Metabolic MayhemMetabolic Mayhem

Anaesthetic considerations in the abdominal catastrophe

Alex Yartsev, March 19th 2012

Uncharted territory.Uncharted territory.

No handy all-encompassing review article.Artwork will be used to distract from lack of content

Abdominocalypse• “Abdominal catastrophe” • Peritonitis from a visceral source• Mesenteric ischaemia• Perforated viscus• Abdominal compartment syndrome• Septic shock• Metabolic acidosis• Multi-organ system failure

AbdominocalypseTable of Contents:

•Preoperative considerations•Choice of induction and maintenance agents•Neuromuscular blockade and its reversal

•Ventilation•Fluid management•Vasopressors

•Systemic and regional analgesia

Preoperative considerations- Treat the shock- Treat the sepsis- Get central access

- Hope for the best with the severe acidosis

- Correct coagulopathy- Correct anaemia- Aim for normothermia- Organize ICU bed

Preoperative considerationsCui bono? They may still dieMesenteric infarction mortality:•Without surgery: – 87% to 99%•With surgery – 32% to 77%•Cause of death: MOSF in 75%.

•Age increases risk of death •In the over-85 age group, mortality is very similar with and without surgery

•Delay of 6 hours = increase in mortality by 30%

Schoots et al (2004), Systematic review of survival after acute mesenteric ischaemia according to disease aetiology. Br J Surg, 91: 17–27. doi: 10.1002/bjs.4459Woosup M. et al Contemporary management of acute mesenteric ischemia: Factors associated with survival Journal of Vascular Surgery Volume 35, Issue 3 , Pages 445-452, March 2002

Preoperative considerations

Treating the sepsis while you wait•Each hour without antibiotics increases mortality by 1%•Management of septic shock– Surviving Sepsis campaign– Goal-directed therapy

D. Eissa, E. G. Carton and D. J. Buggy Anaesthetic management of patients with severe sepsis Br. J. Anaesth. (2010) 105 (6): 734-743.

Preoperative considerationsAggressive management of sepsis:Goals in the first 6 hours:•MAP > 65•CVP 8-12•Urine output > 5ml/kg/hr•SvO2 > 75%•BSL < 8.0

•Think about steroids….

Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008 .

Choice of anaesthetic agentsPropofol vs volatile agents•Both decrease mesenteric arterial blood flow•Its decreased to an equal degree by both•Decrease in cardiac output is the main cause•Thankfully, severe sepsis decreases MAC.

Zwijsen, J. H. M. J., Bovill, J. G., Geelkerken, R. H., Delahunt, T. A., Van Bockel, J. H. and Hermans, J. (1996), Comparison of sufentanil/propofol versus isoflurane/nitrous oxide anaesthesia on mesenteric artery blood flow. Anaesthesia, 51: 1060–1063. doi: 10.1111/j.1365-2044.1996.tb15006.x.Allaouchiche B, Duflo F, Tournadre JP, Debon R, Chassard D. Influence of sepsis on sevoflurane minimum alveolar concentration in a porcine model. Br J Anaesth 2001;86:832-6.Lundeen G. Manohar M. Parks C. Systemic distribution of blood flow in swine while awake and during 1.0 and 1.5 MAC isoflurane anesthesia with or without 50% nitrous oxide. Anesthesia & Analgesia. 62(5):499-512, 1983 May.

Choice of anaesthetic agents

Which gas?•Desflurane is slightly more likely to vasoconstrict splanchnic circulation•With or without nitrous, doesn’t seem to matter.•Less volatile agent = less hemodynamic instability•Dead kidneys = cant excrete those fluoride ions (not that it matters)

Muller M. Schindler E. Roth S. Schurholz A. Vollerthun M. Hempelmann G. Effects of desflurane and isoflurane on intestinal tissue oxygen pressure during colorectal surgery. Anaesthesia.

57(2):110-5, 2002 Feb.

