Gastrointestinal perforation medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
* Initial management of the patient with gastrointestinal perforation includes: | * 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 | * Intravenous fluid therapy and broad-spectrum [[antibiotics]]. Patients with intestinal perforation can have severe volume depletion. | ||
* The administration of intravenous proton pump inhibitors | * 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. | * [[Electrolyte disturbance|Electrolyte abnormalities]] correction especially [[metabolic alkalosis]] if [[fistula]] developed. The severity of any [[Electrolyte disturbance|electrolyte abnormalities]] depends upon the nature and volume of material leaking from the [[gastrointestinal tract]]. | ||
==== '''Antibiotics''' ==== | ==== '''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: | [[Broad-spectrum antibiotic]] therapy is initiated if the level of perforation is unknown. The following tabel shows the regimens of choice in these cases: | ||
{| class="wikitable" | {| class="wikitable" | ||
|'''Regimen''' | |'''Regimen''' | ||
| Line 18: | Line 18: | ||
| colspan="2" |'''First choice regimens''' | | colspan="2" |'''First choice regimens''' | ||
|- | |- | ||
|Ampicillin-sulbactam | |[[Ampicillin-Sulbactam|Ampicillin-sulbactam]] | ||
|3 g IV every six hours | |3 g IV every six hours | ||
|- | |- | ||
|Piperacillin-tazobactam | |[[Piperacillin-tazobactam]] | ||
|3.375 or 4.5 g IV every six hours | |3.375 or 4.5 g IV every six hours | ||
|- | |- | ||
|Ticarcillin-clavulanate | |[[Ticarcillin-Clavulanate|Ticarcillin-clavulanate]] | ||
|3.1 g IV every four hours | |3.1 g IV every four hours | ||
|- | |- | ||
|Ceftriaxone | |[[Ceftriaxone]] | ||
|1 g IV every 24 hours | |1 g IV every 24 hours | ||
|- | |- | ||
|Metronidazole | |[[Metronidazole]] | ||
|500 mg IV every eight hours | |500 mg IV every eight hours | ||
|- | |- | ||
| colspan="2" |'''Alternative regimens''' | | colspan="2" |'''Alternative regimens''' | ||
|- | |- | ||
| | |[[Ciprofloxacin]] | ||
|400 mg IV every 12 hours | |400 mg IV every 12 hours | ||
|- | |- | ||
|Levofloxacin | |[[Levofloxacin]] | ||
|500 or 750 mg IV once daily | |500 or 750 mg IV once daily | ||
|- | |- | ||
|Metronidazole | |[[Metronidazole]] | ||
|500 mg IV every eight hours | |500 mg IV every eight hours | ||
|- | |- | ||
|Imipenem-cilastatin | |[[Imipenem-Cilastatin|Imipenem-cilastatin]] | ||
|500 mg IV every six hours | |500 mg IV every six hours | ||
|- | |- | ||
|Meropenem | |[[Meropenem]] | ||
|1 g IV every eight hours | |1 g IV every eight hours | ||
|- | |- | ||
|Doripenem | |[[Doripenem]] | ||
|500 mg IV every eight hours | |500 mg IV every eight hours | ||
|- | |- | ||
|Ertapenem | |[[Ertapenem]] | ||
|1 g IV once daily | |1 g IV once daily | ||
|} | |} | ||
| Line 61: | Line 61: | ||
* Using the following targets to measure the response: | * Using the following targets to measure the response: | ||
* Central venous oxyhemoglobin saturation (ScvO<sub>2</sub>) ≥70 percent | * Central venous oxyhemoglobin saturation (ScvO<sub>2</sub>) ≥70 percent | ||
* Central venous pressure (CVP) 8 to 12 mmHg | * [[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. | * [[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 [8-10] | * [[Urine output]] ≥0.5 mL/kg/hour [8-10] | ||
* The clinical and hemodynamic response and the presence or absence of pulmonary edema must be assessed before and after each bolus. | * 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 | * Crystalloid solutions ([[Saline (medicine)|saline]], [[Lactated Ringer's solution|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. [20] [18-27] | ||
* There is no role for hypertonic saline. [28] | * There is no role for [[Hypertonic|hypertonic saline]]. [28] | ||
* An arterial catheter may be inserted if blood pressure is labile, sphygmomanometer readings are unreliable, restoration of perfusion is expected to be protracted | * 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 ==== | ==== Dynamic measures for circulation ==== | ||
* There is an evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures. These measures include: | * There is an evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures. These measures include: | ||
* Respiratory changes in the vena | * Respiratory changes in the [[Vena cavae|vena cava]] | ||
* Radial artery pulse pressure | * [[Radial artery]] pulse pressure | ||
* Aortic blood flow peak velocity | * Aortic blood flow peak velocity | ||
* Left ventricular outflow tract velocity-time integral | * Left ventricular outflow tract velocity-time integral | ||
* Brachial artery blood flow velocity are considered dynamic measures of fluid responsiveness | * 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. [3] | * Serum [[Lactic acid|lactate]] in patients with sepsis should be assessed until the lactate value has clearly fallen. [3] | ||
'''Vasopressors''' | |||
* Intravenous vasopressors are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic pulmonary edema. | ==== '''Vasopressors''' ==== | ||
* | * Intravenous [[vasopressors]] are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic [[pulmonary edema]]. | ||
* The addition of a second or third agent | * [[Norepinephrine]] is the first-line single agent in septic shock. [86-92] | ||
* Central venous and arterial access especially when vasopressor administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter. [3] | * The addition of a second or third agent to [[norepinephrine]] may be required ([[epinephrine]], [[dobutamine]], or [[vasopressin]]). | ||
* [[Central venous catheter|Central venous]] and [[Arterial catheter|arterial access]] especially when [[vasopressor]] administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter. [3] | |||
== References == | == References == | ||
Revision as of 20:20, 8 January 2018
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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Gastrointestinal perforation Microchapters |
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Differentiating gastrointestinal perforation from other diseases |
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Risk calculators and risk factors for Gastrointestinal perforation medical therapy |
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.
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:
| 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.[7-12].
- Using the following targets to measure the response:
- 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 [8-10]
- 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. [20] [18-27]
- There is no role for hypertonic saline. [28]
- 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:
- 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. [3]
Vasopressors
- 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. [86-92]
- 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. [3]