Surgical Source Control in Sepsis (SSC 2021)

Algorithm Steps

1. ▶

   Start

   Sepsis with Suspected Source Requiring Control

   Sepsis identified (organ dysfunction + suspected infection). Now determine if there is an anatomic source amenable to intervention. Common sources: intra-abdominal, soft tissue, urinary tract, vascular access, lung.

   1. ●

      Action

      Identify the Source

      1) History and exam: Focus on pain location, recent procedures, devices. 2) Imaging: CT with contrast for abdominal/pelvic sources; US for biliary/soft tissue. 3) Labs: Lactate, procalcitonin trending. 4) Consider: Recent surgery, indwelling devices (lines, drains, catheters).

      1. ◆

         Decision

         Type of Source?

         Categorize by intervention type needed: DRAINAGE: Abscess, empyema, obstructed system. DEBRIDEMENT: Necrotic tissue, necrotizing infection. DEVICE REMOVAL: Infected catheter, prosthesis. DEFINITIVE: Perforation repair, resection.

         1. ●

            Action

            Drainage Source

            ABSCESS: Intra-abdominal, pelvic, hepatic, splenic, soft tissue. OBSTRUCTED SYSTEM: Biliary (cholangitis), urinary (pyelonephritis with obstruction). EMPYEMA: Pleural space infection. Options: Percutaneous (IR), endoscopic (ERCP), open surgical drainage.

            1. ◆

               Decision

               Urgency of Source Control?

               SSC 2021: Source control as soon as medically and logistically practical. For MOST: Within 6-12 hours. EMERGENT (<6h): NSTI, clostridial myonecrosis, bowel infarction, perforation with peritonitis. MAY DELAY: Allow limited resuscitation if hypotensive, but don't delay indefinitely.

               1. ●

                  Action

                  Emergent Source Control (<6 hours)

                  Don't wait for stabilization - source control IS the resuscitation. Conditions: NSTI, gas gangrene, bowel perforation/ischemia, ascending cholangitis not responsive to drainage. Continue resuscitation during and after procedure. Consider damage control surgery if unstable.

                  1. ◆

                     Decision

                     Intervention Approach?

                     Choose LEAST INVASIVE option that will achieve source control. Percutaneous/endoscopic preferred over open when possible. Consider: Patient stability, anatomy, available expertise.

                     1. ●

                        Action

                        Percutaneous/Endoscopic

                        CT-guided abscess drainage. ERCP for biliary obstruction. Nephrostomy for obstructed kidney. Advantages: Less invasive, avoid anesthesia risk in unstable patient. Limitations: May not achieve complete source control, may need escalation.

                        1. ●

                           Action

                           Post-Source Control Care

                           1) Continue resuscitation (may still need vasopressors). 2) Continue antibiotics (duration based on source and adequacy of control). 3) Reassess for adequate source control - if persistent sepsis, re-image. 4) Consider return to OR for 'second look' if damage control. 5) ICU monitoring.

                           1. ✓

                              Outcome

                              Source Controlled

                              Septic focus eliminated or controlled. Continue antibiotics appropriate duration. Monitor for resolution of organ dysfunction.

                     2. ●

                        Action

                        Open Surgical Intervention

                        Required for: Perforation repair, bowel resection, extensive debridement, failed percutaneous approach. Consider damage control if unstable. Resect/debride all necrotic tissue. Leave abdomen open if ACS risk. Plan return to OR for reassessment.

               2. ●

                  Action

                  Early Source Control (6-12 hours)

                  Standard approach for most abdominal abscesses, complicated UTI, localized infection. Brief resuscitation acceptable: Fluid bolus, initiate vasopressors, start antibiotics. Then proceed to intervention. Don't delay beyond 12 hours.

               3. ●

                  Action

                  Staged/Delayed Source Control

                  Select situations only: Infected pancreatic necrosis (prefer day 3-4 walled-off). Stable contained abscess responding to antibiotics. Balance benefits of waiting vs. ongoing sepsis. Close monitoring essential - intervene sooner if deteriorating.

               4. ⚠

                  Warning

                  ⚠️ Source Control Saves Lives

                  Every hour delay in source control increases mortality in sepsis. Antibiotics alone cannot control an undrained abscess or necrotic tissue. 'Cannot resuscitate a patient who needs surgery' - sometimes source control IS the resuscitation.

         2. ●

            Action

            Debridement Source

            NSTI/Fournier's: Aggressive surgical debridement, often multiple returns to OR. PANCREATIC NECROSIS: Consider step-up approach (drain first, then debridement if needed). OSTEOMYELITIS: May need surgical debridement. GAS GANGRENE: Emergency debridement + amputation if needed.

         3. ●

            Action

            Device-Related Source

            INTRAVASCULAR: Central lines, PICC lines - remove if infected. PROSTHETIC: Joint replacement, vascular graft - may need removal. URINARY: Foley catheter - change or remove. CARDIAC: Pacemaker/ICD - evaluate for extraction if endocarditis.