1. bookVolumen 76 (2022): Heft 1 (January 2022)
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Diagnostic challenges in postoperative intra-abdominal sepsis in critically ill patients: When to reoperate?

Online veröffentlicht: 14 Oct 2022
Volumen & Heft: Volumen 76 (2022) - Heft 1 (January 2022)
Seitenbereich: 420 - 430
Eingereicht: 04 Nov 2021
Akzeptiert: 14 Mar 2022
Zeitschriftendaten
License
Format
Zeitschrift
eISSN
1732-2693
Erstveröffentlichung
20 Dec 2021
Erscheinungsweise
1 Hefte pro Jahr
Sprachen
Englisch
Introduction

Sepsis is a significant cause of mortality in surgical intensive care units [1, 2]. Intra-abdominal sepsis (IAS) includes localized and generalized peritonitis and is a systemic inflammatory response to infection. IAS is the second most common sepsis in Intensive Care Units (ICUs), presenting severe morbidity and mortality [3, 4]. In intra-abdominal infections (IAI), the reported mortality rate is about 10%; however, in patients with acute sepsis, it can reach 40% or higher [1]. In terms of the number of cases presented in ICUs, sepsis accounts for about 25% of all admissions. Moreover, during their stay in the hospital, a significant fraction (~12%) of patients also develop sepsis, further increasing the disease burden.

The reported incidence rates of sepsis have increased in recent years [5]. The increase has been attributed to changes in demographics and invasive medical and intensive care measures [6]. The Surviving Sepsis Campaign (SSC) guidelines are recently updated [4]. These guidelines are used to manage sepsis in general, but they are not specific to the management of IAIs. Sepsis is a systemic process; however, an organ-specific management approach for sepsis can be more effective as the pathophysiological cascade of sepsis may differ from organ to organ.

It is well established that sepsis early diagnosis plays an essential role in effective control and favorable clinical outcome [7]. Sepsis can be controlled/treated by nonoperative or operative means, depending on the anatomical source of infection, severity, and patient-related factors [1, 8, 9, 10, 11, 12]. After the initial surgery, early diagnosis of IAS and an early sepsis control by relaparotomy might significantly reduce the risk of multiorgan failure and mortality [13]. The decision-making process is not straightforward. Mainly, in most of the cases presented at the Emergency Department (ED), the severity of sepsis is not apparent enough to allow easy diagnosis and management [14, 15, 16]. Considerable efforts have been made to devise an assessment criterion for sepsis. Careful consideration is nonetheless required in assessing the sensitivity and specificity of screening tools available for sepsis. For example, systemic inflammatory response syndrome (SIRS)–based criteria for sepsis have been in wide use. However, it has been found that the SIRS-based criteria have very low specificity for sepsis, though its sensitivity is good. Since the specificity is a significant consideration, in key recommendations in sepsis [3], SIRS criteria have been eliminated, and the quick SOFA (qSOFA) score is introduced due to its higher specificity [17]. However, in the ED setting, the effectiveness of qSOFA is not fully established [18, 19].

Unavailability of sensitive, specific, and rapid methods for monitoring sepsis in critical care settings makes the timely and adequate management of sepsis difficult [2, 9, 14, 20]. The situation is even more complicated in postoperative IAS [21]. As stated above, postoperative IAS is associated with a high mortality rate (28–47%) [3]. Early diagnosis and proper management are critical in reducing the probability of adverse outcomes. Due to restrictions in the patient's movement and high mortality risks associated with diagnostic assessments, the surgeons face a dilemma selecting cases suitable for reoperation and cases not suitable for this [22, 23, 24]. The dilemma is compounded by the risks associated with the use of different diagnosis techniques, portability, and sensitivity and specificity [21, 25, 26, 27]. In this scenario, critical concerns for surgeons are (1) the possibility of rapidly deteriorating septic state (2) the stress and complications of the initial surgery (3) the potential risk of ischemia to the tissue and other complications during relaparotomy.

The present research aimed to review techniques commonly used to help surgeons decide the suitable management strategy for postoperative IAS. Additionally, the present research presents a brief discussion of sepsis's epidemiology and pathology, abdominal sepsis, and postoperative IAS. A detailed account discussion is made on the advantages and disadvantages of diagnostic techniques used in the surgical course's clinical decision process. Attempts have been made to elucidate the scenario with the help of seminal articles. While discussing the diagnostic techniques, the focus has been made to present significance, sensitivity, and discriminate power wherever available. Scales and scores available for sepsis and reoperation assessment in postoperative IAS are discussed in detail.

