A retrospective cohort study of perioperative prognostic factors

associated with intra-abdominal sepsis

R. V. Arun Kumar and Shivakumar M. Channabasappa1

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Abstract
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INTRODUCTION
Sepsis following laparotomy is one of the common condition encountered by an
anesthesiologist in surgical Intensive Care Units (ICUs), intra-abdominal sepsis is associated
with significantly increased mortality, and morbidity in spite of advances in diagnosis and
management.[1]
Despite the advances, antimicrobial therapy and ICU support the mortality due to intra-
abdominal sepsis remains significantly high. The pathogenesis of intra-abdominal sepsis is
dependent on bacterial load, virulence and synergy between bacterial species and promotional
growth of bacteria by the presence of intestinal contents. In addition to this host defense
mechanism and appropriate medical intervention contribute to the successful outcome.[2]
In this study, we have studied various prognostic risk factors in the patients with severe
abdominal sepsis requiring intensive care therapy. The primary aim was to compare risk
factors among septic shock patients with sepsis without systemic hypotension in terms of
their clinical, laboratory, microbiological, and therapeutic data. It was hoped that by
identifying and addressing these factors it might be possible to identify poor prognostic
factors and ultimately improve outcome.
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SUBJECTS AND METHODS

This was a retrospective observational study of adult patients with intra-abdominal sepsis
admitted to ICU of University Medical College from March 2012 to March 2015. This study
was approved by Intuitional Ethical Committee.
Data were collected from registered files at the Department of Surgery. For the purpose of
patients selection, we defined intra-abdominal sepsis with shock as patients with peritonitis or
localized abscess at laparotomy associated with systemic hypotension (mean arterial pressure
[MAP] <60 mm of Hg) and intra-abdominal sepsis without shock in the patients with
peritonitis or localized abscess at laparotomy without systemic hypotension (MAP > 60 mm
of Hg) who subsequently required admission to ICU.
During this study, we reviewed the ICU chart, treatment strategy, investigation, and
mortality.
Following data were collected for analysis of risk factors. Age and gender, co-morbid illness,
duration of ICU stay, time duration between onset of symptoms and time of surgery,
preoperative steroid use, whether the initial surgery was elective or an emergency, whether
mechanical ventilation was required, coagulation profile, preoperative hematocrit and
albumin, requirement for and duration of inotropic support, dialysis, corticosteroids, and
blood transfusions.

Statistical analysis
Statistical analysis were has done by SPSS version 13 software (SPSS South Asia Pvt. Ltd.,
Bengaluru, Karnataka, India), where categorical variables were analyzed by using Fisher's
exact (two-tail) test and continuous variable, were analyzed by using Mann–Whitney (two-
tail) U-test.
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RESULTS
Demographic variables were represented in Table 1. There were no differences between
genders in this severity of sepsis. The median age of patients with septic shock was 49 years
ranges from 31 to 88 years as compared 28 years in the patients with sepsis without
hypotension which was statistically significant. Twelve patients older than 65 years
developed septic shock as compared to only 4 patients with sepsis without shock which was
statistically significant. There was no difference in the severity of sepsis among male and
female gender though there was more male in both the groups.
Table 1
Age group and gender distribution

Co-morbid illnesses were present in both groups as shown in Table 2. Thepatients in septic
shock group had higher co-morbid illness and 8 patients aged more than 65 years developed
septic shock had more than 2 co-morbidities as compared to only 1 patient in sepsis group.
Table 2
Co-morbid illnesses in study group

Forty-four percent (23 patients) of the patients who developed intra-abdominal sepsis surgery
was done as an emergency procedure. Out of these 69.5% of patients, 16 patients developed
septic shock as compared to 27% in patients who have undergone elective surgical producers
(29 patients) [Table 3]. Table 4 shows preoperative albumin and hematocrit levels were
significantly low in the patients with septic shock. Mean preoperative albumin level was 18
g/L as compared to 27 g/L in the patients with sepsis without systemic hypotension. Mean
preoperative hemoglobin level was 28.1% in case of sepsis as compared to 21.6% in the
patients with septic shock. This was statistically significant.
Table 3
Urgency of surgery

