT evidence) • There is a decrease in post-op inflammatory lung injury • Hypercapnea improves splanchnic perfusion • In summary, high ETCO 2 is beneficial or at least not harmful The Acute Respiratory Distress Syndrome Network - Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome N Engl J Med 2000; 342: 1301 -1308 Hongwei Cai, Ph. Da (Professor of Anesthesia), Hua Gong, MDa, , (Staff Anesthesiologist), Lina Zhang, MDa (Staff Anesthesiologist), Yanjin Wang, MDb (Staff Radiologist), Yuke Tian, Ph. Dc (Professor of Anesthesia) Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: a computed tomographic scan Journal of Clinical Anesthesia Volume 19, Issue 2, March 2007, Pages 125– 129 Wolthuis, Esther K. M. D. *; Choi, Goda M. D. , Ph. D. †; Dessing, Mark C. Ph. D. ‡; Bresser, Paul M. D. , Ph. D. §; Lutter, Rene Ph. D. ∥; Dzoljic, Misa M. D. , Ph. D. #; van der Poll, Tom M. D. , Ph. D. **; Vroom, Margreeth B. M. D. , Ph. D. ††; Hollmann, Markus M. D. , Ph. D. ‡‡; Schultz, Marcus J. M. D. , Ph. D. §§ Mechanical Ventilation with Lower Tidal Volumes and Positive End-expiratory Pressure Prevents Pulmonary Inflammation in Patients without Preexisting Lung Injury. Anesthesiology: January 2008 - Volume 108 - Issue 1 - pp 46 -54
Fluid management Which fluid? • Colloid apparently better for mesenteric perfusion (starch vs Hartmanns) • Systemically, in severe sepsis, it doesn’t matter: nothing stays in the intravascular compartment. • However, in the short term, colloid increases cardiac output more than saline or Hartmanns. – (at least in French sheep with 0. 5 g/kg faeces in their abdominal cavity) • No mortality difference (SAFE study) Lang K, Boldt J, Suttner S, Haisch GColloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesthesia and Analgesia [2001, 93(2): 405 -9 Nisanevich, Vadim M. D. *; Felsenstein, Itamar M. D. †; Almogy, Gidon M. D. †; Weissman, Charles M. D. ‡; Einav, Sharon M. D. §; Matot, Idit M. D Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery. Anesthesiology: July 2005 - Volume 103 - Issue 1 - pp 25 -32 Cittanova ML, Leblanc I, Legendre C, et al: Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidneytransplant recipients. Lancet 1996, 348: 1620– 1622 The SAFE Study Investigators A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit N Engl J Med 2004; 350: 2247 -2256 May 27, 2004 Su, Fuhong*; Wang, Zhen*; Cai, Ying†; Rogiers, Peter‡; Vincent, Jean-Louis* Fluid Resuscitation in Severe Sepsis and Septic Shock: Albumin, Hydroxyethyl Starch, Gelatin or Ringer's Lactate-Does It Really Make A Difference? Shock: May 2007 - Volume 27 - Issue 5 - pp 520 -526 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No. : CD 000567. DOI: 10. 1002/14651858. CD 000567. pub 4
Fluid management Maybe albumin? • No influence on mortality in SAFE study • Increases blood volume by more than the volume infused • No adverse hepatic or renal effects • At least in severely septic ICU patients, reduces mortality (OR: 0. 82) Rackow EC, Falk JL, Fein IA, et al: Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983, 11: 839– 850 Weaver DW, Ledgerwood AM, Lucas CE, et al: Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 1978, 113: 387– 392 Ernest, David MBBS; Belzberg, Allan S. MD; Dodek, Peter M. MD, MHSc Distribution of normal saline and 5% albumin infusions in septic patients. Critical Care Medicine: January 1999 - Volume 27 - Issue 1 - pp 46 -50 Delaney, Anthony P. MD, FCICM; Dan, Arina MD, FCICM; Mc. Caffrey, John MD, FCICM; Finfer, Simon MD, FCICM The role of albumin as a resuscitation fluid for patients with sepsis: A systematic review and meta-analysis* Critical Care Medicine: February 2011 - Volume 39 - Issue 2 - pp 386 -391
