Early administration of hydrocortisone replacement after the advent of septic shock: impact on survival and immune response*.

OBJECTIVES: To investigate the impact of early initiation of hydrocortisone therapy on the clinical course of septic shock and on cytokine release. DESIGN: Prospective study in patients with septic shock treated with low doses of hydrocortisone. SETTING: ICUs and general wards. PATIENTS: Over a 2-year period, 170 patients with septic shock treated with low doses of hydrocortisone were enrolled. Blood was sampled from 34 patients for isolation of peripheral blood mononuclear cells and cytokine stimulation before and 24 hours after the start of hydrocortisone. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After quartile analysis, patients were divided into those with early initiation of hydrocortisone (< 9 hr after vasopressors, n = 46) and those with late initiation of hydrocortisone (> 9 hr after vasopressors, n = 124). After adjusting for disease severity and type of infection, a protective effect of early hydrocortisone administration against unfavorable outcome was found (hazard ratio, 0.20; p = 0.012). Time of discontinuation of vasopressors was earlier among patients with initiation of hydrocortisone within 9 hours. Production of tumor necrosis factor-α was lower among patients who had had hydrocortisone early. CONCLUSIONS: In patients receiving hydrocortisone for septic shock, early initiation of treatment was associated with improved survival. This treatment was also associated with attenuated stimulation of tumor necrosis factor-α.

Anastomotic leak management after a low anterior resection leading to recurrent abdominal compartment syndrome: a case report and review of the literature.

INTRODUCTION: Low anterior resection is usually the procedure of choice for rectal cancer, but a series of complications often accompany this procedure. This case report describes successful management of an intricate anastomotic leak after a low anterior resection. CASE PRESENTATION: A 66-year-old Caucasian man was admitted to our hospital and diagnosed with a low rectal adenocarcinoma. He underwent a low anterior resection but subsequently developed fecal peritonitis due to an anastomotic leak. He was operated on again but developed abdominal compartment syndrome, multi-organ failure and sepsis. He was aggressively treated in the intensive care unit and in the operating room. Overall, the patient underwent four laparotomies and stayed in the intensive care unit for 75 days. He was discharged after 3 months of hospitalization. CONCLUSION: Abdominal compartment syndrome may present as a devastating complication of damage control laparotomy. Prompt recognition and goal-directed management are the cornerstones of treatment.