complications are rare in the gynaecologic patient and with
modern technology, it is rare to see post-operative patients
go into septic shock. However, once in a while, a seemingly
innoccuous caesarian section or hysterectomy can sometimes end
in septic shock, which quite often takes the patient’s life.
This may happen in spite of all precautions that the doctor
apparently takes to avoid catastrophes. Is it true that we can
prevent all septic shocks? Does patient factor have anything
to do with it? Probably, if the patient is in the pink of
health, small lapses will be covered by the body’s defence
mechanisms. But, in the slightly compromised patient, giving
optimum conditions at time of surgery and in the
post-operative period can probably minimise the rate of
sepsis. Some of the views given below are personal views
gained after both good and bad experiences and some of the
views are backed by literature.
Sterilisation of instruments should be given top priority in
all hospitals. Autoclaved instruments should be packed in
adequate quantities in the operation theatre. In case of
emergencies, under no circumstance, should hurriedly boiled
instruments be used. Chemical indicators are available to
check if the instruments are really sterile or not. These are
small strips which change colour if the instruments are
adequately sterilised. In case of inadequacies, these strips
will not attain the desired colour. Using these strips may
appear costly when things are going smooth. But prevention is
better than cure and it is better to invest in scientific
methods of checking sterilisation rather than regret over
The staff handling
instruments in the theatre should be either fully qualified as
in major hospitals, or adequately trained in smaller
hospitals. For this the doctor in charge of the hospital will
probably have to learn the nuances of sterilisation
herself/himself to accommodate for frequent change of staff.
Post-operative care is very
important not only in the immediate post-operative period, but
also in the next few days. Early discharges being the norm of
the day, care of the patient may take a back seat on the 2nd or
as many patients, specially following endoscopy will get
discharged by then. The basic rule of thumb should be that
any patient who is not getting better and better as the hours
and days go by needs close surveillance. A patient who says,
my pain/distension, nausea etc is worse today compared to
yesterday needs constant surveillance. It is here that the
role of nursing assumes importance.
A rising pulse may be an
important sign of serious infection in the body. In the
absence of a falling Blood pressure, it may be mistakenly
construed to be a sign of anxiety. When a rising pulse along
with breathlessness or signs of peritonitis, is present, the
clinician should be on high alert. The monitoring of pulse,
blood pressure and respiration, should be delegated to the
senior staff. The senior staff will more often than not ask
the student nurse to record the pulse and temperature. But it
would be prudent for the doctor to supervise the vital
parametres by oneself in special cases at least, so that the
staff will be more diligent in monitoring the patient . One
may encounter situations where over the phone a casual
inquiry about the pulse invariably is given the answer, 80 to
90 per minute. If the doctor goes personally to monitor the
pulse it may be 120 per minute, which will hurriedly be
attributed to patient anxiety. Surprise checks of vital
parametres by treating physicians will go a long way in
optimising the monitoring of vital parametres.
Just as sterilising the
instruments is important, so also proper antiseptic
precautions while performing surgery is important. The
breach in adhering to principles of antisepsis are most likely
to occur in difficult cases on difficult days and invariably
these are the cases which are prone to infections. Invariable
pricks in the gloves, will decrease as the years go by in a
surgeon’s life, but it is always better to clean the hands
with alcohol before surgery, be it the cheap methylated spirit
or the costlier company made solutions. In case of inadvertent
pricks or unsterile touches, strictness in changing gloves
will take away only 2 minutes from the operating time, but the
habit once learned, will help on a difficult day,
Factors that can reduce infection rate:
Decreasing the time of surgery can reduce the rate of
complications. Surgery prolonged for more than 3hours may
also be associated with increased risk of pulmonary infections
and this risk cannot
be reduced with the use of
Having a well planned theatre can reduce operating time to a
great extent. Additional instruments should be readily
available so that precious time is not lost searching for it.
The surgeon should preferably be washed up in the theatre by
the time the anaesthetist gives anaesthesia.
In a study on patients undergoing
elective colorectal surgery, Jimenez et al have summarized
that bowel preparation is not the key factor that prevents
infection in patients undergoing colorectal surgery2.
