|ORIGINAL RESEARCH REPORT
|Year : 2020 | Volume
| Issue : 4 | Page : 108-112
Factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary center in Nigeria - A cross-sectional study
Tinuola Abiodun Adigun1, Olusola K Idowu1, Omobolaji O Ayandipo1, Oludolapo O Afuwape2, Modupe Kuti3
1 Department of Anaesthesia, University College Hospital, Ibadan, Nigeria
2 Department of Surgery, University College Hospital, Ibadan, Nigeria
3 Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
|Date of Submission||02-Dec-2019|
|Date of Acceptance||11-Aug-2020|
|Date of Web Publication||19-Oct-2020|
Dr. Tinuola Abiodun Adigun
Department of Anaesthesia, University College Hospital, Ibadan
Source of Support: None, Conflict of Interest: None
Background: Peritonitis is one of the surgical emergencies commonly encountered by the general surgeons. Sepsis, dehydration, hypovolemia, and multiple organ dysfunctions have been associated with high mortality rate. The study aimed to assess risk factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary institution. Methods: We conducted a prospective cross-sectional study involving consenting patients managed for peritonitis under general anesthesia over a year period. A study proforma was used to collect the data on demographic characteristics and clinical and biochemical parameters. The association between postoperative mortality and demographic characteristics and clinical and biochemical parameters was determined with Chi-square test, and the level of significance was set at P < 0.05. Results: A total of 52 adult patients were studied with 38 (73.1%) males and 14 (26.9%) females. The mean age was 39.7 ± 15.3 years. Nineteen patients died, and the mortality rate was 36.5%. Mortality was more in females and in patients more than 50 years (P = 0.917 and P = 0.34), respectively. Preoperative high American Society of Anesthesiologists (ASAs) physical status (P = 0.002), higher Mannheim Peritonitis Index (MPI) scores (P = 0.005), preoperative systolic blood pressure <100 mmHg (P = 0.006) and preoperative respiratory rate more than 30 breaths/min (P = 0.002), serum creatinine level more than 1.5 (P = 0.04), and acidosis (P = 0.02) were statistically significant risk factors for mortality in this study. Conclusion: The mortality following perforation peritonitis is high in our center. Poor outcome is seen in patients with high ASA status, high MPI scores, preoperative shock, acidosis, renal failure, and tachypnea. Proper resuscitation from shock, correction of acidosis, and improving the ASA status will improve survival in patients with perforated peritonitis.
Keywords: Anesthesia, general, mortality, peritonitis, risk factors
|How to cite this article:|
Adigun TA, Idowu OK, Ayandipo OO, Afuwape OO, Kuti M. Factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary center in Nigeria - A cross-sectional study. J Clin Sci 2020;17:108-12
|How to cite this URL:|
Adigun TA, Idowu OK, Ayandipo OO, Afuwape OO, Kuti M. Factors associated with mortality in patients with peritonitis presenting for anesthesia and surgery in a tertiary center in Nigeria - A cross-sectional study. J Clin Sci [serial online] 2020 [cited 2022 Jun 26];17:108-12. Available from: https://www.jcsjournal.org/text.asp?2020/17/4/108/298461
| Introduction|| |
Peritonitis is defined as inflammation of the serous membrane that lines the abdominal cavity and abdominal organs. Peritonitis is the most common surgical emergency encountered by the general surgeons worldwide. It is conventionally divided into primary and secondary peritonitis based on the source and type of microbial contamination; secondary peritonitis is due to loss of epithelial integrity from perforation of the gut, bacteria pathogens transverse into the peritoneal cavity leading to cascade of inflammatory response, sepsis, dehydration, hypovolemia with multiple organ failure, and death if not treated in a timely manner.
Emergency exploratory laparotomy is performed to determine the underlying pathology, anatomical site of perforation, and eliminate foci of infection. Despite the diagnosis, resuscitation, modern surgical technique, and early goal-directed therapy according to the surviving sepsis campaign and intensive care, the morbidity and mortality associated with peritonitis is still high.
Al-Temimi et al. reported the outcome of emergency laparotomy using a large patient database collected over 4 years in the United States of America; intestinal obstruction and perforation were the most common condition requiring emergency laparotomy (33% and 19%, respectively), and the overall 30-day mortality was 14.4%; similarly, in another multicenter study in Europe reported by the UK National Emergency Laparotomy Network, a 30-day mortality was 14.9% among 1853 patients. However, the mortality rate in Nigeria and other developing countries is still high up to 56%, although 2.5% of mortality rate was obtained by Ayandipo et al. in a retrospective study.
