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Chan KS, Lim WW, Goh SSN, Lee J, Ong YJ, Ong MW, Goo JTT. Sustained improved emergency laparotomy outcomes over 3 years after a transdisciplinary perioperative care pathway-A 1:1 propensity score matched study. Surgery 2024; 176:849-856. [PMID: 38839432 DOI: 10.1016/j.surg.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 04/09/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Emergency laparotomy is associated with high morbidity and significant global health burden. This study aims to compare postoperative outcomes of patients who underwent emergency laparotomy before and after implementation of a emergency laparotomy pathway. METHODS This is a single-center study of all patients who presented with an acute abdomen and/or conditions requiring emergency laparotomy during pre-emergency laparotomy pathway (retrospective cohort from January 2016 to December 2018) and after the emergency laparotomy pathway (prospective cohort from January 2019 to December 2021). Patients who underwent emergency laparotomy for trauma or vascular surgery were excluded. A 1:1 propensity score matching was performed to address for confounding factors. RESULTS There were 888 patients (emergency laparotomy pathway, n = 428, and pre-emergency laparotomy pathway, n = 460) in the unmatched cohort. The mean age was 63.0 ± 15.4 years, and 43.8% had predicted mortality >10% using Portsmouth-Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity. The most common indication for emergency laparotomy was intestinal obstruction (30.5%). Overall incidence rates of major morbidity and 30-day mortality were 16.2% and 3.5%, respectively. There were 736 patients (n = 368 patients per arm) after propensity score matching. Demographic characteristics were comparable after propensity score matching. The emergency laparotomy pathway was associated with more patients assessed by geriatric medicine (odds ratio = 15.22; P < .001), reduced major morbidity (odds ratio = 0.63; P = .024), reduced intra-abdominal collection (odds ratio = 0.39; P = .006), and need for unplanned radiological and/or surgical intervention after index emergency laparotomy (odds ratio = 0.63; P = .024). Length of stay and 30-day mortality were comparable between the emergency laparotomy pathway and pre-emergency laparotomy pathway in both the unmatched and propensity score matched cohort. CONCLUSION Sustained improved postoperative outcomes were achieved 3 years postimplementation of the emergency laparotomy pathway .
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Woan Wui Lim
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | | | - Jingwen Lee
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Yu Jing Ong
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
| | - Marc Weijie Ong
- Department of General Surgery, Khoo Teck Puat Hospital, Singapore
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Lau FF, Agerskov M, Thusholdt ANW, Højlund J, Meyhoff CS, Jans Ø, Foss NB. Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study. J Clin Anesth 2024; 95:111472. [PMID: 38613938 DOI: 10.1016/j.jclinane.2024.111472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/20/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
STUDY OBJECTIVE Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. DESIGN Multicenter cohort study. SETTING Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. PATIENTS We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. INTERVENTIONS No interventions were carried out. MEASUREMENTS Principal values collected included measurements of peripheral perfusion index and hemoglobin values. METHODS The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. MAIN RESULTS We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62-5.45]) and 90-day mortality (3.13, [1.45-7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57-162.10]). CONCLUSION High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.
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Affiliation(s)
- Frederik F Lau
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Marianne Agerskov
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna N W Thusholdt
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Øivind Jans
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Downey CL, Lessing J, Jayne DG. Reporting of health-related quality of life in emergency laparotomy trials: a systematic review and narrative synthesis. Qual Life Res 2024; 33:599-605. [PMID: 37882901 PMCID: PMC10894131 DOI: 10.1007/s11136-023-03531-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE Emergency laparotomy is associated with high morbidity for the surgical patient. Understanding patients' health-related quality of life after their surgery is important to enhance the informed consent process, and to enable the evaluation and improvement of surgical care. This review aims to summarise the use of health-related quality of life tools in clinical trials involving patients undergoing emergency laparotomy. METHODS A systematic review was undertaken of the scientific literature published in the MEDLINE® and PubMed databases between January 2011 and July 2021. A narrative synthesis approach was chosen to synthesise the diverse range of studies in a structured manner. All included papers were evaluated using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS Eleven studies were selected for inclusion. Most of the studies had a low risk of bias. Two of the studies used health-related quality of life as the primary outcome measure. A variety of health-related quality of life measurement tools were used; the EQ-5D tool was the most popular questionnaire. Protocol adherence was dependent on the length of time which had elapsed after emergency surgery. CONCLUSION There are many perceived challenges to collecting health-related quality of life data in the emergency surgery setting. Many of these can be offset with progressive trial designs. There is a need for further research in the systematic development of patient-reported outcomes for use in emergency surgery.
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Affiliation(s)
- Candice L Downey
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, University of Leeds, Level 7, Clinical Sciences Building, Leeds, LS9 7TF, UK.
| | - J Lessing
- Leeds Teaching Hospital Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - D G Jayne
- Leeds Institute of Medical Research at St James's, St. James's University Hospital, University of Leeds, Level 7, Clinical Sciences Building, Leeds, LS9 7TF, UK
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Khanderia E, Aggarwal R, Bouras G, Patel V. Quality of life after emergency laparotomy: a systematic review. BMC Surg 2024; 24:73. [PMID: 38409008 PMCID: PMC10898072 DOI: 10.1186/s12893-024-02337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/30/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Emergency laparotomy is a commonly performed surgical procedure that has higher post-operative morbidity and mortality than elective surgery. Previous research has identified that patients valued postoperative quality of life (QoL) more than the risk of mortality when deciding to undergo emergency surgery. Current pre-operative scoring and risk stratification systems for emergency laparotomy do not account for or provide prediction tools for post-operative QoL. This study aims to systematically review previous literature to determine post-operative QoL in patients who undergo emergency laparotomy. METHODS A literature search was undertaken in Medline, EMBASE and the Cochrane Library to identify studies measuring post-operative QoL in patients who have had emergency laparotomy up to 29th April 2023. Mean QoL scores from the studies included were combined to calculate the average effect of emergency laparotomy on QoL. The primary outcome of the review was postoperative QoL after emergency laparotomy when compared with a comparator group. Secondary outcomes included the quality of included studies. RESULTS Ten studies in the literature assessing the QoL of patients after emergency laparotomy were identified. Three studies showed that patients had improved QoL and seven showed worse QoL following emergency laparotomy. Length of time for QoL to return to baseline varied ranged from 3 to 12 months post-operatively. Length of hospital stay was identified as an independent risk factor for poorer QoL post-surgery. CONCLUSIONS Outcome reporting for patients who undergo emergency laparotomy should be expanded further to include QoL. Further work is required to investigate this and elicit factors that can improve QoL post-operatively.
