Infectious shock (septic shock) is a type of shock that is surgically common and difficult to treat. Sepsis is an acute organ dysfunction secondary to infection, with clinical manifestations such as fever, chills, tachycardia, altered mental status, and increased white blood cells. These changes are not specific to infection, but can also be seen in cases of severe trauma, pancreatitis, etc. The essence is the systemic effect caused by inflammatory mediators. These clinical signs are also known as systemic inflammatory response syndrome (SIRS). Infectious shock, also known as toxic shock, endotoxic shock or septic shock, occurs when severe sepsis progresses to hypotension or multi-organ insufficiency that is difficult to reverse with fluid resuscitation. Common causes of surgical infectious shock include acute obstructive purulent cholangitis, acute peritonitis (perforated acute appendicitis, perforated gastroduodenal ulcer, perforated acute gangrenous cholecystitis, perforated small intestine and colon from various causes), strangulated intestinal obstruction, acute severe pancreatitis, perianal abscess, gas gangrene, abdominal abscess from various causes, purulent pyel abscess with urinary tract obstruction In recent years, with the aging of the population, the number of patients has increased. In recent years, with the aging of the population, the increasing incidence of diabetes mellitus, the widespread development of transplantation, intravenous placement, and the increased application of immunosuppressive drugs, the occurrence and development of infectious shock has become more complex and variable. Infectious shock of different etiologies have similar pathophysiological processes. The development of infectious shock involves the participation of pathogenic microorganisms and host defense mechanisms. Most patients with infectious shock present with either a hyperdynamic or hypodynamic hemodynamic state early or throughout the course of the disease, with a particular prevalence of the hypodynamic type caused by Gram-staining-negative bacterial infections. Nearly 50% of patients will eventually develop myocardial depression, DIC and organ failure leading to death. Perioperative management Treatment of infectious shock includes early fluid resuscitation, pathogenic diagnosis and anti-infective drug therapy, surgical management of the primary focus, supportive measures for circulatory, respiratory and other vital organ functions, and suppressive or conditioning therapy for inflammatory mediators. Nearly 50% of infectious shock requires urgent surgical management, and choosing the right timing and correct surgical approach is the key to determining the outcome of treatment. Therefore, great importance must be attached to the perioperative treatment to really achieve positive and effective. 1, the choice of surgical timing: surgical infectious shock need to buy time to operate as soon as possible, but the anesthesia itself will aggravate the shock, surgical trauma and toxin absorption will aggravate the condition, so in the basis of shock surgery, easy to form a vicious circle, causing irreversible toxic shock, and eventually the patient due to combined multi-organ failure and death; and overemphasis to be shock stabilization before surgery, but also may The best time for surgery may be lost and lead to failure of rescue. At present, it is considered necessary to surgically remove the lesion, even if the condition is critical, we should create conditions to operate as soon as possible, and the preoperative preparation should be as fast as possible, and strive to operate within 2 to 3h. 2.Pre-operative preparation: mainly fluid resuscitation, rapid volume expansion, correction of acidosis, application of vasoactive drugs, high-dose antibiotics and hormones. In severe sepsis should be treated with broad-spectrum antibiotics intravenously as early as possible, and appropriate specimens should be retained before antibiotic application, but the use of antibiotics should not be delayed for the sake of retaining specimens. At the same time, catheterization should be left in place and cardiopulmonary and circulatory function (including CVP) should be monitored. 