Kerstin D. Röhm, MD*, Andinet Mengistu, MD*, Joachim Boldt, MD*, Jochen Mayer, MD*, Grietje Beck, MD† and Swen N. Piper, MD* Renal Integrity in Sevoflurane Sedation in the

Intensive Care Unit with the Anesthetic-Conserving Device: A Comparison with Intravenous Propofol Sedation A & A June 2009 vol. 108 no. 6 1848-1854

Neuromuscular blockadeNo organs to metabolise withSuxamethonium?Severe sepsis = reduced plasma cholinesterase activity -hepatic dysfunction; half-life = 8 hrs, -significant when less than 25% is left

Aminoglycosides in therapeutic doses (~ 4mg/kg) = inhibition of Ach release = sensitization to NMJ blockade

Cisatracurium is the natural choice.…Does it matter? Going to ICU

Sladen, Robert N Anesthetic Concerns for the Patient with Renal or Hepatic Disease ASA Refresher Courses in Anesthesiology: 2001 - Volume 29 - Issue 1 - pp 213-228

Blanloeil Y, Delaroche O. [Decrease in plasmatic cholinesterase activity in severe bacterial infections: comparison with the decrease observed in severe liver cirrhosis]. Ann Fr Anesth Reanim. 1996;15(2):220-2.

Zohar A. Dotan, MD*, Rene Hana, MD†, Daniel Simon, MD†, Daniel Geva, MD‡, Reuven A. Pfeffermann, MD† and Tiberiu Ezri, MD§ The Effect of Vecuronium Is Enhanced by a Large Rather than a Modest Dose of

Gentamicin as Compared with No Preoperative Gentamicin A & A March 2003 vol. 96 no. 3 750-754

Al-Kassab, A. S. / Vijayakumar, E. Profile of Serum Cholinesterase in Systemic Sepsis Syndrome (Septic Shock) in Intensive Care Unit Patients. Clinical Chemistry and Laboratory Medicine. Volume 33, Issue 1, Pages

11–14

Neuromuscular blockade

Reversal•Neostigmine increases gut motility•In at least one old series, this increased the rates of anastomotic breakdown (from 4% to 36%)•No recent data •No data regarding influence from anticholinergics•But now, we have sugammadex •And anyway,

…Does it matter? Going to ICU

Bell CM. Lewis CB. Effect of neostigmine on integrity of ileorectal anastomoses. British Medical Journal. 3(5618):587-8, 1968 Sep 7.

Ventilation

Oxygenation •Sepsis microarteriovenous shunt tissue hypoxia•Sepsis impaired mitochondrial oxygen utilization•Sepsis SIRS ALI and ARDS

•In summary, high FiO2 is beneficial,

or at least not harmful.Ince, Can PhD; Sinaasappel, Michiel PhDb Microcirculatory oxygenation and shunting in sepsis and shock Critical Care Medicine: July 1999 - Volume 27 - Issue 7 - pp 1369-1377

Richard S. Hotchkiss, MD; Irene E. Karl, PhD Reevaluation of the Role of Cellular Hypoxia and Bioenergetic Failure in Sepsis JAMA. 1992;267(11):1503-1510

Glòria Garrabou1, Constanza Morén1, Sònia López1, Ester Tobías1, Francesc Cardellach1, Òscar Miró1 and Jordi Casademont2 The Effects of Sepsis on Mitochondria J Infect Dis. (2012)

205 (3): 392-400.

.

VentilationVentilation•ARDS decreased compliance•Low tidal volume ventilation strategy improves survival•There is no greater risk of atelectasis (CT evidence)•There is a decrease in post-op inflammatory lung injury•Hypercapnea improves splanchnic perfusion

•In summary, high ETCO2 is beneficial or at least not harmful

The Acute Respiratory Distress Syndrome Network - Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome N Engl J Med 2000; 342:1301-1308

Hongwei Cai, PhDa (Professor of Anesthesia), Hua Gong, MDa, , (Staff Anesthesiologist), Lina Zhang, MDa (Staff Anesthesiologist), Yanjin Wang, MDb (Staff Radiologist), Yuke Tian, PhDc (Professor of Anesthesia) Effect of low tidal volume ventilation

on atelectasis in patients during general anesthesia: a computed tomographic scan Journal of Clinical Anesthesia Volume 19, Issue 2, March 2007, Pages 125–129

Wolthuis, Esther K. M.D.*; Choi, Goda M.D., Ph.D.†; Dessing, Mark C. Ph.D.‡; Bresser, Paul M.D., Ph.D.§; Lutter, Rene Ph.D. ; Dzoljic, Misa M.D., Ph.D.#; van der Poll, Tom M.D., Ph.D.**; Vroom, Margreeth B. M.D., Ph.D.††; Hollmann, Markus M.D., ∥