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Affiliation(s)
- Esha Khanderia
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK.
| | - Ravi Aggarwal
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - George Bouras
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Vanash Patel
- Watford General Hospital, West Hertfordshire Teaching Hospitals NHS Trust, Watford, UK
- Department of Surgery & Cancer, Imperial College London, London, UK
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Chawla M, Baselice H, Negash R, Helkin A, Young A. Adjusting the Split: Examining Complications After Emergency Exploratory Laparotomy in Older Adults. J Surg Res 2024; 294:58-65. [PMID: 37864960 PMCID: PMC10841194 DOI: 10.1016/j.jss.2023.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 10/23/2023]
Abstract
INTRODUCTION Older adults experience higher rates of complications after an emergency exploratory laparotomy (EEL). To better understand the shift to an aging population in the United States, identifying how age may influence these complications in older patients is important. The current standard age category for older adult patients is ≥65. We analyzed postlaparotomy complications using a lower age split. METHODS A retrospective analysis was done on patients who required an EEL from October 2015 to December 2019 at an academic medical center. Patient demographics and hospital course variables were collected. Differences in complications in patients aged ≥/<55 y and ≥/<65 y were measured using univariate and multivariable analyses. RESULTS A total of 481 patients were reviewed. Both patient groups of ≥55 and ≥65 were typically male, White, had 3+ comorbidities, Medicare insurance, were retired, and presented in extremis to the emergency department. Patients aged ≥55 y had significant rates of pulmonary complications and inpatient mortality (odds ratio 2.2, 2.7, respectively). Patients aged ≥65 y had significant rates of genitourinary and cardiac complications (odds ratio 2.3, 1.8, respectively). CONCLUSIONS Patients aged ≥55 y undergoing EEL had higher odds of experiencing pulmonary complications and death during their index hospitalizations, which was not present with the standard ≥/<65-y-old patient analysis. Those aged ≥65 y experienced index genitourinary and cardiac complications. The ≥/<55 age split has a unique set of complications that should be considered. Given the increased odds of inpatient mortality and types of complications in patients aged ≥55 y, the current age split for older adults should be reconsidered.
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Affiliation(s)
- Mehak Chawla
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Holly Baselice
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rosa Negash
- The Ohio State University College of Public Health, Columbus, Ohio
| | - Alex Helkin
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew Young
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Edwards MR, Forbes G, Walker N, Morton DG, Mythen MG, Murray D, Anderson I, Mihaylova B, Thomson A, Taylor M, Hollyman M, Phillips R, Young K, Kahan BC, Pearse RM, Grocott MPW. Fluid Optimisation in Emergency Laparotomy (FLO-ELA) Trial: study protocol for a multi-centre randomised trial of cardiac output-guided fluid therapy compared to usual care in patients undergoing major emergency gastrointestinal surgery. Trials 2023; 24:313. [PMID: 37149623 PMCID: PMC10163929 DOI: 10.1186/s13063-023-07275-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 05/08/2023] Open
Abstract
INTRODUCTION Postoperative morbidity and mortality in patients undergoing major emergency gastrointestinal surgery are a major burden on healthcare systems. Optimal management of perioperative intravenous fluids may reduce mortality rates and improve outcomes from surgery. Previous small trials of cardiac-output guided haemodynamic therapy algorithms in patients undergoing gastrointestinal surgery have suggested this intervention results in reduced complications and a modest reduction in mortality. However, this existing evidence is based mainly on elective (planned) surgery, with little evaluation in the emergency setting. There are fundamental clinical and pathophysiological differences between the planned and emergency surgical setting which may influence the effects of this intervention. A large definitive trial in emergency surgery is needed to confirm or refute the potential benefits observed in elective surgery and to inform widespread clinical practice. METHODS The FLO-ELA trial is a multi-centre, parallel-group, open, randomised controlled trial. 3138 patients aged 50 and over undergoing major emergency gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intra-venous fluid, or usual care without cardiac output monitoring. The trial intervention will be carried out during surgery and for up to 6 h postoperatively. The trial is funded through an efficient design call by the National Institute for Health and Care Research Health Technology Assessment (NIHR HTA) programme and uses existing routinely collected datasets for the majority of data collection. The primary outcome is the number of days alive and out of hospital within 90 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation. Participant recruitment started in September 2017 with a 1-year internal pilot phase and is ongoing at the time of publication. DISCUSSION This will be the largest contemporary randomised trial examining the effectiveness of perioperative cardiac output-guided haemodynamic therapy in patients undergoing major emergency gastrointestinal surgery. The multi-centre design and broad inclusion criteria support the external validity of the trial. Although the clinical teams delivering the trial interventions will not be blinded, significant trial outcome measures are objective and not subject to detection bias. TRIAL REGISTRATION ISRCTN 14729158. Registered on 02 May 2017.
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Affiliation(s)
- Mark R Edwards
- Department of Anaesthesia, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.
- Perioperative & Critical Care Research Group, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust / University of Southampton, Southampton, UK.
| | - Gordon Forbes
- Department of Biostatistics & Health Informatics, King's College London, London, UK
| | - Neil Walker
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Dion G Morton
- Academic Department of Surgery, University of Birmingham, Birmingham, UK
| | - Monty G Mythen
- University College London Hospitals NIHR Biomedical Research Centre, London, UK
| | - Dave Murray
- James Cook University Hospital, Middlesbrough, UK
| | - Iain Anderson
- Salford Royal NHS Foundation Trust, Salford, UK
- University of Manchester, Manchester, UK
| | - Borislava Mihaylova
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Mary University of London, London, Queen, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ann Thomson
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Matt Taylor
- Department of Critical Care, University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | | | - Rachel Phillips
- School of Public Health, Imperial College London, London, UK
| | | | - Brennan C Kahan
- MRC Clinical Trials Unit at UCL, University College London, London, UK
| | - Rupert M Pearse
- Faculty of Medicine & Dentistry, Mary University of London, London, Queen, UK
| | - Michael P W Grocott
- Perioperative & Critical Care Research Group, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust / University of Southampton, Southampton, UK
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Wu A, Fahey MT, Cui D, El‐Behesy B, Story DA. An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery. Anaesthesia 2022; 77:901-909. [PMID: 35489814 PMCID: PMC9543156 DOI: 10.1111/anae.15742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/11/2023]
Abstract
'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.
