Scoring Systems

Report
Peritonitis Priorities
Paul Finan
Department of Colorectal Surgery
Leeds General Infirmary
Peritonitis
Classification
• Primary - often spontaneous and single
organism
• Secondary - multiple organisms,
perforations, leaks, ischaemia etc
• Tertiary - no organisms, disturbance in
host immune response
Priorities in Peritonitis
Early Recognition
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Often classical clinical picture but….
Beware of immuno-suppressed patients
Elderly patients
Post-operative patients with cardiac
problems
• Unexplained failure to progress clinically
Peritonitis Priorities
Radiological Support
• Plain films e.g. free gas or unexplained
ileus
• Abdominal ultrasound – simple collections
• CT scanning – of particular value in the
post-operative patient
• Labelled white cell scans
• MR imaging – no experience
Peritonitis on CT Scanning
Peritonitis Priorities
Radiologist
Wound Care Specialists
Anaesthetist
Nutritional Team
Nursing Staff
Microbiologist
Surgical Staff
Scoring Systems
Scoring Systems
An effort to quantify case mix and so
estimate outcome
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APACHE – initially 34 variables
APACHE II – reduced to 12 variables
Sepsis Score (SS)
Sepsis Severity Score (SSS)
Relationship Between APACHE-II
and Mortality
Prognostic Scoring Systems in
Peritonitis
Comparison of APACHE II, APS, SSS, MOF and MPI, in
50 patients with peritonitis
• All scoring systems predicted outcome in univariate
analysis
• APACHE II and MPI contributed independently in a
multivariate analysis
• All patients with an APACHE II of >20 or
MPI >27
died in hospital
Bosscha et al 1997
Peritonitis Priorities
Source
SourceControl
Control
Damage Limitation
Source Control
• Drainage of abscesses
• Debridement of devitalised tissue
• Diversion, repair or excision of focus of
infection from a hollow viscus
Source Control
Drainage of abscesses
Surgical or non-surgical drainage
governed by..
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Clinical state of patient
Site of collection
Extent of collection
Underlying aetiology
Diverticular Abscess
Drainage of Diverticular Abscess
Drainage of Diverticular Abscess
Non-surgical Drainage of Intra-abdominal
Abscesses
A study of PCD in 96 patients with 137
abscesses accumulated over a 3-year period
• Successful resolution in 70% after a single
procedure and 82% with a second drainage
• More often successful in post-operative
abscesses.
• Poorer results with pancreatic abscesses and
those containing yeasts
Cinat et al 2002
Non-surgical drainage of Intra-abdominal
Abscesses
A study of 75 patients undergoing PCD of intraabdominal abscess
• Successful treatment in 62/75 patients (83%)
• Success associated with unilocular collections,
<200 mls., APACHE score <30 and accessible
regions
Betsch et al 2002
Pancreatic Collection
Pancreatic Drainage
Source Control
Debridement of Devascularised Tissue
• Most commonly encountered in necrotic
pancreatitis
• Removal of dead bowel
• Debridement of other necrotic intraabdominal tissue
Source Control
Management of the Source of Contamination
• Excision – appendicitis, cholecystitis
• Repair – perforated ulcer, early iatrogenic injury
• Diversion +/- excision – leaking anastamosis
NB These are the decisions that require experience
Damage Limitation
• Procedures at the time of surgery
• Decisions in the post-operative period
Peritoneal Lavage
Damage Limitation
Decisions at the time of Surgery
• Management of the infective source
• Peritoneal toilet and removal of particulate
matter
• Peritoneal lavage
• Drains
• Wound closure
VAC Dressing
Damage Limitation
Post-operative Decisions
• Re-laparotomy
• Laparostomy
• Interval imaging
• Duration of antibiotic therapy
Re-laparotomy in Peritonitis
• Failure to progress clinically
• Prompted by radiological imaging
• Where viability is in doubt
• Failure to control source of infection
Relaparotomy for Secondary
Peritonitis
Meta-analysis comparing planned
relaparotomy and laparotomy on demand
• No randomised studies
• Non-significant reduction in mortality with
the latter approach
• Evidence based on eight heterogeneous
studies
Lamme et al 2002
Laparostomy
Abdominal wall cannot or should not be
closed
• Major loss of the abdominal wall
• Visceral or retroperitoneal oedema
• If decision has already been taken to
perform a re-laparotomy
• Likelihood of creating abdominal
compartment syndrome
Peritonitis Priorities
Radiologist
Wound Care Specialists
Anaesthetist
Nutritional Team
Nursing Staff
Microbiologist
Surgical Staff
Antibiotics in Peritonitis
• Consideration to source of infection and
likely bacteria
• Fewer drugs for shorter periods of time
• A policy of reculture and change if
necessary
• No clear benefit of a particular regimen in
the Cochrane review (Wong et al 2005)
Peritonitis Priorities
Conclusions
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Multi-disciplinary approach
Increasing role of the radiologist
Emphasis on source control
Need for correct decision at time of
laparotomy
• Lack of trial evidence

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