Evaluation of the abdomen in the critically ill patient: opening the black box

Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate?

The present paper was done to review common diagnostic techniques used to help surgeons find the most suitable way to diagnose postoperative intra-abdominal sepsis (IAS). The topic was searched on MEDLINE, Embase, and Cochrane Library databases. Collected articles were classified and checked for their quality. Findings of selected research were included in this study and analyzed to find the best diagnostic method for intra-abdominal sepsis. IAS presents severe morbidity and mortality, and its early diagnosis can improve the outcome. Currently, there is no consensus among surgeons on a single diagnostic modality that should be used while deciding reoperation in patients with postoperative IAS. Though it has a high sensitivity for abdominal infections, computed tomography has limited applications due to mobility and time constraints. Diagnostic laparoscopy is a safe process that produces usable images, and can be used at the bedside. Diagnostic peritoneal lavage (DPL) has high sensitivity, and the patients testing positive through DPL can be subjected to exploratory laparotomy, depending on severity. Abdominal Reoperation Predictive Index (ARPI) is the only index reported as an aid for this purpose. Serial intra-abdominal pressure measurement has also emerged as a potential diagnostic tool. A proper selection of diagnostic modality is expected to improve the outcome in IAS, which presents high mortality risk and a limited time frame.

Clinical Approach to the Patient in Critical State Following Immunotherapy and/or Stem Cell Transplantation: Guideline for the On-Call Physician

: The initial management of the hematology patient in a critical state is crucial and poses a great challenge both for the hematologist and the intensive care unit (ICU) physician. After years of clinical practice, there is still a delay in the proper recognition and treatment of critical situations, which leads to late admission to the ICU. There is a much-needed systematic ABC (Airway, Breathing, Circulation) approach for the patients being treated on the wards as well as in the high dependency units because the underlying hematological disorder, as well as disease-related complications, have an increasing frequency. Focusing on score-based decision-making on the wards (Modified Early Warning Score (MEWS), together with Quick Sofa score), active sepsis screening with inflammation markers (C-reactive protein, procalcitonin, and presepsin), and assessment of microcirculation, organ perfusion, and oxygen supply by using paraclinical parameters from the ICU setting (lactate, central venous oxygen saturation (ScVO2), and venous-to-arterial carbon dioxide difference), hematologists can manage the immediate critical patient and improve the overall outcome.

Diagnostic laparoscopy to investigate unexplained lactic acidosis in critically ill patients - A descriptive single centre cohort study

Introduction

Unexplained lactic acidosis (LA) in a critically ill patient often prompts investigations to rule out any reversible intra-abdominal cause. Equivocal results can lead to an emergency laparotomy (EL) with subsequent high morbidity and mortality rates. Our objective was to determine the clinical impact of urgent diagnostic laparoscopy (UDL) in such patients.

Methods

This was a descriptive single-centre cohort study. UDL on 28 consecutive critically ill patients with unexplained LA who were referred to a single surgeon over 16 years period were analysed. UDL was proformed either at bedside or in theatre without prior computerised tomography (CT) scan. Patient's demographics, ASA grade, referral route and intraoperative findings were analysed.

Results

Eighteen patients underwent bedside UDL in the critical care setting and further 10 had UDL in theatre. Fourteen patients had normal UDL, out of these 10 had LA secondary to low cardiac output states. Fourteen patients had positive UDL findings. Seven patients had features of mesenteric ischaemia, two had gangrenous gallbladder, two had hepatic ischaemia, one patient had acute pancreatitis, one had gangrenous uterus and one had gastric volvulus. Five of the 14 patients with positive UDL were converted to laparotomy for definitive management. In total, of the 28 patients in the cohort, 23 patients avoided EL.

Conclusion

UDL is useful and feasible investigation for unexplained LA in the critically ill patients and it can avoid unnecessary EL in many patients. We would recommend the use of UDL as a safe and feasible investigation in such patients.

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Lactic Acidosis likely from an intra-abdominal source usually prompts explorative Laparotomy.

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We performed diagnostic laparoscopy for 28 critically ill patients with Lactic Acidosis.

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These patients underwent diagnostic laparoscopy prior to any CT scanning, in either bedside or theatre setting.

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50% of patients had a normal Laparoscopy results and Explorative laparotomy was prevented in 18% of patients.

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Diagnostic Laparoscopy is safe and feasible when investigating lactic acidosis from an intra-abdominal source and risks are reduced with explorative laparotomy.

The delta neutrophil index is a prognostic factor for postoperative mortality in patients with sepsis caused by peritonitis

Introduction

The delta neutrophil index (DNI) represents the fraction of circulating immature granulocytes and is a marker of infection and sepsis. Our objective was to evaluate the usefulness of DNI for predicting in-hospital mortality within 30 days after surgery in patients with sepsis caused by peritonitis by means of comparing DNI, white blood cell (WBC) count, neutrophil percentage, and C-reactive protein (CRP) before and after surgery.

Materials and methods

We performed a retrospective analysis of demographic, clinical, and laboratory data. DNI, WBC count, neutrophil percentage, and CRP were measured before surgery, and at 12–36 h (day 1) and 60–84 h (day 3) after surgery.