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Affiliation(s)
- A. Wu
- Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia
| | - M. T. Fahey
- Department of Health Sciences and BiostatisticsSwinburne University of TechnologyMelbourneAustralia,Department of Biostatistics and Clinical TrialsPeter MacCallum Cancer CentreMelbourneVictoriaAustralia
| | - D. Cui
- Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia,Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia
| | - B. El‐Behesy
- Department of AnaestheticsMaroondah Hospital, Eastern HealthMelbourneAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneAustralia
| | - D. A. Story
- Department of Critical CareUniversity of Melbourne and Melbourne Academic Centre for HealthMelbourneAustralia
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. AHA STEROID trial, dexamethasone in acute high-risk abdominal surgery, the protocol for a randomized controlled trial. Acta Anaesthesiol Scand 2022; 66:640-650. [PMID: 35124808 DOI: 10.1111/aas.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/10/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Existing multimodal pathways for patients undergoing acute high-risk abdominal surgery for intestinal obstruction (IO) and perforated viscus (PV) have focused on rescue in the immediate perioperative period. However, there is little focus on the peri-operative pathophysiology of recovery in this patient group, as done to develop enhanced recovery pathways in elective care. Acute inflammation is the main driver of the perioperative pathophysiology leading to adverse outcomes. Pre-operative high-dose of glucocorticoids provides a reduction in the inflammatory response after surgery, effective pain relief in several major surgical procedures, as well as reduce fatigue and improving endothelial dysfunction. AIM To evaluate the effect of high-dose glucocorticoid on the inflammatory response, fluid distribution and recovery after acute high-risk abdominal surgery in patients with IO and PV. METHODS AHA STEROID trial is a sponsor-initiated single-center, randomized, double-blind placebo-controlled trial, assessing preoperative high-dose dexamethasone (1 mg/kg) versus placebo (normal saline) in patients undergoing emergency high-risk abdominal surgery. We plan to enroll 120 patients. Primary outcome is the reduction in C-reactive protein on postoperative day 1 as a marker of successful attenuation of the acute stress response. Secondary outcomes include perioperative changes in endothelial and other inflammatory markers, fluid distribution, pulmonary function, pain, fatigue, and mobilization. The statistical plan is outlined in the protocol. DISCUSSION The AHA STEROID trial will provide important evidence to guide the potential use of high-dose glucocorticoids in emergency high-risk abdominal surgery, with respect to different pathophysiologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Rigshospitalet Denmark
| | | | - Jakob Højlund
- Department of Anesthesiology Hvidovre Hospital Copenhagen Denmark
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Agerskov M, Sørensen H, Højlund J, Secher NH, Foss NB. Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study. Acta Anaesthesiol Scand 2022; 66:660-673. [PMID: 35396854 DOI: 10.1111/aas.14070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/27/2022] [Accepted: 04/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase. METHODS In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance. RESULTS Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7 L [2.1-3.3] vs. 2.8 L [2.3-3.4], p = .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p = .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2 L [1.7-2.7] vs. 2.9 L [2.3-3.5], p = .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p = .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p = .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p = .007). CONCLUSIONS Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen Copenhagen Denmark
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
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10
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Kassahun WT, Babel J, Mehdorn M. Assessing differences in surgical outcomes following emergency abdominal exploration for complications of elective surgery and high-risk primary emergencies. Sci Rep 2022; 12:1349. [PMID: 35079087 PMCID: PMC8789789 DOI: 10.1038/s41598-022-05326-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/06/2022] [Indexed: 11/09/2022] Open
Abstract
Irrespective of its etiology, emergency surgical abdominal exploration (EAE) is considered a high-risk procedure with mortality rates exceeding 20%. The aim of this study was to evaluate differences in outcomes in patients who required EAE due to complications of complex elective abdominal procedures and those who required EAE due to high-risk primary abdominal emergencies. Patients undergoing EAE for acute surgical complications of complex abdominal elective surgical procedures (N = 293; Elective group) and patients undergoing EAE for high-risk primary abdominal emergencies (N = 776; Emergency group) from 2012 to 2019 at our institution were retrospectively assessed for morbidity and mortality. Postoperative complications occurred in 196 patients (66.94%) in the elective group and 585 patients (75.4%) in the emergency group. The relatively low complication burden in the elective group was also evidenced by a significantly lower comprehensive complication index score (54.00 ± 37.36 vs. 59.25 ± 37.08, p = 0.040). The in-hospital mortality rates were 31% (91 of 293) and 38% (295 of 776) in the elective and emergency groups, respectively. This difference between the two groups was statistically significant (p = 0.035). In multivariate analysis, age, peripheral artery disease, pneumonia, thromboembolic events, ICU stay, ventilator dependence, acute kidney failure and liver failure were independent predictors of mortality. Our data show that patients undergoing EAE due to acute complications of major elective surgery tolerate the procedure relatively well compared with patients undergoing EAE due to primary high-risk abdominal emergencies.
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Affiliation(s)
- Woubet Tefera Kassahun
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany.
| | - Jonas Babel
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
| | - Matthias Mehdorn
- Faculty of Medicine, Clinic for Visceral, Transplantation, Thoracic and Vascular Surgery, University Hospital of Leipzig, Liebig Strasse 20, 04103, Leipzig, Germany
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Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00500-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes.
Recent Findings
Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function.
Summary
This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.