Literature review

Postoperative sepsis is usually caused by a failure to eradicate infection at an initial laparotomy or anastomotic breakdown and can be extremely difficult to diagnose. Detection of complicated intra-abdominal sepsis is primarily a clinical diagnosis. However, critically ill patients may be difficult to evaluate due to distracting injuries, respiratory failure, obtundation, or other comorbidities [28]. Some researchers reported the efficacy of clinical assessment of patients admitted to the emergency department with abdominal pain and a systemic inflammatory response, including fever, tachycardia, tachypnea, and peritonitis in some cases [29]. Signs of hypoperfusion and hypotension including oliguria, lactic acidosis, and acute alteration of mental status are indicative of ongoing sepsis [30]. Some researchers have assessed the predictive value of C-reactive protein (CRP) for postoperative intra-abdominal sepsis [31, 32, 33]. Typically, CRP peaks between postoperative day (POD) 2 and POD 3 (about 12–24 h after interleukin [IL]- 6 peaks) and declines to baseline level on POD 5 [33]. Ultrasound-guided diagnostic drainage of suspicious fluid collections, combined with therapeutic tube insertion on demand, help surgeons to diagnose conditions including intra-abdominal abscesses, hematoma, and pancreatic fistula [34, 35]. Computed tomography (CT) scan is considered the diagnostic gold standard for both secondary and ongoing peritonitis, with diagnostic sensitivity of 97.2% [36]. Laparatomy has been considered one of the most routine diagnostic techniques for postoperative intra-abdominal sepsis [37]. However, this technique presents the risk of the development of acute abdominal compartment syndrome (ACS), recognized by peritonitis, capillary leakage, and fluid resuscitation [37, 38]. Documented data reported that when CT and abdominal ultrasound are not available, diagnostic peritoneal lavage may be useful for the diagnosis of postoperative intra-abdominal sepsis [39]. However, there is no exclusive standard protocol for the diagnosis of postoperative IAS in critically ill patients.

Definitions and discussion
Sources of infection, sepsis, and septic shock

Sepsis is the systemic inflammatory response to an infection [40, 41, 42]. It can be defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” The Sequential Organ Failure Assessment (SOFA) score is used to identify the organ dysfunction. Severe sepsis is the condition involving sepsis and dysfunction of at least one acute organ, hypoperfusion, or hypotension. The SIRS score, which was used in earlier definitions of sepsis, is now not used. The quick SOFA (qSOFA) has been introduced in the new definition of sepsis (Table 1) [43].

Scores of the Quick Sequential Organ Failure Assessment (qSOFA)

Criteria Scores
Systolic blood pressure (≤100 mmHg) 1
Change in mental status 1
Respiratory rate (≥22/min) 1

qSOFA is a specific attempt to identify high-risk patients with a suspected infection at the bedside. A several-fold increase in in-hospital mortality has been reported with an increase in two or higher points in qSOFA, reflecting the prognostic efficacy of the score [43]. However, the efficacy of qSOFA in the ED setting is not fully established. Dykes et al. reported a comparative study on qSOFA and SIRS criteria for early sepsis [17]. The study involved an elderly population, and the primary outcome was sepsis within 48 hours of admission. They reported that the qSOFA had lower sensitivity than SIRS (44.7% vs. 80.0%) but higher specificity (83.6% vs. 25.7%). Their results reflect low sensitivity of qSOFA; however, based on specificity and positive predictive value, the authors concluded that veterans with higher qSOFA had a high probability of having sepsis. The National Early Warning Score (NEWS) has also been reported to be useful in the ED setting; Lim et al. recently reported the effectiveness of NEWS in infection-related acute medical settings [44]. SIRS, SOFA, qSOFA, NEWS, and other scores are useful and have their own merits; however, none of them is specific enough to assist surgeons in deciding the feasibility of reoperation in patients with post-operative IAS.

Post-operative sepsis

Prophylactic antimicrobial therapy and other advances have reduced the incidences of surgery-bound infections. However, infections are still the leading causes of post-surgery morbidity and mortality [24, 45, 46, 47, 48]. Failure to remove infection at the initial surgery or anastomotic breakdown is the major contributor to postoperative IAS. Postoperative IAS is a challenging condition to diagnose. The outcome of patients with postoperative IAS correlates with the delay between the first and the corrective operation. With a rapid control of infection sources, the outcome is known to improve [7, 21].

