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ICU patients with infectious complications after abdominopelvic surgery: Is thoracic CT in addition to abdominal CT helpful?

ICU patients with infectious complications after abdominopelvic surgery: Is thoracic CT in... Background The aim of this study was to assess the usefulness of adding thoracic CT to abdominal CT in intensive care unit (ICU) patients with signs of infection after abdominopelvic surgery. Methods 143 thoracoabdominal CTs of ICU patients with signs of infection after abdominopelvic surgery were ret‑ rospectively reviewed for thoracic pathologies. It was determined if pathologic findings were visible only on thoracic CT above the diaphragmatic dome or also on abdominal CT up to the diaphragmatic dome. All thoracic pathologies visible only above the diaphragmatic dome were retrospectively analyzed by an ICU physician in terms of clinical relevance. Diagnostic and therapeutic efficacy of thoracic CT were assessed with regard to an infectious focus and to other pathologic findings. Results 297 pathologic thoracic findings were recorded. 26 of the 297 findings could only be detected on images obtained above the diaphragmatic dome (in 23 of 143 CTs). A change in patient management was initiated due to only one of the 26 supradiaphragmatic findings. Diagnostic efficacy of thoracic CT in addition to abdominal CT to identify an infectious focus was 3.5% (95%‑ CI: 0.5–6.5%) and therapeutic efficacy was 0.7% (95%‑ CI: 0–2.1%). With regard to all pathologic thoracic findings, diagnostic efficacy was 16.1% (95%‑ CI: 10.1–22.1%) and therapeutic efficacy remained at 0.7%. Conclusions Additional thoracic CT to detect an infectious focus in ICU patients after abdominopelvic surgery leads to identification of the focus in only 3.5% and to changes in patient management in only 0.7%. Other relevant find‑ ings are more common (16.1%), but very rarely affect patient management. Keywords Diagnostic imaging, Multidetector computed tomography, Intensive care units, Surgery, Infections Background Infectious complications after surgery are common. *Correspondence: Heiner Nebelung Around 11% of patients develop nosocomial infections heiner.nebelung@uniklinikum‑ dresden.de [1], with postoperative pneumonia affecting around 5% of Institute and Polyclinic for Diagnostic and Interventional Radiology, patients [2] and up to 40% of patients developing surgi- University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Fetscherstr. 74, 01307 Dresden, Germany cal site infections, depending on the type of surgery [3]. Department of Visceral, Thoracic and Vascular Surgery, University Severe postoperative infectious complications, such as Hospital Carl Gustav Carus Dresden at the Technical University Dresden, sepsis, are also not uncommon with an overall incidence Fetscherstr. 74, 01307 Dresden, Germany National Center for Tumor Diseases (NCT/UCC), Dresden, Germany of 1.84% [4]. If sepsis occurs after surgery, the infectious German Cancer Research Center (DKFZ), Heidelberg, Germany focus involves the abdominal cavity in 66% of patients Helmholtz‑Zentrum Dresden‑Rossendorf (HZDR), Dresden, Germany [5]. In a cohort of septic patients with re-laparotomy after © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 2 of 9 abdominal surgery, CT was found to play a significant patients in comparison to CXR and concluded that role in identifying the septic focus [6]. CT resulted in a high number of additional diagnoses, Imaging generally plays an important role in the man- another study by Miller et  al. in 1998 stated that CT is agement of patients in intensive care units (ICUs). useful in selected patients [14, 15]. The recently published American College of Radiol - In our center, the standard of care is to liberally per- ogy Appropriateness Criteria for Intensive Care Unit form thoracic CT in addition to simultaneous abdominal Patients state that portable chest radiography (CXR) is CT in patients with signs of infection after abdominopel- still the most commonly used imaging modality in ICU vic surgery. The advantage of this approach is the pos - patients [7]. Extensive research has shown not only the sibility of a whole-body overview of potential infectious usefulness of CXR but also the potential for overuse and foci in critically ill patients. This avoids repeated, poten - a meta-analysis found no harm associated with a restric- tially detrimental patient transfers with accompanying tive strategy [7–10]. ICU personnel and preserves critical resources. On the There has been little research on the topic of thoracic other hand, unnecessary CT imaging is a rising concern CT in ICU patients, especially in recent years, but the and should be avoided due to increased exposure of number of CT scans has been ever increasing over the patients to ionizing radiation as well as increasing costs. years [11–13]. An article by Dorenbeck et  al. in 2002 To the best of our knowledge, no study thus far has evaluated the usefulness of thoracic CT in general ICU assessed the usefulness of additional thoracic CT in ICU Fig.1 Study population and exclusion criteria Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 3 of 9 Table 1 Primary diagnoses and surgical procedures of our study population Primary diagnosis Surgical procedure n Acute cholecystitis Cholecystectomy 2 Chronic pancreatitis Pylorus‑preserving pancreaticoduodenectomy 2 Duodenum‑preserving pancreatic head resection 2 Whipple’s procedure 1 Pancreatectomy 1 Diabetes mellitus type 1 Pancreas transplant 1 Pancreatic cancer Pancreatectomy 1 Pylorus‑preserving pancreaticoduodenectomy 3 Left pancreatic resection 1 Multivisceral resection 1 Main duct intraductal papillary mucinous neoplasm Pancreatectomy 1 Benign tumor of the papilla Pylorus‑preserving pancreaticoduodenectomy 1 Klatskin tumor Pylorus‑preserving pancreaticoduodenectomy 1 Whipple’s procedure 1 Left hemihepatectomy 1 Cholangiocellular carcinoma Right hemihepatectomy 1 Extended right hemihepatectomy 2 Cholecystic myosarcoma Right hemihepatectomy + cholecystectomy 1 Caroli’s syndrome Left hemihepatectomy 1 Hepatic metastases of rectal cancer Right hemihepatectomy 1 Gastric cancer Gastrectomy 3 Subtotal gastrectomy 1 Recurrent gastric cancer Pylorus‑preserving pancreaticoduodenectomy 1 Esophageal cancer Esophagectomy 1 Colon cancer Peritonectomy + HIPEC 1 Rectal