Fluid management Maybe gelofusine? • Increases blood volume by as much as all the other colloids; i. e. no better or worse • no dose limit, unlike HES • May impair hemostasis by decreasing availability of v. Wf • Risk of anaphylaxis (2. 7% of total anaphylaxis in anaesthetics, compared to muscle relaxant 67%) • Embryotoxic in pregnant rats (? Relevance) Lobo, Dileep N. DM, FRCS; Stanga, Zeno MD; Aloysius, Mark M. MRCS; Wicks, Catherine BMed. Sci, BM, BS; Nunes, Quentin M. MRCS; Ingram, Katharine L. FRCA; Risch, Lorenz MD, MPH; Allison, Simon P. MD, FRCP Effect of volume loading with 1 liter intravenous infusions of 0. 9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: A randomized, threeway crossover study in healthy volunteers. Critical Care Medicine: February 2010 - Volume 38 - Issue 2 - pp 464 -470 E. de Jonge (1), M. Levi (3), F. Berends (2), A. E. van der Ende (3), J. W. ten Cate (3), C. P. Stoutenbeek (1) Impaired Haemostasis by Intravenous Administration of a Gelatin-based Plasma Expander in Human Subjects Thrombosis and Hemsotasis 1998: 79/2 (Feb) pp. 244 -455 Plus, Gelofusine propaganda from the manufacturer
Fluid management Maybe hydroxyethyl starch? • Starch seems to be safe in non-cardiac surgical patients • More nephrotoxic in sepsis: starch use in sepsis is an independent predictor of ARF (OR 2. 57 compared to gelo) But… the blood bank is too far… • those kidneys are doomed anyway …Does it matter? Going to ICU Rackow EC, Falk JL, Fein IA, et al: Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983, 11: 839– 850 Lazrove S, Waxman K, Shippy C, Shoemaker WC: Hemodynamic, blood volume, and oxygen transport responses to albumin and hydroxyethyl starch infusions in critically ill postoperative patients. Crit Care Med 1980, 8: 302– 306 Cittanova ML, Leblanc I, Legendre C, et al: Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidneytransplant recipients. Lancet 1996, 348: 1620– 1622 Frédérique Schortgen MD a, Jean-Claude Lacherade MD a, Fabrice Bruneel MD c, Isabelle Cattaneo MD d, François Hemery MD b, Prof François Lemaire MD a, Prof Laurent Brochard a Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study The Lancet, Volume 357, Issue 9260, Pages 911 - 916, 24 March 2001
Fluid management How much fluid? • Less is apparently better • “Restrictive” fluid protocol: 4 ml/kg/hr is better than 12. – That’s 1120 ml for a 4 hr 70 kg laparotomy! – That study was in elective patients… • Might this interfere with management of septic shock? • Does this compensate for abdominal evaporative losses? Lang K, Boldt J, Suttner S, Haisch GColloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesthesia and Analgesia [2001, 93(2): 405 -9 Nisanevich, Vadim M. D. *; Felsenstein, Itamar M. D. †; Almogy, Gidon M. D. †; Weissman, Charles M. D. ‡; Einav, Sharon M. D. §; Matot, Idit M. D Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery. Anesthesiology: July 2005 - Volume 103 - Issue 1 - pp 25 -32
Blood products Hemoglobin target • Experts disagree regarding benefits of transfusion • Higher oxygen carrying capacity vs. increased viscosity • Consensus is to keep it over 70 and under 125 • If they have acute coronary ischaemia, target Hb over 100 …Remember calcium Tagart REB. Colorectal anastomosis: factors influencing success. J R Soc Med. 1981 February; 74(2): 111– 118. P C Hébert, G Wells, M Tweeddale, C Martin, J Marshall, B Pham, M Blajchman, I Schweitzer and G Pagliarello Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am. J. Respir. Crit. Care Med. May 1, 1997 vol. 155 no. 51618 -1623
