Gastrointestinal perforation medical therapy: Difference between revisions
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==== '''Antibiotics''' ==== | ==== '''Antibiotics''' ==== | ||
[[Broad-spectrum antibiotic]] therapy is initiated if the level of perforation is unknown. The following tabel shows the regimens of choice in these cases: | [[Broad-spectrum antibiotic]] therapy is initiated if the level of perforation is unknown. The following tabel shows the regimens of choice in these cases:<ref name="pmid10893372">{{cite journal| author=Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH| title=The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. | journal=Chest | year= 2000 | volume= 118 | issue= 1 | pages= 146-55 | pmid=10893372 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10893372 }}</ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
|'''Regimen''' | |'''Regimen''' | ||
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==== Intravenous fluid therapy ==== | ==== Intravenous fluid therapy ==== | ||
* Tissue perfusion is achieved by the aggressive administration of intravenous fluids, given at '''30 mL/kg''' within the first '''three '''hours following presentation.[ | * Tissue perfusion is achieved by the aggressive administration of intravenous fluids, given at '''30 mL/kg''' within the first '''three '''hours following presentation.<ref name="pmid24635773">{{cite journal| author=ProCESS Investigators. Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA et al.| title=A randomized trial of protocol-based care for early septic shock. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 18 | pages= 1683-93 | pmid=24635773 | doi=10.1056/NEJMoa1401602 | pmc=4101700 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24635773 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24935515 Review in: Ann Intern Med. 2014 Jun 17;160(12):JC9]</ref> | ||
* Using the following targets to measure the response: | * Using the following targets to measure the response:<ref name="pmid25272316">{{cite journal| author=ARISE Investigators. ANZICS Clinical Trials Group. Peake SL, Delaney A, Bailey M, Bellomo R et al.| title=Goal-directed resuscitation for patients with early septic shock. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 16 | pages= 1496-506 | pmid=25272316 | doi=10.1056/NEJMoa1404380 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25272316 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25775347 Review in: Ann Intern Med. 2015 Mar 17;162(6):JC4]</ref><ref name="pmid25776532">{{cite journal| author=Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD et al.| title=Trial of early, goal-directed resuscitation for septic shock. | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 14 | pages= 1301-11 | pmid=25776532 | doi=10.1056/NEJMoa1500896 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25776532 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26280432 Review in: Ann Intern Med. 2015 Aug 18;163(4):JC10]</ref> | ||
* Central venous oxyhemoglobin saturation (ScvO<sub>2</sub>) ≥70 percent | * Central venous oxyhemoglobin saturation (ScvO<sub>2</sub>) ≥70 percent | ||
* [[Central venous pressure]] (CVP) 8 to 12 mmHg | * [[Central venous pressure]] (CVP) 8 to 12 mmHg | ||
* [[Mean arterial pressure]] (MAP) ≥65 mmHg. A [[central venous catheter]] and an [[arterial catheter]] are placed, although they are not always necessary. | * [[Mean arterial pressure]] (MAP) ≥65 mmHg. A [[central venous catheter]] and an [[arterial catheter]] are placed, although they are not always necessary. | ||
* [[Urine output]] ≥0.5 mL/kg/hour | * [[Urine output]] ≥0.5 mL/kg/hour | ||
* The clinical and hemodynamic response and the presence or absence of [[pulmonary edema]] must be assessed before and after each bolus. | * The clinical and hemodynamic response and the presence or absence of [[pulmonary edema]] must be assessed before and after each bolus. | ||
* Crystalloid solutions ([[Saline (medicine)|saline]], [[Lactated Ringer's solution|Ringer's lactate]]) is the fluid of choice in treatment of [[sepsis]] or [[septic shock]]. | * Crystalloid solutions ([[Saline (medicine)|saline]], [[Lactated Ringer's solution|Ringer's lactate]]) is the fluid of choice in treatment of [[sepsis]] or [[septic shock]]. | ||
* [[Pentastarch]] or [[hydroxyethyl starch]] have been identified harmful. Use of [[HES]] resulted in increased mortality. [ | * [[Pentastarch]] or [[hydroxyethyl starch]] have been identified harmful. Use of [[HES]] resulted in increased mortality.<ref name="pmid24635772">{{cite journal| author=Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M et al.| title=Albumin replacement in patients with severe sepsis or septic shock. | journal=N Engl J Med | year= 2014 | volume= 370 | issue= 15 | pages= 1412-21 | pmid=24635772 | doi=10.1056/NEJMoa1305727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24635772 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25023272 Review in: Ann Intern Med. 2014 Jul 15;161(2):JC6]</ref> | ||