cancer Rectal resection 1 Rectal exstirpation 1 Recurrent rectal cancer Pelvic exenteration 1 Recurrent chordoma Pelvic exenteration 1 Peritoneal fibrosarcoma Multivisceral resection 1 Peritoneal carcinosis (endometrial cancer) Multivisceral resection 1 Colitis ulcerosa Proctocolectomy 1 Acute abdomen Explorative laparotomy 3 Mechanical ileus Partial small bowel resection 1 Incarcerated incisional hernia Hernia repair 1 Ogilvie syndrome Subtotal colectomy 1 Sigmoid perforation Sigmoid resection 1 Duodenal ulcer Ulcer excision and repair 1 Upper gastrointestinal bleed Explorative laparotomy 1 Partial small bowel resection 1 Pancreatectomy 2 Lower gastrointestinal bleed Explorative laparotomy 2 Bleed from right hepatic artery Evacuation of hematoma 1 Retroperitoneal hematoma Embolization of lumbal artery 1 Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 4 of 9 Table 1 (continued) Primary diagnosis Surgical procedure n Mesenteric ischemia Explorative laparotomy 2 Total colectomy 2 Subtotal colectomy 1 Right hemicolectomy 1 Right hemicolectomy + partial small bowel resection 1 Left hemicolectomy + partial small bowel resection 1 Abdominal aortic aneurysm Endovascular aortic repair 1 Infection of iliac bypass Explantation of bypass 1 Gluteal/perianal ulcers Debridement 4 Retroperitoneal abscess Abscess drainage 1 Inguinal infected seroma Wound revision 1 Methods Study population and baseline characteristics Approval by the local ethics committee was granted for this study, which was performed in accordance with the ethical standards as laid down in the 1964 Declara- tion of Helsinki and its later amendments. Patients, who were examined in non-emergency situations and who were able to, had given written informed consent to CT. All CTs had been performed within the scope of clinical routine. Clinical data and imaging of 180 surgical ICU patients (51 women, 129 men), who had received post- operative thoracoabdominal CT scans at our institution between July 2019 and December 2019, were retrospec- tively reviewed. Patients were referred for CT with clini- cal signs of infection, e.g., fever, elevated leukocytes, and C-reactive protein. Some patients received more than one CT; thus, a total of 396 CTs was reviewed. 119 CTs were excluded, because the patients had non-abdom- inopelvic primary pathologies (for details see Fig.  1). Out of the remaining 277 CTs, 134 CTs were excluded, because thoracic CT was performed for reasons other than suspected infectious focus. Examples are sus- pected pulmonary artery embolism, suspected tho- Fig. 2 CT planning scout. Green: scout for thoracoabdominal CT. racic hemorrhage, and follow-up of known pathologies, Red: examined region in thoracic CT alone. Blue: examined region in like thoracic abscess, pleural empyema, hemothorax, or abdominal CT alone pneumonia. The remaining 143 CTs were included in this study (99 CTs of 50 male patients and 44 CTs of 22 female patients). The mean age of patients was 62.5 years patients with infectious complications after abdomin- (± 14.5). At the time of imaging, mean value of leuko- opelvic surgery. Thus, the aim of this study was to deter - cytes was 16.40 (± 9.48) GPt/L (reference value 3.8–9.8 mine the value of thoracic CT in this setting. GPt/L) and of C-reactive protein was 155.84 (± 101.75) Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 5 of 9 Table 2 Pathologic thoracic findings in thoracoabdominal CT Pathologic findings Thoracal Visible only above diaphragmatic Clinically relevant dome % on all 143 CTs % on all 143 CTs % on all 143 CTs Pneumonic infiltrate 42 29.4% 5/42 3.5% 1/5 0.7% Pulmonary congestion 21 14.7% 8/21 5.6% 0/8 0% Catheter‑associated thrombosis 7 4.9% 7/7 4.9% 0/7 0% Endotracheal tube malposition 3 2.1% 3/3 2.1% 0/3 0% Chest tube malposition 1 0.7% 1/1 0.7% 0/1 0% Pulmonary artery embolism 1 0.7% 1/1 0.7% 0/1 0% Pulmonary nodule 2 1.4% 1/2 0.7% 0/1 0% Pleural effusion 131 91.6% 0/131 0% N/A N/A Dystelectasis 79 55.2% 0/79 0% N/A N/A Pericardial effusion 10 7.0% 0/10 0% N/A N/A We determined diagnostic efficacy of thoracic CT mg/L (reference value < 5.0 mg/L). In 72 CTs, the patients imaging by calculating the proportion of CTs with patho- were mechanically ventilated. The primary diagnoses and logic thoracic findings visible only above diaphragmatic surgical procedures are summarized in Table 1. dome out of all performed CTs. In the next step, we determined therapeutic efficacy by calculating the pro - Image interpretation portion of CTs with pathologic thoracic findings visible The 143 CTs were reviewed independently by three radi - only above the diaphragmatic dome that affected patient ologists with fifteen, three, and one year(s) of experience management out of all performed CTs. in CT imaging. They looked for thoracic pathologies and Effective doses (in mSv) were calculated by multiply - recorded, if they were visible only above an imaginary ing the dose length products, which were provided by the plane at the tip of the diaphragm or if they were vis- scanner, with a conversion factor of 18 μSv/mGycm, as ible below as well (Fig.  2). All occurring pathologies are recommended by Huda et al. [17]. shown in Table 2. For all thoracic pathologies, which were visible only above the diaphragmatic dome, an intensive Results care physician (> 15 years of experience) determined ret- In 143 CTs we found a total of 297 thoracic pathologies rospectively, if they were clinically relevant. Therefore, he (median 2; IQR 1), see Table  2. More than two-thirds searched our hospital information system for changes in were pleural effusions and compression atelectases. In patient management due to the pathologic findings on 29.4% of the CTs, patchy consolidations of the lungs com- CT (only above the diaphragmatic dome). patible with the imaging diagnosis of pneumonia were found. In most cases, pathologic thoracic findings were Data analysis visible below diaphragmatic dome. Only in 23 of 143 CTs To assess the usefulness of thoracic CT we employed the we found thoracic pathologies, which were visible only concept developed by Fryback and Thornbury, which above diaphragmatic dome (Fig.  3), so overall diagnostic defines six levels of efficacy. Efficacy of diagnostic imag - efficacy of dedicated thoracic CT as part of the imaging ing is defined as its contribution to the patient manage - protocol was 16.1% (95%-CI: 