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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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12 Surgical Intensive Care
Complications of enteral access techniques and their treatment
Complication Description Management
Bumper is overgrown by hypertrophic
gastric mucosa and embedded into the
gastric wall
Is a consequence of enforced tightening of
the PEG tube, causing an ulcer in the
Buried bumper
syndrome
gastric mucosa
Endoscopically: bumper is no longer
visible
Present as a PEG tube that cannot be
mobilized, secretion along the tube, and
upper abdominal pain
Endoscopic approach to remove the bumper ➔ if
not ➔ operative removal
Research
Reference Findings
423
Petrov MS, van Santvoort HC, Besselink
MG, etal. Enteral nutrition and the risk of
mortality and infectious complications in
patients with severe acute pancreatitis: a
meta- analysis of randomized trials. Arch
Surg. 2008;143(11):1111–1117
A meta-analysis of ve randomized controlled trials of enteral
versus parental nutrition in patients with severe acute pancreatitis
showed a decreased incidence of pancreatic infections and
mortality with early (dened as within 3days) enteral nutrition
Parenteral nutrition
Indications Patients who have contraindications or intolerance to enteral nutrition
Timing • In a well-nourished patient: NPO status can be tolerated for 7days
• For patients with antecedent starvation or wasting or other risk factors of malnutrition ➔ initiate
parenteral nutrition before 1 week have elapsed
Components • Parenteral nutrition is customized via weight-based calculations and patient factors, or indirect
calorimetry
• Key components are amino acids, lipids, dextrose, trace elements, vitamins, and electrolytes
Prevention • Infectious risks are minimized by having a dedicated lumen for administration of parenteral
nutrition
424
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
A. H. Sohail et al.
Complications associated with parenteral nutrition
Complication Cause Management
Hyperosmolar hyperglycemia Excessive rate Decrease rate
Diabetic ketoacidosis Inadequate insulin Insulin administration
Rebound hypoglycemia Persistent insulin production Give 5% glucose before TPN
infusion is discontinued
Hypercarbia Decrease carbohydrate and increase
fat percentage
Prerenal azotemia Excessive amino acids with inadequate
calories
Refeeding syndrome Metabolic disturbances as a result of
reinstitution of nutrition in starved
patients
• Hypokalemia
• Hypophosphatemia
• Hypomagnesemia
Reduce amino acids/increase
glucose
• Replete thiamine, B12
• Electrolyte repletion (mg/K/Ph)
• Avoid giving insulin
• Cut back rate of nutrition
Abdomen andPelvis
Stress-related mucosal disease and stress ulcer
Denition Ulceration of the upper gastrointestinal (GI) tract (esophagus, stomach, duodenum) that
occurs due to hypoperfusion that occurs during hospitalization
Pathophysiology
Risk factors Two strong independent risk factors for stress ulcers have been identied:
Management Observation
Prophylaxis (PPI or
H2 blocker)
Hypoperfusion of the mucosa in the upper gastrointestinal tract ➔ predisposes to upper
gastrointestinal bleeding
• Mechanical ventilation for more than 48h
• Coagulopathy
Mechanical ventilation for >48h
Coagulopathy
Gastrointestinal ulceration or bleeding within the past year
Traumatic brain injury
Traumatic spinal cord injury
Severe burns >35% of the body surface area
12 Surgical Intensive Care
Abdominal compartment syndrome
Denitions Normal intra-abdominal pressure: 5mm Hg
Intra-abdominal hypertension (IAH): Intra-abdominal pressure (IAP)>12mm Hg
Abdominal compartment syndrome: Intra- abdominal pressure (IAP)>20mm
hg+new onset of multiple organ failure
Physiologic changes Increased IAP causes Physiologic change
CNS Increase intracranial pressure (ICP)
Decreased cerebral perfusion pressure
(CPP)
Thoracic Cephalad displacement of diaphragm
Increased intra-thoracic pressure
Elevated airway pressures and inability to
ventilate
425
Cardiovascular
Abdomen Compression of inferior vena cava
Renal Inadequate renal perfusion
Etiology Trauma, diffuse peritonitis, acute pancreatitis, ascites, intra-abdominal uid
accumulation, retroperitoneal hematoma, pregnancy, burns, large-volume resuscitation,
abdominal packing for control of hemorrhage, reperfusion injury following bowel
ischemia, ileus and bowel obstruction
Diagnosis The diagnosis of ACS should be considered when patients have a distended abdomen,
oliguria, increasing airway pressures, and elevated systemic vascular resistance(SVR)
Intra-vesicular pressure monitoring is the standard for measuring IAP (measured at
end-expiration) with paralysis
Grading Grading scale for IAH of world Society of Abdominal Compartment Syndrome
(WSACS):
Grade Pressure
Grade I 12–15mm Hg
Grade II 16–20mm Hg
Grade III 21–25mm Hg
Decrease venous return ➔ decrease cardiac
output and cardiac index
Intestinal ischemia
Oliguria
Hepatic dysfunction
Oliguria
Grade IV 25mm Hg
426
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Abdominal compartment syndrome