Disease-dependent and critical condition–dependent scoring systems for IAI

The abdomen is the second most common source of sepsis [1, 49, 50]. Peritonitis, a common etiology of IAS, is categorized into primary, secondary, or tertiary. Around 11% of all patients with peritonitis are known to have complications of severe sepsis [51, 52, 53]. Early diagnosis and treatment of IAIs are important to sepsis control [2, 54, 55, 56, 57]. As many cases of complicated IAI involve the ICU setting, severity scoring systems for IAI can be disease-independent or disease-specific. Disease-independent scores include Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS II). Among disease-specific scores, Mannheim Peritonitis Index (MPI) is a valuable prognostic tool. However, some concerns have been raised regarding the prognostic significance of APACHE II in peritonitis, as the score does not include the role of interventions. The MPI has the advantage of being specific for peritonitis. However, these scoring systems or their combinations are not specific to prognosticate the reoperation decision-making process in postoperative IAS.

Reoperation diagnostic techniques used for sepsis assessment

After abdominal surgery, reoperation presents severe morbidity and mortality risks, especially in IAS, in critically ill patients [22, 26, 48, 58, 59]. Currently, for patients with postoperative IAS, there are no accepted guidelines or scoring systems that can be used to select the patients for relaparotomy for sepsis control. Even with the recent advances in diagnostic technologies (radiological or laparoscopic), prognosis after laparotomy remains a challenge. A combination of diagnostic tests and clinical examinations is used in the clinical decision-making process. Different diagnostic methods, including laboratory, radiologic, and interventional techniques have been developed to assess the abdomen in postoperative IAS (Figure 1) [58].

Fig. 1

Common diagnostic techniques that assist the surgical decision-making process in abdominal reoperation in a critical care setting

Several factors need to be analyzed in the critical care setting before selecting an appropriate diagnostic modality for a patient with suspected postoperative IAS. The foremost consideration is the hemodynamic stability of the patient. For unstable patients, techniques that involve the transfer of patients from the ICU to another unit might not be feasible. Computerized tomography is among the most common modalities for the intra-abdominal examination for stable patients. The comparative efficacy of computed tomography (CT) and ultrasonography (US) for the diagnosis of IAIs have been reported in several studies [60]. It may be noted that though, in the critical care setting, portability of the sonography techniques offers an advantage over CT, the considerably low sensitivity and specificity of sonography make it of little help in surgical decision-making on patients with postoperative IAS. Magnetic resonance imaging and nuclear techniques are not routinely available in most hospitals in the ICU. Therefore, their uses are expected to have limited applications in postoperative IAS [61]. When imaging is not feasible or conclusive in identifying the causative pathology, diagnostic laparoscopy techniques or exploratory laparotomy may be used [62]. Abdominal Reoperation Predictive Index (ARPI) is the only predictive index developed for assessing the suitability of the surgical approach in postoperative care of IAS [23].

Serial intra-abdominal pressure is another technique that has been explored for the prognosis of the patient with suspected postoperative IAS. A detailed discussion of these techniques is presented in the following sections.

Computed tomography (CT)

CT of the abdomen is extensively explored for IAI because of its high accuracy in diagnosing intra-abdominal abscess [36, 63, 64, 65, 66, 67]. However, a few factors restrict the use of CT in the critical care setting, including the risk associated with the movement of the patient from the safety of the ICU to the radiology room and the transfer- and optimization-associated time delays. Significant respiratory and hemodynamic deterioration can take place during transportation. Careful consideration of the patient's condition should be given before using CT in a patient with suspected postoperative IAS. CT scan has high sensitivity and specificity for intra-abdominal fluid collections and abscesses [68, 69, 70]. Velmahos et al. conducted a prospective case series of 85 critically injured patients. The reported sensitivity was around 98% in their work, and the reported specificity was around 62%. Around 70% of the total patients benefited from treatment changes due to the inputs provided from the CT scan [36]. Kumta et al. indicated that in around 80% of the patients in their study group, the management course was altered based on decisions made after CT [71]. As the patient's transfer to a CT scan is a severe limitation of the management of patients receiving critical care, one way to overcome this limitation is the use of portable CT [71]. However, portable CT is expensive, and not much work has been reported on its diagnostic efficacy for postoperative IAS. Maher et al. investigated the quality and clinical Impact of portable abdominal CT in 100 cases [72]. They reported the relatively low quality of the image obtained from portable CT compared to the image obtained from conventional CT. However, the authors concluded that, despite the inferior image quality, portable abdominal CT provides essential diagnostic information with the benefit of avoiding transport of the patient outside the ICU. Nonetheless, the interpretation of portable CT scans should be conducted with caution. Even the suitability of conventional CT scans for the patient with suspected postoperative IAS was questioned in some studies. Norwood et al. analyzed the influence of CT scans on the clinical decisions made on critically ill patients. They concluded 70% of scans were either of no help or were not used in the clinical decision process [73]. CT examinations should therefore be used according to proven clinical rationale; when case severity is high, alternative diagnostic techniques may be explored [74]. There is not much data on predicting the power of CT scans for reoperation for postoperative IAS. Bader et al. focused on elucidating early indications for relaparotomy in patients with diffuse secondary peritonitis. They reported a higher sensitivity in CT scans (97.2%) than in conventional radiography (66.2%) or in ultrasonography (44.3%) [75]. The use of multidetector-row CT (MDCT) scanners can further enhance the diagnostic efficacy for detecting the cause of abdominal sepsis. A sensitivity of 95% and a specificity of 91% was reported for abdominal sepsis [76].

