Page 1561 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1080 PART 10: The Surgical Patient

enteric gram-negative rods and gram-positive cocci. 11,12 If the diagnosis appropriate antibiotics are administered. Success depends on adequate
may be secondary peritonitis so there is concern about distal small biliary decompression, accomplished by either operative common bile
bowel, appendix, or colonic derived pathogens, then coverage of obli- duct exploration and T tube insertion; endoscopic sphincterotomy,
gate anaerobic bacilli is warranted. Treatment with a third- or fourth- stone extraction, and internal or external biliary drainage; or transhe-
generation cephalosporin or quinolone is usually sufficient for primary patic biliary drainage. The adequacy of drainage is confirmed by clinical
bacterial peritonitis. For secondary bacterial peritonitis, metronidazole and biochemical improvement within 24 to 48 hours. Need for ongoing
is usually added to this regimen; other appropriate agents include a car- cardiopulmonary support beyond that implies inadequate biliary drain-
bapenem or β-lactam/β-lactamase combination. Prognosis of primary age, and mandates reimaging of the biliary tree to assess drainage and
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peritonitis depends mainly on the severity of the underlying cause of plan further decompression. Failure to improve may also be caused by
the ascites. hepatic abscess secondary to cholangitis, for which CT scan should be
Patients who develop peritonitis secondary to an infected peritoneal diagnostic.
https://kat.cr/user/tahir99/
dialysis catheter generally improve on antibiotics (usually instilled into
the dialysis fluid). Depending on the clinical scenario and peritoneal Acalculous Cholecystitis: A treacherous and potentially lethal condition,
fluid microbiology, nonresponse may necessitate removal of the catheter, acute acalculous cholecystitis may occur in patients without known bili-
treatment of fungal infection, or consideration of secondary peritonitis ary disease who are severely compromised by trauma or gastrointestinal
of gastrointestinal origin including catheter-induced gut perforation. dysfunction under prolonged intensive care. Onset is insidious, clinical
findings may be subtle, and delay in diagnosis is associated with necrosis
The Jaundiced Intensive Care Unit Patient: Sepsis and hyperbilirubinemia of the gallbladder, sepsis, and death. 15,16
occur commonly in critically ill patients. When they coexist, biliary tract This condition occurs in approximately 1% of long-term (>1 week)
sepsis may be the cause. However, most jaundiced ICU patients do not ICU patients, 15-18 likely more prevalent in patients on total parenteral
have pathology in their biliary tract. Before we discuss biliary sepsis, nutrition. Etiology and therefore preventive measures are not under-
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we will briefly outline the approach to the jaundiced patient. stood well. In about one-third of patients, the inflammation induces
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Abnormalities on liver function tests and even clinically evident necrosis of the gallbladder wall by the time of diagnosis.
jaundice are quite common in patients in the ICU. A review article The diagnostic and therapeutic challenge is the difficulty establish-
on jaundice in the ICU provides a simple classification, distinguishing ing a diagnosis without resorting to laparotomy or laparoscopy in a
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jaundice caused by obstructive and nonobstructive etiologies. Most ICU critically ill patient. An ICU patient can have right upper quadrant
patients with abnormal liver function tests represent the nonobstructive tenderness without cholecystitis, from liver capsule distension from
category. Exclusion of extrahepatic biliary obstruction is best accom- other causes. Liver function tests are not specific. A biliary radionuclide
plished by history, physical examination, and routine laboratory tests scan is not useful to demonstrate acalculous cholecystitis but may help
(ie, the clinical context), ultrasonography to look for bile duct dilation, rule it out by showing filling of the gallbladder. The most valuable tests
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and magnetic resonance imaging. In unusual circumstances, obstructed are ultrasonography and CT. Findings of pericholecystic fluid (without
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bile ducts may not be dilated, and clinical suspicion will necessitate ascites), intramural gas, or a sloughed mucosal membrane are virtually
visualization of the biliary tree with endoscopic retrograde cholangio- diagnostic. Unfortunately, not all patients have these findings. 16-17 A thick-
pancreatography (ERCP), percutaneous transhepatic cholangiography walled gallbladder is suggestive, but that is a common finding in ICU
(PTC), or magnetic resonance cholangiopancreatography (MRCP). 14 patients with generalized edema. Percutaneous bile aspiration for culture
■ BILIARY TRACT SEPSIS has high false-positive and false-negative rates and is therefore not helpful.