A. H. Sohail et al.
Condition Management
Signs and symptoms of increased IAP
or IAH without organ dysfunction
Management
Signs and symptoms of IAH+organ
dysfunction
Decompressive laparotomy can precipitate hypotension and cardiac dysfunction (due to
sudden decrease in SVR and byproducts of anaerobic metabolism ➔ risk of cardiac
arrhythmias and asystolic arrest ➔ correct acid-base and electrolyte imbalances and
proper uid resuscitation
Infectious Disease
Gram-positive
organisms
Gram-negative
organisms
Gastrointestinal
pathogens
Gram-positive cocci (Coagulase Positive Staphylococcus ➔Staphylococcus aureus) and
(Coagulase negative Staphylococcus ➔Staphylococcus epidermidis) are common pathogens in
skin and soft tissue infections as well as in catheter- associated bloodstream infections
Gram-positive cocci (Enterococcus) is common in the gastrointestinal tract
Gram-negative rods (Escherichia coli) and anaerobic bacteria (Bacteroides fragilis) are
common in intra-abdominal infections of colonic origin
Organisms found with highest frequency in the proximal small bowel are facultative aerobes
such as E. coli
• Sedation
• Chemical paralysis to improve abdominal
relaxation
• Fluid restriction/diuresis
Urgent decompressive laparotomy +
temporary abdominal closure
Colon ora consist primarily of anaerobic organisms, namely B. fragilis
Biliary tree is sterile but can become inltrated by E coli, enterococcus, and Klebsiella when
obstructed
Catheter-associated urinary tract infection (CAUTI)
Bacteriuria in the setting of a urinary catheter with clinical features indicative of a UTI or
Diagnostic
criteria
Microbiology Enterobacteriaceae (most commonly E. coli), Enterococcus species, Pseudomonas, Staphylococci
Diagnosis
systemic infection (not otherwise explained)
UTI in individuals with a urinary catheter removed within the last 48h is also classied as CAUTI
Midstream specimens are most accurate
If suspected, catheter must be removed; urine sample from the newly placed catheter should be
obtained, if catheterization is required
CAUTI diagnosis should be supported with urine culture with 100,000CFU/mL of pathogens
Fungal growth usually indicates colonization
12 Surgical Intensive Care
Catheter-associated urinary tract infection (CAUTI)
Duration of antibiotics: 7 days; if response is delayed or patient has bacteremia, can extend to
10–14days
Treatment
Prevention
Treatment with antifungals should be reserved only for immunocompromised patients and
patients with two sites of positive fungal cultures
The most important risk factor is the duration of catheterization: remove as soon as possible
If long-term catheterization is required, intermittent catheterization is preferable (associated with
lower UTI rates)
Antibiotic-impregnated catheters may be associated with a lower incidence of UTIs vs antisepticcoated catheters
Central line–associated bloodstream Infection (CLABSI)
427
Microbiology and
risk factors
Diagnosis
Management
Staphylococcus aureus, Enterococcus, Candida species (if total parenteral nutrition and
intensive care unit, Pseudomonas)
Patients with chemotherapy ports, tunneled dialysis catheters or arteriovenous grafts,
implantable cardiac devices, mechanical valves, or other devices have a high risk of infection
The most common cause of candidemia is the presence of intravascular devices
Presence of bloodstream infection and demonstration that the infection is related to the
catheter
Must be suspected in patients with central venous catheter and fever, leukocytosis, and
evidence of sepsis with organ dysfunction
Preferable to obtain peripheral blood cultures rather than from suspected catheter only
Catheter removal and the administration of systemic antibiotics
Empiric therapy for gram-positive organisms includes vancomycin
Antimicrobial for gram-negative bacteria must cover pseudomonas if the patient has risk
factors for pseudomonas infection (neutropenia, severe burns, etc.)
