Does reoperation for abdominal sepsis enhance the inflammatory host response?

OBJECTIVE: To determine the effect of reoperation for severe abdominal sepsis on the course of proinflammatory mediators and hemodynamic factors. DESIGN: Inception cohort. SETTING: A university hospital and a secondary care hospital. PATIENTS AND METHODS: Fifteen patients suffering from severe peritonitis due to intestinal perforation or infected necrotizing pancreatitis were studied following 19 subsequent operations. Plasma samples were obtained immediately before and after reoperation, as well as at 1, 3, 6, 12, and 24 hours after operation to determine endotoxin, tumor necrosis factor alpha, and interleukin-6 levels. Clinical factors and therapeutic support were recorded at the corresponding times. MAIN OUTCOME MEASURES: Postoperative hemodynamic instability as defined by changes of the mean arterial pressure, pulmonary capillary wedge pressure, and vasopressor support. Courses of proinflammatory mediators were correlated to the hemodynamic findings. RESULTS: Mean arterial pressure decreased from 94 mm Hg postoperatively to 80 mm Hg at 3 hours (P = .006) and 81 mm Hg at 6 hours postoperatively (P = .005). Pulmonary capillary wedge pressure dropped from 14 mm Hg postoperatively to 12 mm Hg at 1 hour (P = .05). Vasopressor support significantly increased from 1 to 6 hours postoperatively (P = .02). Neither endotoxin nor tumor necrosis factor alpha levels showed significant changes in the postoperative course. Interleukin-6 levels continously increased from 586 pg/mL preoperatively to 910 pg/mL at 1 hour (P = .02) and 931 pg/mL at 3 hours postoperatively (P = .04). Overall interleukin-6 levels (R = -0.38, P = .003) and especially early postoperative interleukin-6 levels inversely correlated with postoperative mean arterial pressure. CONCLUSIONS: Reoperation for abdominal sepsis frequently causes substantial hypotension, and is, thus, potentially harmful to the patient. Reoperative trauma may induce an early postoperative increase in interleukin-6 levels. Because this increase occurs before the development of hypotension, a relationship between the kinetics of this cytokine and the observed hemodynamic instability may be present.

The effects of norepinephrine on hemodynamics and renal function in severe septic shock states.

OBJECTIVE: To investigate the effect of norepinephrine (NE) on hemodynamics, oxygen metabolism and renal function in patients with severe septic shock. DESIGN: Prospective study. SETTING: Post-operative ICU in a municipal general hospital. PATIENTS: The study included 56 patients with extreme low resistance states due to abdominal sepsis, who remained hypertensive (MAP < 60 mmHg) despite optimal fluid therapy and dopamine > 20 micrograms/kg/min and cumulative doses of dopamine and dobutamine > 30 micrograms/kg/min, respectively. INTERVENTIONS: After registration of baseline values dopamine was reduced to 2.5 micrograms/kg/min, and norepinephrine was administered starting at a dose of 0.05 micrograms/kg/min until a mean arterial pressure of more than 60 mmHg could be maintained. MEASUREMENTS AND RESULTS: During norepinephrine infusion (dosage ranging between 0.1-2 micrograms/kg/min, mean dose rate: 0.4 micrograms/kg/min) mean arterial pressure and systemic vascular resistance index increased significantly (p < 0.001). After 8 h a significant increase in stroke volume (p < 0.05) and decrease in heart rate (p < 0.05) could be observed. There was no significant change in cardiac index (CI), oxygen delivery (O2AVI) and oxygen consumption (VO2I). Creatinine clearance increased significantly (p < 0.005) from a control value of 75 +/- 37 ml/min to 102 +/- 43 ml/min after 48 h NE-treatment. CONCLUSION: Our results suggest that norepinephrine can be used safely in the treatment of severe septic shock states. Mean arterial pressure and glomerular filtration rate improved markedly without deleterious effects on CI, O2AVI and VO2I.

[Noradrenaline in the "high output-low resistance" state of patients with abdominal sepsis]. / Noradrenalin im "High Output-Low Resistance State" beim septischen Abdominalpatienten.

We investigated the impact of norepinephrine administration on hemodynamics, oxygen metabolism and renal function in patients in severe septic shock. PATIENTS AND METHODS. Twenty-six patients with extremely low resistance who were between 24 and 87 years of age were included in the study. In 7 patients, acute necrotizing pancreatitis and superinfection was diagnosed; 19 patients suffered from diffuse peritonitis. The entrance criteria for the study were: a mean arterial pressure (MAP) of below 60 torr or, in chronic hypertensive patients, a decrease in systolic pressure of more than 50 torr compared to previous values, despite volume optimization, and dopamine greater than 20 micrograms/kg per min and cumulative doses of dopamine/dobutamine greater than 30 micrograms/kg per min, respectively. Cases with tachycardia greater than 140/min were also included in the study even when the inotropic medication dose was lower. After registration of baseline values, dopamine was reduced to 2.5 micrograms/kg per min, and norepinephrine was administered starting at a dose rate of 0.05 micrograms/kg per min, until a MAP of greater than 60 torr could be maintained. RESULTS. Of the 26 patients investigated, 16 survived; 10 patients with persisting sepsis died due to multiple organ failure (mortality: 38.5%). During the study period, a norepinephrine dosage ranging between 0.1 and 2 micrograms/kg per min was necessary to stabilize the arterial pressure. The mean dose rate was 0.3 micrograms/kg per min. The mean arterial pressure and systemic vascular resistance index showed a statistically significant increase of 30 and 20%, respectively, just after 1 h and distinctly remained above the initial values in the further course. The cardiac index remained constant or increased slightly. After 24 h a statistically significant increase in stroke volume and a decrease in heart rate could be observed. Creatinine clearance increased significantly from the control value of 73 +/- 48 ml/min to 114 +/- 37 ml/min after 48 h under norepinephrine treatment. O2-delivery and O2-consumption did not change significantly, although they showed a slight tendency to increase. CONCLUSION. When patients are in a septic high output-low resistance condition, particular attention must be paid to maintaining sufficient mean arterial pressures. Our results suggest that this essential goal can be achieved by norepinephrine. The mean arterial pressure and glomerular filtration rate improved markedly, and there was no evidence of bad effects such as an increased afterload on critical parameters like cardiac index, O2-delivery and O2-consumption.