For infection in surgery field

1. Source control principles of sepsis
DR.dr. Toar Lalisang, SpB-KBD
Department of Surgery FMUI/RSUPN-CM
Jakarta Indonesia.

2. Source control
All physical measures can be used to control a focus on
infection, modified factor in infectious milieu that promote
bacterial growth or impair host defense

3. Biology & Therapeutic priNciples
Invasion micro org. Recruit inflammatory cells
Local defense to:
Therapeutic strategy
kill invading bacteria,
minimize dissemination &
Initiate tissue repair

4. Sepsis Management
 A. Initial Resuscitation
 B. Screening for Sepsis
and Performance
Improvement
 C. Diagnosis
 D. Antimicrobial Therapy
 E. Source Control
 F. Infection Prevention
 Resuscitation
 Initial, fluids, vasopressors, Inotropic
 Diagnostic Culture, Imaging
 Definitive
 Source control & Antimicrobials
 Adjunctive Steroid, RHAP C
 Miscellaneous Nutrition, Glucose
control, CRRT, anti DVT, Prevent
GI Bleeding.

5. Life Threatening Infection (Peritonitis/cIAI )
 Resuscitation to restore adequate organ perfusion
 Antibiotic
 Intensive care
 Minimal Invasive Surgical source control
.

6. Source Control in the Management of Severe
Sepsis and Septic Shock :
“ Although highly logical, since source control
is the best way to reduce quickly the
bacterial inoculum, most recommendations
are, graded as D or E due to the difficulty to
perform appropriate RCTs”

7. Source of sepsis
Sepsis Output
Sepsis Cascade
Role of Surgery

8. E. Source Control
1. A specific anatomical diagnosis of infection requiring consideration for
emergent source control be sought and diagnosed or excluded as rapidly
as possible, and intervention be undertaken for source control within the
first 12 hr after the diagnosis is made, if feasible (grade 1C).
2. When infected peripancreatic necrosis is identified as a potential source of
infection, definitive intervention is best delayed until adequate demarcation
of viable and nonviable tissues has occurred (grade 2B).
3. When source control in a severely septic patient is required, the effective
intervention associated with the least physiologic insult should be used (eg,
percutaneous rather than surgical drainage of an abscess) (UG).
4. If intravascular access devices are a possible source of severe sepsis or
septic shock, they should be removed promptly after other vascular access
has been established (UG).

9. Source Control
Any single or series procedure that :
 eliminate infectious foci,
 control factor that promote ongoing infection
 correct or control anatomic derangements to restore
normal physiology function.

10. Source control
 Is particularly important in managing patients who
have sepsis.
 A persistent, septic source that continuously
stimulates the inflammatory reaction cascade
usually will result in development of multiple organ
failure syndrome.
 This syndrome is associated with a particularly
increased morbidity and mortality.

11. Source control
 in general the intervention that accomplishes the
objective of source control with the least
physiological upset should be employed
 measures should be instituted as soon as possible
after initial resuscitation

12. Source control
 Inefficient control is associated with a poor prognosis.
 The potential indication for and role of source control
should be assessed for all patients with severe sepsis.
 In many circumstancesthe need to control the septic
source is clear.(eg, in diffuse peritonitis from a perforated
ulcer or clostridial myonecrosis after a traumatic injury)

13. Source control of SEPTIC FOCUS
 Prompt identification and treatment of the culprit
site of infection are essential.
Is the critical
targeted intervention in the treatment of sepsis
Most other therapies are purely supportive.

14. Key Principles of Source Control
1. Identification of an infection focus amenable
to source control measures
2. Risk and benefit of methods
3. Measures should be instituted as soon as
possible following initial resuscitation
4. Removal of any intravascular access devices
that are potentially causing severe sepsis or
septic shock

15. Identification of the septic focus
Careful history and Physical examination
clues the source of sepsis and help guide subsequent
microbiologic evaluation
Gram stain of material from sites of possible
infection may give early clues to the etiology of infection
while cultures are incubating.

16. Identification of the septic focus
Examples,
urine should be routinely Gram stained and
cultured, sputum should be examined in a
patient with a productive cough,
intra-abdominal collection in a postoperative
patient should be percutaneously sampled
under radiologic guidance

17. Valuable Imaging Techniques
Identification of occult yet clinically important
focus of IAI
Avoid unnecessary “blind laparotomy”

18. Source control Concept
Elimination of infection focus
Not hit and run approach
Adequate Steps procedure

19. Eradication of infection
 Eradication of the inciting infection is essential to the
successful treatment of severe sepsis and septic shock.
 Source control (physical measures undertaken to eradicate
a focus of infection and eliminate ongoing microbial
contamination) should be undertaken since undrained foci
of infection may not respond to antibiotics alone.

20. Eradication of infection
 As examples, potentially infected foreign bodies (eg,
vascular access devices) should be removed when
possible,
 Abscesses should undergo percutaneous or surgical
drainage.
 Some patients require extensive soft tissue debridement or
amputation; in rare cases, fulminant Clostridium difficile-
associated colitis may necessitate colectomy

21. 3 technique principles on Source control
Drainage
Debridement
Definitive management.

22. Appropriate Source Control
 Drain infected foci
 Control ongoing contamination
 Diversion , resection and restore
anatomic / physiologic structure

23. Surgical drainage is indicated for:
 Failures of percutan drainage,
 Collections with a significant solid tissue
component,
 A source of ongoing contamination
 Local peritoneal defenses have not contained the
infectious focus, leading to generalized
peritonitis.
Crit Care Med 2003 Vol. 31, No. 8

24. GOAL of Surgery
 Complete surgical debridement by wide resection of all
nonviable tissue until viable tissue is encountered.
 To address muscular necrosis, the fascial compartment
should be opened wide to relieve increased pressure
(compartment syndrome) and allow adequate blood flow to the
muscle.

