World Journal of Surgery

, 33:34 | Cite as

Prognostic Factors in Critically Ill Patients Suffering from Secondary Peritonitis: A Retrospective, Observational, Survival Time Analysis

  • Christian P. Schneider
  • Carol Seyboth
  • Markus Vilsmaier
  • Helmut Küchenhoff
  • Benjamin Hofner
  • Karl-Walter Jauch
  • Wolfgang H. Hartl
Article

Abstract

Background

Acute mortality of unselected critically ill patients has improved during the last 15 years. Whether these benefits also affect survival of critically ill patients with secondary peritonitis is unclear as is the relevance of specific prognostic factors, such as source control.

Methods

We performed a retrospective analysis of data collected prospectively from March 1993 to February 2005. A cohort of 319 consecutive postoperative patients with secondary peritonitis requiring intensive care was evaluated. End points for outcome analysis were derived from daily changes of hazard rate.

Results

Four-month survival rate after intensive care unit (ICU) admission was 31.7%. For patients who have survived for more than 4 months, the 1-year survival was 82.7%. After adjustment for relevant covariates, a high disease severity at ICU admission and during ICU stay, specific comorbidities (extended malignancies, liver cirrhosis) and sources of infection (distal esophagus, stomach), and an inadequate initial antibiotic therapy were associated with worse 4-month prognosis. Inability to obtain source control was the most important determinant of mortality, and treatment after 2002 was combined with improved prognosis.

Conclusions

Four-month prognosis of critically ill, surgical patients with secondary peritonitis is poor and mostly determined by the ability to obtain source control. Outcome has improved since 2002, and after successful surgical and intensive care therapy long-term survival seems to be good.

Notes

Acknowledgement

The authors thank D. Inthorn and H. Schneeberger for initiation and maintenance of the database.

