What is the management of gastrointestinal (GI) sepsis?

Management of Gastrointestinal Sepsis

Early recognition and immediate initiation of resuscitation with crystalloid fluids, broad-spectrum antibiotics within 1 hour, and urgent source control within 12 hours form the foundation of GI sepsis management, with careful attention to avoiding fluid overload that can worsen intra-abdominal hypertension. 1

Immediate Recognition and Resuscitation (First 3 Hours)

Early Identification

• Screen patients using qSOFA criteria: Glasgow Coma Scale ≤14, systolic blood pressure ≤100 mmHg, or respiratory rate ≥22/min indicate potential sepsis requiring urgent evaluation 1
• Measure serum lactate immediately as part of initial assessment, though elevated lactate alone no longer defines sepsis 1
• Calculate SOFA score to confirm organ dysfunction (increase of ≥2 points defines sepsis) 1

Fluid Resuscitation

• Administer 30 mL/kg of intravenous crystalloid fluid within the first 3 hours for sepsis-induced hypoperfusion 2
• Use crystalloid solutions as first-line therapy because they are well-tolerated and cost-effective 1
• Infuse fluids rapidly enough to induce quick response but not so fast as to create artificial stress response 1
• Target mean arterial pressure (MAP) of 65-70 mmHg as the initial hemodynamic goal 1, 2

Critical Caveat for GI Sepsis

Avoid aggressive fluid overload in patients with generalized peritonitis, as this worsens bowel edema and increases intra-abdominal pressure, potentially leading to abdominal compartment syndrome 1. Monitor for:

• Abdominal distention and increased abdominal girth 1
• Intra-abdominal pressure (IAP) elevation >20 mmHg with new organ failure indicates abdominal compartment syndrome 1
• Use ultrasound measurement of inferior vena cava diameter to guide fluid requirements rather than predetermined protocols 1

Antimicrobial Therapy

• Administer empiric broad-spectrum intravenous antibiotics within 1 hour of sepsis recognition to cover all likely pathogens including gram-negative bacilli and anaerobes 2
• Obtain blood cultures and other appropriate cultures before antibiotics if this causes no significant delay (<45 minutes) 2
• For community-acquired GI sepsis, narrow-spectrum agents covering enteric gram-negatives and anaerobes are typically adequate 3
• For healthcare-acquired GI sepsis (postoperative, anastomotic dehiscence), use broad-spectrum therapy covering multi-drug resistant pathogens, guided by local antibiograms 3
• Piperacillin-tazobactam represents a reasonable empiric choice for GI sepsis, dosed appropriately for renal function 4

Source Control

Identify and control the anatomical source of infection within 12 hours of diagnosis 1. This is the cornerstone of effective treatment and the most critical determinant of outcome after patient factors 5, 3.

Surgical Intervention Principles

• Perform urgent surgical intervention for diffuse peritonitis, necrotizing soft tissue infection, intestinal perforation, or intestinal ischemia 1, 5
• Use the least physiologically invasive effective intervention (percutaneous drainage over surgical drainage when feasible) 1
• For infected peripancreatic necrosis, delay definitive intervention until adequate demarcation of viable/nonviable tissue occurs 1
• Remove intravascular access devices promptly if they are potential infection sources, after establishing alternative access 1

Damage Control Strategy

In patients with severe physiological derangement or difficult intraperitoneal conditions:

• Consider abbreviated laparotomy with planned reoperations 5
• Defer intestinal anastomoses to second operation when patient is unstable 5
• Use temporary abdominal closure with negative pressure devices if needed 5
• Modern techniques achieve fascial closure rates approaching 90% 5

Vasopressor Support

• Use norepinephrine as first-line vasopressor if hypotension persists after initial fluid resuscitation 1
• Norepinephrine is more efficacious than dopamine for reversing hypotension in septic shock 1
• Optimal timing: mortality is lowest when vasopressors are initiated approximately 1 hour after shock onset, during hours 1-6 of resuscitation 1
• Continue targeting MAP ≥65 mmHg; higher targets (80-85 mmHg) show no mortality benefit 1

Supportive Care Specific to GI Sepsis

Gastrointestinal Management

• Implement bowel rest by restricting oral intake until bowel function returns 2
• Place nasogastric tube for decompression if significant abdominal distention is present 2
• Monitor for return of bowel sounds, passage of flatus, and bowel movements as signs of resolving ileus 2
• Consider prokinetic agents once patient is stabilized and source control achieved 1, 2

Nutrition

• Start enteral nutrition as soon as hemodynamically stable but withhold when patient requires significant vasopressor doses or when GI hypoperfusion is suspected 5
• Consider parenteral nutrition only if ileus is prolonged (>5-7 days) 2
• Avoid early parenteral nutrition in favor of early enteral feeding when GI tract is functional 1

Electrolyte and Metabolic Management

• Correct electrolyte abnormalities, particularly potassium, magnesium, and phosphate 2
• Monitor lactate levels and target normalization in patients with elevated levels 2

Monitoring and Reassessment

• Perform regular clinical examinations multiple times daily to assess for improvement or deterioration 2
• Monitor vital signs, urine output (target >0.5 mL/kg/h), and mental status continuously 2
• Follow trends in inflammatory markers (C-reactive protein, procalcitonin) 2
• Specifically monitor for abdominal compartment syndrome in patients with significant distention 1, 2

Additional Supportive Measures

• Implement stress ulcer prophylaxis with proton pump inhibitors or H2-receptor antagonists in patients with risk factors for GI bleeding 1
• Provide adequate pain control while minimizing opioids that worsen ileus 2
• Implement early mobilization when hemodynamically stable to promote return of bowel function 2

What NOT to Do

• Do not use hydroxyethyl starches for fluid resuscitation (associated with worse outcomes) 1
• Do not follow rigid early goal-directed therapy protocols; recent trials (ProCESS, ARISE, ProMISe) show no mortality benefit over usual care 1
• Do not routinely use adjunctive therapies like polymyxin B hemoperfusion or blood purification techniques (insufficient evidence of benefit) 1
• Avoid forced abdominal closure in the presence of bowel edema and elevated intra-abdominal pressure 1