Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock

Abstract

Introduction: We developed a protocol to initiate surgical source control immediately after admission (early source control) and perform initial resuscitation using early goal-directed therapy (EGDT) for gastrointestinal (GI) perforation with associated septic shock. This study evaluated the relationship between the time from admission to initiation of surgery and the outcome of the protocol.

Methods: This examination is a prospective observational study and involved 154 patients of GI perforation with associated septic shock. We statistically analyzed the relationship between time to initiation of surgery and 60-day outcome, examined the change in 60-day outcome associated with each 2 hour delay in surgery initiation and determined a target time for 60-day survival.

Results: Logistic regression analysis demonstrated that time to initiation of surgery (hours) was significantly associated with 60-day outcome (Odds ratio (OR), 0.31; 95% Confidence intervals (CI)), 0.19-0.45; P <0.0001). Time to initiation of surgery (hours) was selected as an independent factor for 60-day outcome in multiple logistic regression analysis (OR), 0.29; 95% CI, 0.16-0.47; P <0.0001). The survival rate fell as surgery initiation was delayed and was 0% for times greater than 6 hours.

Conclusions: For patients of GI perforation with associated septic shock, time from admission to initiation of surgery for source control is a critical determinant, under the condition of being supported by hemodynamic stabilization. The target time for a favorable outcome may be within 6 hours from admission. We should not delay in initiating EGDT-assisted surgery if patients are complicated with septic shock.

Figure 1

Protocol for gastrointestinal perforation with associated septic shock. The protocol for early infectious source control (EISC) and early goal-directed therapy (EGDT) for gastrointestinal perforation with septic shock was implemented at Nihon University Itabashi Hospital. GI, gastrointestinal; SIRS: systemic inflammatory response syndrome; IVF, intravenous fluids; CVP, central venous pressure; MAP, mean arterial pressure; ScvO₂, central venous oxygen saturation. Revised points from the original protocol of Rivers et al. [3]; *in mechanical ventilation control, the target CVP is ≥8 mm Hg; **the original protocol specified dobutamine, but this was not used; ***blood gas analysis (BGA) measurement of ScvO₂ in blood drawn from the internal jugular vein via an indwelling catheter.

Figure 2

Time from admission to initiation of surgery and 60-day outcome. All patients were classified into 2-hour groups (from 0 to 12 hours) from admission to initiation of surgery. The number of survivors and non-survivors and the survival rate on day 60 are shown. As the time to initiation of surgery increased, survival rate decreased and the survival rate was 0% in the group that waited more than 6 hours. There were no patients who needed more than 10 hours to initiate surgery.