WHAT YOU NEED TO KNOW SERIES – REVIEWS

Sepsis management of the acute care surgery patient: What you

need to know

Lydia R. Maurer, MD, MPH and Niels D. Martin, MD, FACS, FCCM, Philadelphia, Pennsylvania

ABSTRACT: Increasingly, acute care surgeons have taken over the management of general surgery consult patients in the hospital, many of whom present
with sepsis and/or in septic shock. In this article, we will discuss the intricacies of sepsis management for acute care surgery. The underlying
tenants of sepsis management will be outlined with specific attention to the nuances associated with surgical patients. Ultimately, when a sur-
gical problem is identified, this management will culminate with the need for specific source control — the unique aspect when a surgical as
opposed to a medical disease process is the cause of sepsis. However, surgeons must also be competent in the other components of sepsis man-
agement including antimicrobial therapy and hemodynamic support. This article is designed for the surgeon or for any provider caring for pa-
tients with a potential acute care surgical problem, recognizing that different practice settings will vary with regard to resource availability for
laboratory tests, invasive monitoring, diagnostics, and surgeon availability. (J Trauma Acute Care Surg. 2025;98: 533–540. Copyright © 2024
Wolters Kluwer Health, Inc. All rights reserved.)
KEY WORDS: Sepsis; infection; surgery; surgical critical care; acute care surgery.

33% of patients left with chronic critical illness.3 As such, opti-

S eptic patients who present with surgical emergencies benefit
from a standardized approach to evaluation, resuscitation,
and management in the process toward source control. Within
mizing care for these patients from identification of sepsis to
source control and, finally, deescalation of therapy is critical.
the acute care surgery (ACS) patient population is a diverse
group of patients with a wide array of underlying risk factors
for surgical disease and progression, along with a range of septic
etiologies. As such, a systematic approach is useful when ap- BACKGROUND CONTEMPORARY DATA: WHAT
proaching an unstable septic patient, ultimately tailored in a ARE THE MOST RECENT GUIDELINES ON
patient-centered way, based on their presentation. The aim of SEPSIS MANAGEMENT?
this article is to provide an overview of the tenets of managing
a septic patient with a surgical emergency. In the last 25 years, the overall management of sepsis has
shifted from one of a high-volume resuscitative approach advo-
STARTING WITH THE BASICS: WHAT DEFINES cated by the Rivers trial and early goal directed therapy pub-
SEPSIS? DEFINITIONS, INCIDENCE, lished in 20014 to an approach more focused on resuscitation
based on dynamic end organ perfusion markers. Tenets of the
AND IMPORTANCE
Rivers trial and early goal-directed therapy included large-
According to the surviving sepsis guidelines, sepsis is volume fluid resuscitation to obtain a central venous pressure
defined as “life-threatening organ dysfunction caused by a dys- target of 8 to 12 and an ScvO2 greater than 70. In patients man-
regulated host response to infection.”1 Despite innumerable ad- aged this way, we learned that many people were overresuscitated
vances in health care over time, sepsis remains a leading cause and developed sequelae including adult respiratory distress syn-
of death in US hospitals (30–50% of in-hospital deaths).2 Among drome and intra-abdominal hypertension. Subsequent random-
septic surgical intensive care unit patients, short-term mortality ized studies comparing early goal-directed therapy and standard
has improved over time, but long-term outcomes are still poor care (PROCESS,5 ARISE,6 PROMISE7) showed no difference
with 10% mortality at 30 days, 20% mortality at 1 year, and between the two. As a consequence, we now tend to use multiple
markers of end-organ perfusion to appropriately resuscitate (and
ideally not overresuscitate) patients.
More recently, management of sepsis has been guided by
Submitted: July 31, 2024, Accepted: August 3, 2024, Published online: November 13,
2024. the Surviving Sepsis campaign, 8 a series of articles designed to
From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery, offer systems-level recommendations for sepsis care. The most
Department of Surgery, Perelman School of Medicine, University of Pennsylvania, recent of these guidelines (Sepsis-3) was published in 2021,
Philadelphia, Pennsylvania.
Address for correspondence: Niels D. Martin, MD, FACS, FCCM, Division of
the principles of which cover initial resuscitation and manage-
Traumatology, Surgical Critical Care, and Emergency Surgery, Department of ment in the first hour, antimicrobial selection and initiation (pri-
Surgery, Perelman School of Medicine, University of Pennsylvania, 51 N 39th oritizing an early start for antibiotics in the first hour), source
ST, MOB Ste 120 (Trauma), Philadelphia, PA 19104; email: Niels.Martin@ control as early as possible, when to stop antibiotics after source
pennmedicine.upenn.edu.
control including deescalation, and incorporating goals of care
DOI: 10.1097/TA.0000000000004467 discussions early.9
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Volume 98, Issue 4 533