10.1–22.1%). ment process. In five cases (3.5%) we found pneumonic infiltrates, Level 1 addresses technical efficacy, level 2 the yield of which were visible only above diaphragmatic dome (Fig. 4 abnormal or normal diagnoses in a case series, as well as and 5). There were no other findings above the diaphrag - diagnostic accuracy, sensitivity, and specificity associ - matic dome, which could be reported as an infectious ated with interpretation of the images. Level 3 focuses on focus, so the diagnostic efficacy of thoracic imaging whether the information results in change in the referring with regard to an infectious focus was 3.5% (95%-CI: physician’s diagnostic thinking. Level 4 efficacy concerns 0.5–6.5%). possible effects on the patient management plan. Level 5 In one of these five cases, antibiotic therapy was initi - focuses on patients’ outcome and level 6 deals with soci- ated due to the imaging diagnosis of pneumonic infiltrate. etal efficacy addressing benefits and costs [16]. Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 6 of 9 Fig. 3 Thoracoabdominal CTs of ICU patients after abdominopelvic surgery In the other four cases, there was no change in patient The mean dose length product was 1191.8 (± 688.5) management due to the reported pulmonary infiltrate on mGycm. The corresponding mean effective doses was CT, so the therapeutic efficacy of thoracic imaging with 21.45 (± 12.39) mSv. regard to an infectious focus was 0.7% (95%-CI: 0–2.1%). There were some other pathologic findings only visible above the diaphragmatic dome (Fig. 4). In one case (0.7%) Discussion we could not exclude peripheral pulmonary artery embo- To identify an infectious focus in ICU patients after lism, but this did not influence patient management. In abdominopelvic surgery, diagnostic efficacy of thoracic seven cases (4.9%) we found catheter-associated throm- CT in addition to abdominal CT was 3.5% and thera- boses (Fig. 5), which in no case led to changes in patients’ peutic efficacy was 0.7%, signifying that we could iden - management, since all patients already received antico- tify an infectious focus in 3.5% of the additional thoracic agulation. In three cases (2.1%) we found endotracheal CTs with an effect on patient management in 0.7%. With tube malposition in the right main bronchus  (Fig.  5) regard to all pathologic thoracic findings, diagnostic and in one case (0.7%) we found chest tube malposition efficacy was 16.1% and therapeutic efficacy remained within the soft tissues of the chest wall. These findings 0.7%, since no other pathologic findings affected patient were already visible and reported on previous chest X-ray management. imaging. In one case (0.7%), there was a pulmonary nod- Whereas on the use of CXR in ICU extensive research ule above the diaphragmatic dome. This was a known has been published, there is comparatively little data on metastasis of colorectal cancer, which was equal in size the use of chest CT in this setting. (6 mm) compared to the last staging CT six weeks prior. An article by Dorenbeck et  al. in 2002 evaluated the In eight cases (5.6%) pulmonary congestion was found usefulness of thoracic CT in comparison to CXR and con- only above the diaphragmatic dome. Pulmonary conges- cluded that CT resulted in a high number of additional tion was very mild in all cases, in five of these cases it was diagnoses, with therapeutic consequences in around half already known prior to CT and treatment had already of the 558 CT studies [14]. This study included patients been initiated. In the remaining three cases fluid over - with a variety of primary diagnoses on an anesthetist- load was not considered clinically relevant (in accordance led ICU. In total, 56% of the study population suffered with the mild extent on CT), and therefore, no change to from known primary or secondary pulmonary diseases patient management was made. Overall, therapeutic effi - and only 35%  of CTs were requested to identify a septic cacy of thoracic imaging exceeding the primary goal of focus. 65% of indications were pulmonary pathologies, identifying an infectious focus was 0%. like deteriorating gas exchange, possible misplacement Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 7 of 9 Fig. 4 Pathologic thoracic findings on CT visible only above diaphragmatic dome Fig. 5 Examples of imaging findings on thoracic CT above the diaphragmatic dome. Left: Coronal contrast enhanced CT showing pneumonic infiltrate in the right upper lobe. Middle: Coronal contrast enhanced CT showing endotracheal tube malposition in the right main bronchus. Right: Coronal contrast enhanced CT showing catheter‑associated thrombosis in the left brachiocephalic vein of thoracic drain, and pulmonary embolism. This plausi - Another study by Miller et  al. in 1998 included 85 bly explains why in our study we found markedly lower patients/108 thoracic CTs in patients on a surgical numbers of previously unknown pulmonary diagnoses (55/65%), medical, or cardiac ICU [14, 15]. 92% of all CTs as well as less therapeutic consequences. Another reason were requested by thoracic surgeons, cardiac surgeons, could be that we assessed if pathologies were only visible or pulmonary physicians, suggesting that the majority on thoracic CT (above the diaphragmatic dome) or also of patients suffered from primary thoracic pathologies, on abdominal CT (including the diaphragmatic domes although the primary diagnosis is not mentioned in the and lower lungs), which reduced diagnostic efficacy to article. CT findings were compared with CXR and it was 16.1%. The most common findings (57.7%) in the study of demonstrated that CT showed at least one new clini- Dorenbeck et  al. were dys-/atelectases, pneumonic infil - cally important finding in 30%, which led to a change in trates, and pleural effusions, which is in keeping with our patient management in 22%. The higher numbers com - results. pared to our study are likely due to the different study Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 8 of 9 populations and our approach of differentiating between Conclusions pathologies below/above the diaphragmatic dome. There Thoracic CT to identify an infectious focus in ICU have been few studies on the frequency of incidental patients after abdominopelvic surgery led to the detec- findings on CT in ICU patients. A study by Schramm tion of previously unknown pathologies