Ph.D.‡‡; Schultz, Marcus J. M.D., Ph.D.§§ Mechanical Ventilation with Lower Tidal Volumes and Positive End-expiratory Pressure Prevents Pulmonary Inflammation in Patients without Preexisting Lung Injury. Anesthesiology: January 2008 - Volume 108

- Issue 1 - pp 46-54

Fluid managementWhich fluid?•Colloid apparently better for mesenteric perfusion (starch vs Hartmanns)•Systemically, in severe sepsis, it doesn’t matter: nothing stays in the intravascular compartment.•However, in the short term, colloid increases cardiac output more than saline or Hartmanns.

– (at least in French sheep with 0.5g/kg faeces in their abdominal cavity)

•No mortality difference (SAFE study)

Lang K, Boldt J, Suttner S, Haisch GColloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesthesia and Analgesia [2001, 93(2):405-9

Nisanevich, Vadim M.D.*; Felsenstein, Itamar M.D.†; Almogy, Gidon M.D.†; Weissman, Charles M.D.‡; Einav, Sharon M.D.§; Matot, Idit M.D Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery. Anesthesiology: July

2005 - Volume 103 - Issue 1 - pp 25-32

Cittanova ML, Leblanc I, Legendre C, et al: Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidneytransplant recipients. Lancet 1996, 348:1620–1622

The SAFE Study Investigators A Comparison of Albumin and Saline for Fluid Resuscitation in the Intensive Care Unit N Engl J Med 2004; 350:2247-2256May 27, 2004

Su, Fuhong*; Wang, Zhen*; Cai, Ying†; Rogiers, Peter‡; Vincent, Jean-Louis* Fluid Resuscitation in Severe Sepsis and Septic Shock: Albumin, Hydroxyethyl Starch, Gelatin or Ringer's Lactate-Does It Really Make A Difference? Shock: May 2007 - Volume

27 - Issue 5 - pp 520-526

Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD000567. DOI: 10.1002/14651858.CD000567.pub4

Fluid management

Maybe albumin?•No influence on mortality in SAFE study•Increases blood volume by more than the volume infused•No adverse hepatic or renal effects•At least in severely septic ICU patients, reduces mortality (OR: 0.82)

Rackow EC, Falk JL, Fein IA, et al: Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock.

Crit Care Med 1983, 11:839–850

Weaver DW, Ledgerwood AM, Lucas CE, et al: Pulmonary effects of albumin resuscitation for severe hypovolemic shock. Arch Surg 1978, 113:387–392

Ernest, David MBBS; Belzberg, Allan S. MD; Dodek, Peter M. MD, MHSc Distribution of normal saline and 5% albumin infusions in septic patientsCritical Care Medicine:January 1999 - Volume 27 - Issue 1 - pp 46-50

Delaney, Anthony P. MD, FCICM; Dan, Arina MD, FCICM; McCaffrey, John MD, FCICM; Finfer, Simon MD, FCICM The role of albumin as a resuscitation fluid for patients with sepsis: A systematic review and meta-

analysis* Critical Care Medicine: February 2011 - Volume 39 - Issue 2 - pp 386-391

Fluid management

Maybe gelofusine?•Increases blood volume by as much as all the other colloids; i.e. no better or worse•no dose limit, unlike HES•May impair hemostasis by decreasing availability of vWf•Risk of anaphylaxis (2.7% of total anaphylaxis in anaesthetics, compared to muscle relaxant 67%)•Embryotoxic in pregnant rats (? Relevance)

Lobo, Dileep N. DM, FRCS; Stanga, Zeno MD; Aloysius, Mark M. MRCS; Wicks, Catherine BMedSci, BM, BS; Nunes, Quentin M. MRCS; Ingram, Katharine L. FRCA; Risch, Lorenz MD, MPH; Allison, Simon P. MD, FRCP Effect of volume loading with 1 liter intravenous infusions of 0.9% saline, 4% succinylated gelatine (Gelofusine) and 6% hydroxyethyl starch (Voluven) on blood volume and endocrine responses: A randomized, three-way crossover study in healthy volunteers. Critical Care Medicine: February 2010 - Volume 38 - Issue 2 - pp 464-470E. de Jonge (1), M. Levi (3), F. Berends (2), A. E. van der Ende (3), J. W. ten Cate (3), C. P. Stoutenbeek (1) Impaired Haemostasis by Intravenous Administration of a Gelatin-based Plasma Expander in Human Subjects Thrombosis and Hemsotasis 1998: 79/2 (Feb) pp.244-455