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 J Trauma Acute Care Surg
Maurer and Martin Volume 98, Issue 4

STEP-BY-STEP GUIDE: CRITICAL STEPS IN THE result in interstitial edema and subsequent abnormalities in
INITIAL RESUSCITATION OF PATIENTS WITH gas exchange. As such, patients may require adjuncts such as
POSSIBLE SEPSIS high flow nasal cannula or bilevel positive airway pressure to
correct hypoxemia while antibiosis is initiated and progress
In evaluating and initially managing patients with possible toward source control is made.10 However, as the systemic
sepsis, the ABC approach (airway, breathing, circulation) can impact of sepsis progresses, intubation should not be delayed
guide initial management of the critically ill patient (Fig. 1). in the patient with progressive tachypnea and respiratory
One of the tenets of the ABC approach is to address and com- insufficiency.
plete step one (airway), before moving to the next step (breath-
ing), and so on. In clinical reality, depending on availability of
skilled personnel and resources, many of these aspects can hap- Circulation
pen simultaneously. For instance, while the anesthesia or emer- A critical feature of the early management of shock for
gency department team is securing the airway, another provider the acute care surgeon is to consider multiple possible causes
may be placing large bore intravenous (IV) or intraosseous ac- of shock including cardiogenic, hemorrhagic, hypovolemic, ana-
cess and starting resuscitation. Early consideration of the envi- phylactic, or obstructive. Septic patients may also have multifac-
ronment of care including monitored setting or intensive care torial shock with etiology that is not exclusively septic. In the
unit should be undertaken. In addition, considering the overall circulation step, the team should assess the patient's heart rate
resources of the hospital early can be valuable in deciding and rhythm with an ECG, blood pressure, and markers of end or-
whether to initiate transfer to a higher level of care. gan perfusion including an examination of the patient to see if
they are warm or cool peripherally along with assessing capillary
Airway refill and initial lactate. Large bore IVaccess is imperative in the
The decision to intubate may be multifactorial, but at the care of the septic ACS patient and should be done simulta-
outset, the team should consider the patient's ability to protect neously with airway and breathing in the initial assessment and
their airway, to oxygenate, and to ventilate (expel CO2). Septic management. Central access can be considered, but it is reason-
patients can develop altered mental status and become unable able to start with peripheral IV access. Consider invasive blood
to protect their airway. Septic patients, particularly those in shock, pressure monitoring with an arterial line in the hypotensive pa-
may develop a lactic acidosis and thus become tachypneic in an tient. According to the surviving sepsis campaign, initial fluid
effort to compensate and normalize their pH. Some patients can resuscitation should be initiated with 30 mL/kg in the first
tolerate this respiratory effort, while others may fatigue over 3 hours for goal mean arterial pressure of >65 mmHg.9 As
time. If tiring out, or unable to maintain a minute ventilation suf- always, a patient-centered approach must be taken, with other
ficient to buffer their metabolic acidosis, patients may need to be underlying medical problems considered as far as the volume
intubated. of resuscitation, including heart failure with reduced ejection
fraction, diastolic heart failure, pulmonary hypertension, and se-
Breathing vere lung disease, among others. After this initial volume resus-
The pulmonary interstitium is very sensitive to circulating in- citation, the volume of additional fluid should be guided by
flammatory cytokines. Even a distant source of infection can markers of end-organ perfusion including physical examination

Figure 1. Step-by-step guide to initial resuscitation of the patient with intra-abdominal sepsis.