Administer antibiotics for 2–3days before replacing the catheter
If catheter removal is not feasible ➔ catheter salvage with systemic antibiotics and antibiotic
lock therapy can be attempted
Internal jugular and subclavian catheters preferred over femoral due to lower risk of infection
Prevention
Routine replacement of catheters at new sites does not lower infection rates and is associated
with a higher risk of mechanical complications
When replacing catheter, avoid exchange over guidewire
Antimicrobial-impregnated catheters may lower CLABSI rates
Antibiotic lock solution lowers infection rates and can be considered in patients with
long-term catheters
428
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Ventilator-associated pneumonia (VAP)
Hospital-acquired pneumonia that develops >48h after initiation of mechanical ventilation
Diagnostic
criteria
Identication of a new or worsening inltrate on imaging and positive cultures are prerequisites
for diagnosis of VAP
May manifest as change in the quality or quantity of respiratory secretions, fevers, leukocytosis
A. H. Sohail et al.
Presentation
Microbiology
Prevention
Diagnosis
Management
Changes in lung mechanics (reduced tidal volume, increased inspiratory pressures, higher FIO2 or
PEEP requirement)
New inltrates on imaging
Gram-positive cocci and/or gram-negative bacilli (especially Staphylococcus aureus and
Pseudomonas aeruginosa)
Methicillin-resistant S aureus (MRSA) in patients with prolonged hospitalization and/or prior
antibiotic exposure
A positive culture without radiologic ndings of an inltrate maybe indicative of tracheobronchitis
VAP bundles in the ICU (elevation of the head of the bed, sedation vacation with daily weaning
assessment, chlorhexidine mouth care, subglottic drainage)
Bronchoscopic bronchoalveolar lavage (BAL) is performed by a exible bronchoscope, infusion
and aspiration of saline at the bronchial segmental/subsegment in question
Thresholds for positive culture: BAL, 10,000cfu/mL
Risk factors for multi-drug resistance (MDR: IV antibiotics within 90days, septic shock, ARDS
before VAP, need for RRT before VAP, VAP after 5days of hospitalization)
Percentage of gram-negative pathogens (≤ 10% vs. >10%)
Staph. aureus (≤20% vs. >20%) causing VAP in the unit that are resistant to the antibiotic
≤10% gram-negative resistance and ≤20% MRSA rate ➔ use a single agent for Pseudomonas,
and one methicillin-susceptible Staph. Aureus (MSSA) antibacterial
>10% gram-negative resistance ➔ use two antibiotics against gram-negative bacilli
>20% MRSA: use an antibiotic with activity against MRSA
If any risk factors for MDR VAP ➔ two antibiotics against gram-negative bacilli + one for MRSA
Clostridium difcile infection (CDI)
C difcile is a spore-forming bacterial organism that can remain dormant on various fomites
Intestinal infection can occur when the normal colonic ora is altered by antibiotic use
Risk factors
Most commonly caused by uoroquinolones, cephalosporins, penicillins, and clindamycin
Age and recent hospitalization are other risk factors
12 Surgical Intensive Care
Clostridium difcile infection (CDI)
Fever, abdominal distention, with or without tenderness, and copious diarrhea may occur
Ileus and constipation may be presenting ndings of CDI
429
Presentation
Prevention Minimizing antibiotic use
Diagnosis
Management
The patient’s condition can progress to septic shock and organ failure that will require
emergent colectomy
Recurrent C. diff infection is dened as recurrence of symptoms within 2–8weeks of
resolution after antibiotic use
Avoiding gastric acid suppression
Positive nucleic acid amplication test (NAAT) for C. difcile toxin gene, or a positive stool
test for C. difcile toxins A and B
Only symptomatic patients must be tested; asymptomatic carriers do not require treatment
Perirectal swab for toxin or anaerobic culture to conrm diagnosis in individuals with ileus
has high sensitivity
Discontinuation of the inciting antibiotic agents as soon as possible
Diagnosis Initial episode First recurrence
Nonsevere CDI WBC<15,000 cells/
mL
And
Serum creatinine <1.5
Severe CDI WBC >15,000 cells/
mL
And/or
Serum creatinine ≥1.5
Oral vancomycin
Or
Oral Fidaxomicin
(for 10days)
Oral vancomycin
(125mg four times
daily)
Or
Fidaxomicin
(200mg twice daily)
Oral vancomycin
Oral vancomycin
Fulminant colitis Hypotension, shock,
ileus, or megacolon
Early operative
management with
subtotal colectomy and
end ileostomy
+
Enteric vancomycin
plus parenteral
metronidazole:
If ileus is present ➔
Rectal vancomycin
Enteric vancomycin
plus parenteral
metronidazole
If ileus is present
Rectal vancomycin
430
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Surgical site infection (SSI)
• SSIs are dened as infection related to a surgical procedure occurring near the surgical site
within 30days of the procedure or 90days of the procedure when an implant is involved