Vasopressors Do you need a CVC? • Noradrenaline is no better than metaraminol in its hemodynamic effects (HR, SVI, PAWP, SVRI) • Less splanchnic vasoconstriction than adrenaline • More easily titrated than phenylephrine De Backer, Daniel MD, Ph. D; Creteur, Jacques MD, Ph. D; Silva, Eliézer MD, Ph. D; Vincent, Jean-Louis MD, Ph. D, FCCM Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: Which is best? Critical Care Medicine: June 2003 - Volume 31 - Issue 6 - pp 1659 -1667 Giuseppe Natalini, Valeria Schivalocchi, Antonio Rosano, Maria Taranto, Cristina Pletti and Achille Bernardini Norepinephrine and metaraminol in septic shock: a comparison of the hemodynamic effects INTENSIVE CARE MEDICINE Volume 31, Number 5, 634 -63
Vasopressors Vasopressin for sepsis • Sensitivity to it is increased in sepsis • Some think, sepsis = relative vasopressin deficiency • • Not a familiar drug May cause coronary ischaemia May cause splanchnic ischaemia May cause ischaemia of everything else Landry DW, Levin HR, Gallant et al. Vasopressin pressor hypersensitivity in vasodilatory septic shock. Crit Care Med. 1997; 25(8): 1279 -128 Morales MD, Madigan J, Cullinane S et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation July 20, 1999: 226 -228 Morelli A, Tritapepe L, Rocco M, Conti G, Orecchioni A, De Gaetano A, Picchini U, Pelaia P, Reale C, Pietropaoli P. Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system inhibitors: effects on systemic and regional hemodynamics. Anesthesiology. 2005 Jan; 102(1): 12 -9. Medel J, Boccara G, Van de Steen E, Bertrand M, Godet G, Coriat P. Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia? Anesth Analg. 2001 Jul; 93(1): 53 -5, TOC. Martin W. Dünser, MD; Andreas J. Mayr, MD; Hanno Ulmer, Ph. D; Hans Knotzer, MD; Günther Sumann, MD; Werner Pajk, MD; Barbara Friesenecker, MD; Walter R. Hasibeder, MD Arginine Vasopressin in Advanced Vasodilatory Shock A Prospective, Randomized, Controlled Study. Circulation. 2003; 107: 2313 -2319
Vasopressors Vasopressin for sepsis • • Additive effect with noradrenaline Receptors unaffected by acidosis Non-arrhythmogenic Splanchnic perfusion is going to suffer anyway if your MAP is 40. • in SEVERE catecholamine-resistant shock, its better to start vasopressin than to keep going up on noradrenaline (RCT: NA 1. 2 -1. 5 mcg/kg/min vs 4 u/hr of AVP ) …that’s 84 -105 ml/hr of single strength norad…. Landry DW, Levin HR, Gallant et al. Vasopressin pressor hypersensitivity in vasodilatory septic shock. Crit Care Med. 1997; 25(8): 1279 -128 Morales MD, Madigan J, Cullinane S et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation July 20, 1999: 226 -228 Morelli A, Tritapepe L, Rocco M, Conti G, Orecchioni A, De Gaetano A, Picchini U, Pelaia P, Reale C, Pietropaoli P. Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system inhibitors: effects on systemic and regional hemodynamics. Anesthesiology. 2005 Jan; 102(1): 12 -9. Medel J, Boccara G, Van de Steen E, Bertrand M, Godet G, Coriat P. Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia? Anesth Analg. 2001 Jul; 93(1): 53 -5, TOC. Martin W. Dünser, MD; Andreas J. Mayr, MD; Hanno Ulmer, Ph. D; Hans Knotzer, MD; Günther Sumann, MD; Werner Pajk, MD; Barbara Friesenecker, MD; Walter R. Hasibeder, MD Arginine Vasopressin in Advanced Vasodilatory Shock A Prospective, Randomized, Controlled Study. Circulation. 2003; 107: 2313 -2319
Acid-base management Severe lactic acidosis • Circulatory support and surgical removal of ischaemic tissue Role of bicarbonate • There is probably none. • Surviving Sepsis guidelines recommend against it (p. H >7. 15) • But, it improves sensitivity of catecholamine receptors • Remember calcium - will rise with acidosis, drop with alkalosis J. D. Marsh, T. I. Margolis, and D. Kim Mechanism of diminished contractile response to catecholamines during acidosis AJP - Heart January 1988 vol. 254 no. 1 H 20 -H 27 Boyd JH, Walley KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Curr Opin Crit Care. 2008 Aug; 14(4): 379 -83.