* There is no role for [[Hypertonic|hypertonic saline]]. | * There is no role for [[Hypertonic|hypertonic saline]].<ref name="pmid28219612">{{cite journal| author=Asfar P, Schortgen F, Boisramé-Helms J, Charpentier J, Guérot E, Megarbane B et al.| title=Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial. | journal=Lancet Respir Med | year= 2017 | volume= 5 | issue= 3 | pages= 180-190 | pmid=28219612 | doi=10.1016/S2213-2600(17)30046-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28219612 }}</ref> | ||
* An [[arterial catheter]] may be inserted if blood pressure is labile, [[sphygmomanometer]] readings are unreliable, restoration of perfusion is expected to be protracted, or dynamic measures of fluid responsiveness are selected to follow the hemodynamic response. | * An [[arterial catheter]] may be inserted if blood pressure is labile, [[sphygmomanometer]] readings are unreliable, restoration of perfusion is expected to be protracted, or dynamic measures of fluid responsiveness are selected to follow the hemodynamic response. | ||
==== Dynamic measures for circulation ==== | ==== Dynamic measures for circulation ==== | ||
* There is an evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures. These measures include: | * There is an evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures. These measures include:<ref name="pmid28101605">{{cite journal| author=Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R et al.| title=Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. | journal=Intensive Care Med | year= 2017 | volume= 43 | issue= 3 | pages= 304-377 | pmid=28101605 | doi=10.1007/s00134-017-4683-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28101605 }}</ref> | ||
* Respiratory changes in the [[Vena cavae|vena cava]] | * Respiratory changes in the [[Vena cavae|vena cava]] | ||
* [[Radial artery]] pulse pressure | * [[Radial artery]] pulse pressure | ||
| Line 77: | Line 77: | ||
* Left ventricular outflow tract velocity-time integral | * Left ventricular outflow tract velocity-time integral | ||
* Brachial artery blood flow velocity are considered dynamic measures of fluid responsiveness | * Brachial artery blood flow velocity are considered dynamic measures of fluid responsiveness | ||
* Serum [[Lactic acid|lactate]] in patients with sepsis should be assessed until the lactate value has clearly fallen. | * Serum [[Lactic acid|lactate]] in patients with sepsis should be assessed until the lactate value has clearly fallen. | ||
==== '''Vasopressors''' ==== | ==== '''Vasopressors''' ==== | ||
* Intravenous [[vasopressors]] are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic [[pulmonary edema]]. | * Intravenous [[vasopressors]] are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic [[pulmonary edema]].<ref name="pmid20200382">{{cite journal| author=De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C et al.| title=Comparison of dopamine and norepinephrine in the treatment of shock. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 9 | pages= 779-89 | pmid=20200382 | doi=10.1056/NEJMoa0907118 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20200382 }}</ref> | ||
* [[Norepinephrine]] is the first-line single agent in septic shock. | * [[Norepinephrine]] is the first-line single agent in septic shock.<ref name="pmid7933396">{{cite journal| author=Marik PE, Mohedin M| title=The contrasting effects of dopamine and norepinephrine on systemic and splanchnic oxygen utilization in hyperdynamic sepsis. | journal=JAMA | year= 1994 | volume= 272 | issue= 17 | pages= 1354-7 | pmid=7933396 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7933396 }}</ref> | ||
* The addition of a second or third agent to [[norepinephrine]] may be required ([[epinephrine]], [[dobutamine]], or [[vasopressin]]). | * The addition of a second or third agent to [[norepinephrine]] may be required ([[epinephrine]], [[dobutamine]], or [[vasopressin]]). | ||
* [[Central venous catheter|Central venous]] and [[Arterial catheter|arterial access]] especially when [[vasopressor]] administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter. | * [[Central venous catheter|Central venous]] and [[Arterial catheter|arterial access]] especially when [[vasopressor]] administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter. | ||
== References == | == References == | ||
Revision as of 18:07, 22 January 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
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Gastrointestinal perforation Microchapters |
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Differentiating gastrointestinal perforation from other diseases |
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Overview
- Initial management of the patient with gastrointestinal perforation includes:
- Intravenous fluid therapy and broad-spectrum antibiotics. Patients with intestinal perforation can have severe volume depletion.
- The administration of intravenous proton pump inhibitors
- Electrolyte abnormalities correction especially metabolic alkalosis if fistula developed. The severity of any electrolyte abnormalities depends upon the nature and volume of material leaking from the gastrointestinal tract.