3. Intraoperative precautions: anesthesia and anti-shock are performed simultaneously. In principle, surgery can be started when systolic blood pressure reaches 90 mmHg; pulse pressure 30 mmHg; heart rate ≤ 100 times/min and respiration ≤ 32 times/min; nail and lip coloration improves and urine volume increases by 30 ml/h. However, if the lesion cannot be improved without treatment of the shock state, surgical treatment should be decisively performed. The operation time should be as short as possible, and the principle of simple and effective is the principle. Definitive surgery that does not force complete treatment of the lesion should be performed, and the surgeon should actively cooperate with the anesthesiologist during the operation, and the surgical plan needs to be adjusted accordingly according to the patient’s intraoperative vital signs, and the operation should be ended as soon as the patient’s circulation is unstable. In recent years, the concept of damage control (DC) has been gradually accepted, and the core of DC is to change the previous strategy of complex and complete surgery at an early stage for patients with severe trauma and to adopt the principle of staged treatment. Firstly, simple, effective and less damaging surgery is used to quickly solve the problems of bleeding and contamination, and then the patient is admitted to ICU for second-stage resuscitation treatment to adjust the internal environment of the organism to maintain the stability of physiological functions and improve the patient’s ability to withstand the second surgical blow, and then complete and reasonable definitive surgery is implemented after the situation improves. DC has important significance in the management of surgical infectious shock, and in fact, in many infectious In fact, in the management of many infectious shocks, we are already practicing the concept of “damage control”. 1. Acute septic cholangitis: It is the most common surgical emergency that causes infectious shock. The lesion is characterized by complete obstruction of the bile duct with purulent bile, so measures must be taken to decompress the bile duct and drain the bile. Therefore, treatment such as endoscopic sphincterectomy (EST) or endoscopic nasobiliary drainage (ENBD) to relieve biliary obstruction will immediately reduce the symptoms of shock. EST or ENBD can be performed in the operating room, and if they fail, immediate surgery is performed to decompress the common bile duct by choledochotomy, and the decompression must reach the proximal end of the obstruction. If the situation permits then remove the stone and remove the lesion. 2. Acute purulent peritonitis: appendiceal perforation and ulcer perforation are the most common, followed by small intestine, colon and gallbladder perforation. The principle of surgery is local excision or suture repair according to the lesion, as well as effective abdominal flushing and drainage. The choice of treatment for colonic perforation can be based on the cause of perforation, the duration of perforation, abdominal contamination, and the patient’s general condition. Elderly spontaneous colonic perforation, mostly located in the middle part of the sigmoid colon, can be directly externalized due to the often severe inflammatory response at the lesion site and heavy intra-abdominal contamination, and if it cannot be dragged out, the perforation can be repaired and the proximal end dragged out with a collaterals fistula. Tumor perforation, mostly seen in elderly patients, often do not have the opportunity to perform radical surgery, in the case of serious intra-abdominal contamination and circulatory instability, the operation strives to be simple and effective to save lives, the perforation site can be directly externalized or proximal to the fistula, and the tumor is left to circulate and stabilize after the second stage of surgical treatment. If the circulation is stable during the operation and the right hemicolectomy is perforated, the lesion can be resected and then the first-stage anastomosis can be done, and the application of anastomosis can increase the safety of the anastomosis. If the left hemicolectomy or rectal tumor is perforated, the lesion can be removed, the distal end can be closed and the proximal end can be fistulized. Whether gastric cancer perforation has a chance to do lesion resection or not depends on the stability of intraoperative circulation. Since resection surgery is complicated, even if the tumor is removed, radical cure is not forced. Otherwise, it can be repaired with large omental tamponade first, and then consider whether to perform further surgery after 2 weeks. The pathogenesis of patients with acute peritonitis is intertwined with excessive release of pro-inflammatory and anti-inflammatory factors. Therefore, timely removal of inflammatory factors from the peritoneal cavity is essential for the treatment of acute peritonitis. Therefore, for visceral perforation or diffuse peritonitis, a large amount of warm saline (10,000ml-20,000ml) is used to flush the peritoneal cavity before closing the abdomen in order to reduce the bacteria and inflammatory factors in the peritoneal cavity and remove “peritoneal sepsis”, avoid flushing with cold water to avoid a sudden drop in body temperature, causing arrhythmia and aggravating shock. 