Therapeutic management of peritonitis: a comprehensive guide for intensivists
Therapeutic management of peritonitis: a comprehensive guide for intensivists
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DOI：
10.1007/s00134-016-4307-6
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发表时间：
2016-08-01
影响因子：
38.9
通讯作者：
De Waele, J.
中科院分区：
文献类型：
--
作者：
Montravers, P.;Blot, S.;De Waele, J.
由于其特征的变化和多重耐药 (MDR) 细菌的日益流行，危重患者腹膜炎的治疗变得越来越复杂。多学科小组总结了这些危重患者治疗管理的最新进展。阑尾炎、胆囊炎和肠穿孔占所有社区获得性感染的大多数，而大多数医疗相关感染病例发生在缝线泄漏和/或肠穿孔之后。涉及的微生物包括一系列革兰氏阳性菌和革兰氏阴性菌，以及厌氧菌和真菌。医疗保健相关感染与耐多药病原体的可能性增加有关。成功的关键因素是早期和最佳的源头控制以及充分的手术和适当的抗生素治疗。引流、清创、腹部清洗、冲洗和控制污染源是确保源头控制的主要步骤。在危及生命的情况下，“损害控制”方法是赢得时间和实现稳定的最安全方法。最初的经验性抗感染治疗应迅速进行，并且必须根据可疑的危险因素针对所有可能涉及的微生物，包括耐多药细菌和真菌。剂量调整需要基于药代动力学参数。支持治疗包括疼痛管理、通气优化、血流动力学和液体监测、肾功能改善、营养和抗凝。大多数腹膜炎患者会出现并发症，包括原有器官功能障碍恶化、手术并发症和医疗保健相关感染。在手术前的决策过程中必须考虑术后并发症的可能性。
The management of peritonitis in critically ill patients is becoming increasingly complex due to their changing characteristics and the growing prevalence of multidrug-resistant (MDR) bacteria.A multidisciplinary panel summarizes the latest advances in the therapeutic management of these critically ill patients.Appendicitis, cholecystitis and bowel perforation represent the majority of all community-acquired infections, while most cases of healthcare-associated infections occur following suture leaks and/or bowel perforation. The micro-organisms involved include a spectrum of Gram-positive and Gram-negative bacteria, as well as anaerobes and fungi. Healthcare-associated infections are associated with an increased likelihood of MDR pathogens. The key elements for success are early and optimal source control and adequate surgery and appropriate antibiotic therapy. Drainage, debridement, abdominal cleansing, irrigation, and control of the source of contamination are the major steps to ensure source control. In life-threatening situations, a "damage control" approach is the safest way to gain time and achieve stability. The initial empirical antiinfective therapy should be prescribed rapidly and must target all of the micro-organisms likely to be involved, including MDR bacteria and fungi, on the basis of the suspected risk factors. Dosage adjustment needs to be based on pharmacokinetic parameters. Supportive care includes pain management, optimization of ventilation, haemodynamic and fluid monitoring, improvement of renal function, nutrition and anticoagulation.The majority of patients with peritonitis develop complications, including worsening of pre-existing organ dysfunction, surgical complications and healthcare-associated infections. The probability of postoperative complications must be taken into account in the decision-making process prior to surgery.