Plus, Gelofusine propaganda from the manufacturer

Fluid managementMaybe hydroxyethyl starch?•Starch seems to be safe in non-cardiac surgical patients

•More nephrotoxic in sepsis: starch use in sepsis is an independent predictor of ARF (OR 2.57 compared to gelo)

But… the blood bank is too far…

•those kidneys are doomed anyway

…Does it matter? Going to ICURackow EC, Falk JL, Fein IA, et al: Fluid resuscitation in circulatory shock: a comparison of the cardiorespiratory effects of albumin, hetastarch, and saline solutions in patients with hypovolemic and septic shock. Crit Care Med 1983, 11:839–850

Lazrove S, Waxman K, Shippy C, Shoemaker WC: Hemodynamic, blood volume, and oxygen transport responses to albumin and hydroxyethyl starch infusions in critically ill postoperative patients. Crit Care Med 1980, 8:302–306

Cittanova ML, Leblanc I, Legendre C, et al: Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidneytransplant recipients. Lancet 1996, 348:1620–1622

Frédérique Schortgen MD a, Jean-Claude Lacherade MD a, Fabrice Bruneel MD c, Isabelle Cattaneo MD d, François Hemery MD b, Prof François Lemaire MD a, Prof Laurent Brochard a Effects of hydroxyethylstarch and gelatin on renal function in

severe sepsis: a multicentre randomised study The Lancet, Volume 357, Issue 9260, Pages 911 - 916, 24 March 2001

Fluid management

How much fluid?•Less is apparently better•“Restrictive” fluid protocol: 4ml/kg/hr is better than 12.

– That’s 1120ml for a 4 hr 70kg laparotomy!– That study was in elective patients…

•Might this interfere with management of septic shock?•Does this compensate for abdominal evaporative losses?

Lang K, Boldt J, Suttner S, Haisch GColloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery. Anesthesia and Analgesia

[2001, 93(2):405-9

Nisanevich, Vadim M.D.*; Felsenstein, Itamar M.D.†; Almogy, Gidon M.D.†; Weissman, Charles M.D.‡; Einav, Sharon M.D.§; Matot, Idit M.D Effect of Intraoperative

Fluid Management on Outcome after Intraabdominal Surgery. Anesthesiology: July 2005 - Volume 103 - Issue 1 - pp 25-32

Blood products

Hemoglobin target•Experts disagree regarding benefits of transfusion

•Higher oxygen carrying capacity vs. increased viscosity

•Consensus is to keep it over 70 and under 125

•If they have acute coronary ischaemia, target Hb over 100

…Remember calcium

Tagart REB. Colorectal anastomosis: factors influencing success. J R Soc Med. 1981 February; 74(2): 111–118.

P C Hébert, G Wells, M Tweeddale, C Martin, J Marshall, B Pham, M Blajchman, I Schweitzer and G Pagliarello

Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am. J. Respir. Crit. Care Med.May 1,

1997 vol. 155 no. 51618-1623

Vasopressors

Do you need a CVC?•Noradrenaline is no better than metaraminol in its hemodynamic effects(HR, SVI, PAWP, SVRI)

•Less splanchnic vasoconstriction than adrenaline

•More easily titrated than phenylephrine

De Backer, Daniel MD, PhD; Creteur, Jacques MD, PhD; Silva, Eliézer MD, PhD; Vincent, Jean-Louis MD, PhD, FCCM Effects of dopamine, norepinephrine, and epinephrine on the splanchnic

circulation in septic shock: Which is best? Critical Care Medicine: June 2003 - Volume 31 - Issue 6 - pp 1659-1667

Giuseppe Natalini, Valeria Schivalocchi, Antonio Rosano, Maria Taranto, Cristina Pletti and Achille Bernardini Norepinephrine and metaraminol in septic shock: a comparison of the

hemodynamic effects INTENSIVE CARE MEDICINE Volume 31, Number 5, 634-63

VasopressorsVasopressin for sepsis

•Sensitivity to it is increased in sepsis•Some think, sepsis = relative vasopressin deficiency