They find that intravenous administration of a long acting
injectable antibiotic with adequate coverage for aerobic and
anaerobic bacteria with adequate serum levels at the time of
incision was very effective in reducing infection rate.
Frequently-used antibiotics such as cefuroxime with
metronidazole and gentamicin with metronidazole may be
The conclusions drawn in this study could
probably be extrapolated to gynecological patients undergoing
bowel surgery, either electively or because the bowel was
inadvertently injured during surgery.
Intra and Post-operative blood
transfusion was assossiated with increased infection
rate. Allogenic leukocytes in the transfused blood is
hypothesized to cause immunosuppression and consequent
impaired immunity. Leucocyte depleted blood was found to have
the same rate of infection as untransfused patients,
supporting the above hypothesis.
4. Intraoperative hypothermia
appeared to o triple the rate of postoperative infectious
complications. Maintaining the temperature of the patient at
36.5degree Celsius during surgery could reduce infection
5.Increased oxygen tension by way
of administering 80%oxygen in the first two post-operative
days increased the ability for oxidative killing at the
surgical site, along with increased neutrophil activity
leading to improved tissue healing according to a study by
Greif et al2.
This may mean that oxygen administration for longer periods
will benefit the patient who has undergone prolonged handling
of the bowel/extensive adhesiolysis.
Post-operative period: Peritonitis
and pulmonary infection are common modes of infection which in
compromised patients lead to the toxic shock state.
Classic signs of peritonitis: The
classic signs and symptoms of peritonitis include pain,
distention, fever and leukocytosis. The vital signs and input
and output must be carefully monitored. If the situation does
not improve withn 12- 24 hours, or worsens, immediate
exploration is indicated3.
Mild hypotension, tachycardia, fluid retention and change in
mental status are signs of sepsis.
Antibiotic management of patients with
peritonitis:Antimicrobial therapy is started preferably
with or just before reoperation, and is aimed at the usual
pathogens, Bacteroides fragilis and enterobacteriaceae. A
combination of nitro-imidazole and aminoglycoside or 3rd
generation cephalosporin appears suitable in most cases.
Harbath.S. et al recommend routine coverage for enterococci
also in patients with post-operative peritonitis5.
Sitges-Serra et al suggest that only triple therapy including
a beta lactam agent along with cephalosporins, aminoglycosides
and an anti aerobic agent, or monotherapy with
piperacillin-tazobactam (4gm 8 hourly)would afford optimal
coverage against enterococci6.
In my practice, whenever, in a tight spot
in a post-operative patient, specially in cases where
extensive laparoscopic adhesiolysis has been performed, if
the patient starts getting high temperature, the patient is
usually started on amikacin along with magnamycin. In special
cases where, extensive adhesions have been released, there is
always a possiblity of inadvertent pricks to the intestine. In
such patients and in patients who do not do well on magnamycin,
by way of showing high grade fever or rapid pulse or increased
respiratory rate, I usually start them on
piperacillin-tazobactum combination. If the surgery has gone
well it may look like overkilling to give expensive
antibiotics to patients, but probably, taking such a stand may
be more useful in the set up that we work in, to prevent the
patient from going into toxic shock. This is specially so
since hospital aquired infections are usually resistant to
antibacterials that are routinely used in the hospital.
after prolonged laparoscopic adhesiolysis of bowel, difficult
abdominal hysterectomy for higher grades of endometriosis, or
even seemingly uncomplicated LSCS can sometimes culminate in
septic shock. Some of these are due to tertiary peritonitis.
Here, the peritonitis and sepsis may have been controlled
during surgery and the bacteria eliminated by successful
antibiotic therapy. These patients sometimes go into a state
in which a syndrome of continued systemic inflammation is
produced. There is a hyperdynamic cardiovascular state,
low-grade fever and general hypermetabolism. The patient has
the clinical picture of sepsis without radiographically
Such patients sometimes are subjected to laparotomy seeking to
provide drainage of anticipated recurrent or residual
collections of infected fluid. On operation, no localized
infection is identified. Management is generally supportive
and any identified micro-organisms should be treated.