in around 16%. et  al. found that thromboses were a common incidental For the purpose of identifying an infectious focus, the finding, which is in keeping with our results [18]. diagnostic efficacy was 3.5%, and overall, changes in In times of ever-increasing medical radiation exposure, patient management were only made in one case (0.7%). indications for CT scans should be critically assessed on a u Th s, the widespread use of thoracic CT in this patient per-case basis. Radiation exposure due to thoracoabdom- population should be critically evaluated on an individual inal CT scans in our study population was very hetero- level, particularly since many relevant thoracic patholo- geneous due to varying combinations of contrast phases gies are readily visible on abdominal CT. and exam protocols. The mean dose length product was 1191.8 (± 688.5) mGycm. The corresponding mean effec - Abbreviations tive doses was 21.45 (± 12.39) mSv. The diagnostic refer - ICU Intensive care unit ence level (giving an indication of the expected radiation CXR Chest radiography dose received by an average-sized patient undergoing Acknowledgements an imaging procedure) for thoracoabdominal CT scans Not applicable. performed with one contrast phase is 1000 mGycm or Author contributions 16 mSv, for abdominal CT scans 700 mGycm or 11.4 mSv HN contributed to conceptualization, methodology, formal analysis and inves‑ [19]. These reference values cannot be easily transferred tigation, and writing—original draft preparation. NW contributed to meth‑ to our patient population due to the complexity of ICU odology, formal analysis and investigation, and writing—review and editing. HCH was involved in formal analysis and investigation, and writing—review patients and therefore frequently extensive necessary CT and editing. JK was involved in writing—original draft preparation and writ‑ protocols, but it is still obvious that the addition of tho- ing—review and editing. JW, CGR, and ML were involved in writing—review racic CT to abdominal CT leads to a marked increase in and editing. RTH contributed to writing—review and editing and supervision. VP contributed to conceptualization, methodology, formal analysis and inves‑ radiation exposure. tigation, writing—original draft preparation, and supervision. All the authors There are several limitations to our study: Firstly, the read and approved the final manuscript. retrospective study design, secondly, the method we Funding employed to establish diagnostic and therapeutic efficacy. Open Access funding enabled and organized by Projekt DEAL. We defined diagnostic efficacy of thoracic CT imaging by calculating the proportion of CTs with pathologic tho- Availability of data and materials The datasets used and analyzed during the current study are available from racic findings visible only above diaphragmatic dome out the corresponding author on reasonable request. of all performed CTs, based on the definition of Fryback and Thornbury, who defined “diagnostic accuracy effi - Declarations cacy” as the yield of abnormal or normal diagnoses in a case series as well as diagnostic accuracy, sensitivity, and Ethics approval and consent to participate Ethical approval was granted by the local Ethics Committee of the TU Dresden specificity, which was not evaluated in our study. On the (IRB00001473/IORG0001076). Consent to participate was waived in view of other hand, they defined “diagnostic thinking efficacy” the retrospective nature of the study and due to all images performed being focusing on whether the information produces change part of the routine care. in the referring physician’s diagnostic thinking. Probably, Consent for publication diagnostic thinking efficacy is higher than our defined Not applicable. diagnostic efficacy, since the information, that no tho - Competing interests racic pathologies are present, can also lead to a change The authors declare that they have no competing interests. in diagnostic thinking. Since this is very difficult to meas - ure, we decided to use the abovementioned definition. Received: 27 November 2022 Accepted: 31 January 2023 We also tried to counter this limitation by assessing the even more relevant therapeutic efficacy, which assesses effects on patient management. Another limitation is the heterogeneity of our study population. 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Clinical‑ and surgery‑specific risk factors for post ‑ operative sepsis: a sys‑ tematic review and meta‑analysis of over 30 million patients. Surg Today. 2020;50:427–39. 5. Hecker A, Reichert M, Reuß CJ, Schmoch T, Riedel JG, Schneck E, et al. Intra‑abdominal sepsis: new definitions and current clinical standards. Langenbecks Arch Surg. 2019;404:257–71. 6. Chidambaranath R, Rajebhosale R, Thomas P. Post‑ operative sepsis: Is CT reliable in diagnosing the cause of post‑ operative sepsis? Br J Surg. 2021;108:309082. 7. Laroia AT, Donnelly EF, Henry TS, Berry MF, Boiselle PM, et al. ACR Appropriateness Criteria Intensive Care Unit Patients. J Am Coll Radiol. 2021;18:S62‑72. 8. Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x‑rays in intensive care units: a systematic review and meta‑analysis. Crit Care. 2012;16:R68. 9. Palazzetti V, Gasparri E, Gambini C, Sollazzo S, Saric S, Salvolini L, et al. Chest radiography in intensive care: an irreplaceable survey? 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Anasthesiol Intensivmed Notfallmed Schmerzther. 2002;37:273–9. 15. Miller WT, Tino G, Friedburg JS. Thoracic CT in the intensive care unit: assessment of clinical usefulness. Radiol Radiolog Soc NAm. 1998;209:491–8. 16. Fryback DG, Thornbury JR. The Efficacy of Diagnostic Imaging. Med Decis Making. 1991;11:88–94. 17. Huda W, Ogden KM, Khorasani MR. Converting dose‑length product to effective dose at CT. Radiology. 2008;248:995–1003. 18. Schramm D, Bach AG, Meyer HJ, Surov A. Thrombotic events as incidental finding on computed tomography in intensive care unit patients. Thromb Res. 2016;141:171–4. 19. Schegerer A, Loose R, Heuser LJ, Brix G. Diagnostic reference levels for diagnostic and interventional X‑Ray procedures in Germany: update and handling. Fortschr Röntgenstr. 2019;191:739–51. 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ICU patients with infectious complications after abdominopelvic surgery: Is thoracic CT in addition to abdominal CT helpful?