Systemic analgesia PCA • Not as good as epidural in abdominal surgery • Better than PRNs • Usually, need to resort to continuous infusion Fentanyl vs morphine / hydromorphone • No real difference • Little data specific to severe abdominal sepsis Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intraabdominal surgery. Cochrane Database Syst Rev. 2005 Hudcova J, Mc. Nicol E, Quah C, Lau J, Carr DB Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev. 2006;
Systemic analgesia No organs to metabolise with? • Remifentanil is the obvious choice • RCT of remi vs morphine PCA: more boluses required, more expensive, but otherwise the same effect. • May make ventilator weaning easier, ICU will thank you for not using tons of morphine F. Kucukemre a 1, N. Kunt a 2 c 1, K. Kaygusuz a 2, F. Kiliccioglu a 2, B. Gurelik a 2 and A. Cetin a 3 Remifentanil compared with morphine for postoperative patient-controlled analgesia after major abdominal surgery: a randomized controlled trial European Journal of Anaesthesiology (2005), 22 : pp 378 -385 Des Breen, 1 Alexander Wilmer, 2 Andrew Bodenham, 3 Vagn Bach, 4 Jan Bonde, 5 Paul Kessler, 6 Sven Albrecht, 7 and Soraya Shaikh 8 Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment Crit Care. 2004; 8(1): R 21–R 30
Spinal/epidural analgesia • Studies in elective patients recommend use of epidural analgesia • Few studies in acute abdomen: also positive • No studies in the severely septic laparotomy patients • Concerns regarding epidural abscesses in bacteraemia
Spinal/epidural analgesia Main problem: hemodynamics • Vasodilation from spinal/epidural causes splanchnic vasodilation, which is good in stable elective patients • Everything else vasodilates as well • Shock becomes more profound • One case report: a parturient with twins and a severe streptococcal sepsis died mid-caesarian shortly after the epidural was administered: hypotension blamed. Morgan PJ. Maternal death following epidural anaesthesia for caesarean section delivery in a patient with unsuspected sepsis. Canadian Journal of Anaesthesia. 42(4): 330 -4, 1995 Apr. David R. Spackman, Andrew D. M. Mc. Leod, Steven N. Prineas, Richard M. Leach and F. Reynolds Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine. INTENSIVE CARE MEDICINE Volume 26, Number 11, 1638 -1645, DOI: 10. 1007/s 001340000671
Spinal/epidural analgesia Will it get infected? • Short answer: probably. – Japanese group: epidural improves 3 month mortality after emergency abdominal surgery. No mention of extent of sepsis or rates of neurological complications. – Other case series of frequently debrided infected ICU patients: many pulled catheters cultured S. epi but no actual abscesses. – Some studies in patients with chorioamnionitis: encouraging. – No studies in severe ICU-style sepsis. Bengtsson M, Nettelblad H, Sjoberg F (1997) Extradural catheter-related infections in patients with infected cutaneous wounds. Br J Anaesth 79: 668 -670 Jakobsen KB. Christensen MK. Carlsson PS. Extradural anaesthesia for repeated surgical treatment in the presence of infection. British Journal of Anaesthesia. 75(5): 536 -40, 1995 Nov. [Case Reports. Journal Article] Jomura K, Hamada T, Sugiki K, Ito Y (1997) Epidural anesthesia reduces mortality rate in the patients after emergency abdominal surgery. Masui 46: 16021608 Goodman EJ, De. Horta E, Taguiam JM. Safety of spinal and epidural anesthesia in parturients with chorioamnionitis. Reg Anesth 1996; 21: 436 -441. Bader AM, Datta S, Gilbertson L, Kirz L. Regional anesthesia in women with chorioamnionitis. Reg Anesth 1992; 17: 84 -86. Wedel, Denise J. M. D. *; Horlocker, Terese T. M. D. Regional Anesthesia in the Febrile or Infected Patient Regional Anesthesia & Pain Medicine: July/August 2006 - Volume 31 - Issue 4 - p 324– 333
In summary HARD EVIDENCE WEAK EVIDENCE • Minimal delay before theatre • Minimal delay before antibiotics • Aggressive resuscitation of shock including early vasopressors • Low tidal volume ventilation • Permit hypercapnea • If hemodynamically stable, conservative fluid management • More colloid • Less neostigmine • Keep Hb under 125, above 70 • Bicarbonate for acidosis “In deciding whether to site an epidural catheter in a critically ill patient the overall balance lies between unproven benefit and uncertain risk”. In spite of everything, many of them will die anyway. Get them off the table. Let ICU sort it out.
No further questions, please
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