References

  1. 1.
    Anaya DA, Nathens AB (2003) Risk factors for severe sepsis in secondary peritonitis. Surg Infect (Larchmt) 4:355–362CrossRefGoogle Scholar
  2. 2.
    Pieracci FM, Barie PS (2007) Management of severe sepsis of abdominal origin. Scand J Surg 96:184–196PubMedGoogle Scholar
  3. 3.
    Barie PS, Hydo LJ, Eachempati SR (2004) Longitudinal outcomes of intra-abdominal infection complicated by critical illness. Surg Infect (Larchmt) 5:365–373CrossRefGoogle Scholar
  4. 4.
    Dellinger RP, Carlet JM, Masur H et al (2004) Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873PubMedCrossRefGoogle Scholar
  5. 5.
    Mulier S, Penninckx F, Verwaest C, Filez L, Aerts R, Fieuws S, Lauwers P (2003) Factors affecting mortality in generalized postoperative peritonitis: multivariate analysis in 96 patients. World J Surg 27:379–384PubMedCrossRefGoogle Scholar
  6. 6.
    Wacha H, Hau T, Dittmer R, Ohmann C (1999) Risk factors associated with intra-abdominal infections: a prospective multicenter study. Peritonitis Study Group. Langenbecks Arch Surg 384:24–32CrossRefGoogle Scholar
  7. 7.
    McLauchlan GJ, Anderson ID, Grant IS, Fearon KC (1995) Outcome of patients with abdominal sepsis treated in an intensive care unit. Br J Surg 82:524–529PubMedCrossRefGoogle Scholar
  8. 8.
    Kahn JM, Kramer AA, Rubenfeld GD (2007) Transferring critically ill patients out of hospital improves the standardized mortality ratio: a simulation study. Chest 131:68–75PubMedCrossRefGoogle Scholar
  9. 9.
    Ochiai T, Hiranuma S, Takiguchi N, Ito K, Kawaguchi A, Iwai T, Arii S (2004) SOFA score predicts postoperative outcome of patients with colorectal perforation. Hepatogastroenterology 51:1007–1010PubMedGoogle Scholar
  10. 10.
    Williams TA, Dobb GJ, Finn JC, Webb SA (2005) Long-term survival from intensive care: a review. Intensive Care Med 31:1306–1315PubMedCrossRefGoogle Scholar
  11. 11.
    Barie PS, Williams MD, McCollam JS, Bates BM, Qualy RL, Lowry SF, Fry DE (2004) PROWESS Surgical Evaluation Committee. Benefit/risk profile of drotrecogin alfa (activated) in surgical patients with severe sepsis. Am J Surg 188:212–220PubMedCrossRefGoogle Scholar
  12. 12.
    Laterre PF, Levy H, Clermont G, Ball DE, Garg R, Nelson DR, Dhainaut JF, Angus DC (2004) Hospital mortality and resource use in subgroups of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) Trial. Crit Care Med 32:2207–2218PubMedGoogle Scholar
  13. 13.
    Vincent JL, Bernard GR, Beale R, Doig C, Putensen C, Dhainaut JF, Artigas A, Fumagalli R, Macias W, Wright T, Wong K, Sundin DP, Turlo MA, Janes J (2005) Drotrecogin alfa (activated) treatment in severe sepsis from the global open-label trial ENHANCE: further evidence for survival and safety and implications for early treatment. Crit Care Med 33:2266–2277PubMedCrossRefGoogle Scholar
  14. 14.
    Billing A, Fröhlich D, Mialkowskyj O, Stokstad P, Schildberg FW (1992) [Treatment of peritonitis with staged lavage: prognostic criteria and course of treatment]. Langenbecks Arch Chir 377:305–313PubMedGoogle Scholar
  15. 15.
    Rüttinger D, Wolf H, Küchenhoff H, Jauch KW, Hartl WH (2007) Red cell transfusion: an essential factor for patient prognosis in surgical critical illness? Shock 28:165–171PubMedCrossRefGoogle Scholar
  16. 16.
    Müller M, Moubarak P, Wolf H, Küchenhoff H, Jauch KW, Hartl WH (2008) Independent determinants of early death in critically ill surgical patients. Shock 30:11–16PubMedCrossRefGoogle Scholar
  17. 17.
    Hartl WH, Wolf H, Schneider CP, Küchenhoff H, Jauch KW (2007) Secular trends in mortality associated with new therapeutic strategies in surgical critical illness. Am J Surg 194:535–541PubMedCrossRefGoogle Scholar
  18. 18.
    Schneider CP, Wolf H, Küchenhoff H, Jauch KW, Hartl WH (2006) Trends in der chirurgischen Intensivmedizin. 12 Jahre Erfahrung an einer einzelnen Institution. Chirurg 77:700–708PubMedCrossRefGoogle Scholar
  19. 19.
    Fertmann J, Wolf H, Küchenhoff H, Hofner B, Jauch KW, Hartl WH (2008) Prognostic factors in critically ill, surgical patients requiring continuous renal replacement therapy. J Nephrol (in press)Google Scholar
  20. 20.
    Hartl WH, Wolf H, Schneider CP, Küchenhoff H, Jauch KW (2007) Acute and long-term survival in chronically critically ill surgical patients: a retrospective observational study. Critical Care 11:R55PubMedCrossRefGoogle Scholar
  21. 21.
    Lowenkron SE, Niederman MS (1992) Definition and evaluation of the resolution of nosocomial pneumonia. Semin Respir Infect 7:271–281PubMedGoogle Scholar
  22. 22.
    Nathens AB, Rotstein OD (1994) Therapeutic options in peritonitis. Surg Clin North Am 74:677–692PubMedGoogle Scholar
  23. 23.
    Wolfe RA, Strawderman RL (1996) Logical and statistical fallacies in the use of Cox regression models. Am J Kidney Dis 27:124–129PubMedCrossRefGoogle Scholar
  24. 24.
    Hosmer DW, Lemeshow S (1999) Applied survival analysis. Wiley, New York, p 158Google Scholar
  25. 25.
    Therneau TM, Grambsch PM (2000) Modeling survival data: extending the Cox model. Springer-Verlag, Berlin Heidelberg, p 128Google Scholar
  26. 26.
    Klein JP, Moeschberger ML (2003) Survival analysis. Techniques for censored and truncated data. Springer, New York, p 295Google Scholar
  27. 27.
    Hosmer DW, Lemeshow S (1989) Applied logistic regression. Wiley, New York, p 84Google Scholar
  28. 28.
    Scheingraber S, Kurz T, Dralle H (2002) Short- and long-term outcome and health-related quality of life after severe peritonitis. World J Surg 26:667–671PubMedCrossRefGoogle Scholar