Table 4
Preoperative investigations

According to Table 5, the mean duration of ICU stay of patients with septic shock was 13
days as compared to 4 days in the patients with sepsis. 70% of patients with septic shock
patients required more than 10 days ICU admission as compared to 18% of patients with
sepsis. Out of these 78% of the patients with a septic shock, 6 patients died in ICU. All these
patients had multi organ dysfunction syndrome. 40% of these patients with sepsis shock
required renal replacement therapy.
Table 5
ICU stay

The septic shock patients had a significantly longer stay in the ICU than the sepsis group
patients (13 days vs. 4 days; P = 0.022), all the patient required mechanical ventilation as
compared to only three patients in sepsis group (P = 0.024), septic shock patients had
significantly more blood transfusions (6 vs. 0.5; P = 0.001), they required more inotropic
support and corticosteroids.
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DISCUSSION
This is the retrospective consecutive cohort study to investigate the perioperative prognostic
risk factors associated with severe sepsis and septic shock. The current study confirmed that
the proportion of the patients with preoperative low albumin level, low hematocrit, more than
2 co-morbidity increases the risk of septic shock after surgery. Co-morbid illnesses were
present in both the sepsis and septic shock patients. The common co-morbidities were mainly
risk factors for systemic vascular diseases such as hypertension, chronic obstructive
pulmonary disease, ischemic heart disease, and diabetes mellitus.
In our study, the albumin and hematocrit levels on admission were low in both the septic
shock and sepsis without hypotension patients. The presence of a low serum albumin and
hematocrit has been shown to be an important risk factor for perioperative septic shock[3]
and for treatment failure in patients with bacterial peritonitis. Preoperative correction of
hypoalbuminemia and anemia may reduce these complications.
It is well-known that hypotension is associated with an increased risk of sudden and
unexpected death in the patients admitted to hospital with nontraumatic diseases;[4]
identifying patients with severe sepsis early and correcting the underlying micro vascular
dysfunction may improve patient outcomes. If not corrected, micro vascular dysfunction can
lead to global tissue hypoxia, direct tissue damage, and ultimately, organ failure.[5]
In this study, the most important factors related to the severity of septic shock were the
inability to gain early source control, as determined by the ongoing need for surgery, delay in
surgery, the number of blood transfusions, and dialysis. The timing and adequacy of source
control are of most importance in the management of intra-abdominal sepsis, as late and/or
incomplete procedures may have severely adverse consequences on the outcome.
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.[6,7]
Renal failure requiring continuous renal replacement therapy (CRRT) in abdominal sepsis
appears to be a poor prognostic factor. In our patients, none of those with sepsis without
systemic hypotension required CRRT, whereas 25% of patients with septic shock required
renal replacement therapy. In patients with sepsis, attention should always be paid to acute
kidney injury (AKI). Patients with AKI had lesser ventilator-free and ICU free days and a
decreased likelihood of discharge to home. Morbidity and mortality increased with severity
of AKI, and AKI of any severity was found to be a strong predictor of hospital mortality.[8,9]
In our study, age more than 65 years increases the risk of septic shock and mortality, some
reports have also noted that mortality is higher in those aged >60 years.[10,11,12]
The first-line management of the septic shock patients is the administration of intravenous
antimicrobial therapy. Antimicrobials play an important role in the management of intra-
abdominal sepsis, especially in the patients with severe shock who require immediate
empirical antibiotic therapy.
An insufficient or otherwise inadequate antimicrobial regimen is one of the variables more
strongly associated with unfavorable outcomes in critical ill patients.[13] Empiric
antimicrobial therapy should be started as soon as possible in the patients with severe sepsis
with or without septic shock.[14,15,16]
Considering recent trials with novel treatment, it will be important to delineate the risk
factors that reflect septic processes that are potentially modifiable. We have found that
preoperative low albumin and hematocrit, increases the risk of perioperative septic shock,
correcting these may reduce perioperative mortality and morbidity due to sepsis.
Our results should be considered in light of several limitations. First, data used in this study
are subject to possible inaccuracies inherent in administrative datasets. Further prospective
randomized studies will mitigate the shortcoming of this retrospective study.
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CONCLUSIONS
We conclude that the patients with abdominal sepsis are at increased risk severe sepsis with
systemic hypotension if preoperative albumin and hematocrit are low, and there is inadequate
initial source control. Additionally, the outcome is worse if the patient required renal
replacement therapy. The requirement for inotropes, longer ICU stays, and the requirement
for blood transfusion also significantly increases the severity of sepsis.