Intra abdominal infections other than
In the absence of physical
findings of diffuse peritonitis, diagnostic imaging with
either computed tomography (CT) or ultrasound should be
routinely performed in patients with clinically suspected
intra-abdominal infection. The evaluation whould be done
If there is a collection of pus, it may be
better to drain the pus percutaneously without a laparotomy,
as manipulation of the bowel in the presence of an
intraabdominal infection is usually followed by deterioration
in the patient’s condition initially. Usually, a well
established fluid collection (e.g: infected haematoma forming
pus) can be drained percutaneously, provided there is a safe
access to drain it.Drainage could be performed following fine
needle (18–22 gauge) aspiration, with the aspirate being used
to document infection and gauge the viscosity of the fluid.
For most collections, a drain should be placed to ensure
complete evacuation and minimize the chance of recurrence.
Recent evidence describes sepsis as
having two distinct stages. In the early stage, there is an
increase in inflammatory mediators, but as sepsis progresses,
there is a trend toward an anti-inflammatory immunosuppressive
state. Manifestations of sepsis include tachycardia,
tachypnea, alterations in temperature, and leukocytosis.
Severe sepsis is manifested by hypoperfusion (eg, lactic
acidosis or oliguria), organ dysfunction, or hypotension
(septic shock)6 .
The organ systems commonly affected include the heart,
kidneys, lungs, liver, coagulation system, and central nervous
system. Problems may manifest as myocardial dysfunction, acute
renal failure, adult respiratory distress syndrome, hepatic
failure, disseminated intravascular coagulation, and mental
status changes, respectively. Mortality rates with septic
shock range from 20% to 80% .
Septic shock in obstetric patients is
usually associated with four specific infections: septic
abortion, acute pyelonephritis, and severe chorioamnionitis or
endometritis.The most common organisms responsible for septic
shock are the aerobic gram-negative bacilli, principally E.
coli, Klebsiella pneumoniae, and Proteus species.
In the early stages of septic shock, patients usually are
restless, disoriented, tachycardic, and hypotensive.
Although hypothermia is occasionally present, most
patients have a relatively high fever (39° to 40°C). Their
skin may be warm and flushed due to an initial phase of
shock). Subsequently, as extensive vasoconstriction
occurs, the skin becomes cool and clammy. Cardiac arrhythmias
may be present, and signs of myocardial ischemia may occur.
Jaundice, often due to hemolysis, may be evident. Urinary
output typically decreases, and frank anuria may develop.
Spontaneous bleeding from the genitourinary tract or
venipuncture sites may occur as a result of disseminated
intravascular coagulation (DIC). ARDS is a common complication
of severe sepsis and is associated with manifestations such as
dyspnea, stridor, cough, tachypnea, and bilateral rales and
1.Any source of infection should be
identified and removed. For women with an infected abortion
the uterine contents must be removed promptly by curettage. .
Hysterectomy is seldom indicated unless gangrene sets in. With
pyelonephritis, ureteral catheterization, percutaneous
nephrostomy or flank exploration may be life saving.
2.Antibiotics: Choice of antibiotic
should ideally be dictated by epidemiologic and hospital data,
which is not always available in the Indian set up.
Recommended antimicrobial regimens for
high-risk patients with intra-abdominal infection8:
1. Aminoglycoside (amikacin, gentamicin,
netilmicin, tobramycin) plus an anti-anaerobe (clindamycin or
2.Aztreonam plus clindamycin
3.Ciprofloxacin plus metronidazole
4.Third/fourth generation cephalosporin
(cefepime, cefotaxime, ceftazidime, ceftizoxime, ceftriaxone)
plus an anti-anaerobe (clindamycin or metronidazole)
Genital tract infections6:For
genital tract infections, the following drugs may be chosen:
a.penicillin (5 million units IV every 6
hours) or ampicillin (2 g IV every 6 hours) plus clindamycin
(900 mg IV every 8 hours)
b.metronidazole (500 mg IV every 12
hours) plus gentamicin (1.5 mg/kg IV every 8 hours or 7 mg/kg
ideal body weight IV every 24 hours) or aztreonam (1 to 2 g
IV every 8 hours)
a.. imipenem-cilastatin (500 mg IV every
b.meropenem (1 g every 8 hours).