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J Trauma Acute Care Surg
Volume 98, Issue 4 Maurer and Martin

(to be discussed hereinafter). In general, balanced crystalloid so- associated with placement and use.45 More recently, newer tech-
lution is preferable to saline or colloid.11 nology has become increasingly widespread including various
Initial laboratory investigations prior to initiating antibi- kinds of noninvasive and less invasive cardiac output monitors
otics should include complete blood count, basic metabolic (e.g., Flotrac/Vigileo (Edwards Lifescience, Irvine, CA), etc.).
panel, liver function tests, lipase, coagulation factors, type and While there is some evidence for use of these monitors in certain
screen, lactate (part of the Sepsis-3 definition of septic shock),1 patient populations, their use should be balanced by the limita-
blood cultures from two sites, and an arterial blood gas. Of note, tions of the technologies such as that extremely low systemic
lactate should be used as an adjunct within a group of tests vascular resistance can make cardiac output measurements un-
and additional markers of end-organ perfusion, not as a solo reliable.46,47 In addition, it should be noted that many measures
screening test for sepsis.9 Initial antibiotics should be broad such as cardiac output and index, stroke volume variation, sys-
spectrum; consider patient factors including comorbidities, pres- temic vascular resistance, and others should be considered more
ence of immunosuppressed status, and previous exposure to the as trends than acted on as isolated values.
health care environment; and cover multiple possible sources.
Some examples of empiric choices are listed in the Table 1, DIAGNOSTIC WORKUP AND SOURCE
but these should be tailored to both patient factors and individual INVESTIGATIONS
institutional antibiograms and policies. Empiric antifungal cov-
erage is generally not recommended in the patient who is not While some of the diagnostic evaluation such as x-rays and
neutropenic or otherwise immunosuppressed.40 point-of-care ultrasound can happen simultaneous with the initial
resuscitation, patients who need a computed tomography (CT) scan
HEMODYNAMIC MONITORING AND MARKERS should have a reassuring respiratory status and be well resuscitated
OF END-ORGAN PERFUSION before traveling for a scan. In general, the appropriate imaging
study will be guided by the initial history, physical examination,
In the hypotensive patient who does not respond to initial and laboratory tests. We have summarized some of the common
volume resuscitation and/or is persistently hypotensive in the ACS diagnoses related to sepsis in Table 1, along with appropriate
process of volume resuscitation with a mean arterial pressure target antibiotics, workup, and appropriate source control.
of <65 mmHg, norepinephrine is the pressor of choice, generally The initial approach and resuscitation of the postoperative
followed by vasopressin if a second pressor is needed.41–43 Fol- patient with undifferentiated sepsis follow the same principles of
lowing the initial resuscitation phase, ongoing volume status as- any septic patient with rapid assessment and initiation of resus-
sessment and hemodynamic optimization are critical and should citation and antimicrobials. Workup should include pan-culturing,
start in the first hour. This should be concurrent with initiating a a thorough physical examination including any incisions (with
workup for the underlying cause of sepsis. Surviving sepsis of- dressings removed) or wounds, and imaging of the appropriate
fers the recommendation (albeit weak and based on low quality body region (often in the form of a CT scan if the patient is sta-
evidence) of using “dynamic” as opposed to “static” measures of ble to travel). For a patient with undifferentiated shock after an
end-organ perfusion such as response to passive leg raise or fluid operation, the team can also consider return to the operating
bolus (in the form of cardiac output and stroke volume variation room (OR) without additional diagnostic imaging if the appro-
if available or pulse pressure variation if unavailable), serial priate clinical suspicion exists based on physical examination
echocardiography (including respiratory variation of inferior and clinical status. Conversely, the team should also consider
vena cava diameter and left ventricular outflow tract velocity other causes of sepsis that can occur in any patient, including
time integral), trending lactate (if available), and capillary refill but not limited to sinusitis, pneumonia, perirectal abscess, cen-
time (we know from ANDROMEDA-SHOCK that outcomes tral line infection, and urinary tract infection.
were no different than following lactate and therefore could be
an option in lower resource setting).9,44 Urine output, when SOURCE CONTROL AND ANTIBIOTIC
robust (>0.5 mL/kg), can be helpful to indicate that renal perfu- DEESCALATION
sion, and generally volume resuscitation, may be adequate.
However, the converse is not necessarily true — oliguria does For the septic patient requiring a source control interven-
not necessarily indicate a need for more fluid, especially in the tion, timely intervention commensurate with patient status is
setting of an acute kidney injury. In sepsis management, the goal important — within 6 hours for high-risk septic patients and
of volume and hemodynamic optimization is to adequately but within 12 hours for lower-risk patients according to the Surgical
not overresuscitate, which can result in pulmonary congestion, Infection Society guidelines.12 The specific source control inter-
abdominal compartment syndrome, and additional systemic in- vention will of course depend on the presumed septic source.
flammation, among others.9 Throughout management of shock, Table 1 covers common ACS diagnoses and their associated
the team must consider all hemodynamic components and resus- source control needs. In the septic patient, depending on the ex-
citate as appropriate based on markers of end-organ perfusion. tent of physiologic derangement, the acute care surgeon should
Several adjuncts have been used historically to assist with consider whether a damage-control approach may be needed
hemodynamic monitoring, including the Swan-Ganz catheter for the particular clinical context, a discussion of which is cov-
and with it ScvO2, notably used in the Rivers trial to monitor ered extensively by Drs. Risinger and Smith in another article
end-organ perfusion.4 Since this time, however, the widespread of this journal's “What you need to know” series.48
use of Swan-Ganz catheters has been discouraged, as no im- When it comes to duration of antibiotics in septic patients,
provement in outcomes has been shown, and there are risks duration and deescalation really depend on the particular clinical