•Not a familiar drug •May cause coronary ischaemia•May cause splanchnic ischaemia•May cause ischaemia of everything else

Landry DW, Levin HR, Gallant et al.Vasopressin pressor hypersensitivity in vasodilatory septic shock. Crit Care Med. 1997;25(8):1279-128

Morales MD, Madigan J, Cullinane S et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation July 20, 1999: 226-228

Morelli A, Tritapepe L, Rocco M, Conti G, Orecchioni A, De Gaetano A, Picchini U, Pelaia P, Reale C, Pietropaoli P. Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system

inhibitors: effects on systemic and regional hemodynamics. Anesthesiology. 2005 Jan;102(1):12-9.

Medel J, Boccara G, Van de Steen E, Bertrand M, Godet G, Coriat P. Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia? Anesth Analg. 2001 Jul;93(1):53-5, TOC.

Martin W. Dünser, MD; Andreas J. Mayr, MD; Hanno Ulmer, PhD; Hans Knotzer, MD; Günther Sumann, MD; Werner Pajk, MD; Barbara Friesenecker, MD; Walter R. Hasibeder, MD Arginine Vasopressin in Advanced Vasodilatory Shock A Prospective,

Randomized, Controlled Study. Circulation. 2003; 107: 2313-2319

VasopressorsVasopressin for sepsis•Additive effect with noradrenaline•Receptors unaffected by acidosis•Non-arrhythmogenic•Splanchnic perfusion is going to suffer anyway if your MAP is 40.

•in SEVERE catecholamine-resistant shock, its better to start vasopressin than to keep going up on noradrenaline (RCT: NA 1.2-1.5 mcg/kg/min vs 4u/hr of AVP )

…that’s 84-105ml/hr of single strength norad….

Landry DW, Levin HR, Gallant et al.Vasopressin pressor hypersensitivity in vasodilatory septic shock. Crit Care Med. 1997;25(8):1279-128

Morales MD, Madigan J, Cullinane S et al. Reversal by vasopressin of intractable hypotension in the late phase of hemorrhagic shock. Circulation July 20, 1999: 226-228

Morelli A, Tritapepe L, Rocco M, Conti G, Orecchioni A, De Gaetano A, Picchini U, Pelaia P, Reale C, Pietropaoli P. Terlipressin versus norepinephrine to counteract anesthesia-induced hypotension in patients treated with renin-angiotensin system

inhibitors: effects on systemic and regional hemodynamics. Anesthesiology. 2005 Jan;102(1):12-9.

Medel J, Boccara G, Van de Steen E, Bertrand M, Godet G, Coriat P. Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia? Anesth Analg. 2001 Jul;93(1):53-5, TOC.

Martin W. Dünser, MD; Andreas J. Mayr, MD; Hanno Ulmer, PhD; Hans Knotzer, MD; Günther Sumann, MD; Werner Pajk, MD; Barbara Friesenecker, MD; Walter R. Hasibeder, MD Arginine Vasopressin in Advanced Vasodilatory Shock A Prospective,

Randomized, Controlled Study. Circulation. 2003; 107: 2313-2319

Acid-base managementSevere lactic acidosis•Circulatory support and surgical removal of ischaemic tissue

Role of bicarbonate•There is probably none.•Surviving Sepsis guidelines recommend against it (pH >7.15)•But, it improves sensitivity of catecholamine receptors

•Remember calcium - will rise with acidosis, drop with alkalosis

J. D. Marsh, T. I. Margolis, and D. Kim Mechanism of diminished contractile response to catecholamines during acidosis AJP - Heart January 1988 vol. 254 no. 1 H20-H27Boyd JH, Walley KR. Is there a role for sodium bicarbonate in treating lactic acidosis from shock? Curr Opin Crit Care. 2008 Aug;14(4):379-83.

Systemic analgesiaPCA•Not as good as epidural in abdominal surgery•Better than PRNs •Usually, need to resort to continuous infusion

Fentanyl vs morphine / hydromorphone•No real difference

•Little data specific to severe abdominal sepsis

Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005Hudcova J, McNicol E, Quah C, Lau J, Carr DB Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain.Cochrane Database Syst Rev. 2006;

Systemic analgesiaNo organs to metabolise with?•Remifentanil is the obvious choice•RCT of remi vs morphine PCA: more boluses required, more expensive, but otherwise the same effect.

