Anesthetic management of patients with sepsis/septic shock

Intraoperative Low-Dose Glucocorticoids in Surgical Patients With Abdominal Sepsis: A Multicenter Retrospective Cohort Study

Background and Aims

Abdominal sepsis refers to a severe and potentially life-threatening condition characterized by the presence of infection, inflammation, and tissue damage within the abdominal cavity. Glucocorticoids (GCs) play an important role in regulation of the host immune and inflammation responses involved in sepsis and surgery. This study aimed to investigate the potential impact of intraoperative GCs administration on the clinical outcome of surgical patients with abdominal sepsis.

Methods

This retrospective cohort study included a 1:1 propensity score-matched cohort of surgical patients afflicted with abdominal sepsis at two medical centers from January 2008 to December 2022. Patients were classified into low-GCs, high-GCs, and non-GCs groups according to the dosage of steroids used intraoperatively, and in-hospital mortality was designated as the primary outcome.

Results

This study included a total of 476 patients, with 217 in the non-GCs group, 213 in the low-GCs group, and 46 in the high-GCs group. The overall in-hospital mortality rate was 7.56%. After propensity score matching (PSM), there were 168 cases in both the low-GCs group and the non-GCs group, with no significant differences observed between the groups regarding mortality rate, length of hospital-stay, and duration of intensive care unit (ICU) stay. In patients with septic shock, the use of low-dose GCs increased the urine output and decreased the requirements for vasopressors on the first postoperative day, however, it had no impact on the in-hospital mortality or ICU stay. Moreover, prophylactic use of GCs during anesthesia induction did not decrease the incidence of intraoperative hypotension or necessity of vasopressors use.

Conclusion

Intraoperative administration of low-dose GCs demonstrates a transient improvement in hemodynamics of patients with septic shock, however, it did not lead to improved clinical outcomes. Further research remains necessary to elucidate the optimal perioperative dosing strategy.

Anesthesia Management Using Remimazolam for Lower Limb Amputation in a Patient With Septic Shock Due to Necrotizing Fasciitis

We report a case of a patient with necrotizing fasciitis and septic shock caused by streptococcal toxic shock syndrome, who was anesthetized and managed with remimazolam. The patient, a woman in her 40s, was admitted to the ICU with a diagnosis of necrotizing fasciitis of the right lower extremity and septic shock and was scheduled for above-the-knee amputation under general anesthesia. She was anesthetized with remimazolam for sedation and fentanyl and remifentanil for analgesia. Intraoperatively, we were able to maintain hemodynamic stability with similar or only slightly higher doses of circulatory agonists during admission. In the present case, remimazolam, an ultrashort-acting benzodiazepine, was safely used to provide anesthesia to a patient in septic shock due to necrotizing fasciitis, who was receiving high doses of vasopressor agents for cardiovascular support, as it was necessary to select an anesthetic drug that would cause minimal circulatory depression.

Boerhaave's Syndrome Presenting in the Setting of Third-Degree Heart Block

Introduction

Boerhaave's syndrome, or the spontaneous transmural perforation of the esophagus, is typically thought to be due to an increase in esophageal pressure such as that which occurs during vomiting or retching. Another common etiology of esophageal perforation is esophageal instrumentation, such as during esophagogastroduodenoscopy or transesophageal echocardiography. This life-threatening condition requires prompt diagnosis and treatment to prevent patient demise. While a history of vomiting can aid in diagnosis, this history can be difficult to elicit in an unconscious patient or may be altogether absent. Additionally, Boerhaave's syndrome can present similarly to more common upper gastrointestinal or cardiac conditions. Since mortality increases with delays in diagnosis and treatment, it is imperative that clinicians maintain a high level of suspicion for Boerhaave's syndrome and initiate treatment urgently.

Case Description

This report presents a 76-year-old man who presented to the emergency department after a history of several syncopal episodes and was found to be in complete heart block. Two days later, he acutely developed abdominal distention and coffee ground emesis. As the medical team was able to gather more history from the patient and his family, it was revealed that he had associated vomiting with his episodes of syncope. CT scan of the abdomen and pelvis demonstrated pneumomediastinum concerning for esophageal perforation. His clinical status subsequently deteriorated. He was intubated and a temporary transvenous pacer was placed before being transferred to our facility for emergent surgery.

Discussion

Complete heart block in the setting of Boerhaave's syndrome is exceptionally rare, with only 2 cases reported in the literature. The decision to place a pacemaker in the setting of esophageal perforation/sepsis is complicated and depends on the patient's bacteremia status related to noncardiac comorbidities. Clearly this case represents the need for excellent multidisciplinary decision-making processes with excellent communication between hospital staff and all caretakers. Expeditious diagnosis and treatment of esophageal perforation is essential to prevent leaking of gastric contents into the mediastinum and worsening of cardiac complications and sepsis. Additionally, critical timing of various surgical procedures, especially the need for a permanent pacemaker implant with bacteremia is a complicated process not well described in the surgical literature.