Peritonitis fluid therapy

Clinical improvement should be seen within 48 hours of initiating treatment for peritonitis or catheter-related infections. Perform daily inspections of peritoneal fluid or the exit site to determine clinical improvement. Peritoneal fluid should become clear with improvement of peritonitis and erythema and discharge should remit with improvement of catheter-related infections. If no improvement is seen within 48 hours, obtain additional cultures and cell counts to determine the appropriate alterations in therapy. 

In patients with peritonitis, hypovolemia is often accompanied by acidosis, so large volumes of a solution such as lac-tated Ringers may be required initially to restore intravascular volume. Maintenance fluids should be instituted (after intravascular volume is restored) with 0.9% sodium chloride and potassium chloride (20 mEq/L) or 5% dextrose and 0.45% sodium chloride with potassium chloride (20 mEq/L). The administration rate should be based on estimated daily fluid loss through urine and nasogastric suction, including 0.5 to 1.0 L for insensible fluid loss. Potassium would not be included routinely if the patient is hyperkalemic or has renal insufficiency. Aggressive fluid therapy often must be continued in the postoperative period because fluid will continue to sequester in the peritoneal cavity, bowel wall, and lumen. 

Ascites. Patients with cirrhosis, especially fiver cirrhosis, very often develop ascites, ie, accumulation of fluid in the peritoneal cavity. This is the final event resulting from the hemodynamic disturbances in the systemic and splanchnic circulations that lead to sodium and water retention. When therapy with a low sodium diet fails, the dmg of choice for the treatment of ascites is furosemide, a high ceiling (loop) diuretic, or spironolactone, an aldosterone receptor antagonist/potassium-sparing diuretic. 

Patients who have previously experienced spontaneous bacterial peritonitis and have low-protein ascites (ascitic fluid albumin less than 1 g/dL [less than 10 g/L]) are candidates for long-term prophylactic therapy. Recommended regimens include either a single trimethoprim-sulfamethoxazole doublestrength tablet 5 days per week (Monday through Friday) or ciprofloxacin 750 mg once weekly.19,46 Any patient who has experienced an episode of variceal bleeding should also receive prophylactic antibiotics. 

For peritonitis, early and aggressive intravenous fluid resuscitation and electrolyte replacement therapy are essential. A common cause of early death is hypovolemic shock caused by inadequate intravascular volume expansion and tissue perfusion. 

Renal replacement therapy (RRT), such as hemodialysis and peritoneal dialysis, maintains fluid and electrolyte balance while removing waste products. See Table 75-4 for indications for RRT in ARF. Intermittent and continuous options have different advantages (and disadvantages) but, after correcting for severity of illness, have similar outcomes. Consequently, hybrid approaches (e.g., sustained low-efficiency dialysis and extended daily dialysis) are being developed to provide the advantages of both. 

Gonadotropins are used to treat infertility in women with potentially functional ovaries who have not responded to other treatments. The therapy is designed to simulate the normal menstrual cycle as far as is practical. A common protocol is daily injections of menotropins for 9 to 12 days, until estradiol levels are equal to that in a normal woman, followed by a single dose of hCG to induce ovulation. Two problems with this treatment are risks of ovarian hyperstimulation and of multiple births. Ovarian hyperstimulation is characterized by sudden ovarian enlargement associated with an increase in vascular permeability and rapid accumulation of fluid in peritoneal, pleural, and pericardial cavities. To prevent such occurrences, ovarian development is monitored during treatment by ultrasound techniques and by measurements of serum levels of estradiol. 

In addition to spironolactone, ascites can be managed by paracentesis. That is the removal ( tapping ) of ascitic fluid from the peritoneal cavity under aseptic conditions. A colloid (human albumin solution (20%)) is infused (40 mL (8 g of albumin) per litre of ascites drained) intravenously during paracentesis, in order to prevent intravascular volume depletion and the onset of renal failure. Following paracentesis, ascites recurs in the majority (93%) if diuretic therapy is not reinstituted, but recurs in only 18% of patients treated with... 

Secondary bacterial peritonitis, ascitic fluid infection caused by a treatable intra-abdominal source, can masquerade as SBP and should be considered when multiple or atypical organisms are cultured, a very high ascitic fluid PMN count is seen, or in patients who fail to respond to appropriate antibiotic therapy. Uncomplicated SBP usually responds rapidly to appropriate therapy and the 48-hour PMN count, if obtained, is predictably lower than the initial count. In this setting a follow-up paracentesis revealing a PMN count that continues to rise despite antibiotic therapy can be helpful in detecting secondary peritonitis. ... 

Renal replacement therapies (RRTs) like hemodialysis, peritoneal dialysis, and other related treatments have been available for decades, but have not resulted in dramatic improvements in patient outcomes. RRT can help patient management by normalizing blood electrolyte values, augmenting waste product removal, and maintaining fluid balance. Despite the supportive care that RRT offers, development of ARF is frequently a catastrophic event. 

Primary peritonitis is treated with antimicrobials and rarely requires drainage. Secondary peritonitis requires surgical correction of the underlying pathology. The drainage of the purulent material is the critical component of management of an intraabdominal abscess. Without adequate drainage of the abscess, antimicrobial therapy and fluid resuscitation can be expected to fail. 

The usual duration of therapy for peritonitis associated with CAPD is 10 to 14 days, but up to 3 weeks of therapy may be required. Antimicrobial therapy should be continued until dialysate fluid is clear, cultures are negative for 2 to 3 days, and the patient is asymptomatic. When parenteral agents are administered, the initial dose would be the same as that for patients with normal renal function, whereas subsequent doses should be much less or given less frequently for renally excreted agents and should account for possible loss through peritoneal dialysis. Serum concentrations should be performed for aminoglycosides and vancomycin. Some studies have demonstrated that for patients with spontaneous bacterial peritonitis associated with cirrhotic ascites, treatment duration may be as short as 5 days when ascitic fluid polymorphonuclear cell counts are used to guide treatment. 

Complications from IP therapy may be related to catheter fnnc-tion, infection, or bowel problems. Mechanical obstrnction to flnid inflow has been reported in approximately 5% of patients. Most commonly, this results from fibrin sheath formation around the catheter tip. In some cases, peritoneal adhesions obstruct fluid entry into the abdominal cavity, causing uneven distribution of the chemotherapentic agent. Infections complications, such as superficial cellulitis around the catheter entry site, deep tissue infections, and peritonitis, are the most prevalent IP-related comphcations and are reported in approximately 10% of patients. Bowel-related comphcations (approximately 3% incidence) inclnde obstruction. Ecus, and perforation. IP administration may also resnlt in a false CA-125 elevation. ... 

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