Correction of hypotension:Large
fluid deficits can exist in septic shock due to external
(e.g., diarrhea, sweating) or internal (e.g., edema,
peritonitis) losses. a.Fluid resuscitation may consist of
natural or artificial colloids or crystalloids. There is no
evidence-based support for one type of fluid over another9.
b.Fluid challenge in patients with
suspected hypovolemia (suspected inadequate arterial
circulation) may be given at a rate of 500–1000 mL of
crystalloids or 300–500 mL of colloids over 30 mins and
repeated based on response (increase in blood pressure and
urine output) and tolerance (evidence of intravascular volume
overload). Fluid challenge is a term used to describe the
initial volume expansion period in which the response of the
patient to fluid administration is carefully evaluated. During
this process, large amounts of fluids may be administered over
a short period of time under close monitoring to evaluate the
patient’s response and avoid the development of pulmonary
Fluid challenges require the definition
of four components: 1) the type of fluid to be administered
(e.g., natural or artificial colloids, crystalloids), 2) the
rate of fluid infusion (e.g., 500–1000 mL over 30 mins), 3)
the end points (e.g., mean arterial pressure of >70 mm Hg,
heart rate of <110 beats/min), and 4) the safety limits (e.g.,
central venous pressure of 15 mm Hg).
With vasodilation and ongoing capillary
leak, most patients require continuous aggressive fluid
resuscitation during the first 24 hrs of management. Input is
typically much greater than output, and input/output ratio is
of no utility to judge fluid resuscitation needs during this
time period.c.Human albumin may be used when considered
appropriate, notably in hypoalbuminemic patients.
d.Blood transfusion should be cautiously
given as it may be assossiated with increased mortality.
Patients can tolerate and may even benefit from hemoglobin
levels lower than the traditional 10 g/dL
e.If hypotension and organ hypoperfusion
do not respond to volume infusion, then inotropic drugs (to
improve cardiac performance) and vasopressor therapy (for
hypotension) are indicated.
Dopamine or norepinephrine is recommended
as the first-line drug10.
End point of treating hypotension is
restoration of central venous pressureto 8-12mmHg, mean
arterial pressure 65-90Hg and central venousoxygen saturation
a.Core temperature should be maintained
as close to normal as possible by use of antipyretics and a
b.Coagulation abnormalities should be
identified promptly and treated by infusion of platelets and
coagulation factors, as indicated.
c.Patients should be given oxygen
supplementation and observed closely for evidence of ARDS, one
of the major causes of mortality in cases of severe
sepsis.Oxygenation should be monitored by means of a pulse
oximeter or radial artery catheter. At the first sign of
respiratory failure, the patient should be intubated and
supported with mechanical ventilation.
d. Daily haemodialysis or continuous
venovenous haemofiltration should be used in patients with
overt acute renal failure.
Newer modalities of therapy10:
1.Use of steroids in septic shock has
been controversial. A meta-analysis showed that
hydrocortisone in doses from 200-300mg for 5 days or more
reduced duration of shock, systemic inflammation, and
mortality without causing harm Only patients with refractory
septic shock and adrenal insufficiency benefit from
hydrocortisone and 50 micrograms /day oral fludrocortisone can
2. Vasopressin replacement therapy in
doses ranging from 0.01-0.04IU/min improved haemodynamics and
decreased catecholamine requirements. However,vasopressin
might induce myocardial, cutaneous, or mesenteric
3.Recombinant human protein C (detrecogin
alfa,24microgram/kgper h for 96h provided a 6% reduction in
28-day mortality from sepsis with at least one recent (<48h)
organ dysfunction.(eg.,acute lung injury or acute respiratory
distress syndrome or acute renal failure). There should be
no risk of bleeding. One large study on this drug was
prematurely stopped because it was found inefficient. This
drug is available locally as “Xigris”.I have adminstered this
drug to a septicaemic patient referred to my centre with
multiple organ failure following sepsis, but she lost her
4. Use of polyvalent intravenous
immunoglobulins were found to reduce mortality in studies, but
high quality trials found no evidence that immunoglobulins
Morbidity following septic shock:
There may be long term sequels like physical disability
related to muscle weakness and post-traumatic stress
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Complications in gynaecologic Surgery: Prevention,
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