Denition
• SSIs are the most common reason for unplanned post-surgical readmission
• The incidence of SSIs is highest after abdominal, especially colon, surgery
A. H. Sohail et al.
Risk factors
Classication
Microbiology
Treatment
• Age, diabetes, obesity, nutritional status, tissue handling, pre- operative prophylactic antibiotic
use
• SSIs are classied into
– Supercial (skin, up to subcutaneous fat)
– Deep (involving muscle / fascia), organ / space SSIs
• Necrotizing SSI (usually caused by group A Streptococcus or Clostridia) can present within 24h
after procedure
• Most supercial SSIs are caused by skin ora ➔ most common supercial SSI pathogens are
gram-positive cocci—Staphylococcus epidermidis, S. aureus, and Enterococcus
• For infrainguinal incisions and intracavitary surgery ➔ gram- negative bacilli, such as E. coli and
Klebsiella spp. are potential pathogens
• In a surgical site without foreign material, antibiotics should be discontinued with resolution of
cellulitis and laboratory/clinical ndings suggesting infection
• With deep infection ➔ debridement may be required
• If there is concern for necrotizing infection, management includes operative intervention to
conrm; imaging is not the rst step
• A 4-day antibiotic course after source control is recommended for organ/space SSIs, while a
24–48-hour course is recommended for cellulitis
• Importantly, when fascial debridement is performed for deep SSI, biologic or absorbable
synthetic mesh maybe required to close fascia
Vancomycin-resistant enterococci (VRE)
Risk factors • Prior antibiotic therapy, particularly Vancomycin and Cephalosporins
• Patient characteristics, including include hospitalization >72h, signicant underlying
medical conditions, ICU stay, and invasive devices
• Colonization pressure due to hospitalization in a facility with a specic strain
• Exposure to contaminated surfaces
• Residence in long-term care facilities
Prevention • Hand hygiene (either with soap / water or alcohol-based hand rub)
• Contact precautions
• Cohorting patients with VRE
• Surveillance cultures
12 Surgical Intensive Care
Research
Reference Findings
431
Solomkin JS, Mazuski JE, Bradley JS, etal.
Diagnosis and management of complicated
intra-abdominal infection in adults and children:
guidelines by the Surgical Infection Society and the
Infectious Diseases Society of America. Clin Infect
Dis. 2010;50(2):133–164
Sawyer RG, Al. E, Investigators* for the STOPITT, etal. Trial of Short-Course Antimicrobial
Therapy for Intraabdominal Infection:
NEJM.New England Journal of Medicine. https://
www.nejm.org/doi/full/10.1056/nejmoa1411162.
Published May 21, 2015. Accessed February 8, 2021
A paper from the surgical infection society reveals that the
most common pathogens in intra-abdominal infections are
Escherichia coli, Bacteroides, enterococcus and
Streptococcus. Given the need to cover gram-positive and
gram-negative bacteria and anaerobes, the only choice that
provides that coverage is ertapenem (for non-VRE
infections)
The STOP-IT trial guidelines, antibiotics should continue
for 4days from when source control for abdominal
infection is achieved, such as the appropriate placement of
a drain
Opportunistic infections
Infection Characteristics Management
Cytomegalovirus (CMV) Asymptomatic viremia, viral
syndrome, or invasive disease
(transplant organ-specic, esophagitis,
colitis, retinitis, or encephalitis)
Evaluation is by CMV polymerase
chain reaction, with biopsy if needed
Herpes simplex virus Causes vesicular rash on oral or
genital mucosa
Eye, CNS (aseptic meningitis, sacral
radiculopathy, and transverse
myelitis), viscera can be involved
Common in HIV and transplant
recipients
Ganciclovir or Valganciclovir
Acyclovir
Polyomavirus (BK virus) Renal dysfunction, ureteral
obstruction, or asymptomatic
condition that affects renal transplant
recipients almost exclusively and
causes viremia
Epstein-Barr virus (EBV) Asymptomatic, febrile mononucleosis;
gastrointestinal symptoms, or
lymphadenopathy most frequently
More common in children
Associated with post-transplant
lymphoproliferative disorder (PTLD)
Aspergillus Fever, cough, and possibly hemoptysis
in pulmonary infection
Sinus involvement with central
nervous system extension can cause
brain abscess
Most common after lung transplant
High mortality
Reduction in immunosuppression and/
or removal of foreign bodies
Reduction in immunosuppression
Itraconazole or voriconazole
432
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Opportunistic infections
Infection Characteristics Management
A. H. Sohail et al.
Cryptococcus Seen in AIDS, chronic glucocorticoid
use, organ transplantation, malignancy
Found in soil in regions with pigeons
and chickens; role of birds in
transmission is unclear
Fluconazole or amphotericin B
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