3, strangulated intestinal obstruction: the surgical principle of small intestinal obstruction is to lift the obstruction, remove the necrotic intestinal tube, restore intestinal patency and abdominal drainage. For colonic strangulated intestinal obstruction, the principle is resection of necrotic intestinal canal and proximal fistula. In the case of intestinal necrosis caused by mesenteric artery embolism or mesenteric vein thrombosis, sometimes the intestinal canal is preserved as much as possible in order to avoid the short bowel syndrome after massive small bowel resection, and when the condition is unstable intraoperatively, the blood flow of the preserved intestinal canal and anastomosis does not need to be observed for too long, the anastomosis can be externalized or the abdomen can be closed, and then the abdomen can be opened after 48-72 hours (second look (laparotomy) to observe the viability of the preserved intestinal tube, and during this period, closely observe the correction of shock and abdominal signs. 4, acute severe pancreatitis (SAP): SAP is mainly treated conservatively, and the 2002 International Academy of Pancreatology (IAP) Guidelines for the Surgical Management of Acute Pancreatitis recommends that unless there are specific indications, early surgery is not recommended for patients with necrotizing pancreatitis within 14 days after the onset of the disease. In addition to EST or ENBD for biliary pancreatitis, we believe that simple and modest surgical treatment can still play a positive role when conservative treatment is ineffective, especially when shock is difficult to correct. SAP is divided into an early acute reaction phase and a late necrotic infection phase, which often has a bimodal course and a mortality rate of 20%. However, the causes of shock in the early and late stages are different, so the choice of surgery and the timing of surgery are also different. In the acute response period, the body is in a period of severe internal environmental disturbance, and SAP-induced SIRS with resultant systemic multiple organ dysfunction (MODS) is the main cause of death. Surgery at this time, on the contrary, tends to aggravate the disease. In the event of a large amount of inflammatory peritoneal exudate, especially in fulminant pancreatitis (FAP), often accompanied by abdominal septal compartment syndrome (ACS), ARDS or renal failure or even MODS will soon appear if surgery is not performed in time. surgery at this time can reduce abdominal and retroperitoneal pressure, drain abdominal exudate, and reduce the absorption of toxic substances, all of which cannot be achieved by other conservative treatments. Infectious shock caused by pancreatic necrosis in the later stage is the main cause of death, at this time surgery is an absolute indication, the key is to grasp the timing of surgery, the early necrotic tissue range boundary is not clear enough, when the pancreas and peripancreatic necrotic tissue fully demarcated, at this time is conducive to surgical clearance, can reduce the rate of reoperation. Surgery tries to remove as much necrotic tissue as possible, but does not force complete removal to avoid complications such as increased surgical difficulty and hemorrhage. After surgery, CT and other examinations can be used to decide whether to perform re-invasive surgery. In recent years, some minimally invasive concepts of surgical methods have been applied to the treatment of SAP, such as laparoscopic surgery, retroperitoneal access surgery, percutaneous puncture drainage under CT and ultrasound guidance, transgastric or duodenal endoscopic drainage, etc. These surgical methods can be repeatedly and synergistically applied to the treatment of SAP, so as to achieve simple and effective purposes. 5.Surface abscess, perianal abscess, renal pelvic abscess and part of abdominal abscess: superficial abscess can be directly incised and drained to remove necrotic tissue. Renal pelvic abscess and part of abdominal cavity abscess can be drained by percutaneous puncture under the guidance of CT and B ultrasound first to buy time for shock resuscitation, which can be done repeatedly, and definitive surgery will be performed after the shock improves. 6.Severe burns: after burns, the muscle loses its natural barrier, and a large number of bacteria multiply and release toxins on the trauma surface and under the skin, which is enough to be fatal. The principle of treatment is timely removal of pus scabs, drainage of necrotic tissue, covering the granulation wound. Repeated bacterial culture and drug sensitivity tests are performed to maintain an effective concentration of antibiotics in the blood. Experience has shown that the promptness of treatment and the measures taken in the first hours of infectious shock can greatly affect the patient’s prognosis. Therefore, careful assessment of the patient’s shock level, selection of the appropriate surgical timing, and adoption of a reasonable surgical approach, together with other anti-shock treatments, are the keys to improving the success rate of surgical infectious shock resuscitation.