•May make ventilator weaning easier, ICU will thank you for not using tons of morphine

F. Kucukemre a1, N. Kunt a2c1, K. Kaygusuz a2, F. Kiliccioglu a2, B. Gurelik a2and A. Cetin a3 Remifentanil compared with morphine for postoperative patient-controlled analgesia after major abdominal surgery: a randomized controlled trial European Journal of Anaesthesiology (2005), 22 : pp 378-385Des Breen,1 Alexander Wilmer,2 Andrew Bodenham,3Vagn Bach,4 Jan Bonde,5 Paul Kessler,6 Sven Albrecht,7 and Soraya Shaikh8 Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment Crit Care. 2004; 8(1): R21–R30

Spinal/epidural analgesia• Studies in elective patients

recommend use of epidural analgesia

• Few studies in acute abdomen: also positive

• No studies in the severely septic laparotomy patients

• Concerns regarding epidural abscesses in bacteraemia

Spinal/epidural analgesiaMain problem: hemodynamics•Vasodilation from spinal/epidural causes splanchnic vasodilation, which is good in stable elective patients•Everything else vasodilates as well•Shock becomes more profound•One case report:

a parturient with twins and a severe streptococcal sepsis died mid-caesarian shortly after the epidural was administered: hypotension blamed.

Morgan PJ. Maternal death following epidural anaesthesia for caesarean section delivery in a patient with unsuspected sepsis. Canadian Journal of Anaesthesia. 42(4):330-4, 1995 Apr. David R. Spackman, Andrew D.M. McLeod, Steven N. Prineas, Richard M. Leach and F. Reynolds Effect of epidural blockade on indicators of splanchnic perfusion and gut function in critically ill patients with peritonitis: a randomised comparison of epidural bupivacaine with systemic morphine. INTENSIVE CARE MEDICINE Volume 26, Number 11, 1638-1645, DOI: 10.1007/s001340000671

Spinal/epidural analgesia

Will it get infected?•Short answer: probably.

– Japanese group: epidural improves 3 month mortality after emergency abdominal surgery. No mention of extent of sepsis or rates of neurological complications.

– Other case series of frequently debrided infected ICU patients: many pulled catheters cultured S.epi but no actual abscesses.

– Some studies in patients with chorioamnionitis: encouraging.

– No studies in severe ICU-style sepsis. Bengtsson M, Nettelblad H, Sjoberg F (1997) Extradural catheter-related infections in patients with infected cutaneous wounds. Br J Anaesth 79:668-670 Jakobsen KB. Christensen MK. Carlsson PS. Extradural anaesthesia for repeated surgical treatment in the presence of infection. British Journal of Anaesthesia. 75(5):536-40, 1995 Nov. [Case Reports. Journal Article] Jomura K, Hamada T, Sugiki K, Ito Y (1997) Epidural anesthesia reduces mortality rate in the patients after emergency abdominal surgery. Masui 46:1602-1608Goodman EJ, DeHorta E, Taguiam JM. Safety of spinal and epidural anesthesia in parturients with chorioamnionitis. Reg Anesth 1996;21:436-441.Bader AM, Datta S, Gilbertson L, Kirz L. Regional anesthesia in women with chorioamnionitis. Reg Anesth 1992;17:84-86.Wedel, Denise J. M.D.*; Horlocker, Terese T. M.D. Regional Anesthesia in the Febrile or Infected Patient Regional Anesthesia & Pain Medicine: July/August 2006 - Volume 31 - Issue 4 - p 324–333

In summaryHARD EVIDENCE•Minimal delay before theatre•Minimal delay before antibiotics•Aggressive resuscitation of shock including early vasopressors•Low tidal volume ventilation•Permit hypercapnea

WEAK EVIDENCE•If hemodynamically stable, conservative fluid management•More colloid •Less neostigmine•Keep Hb under 125, above 70•Bicarbonate for acidosis

“In deciding whether to site an epidural catheter in a critically ill patient the overall balance lies between unproven benefit and uncertain risk”.

In spite of everything, many of them will die anyway.

Get them off the table.

Let ICU sort it out.

No further questions, please