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Abstract

Background The aim of this study was to assess the usefulness of adding thoracic CT to abdominal CT in intensive care unit (ICU) patients with signs of infection after abdominopelvic surgery. Methods 143 thoracoabdominal CTs of ICU patients with signs of infection after abdominopelvic surgery were ret‑ rospectively reviewed for thoracic pathologies. It was determined if pathologic findings were visible only on thoracic CT above the diaphragmatic dome or also on abdominal CT up to the diaphragmatic dome. All thoracic pathologies visible only above the diaphragmatic dome were retrospectively analyzed by an ICU physician in terms of clinical relevance. Diagnostic and therapeutic efficacy of thoracic CT were assessed with regard to an infectious focus and to other pathologic findings. Results 297 pathologic thoracic findings were recorded. 26 of the 297 findings could only be detected on images obtained above the diaphragmatic dome (in 23 of 143 CTs). A change in patient management was initiated due to only one of the 26 supradiaphragmatic findings. Diagnostic efficacy of thoracic CT in addition to abdominal CT to identify an infectious focus was 3.5% (95%‑ CI: 0.5–6.5%) and therapeutic efficacy was 0.7% (95%‑ CI: 0–2.1%). With regard to all pathologic thoracic findings, diagnostic efficacy was 16.1% (95%‑ CI: 10.1–22.1%) and therapeutic efficacy remained at 0.7%. Conclusions Additional thoracic CT to detect an infectious focus in ICU patients after abdominopelvic surgery leads to identification of the focus in only 3.5% and to changes in patient management in only 0.7%. Other relevant find‑ ings are more common (16.1%), but very rarely affect patient management. Keywords Diagnostic imaging, Multidetector computed tomography, Intensive care units, Surgery, Infections Background Infectious complications after surgery are common. *Correspondence: Heiner Nebelung Around 11% of patients develop nosocomial infections heiner.nebelung@uniklinikum‑ dresden.de [1], with postoperative pneumonia affecting around 5% of Institute and Polyclinic for Diagnostic and Interventional Radiology, patients [2] and up to 40% of patients developing surgi- University Hospital Carl Gustav Carus Dresden at the Technical University Dresden, Fetscherstr. 74, 01307 Dresden, Germany cal site infections, depending on the type of surgery [3]. Department of Visceral, Thoracic and Vascular Surgery, University Severe postoperative infectious complications, such as Hospital Carl Gustav Carus Dresden at the Technical University Dresden, sepsis, are also not uncommon with an overall incidence Fetscherstr. 74, 01307 Dresden, Germany National Center for Tumor Diseases (NCT/UCC), Dresden, Germany of 1.84% [4]. If sepsis occurs after surgery, the infectious German Cancer Research Center (DKFZ), Heidelberg, Germany focus involves the abdominal cavity in 66% of patients Helmholtz‑Zentrum Dresden‑Rossendorf (HZDR), Dresden, Germany [5]. In a cohort of septic patients with re-laparotomy after © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 2 of 9 abdominal surgery, CT was found to play a significant patients in comparison to CXR and concluded that role in identifying the septic focus [6]. CT resulted in a high number of additional diagnoses, Imaging generally plays an important role in the man- another study by Miller et  al. in 1998 stated that CT is agement of patients in intensive care units (ICUs). useful in selected patients [14, 15]. The recently published American College of Radiol - In our center, the standard of care is to liberally per- ogy Appropriateness Criteria for Intensive Care Unit form thoracic CT in addition to simultaneous abdominal Patients state that portable chest radiography (CXR) is CT in patients with signs of infection after abdominopel- still the most commonly used imaging modality in ICU vic surgery. The advantage of this approach is the pos - patients [7]. Extensive research has shown not only the sibility of a whole-body overview of potential infectious usefulness of CXR but also the potential for overuse and foci in critically ill patients. This avoids repeated, poten - a meta-analysis found no harm associated with a restric- tially detrimental patient transfers with accompanying tive strategy [7–10]. ICU personnel and preserves critical resources. On the There has been little research on the topic of thoracic other hand, unnecessary CT imaging is a rising concern CT in ICU patients, especially in recent years, but the and should be avoided due to increased exposure of number of CT scans has been ever increasing over the patients to ionizing radiation as well as increasing costs. years [11–13]. An article by Dorenbeck et  al. in 2002 To the best of our knowledge, no study thus far has evaluated the usefulness of thoracic CT in general ICU assessed the usefulness of additional thoracic CT in ICU Fig.1 Study population and exclusion criteria Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 3 of 9 Table 1 Primary diagnoses and surgical procedures of our study population Primary diagnosis Surgical procedure n Acute cholecystitis Cholecystectomy 2 Chronic pancreatitis Pylorus‑preserving pancreaticoduodenectomy 2 Duodenum‑preserving pancreatic head resection 2 Whipple’s procedure 1 Pancreatectomy 1 Diabetes mellitus type 1 Pancreas transplant 1 Pancreatic cancer Pancreatectomy 1 Pylorus‑preserving pancreaticoduodenectomy 3 Left pancreatic resection 1 Multivisceral resection 1 Main duct intraductal papillary mucinous neoplasm Pancreatectomy 1 Benign tumor of the papilla Pylorus‑preserving pancreaticoduodenectomy 1 Klatskin tumor Pylorus‑preserving pancreaticoduodenectomy 1 Whipple’s procedure 1 Left hemihepatectomy 1 Cholangiocellular carcinoma Right hemihepatectomy 1 Extended right hemihepatectomy 2 Cholecystic myosarcoma Right hemihepatectomy + cholecystectomy 1 Caroli’s