Financial support and sponsorship

Subbaiah Institute of Medical Sciences, Shimoga, Karnataka, India.

Conflicts of interest
There are no conflicts of interest
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REFERENCES
1. Morar R, Richards GA, Galpin J, Herbert V. Outcome of patients with severe abdominal
sepsis in intensive care – Experience at Charlotte Maxeke Johannesburg Academic Hospital:
Clinical case study. South Afr J Epidemiol Infect. 2010;25:23–7.
2. Malangoni MA. Evaluation and management of tertiary peritonitis. Am
Surg. 2000;66:157–61.[PubMed]
3. Gibbs J, Cull W, Henderson W, Daley J, Hur K, Khuri SF. Preoperative serum albumin
level as a predictor of operative mortality and morbidity: Results from the National VA
Surgical Risk Study. Arch Surg. 1999;134:36–42. [PubMed]
4. Jones AE, Yiannibas V, Johnson C, Kline JA. Emergency department hypotension predicts
sudden unexpected in-hospital mortality: A prospective cohort study. Chest. 2006;130:941–
6. [PubMed]
5. Esteban A, Frutos-Vivar F, Ferguson ND, Peñuelas O, Lorente JA, Gordo F, et al. Sepsis
incidence and outcome: Contrasting the intensive care unit with the hospital ward. Crit Care
Med. 2007;35:1284–9.[PubMed]
6. Marshall JC. Principles of source control in the early management of sepsis. Curr Infect
Dis Rep. 2010;12:345–53. [PubMed]
7. Marshall JC, al Naqbi A. Principles of source control in the management of sepsis. Crit
Care Clin. 2009;25:753. [PubMed]
8. White LE, Hassoun HT, Bihorac A, Moore LJ, Sailors RM, McKinley BA, et al. Acute
kidney injury is surprisingly common and a powerful predictor of mortality in surgical
sepsis. J Trauma Acute Care Surg. 2013;75:432–8. [PMC free article] [PubMed]
9. Dellinger EP, Wertz MJ, Meakins JL, Solomkin JS, Allo MD, Howard RJ, et al. Surgical
infection stratification system for intra-abdominal infection. Multicenter trial. Arch
Surg. 1985;120:21–9. [PubMed]
10. Christou NV, Barie PS, Dellinger EP, Waymack JP, Stone HH. Surgical Infection Society
intra-abdominal infection study. Prospective evaluation of management techniques and
outcome. Arch Surg. 1993;128:193–8. [PubMed]
11. Wilson SE, Faulkner K. Impact an anatomical site on bacteriological and clinical outcome
in the management of intra-abdominal infections. Am Surg. 1998;64:402–7. [PubMed]
12. Butler JA, Huang J, Wilson SE. Repeated laparotomy for postoperative intra-abdominal
sepsis. An analysis of outcome predictors. Arch Surg. 1987;122:702–6. [PubMed]
13. Paul M, Shani V, Muchtar E, Kariv G, Robenshtok E, Leibovici L. Systematic review and
meta-analysis of the efficacy of appropriate empiric antibiotic therapy for sepsis. Antimicrob
Agents Chemother. 2010;54:4851–63. [PMC free article] [PubMed]
14. Ferrer R, Artigas A, Suarez D, Palencia E, Levy MM, Arenzana A, et al. Effectiveness of
treatments for severe sepsis: A prospective, multicenter, observational study. Am J Respir
Crit Care Med. 2009;180:861–6. [PubMed]
15. Castellanos-Ortega A, Suberviola B, García-Astudillo LA, Holanda MS, Ortiz F, Llorca
J, et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and
mortality in septic shock patients: Results of a three-year follow-up quasi-experimental
study. Crit Care Med. 2010;38:1036–43.[PubMed]
16. Puskarich MA, Trzeciak S, Shapiro NI, Arnold RC, Horton JM, Studnek JR, et al.
Association between timing of antibiotic administration and mortality from septic shock in
patients treated with a quantitative resuscitation protocol. Crit Care Med. 2011;39:2066–
71. [PMC free article] [PubMed]