Skip to main content
SpringerLink
Log in

Identification of Patients at Risk for Development of Tertiary Peritonitis on a Surgical Intensive Care Unit

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Tertiary peritonitis (TP) is defined as a severe recurrent or persistent intra-abdominal infection after adequate surgical source control of secondary peritonitis (SP). The aim of this study was to analyze the characteristics of patients with SP who will further develop TP in order to define early diagnostic markers for TP.

Study Design

Over a 1-year period, all patients on the surgical intensive care unit (ICU) with SP were prospectively assessed for the development of TP applying the definition of the ICU consensus conference. The Mannheim Peritonitis Index (MPI), C-reactive protein (CRP) and Simplified Acute Physiology Score II (SAPS II) were assessed at the initial operation (IO) that was diagnostic for SP and in the postoperative period.

Results

Among 69 patients with SP, 15 patients further developed TP, whereas 54 patients did not develop TP. Compared to SP, patients with transition to TP had significantly higher MPI at IO (28.6 vs. 19.8; p < 0.001), relaparotomy rate (2.00 vs. 0.11; p < 0.001), mortality (60% vs. 9%; p < 0.001), duration of ICU stay (14 vs. 4 days; p < 0.005), as well as SAPS II (45.1 vs. 28.4; p < 0.005) and CRP (265 mg/dL vs. 217 mg/dL; p < 0.05) on the second postoperative day after IO.

Conclusions

The MPI at IO as well as CRP and SAPS II at the second postoperative day helps to identify patients at risk for tertiary peritonitis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9

Similar content being viewed by others

Abbreviations

CRP:

C-reactive protein

ICU:

Intensive care unit

IO:

Initial operation

MPI:

Mannheim Peritonitis Index

SAPS II:

Simplified Acute Physiology Score II

SP:

Secondary peritonitis

TP:

Tertiary peritonitis

SP patient:

Patient with SP who did not further develop TP

TP patient:

Patient with SP who further developed TP

References

  1. Weiss G, Steffanie W, Lippert H. Peritonitis: main reason of severe sepsis in surgical intensive care. Zentralbl Chir 2007;132:130–137. doi:10.1055/s-2006-960478.

    Article  PubMed  CAS  Google Scholar 

  2. Calandra T, Cohen J. The international sepsis forum consensus conference on definitions of infection in the intensive care unit. Crit Care Med 2005;33:1538–1548. doi:10.1097/01.CCM.0000168253.91200.83.

    Article  PubMed  Google Scholar 

  3. Reemst P, Van Goor H, Goris RJ. SIRS, MODS and tertiary peritonitis. Eur J Surg 1996;576(Suppl):47–48. discussion 49.

    Google Scholar 

  4. Buijk SE, Bruining HA. Future directions in the management of tertiary peritonitis. Intensive Care Med 2002;28:1024–1029. doi:10.1007/s00134-002-1383-6.

    Article  PubMed  CAS  Google Scholar 

  5. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG. Diagnosis of intra-abdominal infection in the critically ill patient. Curr Opin Crit Care 2001;7:117–121. doi:10.1097/00075198-200104000-00010.

    Article  PubMed  CAS  Google Scholar 

  6. Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg 2000;24:32–37. doi:10.1007/s002689910007.

    Article  PubMed  CAS  Google Scholar 

  7. Koperna T. Surgical management of severe secondary peritonitis. Br J Surg 2000;87:378. doi:10.1046/j.1365-2168.2000.01369-12.x.

    Article  PubMed  CAS  Google Scholar 

  8. Linder MM, Wacha H, Feldmann U, Wesch G, Streifensand RA, Gundlach E. The Mannheim Peritonitis Index. An instrument for the intraoperative prognosis of peritonitis. Chirurg 1987;58:84–92.

    PubMed  CAS  Google Scholar 

  9. Billing A, Frohlich D, Schildberg FW. Prediction of outcome using the Mannheim Peritonitis Index in 2003 patients. Peritonitis Study Group. Br J Surg 1994;81:209–213. doi:10.1002/bjs.1800810217.

    Article  PubMed  CAS  Google Scholar 

  10. Fugger R, Rogy M, Herbst F, Schemper M, Schulz F. Validation study of the Mannheim Peritonitis Index. Chirurg 1988;59:598–601.

    PubMed  CAS  Google Scholar 

  11. Panhofer P, Izay B, Riedl M, Ferenc V, Ploder M, Jakesz R, Gotzinger P. Age, microbiology and prognostic scores help to differentiate between secondary and tertiary peritonitis. Langenbecks Arch Surg 2009;394(2):265–271.