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Agerskov M, Thusholdt ANW, Holm-Sørensen H, Wiberg S, Meyhoff CS, Højlund J, Secher NH, Foss NB. Association of the intraoperative peripheral perfusion index with postoperative morbidity and mortality in acute surgical patients: a retrospective observational multicentre cohort study. Br J Anaesth 2021; 127:396-404. [PMID: 34226038 PMCID: PMC8451236 DOI: 10.1016/j.bja.2021.06.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background We hypothesised that in acute high-risk surgical patients, a lower intraoperative peripheral perfusion index (PPI) would indicate a higher risk of postoperative complications and mortality. Methods This retrospective observational study included 1338 acute high-risk surgical patients from November 2017 until October 2018 at two University Hospitals in Denmark. Intraoperative PPI was the primary exposure variable and the primary outcome was severe postoperative complications defined as a Clavien–Dindo Class ≥III or death, within 30 days. Results intraoperative PPI was associated with severe postoperative complications or death: odds ratio (OR) 1.12 (95% confidence interval [CI] 1.05–1.19; P<0.001), with an association of intraoperative mean PPI ≤0.5 and PPI ≤1.5 with the primary outcome: OR 1.79 (95% CI 1.09–2.91; P=0.02) and OR 1.65 (95% CI 1.20–2.27; P=0.002), respectively. Each 15-min increase in intraoperative time spend with low PPI was associated with the primary outcome (per 15 min with PPI ≤0.5: OR 1.11 (95% CI 1.05–1.17; P<0.001) and with PPI ≤1.5: OR 1.06 (95% CI 1.02–1.09; P=0.002)). Thirty-day mortality in patients with PPI ≤0.5 was 19% vs 10% for PPI >0.5, P=0.003. If PPI was ≤1.5, 30-day mortality was 16% vs 8% in patients with a PPI >1.5 (P<0.001). In contrast, intraoperative mean MAP ≤65 mm Hg was not significantly associated with severe postoperative complications or death (OR 1.21 [95% CI 0.92–1.58; P=0.2]). Conclusions Low intraoperative PPI was associated with severe postoperative complications or death in acute high-risk surgical patients. To guide intraoperative haemodynamic management, the PPI should be further investigated.
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Affiliation(s)
- Marianne Agerskov
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anna N W Thusholdt
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Holm-Sørensen
- Department of Integrative Physiology, NEXS, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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Vetrugno L, Boero E, Bignami E, Cortegiani A, Raineri SM, Spadaro S, Moro F, D’Incà S, D’Orlando L, Agrò FE, Bernardinetti M, Forfori F, Corradi F, Pregnolato S, Mosconi M, Bellini V, Franchi F, Mongelli P, Leonardi S, Giuffrida C, Tescione M, Bruni A, Garofalo E, Longhini F, Cammarota G, De Robertis E, Giglio G, Urso F, Bove T. Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP). Ultrasound J 2021; 13:30. [PMID: 34100124 PMCID: PMC8184059 DOI: 10.1186/s13089-021-00230-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of "indirect" and "direct" cardiac and pulmonary lung ultrasound signs. METHODS LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged > 65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns-each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5. CONCLUSIONS Lung ultrasound (LU), as a tool within the anesthesiologist's armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.
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Affiliation(s)
- Luigi Vetrugno
- Department of Medicine, University of Udine, Via Colugna no. 50, 33100 Udine, Italy
- University-Hospital of Friuli Centrale, ASFC, P.le S. Maria della Misericordia no. 15, 33100 Udine, Italy
| | - Enrico Boero
- Anesthesia and Intensive Care Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S), University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Santi Maurizio Raineri
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S), University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Savino Spadaro
- Department of translational medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Federico Moro
- Department of translational medicine, Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Stefano D’Incà
- Department of Medicine, University of Udine, Via Colugna no. 50, 33100 Udine, Italy
| | - Loris D’Orlando
- Department of Medicine, University of Udine, Via Colugna no. 50, 33100 Udine, Italy
| | - Felice Eugenio Agrò
- Department of Medicine, Unit of Anesthesia Intensive Care Pain Management, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Mattia Bernardinetti
- Department of Medicine, Unit of Anesthesia Intensive Care Pain Management, Università Campus Bio-Medico Di Roma, Rome, Italy
| | - Francesco Forfori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Corradi
- Department of Anesthesia and Intensive Care, Ente Ospedaliero Ospedali Galliera, Genova, Italy
| | - Sandro Pregnolato
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Mario Mosconi
- Orthopedics and Traumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Bellini
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University of Siena, Siena, Italy
| | - Pierpaolo Mongelli
- Department of Medicine, Surgery and Neuroscience, Anesthesiology and Intensive Care, University of Siena, Siena, Italy
| | | | | | - Marco Tescione
- Anesthesia and Intensive Care Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Science, Magna Graecia University, Catanzaro, Italy
| | - Gianmaria Cammarota
- Section of Anaesthesia, Analgesia, and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Edoardo De Robertis
- Section of Anaesthesia, Analgesia, and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Giuseppe Giglio
- University-Hospital of Friuli Centrale, ASFC, P.le S. Maria della Misericordia no. 15, 33100 Udine, Italy
| | - Felice Urso
- Anesthesia and Intensive Care Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Tiziana Bove
- Department of Medicine, University of Udine, Via Colugna no. 50, 33100 Udine, Italy
- University-Hospital of Friuli Centrale, ASFC, P.le S. Maria della Misericordia no. 15, 33100 Udine, Italy
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14
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Petring Hasselager R, Foss NB, Andersen O, Cihoric M, Bay‐Nielsen M, Nielsen HJ, Camilla Andresen L, Toft Tengberg L. Mortality and major complications after emergency laparotomy: A pilot study of risk prediction model development by preoperative blood-based immune parameters. Acta Anaesthesiol Scand 2021; 65:151-161. [PMID: 33108695 DOI: 10.1111/aas.13722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 09/04/2020] [Accepted: 09/28/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Emergency laparotomy is associated with high risk of postoperative complications and mortality. Preoperative identification of patients at high risk of adverse outcome is important. The immune response to conditions requiring emergency laparotomy is not understood in detail. The present study describes preoperative blood-based immune profiles and their potential value in surgical risk assessment. METHOD Patients (N = 100) referred for emergency laparotomy at Hvidovre Hospital were consecutively included from 3 June 2013-11 April 2014. All patients had blood samples collected before surgery and the immune parameters c-reactive protein (CRP), Interleukin-6 (IL-6), Interleukin-10 (IL-10), interferon-γ induced protein 10 kDa (IP-10), tumor necrosis factor α (TNF-α) and soluble urokinase plasminogen receptor activator (suPAR) were determined. Patients were stratified according to major postoperative complications (including death), 30- and 180-day mortality. Using logistic regression models and receiver operating characteristics curves the predictive ability of the immune parameters were estimated. RESULTS Major complications were recorded in 45 (45.0%) of the patients, whereas 30-day and 180-day mortalities were 17 (17.0%) and 25 (25.0%), respectively. Concentrations of suPAR and TNF-α were associated with major complications while CRP, IL-6, suPAR and TNF-α were associated with mortality. Adding the combined immune parameters to a regression model including age, sex, American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status significantly improved the predictive ability for major complications, 30-day mortality and 180-day mortality. CONCLUSION In emergency laparotomy, preoperative blood-based immune parameters added predictive power to regression models and could be considered in risk prediction model development.