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 J Trauma Acute Care Surg
Maurer and Martin Volume 98, Issue 4

TABLE 1. Common ACS Diagnoses Related to Sepsis and Their Management

Important
ACS Concern Empiric Antibiotics* Recommended Diagnostics Source Control Strategy Citations
Intra-abdominal infections
Peritonitis, concern for Vancomycin, cefepime, flagyl (to CTAP I+/O+ Exploratory laparotomy, other Huston et al.12
intra-abdominal sepsis, cover gram-negative indicated procedures
and free air of unclear enterobactereae, gram-positive
etiology cocci, obligate anaerobes)
Mesenteric ischemia Vancomycin, cefepime, flagyl (to CTAP I+/O+ Anticoagulation (with acute arterial or Bala et al.13
cover gram-negative venous occlusion), bowel resection, Silvestri et al.14
enterobactereae, gram-positive and revascularization (if necessary)
cocci, obligate anaerobes)
Peptic ulcer disease Vancomycin, cefepime, flagyl +/− CTAP I+/O+ Laparotomy versus laparoscopy, Huston et al.15
fluconazole** (to cover gram- graham patch versus partial
negative enterobactereae, gram- gastrectomy
positive cocci, obligate anaerobes)
Cholangitis Ceftriaxone/metronidazole RUQUS +/− MRCP ERCP Miura et al.16
or
Ampicillin/sulbactam
or
Piperacillin/tazobactam
Cholecystitis Ceftriaxone/metronidazole RUQUS versus CTAP I+/O+ Percutaneous cholecystostomy tube Colling et al.17
or versus cholecystectomy Miura et al.16
Ampicillin/sulbactam Gallaher and
or Charles18
Piperacillin/tazobactam
Infected pancreatic Vancomycin, cefepime, flagyl CTAP I+/O+ Step-up approach including an Maurer and
necrosis individualized combination of IR Fagenholz19
drainage, endoscopic debridement,
minimally invasive debridement,
and open debridement
Diverticulitis In the setting of sepsis: cefepime/ CTAP I+ Dependent on severity, ranging from Kodadek and
flagyl or piperacillin/tazobactam nonoperative management with no Davis20
(gram-negative and anaerobic antibiotics to IV antibiotics, to IR Hall et al.21
coverage) drainage of an abscess >3 cm, and to Huston et al.22
sigmoidectomy
Appendicitis Cefoxitin or ceftriaxone/ CTAP I+ Antibiotics versus laparoscopic The CODA
metronidazole appendectomy Collaborative23
Enterocutaneous fistula Not always necessary but CTAP I+/O+ Drainage of any abscesses or Kaushal and
recommended in the patient with collections, skin protection (taking Carlson24
systemic signs of sepsis and/or down the ECF in the acute setting is Gribovskaja-
cellulitis not indicated) Rupp and
Melton25
Soft tissue infections
Perirectal abscess Not always necessary but Not always necessary; if diagnosis or Incision and drainage Gaertner et al.26
recommended in the patient with extent unclear, obtain CTAP I+/O+
immunosuppression, systemic
signs of sepsis, and/or cellulitis
Infected pressure ulcers Vancomycin, cefepime, flagyl Not always necessary; if diagnosis or Debridement of infected and/or Schiffman et al.27
extent unclear, obtain CTAP I+/O+ devitalized tissue Wong et al.28
Necrotizing soft tissue Vancomycin, cefepime, flagyl, Not always necessary; if diagnosis or Radical debridement of all necrotic and Duane et al.29
infections clindamycin extent unclear, obtain CT of the infected tissue
appropriate body region (I+)
Extremity/trunk abscess Not always necessary but Not always necessary; if diagnosis or Incision and drainage Duane et al.29
recommended in the patient with extent unclear, obtain CT of the
immunosuppression or systemic appropriate body region (I+)
signs of sepsis and/or cellulitis
If IV: vancomycin (to cover gram
positives including MRSA)
If PO: doxycycline
Thoracic infections
Empyema Vancomycin, cefepime, flagyl CT chest I+ Chest tube drainage with or without Shen et al.30
surgical debridement/decortication

