An immediate operation in these patients results in a high risk Dinaciclib in vitro for postoperative acute kidney PF299 order injury (AKI) sets the stage for MOF, prolonged intensive care unit (ICU) stays and dismal long-term outcomes [40, 44, 45]. By their protocol, patient presenting in septic shock warrant pre-operative optimization with early goal directed therapy. If they

are not optimized pre-operatively, they will experience profound hypotension when subjected to general anesthesia and require high doses vasopressors (typically boluses of phenylephrine) to maintain mean arterial pressure (MAP) and if they undergo a traditional HP this will be prolonged and contribute substantially to post-operative AKI [45]. After optimization (described below), the patient is taken to the OR. After undergoing general anesthesia, the surgeon assesses whether the patient is still in septic shock. If so, the OR team is informed that a DCL is going to be performed. They should anticipate a short operation (roughly 30–45 minutes) and get the supplies necessary

for a TAC. A limited colon resection of the inflamed perforated colon is performed using staplers (referred Crenigacestat to as a “perforection”) with no colostomy and a TAC is performed using a “vac pack” technique. The patient is returned to the ICU for ongoing resuscitation. Once physiologic abnormalities are corrected, the patient is returned to the OR for peritoneal lavage and colostomy formation. A definitive resection should be done if feasible for patients who have undergone a limited resection at the previous DCL to prevent a fistula and recurrence. However, Kafka-Ritsch et al. propose

an alternative reason to Sclareol perform DCL in patients with diverticulitis is to avoid a colostomy by performing a delayed anastomosis [43]. In a prospective study 51 patients with perforated diverticulitis (stage III/IV) were initially managed with limited resection, lavage and TAC with a vacuum-assisted closure device followed by second, reconstructive operation 24–48 hours later supervised by a colorectal surgical specialist. Bowel continuity was restored in 38 (84%) patients, of which four were protected by a loop ileostomy. Five anastomotic leaks (13%) were encountered requiring loop ileostomy in two patients or HP in three patients. Postoperative abscesses were seen in four patients, abdominal wall dehiscence in one and relaparotomy for drain-related small bowel perforation in one. The overall mortality rate was 10% and 35/46 (76%) of the surviving patients left the hospital with reconstructed colon continuity. Fascial closure was achieved in all patients.