  29. 29.
    Hynninen M, Wennervirta J, Leppäniemi A, Pettilä V (2008) Organ dysfunction and long-term outcome in secondary peritonitis. Langenbecks Arch Surg 393:81–86PubMedCrossRefGoogle Scholar
  30. 30.
    Lamme B, Boermeester MA, Belt EJ, van Till JW, Gouma DJ, Obertop H (2004) Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg 91:1046–1054PubMedCrossRefGoogle Scholar
  31. 31.
    Van Ruler O, Mahler CW, Boer KR, Reuland EA, Gooszen HG, Opmeer BC, de Graaf PW, Lamme B, Gerhards MF, Steller EP, van Till JW, de Borgie CJ, Gouma DJ, Reitsma JB, Boermeester MA, Dutch Peritonitis Study Group (2007) Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA 298:865–872PubMedCrossRefGoogle Scholar
  32. 32.
    Haraldsen P, Andersson R (2003) Quality of life, morbidity, and mortality after surgical intensive care: a follow-up study of patients treated for abdominal sepsis in the surgical intensive care unit. Eur J Surg Suppl 588:23–27PubMedGoogle Scholar
  33. 33.
    Bosscha K, Reijnders K, Jacobs MH, Post MW, Algra A, van der Werken C (2001) Quality of life after severe bacterial peritonitis and infected necrotizing pancreatitis treated with open management of the abdomen and planned re-operations. Crit Care Med 29:1539–1543PubMedCrossRefGoogle Scholar
  34. 34.
    Demetriades D, Constantinou C, Salim A, Velmahos G, Rhee P, Chan L (2004) Liver cirrhosis in patients undergoing laparotomy for trauma: effect on outcomes. J Am Coll Surg 199:538–542PubMedCrossRefGoogle Scholar
  35. 35.
    Farnsworth N, Fagan SP, Berger DH, Awad SS (2004) Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg 188:580–583PubMedCrossRefGoogle Scholar
  36. 36.
    Micek ST, Roubinian N, Heuring T, Bode M, Williams J, Harrison C, Murphy T, Prentice D, Ruoff BE, Kollef MH (2006) Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 34:2707–2713PubMedCrossRefGoogle Scholar
  37. 37.
    Kollef MH, Sherman G, Ward S, Fraser VJ (1999) Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 115:462–474PubMedCrossRefGoogle Scholar
  38. 38.
    Krobot K, Yin D, Zhang Q, Sen S, Altendorf-Hofmann A, Scheele J, Sendt W (2004) Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis 23:682–687PubMedCrossRefGoogle Scholar
  39. 39.
    Sturkenboom MC, Goettsch WG, Picelli G, in ‘t Veld B, Yin DD, de Jong RB, Go PM, Herings RM (2005) Inappropriate initial treatment of secondary intra-abdominal infections leads to increased risk of clinical failure and costs. Br J Clin Pharmacol 60:438–443PubMedCrossRefGoogle Scholar
  40. 40.
    Kollef MH, Ward S (1998) The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia. Chest 113:412–420PubMedCrossRefGoogle Scholar
  41. 41.
    Rello J, Gallego M, Mariscal D, Soñora R, Valles J (1997) The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med 156:196–200PubMedGoogle Scholar
  42. 42.
    Marshall JC, Innes M (2003) Intensive care unit management of intra-abdominal infection. Crit Care Med 31:2228–2237PubMedCrossRefGoogle Scholar
  43. 43.
    Dellinger EP (1995) Intra-abdominal infections: treatment considerations. Infect Dis Clin Pract 4(Suppl 3):S163–S169Google Scholar
  44. 44.
    Montravers P, Dupont H, Gauzit R, Veber B, Auboyer C, Blin P, Hennequin C, Martin C (2006) Candida as a risk factor for mortality in peritonitis. Crit Care Med 34:646–652PubMedCrossRefGoogle Scholar
  45. 45.
    Boos C, Kujath P, Bruch HP (2005) [Intra-abdominal mycoses]. Mycoses 48(Suppl 1):22–26PubMedCrossRefGoogle Scholar
  46. 46.
    Adrie C, Azoulay E, Francais A, Clec’h C, Darques L, Schwebel C, Nakache D, Jamali S, Goldgran-Toledano D, Garrouste-Orgeas M, Timsit JF, for the OutcomeRea Study Group (2007) Influence of gender on the outcome of severe sepsis: a reappraisal. Chest 132:1786–1793PubMedCrossRefGoogle Scholar
  47. 47.
    Wichmann MW, Inthorn D, Andress HJ, Schildberg FW (2000) Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome. Intensive Care Med 26:167–172PubMedCrossRefGoogle Scholar
  48. 48.
    Eachempati SR, Hydo L, Barie PS (1999) Gender-based differences in outcome in patients with sepsis. Arch Surg 134:1342–1347PubMedCrossRefGoogle Scholar
  49. 49.
    Fowler RA, Sabur N, Li P, Juurlink DN, Pinto R, Hladunewich MA, Adhikari NK, Sibbald WJ, Martin CM (2007) Sex-and age-based differences in the delivery and outcomes of critical care. CMAJ 177:1513–1519PubMedGoogle Scholar
  50. 50.
    Angus DC, Laterre PF, Helterbrand J, Ely EW, Ball DE, Garg R, Weissfeld LA, Bernard GR, PROWESS Investigators (2004) The effect of drotrecogin alfa (activated) on long-term survival after severe sepsis. Crit Care Med 32:2199–2206PubMedCrossRefGoogle Scholar
  51. 51.
    Ympa YP, Sakr Y, Reinhart K, Vincent JL (2005) Has mortality from acute renal failure decreased? A systematic review of the literature. Am J Med 118:827–832PubMedCrossRefGoogle Scholar
  52. 52.
    Garland A (2005) Improving the ICU: part 2. Chest 127:2165–2179PubMedCrossRefGoogle Scholar
  53. 53.
    Kelly WF, Eliasson AH, Stocker DJ, Hnatiuk OW (2002) Do specialists differ on do-not-resuscitate decisions? Chest 121:957–963PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Christian P. Schneider
    • 1
  • Carol Seyboth
    • 1
  • Markus Vilsmaier
    • 1
  • Helmut Küchenhoff
    • 2
  • Benjamin Hofner
    • 2
  • Karl-Walter Jauch
    • 1
  • Wolfgang H. Hartl
    • 1
  1. 1.Department of SurgeryKlinikum GrosshadernMunichGermany
  2. 2.Statistical Consulting Unit, Department of StatisticsLudwig-Maximilian Universität München MunichGermany

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