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Affiliation(s)
| | - Nicolai Bang Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Ove Andersen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
| | - Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Hvidovre Hospital Hvidovre Denmark
| | - Morten Bay‐Nielsen
- Department of Surgery Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Hans J. Nielsen
- Department of Surgical Gastroenterology 360 Hvidovre Hospital Hvidovre Denmark
| | - Linda Camilla Andresen
- Department of Clinical Research and the Emergency Department Hvidovre Hospital Hvidovre Denmark
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15
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Costa G, Fransvea P, Podda M, Pisanu A, Carrano FM, Iossa A, Balducci G, Agresta F. The use of emergency laparoscopy for acute abdomen in the elderly: the FRAILESEL Italian Multicenter Prospective Cohort Study. Updates Surg 2020; 72:513-525. [PMID: 32088854 DOI: 10.1007/s13304-020-00726-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
As the world population is aging rapidly, emergency abdominal surgery for acute abdomen in the elderly represents a global issue, both in developed and developing countries. Data regarding all the elderly patients who underwent emergency abdominal surgery from January 2017 to December 2017 at 36 Italian surgical departments were analyzed with the aim to appraise the contemporary reality regarding the use of emergency laparoscopy for acute abdomen in the elderly. 1993 patients were enrolled. 1369 (68.7%) patients were operated with an open technique; whereas, 624 (31.3%) underwent a laparoscopic operation. The postoperative morbidity rate was 32.6%, with a statically significant difference between the open and the laparoscopic groups (36.2% versus 22.1%, p < 0.001). The reported mortality rate was 8.8%, with a statistically significant difference between the open and the laparoscopic groups (11.2% versus 2.2%, p < 0.001). Our results demonstrated that patients in the ASA II (58.1%), ASA III (68.7%) and ASA IV (88.5%) groups were operated with the traditional open technique in most of the cases. Only a small percentage of patients underwent laparoscopy for perforated gastro-duodenal ulcer repair (18.9%), adhesiolyses with/without small bowel resection (12.2%), and large bowel resection (10.7%). Conversion to open technique was associated with a higher mortality rate (11.1% versus 2.2%, p < 0.001) and overall morbidity (38.9% versus 22.1%, p = 0.001) compared with patients who did not undergo conversion. High creatinine (p < 0.001) and glycaemia (p = 0.006) levels, low hemoglobin levels (p < 0.001), oral anticoagulation therapy (p = 0.001), acute respiratory failure (p < 0.001), presence of malignancy (p = 0.001), SIRS (p < 0.001) and open surgical approach (p < 0.001) were associated with an increased risk of postoperative morbidity. Regardless of technical progress, elderly patients undergoing emergency surgery are at very high risk for in-hospital complications. A detailed analysis of complications and mortality in the present study showed that almost 9% of elderly patients died after surgery for acute abdomen, and over 32% developed complications.
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Affiliation(s)
- Gianluca Costa
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy.
| | - Adolfo Pisanu
- Department of General, Emergency and Minimally Invasive Surgery, Cagliari University Hospital "D. Casula", University of Cagliari, SS 554, Km 4,500, Monserrato, 09042, Cagliari, Italy
| | - Francesco Maria Carrano
- Department of General, Emergency and Transplant Surgery, Ospedale di Circolo e "Fondazione Macchi", ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Angelo Iossa
- Department of Medicine and Surgical Sciences and Biotechnologies, "La Sapienza" University of Rome, Polo Pontino, Latina, Italy
| | - Genoveffa Balducci
- Emergency Surgery Unit, Sant'Andrea Teaching Hospital, "La Sapienza" University of Rome, Rome, Italy
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16
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Foss NB. Emergency laparotomy success - optimisation or triage? Anaesthesia 2020; 75:1289-1292. [PMID: 32472947 DOI: 10.1111/anae.15114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 12/26/2022]
Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
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17
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Boyd-Carson H, Shah A, Sugavanam A, Reid J, Stanworth SJ, Oliver CM. The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia 2020; 75:904-912. [PMID: 32315080 DOI: 10.1111/anae.15021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 01/28/2023]
Abstract
Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as 'mild' 129-110 g.l-1; 'moderate' 109-80 g.l-1; or 'severe' ≤ 79 g.l-1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09-1.21); moderate, 1.44 (1.36-1.52); and severe, 1.42 (1.24-1.63), p < 0.001 for all; mild, 1.07 (1.00-1.12), p = 0.030; moderate, 1.30 (1.21-1.38), p < 0.001; and severe, 1.22 (1.05-1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01-1.62); moderate, 3.41 (3.04-3.77); severe, 2.80 (1.83-3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06-1.21), p < 0.001; and severe 1.23 (1.06-1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - A Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Department of Anaesthesia, Danube Hospital, Vienna, Austria
| | - J Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C M Oliver
- Royal College of Anaesthetists, London, UK.,UCL Division of Surgery and Interventional Science, London, UK
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18
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Foss NB, Kehlet H. Challenges in optimising recovery after emergency laparotomy. Anaesthesia 2020; 75 Suppl 1:e83-e89. [PMID: 31903571 DOI: 10.1111/anae.14902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 12/19/2022]
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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19
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20
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Agerskov M, Thusholdt ANW, Højlund J, Meyhoff CS, Sørensen H, Wiberg S, Secher NH, Bang Foss N. Protocol for a multicentre retrospective observational cohort study in Denmark: association between the intraoperative peripheral perfusion index and postoperative morbidity and mortality in acute non-cardiac surgical patients. BMJ Open 2019; 9:e031249. [PMID: 31753878 PMCID: PMC6886954 DOI: 10.1136/bmjopen-2019-031249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Perioperative haemodynamic instability is associated with postoperative morbidity and mortality. Macrocirculatory parameters, such as arterial blood pressure and cardiac output are associated with poor outcome but may be uncoupled from the microcirculation during sepsis and hypovolaemia and may not be optimal resuscitation parameters. The peripheral perfusion index (PPI) is derived from the pulse oximetry signal. Reduced peripheral perfusion is associated with morbidity in critically ill patients and in patients following acute surgery. We hypothesise that a low intraoperative PPI is independently associated with postoperative complications and mortality. METHODS AND ANALYSIS We plan to conduct a retrospective cohort study in approximately 2300 patients, who underwent acute non-cardiac surgery (1 November 2017 to 31 October 2018) at two Danish University Hospitals. Data will be collected from patient records including patient demographics, comorbidity and intraoperative haemodynamic values with PPI as the primary exposure variable, and postoperative complications and mortality within 30 and 90 days as outcome variables. We primarily assess association between PPI and outcome in multivariate regression models. Second, the predictive value of PPI for outcome, using area under the receiver operating characteristics curve is assessed. ETHICS AND DISSEMINATION Data will be reported according to the Strengthening the Reporting of Observational Studies in Epidemiology and results published in a peer-reviewed journal. The study is approved by the regional research ethics committee, storage and management of data has been approved by the Regional Data Protection Agency, and access to medical records is approved by the hospital board of directors (ClinicalTrials.gov registration no: NCT03757442).
