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July 18, 2016

ICM ARTICLE REVIEW

ICM ARTICLE REVIEW

Peritonitis characterises 5.8-10% of admissions in Intensive Care Unit and represents a leading cause of morbidity and mortality. Community-acquired and healthcare-associated peritonitis require a multidisciplinary approach sustained by several specialties collaboration. 

In the current issue of Intensive Care Medicine, a panel of experts in the field develop clear and practical recommendations for the optimal therapeutic management of patients with peritonitis. All the recommendations were based on the results of clinical and epidemiological studies in addition to expert opinions when data from current literature were not available.

INITIAL PHASE 

  • Severity assessment of clinical condition based on illness and individual factors.
  • Sepsis containment with adequate and early empirical antibiotic therapy based on suspicion of community-/healthcare- acquired peritonitis, Multi Drug Resistant species sustaining infection.
  • Supportive care including sedation and pain management, mechanical ventilation, haemodynamic optimisation and fluid management monitor-guided, renal function improvement, nutrition support (1.2 and 3.0 g/kg/day), anticoagulation for deep vein thrombosis prophylaxis.

SOURCE CONTROL

  • Source control with early and adequate surgical management of clusters of infection. Reoperations are required to remove persistent clusters of infections.
  • Microbiological diagnosis by samples collected from peritoneal fluids. Culture results cannot discriminate contaminating bacteria from true pathogens.
  • Antibiotic therapy: Dosage adjustment needs to be based on pharmacokinetic parameters reported in patients with severe sepsis as few data are available on peritoneal diffusion of antibiotics. Antibacterial therapy should be administered until clinical and laboratory signs of infection have resolved. The use of procalcitonin to determine the duration of antibiotic therapy has not been assessed in peritonitis and remains debated.

POSTOPERATIVE COMPLICATION

  • Decompensation and worsening of pre-existing organ dysfunction.
  • Surgical site infection could be a sign of an occult intra-abdominal disease requiring reoperation.
  • Tertiary peritonitis is persistent intra-abdominal infection without a surgically treatable focus, following previous surgery and source control.
  • Healthcare-associated infections: pneumonia (up to 30%), urinary tract infections (2–8 %).
  • Intra-Abdominal Hypertension (IAH) due to increased intra-abdominal volume and decreased abdominal wall compliance. Intra-Abdominal Pressure monitoring is advised in most severe patients. When IAH develops, fluid administration should be considered carefully; adequate analgesia and removal of constrictive bandages can help to increase abdominal wall compliance.

SPECIAL ISSUES

  • Obese patients: surgical complications most commonly requiring ICU admission after bariatric surgery include fistulas and anastomosis leaks. The appropriate doses of anti-infective agents remain controversial caused by septic and obesity-related alteration on Volume of distribution and Antibiotic clearance.
  • Candida in peritonitis: Early empirical treatment should be based on risk-assessment strategies, such as colonisation index, Candida scores, previous use of broad-spectrum antibiotics and previous abdominal surgery. 1,3-β-d glucan  and Candida albicans germ tube antibody can be detected early in patients with peritonitis. Antifungal therapy (echinocandines) should be started early in severe clinical condition.

CONCLUSION
General recommendations should be usually adapted to single cases in daily clinical practice. However the consensus from this expert panel may represent an extremely useful tool for ICU physicians in the management of critically ill patients affected  by peritonitis.

Article review submitted by Gennaro De Pascale and Salvatore Lucio Cutuli on behalf of the ESICM Journal Review Club.


Reference

Montravers P et al. Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Medicine. My Paper 20 Years Later; Volume 42, Issue 8 / August, 2016; Pages 1234 – 1247

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