Anesthesia for emergency abdominal surgery

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study

BACKGROUND

Acute high-risk abdominal surgery is common, as are the attendant risks of organ failure, need for intensive care, mortality, or long hospital stay. This study assessed the implementation of standardized management.

METHODS

A prospective study of all adults undergoing emergency laparotomy over an interval of 42 months (2018-2021) was undertaken; outcomes were compared with those of a retrospective control group. A new standardized clinical protocol was activated for all patients including: prompt bedside physical assessment by the surgeon and anaesthetist, interprofessional communication regarding location of resuscitation, elimination of unnecessary factors that might delay surgery, improved operating theatre competence, regular epidural, enhanced recovery care, and frequent early warning scores. The primary endpoint was 30-day mortality. Secondary endpoints were duration of hospital stay, need for intensive care, and surgical complications.

RESULTS

A total of 1344 patients were included, 663 in the control group and 681 in the intervention group. The use of antibiotics increased (81.4 versus 94.7 per cent), and the time from the decision to operate to the start of surgery was reduced (3.80 versus 3.22 h) with use of the new protocol. Fewer anastomoses were performed (22.5 versus 16.8 per cent). The 30-day mortality rate was 14.5 per cent in the historical control group and 10.7 per cent in the intervention group (P = 0.045). The mean duration of hospital (11.9 versus 10.2 days; P = 0.007) and ICU (5.40 versus 3.12 days; P = 0.007) stays was also reduced. The rate of serious surgical complications (grade IIIb-V) was lower (37.6 versus 27.3 per cent; P = <0.001).

CONCLUSION

Standardized management protocols improved outcomes after emergency laparotomy.

Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study

BACKGROUND

Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL.

METHODS

This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications.

RESULTS

A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications.

CONCLUSIONS

This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Emergency Laparotomy

Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.

Mortality following emergency laparotomy: a Swedish cohort study

Background

Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management.

Methods

Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort.

Results

A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification.

Conclusions

In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies.

Trial registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

METHODS

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

RESULTS

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

CONCLUSIONS

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Covid-19 mimicking symptoms in emergency gastrointestinal surgery cases during pandemic: A case series

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Digestive surgery emergency cases can present with COVID-19 mimicking symptoms.

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Indications of emergency surgery are the same in during pandemic compared to non-pandemic settings.

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Strict screening, examination, and protocol are necessary during pandemic.

Background

The COVID-19 pandemic has changed patient management in all sectors. All patients need to be examined for COVID-19, including in digestive surgery emergency cases. In this paper, we report four digestive surgery emergency cases with clinical and radiological findings similar to COVID-19.

Case presentation

We report four digestive surgery emergency cases admitted with fever and cough symptoms. Case 1 is a 75-year-old male with gastric perforation and pneumonia, case 2 is a 32-year-old female with intestinal and pulmonal tuberculosis, case 3 is a 30-year-old female with acute pancreatitis with pleuritis and pleural effusion, and the last case is a 56-year-old female with rectosigmoid cancer with pulmonal metastases. All the patients underwent emergency laparotomy, were hospitalized for therapy, and discharged from the hospital. After 1-month follow-up after surgery, 1 patient had no complaints, 2 patients had surgical site infection, and 1 patient died because of ARDS due to lung metastases.

Discussion

For all four cases, the surgeries were done with strict COVID-19 protocol which included patient screening, examination, laboratory assessment, rapid test screening, and RT-PCR testing. There were no intrahospital mortalities and all the patients were discharged from the hospital. Three patients were followed-up and recovered well with 2 patients having surgical site infection which recovered within a week. However, 1 patient did not show up for the scheduled follow-up and was reported dead 2 weeks after surgery because of ARDS due to lung metastases.

Conclusions

Emergency surgery, especially digestive surgery cases, can be done in the COVID-19 pandemic era with strict prior screening and examination, and safety protocol.

Practical approach for safe anesthesia in a COVID-19 patient scheduled for emergency laparotomy

COVID-19 patients presenting for emergency laparotomy require evaluation of surgical illness and viral disease. As these patients are likely to have a wide spectrum of deranged physiology and organ dysfunction, optimization should start preoperatively and continue through intraoperative and postoperative recovery periods along with appropriate antimicrobial cover. The goal should be not to delay damage control surgery in favor of evaluation and optimization. When a COVID-19 positive or suspected patient is to be operated for laparotomy, the situation often demands general anesthesia with invasive monitoring and analgesia complemented by regional anesthesia to minimize postoperative opioid requirements to facilitate early recovery. This particular article addresses the issues related to emergency laparotomy management in relation to COVID-19 patient. Healthcare workers should diligently use effective PPE and practice disinfection to prevent spread. Video-communication is an effective means of evaluation. Information expected from investigations should be weighed against risk of exposure to healthcare workers/laypersons. Simulation and memory aids should be used to familiarize team members with roles and techniques of management while in PPE. Step-wise detailed planning for patient transfer, anesthesia induction, maintenance and emergence, aid in enhancing HCW safety without compromising patient care.

Physical performance following acute high-risk abdominal surgery: a prospective cohort study

BACKGROUND

Acute high-risk abdominal (AHA) surgery is associated with high mortality, multiple postoperative complications and prolonged hospital stay. Further development of strategies for enhanced recovery programs following AHA surgery is needed. The aim of this study was to describe physical performance and barriers to independent mobilization among patients who received AHA surgery (postoperative days [POD] 1-7).

METHODS

Patients undergoing AHA surgery were consecutively enrolled from a university hospital in Denmark. In the first postoperative week, all patients were evaluated daily with regards to physical performance, using the Cumulated Ambulation Score (CAS; 0-6 points) to assess basic mobility and the activPAL monitor to assess the 24-hour physical activity level. We recorded barriers to independent mobilization.

RESULTS

Fifty patients undergoing AHA surgery (mean age 61.4 ± 17.2 years) were included. Seven patients died within the first postoperative week, and 15 of 43 (35%) patients were still not independently mobilized (CAS < 6) on POD-7, which was associated with pulmonary complications developing (53% v. 14% in those with CAS = 6, p = 0.012). The patients lay or sat for a median of 23.4 hours daily during the first week after AHA surgery, and the main barriers to independent mobilization were fatigue and abdominal pain.

CONCLUSION

Patients who receive AHA surgery have very limited physical performance in the first postoperative week. Barriers to independent mobilization are primarily fatigue and abdominal pain. Further studies investigating strategies for early mobilization and barriers to mobilization in the immediate postoperative period after AHA surgery are needed.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74–2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30–2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Multicentre observational study of adherence to Sepsis Six guidelines in emergency general surgery

BACKGROUND

Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency.

METHODS

Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days).

RESULTS

Of a total of 5067 patients from 97 hospitals across the UK, 911 (18·0 per cent) fulfilled the criteria for sepsis, 165 (3·3 per cent) for severe sepsis and 24 (0·5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17·6-94·5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19·8 (i.q.r. 10·0-35·4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality.

CONCLUSION

Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent.

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Enhanced recovery after surgery (ERAS) has been adopted by many centres and across whole healthcare systems. The results have shown significant reductions in length of stay and postoperative complications. However, there has been very little change in these factors and mortality in emergency surgery. Can we learn from principles of ERAS for emergency abdominal surgery?

Emergency general surgery in the geriatric patient

BACKGROUND

Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care.

METHODS

This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient.

RESULTS

The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care.

CONCLUSION

Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited.

Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement

The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.