It is our practice to operate on the patient if clinical suspicion is suffi-
Infection in the biliary tree can cause one or more of three different ciently high and the patient deteriorates without other cause. We remove
clinical entities. The most common is acute calculous cholecystitis, the gallbladder; if the gallbladder is normal, we place a cholecystostomy
infection of the gallbladder caused by cystic duct obstruction by a gall- tube to prevent the condition from developing and obviate the need to
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stone. Treatment generally consists of cholecystectomy, and results in drain the gallbladder again. Direct visualization of the gallbladder in
ICU admission if the patient has major medical problems. When a cho- the operating room is the only accurate diagnostic measure. This can
lecystectomy is deemed too risky because of the severity of underlying or be carried out under local anesthesia, but this approach seems pointless
current illness, a percutaneous cholecystostomy can temporize until the in the ventilated patient. In the patient considered too sick to undergo
patient is more suitable for operation, though some patients never go on laparotomy, bedside ultrasound guided percutaneous transhepatic or
to have a definitive operation. More relevant to the intensivist are acute transperitoneal drainage of the gallbladder may result in significant
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cholangitis and acute acalculous cholecystitis. clinical improvement. The transhepatic route is preferred if ascites or
bowel loops are in the way; a transperitoneal approach is more suitable
Acute Cholangitis: Cholangitis, infection in the bile ducts, is caused by for patients with coagulopathy. These patients should later undergo cho-
bacteria multiplying in a partially or totally obstructed duct system, induc- lecystectomy ideally before the drainage tube is removed.
ing an inflammatory reaction around the small biliary radicles in the liver.
out of the bile canaliculi into the hepatic sinusoids, resulting in systemic ■ SECONDARY BACTERIAL PERITONITIS
Under increased hydrostatic pressure in the ducts, bacteria are forced
bacteremia. The bacteria are similar to those of the GI tract, and enter the This section covers the ICU management of patients with secondary
biliary tree under a variety of conditions including aging. bacterial peritonitis, defined as the presence of pus or gastrointestinal
The typical clinical presentation of right upper quadrant pain, jaun- contents in the peritoneal cavity. This condition may be either localized
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dice, and fever (Charcot triad) may not be evident in a ventilated patient. (an abscess) or diffuse (generalized peritonitis). Patients with physical
Patients may be only mildly ill with bactobilia or critically ill with frank signs of peritoneal irritation due to localized gastrointestinal tract infec-
pus under pressure in the biliary tree, leading to confusion and shock tions are discussed in Chap. 76.
(Reynold pentad). Diagnosis may be confirmed with ultrasound, CT, Patients with secondary bacterial peritonitis requiring intensive
ERCP, MRCP, or PTC. Treatment consists of biliary decompression care constitute a significant fraction of surgical ICU admissions and of
and the administration of appropriate broad-spectrum antibiotics to patients with peritonitis. At our hospital, 107 of 300 patients with gener-
cover aerobic gram-negative rods, anaerobic gram-negative bacilli, and alized peritonitis or abdominal abscess required posttreatment ventila-
enterococci. Blood for culture is obtained before antibiotics are started tory support, for an average of 10 days; their mean Acute Physiology and
(if possible) to guide antibiotic coverage. Chronic Health Evaluation [APACHE] II score was 19. The 193 patients
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These patients may require intensive care for septic shock. The who did not require ventilation had a mean APAHCE II score of 10.
ICU team should support cardiorespiratory function and ensure that Patients requiring postoperative ventilatory support were severely ill and

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