When is surgery indicated in sepsis/septic shock?

Updated: Oct 07, 2020
  • Author: Andre Kalil, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

Patients with focal infections should be sent for definitive surgical treatment after initial resuscitation and antibiotic therapy. [2] Little is gained by spending hours stabilizing the patient while an infected focus persists. However, even though urgent management is warranted for hemodynamically stable patients without evidence of acute organ failure, it may be possible to delay invasive procedures up to 24 hours—provided that very close clinical monitoring is instituted and appropriate antimicrobial therapy administered. [2]

Any soft-tissue abscess should be drained promptly. Certain conditions will not respond to standard treatment for septic shock until the source of infection is surgically removed. Some of these common foci of infection include intra-abdominal sepsis (perforation or abscess), empyema, mediastinitis, cholangitis, pancreatic abscess, pyelonephritis or renal abscess from ureteric obstruction, infective endocarditis, septic arthritis, infected prosthetic devices, deep cutaneous or perirectal abscess, and necrotizing fasciitis.

Whenever possible, percutaneous drainage of abscesses and other well-localized fluid collections is preferred to surgical drainage. [2] For example, a superficial abscess can be drained in the ED. However, any deep abscess or suspected necrotizing fasciitis should be drained in the surgical suite. Other examples of emergency conditions that call for rapid management are diffuse peritonitis, cholangitis, and intestinal infarction. [11, 60]

In cases of sepsis of unclear etiology, a thorough search for abscesses should be performed, with particular attention paid to the rectal and perianal area.


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