Laparotomy for abdominal sepsis in the critically ill

Among 125 patients admitted to an intensive care unit (ICU) with severe abdominal sepsis over a 3-year period, further laparotomy was required in 60 (48 per cent). The median age of these 60 patients was 67 (range 22-88) years and their admission APACHE (Acute Physiology and Chronic Health Evaluation) II score was 24 (range 7-40); 25 patients (42 per cent) survived to leave the ICU but only 19 (32 per cent) survived to leave hospital. These patients underwent 95 (median 1; range 1-6) operations after admission to the ICU and survival fell with increasing number of operations in the ICU (P = 0.01). A total of 81 operations (85 per cent) were therapeutic in that pus was drained or dead tissue removed, and 41 operations (43 per cent) resulted in improvement in the patient's condition within 48 h of surgery. Only nine per cent of patients not improved by their first operation in the ICU survived (P < 0.0001). The source of sepsis was eradicated from the abdomen in 37 patients (62 per cent); this was a prerequisite for survival but was achieved less frequently with increasing number of operations (P < 0.002). When operations were delayed until the diagnosis was clear, the need for subsequent procedures was significantly increased (P < 0.05). Multiple operations for patients with abdominal sepsis in the ICU were associated with diminishing returns and alternative surgical strategies merit active consideration.