Various risk factors for morbidity and mortality in patients with peritonitis have been studied with conflicting results related to varying methodology., Age, sex, preoperative shock, serum lactate level, acidosis, base excess, multiple organ failure, delay in surgical treatment, degree of contamination, immunodeficiency state, severity of patient's systemic response, and physiologic compromise are some of these risk factors.,,
The aim of this study was to determine the predictors of mortality that may affect the treatment outcome in adult patients presenting with peritonitis in a tertiary center.
| Patients and Methods|| |
This prospective cross-sectional study was conducted on 52 patients with perforated peritonitis scheduled for exploratory laparotomy from April 2016 to March 2017. Ethical approval for the study was obtained from the institutional ethical committee. Adult patients with American Society of Anesthesiologist (ASA) physical Status I–IV who were 18 years and above were recruited. Patients who refused to give consent and those with primary peritonitis were excluded from the study.
The preoperative resuscitative measure included intravenous fluids' (crystalloid) administration and electrolyte correction, nasogastric tube insertion for gastric decompression, urethral catheterization, analgesia, and broad-spectrum antibiotics according to the protocol of the hospital. Hydration was continued during and after the surgery.
Relevant preoperative investigations included packed cell volume (PCV), electrolytes and urea, random blood sugar, and blood gas analysis. After the resuscitation, all patients had a preoperative anesthetic review and patients who were clinically and hemodynamically stable for surgery were subjected to exploratory laparotomy under general anesthesia.
All these 52 patients received general anesthesia with rapid sequence induction, endotracheal intubation, and controlled ventilation. Intraoperative analgesia was with intravenous fentanyl and paracetamol.
Intraoperative monitoring included noninvasive blood pressure, oxygen saturation, electrocardiogram, end-tidal carbon dioxide, temperature, and urinary output. Crystalloid or colloid was given for fluid replacement and blood transfusion was given when necessary. The site of perforation was diagnosed during surgery and the appropriate surgical procedure was done with peritoneal lavage.
Postoperatively, the residual neuromuscular block was reversed with atropine and neostigmine. Patients with inadequate recovery or hypotension on account of septic shock were transferred to the intensive care unit otherwise the recovery room.
The parameters studied were age, gender, duration of symptoms, ASA, Mannheim Peritonitis Index (MPI), preoperative biochemical parameters, intraoperative findings, postoperative care, and outcome. The outcome may be mortality or survival of patients.
Statistical analysis was done with descriptive statistic using theStatistical package for the social sciences version 20.0 (SPSS Inc) for windows 20.0, Chicago, Illinois, USA. Results are presented in percentages/proportion for categorical variables and continuous variables are described as means ± standard deviation. The association between the outcome and clinical and biochemical parameters was determined using Chi-square, and the level of significance was set at P < 0.05.
| Results|| |
A total of 52 patients were included in this study; there were 38 males and 14 females with a male: female ratio of 3:1. The mean age of the patients was 39.7 ± 15.3 years, and the age ranged between 17 and 70 years. Forty patients were without comorbidities and 12 were with comorbidities; hypertension was in 6 (50%) of the patients with comorbidity. The etiology of peritonitis showed that appendix perforation (16, 30.8%) was the most common cause of peritonitis, followed by small bowel perforation (13, 25%). The patients' demographic characteristics are detailed in [Table 1].
The overall mortality rate was 36.5% (19/52). The age, sex, and symptom duration have no significant effect on mortality (P = 0.34, P = 0.91, and 0.86), respectively.
Clinical parameters showed that low systolic blood pressure <100 mmHg and high respiratory rate >30/min have significant effect on mortality (P = 0.006 and P = 0.003), respectively, whereas high heart rate >100 beats/min showed no significant effect on mortality P = 0.53 [Table 2].
There was no mortality in patients with ASA 1, 11.1% mortality in ASA 2, 20% in ASA 3, 86.7% mortality in ASA 4, and 100% mortality in ASA 5 (P = 0.001).
The mortality was 75% in patients with MPI score of >30, 67.1% mortality in patients with MPI scores of 21–29, and 17.4% mortality in MPI score of <20 (P = 0.005).
The laboratory parameters showed that low PCV <30% and low blood sugar <80 mg/dl have no significant effect on mortality (P = 0.22 and P = 0.32), respectively, whereas high creatinine levels >1.5 and acidosis significantly affect mortality (P = 0.03 and 0.02), respectively [Table 3].