Bedside Diagnostic Laparoscopy (BDL)

Due to the risk associated with the transport of patients from ICU and in situations when routine radiological techniques do not yield a conclusive diagnosis, bedside diagnostic techniques are advised to identify causative intra-abdominal pathology [77, 78, 79, 80]. Furthermore, bedside techniques do not interrupt the ongoing treatment in the ICU and can also help in cost and time minimization. In the critical care setting, BDL is a feasible, safe, and efficient tool to examine the intra-abdominal pathology of hemodynamically unstable patients [78]. BDL has high accuracy for IAS diagnosis. BDL in appropriately selected patients can, therefore, be of great help in avoiding negative laparotomies [81]. Even in unstable patients with abdominal sepsis of unknown origin, DL has been found to have good accuracy with a high definitive diagnosis rate (86–100%) [77]. BDL can be successfully used for intubated as well as for non-intubated patients. It can be used when there are other signs of sepsis, but laparotomy indications are not clear. Diagnostic laparoscopy (DL) has very high sensitivity (98%) and specificity (96%) for unexplained severe abdominal pain [82]. In 36–95% of patients, DL has been reported to prevent laparotomy [83]. It is superior to computed tomography or ultrasound of the abdomen in terms of sensitivity and specificity. In BDL, morbidity risks are very low (<8%), and no mortality cases were directly attributed to DL. Due to better safety, DL is also preferred over diagnostic peritoneal lavage. However, since mortality rates among patients admitted in the ICU are generally very high, the diagnostic modality's safety cannot be the sole criterion for its use. The suitable diagnostic modality and the conditions of its use in the patients with suspected postoperative IAS should be case-specific and should not be generalized. The decision should be based on the patient's condition and vital signs and the surgical resources and expertise available at the hospital.

Diagnostic Peritoneal Lavage (DPL)

Before the availability of advanced CT techniques, DPL used to be a preferred method for diagnosing intra-abdominal pathology in the ICU [84, 85, 86, 87]. The process is not associated with mortality risk; however, it is reported to have risks such as small bowel/mesenteric injuries, intra-abdominal abscess, bladder punctures, abdominal wall infusions, and reoperation [88, 89]. Complication rates in DPL have been reported in the range of 0.8%–1.7%. This test is considered 100% sensitive and 88% specific; therefore, a negative diagnostic peritoneal lavage makes intra-abdominal surgical disease highly unlikely. On the other hand, a positive lavage may require further diagnostic examination [89, 90]. For critically ill ICU patients, Lee et al. recommended that DPL be a useful preoperative diagnostic tool for examining suspected intra-abdominal pathology [91]. A patient-specific risk-benefit analysis needs to be conducted before selecting DPL for critically ill patients with suspected postoperative IAS. One of the reasons the author has a low threshold for leaving intra-abdominal drains in high-risk patients is to utilize the drain body fluid analysis as a DPL.

Abdominal Reoperation Predictive Index (ARPI)

Though surgeons can use the techniques mentioned above to better assess the severity of intra-abdomen sepsis and decide on reoperation, none of them is exclusively designed to assist in the decision-making process in postoperative IAS. ARPI is the only predictive index available exclusively for the abdominal re-operation decision-making process in postoperative IAS [27, 92]. A typical flow chart for ARPI is shown in Figure 2.

Fig. 2

Typical ARPI flow chart (special studies imply laboratory assays and imaging tests)

ARPI has lower mortality, reduce the delay between the first operation and reoperation, and shorten the duration of ICU stay [27]. ARPI is calculated using the different parameters listed in Table 2 [27].