Antibiotics
Broad-spectrum antibiotic therapy is initiated if the level of perforation is unknown. The following tabel shows the regimens of choice in these cases:[1]
| Regimen | Dose |
| First choice regimens | |
| Ampicillin-sulbactam | 3 g IV every six hours |
| Piperacillin-tazobactam | 3.375 or 4.5 g IV every six hours |
| Ticarcillin-clavulanate | 3.1 g IV every four hours |
| Ceftriaxone | 1 g IV every 24 hours |
| Metronidazole | 500 mg IV every eight hours |
| Alternative regimens | |
| Ciprofloxacin | 400 mg IV every 12 hours |
| Levofloxacin | 500 or 750 mg IV once daily |
| Metronidazole | 500 mg IV every eight hours |
| Imipenem-cilastatin | 500 mg IV every six hours |
| Meropenem | 1 g IV every eight hours |
| Doripenem | 500 mg IV every eight hours |
| Ertapenem | 1 g IV once daily |
Intravenous fluid therapy
- Tissue perfusion is achieved by the aggressive administration of intravenous fluids, given at 30 mL/kg within the first three hours following presentation.[2]
- Using the following targets to measure the response:[3][4]
- Central venous oxyhemoglobin saturation (ScvO2) ≥70 percent
- Central venous pressure (CVP) 8 to 12 mmHg
- Mean arterial pressure (MAP) ≥65 mmHg. A central venous catheter and an arterial catheter are placed, although they are not always necessary.
- Urine output ≥0.5 mL/kg/hour
- The clinical and hemodynamic response and the presence or absence of pulmonary edema must be assessed before and after each bolus.
- Crystalloid solutions (saline, Ringer's lactate) is the fluid of choice in treatment of sepsis or septic shock.
- Pentastarch or hydroxyethyl starch have been identified harmful. Use of HES resulted in increased mortality.[5]
- There is no role for hypertonic saline.[6]
- An arterial catheter may be inserted if blood pressure is labile, sphygmomanometer readings are unreliable, restoration of perfusion is expected to be protracted, or dynamic measures of fluid responsiveness are selected to follow the hemodynamic response.
Dynamic measures for circulation
- There is an evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures. These measures include:[7]
- Respiratory changes in the vena cava
- Radial artery pulse pressure
- Aortic blood flow peak velocity
- Left ventricular outflow tract velocity-time integral
- Brachial artery blood flow velocity are considered dynamic measures of fluid responsiveness
- Serum lactate in patients with sepsis should be assessed until the lactate value has clearly fallen.
Vasopressors
- Intravenous vasopressors are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic pulmonary edema.[8]
- Norepinephrine is the first-line single agent in septic shock.[9]
- The addition of a second or third agent to norepinephrine may be required (epinephrine, dobutamine, or vasopressin).
- Central venous and arterial access especially when vasopressor administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter.
References
- ↑ Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH (2000). "The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting". Chest. 118 (1): 146–55. PMID 10893372.
- ↑ ProCESS Investigators. Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA; et al. (2014). "A randomized trial of protocol-based care for early septic shock". N Engl J Med. 370 (18): 1683–93. doi:10.1056/NEJMoa1401602. PMC 4101700. PMID 24635773. Review in: Ann Intern Med. 2014 Jun 17;160(12):JC9
- ↑ ARISE Investigators. ANZICS Clinical Trials Group. Peake SL, Delaney A, Bailey M, Bellomo R; et al. (2014). "Goal-directed resuscitation for patients with early septic shock". N Engl J Med. 371 (16): 1496–506. doi:10.1056/NEJMoa1404380. PMID 25272316. Review in: Ann Intern Med. 2015 Mar 17;162(6):JC4
- ↑ Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD; et al. (2015). "Trial of early, goal-directed resuscitation for septic shock". N Engl J Med. 372 (14): 1301–11. doi:10.1056/NEJMoa1500896. PMID 25776532. Review in: Ann Intern Med. 2015 Aug 18;163(4):JC10
- ↑ Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M; et al. (2014). "Albumin replacement in patients with severe sepsis or septic shock". N Engl J Med. 370 (15): 1412–21. doi:10.1056/NEJMoa1305727. PMID 24635772. Review in: Ann Intern Med. 2014 Jul 15;161(2):JC6
- ↑ Asfar P, Schortgen F, Boisramé-Helms J, Charpentier J, Guérot E, Megarbane B; et al. (2017). "Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial". Lancet Respir Med. 5 (3): 180–190. doi:10.1016/S2213-2600(17)30046-2. PMID 28219612.
- ↑ Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R; et al. (2017). "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016". Intensive Care Med. 43 (3): 304–377. doi:10.1007/s00134-017-4683-6. PMID 28101605.
- ↑ De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C; et al. (2010). "Comparison of dopamine and norepinephrine in the treatment of shock". N Engl J Med. 362 (9): 779–89. doi:10.1056/NEJMoa0907118. PMID 20200382.
- ↑ Marik PE, Mohedin M (1994). "The contrasting effects of dopamine and norepinephrine on systemic and splanchnic oxygen utilization in hyperdynamic sepsis". JAMA. 272 (17): 1354–7. PMID 7933396.