Continued next page

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J Trauma Acute Care Surg
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TABLE 1. (Continued)

Important
ACS Concern Empiric Antibiotics* Recommended Diagnostics Source Control Strategy Citations
Esophageal perforation Vancomycin, cefepime, flagyl, CT chest I+/O+ (esophagram timed to Chest tube versus neck drainage, Brinster et al.31
fluconazole evaluate for perforation) or barium surgical debridement and repair
swallow (initially with water soluble versus esophageal stent placement
contrast, followed by thin barium if
clinical suspicion high and
unrevealing)
Periprocedural infections
Surgical site infections Not always necessary but Not always necessary; if diagnosis or Opening of the surgical wound, Zabaglo et al.32
recommended in the patient with extent unclear, obtain CT of the debridement of devitalized tissue
immunosuppression or systemic appropriate body region (I+)
signs of sepsis and/or cellulitis
Intra-abdominal abscess Vancomycin, cefepime, flagyl CTAP I+/O+ IR drainage if accessible versus Bassetti et al.33
antibiotic therapy
Hardware infections Vancomycin, cefepime (dependent on Obtain CT of the appropriate body Depends on timing and extent of Lall et al.34
body region) region (I+) to check for undrained infection, plus location of hardware;
collection long-term antibiosis versus removal
of hardware
General medical infections
UTI and CAUTI Ceftriaxone (consider broader Urinalysis and urine culture Remove or change infected catheter Majumdar and
spectrum pending patient factors or Padiglione35
systemic signs of sepsis)
CLABSI Vancomycin Paired blood cultures from a peripheral Removal of the infected line Majumdar and
site and the central line Antibiotics Padiglione35
Sinusitis Amoxicillin versus amoxicillin- CT sinus Antibiotics +/− surgical debridement Slavin et al.36
clavulanate
Pneumonia Community acquired: Chest x-ray Antibiotics, pulmonary toilet Lee et al.37
Levofloxacin versus ceftriaxone/ Sputum culture Carratalà
azithromycin et al.38
Hospital acquired: Arthur et al.39
Vancomycin-cefepime
Ventilator associated:
Vancomycin-cefepime
*Empiric antibiotic regimens are examples of appropriate initial antibiotic regimens based on available data, but specific institutional recommendations may vary based on specific
antibiograms and resistance patterns. Regimens may then be narrowed when possible based on culture results.
**Minimal evidence for or against use of fluconazole for a perforated peptic ulcer. Not recommended based on Surgical Infection Society guidelines.
CAUTI, catheter-associated urinary tract infection; CLABSI, central line–associated bloodstream infection; CTAP I+/O+, computed tomography abdomen pelvis with intravenous and oral
contrast; ECF, enterocutaneous fistula; ERCP, endoscopic retrograde cholangiopancreatography; IR, interventional radiology; RUQUS, right upper quadrant ultrasound; UTI, urinary tract infection.