Scores of the Abdominal Reoperation Predictive Index (ARPI)

Criteria Score
Respiratory failure 2
Renal failure 2
Alterations in consciousness 2
Emergency surgery (at initial operation) 3
Ileus (72 hours after surgery) 4
Abdominal pain (48 hours after surgery) 5
Persistent symptoms (4th day after surgery) 6
Wound infection 8

It has been claimed that with the proper use of ARPI, the surgical conundrum associated with the decision concerning re-operation of patients suspected with postoperative IAS can be resolved to a great extent [27]. ARPI is reported to be specifically useful in settings with limited resources [93]. In a cross-sectional, retrospective study of 94 patients diagnosed with abdominal sepsis, ARPI was used to assist in the decision process [23]. The authors reported reoperation in 75% of cases when ARPI was greater than 21 and 26% of cases when ARPI was less than 20. In another recent study, ARPI was found to be a helpful surgical decision aid regarding relaparotomy [23]. However, ARPI also has several limitations. The most important is that the accuracy of this scoring system has not been fully established. Furthermore, the variables that have high weight are related to postoperative IAI symptoms rather than peritonitis symptoms. The index also has subjective variables such as altered levels of consciousness and abdominal pain, which are difficult to measure in sedated and ventilated ICU patients [92].

Exploratory laparotomy

Abdominal exploration can also be used as a highly effective diagnostic modality in acute cases of IAS [94, 95, 96]. It is a rapid, cost-effective, and accurate method. However, the long-term mortality and morbidity risks associated with it dictate its use only in cases with apparent anticipation of the diagnosis [97, 98, 99, 100, 101, 102]. Advances in laparoscopic and imaging techniques for abdomen inspection have further reduced the necessity of exploratory laparotomy. Before exploratory laparotomy, it is essential to ensure that necessary expertise and resources are available to perform the adequate and timely therapeutic procedure if the suspected IAS is confirmed on exploration [59]. DPL can be used as the first-line diagnostic modality. If the results are positive, exploratory laparotomy can be used; in case of negative DPL findings, the patient can be closely monitored till the indications for exploratory laparotomy are more evident [103]. In a critical study on exploratory laparotomy, BSL (Bedside Exploratory Laparotomy) in the ICU was compared with emergency laparotomy in the operating room. The study reported 77.8% mortality in BSL and 45.5% in laparotomy [104]. This result does not suggest that BSL has higher mortality risks than laparotomy. This result underscores the ICU setting's mortality risk and the importance of timely and adequate surgical intervention. In cases where there are no rapid ways available to support the surgical decision process, emergent laparotomy may be used to identify surgically correctable causes, despite the anticipated high mortality with laparotomy [62, 104, 105, 106].

Further stressing the importance of timely interventions, some studies recommend on-demand relaparotomy within 48 hours of initial surgery or before the emergence of multiple organ dysfunction syndromes [25, 107, 108, 109]. In terms of deciding for relaparotomy, van Ruler et al. suggested that findings at emergency laparotomy for peritonitis are not adequate, and the monitoring of progressive or persistent organ failure is the best indicator for the need for reoperation [110]. In the absence of extensive studies, it is difficult to make a conclusive argument. However, all studies recognized the benefits of sensitive detection techniques that permit directed laparotomy before septic deterioration [13, 101, 111, 112].

Serial Intra-abdominal pressure

IAS is reported to be associated with higher intra-abdominal pressure (IAP). IAP increase is ascribed to excessive bowel edema due to increased vascular permeability and fluid sequestration [113, 114]. IAP has been classified into four grades, and higher IAP commonly results in reduced regional and global perfusion, posing a severe risk for vital organ failure. After a comprehensive literature search, Plantefeve et al. concluded that IAP could be a useful tool for monitoring critically ill patients with a suspicion of postoperative IAS [115]. Basu et al. investigated the predictive potential of the increased IAP for relaparotomy. A study of 102 patients found that postoperative elevation in IAP is associated with the increased risk of peritonitis, concluding that the elevated IAP can be a predictor of early relaparotomy [116]. It is worth highlighting here that the IAP measurements conducted in the immediate postoperative period were used for predicting the need for relaparotomy. This will be particularly helpful in starting early intervention for the surgical correction of sepsis.