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Affiliation(s)
- Marianne Agerskov
- Department of Anaesthesia, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Jakob Højlund
- Department of Anaesthesia, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Sørensen
- Department of Anaesthesiology, Rigshospitalet, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anaesthesia, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Nicolai Bang Foss
- Department of Anaesthesia, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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21
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Ramachenderan J, Auret K. The Challenge of Perioperative Advance Care Planning. J Pain Symptom Manage 2019; 58:538-542. [PMID: 31029807 DOI: 10.1016/j.jpainsymman.2019.04.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 11/19/2022]
Abstract
As our population ages, there will be an increasing number of patients with life-limiting disease who may be referred for major elective surgery and more pressingly may present acutely, requiring major emergency surgical intervention. Owing to the high risk of perioperative and postoperative complications associated this group of patients, it is paramount that specific advance care planning that encompasses a patient's goals of care and resuscitative status be clarified before undergoing surgery in this acute period. In doing so, this will lead to a better quality of life for patients with a limited trajectory and allow for more informed decisions to be made about their health care. Furthermore, it will help to prevent futile and inappropriate treatments that do not respect a patient's wishes and their clinical status. In this case discussion, we explore the key themes about the challenge of perioperative advance care planning for patients with life-limiting disease and provide a framework to help guide conversation in this crucial period.
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Affiliation(s)
- Jonathan Ramachenderan
- Great Southern Regional Palliative Care Service, Albany Health Campus, Western Australia Country Health Service.
| | - Kirsten Auret
- Rural Clinical School of Western Australia, University of Western Australia, Albany, Western Australia, Australia
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22
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Kwong E, Neuburger J, Murray D, Black N. Feasibility of collecting and assessing patient-reported outcomes for emergency admissions: laparotomy for gastrointestinal conditions. BMJ Open Gastroenterol 2018; 5:e000238. [PMID: 30397506 PMCID: PMC6203065 DOI: 10.1136/bmjgast-2018-000238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Audit of emergency surgery is usually limited to immediate clinical outcomes relating to outcomes during the acute hospital episode with little attempt to capture patients' views of their longer-term outcomes. Our aim was to determine the response rate to patient-reported outcome measures (PROMs) for patients who underwent an emergency laparotomy for gastrointestinal conditions, identify response bias and explore the feasibility of comparing outcomes with their prior health based on their recalled view collected during their admission. METHODS Patients undergoing emergency laparotomy in 11 hospitals were recruited to complete a retrospective questionnaire containing the EQ-5D-3L and Gastrointestinal Quality of Life Index (GIQLI). Response rate for 3-month mailed follow-up questionnaire and potential response biases were assessed. Patients' outcomes were compared with their baseline using χ2 and paired t-test to assess for differences. RESULTS Of 255 patients contacted at 3 months, 190 (74.1%) responded. Responders were more likely to be older, female and more affluent. Patients' health improved significantly as regards the GIQLI (93.3 vs 97.9; p=0.048) and the subscale on symptoms (51.9 vs 59.6; p<0.001). No significant change in subscales on emotion or physical aspects or for overall health status (EQ-5D: 0.58 vs 0.64; p=0.06). According to the social subscale, patients had deteriorated (11.0 vs 9.8; p<0.0006). Differences in change scores by patient characteristics were slight, suggesting minimal response bias. CONCLUSION This approach offers the opportunity for assessing the impact of treatment, from the patient's perspective and the potential to evaluate emergency laparotomy care using PROMs.
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Affiliation(s)
- Esther Kwong
- Departement of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Neuburger
- Departement of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Dave Murray
- Anaesthetic Department, James Cook University Hospital, Middlesbrough, UK
| | - Nick Black
- Departement of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Qureshi M, Liew I, Bailey O. CRP monitoring in fractured neck of femur. A waste of resource? Injury 2018; 49:1855-1858. [PMID: 30029777 DOI: 10.1016/j.injury.2018.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/03/2018] [Accepted: 07/04/2018] [Indexed: 02/02/2023]
Abstract
AIM We aim to assess post-operative CRP serum values in a cohort of patients who underwent surgical treatment for neck of femur fracture (NOF#), and whether CRP is a valid tool for the assessment of these patients post-operatively. STUDY DESIGN AND METHODS Retrospective analysis was carried out on all NOF#'s admitted for surgical fixation between August 2015 and July 2016 in a district general hospital. Primary analysis included serum CRP levels until day 7 post-operatively, with secondary analysis of any documented evidence of post-operative complications (medical and surgical) within 30 days post-operatively. RESULTS A total of 365 patients were surgically treated for NOF#'s over the study period. CRP serum levels peaked over the first two days post-operatively to median (IQ range) of 226 mg/L (158-299 mg/L), decreasing to 67 mg/L (45.5-104 mg/L) by day 7 post-operatively. 116 patients had documented post-operative complications within 30 daysof operation. CRP levels in patients with and without complications showed no statistical significance in day-1, day-2 and day-3 post-operatively. However, a significant difference was demonstrated on day-4 (p = 0.017), day-5 (p = 0.003), day-6 (p = 0.02) and day-7 (p = 0.031). CONCLUSIONS During the first three days of the postoperative period we cannot recommend routine CRP serum blood test monitoring in NOF# patients, as it is not diagnostic in the acute inflammatory phase for medical or surgical complications.
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Chambers DJ, Allan MW. Anaesthesia in the elderly. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2017. [DOI: 10.1016/j.mpaic.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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25
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Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Gögenur I, Henriksen R, Jensen TK, Tolstrup MB, Nielsen LBJ. Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients. Anaesthesia 2016; 72:309-316. [PMID: 27809332 DOI: 10.1111/anae.13721] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 12/25/2022]
Abstract
Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.