    Article  PubMed  Google Scholar 

  12. Weiss G, Meyer F, Lippert H. Infectiological diagnostic problems in tertiary peritonitis. Langenbecks Arch Surg 2006;391:473–482. doi:10.1007/s00423-006-0071-3.

    Article  PubMed  CAS  Google Scholar 

  13. Agha A, Bein T, Frohlich D, Hofler S, Krenz D, Jauch KW. “Simplified Acute Physiology Score” (SAPS II) in the assessment of severity of illness in surgical intensive care patients. Chirurg 2002;73:439–442. doi:10.1007/s00104-001-0374-4.

    Article  PubMed  CAS  Google Scholar 

  14. Le Gall Jr., Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993;270:2957–2963. doi:10.1001/jama.270.24.2957.

    Article  Google Scholar 

  15. Malangoni MA. Evaluation and management of tertiary peritonitis. Am Surg 2000;66:157–161.

    PubMed  CAS  Google Scholar 

  16. Evans HL, Raymond DP, Pelletier SJ, Crabtree TD, Pruett TL, Sawyer RG. Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surg Infect (Larchmt) 2001;2:255–263. discussion 264–255. doi:10.1089/10962960152813296.

    Article  CAS  Google Scholar 

  17. Nathens AB, Rotstein OD, Marshall JC. Tertiary peritonitis: clinical features of a complex nosocomial infection. World J Surg 1998;22:158–163. doi:10.1007/s002689900364.

    Article  PubMed  CAS  Google Scholar 

  18. Dahaba AA, Hagara B, Fall A, Rehak PH, List WF, Metzler H. Procalcitonin for early prediction of survival outcome in postoperative critically ill patients with severe sepsis. Br J Anaesth 2006;97:503–508. doi:10.1093/bja/ael181.

    Article  PubMed  CAS  Google Scholar 

  19. Mokart D, Merlin M, Sannini A, Brun JP, Delpero JR, Houvenaeghel G, Moutardier V, Blache JL. Procalcitonin, interleukin 6 and systemic inflammatory response syndrome (SIRS): early markers of postoperative sepsis after major surgery. Br J Anaesth 2005;94:767–773. doi:10.1093/bja/aei143.

    Article  PubMed  CAS  Google Scholar 

  20. Reith HB, Mittelkotter U, Debus ES, Kussner C, Thiede A. Procalcitonin in early detection of postoperative complications. Dig Surg 1998;15:260–265. doi:10.1159/000018625.

    Article  PubMed  CAS  Google Scholar 

  21. Lindberg M, Hole A, Johnsen H, Asberg A, Rydning A, Myrvold HE, Bjerve KS. Reference intervals for procalcitonin and C-reactive protein after major abdominal surgery. Scand J Clin Lab Invest 2002;62:189–194. doi:10.1080/003655102317475443.

    Article  PubMed  CAS  Google Scholar 

  22. Meisner M, Tschaikowsky K, Hutzler A, Schick C, Schuttler J. Postoperative plasma concentrations of procalcitonin after different types of surgery. Intensive Care Med 1998;24:680–684. doi:10.1007/s001340050644.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors thank all the members of the intensive care unit team for continuous support. They further thank Tim Holland-Letz, Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum for statistical assistance.

Author information

Authors and Affiliations

  1. Department of General and Visceral Surgery, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstrasse 56, 44791, Bochum, Germany

    Ansgar M. Chromik, Janine Hölling, Dominique Sülberg, Kirsten Meurer, Matthias H. Seelig & Waldemar Uhl

  2. Department of Anesthesiology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany

    Andreas Meiser & Heike Vogelsang

  3. Department of Plastic Surgery, Burn Center, Hand Center, Sarcoma Reference Center, BG-University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany

    Adrien Daigeler

Authors
  1. Ansgar M. Chromik
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andreas Meiser
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Janine Hölling
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dominique Sülberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Adrien Daigeler
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kirsten Meurer
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Heike Vogelsang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Matthias H. Seelig
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Waldemar Uhl
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Waldemar Uhl.

Additional information

Ansgar M. Chromik and Andreas Meiser contributed equally to this publication.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Chromik, A.M., Meiser, A., Hölling, J. et al. Identification of Patients at Risk for Development of Tertiary Peritonitis on a Surgical Intensive Care Unit. J Gastrointest Surg 13, 1358–1367 (2009). https://doi.org/10.1007/s11605-009-0882-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-009-0882-y

Keywords

Search

Navigation