Sepsis is a common complication occurring in patients undergoing surgical procedures, and is associated with prolonged hospital stay and high mortality rates. A retrospective review of all surgical patients at one academic medical centre in the USA reported that sepsis developed in 3.4 per cent of the more than 25 500 patients who underwent surgery over a 3.5-year interval. Overall, patients with sepsis had significantly longer hospital and ICU stays, greater likelihood of ICU admission, and a higher mortality rate. The incidence of sepsis was highest in patients with procedures performed by cardiothoracic surgery (8.39%), trauma/acute care surgery (7.55%), and plastic/reconstructive surgery (5.35%). Sepsis was associated with a significant increase in the mortality rate among vascular surgery, trauma/acute care surgery, and cardiothoracic surgery patients. The most common infectious sources in sepsis-related deaths were pulmonary infections (39.5%), blood stream infections (35.1%), and gastrointestinal infections (31.6%).
As sepsis develops from infection, strategies to prevent infection can help reduce the occurrence of sepsis. General strategies for prevention of nosocomial infections must be applied rigorously, including hand‐washing.
Due to the possible role of the gut in the emergence of antimicrobial resistance, it is considered important that normal gut function be maintained during and after surgery. Prolonged preoperative fasting is no longer recommended and starting enteral feeding as soon as possible after surgery is encouraged. Similarly, excessive opioid administration slows bowel function and excessive fluid administration may cause bowel oedema, and should be avoided.
The diagnosis of surgical sepsis may be difficult because there are no specific clinical signs and laboratory tests to recognize early sepsis. The atypical clinical presentation may be responsible for a delay in treatment. Moreover, in patients already stressed by the previous operation, sepsis can precipitate quickly to septic shock.
The treatment of sepsis (surgical or medical) is currently based on adequate source control, appropriate antibiotic therapy and organ support.
Fluid support should be initiated as early as possible in patients with sepsis or septic shock. It is a major component of cardiovascular support in early sepsis. When fluid challenge fails to restore adequate arterial pressure and organ perfusion, clinicians should resort to vasopressor agents. Vasopressor drugs maintain adequate blood pressure and preserve perfusion pressure, thereby optimizing blood flow in various organs.
Source control encompasses all measures undertaken to eliminate the source of infection, reduce the bacterial inoculum and correct or control anatomic derangements to restore normal physiologic function. The timing and adequacy of source control are of outmost importance in managing patients with sepsis from abdominal origin as late and/or incomplete procedures may have severely adverse consequences on outcome.
Adequate and appropriate empiric antibiotic therapy should be started as soon as possible in patients with sepsis. Ideally, appropriate cultures should be taken for microbiological evaluation. The principles of empiric antibiotic treatment should be defined according to the most frequently isolated bacteria, always taking into consideration the local healthcare setting trend of antibiotic resistance. In this era of prevalent drug-resistant microorganisms, the threat of resistance is a source of major concern that cannot be ignored. In the past 20 years, the incidence of nosocomial infections caused by drug-resistant microorganisms has risen dramatically, probably in correlation with escalating levels of antibiotic exposure and increasing frequency of patients with one or more predisposing conditions, including elevated severity of illness, advanced age, degree of organ dysfunction, low albumin levels, poor nutritional status, immunosuppression, presence of malignancy, and other comorbidities.
In patients with nosocomial infections the normal flora may be modified and infections may be caused by several unexpected pathogens and by more resistant flora, including methicillin-resistant Staphylococcus Aureus (MRSA), extended-spectrum beta-lactamases producing Enterobacteriaceae (ESBL), P. aeruginosa and Candida spp.
Carbapenem-resistant Klebsiella pneumoniae (CRKP) has emerged as a global threat over the past decade and is now endemic in many countries, largely due to the dissemination of carbapenem-hydrolyzing beta-lactamases such as the K. pneumoniae carbapenemase (KPC).
The worldwide burden of sepsis in surgical patients is considerable. Early recognition, appropriate source control, antimicrobial agents and organ support can help maximize the chances of survival in patients with surgical sepsis.
References
Ramanathan R, Leavell P, Mays C, Duane TM. Impact of Sepsis on Surgical Outcomes. Surg Infect (Larchmt). 2015 Aug;16(4):405-9.
Elias AC, Matsuo T, Grion CM, Cardoso LT, Verri PH. Incidence and risk factors for sepsis in surgical patients: a cohort study. J Crit Care. 2012 Apr;27(2):159-66.
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