scenario and septic source. However, in the septic patient who healthy patient with appendicitis, a neutropenic patient undergo-
requires surgical source control, we know from the Stop-It Trial ing bone marrow transplant with typhlitis, and a cardiac surgery
that a fixed course of antibiotics (4 days) after adequate source patient on multiple pressors with ischemic bowel, among others.
control had similar outcomes to a longer course of therapy (on In general, the approach to the initial management and resusci-
average 8 days).49 Duration of antibiotics for conditions not tation of the septic patient is similar between these patient
managed operatively varies depending on the individual condi- groups, but it is worth discussing certain factors associated with
tion and the ability for antibiotic penetration. For the patient particularly at-risk groups to optimize their evaluation, care, and
with culture-negative or undifferentiated sepsis, following the outcomes.
biomarker procalcitonin can be useful in differentiating an
inflammatory versus infectious etiology, and its use has been as-
sociated with shorter duration of antibiotics in ICU patients
ACS Consults and Sepsis in the
without otherwise worsening of outcomes.50 In an era with wors- Immunosuppressed Patient
ening antibiotic resistance,51 stewardship and deescalation of Patients with immunosuppressed status are a diverse patient
antibiotic therapy are an important aspect of managing the population ranging from outpatients on immunomodulatory med-
septic patient. ications to those with underlying diabetes or malnutrition, to solid
organ transplant patients, and to neutropenic patients undergoing
SPECIAL POPULATIONS chemotherapy or other treatment for malignancy, among others.
In general, what these groups have in common is a higher risk
The patient populations that present with ACS issues and of developing infection and, once that infection has developed,
sepsis can be incredibly diverse. In the same call shift, it is not worse outcomes from those infections.52 In any immunocompro-
uncommon for an acute care surgeon to be consulted for a young mised patient, there is a degree of blunting of the immune

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 J Trauma Acute Care Surg
Maurer and Martin Volume 98, Issue 4