Other notable developments

Using preoperative and intraoperative parameters, Kong et al. also reported developing a clinical model with a predictive value of more than 90% for the need for relaparotomy. In a study involving 1000 patients, four factors were used to accurately predict the need for subsequent relaparotomy. These factors were: patients referred from any rural center, duration of illness greater than 5 days, heart rate higher than 120 bpm, and perforation associated with generalized IAS [117]. Van Ruler et al. used a 10-point visual analog scale (VAS), and VAS score >5.0 was considered “important.” However, only three out of ten “important” variables were found to be independently predictive [118]. In another interesting study, postoperative procalcitonin (PCT) serum levels were monitored. The authors claimed sensitivity of 93% and a specificity of 71% for eliminating septic abdominal focus [119]. Sileikis et al. devised a scoring system using six factors: age, sex, leukocyte count, C reactive protein, time of symptoms to index operation, and MPI. A score ≥37 indicates a planned relaparotomy, and ≤24 indicates other milder therapeutic interventions rather than relaparotomy [120].

Conclusions

Postoperative IAI can rapidly progress to severe sepsis and septic shock. Patients with postoperative IAS are hemodynamically unstable, and the decision to perform a reoperation to correct the infection surgically is complicated due to the associated high morbidity and mortality risk. The on-demand strategy seems a valid option in such conditions; however, the severity of IAS is not well defined, and it can rapidly progress into an advanced stage where the correction by relaparotomy can become more complicated or not possible. There is a need for diagnostic tools and guidelines that can aid in the decision process on whether to operate or not. The limited timeframe between initial surgery and reoperation and a lack of proper score and indices to support the surgical decision are the significant challenges in the successful management of postoperative IAS. Abdominal CT is the most sensitive imaging modality in the assessment of postoperative intra-abdominal infections. However, in a critical care setting, patients' movement is restricted, and may not allow the transfer of the patient from ICU to the CT room. Furthermore, such an exercise may disrupt or delay the ongoing treatment and may pose a serious morbidity risk. Though it may be available, a portable CT scan is expensive, and the clinical data available on its diagnostic efficacy is limited. Bedside diagnostic laparoscopy is a promising technique with high sensitivity and specificity. Diagnostic peritoneal lavage offers 100% sensitivity, and therefore a negative DPL is an essential tool for surgeons to decide the further course. Exploratory laparotomy is an accurate method, though it poses high morbidity and mortality risks. Wherever possible, a DPL positive test should be used to decide on the requirement of exploratory laparotomy. ARPI is the only predictive tool designed exclusively to assist in the decision process for postoperative IAS. Though the effectiveness of ARPI has been reported in a few studies, more efforts are needed on its validation. It has also been advocated to use a part of the assessment tool to evaluate IAP in such conditions. These factors suggest that there is no single tool available for the surgical decision-making process in patients with postoperative IAS. In the author's experience, patients in whom the physical examination is unreliable – e.g., intubated and sedated patients, morbidly obese patients, patients with insensate abdomen, and. immunocompromised patients with a negative CT abdomen, and who have other sources of sepsis – the author prefers DPL, followed by DL and exploratory laparotomy, in that descending order. However, for patients in whom the physical examination is reliable, who are immunocompetent, and who have multiple sources of sepsis and negative CT abdomen, the author prefers a combination of ARPI, Serial IAP measurements, and drain body fluid analysis (if a drain was left from the previous surgery). For patients with no other suspected sepsis source and a negative CT abdomen, the author prefers DL for patients stable enough to go to OR, and DPL for patients who need some resuscitative measures before going to OR: for example, coagulopathy that requires blood components therapy before surgery. Due diligence to patients' condition, timeframe, and risk associated with the diagnostic modalities should be given before deciding on the preoperative approach.

Fig. 1

Common diagnostic techniques that assist the surgical decision-making process in abdominal reoperation in a critical care setting
Common diagnostic techniques that assist the surgical decision-making process in abdominal reoperation in a critical care setting

Fig. 2

Typical ARPI flow chart (special studies imply laboratory assays and imaging tests)
Typical ARPI flow chart (special studies imply laboratory assays and imaging tests)

Scores of the Abdominal Reoperation Predictive Index (ARPI)

Criteria Score
Respiratory failure 2
Renal failure 2
Alterations in consciousness 2
Emergency surgery (at initial operation) 3
Ileus (72 hours after surgery) 4
Abdominal pain (48 hours after surgery) 5
Persistent symptoms (4th day after surgery) 6
Wound infection 8

Scores of the Quick Sequential Organ Failure Assessment (qSOFA)

Criteria Scores
Systolic blood pressure (≤100 mmHg) 1
Change in mental status 1
Respiratory rate (≥22/min) 1

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