25. Approach to Patient with
Suspected Intra-Abdominal Infection
Clinical Sign & Symptoms
MOF,GI Bleeding, Metabolic Acidosis
Supportive measurment
Clinical Assessment
Source Apparent
Yes
No CT scan
Others imaging
Focal collection
Percutaneus Drainage
Laparoscopic
Diffuse Peritonitis
Laparotomy
Laparoscopic
Ischemia/infection
Laparotomy
Resection&Restore
Abd. Closure ;
Unless ACS, Ongoing bleeding
Uncontrol Contamination
+ - Tight observation

26. Source control Approach
USG guided drainage
USG guided decompression
Minimal invasive surgery
Conventional

27. Intra-Abdominal Source Control
1. General Rule: Optimal drainage with the least
degree of anatomic and physical trauma to the
patient
2. Base upon appropriate history and physical
examination as well as radiographic measures

28. Source Control not always Surgery
It is not always possible to use some form
of surgical intervention to neutralize the
septic source.
For example, a patient who has sepsis with
pneumonia needs tracheal suction and
respiratory physiotherapy to help eliminate
infected secretions.

29. Procedure SC
 Diffuse peritonitis, emergency laparotomy
 Abscess, Percutaneous drainage
 Hemodynamically stable, Urgent laparatomy

30. TIMING OF INTERVENTIONS.
 Clinical judgment is required to determine the optimal
timing for the intervention to control the infection source.
 Benefits of the intervention should be measured against
possible associated risks.

31. Laparotomy timing
Planed Laparotomy
On demand Laparotomy
PCT ratio appears to be a valuable aid in
deciding if further relaparotomies are
necessary after initial operative treatment of an
intraabdominal septic focus.

32. On Demand Laparotomy
Not imply a passive wait and see attitude
Vigilant Observation of the postoperative
patient with round the clock monitoring
APACHE II
Active decision making base on clinical
data presentation.

33. Perforation of GI Tract
 Elimination of ongoing leakage of luminal contents
 Through removal of the perforation
 Through the creation of a controlled sinus

34. Obstruction of GB or Biliary tree
 Relief of intraluminal pressure through the creation of a
controlled fistula, timely intervention after stabilization of the
pt is indicated.
 For gangrenous acute cholecystitis or acalculous
cholecystitis, source control  percutaneous
cholecystostomy or operative cholecystectomy.
 Cholangitis necessitates decompression of the biliary tree
by ERCP + papillotomy or nasobiliary drainage,
transhepatic decompression or operative exploration of
CBD

35. Intestinal Infarction
 A surgical emergency
 Gangrenous intestine produces rapid physiologic
decompensation
 Without surgical intervention, it is almost invariably lethal

36. Severe Acute Pancreatitis
 May cause infection of necrotic pancreas or
retroperitoneal fat
 Percutaneous drainage alone may be sufficient if
there is only fluid accumulation
 Debridement of infected necrotic tissue is
necessary to achieve adequate source control
(survival is better if delayed for 2-3 weeks)

37. Adequate Source Control
 Dilute the exudates fluids
 Bleeding control/ Hemostasis
 No fluid collection /good suction
 Temporary Abdominal closure (TAC)

38. IAI Nov-Dec 2010
19 cases
 Male : 14, Female : 5
 Age 17 – 75 years
 Relaparotomy : 5
 necrosis:4 peritonitis/perforation:6, organ
infection :9
 Diversion :5resection &anastomosis: 6, Source
control: 8
 Operative death 3

39. cIAI RSCM 2011 January
 13 cases
 Perforated Appendicitis : 1
 Gut Perforation : 5
 Anastomosis leak : 2
 Small bowel necrosis : 2
 Acute Pancreatitis : 1
 ONE death
 Antibiotic : Ceftazidime, Carbapenem
Tygecycline, Cefotaxime,Cefipime

40. Abdominal Sepsis 2013
 995 Digestive operative cases
 Acute Appendicitis
 Bowel Perforation
 Peptic Ulcer perforation
 Cholecystitis
 Abdominal sepsis 18 %
 Source control procedure 35 %

41. Abdominal wall necrosis&ileum
perforation due to trauma
2
2

43. After 3 weeks
Sepsis overcome
Plan for abdominal surface defect
Closed by flaps.
Ileostomy closure

44. T A C

45. BOGOTA Bag

46. MR H , 63 ys, 345-94-47

48. Abdominal Sepsis at
Ciptomangunkusumo Hospital
 Sepsis cases due abdominal sepsis were common
 The most common causes were gut perforation
 after trauma
 infection process (eg. Typhoid perforation)
 Principles of Management
 Excision of non vital tissue and abdominal toilet
 Local drainage for severe cases

49. Lesson from the cases
 Factor influence the out come;
 Stage of sepsis
 Concomitant disease
 Repeat surgery

50. Source controle on ABDOMIAL INFECTION
The best Solution for Pollution are
Dilution
Multidisciplinary approach
Collaboration: Surgeons, Interventional
Radiologists, Intensivists and
Microbiologists.

51. Conclusions
Source control is important for breakthrough
the sepsis cascade.
Initial resuscitation must be adequate before
source control procedure.
Operative Timing and Source technique care
contribute the result

52. SUMMARY
Abdominal source control must be done
adequately and aggressively
as soon as
the respiratory and circulation can be maintain