Six patients were admitted in the intensive care unit for ventilatory and inotropic support postoperatively and three patients died. The causes of mortality in the study were acute respiratory distress syndrome, renal failure, hypovolemic shock, enterocutaneous fistula, and multiple organ dysfunctions [Table 4].
| Discussion|| |
Peritonitis is a problem worldwide though poor outcome in resource constraint countries like Nigeria, it is associated with high mortality rate despite resuscitation, appropriate systemic antibiotics, surgical intervention, and intensive care medicine. The prevalence of mortality in this study was 36.5%. The poor outcome was associated with high ASA physical status, high MPI score, preoperative tachypnea, hypotension, acidosis, and renal dysfunction.
Although intra-abdominal sepsis affects all age groups, mortality has been reported to be more in elderly patients compared with the younger population; increase in mortality in the older population may be due to loss of physiological reserve, associated comorbid illness, and immunosuppression. The age more than 50 years was not significant in this study; this is contrary to the findings by Correia et al. who found that age more than 50 years is a significant risk factor for mortality; similarly, Boey et al. did not find age as a risk factor for mortality but found concurrent medical illness as a risk factor for mortality in the elderly.
Our series showed a male-to-female ratio of 3:1 similar to a study by Adesunkanmi et al., although Kocer et al. reported a higher male preponderance of 8:1 in their study compared to what was obtained in this study. Mortality was higher in female gender but not significant in this study. Basnet and Sharma also showed a male preponderance in their study, but female gender was not a bad prognosis for mortality. Advanced age and female gender were assigned higher scores in the MPI scoring system.
ASA grading is a useful tool for quick preoperative risk stratification and was found to be a significant risk factor for mortality in this study. This was confirmed by Kocer et al. that with each increase in the ASA score, the mortality increases by 3.5 times in patients with peritonitis. ASA grading, therefore, has a correlation with outcome.
MPI score is commonly used to define risk groups as well as predict the outcome in patients with peritonitis; it takes into account the age of the patient, gender, organ failure, associated cancer, duration of peritonitis, involvement of the colon, extent of spread, and character of the exudates. Mortality rate increases with increase in MPI score. The total score ranged from 0 to 57. Wach et al. showed that patients who obtained <21 points and >29 points had mortality rates of 6% and 50%, respectively. Others' studies have also shown a significant relationship between the increasing mortality rate and increasing MPI score.,, This study also confirms that higher MPI scores is a significant risk factor for mortality in patients with peritonitis.
Poor outcome was more in patients that presented late to the hospital with the duration of symptoms >3 days compared to those who presented early to the hospital in our study, although not significant. A study by Singh et al. compared patients that presented <3 days with symptoms to the hospital with those that presented after 3 days and found that all the patients that died (100% mortality) presented after 3 days compared with no death in those that presented <3 days P = 0.001. Delayed presentation leads to generalized peritonitis and reduced survival rate as a result of widespread dissemination of the insult making the control of pathology difficult and resulting in septic shock, deranged renal parameter, and poor postoperative outcome. Late presentation may be due to the poor health-seeking behavior of many patients.
In our study, mortality was 80% among patients with systolic blood pressure <100 mmHg, whereas it was 25% in patients with systolic blood pressure 100–120 mmHg (P = 0.006). Similarly, Paryani et al. found 80% mortality in patients with systolic blood pressure <100 mmHg, whereas Kocer et al. found a mortality of 68.8% in systolic blood pressure <100 mmHg. Hypotension increases mortality as perfusion to vital organs is reduced. Preoperative aggressive fluid resuscitation is essential before surgery, but this should not unnecessary delay the proposed surgery.
Respiratory rate of >30/min was found to be associated with 55.2% of mortality (P = 0.002) in this study, although 67% of mortality was found in patients with respiratory rate >30/min in a study by Paryani et al. A recent study has also shown that respiratory failure was the main organ failure associated with mortality in peritonitis.
Mortality was 50% in patients with Packed cell volume <30% and 32% in patients with PCV >30%, although not significant in this study; similarly, Singh et al. did not find anemia as a predictor of mortality in patients with peritonitis in their study.
Impaired renal function may be due to dehydration, sepsis, and hemodynamic compromise. Mortality was 52.2% when creatinine >1.5 compared with 24.1% in patients with creatinine <1.5 (P = 0.037) in our study. Muller et al. also reported renal insufficiency as an independent risk factor associated with mortality in patients operated for peptic ulcer perforation in their study.