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Affiliation(s)
- L T Tengberg
- Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital, Hvidovre, Denmark
| | | | - I Gögenur
- Copenhagen University Hospital, Køge, Denmark
| | - R Henriksen
- Copenhagen University Hospital, Hillerød, Denmark
| | - T K Jensen
- Copenhagen University Hospital, Herlev, Denmark
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26
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An analysis of postoperative hemoglobin levels in patients with a fractured neck of femur. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:507-513. [PMID: 27756504 PMCID: PMC6197462 DOI: 10.1016/j.aott.2015.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/22/2015] [Accepted: 11/11/2015] [Indexed: 12/03/2022]
Abstract
Objectives The aim of this study was to analyze the changes in hemoglobin level and to determine a suitable timeline for post-operative hemoglobin monitoring in patients undergoing fixation of femoral neck fracture. Patients and methods Patients who underwent either dynamic hip screw (DHS) fixation (n = 74, mean age: 80 years) or hip hemiarthroplasty (n = 104, mean age: 84 years) for femoral neck fracture were included into the study. The hemoglobin level of the patients was monitored perioperatively. Results Analysis found a statistically and clinically significant mean drop in hemoglobin of 31.1 g/L over time from pre-operatively (D0) to day-5 post-operatively (p < 0.001), with significant reductions from D0 to day-1 and day-1 to day-2 (p < 0.001). At each post-operative time point, DHS patients had lower hemoglobin values over hemiarthroplasty patients (p = 0.046). Conclusion The decrease in hemoglobin in the first 24-h post-operative period (D0 to day-1) is an underestimation of the ultimate lowest value in hemoglobin found at day-2. Relying on the day-1 hemoglobin could be detrimental to patient care. We propose a method of predicting patients likely to be transfused, and recommend a protocol for patients undergoing femoral neck fracture surgery to standardize postoperative hemoglobin monitoring. Level of evidence Level IV Prognostic study.
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27
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Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy. Langenbecks Arch Surg 2016; 402:615-623. [PMID: 27502400 DOI: 10.1007/s00423-016-1493-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 08/03/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Emergency abdominal surgery results in a high rate of post-operative complications and death. There are limited data describing the emergency surgical population in details. We aimed to give a detailed analyses of complications and mortality in a consecutive group of patients undergoing acute abdominal surgery over a 4-year period. METHODS This observational study was conducted between 2009 and 2013 at Copenhagen University Hospital Herlev, Denmark. All patients scheduled for emergency laparotomy or laparoscopy were included. Pre-, intra-, and post-operative data were collected from medical records. Complications were registered according to the Clavien-Dindo classification. Cox regression analysis was performed to identify risk factors for mortality. RESULTS A total of 4,346 patients underwent emergency surgery, of whom 14 % had surgical complications and 23 % medical complications. The overall 30-day mortality was 8 % with 50 % of those in this group over 80 years of age. The 30-day mortality rates were 0.8 % (95 % CI 0.5-1.1) and 17 % (95 % CI 15.5-18.9), respectively, for the laparoscopy and the laparotomy groups. The overall death rate within 24 h of surgery was 21 %. Several risk factors for 30- and 90-day mortality were identified: age, ASA ≥3 (American Society of Anaesthesiologists physical status classification), performance score (Zubroed/WHOclassification), cirrhosis of the liver, chronic nephropathy, several medical conditions, and malignancy. CONCLUSION Almost one in five patients died after emergency laparotomy, of whom one in five died within 24 h of surgery. Predictors for poor outcome were identified.
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Affiliation(s)
- M D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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29
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Cauley CE, Block SD, Koritsanszky LA, Gass JD, Frydman JL, Nurudeen SM, Bernacki RE, Cooper Z. Surgeons' Perspectives on Avoiding Nonbeneficial Treatments in Seriously Ill Older Patients with Surgical Emergencies: A Qualitative Study. J Palliat Med 2016; 19:529-37. [PMID: 27105058 DOI: 10.1089/jpm.2015.0450] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical decisions for seriously ill older patients with surgical emergencies are highly complex. Measuring the benefits of burdensome treatments in this context is fraught with uncertainty. Little is known about how surgeons formulate treatment decisions to avoid nonbeneficial surgery, or engage in preoperative conversations about end-of-life (EOL) care. OBJECTIVE We sought to describe how surgeons approach such discussions, and to identify modifiable factors to reduce nonbeneficial surgery near the EOL. DESIGN Purposive and snowball sampling were used to recruit a national sample of emergency general surgeons. Semistructured interviews were conducted between February and May 2014. MEASUREMENTS Three independent coders performed qualitative coding using NVivo software (NVivo version 10.0, QSR International). Content analysis was used to identify factors important to surgical decision making and EOL communication. RESULTS Twenty-four surgeons were interviewed. Participants felt responsible for conducting EOL conversations with seriously ill older patients and their families before surgery to prevent nonbeneficial treatments. However, wide differences in prognostic estimates among surgeons, inadequate data about postoperative quality of life (QOL), patients and surrogates who were unprepared for EOL conversations, variation in perceptions about the role of palliative care, and time constraints are contributors to surgeons providing nonbeneficial operations. Surgeons reported performing operations they knew would not benefit the patient to give the family time to come to terms with the patient's demise. CONCLUSIONS Emergency general surgeons feel responsible for having preoperative discussions about EOL care with seriously ill older patients to avoid nonbenefical surgery. However, surgeons identified multiple factors that undermine adequate communication and lead to nonbeneficial surgery.