Results

There were 116 (73.7%) survivors and 44 (26.3%) non-survivors. The rates of septic shock, norepinephrine administration, renal replacement, mechanical ventilator therapy, and reoperation, the Simplified Acute Physiology Score-3 (SAPS3), and the Sepsis-related Organ Failure Assessment (SOFA) score were greater in non-survivors. DNI on day 3 was better than the other laboratory variables for predicting mortality. DNI was correlated with the SAPS3 (r = .46, p = .00) and SOFA score (r = .45, p = .00). The optimal cut-off DNI for predicting mortality was 7.8% (sensitivity: 77.3%; specificity: 95.9%). In receiver-operating characteristic curve analysis, DNI on day 3 was the best indicator of mortality (area under the curve: .880; 95% confidence interval: .80–.96).

Conclusions

Our results indicate that DNI is better than other laboratory variables for predicting postoperative mortality in patients with sepsis caused by peritonitis. DNI > 7.8% on day 3 was a reliable predictor of postoperative mortality.

Drainoscopy: a doorway to the abdomen in the post-surgical patient

The ability to optically visualize the abdominal cavity in the post-surgical patient can prove to be invaluable, particularly when imaging studies and exam findings can be difficult to interpret. Post-surgical drains are often used and provide a window into the abdominal cavity. In this proof-of-concept study, it is demonstrated that an ordinary drain can be used as a point of access and hence a doorway into the abdominal cavity. This technique has been termed drainoscopy, and the approach is demonstrated with video supplement.

Grenzen des laparoskopischen Operierens bei abdomineller Sepsis

<b><i>Hintergrund: </i></b>Zahlreiche präklinische Daten weisen auf Vorteile des laparoskopischen Operierens auch bei abdomineller Sepsisquelle und septischem Patienten hin. <b><i>Methode und Ergebnisse: </i></b>Anhand derzeit verfügbarer Literatur betrachten wir die Möglichkeiten und Limitierungen laparoskopischen Operierens beim septischen Patienten mit abdominellem Fokus. Neben generellen Überlegungen werden im Speziellen das Vorgehen bei Appendizitis, Cholezystitis, perforiertem Ulkus, Sigmadivertikulitis und akuter Pankreatitis erörtert. <b><i>Schlussfolgerungen: </i></b>Erfahrene laparoskopische Chirurgen können die Sanierung der abdominellen Sepsisquelle bei Appendizitis, Cholezystitis, perforiertem Ulkus oder auch Sigmadivertikulitis sicher durchführen. Kombinationen aus interventionellen Techniken und minimal invasiven Operationen bieten insbesondere bei der perforierten Sigmadivertikulitis und bei infizierten Pankreasnekrosen innovative Ansätze, die derzeit in multizentrischen prospektiven Studien untersucht werden.

Bedside diagnostic laparoscopy to diagnose intraabdominal pathology in the intensive care unit

Introduction

Delayed diagnosis of intraabdominal pathology in the intensive care unit (ICU) increases rates of morbidity and mortality. Intraabdominal pathologies are usually identified through presenting symptoms, clinical signs, and laboratory and radiological results; however, these could also delay diagnosis because of inconclusive laboratory tests or imaging results, or the inability to safely transfer a patient to the radiology room. In the current study we evaluated the safety and accuracy of bedside diagnostic laparoscopy to confirm the presence of intraabdominal pathology in an ICU setting.

Methods

This retrospective study, carried out between January 2006 and June 2008, evaluated the diagnostic accuracy of bedside diagnostic laparoscopy performed on patients with a suspicion of ongoing intraabdominal pathology. Clinical indications for bedside diagnostic laparoscopy were: ultrasonography (US) images of gallbladder distension or wall thickening of more than 3 to 4 mm, with or without pericholecystic fluid; elevation of laboratory tests (bilirubin, transaminases, myoglobin, lactate dehydrogenase, creatine phosphokinase, gamma-glutamyltransferase); high level of lactate/metabolic acidosis; CT images inconclusive for intraabdominal pathology; or inability to perform a CT scan. Patients did not undergo bedside diagnostic laparoscopy if they presented clear indications for open surgery, coagulopathy, abdominal wall infection or high intraabdominal pressure.

Results

Thirty-two patients underwent bedside diagnostic laparoscopy (Visiport Plus, Autosuture, US), 14 of whom had been admitted to the ICU for major trauma, 12 for sepsis of unknown origin and 6 for complications after cardiac surgery. The procedure was performed on an average of eight days after ICU admission (95% confidence interval = 5 to 15 days) and mean procedure duration was 40 minutes. None of the procedures resulted in complications. Bedside diagnostic laparoscopy was diagnostic for intraabdominal pathology in 15 patients, who subsequently underwent surgery, except in two cases of diffuse gut hypoperfusion. Diagnosis of cholecystitis was obtained in seven cases: two were treated with laparotomic cholecystectomy and five with percutaneous gallbladder drainage positioning.

Conclusions

Bedside diagnostic laparoscopy represents a safe and accurate technique for diagnosing intraabdominal pathology in an ICU setting and should be taken into consideration when patient transfer to radiology or the operating room is considered unsafe, or when routine radiological examinations are not conclusive enough to reach a definite diagnosis.