septic peritonitis

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Septic Peritonitis:Treatment and

Prognosis

Pembimbing : dr Bambang Arianto, SpB

oleh : Gusti Pindo Asa A

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Definition• Peritonitis is an inflammatory condition of

peritoneum that occurs secondary to microbial contamination.

Note: Septic peritonitis may have a wide variety of clinical course and out comes, with high morbidity and mortality

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Treatment• Circulatory shock and fluid therapy

Although surgery is the definitive treatment once the diagnosis of septic peritonitis has been made, establishing vascular acces and initiating aggressive fluid resucitation is the first priority.

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Fluid Therapy• An isotonic electrolyte solution is ussualy

administrated. Such as RL, Normosol-R, Plasmalyte A.

The patients should be monitored by periodic carvas evaluation, and measurements of oxygen content.Rapid redistribution of cristalloids and vascular leakege accompanying sepsis can lead to limited succes when crystalloid fluids are used alone.

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• If the resuscitation fluid volume appears adequate and the patient is still hypotensive, the patient is a candidate for vasopressor or inotrope therapy.

• Dopamine (5-15 µg/kg/min) and NE (0,05 – 0,3 µg/kg/min) are considered the vasopressors of choice for threating septic shock.

• The positive intrope dobutamine may also be effective in treating the cardiac depression and decreased contractility induced by sepsis

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Antimicrobial therapy• Give it as soon as the diagnosis of septic

peritonitis is made and samples of the peritoneal fluid have been obtained for aerobic and aerobic culture and susceptibility testing. The antibiotic should be rational, and cover a broad spectrum.

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• Common antibiotics used include ampicillin combined with an aminoglycoside or fluoroquinolone

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Surgery• Abdominal surgery is performed as soon as the

patient reaces the desired end-point parameters for stabilization.

• The goal include:o Identification and correction of the underlying causeo Lavage of the peritoneal cavityo Consideration for postoperative drainageo Provision of an avenue to ensure nutritional support (feeding tube)

postoperatively

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• Underlying disease is focused on either repair or removal of the incitng cause

• Lavage is crucial to rremove debris, bacteria and toxic by-products. Use warm isotonic saline solution at 200mL/kg

• Drainage: peritoneal drainage, passive drainage, and active drainage. This different types of drains are suitable for use in the peritoneal cavity

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Drainage• Passive drainag such

as : Multiluminal (sump) or column disk cathethers

• Active drainage : requires an external vacuum to create negative pressure within the peritoneal

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• Open peritoneal drainage : the tissue are covered with sterile absorbent dresings that are changed once or twice daily, when fluid from abdomen has penetraed all layers of the bandage or when the bandage becomes wet soiled from outsde

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Suportive Therapy• Pain may be severe because the abdomen has a

large number of sympathetic efferent pain fibers. Use analgesic. Opioid are often used as a first choice.o morphine 0,05 – 0,2 mg/kg/ho Lidocaine 2-4 mg/kg/ho Ketamine 0,2-0,6 mg/kg/h

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Postoperative CareIntensive monitoring is the key to patient management after surgery. • Components must be measured :

o Insensible losso Urine volumeo Ongoing losses

• Monitoring blood pressure (MAO should be maintained above 70mmHg)

• Early nutritional support helps reduce the risk of hipoproteinemia

• Cytologic evaluation of abdominal effusion is a useful monitoring tool

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Prognosis• Fuction of the underlying cause• The health of the patient• The initial medical treatment• The time until surgical intervention• And effectiveness of surgery in treating the

primary problem

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• The reported mortality in veterinity ranges from 20%-68%

• Positive prognostic indicator include focal septic peritonitis, which is usually secondaru to the presence of an intraabdominal abscess.

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Conclucion• Early diagnosis and appropriate initial

managemenr allow rapid stabilizatin.• Surgical treatment of the promary cause is then

indicated.• Prognosis is affected bya the underlying cause,

patients status, adn early appropriate medical and surgical therapies

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Thank’s For Your Attention