Gastrointestinal perforation medical therapy
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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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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. Intravenous vasopressors are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic pulmonary edema. Norepinephrine is the first-line single agent in septic shock. The addition of a second or third agent to norepinephrine may be required.
Gastrointestinal perforation medical therapy
- 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.