syndrome Left hemihepatectomy 1 Hepatic metastases of rectal cancer Right hemihepatectomy 1 Gastric cancer Gastrectomy 3 Subtotal gastrectomy 1 Recurrent gastric cancer Pylorus‑preserving pancreaticoduodenectomy 1 Esophageal cancer Esophagectomy 1 Colon cancer Peritonectomy + HIPEC 1 Rectal cancer Rectal resection 1 Rectal exstirpation 1 Recurrent rectal cancer Pelvic exenteration 1 Recurrent chordoma Pelvic exenteration 1 Peritoneal fibrosarcoma Multivisceral resection 1 Peritoneal carcinosis (endometrial cancer) Multivisceral resection 1 Colitis ulcerosa Proctocolectomy 1 Acute abdomen Explorative laparotomy 3 Mechanical ileus Partial small bowel resection 1 Incarcerated incisional hernia Hernia repair 1 Ogilvie syndrome Subtotal colectomy 1 Sigmoid perforation Sigmoid resection 1 Duodenal ulcer Ulcer excision and repair 1 Upper gastrointestinal bleed Explorative laparotomy 1 Partial small bowel resection 1 Pancreatectomy 2 Lower gastrointestinal bleed Explorative laparotomy 2 Bleed from right hepatic artery Evacuation of hematoma 1 Retroperitoneal hematoma Embolization of lumbal artery 1 Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 4 of 9 Table 1 (continued) Primary diagnosis Surgical procedure n Mesenteric ischemia Explorative laparotomy 2 Total colectomy 2 Subtotal colectomy 1 Right hemicolectomy 1 Right hemicolectomy + partial small bowel resection 1 Left hemicolectomy + partial small bowel resection 1 Abdominal aortic aneurysm Endovascular aortic repair 1 Infection of iliac bypass Explantation of bypass 1 Gluteal/perianal ulcers Debridement 4 Retroperitoneal abscess Abscess drainage 1 Inguinal infected seroma Wound revision 1 Methods Study population and baseline characteristics Approval by the local ethics committee was granted for this study, which was performed in accordance with the ethical standards as laid down in the 1964 Declara- tion of Helsinki and its later amendments. Patients, who were examined in non-emergency situations and who were able to, had given written informed consent to CT. All CTs had been performed within the scope of clinical routine. Clinical data and imaging of 180 surgical ICU patients (51 women, 129 men), who had received post- operative thoracoabdominal CT scans at our institution between July 2019 and December 2019, were retrospec- tively reviewed. Patients were referred for CT with clini- cal signs of infection, e.g., fever, elevated leukocytes, and C-reactive protein. Some patients received more than one CT; thus, a total of 396 CTs was reviewed. 119 CTs were excluded, because the patients had non-abdom- inopelvic primary pathologies (for details see Fig.  1). Out of the remaining 277 CTs, 134 CTs were excluded, because thoracic CT was performed for reasons other than suspected infectious focus. Examples are sus- pected pulmonary artery embolism, suspected tho- Fig. 2 CT planning scout. Green: scout for thoracoabdominal CT. racic hemorrhage, and follow-up of known pathologies, Red: examined region in thoracic CT alone. Blue: examined region in like thoracic abscess, pleural empyema, hemothorax, or abdominal CT alone pneumonia. The remaining 143 CTs were included in this study (99 CTs of 50 male patients and 44 CTs of 22 female patients). The mean age of patients was 62.5 years patients with infectious complications after abdomin- (± 14.5). At the time of imaging, mean value of leuko- opelvic surgery. Thus, the aim of this study was to deter - cytes was 16.40 (± 9.48) GPt/L (reference value 3.8–9.8 mine the value of thoracic CT in this setting. GPt/L) and of C-reactive protein was 155.84 (± 101.75) Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 5 of 9 Table 2 Pathologic thoracic findings in thoracoabdominal CT Pathologic findings Thoracal Visible only above diaphragmatic Clinically relevant dome % on all 143 CTs % on all 143 CTs % on all 143 CTs Pneumonic infiltrate 42 29.4% 5/42 3.5% 1/5 0.7% Pulmonary congestion 21 14.7% 8/21 5.6% 0/8 0% Catheter‑associated thrombosis 7 4.9% 7/7 4.9% 0/7 0% Endotracheal tube malposition 3 2.1% 3/3 2.1% 0/3 0% Chest tube malposition 1 0.7% 1/1 0.7% 0/1 0% Pulmonary artery embolism 1 0.7% 1/1 0.7% 0/1 0% Pulmonary nodule 2 1.4% 1/2 0.7% 0/1 0% Pleural effusion 131 91.6% 0/131 0% N/A N/A Dystelectasis 79 55.2% 0/79 0% N/A N/A Pericardial effusion 10 7.0% 0/10 0% N/A N/A We determined diagnostic efficacy of thoracic CT mg/L (reference value < 5.0 mg/L). In 72 CTs, the patients imaging by calculating the proportion of CTs with patho- were mechanically ventilated. The primary diagnoses and logic thoracic findings visible only above diaphragmatic surgical procedures are summarized in Table 1. dome out of all performed CTs. In the next step, we determined therapeutic efficacy by calculating the pro - Image interpretation portion of CTs with pathologic thoracic findings visible The 143 CTs were reviewed independently by three radi - only above the diaphragmatic dome that affected patient ologists with fifteen, three, and one year(s) of experience management out of all performed CTs. in CT imaging. They looked for thoracic pathologies and Effective doses (in mSv) were calculated by multiply - recorded, if they were visible only above an imaginary ing the dose length products, which were provided by the plane at the tip of the diaphragm or if they were vis- scanner, with a conversion factor of 18 μSv/mGycm, as ible below as well (Fig.  2). All occurring pathologies are recommended by Huda et al. [17]. shown in Table 2. For all thoracic pathologies, which were visible only above the diaphragmatic dome, an intensive Results care physician (> 15 years of experience) determined ret- In 143 CTs we found a total of 297 thoracic pathologies rospectively, if they were clinically relevant. Therefore, he (median 2; IQR 1), see Table  2. More than two-thirds searched our hospital information system for changes in were pleural effusions and compression