Acidosis was associated with mortality in this study; Muller et al. found acidosis as an independent predictor of mortality; lactic acidosis has also been associated with mortality in severe sepsis and septic shock patients. Low values of bicarbonate levels were also associated with higher mortality in the intensive care unit.
| Conclusion|| |
The following factors were associated with mortality in patients with peritonitis scheduled for surgery and anesthesia in our center: high ASA status, high MPI scores, preoperative shock, acidosis, renal failure, and tachypnea. Proper resuscitation from shock, correction of acidosis, and improving the ASA status will improve survival in patients with perforated peritonitis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta S, Kaushik R. Peritonitis – The Eastern experience. World J Emerg Surg 2006;1:13.
Johnson CC, Baldessaire J, Levison ME. Peritonitis. Update on pathophysiology, clinical manifestation and management. Clin infect Dis 1997;24:1035-45.
Ordoñez CA, Puyana JC. Management of peritonitis in the critically ill patient. Surg Clin North Am 2006;86:1323-49.
Al-Temimi MH, Griffee M, Enniss TM, Preston R, Vargo D, Overton S, et al
. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012;215:503-11.
Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ, UK Emergency Laparotomy Network. Variations in mortality after emergency laparotomy: The first report of the UK Emergency Laparotomy Network. Br J Anaesth 2012;109:368-75.
Adesunkanmi AR, Badmus TA, Ogundoyin O. Causes and determinants of outcome of intestinal perforations in a semi-urban African community. Ann Coll Surg Hong Kong 2003;7:116-23.
Ayandipo OO, Afuwape OO, Irabor DO, Abdurrazzaaq AI, Nwafulume NA. Outcome of laparotomy for peritonitis in 302 consecutive patients in Ibadan, Nigeria. Ann Ib Postgrad Med 2016;14:30-4.
Sharma K, Kumar M, Batra UB. Anesthetic management for patients with perforation peritonitis. J Clin Anaesth Pharmacol 2013;29:445-53.
Jhobta RS, Attri AK, Kaushik R, Sharma R, Jhobta A. Spectrum of perforation peritonitis in India--review of 504 consecutive cases. World J Emerg Surg 2006;1:26.
Singh R, Kumar N, Bhattacharya A, Vajifdar H. Preoperative predictors of mortality in adult patients with perforation peritonitis. Indian J Crit Care Med 2011;15:157-63.
] [Full text]
Kocer B, Surmeli S, Solak C, Unal B, Bozkurt B, Yildirim O, et al
. Factors affecting mortality and morbidity in patients with peptic ulcer perforation. J Gastroenterol Hepatol 2007;22:565-70.
Billing A, Fröhlich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis index in 2003 patients. Peritonitis Study Group. Br J Surg 1994;81:209-13.
Correia MM, Thuler LC, Velasco E, Vidal EM, Schancuder A. Prediction of death using the Mannheim peritonitis index in oncology patients. Rev Bras Cancerologia 2001;47:63-8.
Boey J, Wong J, Ong GB. A prospective study of operative risk factors in perforated duodenal ulcers. Ann Surg 1982;195:265-9.
Basnet RB, Sharma VK. Evaluation of predictive power of Mannheim peritonitis index. Postgrad Med J NAMS 2010;10:10-3.
Rogy M, Függer R, Schemper M, Koss G, Schulz F. The value of 2 distinct prognosis scores in patients with peritonitis. The Mannheim Peritonitis Index versus the Apache II score. Chirurg 1990;61:297-300.
Wacha H, Linder MM, Feldmann U, Wesch G, Gundlach E, Steifensand RA. Mannheim peritonitis index-prediction of risk of death from peritonitis; Construction of a statistic and validation of an empirically based index. Theoretical Surgery 1987;1:169-77.
Svanes C, Lie RT, Svanes K, Lie SA, Søreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg 1994;220:168-75.
Paryani JJ, Patl V, Rathod G. Etiology of peritonitis and factors predicting the mortality in peritonitis. Natl J Community Med 2013;4:145-8.
Møller MH, Shah K, Bendix J, Jensen AG, Zimmermann-Nielsen E, Adamsen S, et al
. Risk factors in patients surgically treated for peptic ulcer perforation. Scand J Gastroenterol 2009;44:145-52.
Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, et al
. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009;37:1670-7.
[Table 1], [Table 2], [Table 3], [Table 4]