Secondary peritonitis is the most common form that follows an intra-peritoneal source usually from perforation of hollow viscera. Acute generalized peritonitis due to underlying hollow viscous perforation, is a critical and life-threatening condition. It is a common surgical emergency in most of the general surgical units across the world. It is often associated with significant morbidity and mortality [1,2].

The multifaceted nature of abdominal surgical infections makes it difficult to precisely define the disease and to assess its severity and therapeutic progress. Both the anatomic source of infection and to a greater degree, the physiologic compromise it inflicts, affects the outcome [3].

High-risk patients require timely and aggressive treatment especially in severe peritonitis. To select them reasonably well, evaluation through a prognostic scoring system is the approach of choice. Early prognostic evaluation is desirable so as to be able to select high-risk patients for more aggressive treatment especially in severe peritonitis [3,4].

The prognosis and outcome of peritonitis depend upon the interaction of several factors, which includes patient-related factors, disease-specific factors, diagnostic and therapeutic interventions. Categorizing patients into different risk groups would help prognosticate the outcome, select patients for intensive care and determine operative risk, thereby helping to choose the nature of the operative procedure, e.g. damage control vs. definitive procedure [3,4].

Many practitioners have developed preoperative prediction models aimed at discriminating those patients most likely to survive surgical intervention and return to their pre-morbid level of function from those in whom aggressive, invasive treatment is likely to be futile. Since its introduction, the American Society of Anesthesiologists (ASA) scoring system has been used ubiquitously for preoperative risk stratification and remains the most common system in everyday use [5-7].

The aim of this study is to evaluate the ASA Grading and Duration of stay among Secondary Peritonitis cases and its association with outcome in a tertiary care Hospital. 

Aims and Objectives

To evaluate the ASA Grading and Duration of stay among Secondary Peritonitis cases and its association with outcome in a tertiary care Hospital.

This study was conducted in the Department of Surgery IGMC, Shimla over a period of twelve months from January 2021 -December 2021.

Inclusion Criteria

• All adult patients (>18 years of age) presenting with the clinical diagnosis of perforation peritonitis of either sex

• All Patients willing to participate in the study

Exclusion Criteria

• Patients operated elsewhere before presentation.

• Patients unwilling to participate in the study

• Patients on drugs which alter the level of arterial lactate 

Study Methodology:

• The proposed study was a longitudinal, prospective study 

• All patients presenting to the Department of Surgery, IGMC, Shimla with a diagnosis of secondary peritonitis and fulfilling the inclusion and exclusion criteria were recruited

• The diagnosis of secondary peritonitis was established based on clinical examination, investigations and operative findings

• Informed and written consent was taken from the patient/relative

• Resuscitation, preoperative and postoperative treatment was performed according to the established protocol for perforation peritonitis

• Relevant information was collected 

 Statistical Analysis 

Data compiled in the excel sheet and further analysed by using IBM SPSS Statistics 28 and result displayed in number and percentage. To access the relationship between parameters under study outcome various hypothesis was designed and results were compiled in results and observation section using t-test and Chi-square test.

In this retrospective study total 250 patients with diagnosis of perforation peritonitis were evaluated. Among the total Males were 205 (82%) and Females were 45 (18%). Mean age of the patients was 47.28±17.34 years with range from 18 to 87 years. Among the total, 99(39.6%) patients were age<40 years while 151(60.4%) patients were aged >40 years (Table 1). 

Among the total, 32(12.80%) were expired while 218(87.20%) were discharged after treatment (Figure 1).

Among the total, 114(45.60%) patients were in grade 1 according American Society of Anesthesiologists (ASA) scoring system, 107 (42.80%) were in grade 2, 22(8.80%) were in grade 3 and 7(2.80%) were in grade 4 (Table 2).

Among the total 32 patients who were expired, 2(6.3%) were in grade 1, 19(59.4%) were in grade 2, 9(28.1%) were in grade 3 and 2(6.3%) were in grade 4 while among the total 218 patients who were discharged, 112(51.4%) were in grade 1, 88(40.4%) were in grade 2, 13(6.0%) were in grade 3 and 5(2.3%) were in grade 4 according American Society of Anesthesiologists (ASA) scoring system. There was found significant association between ASA Grading and mortality (Table 3).

Figure 1: Distribution of Outcome of the study participants

Table 1: Age and Gender Distribution of Study Participants

Table 2: Distribution of ASA Grades Among the Study Participants

Table 3: Association Between ASA and Outcome

Chi-square value = 31.950; p-value = 0.000 Significant

Table 4:  Association between Total Stay and Outcome

The mean duration of hospital stay among study participants was 8.99±6.07 days with range 1 to 40 days. The mean duration of hospital stay among 32 expired patients was 9.19±8.26 days while among 218 discharged patients was 8.96±5.70 days. There was no significant association between duration of hospital stay and mortality (Table 4).

In the present study, among the total, 114(45.60%) patients were in grade 1 according American Society of Anesthesiologists (ASA) scoring system, 107 (42.80%) were in grade 2, 22(8.80%) were in grade 3 and 7(2.80%) were in grade 4. Mabewa et al. [8] reported 58 (59.79%) of patients in ASA grade III and 24 (24.74%) in grade IV. Salamone et al. [9] studied 104 elderly patients, out of these 31.7% were in ASA grade II, 45.2% in grade III and 23.1% in grade IV.

In our study mean duration of stay was 8.99 days, maximum duration of stay was 40 days and minimum 1 day. About 49 patients (21.87%) were admitted to ICU postoperatively because of inability to extubate, non-maintenance of saturation leading to ventilatory support, need of intensive monitoring of vitals and bad chest condition. Khan et al. [10] evaluated 110 cases over a period of 2 years and reported 7.85 days of mean duration of hospital stay ranging from 3-40 days [7,1]. Postoperative complications requiring re-exploration like leak at primary repair site, retraction of stoma or gangrene of stoma, burst abdomen and major respiratory complications and cardiac events increase the duration of stay while minimum stay of 1 day was attributed to death of the patient within 1 day of surgery.

The present study concluded that most of patients of secondary peritonitis were in grade 1 of American Society of Anesthesiologists (ASA) scoring system old and there was significant association of mortality with ASA Grading but not with duration of stay in hospital.

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