atelectases. In patient management due to the pathologic findings on 29.4% of the CTs, patchy consolidations of the lungs com- CT (only above the diaphragmatic dome). patible with the imaging diagnosis of pneumonia were found. In most cases, pathologic thoracic findings were Data analysis visible below diaphragmatic dome. Only in 23 of 143 CTs To assess the usefulness of thoracic CT we employed the we found thoracic pathologies, which were visible only concept developed by Fryback and Thornbury, which above diaphragmatic dome (Fig.  3), so overall diagnostic defines six levels of efficacy. Efficacy of diagnostic imag - efficacy of dedicated thoracic CT as part of the imaging ing is defined as its contribution to the patient manage - protocol was 16.1% (95%-CI: 10.1–22.1%). ment process. In five cases (3.5%) we found pneumonic infiltrates, Level 1 addresses technical efficacy, level 2 the yield of which were visible only above diaphragmatic dome (Fig. 4 abnormal or normal diagnoses in a case series, as well as and 5). There were no other findings above the diaphrag - diagnostic accuracy, sensitivity, and specificity associ - matic dome, which could be reported as an infectious ated with interpretation of the images. Level 3 focuses on focus, so the diagnostic efficacy of thoracic imaging whether the information results in change in the referring with regard to an infectious focus was 3.5% (95%-CI: physician’s diagnostic thinking. Level 4 efficacy concerns 0.5–6.5%). possible effects on the patient management plan. Level 5 In one of these five cases, antibiotic therapy was initi - focuses on patients’ outcome and level 6 deals with soci- ated due to the imaging diagnosis of pneumonic infiltrate. etal efficacy addressing benefits and costs [16]. Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 6 of 9 Fig. 3 Thoracoabdominal CTs of ICU patients after abdominopelvic surgery In the other four cases, there was no change in patient The mean dose length product was 1191.8 (± 688.5) management due to the reported pulmonary infiltrate on mGycm. The corresponding mean effective doses was CT, so the therapeutic efficacy of thoracic imaging with 21.45 (± 12.39) mSv. regard to an infectious focus was 0.7% (95%-CI: 0–2.1%). There were some other pathologic findings only visible above the diaphragmatic dome (Fig. 4). In one case (0.7%) Discussion we could not exclude peripheral pulmonary artery embo- To identify an infectious focus in ICU patients after lism, but this did not influence patient management. In abdominopelvic surgery, diagnostic efficacy of thoracic seven cases (4.9%) we found catheter-associated throm- CT in addition to abdominal CT was 3.5% and thera- boses (Fig. 5), which in no case led to changes in patients’ peutic efficacy was 0.7%, signifying that we could iden - management, since all patients already received antico- tify an infectious focus in 3.5% of the additional thoracic agulation. In three cases (2.1%) we found endotracheal CTs with an effect on patient management in 0.7%. With tube malposition in the right main bronchus  (Fig.  5) regard to all pathologic thoracic findings, diagnostic and in one case (0.7%) we found chest tube malposition efficacy was 16.1% and therapeutic efficacy remained within the soft tissues of the chest wall. These findings 0.7%, since no other pathologic findings affected patient were already visible and reported on previous chest X-ray management. imaging. In one case (0.7%), there was a pulmonary nod- Whereas on the use of CXR in ICU extensive research ule above the diaphragmatic dome. This was a known has been published, there is comparatively little data on metastasis of colorectal cancer, which was equal in size the use of chest CT in this setting. (6 mm) compared to the last staging CT six weeks prior. An article by Dorenbeck et  al. in 2002 evaluated the In eight cases (5.6%) pulmonary congestion was found usefulness of thoracic CT in comparison to CXR and con- only above the diaphragmatic dome. Pulmonary conges- cluded that CT resulted in a high number of additional tion was very mild in all cases, in five of these cases it was diagnoses, with therapeutic consequences in around half already known prior to CT and treatment had already of the 558 CT studies [14]. This study included patients been initiated. In the remaining three cases fluid over - with a variety of primary diagnoses on an anesthetist- load was not considered clinically relevant (in accordance led ICU. In total, 56% of the study population suffered with the mild extent on CT), and therefore, no change to from known primary or secondary pulmonary diseases patient management was made. Overall, therapeutic effi - and only 35%  of CTs were requested to identify a septic cacy of thoracic imaging exceeding the primary goal of focus. 65% of indications were pulmonary pathologies, identifying an infectious focus was 0%. like deteriorating gas exchange, possible misplacement Nebelung  et al. Annals of Intensive Care (2023) 13:6 Page 7 of 9 Fig. 4 Pathologic thoracic findings on CT visible only above diaphragmatic dome Fig. 5 Examples of imaging findings on thoracic CT above the diaphragmatic dome. Left: Coronal contrast enhanced CT showing pneumonic infiltrate in the right upper lobe. Middle: Coronal contrast enhanced CT showing endotracheal tube malposition in the right main bronchus. Right: Coronal contrast enhanced CT showing catheter‑associated thrombosis in the left brachiocephalic vein of thoracic drain, and pulmonary embolism. This plausi - Another study by Miller et  al. in 1998 included 85 bly explains why in our study we found markedly lower patients/108 thoracic CTs in patients on a surgical numbers of previously unknown pulmonary diagnoses (55/65%), medical, or cardiac ICU [14, 15]. 