Gastrointestinal perforation medical therapy
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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Overview
- Initial management of the patient with gastrointestinal perforation includes:
- Intravenous fluid therapy and broad-spectrum antibiotics.
- The administration of intravenous proton pump inhibitors is appropriate for those suspected to have an upper gastrointestinal perforation.
- Patients with intestinal perforation can have severe volume depletion.
- 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 (or 2 g IV every 12 hours for CNS infections) |
| Metronidazole | 500 mg IV every eight hours |
| Alternative regimens | |
| Ciprofloxacin or | 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 predominantly 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
- urine output ≥0.5 mL/kg/hour [8-10]
- A lack of benefit of resuscitation protocols has also been reported in low income settings. As an example, in a randomized trial of 212 patients with sepsis (defined as suspected infection plus two systemic inflammatory response syndrome criteria) and hypotension (systolic blood pressure ≤90 mmHg or mean arterial pressure <65 mmHg) in Zambia, a protocolized approach of aggressive fluid resuscitation, monitoring, blood, and vasopressor transfusion within the first six hours of presentation resulted in a higher rate of death (48 versus 33 percent) when compared with usual care [16]. However, several flaws including crude measurements of monitoring, lower than usual rates of lactate elevation, larger than typical volumes of fluid resuscitation, and use of dopamine (as opposed to norepinephrine) in a population with a high percentage of patients with human immune deficiency virus may have biased the results.
- The importance of timely treatment, particularly with antibiotics, was illustrated in a database study of nearly 50,000 patients with sepsis and septic shock who were treated with various types of protocolized treatment bundles (that included fluids and antibiotics, blood cultures, and serum lactate measurements) [17]. Compared with those in whom a three-hour bundle (blood cultures before broad spectrum antibiotics, serum lactate level) was completed within the three-hour time frame, a higher in-hospital mortality was reported when a three-hour bundle was completed later than three hours (odds ratio [OR] 1.04 per hour). Increased mortality was associated with the delayed administration of antibiotics but not with a longer time to completion of a fluid bolus (as part of a six hour bundle) (OR 1.04 per hour versus 1.10 per hour).
- The clinical and hemodynamic response and the presence or absence of pulmonary edema must be assessed before and after each bolus.
- Evidence from randomized trials and meta-analyses have found no convincing difference between using albumin solutions and crystalloid solutions (eg, normal saline, Ringer's lactate) in the treatment of sepsis or septic shock, but they have identified potential harm from using pentastarch or hydroxyethyl starch [18-27]. There is no role for hypertonic saline [28].
- Use of HES resulted in increased mortality and renal replacement therapy. [20]
- a central venous catheter and an arterial catheter are placed, although they are not always necessary. For example, an arterial catheter may be inserted if blood pressure is labile, sphygmomanometer readings are unreliable, restoration of perfusion is expected to be protracted (especially when vasopressors are administered), or dynamic measures of fluid responsiveness are selected to follow the hemodynamic response.
- One trial that randomized patients to a target MAP of 65 to 70 mmHg (low target MAP) or 80 to 85 mmHg. [72][73]
- Static
- Traditionally, in addition to MAP, the following static CVC measurements were used to determine adequate fluid management:
- CVP at a target of 8 to 12 mmHg
- ScvO2 ≥70 percent (≥65 percent if sample is drawn off a PAC)
- Dynamic
Respiratory changes in the vena caval diameter, radial artery pulse pressure, aortic blood flow peak velocity, left ventricular outflow tract velocity-time integral, and brachial artery blood flow velocity are considered dynamic measures of fluid responsiveness. There is increasing evidence that dynamic measures are more accurate predictors of fluid responsiveness than static measures, as long as the patients are in sinus rhythm and passively ventilated with a sufficient tidal volume. For actively breathing patients or those with irregular cardiac rhythms, an increase in the cardiac output in response to a passive leg-raising maneuver (measured by echocardiography, arterial pulse waveform analysis, or pulmonary artery catheterization) also predicts fluid responsiveness. Choosing among these is dependent upon availability and technical expertise, but a passive leg raising maneuver may be the most accurate and broadly available. Future studies that report improved outcomes (eg, mortality, ventilator free days) in association with their use are needed. Further details are provided separately.
Although the optimal frequency is unknown, we follow serum lactate in patients with sepsis until the lactate value has clearly fallen. While guidelines promote normalization of lactate [3], only lactate-guided resuscitation has not been convincingly associated with improved outcomes.
Patients having persistent hypoperfusion despite adequate fluid resuscitation and antimicrobial treatment should be reassessed for fluid responsiveness (see 'Hemodynamic' above) adequacy of the antimicrobial regimen and septic focus control (see 'Septic focus identification and source control' above) as well as the accuracy of the diagnosis and the possibility that unexpected complications or coexisting problems have occurred (eg, pneumothorax following CVC insertion) (see "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock"). Other options including vasopressors, glucocorticoids, inotropic therapy, and blood transfusion are discussed in this section.
Vasopressors
- Intravenous vasopressors are useful in patients who remain hypotensive despite adequate fluid resuscitation or who develop cardiogenic pulmonary edema.
- Guidelines state a preference for central venous and arterial access especially when vasopressor administration is prolonged or high dose, or multiple vasopressors are administered through the same catheter [3]; while this is appropriate, waiting for placement should not delay their administration and the risks of catheter placement should also be taken into account.
- Data that support norepinephrine as the first-line single agent in septic shock are derived from numerous trials that have compared one vasopressor to another [86-92].
- The addition of a second or third agent to norepinephrine may be required (eg, epinephrine, dobutamine, or vasopressin) with little data to support agent selection. For patients with refractory septic shock associated with a low cardiac output, an inotropic agent may be added.