response to infection, and as a consequence, physical examina- particularly in the septic patient with cirrhosis who has undergone
tion findings may not necessarily correlate with severity of in- paracentesis. Clinicians should be particularly cautious in what
fection. For instance, a patient may have minimal abdominal parameters are used for volume resuscitation; for instance, oliguria
tenderness despite extensive intra-abdominal infection or con- can be a result of hepatorenal syndrome and splanchnic vasodi-
tamination.53 Similarly, markers of infection such as white lation, and lactate can be slow to clear due to liver dysfunction.62
In
blood cell count may not be as high as expected in these pa- addition, these patients can be vasoplegic at baseline and thus
tients.52 As such, acute care surgeons must have a high index may not demonstrate as much of a blood pressure response to
of suspicion for infection in these patient populations. volume resuscitation as compared with a patient with normal
Among immunosuppressed patients, neutropenia is de- liver function, and thus, earlier addition of vasopressors can be
fined as an absolute neutrophil count of less than 1.5  109/L, considered to avoid the consequences of overresuscitation.63
with severe neutropenia defined as an absolute neutrophil count
of less than 0.5  109/L. In neutropenic patients who present ACS Consults and Sepsis in the Medical and
with fever and abdominal pain, the differential diagnosis should Cardiac ICU
be broad and include both standard ACS issues in addition to Among medical and cardiac ICU patients in multipressor
those specific to immunocompromised hosts, including typhlitis, shock, a rising lactate and/or worsening pressor requirement
cytomegalovirus colitis, Clostridium difficile colitis, and oppor- may trigger a call to the on call acute care surgeon with a con-
tunistic infections.54 Typhlitis (also known as neutropenic en- cern for bowel ischemia. Within the cardiac surgery population,
terocolitis), one of the most common intra-abdominal issues, one series found 0.8% of patients developed ischemic gastroin-
can present at varying severity levels but often presents with a testinal complications, with approximately 50% of those pa-
combination of neutropenia plus fever, abdominal pain, diar- tients requiring surgery for mesenteric ischemia.64 Of note, these
rhea, and thickening of the bowel (often terminal ileum and as- ICU patients can have multiple potential reasons for shock, in-
cending colon) on CT. Initial management of the patient without cluding multiple possible septic sources, in addition to other eti-
evidence of perforation or necrosis is generally nonoperative ologies of shock. When possible, depending on patient stability,
with IV fluid resuscitation, bowel rest, serial abdominal exami- obtaining a CT angiogram of the abdomen/pelvis to assess the
nations, and broad spectrum antibiotics. Operative management mesenteric vessels and bowel perfusion can be extremely helpful
is generally reserved for patients who worsen clinically with in diagnosis. Intravenous contrast in particular contributes signif-
nonoperative management, or develop frank perforation, refrac- icantly higher sensitivity and specificity for a source of intra-
tory bleeding, or another reason for surgery.55 Immunocompro- abdominal sepsis.65 As with any critically ill patient, goals of care
mised patients generally also have interacted with the health care should be discussed with the patient and family before proceeding
system to a larger degree, exposing them to a higher likelihood with operative intervention, as the mortality of critically ill patients
of resistant organisms. requiring either OR or bedside laparotomy is at least 50%.66 Ulti-
mately, the patient's outcome will depend at least in part on what
ACS Consults and Sepsis in the Cirrhotic Patient is found at the time of laparotomy, from no intra-abdominal pathol-
The associated mortality of surgery in the cirrhotic patient ogy to extensive bowel ischemia that is unrecoverable. The choice
has been shown to approach 50% in a series of these patients of bedside versus OR laparotomy is made by clinical status of the
requiring emergency surgery56,57 but also varies depending on patient, and the mortality for those patients who require bedside
severity of disease, generally classified by Childs-Pugh Score58 laparotomy is substantial, approaching 78% in one series.66 Be-
and/or model for end-stage liver disease59 score. In general, ing too sick to move or travel, these patients are the sickest of
model for end-stage liver disease is used for liver transplant the critically ill patients and have an extremely high mortality,
candidacy and allocation, as opposed to perioperative risk strat- even with a successful operation. These data should be
ification.60 Childs-Pugh score, on the other hand, has been asso- discussed with the family preoperatively to guide goals of care.
ciated with different levels of perioperative mortality, with Childs-
Pugh A associated with a mortality of approximately 10%, CONCLUSION
Childs-Pugh B a predicted mortality of 17% to 30%, and Childs-
Pugh C a predicted mortality of 63% to 82%.56,57 Early evalua- When it comes to sepsis management of the ACS patient,
tion, resuscitation, and management of the cirrhotic patient with the principles of initial evaluation and resuscitation start with the
sepsis are largely similar to any other septic patient, with a few ABCs. These can often be done in parallel or quickly followed
exceptions. First, the possible etiologies of sepsis are expanded by early antibiotics, diagnostic imaging where necessary, and,
to include spontaneous bacterial peritonitis, which must be as swiftly as possible, source control. Surgical pathologies that
differentiated from secondary bacterial peritonitis as a conse- cause sepsis are often unique and benefit from expert decision-
quence of intra-abdominal infection or perforation. Performing making. Thus, surgeons and their teams may be called upon to
a paracentesis to evaluate intra-abdominal ascites can be helpful drive the early resuscitation and management of these patients
both diagnostically and therapeutically.61 In addition, a CT and be asked about the best diagnostic approach. As such, we
abdomen pelvis can provide additional clarity of possible intra- hope this article provides around perioperative management of
abdominal septic pathology requiring source control. Spontaneous these septic patients.
bacterial peritonitis is most commonly caused by gram-negative
enteric organisms such as Escherichia coli and Klebsiella. AUTHORSHIP
With regard to resuscitation and hemodynamic monitor- L.M. and N.M. contributed in the conception and study design, literature
ing, colloid can be considered during volume resuscitation, review, data acquisition, data analysis and interpretation, drafting of the

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J Trauma Acute Care Surg
Volume 98, Issue 4 Maurer and Martin

manuscript, and critical revision. Each has provided final approval of the review of the evidence and future directions. Surg Infect (Larchmt). 2018;
version to be published. 19(7):648–654.
23. The CODA Collaborative. A randomized trial comparing antibiotics with
appendectomy for appendicitis. N Engl J Med. 2020;383(20):1907–1919.
DISCLOSURE
24. Kaushal M, Carlson GL. Management of enterocutaneous fistulas. Clin
Conflicts of Interest: Author Disclosure forms have been supplied and are Colon Rectal Surg. 2004;17(2):79–88.
provided as Supplemental Digital Content (http://links.lww.com/TA/E88). 25. Gribovskaja-Rupp I, Melton GB. Enterocutaneous fistula: proven strategies
and updates. Clin Colon Rectal Surg. 2016;29(2):130–137.
26. Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon
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