92% of all CTs as well as less therapeutic consequences. Another reason were requested by thoracic surgeons, cardiac surgeons, could be that we assessed if pathologies were only visible or pulmonary physicians, suggesting that the majority on thoracic CT (above the diaphragmatic dome) or also of patients suffered from primary thoracic pathologies, on abdominal CT (including the diaphragmatic domes although the primary diagnosis is not mentioned in the and lower lungs), which reduced diagnostic efficacy to article. CT findings were compared with CXR and it was 16.1%. The most common findings (57.7%) in the study of demonstrated that CT showed at least one new clini- Dorenbeck et  al. were dys-/atelectases, pneumonic infil - cally important finding in 30%, which led to a change in trates, and pleural effusions, which is in keeping with our patient management in 22%. The higher numbers com - results. pared to our study are likely due to the different study Nebelung et al. Annals of Intensive Care (2023) 13:6 Page 8 of 9 populations and our approach of differentiating between Conclusions pathologies below/above the diaphragmatic dome. There Thoracic CT to identify an infectious focus in ICU have been few studies on the frequency of incidental patients after abdominopelvic surgery led to the detec- findings on CT in ICU patients. A study by Schramm tion of previously unknown pathologies in around 16%. et  al. found that thromboses were a common incidental For the purpose of identifying an infectious focus, the finding, which is in keeping with our results [18]. diagnostic efficacy was 3.5%, and overall, changes in In times of ever-increasing medical radiation exposure, patient management were only made in one case (0.7%). indications for CT scans should be critically assessed on a u Th s, the widespread use of thoracic CT in this patient per-case basis. Radiation exposure due to thoracoabdom- population should be critically evaluated on an individual inal CT scans in our study population was very hetero- level, particularly since many relevant thoracic patholo- geneous due to varying combinations of contrast phases gies are readily visible on abdominal CT. and exam protocols. The mean dose length product was 1191.8 (± 688.5) mGycm. The corresponding mean effec - Abbreviations tive doses was 21.45 (± 12.39) mSv. The diagnostic refer - ICU Intensive care unit ence level (giving an indication of the expected radiation CXR Chest radiography dose received by an average-sized patient undergoing Acknowledgements an imaging procedure) for thoracoabdominal CT scans Not applicable. performed with one contrast phase is 1000 mGycm or Author contributions 16 mSv, for abdominal CT scans 700 mGycm or 11.4 mSv HN contributed to conceptualization, methodology, formal analysis and inves‑ [19]. These reference values cannot be easily transferred tigation, and writing—original draft preparation. NW contributed to meth‑ to our patient population due to the complexity of ICU odology, formal analysis and investigation, and writing—review and editing. HCH was involved in formal analysis and investigation, and writing—review patients and therefore frequently extensive necessary CT and editing. JK was involved in writing—original draft preparation and writ‑ protocols, but it is still obvious that the addition of tho- ing—review and editing. JW, CGR, and ML were involved in writing—review racic CT to abdominal CT leads to a marked increase in and editing. RTH contributed to writing—review and editing and supervision. VP contributed to conceptualization, methodology, formal analysis and inves‑ radiation exposure. tigation, writing—original draft preparation, and supervision. All the authors There are several limitations to our study: Firstly, the read and approved the final manuscript. retrospective study design, secondly, the method we Funding employed to establish diagnostic and therapeutic efficacy. Open Access funding enabled and organized by Projekt DEAL. We defined diagnostic efficacy of thoracic CT imaging by calculating the proportion of CTs with pathologic tho- Availability of data and materials The datasets used and analyzed during the current study are available from racic findings visible only above diaphragmatic dome out the corresponding author on reasonable request. of all performed CTs, based on the definition of Fryback and Thornbury, who defined “diagnostic accuracy effi - Declarations cacy” as the yield of abnormal or normal diagnoses in a case series as well as diagnostic accuracy, sensitivity, and Ethics approval and consent to participate Ethical approval was granted by the local Ethics Committee of the TU Dresden specificity, which was not evaluated in our study. On the (IRB00001473/IORG0001076). Consent to participate was waived in view of other hand, they defined “diagnostic thinking efficacy” the retrospective nature of the study and due to all images performed being focusing on whether the information produces change part of the routine care. in the referring physician’s diagnostic thinking. Probably, Consent for publication diagnostic thinking efficacy is higher than our defined Not applicable. diagnostic efficacy, since the information, that no tho - Competing interests racic pathologies are present, can also lead to a change The authors declare that they have no competing interests. in diagnostic thinking. Since this is very difficult to meas - ure, we decided to use the abovementioned definition. Received: 27 November 2022 Accepted: 31 January 2023 We also tried to counter this limitation by assessing the even more relevant therapeutic efficacy, which assesses effects on patient management. Another limitation is the heterogeneity of our study population. 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Journal

Annals of Intensive CareSpringer Journals

Published: Feb 10, 2023

Keywords: Diagnostic imaging; Multidetector computed tomography; Intensive care units; Surgery; Infections

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