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Affiliation(s)
- Christy E Cauley
- 1 Ariadne Labs , Boston, Massachusetts.,3 Department of Surgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Susan D Block
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts.,5 Department of Psychiatry, Brigham and Women's Hospital , Boston, Massachusetts.,6 Department of Medicine, Brigham and Women's Hospital , Boston, Massachusetts
| | | | | | | | - Suliat M Nurudeen
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts
| | - Rachelle E Bernacki
- 1 Ariadne Labs , Boston, Massachusetts.,4 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Zara Cooper
- 1 Ariadne Labs , Boston, Massachusetts.,2 Department of Surgery, Brigham and Women's Hospital , Boston, Massachusetts.,8 Center for Surgery and Public Health, Brigham and Women's Hospital , Boston, Massachusetts
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30
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Søreide K, Thorsen K, Søreide JA. Clinical patterns of presentation and attenuated inflammatory response in octo- and nonagenarians with perforated gastroduodenal ulcers. Surgery 2016; 160:341-9. [PMID: 27067159 DOI: 10.1016/j.surg.2016.02.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/03/2016] [Accepted: 02/24/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Perforated gastrodudenal ulcer (PGDU) is an operative emergency with high mortality rates. The growing elderly population increasingly presents with need for geriatric acute operative care. Current knowledge of age-specific characteristics in presentation, diagnosis, and outcome for PGDU in the elderly is scarce. METHODS We reviewed a consecutive, population-based cohort of patients with PGDU, octa- and nonagenarians were compared with younger patients for variation in patterns of presentation and outcomes. Patterns and outcomes observed included 30-day mortality, serious complications (Clavien-Dindo 3 and 4), and duration of stay. RESULTS Of the 244 patients, 127 were women (52%); median age was 68 years; and 59 patients (24.2%) were ≥80 years. Two thirds had gastric ulcers (n = 168; 67.2%). On admission, hemoglobin levels, white blood cell count, and serum levels of C-reactive protein, bilirubin, and albumin differed significantly between the age groups. Diagnosis, treatment, and the occurrence of severe complications did not differ with age. The median hours of delay to definitive treatment did not differ significantly for all ages, but patients ≥80 years had a greater proportion (44.1% compared with 25.8%) of delay >12 hours (odds ratio 2.26, 95% confidence interval 1.22-4.17; P = .008). Overall mortality was 38 (15.6%); no deaths occurred in patients <55 years. Over one half of deaths occurred in those ≥80 years (odds ratio 4.76, 2.30-9.83; P < .001). Duration of hospital stay was significantly greater in elderly survivors, and fewer were discharged within a week. CONCLUSION Octa- and nonagenarians with PGDU present with fewer signs of peritonitis and have an attenuated inflammatory response. The very elderly have twice the risk of long delays to definitive treatment and almost 5 times increased risk of mortality.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kenneth Thorsen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Abstract
Surgery in people aged over 65 years has led to many postoperative gains, although mortality and morbidity is higher than in younger counterparts. The problem is the vulnerability that comes with age, so these patients with complex needs require multidisciplinary care for the best outcomes.
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Affiliation(s)
| | - Soma Kar
- ST7 in Geriatric Medicine in the Department for Medicine for the Elderly, Hull Royal Infirmary, Hull and East Yorkshire NHS Trust, Hull HU3 2JZ
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32
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Recommendations for Best Communication Practices to Facilitate Goal-concordant Care for Seriously Ill Older Patients With Emergency Surgical Conditions. Ann Surg 2016; 263:1-6. [DOI: 10.1097/sla.0000000000001491] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Desserud KF, Veen T, Søreide K. Emergency general surgery in the geriatric patient. Br J Surg 2015; 103:e52-61. [PMID: 26620724 DOI: 10.1002/bjs.10044] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- K F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - T Veen
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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A case-control study investigating factors of preoperative delay in emergency laparotomy. Int J Surg 2015; 22:131-5. [PMID: 26318501 DOI: 10.1016/j.ijsu.2015.08.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/03/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is a procedure that puts a strain on healthcare resources and is associated with a significant morbidity and mortality. Despite these implications little improvement in the outcome of patients undergoing this procedure has been made in the UK over the last few decades. A delay in transferring patients to theatre has been shown to negatively affect outcome of EL. A prospective case-control study was carried out to evaluate which preoperative factors may contribute towards a delay in theatre transfer. METHODS The time between decision to operate and anaesthetic start time was recorded for all patients undergoing EL between April and September 2013 at Gloucestershire Royal Infirmary. Patient selection criteria were based on the National Emergency Laparotomy Audit guidelines. Patients were divided into two groups depending on whether the transfer to theatre was delayed or not. Binary logistic regression analysis was performed on perioperative factors to determine independent predictors of delay. RESULTS A total of 84 EL were included for analyses with 31 classified as delayed. In the delayed group time for theatre transfer was increased at 6.9 vs. 2.3 h (p < 0.005) respectively. Unavailability of emergency theatres due to other cases taking priority was the most frequent cause for delay (n = 24). On binary logistic regression analysis, indication for laparotomy (OR 4.96, CI 1.4-17.6, p < 0.05), patient age (OR 1.04, CI 1.00-1.07, p < 0.04) and presence of a consultant surgeon (OR 0.16, CI 0.03-0.79, p < 0.03) were found to be independent predictors of delay in EL. CONCLUSION In this study, factors that were associated with a delay in commencing EL were operative indication and patient age whereas the presence of a consultant surgeon made a delay less likely. These findings may highlight points of interest for researchers analysing and auditing the provision of EL in the UK.
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Lester L. Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement. Anesthesiol Clin 2015; 33:491-503. [PMID: 26315634 DOI: 10.1016/j.anclin.2015.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Laeben Lester
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6208, Baltimore, MD 21287-7294, USA.
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36
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Löfgren J, Kadobera D, Forsberg BC, Mulowooza J, Wladis A, Nordin P. District-level surgery in Uganda: Indications, interventions and perioperative mortality. Surgery 2015; 158:7-16. [PMID: 25958070 DOI: 10.1016/j.surg.2015.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The world's poorest 2 billion people, benefit from no more than about 3.5% of the world's operative procedures. The burden of surgical disease is greatest in Africa, where operations could save many lives. Previous facility-based studies have described operative procedure caseloads, but prospective studies investigating interventions, indications and perioperative mortality rates (POMR), are rare. METHODS A prospective, questionnaire-based collection of data on all major and minor operative procedures was undertaken at 2 hospitals in rural Uganda covering 4 and 3 months in 2011, respectively. Data included patient characteristics, indications for the interventions performed, and outcome after surgery. RESULTS We recorded 2,790 operative procedures on 2,701 patients. The rate of major operative procedures per 100,000 population per year was 225. Patients undergoing major operative procedures (n = 1,051) were mostly women (n = 923; 88%) because most interventions were performed owing to pregnancy-related complications (n = 747; 67%) or gynecologic conditions (n = 114; 10%). General operative interventions registered included herniorrhaphy (n = 103; 9%), exploratory laparotomy (n = 60; 5%), and appendectomy (n = 31; 3%). The POMR for major operative procedures was 1% (n = 14) and was greatest after exploratory laparotomy (13%; n = 8) and caesarean delivery (1%; n = 4). Most deaths (n = 16) were a result of sepsis (n = 10-11) or hemorrhage (n = 3-5). CONCLUSION The volume of surgery was low relative to the size of the catchment population. The POMR was high. Exploratory laparotomy and caesarean section were identified as high-risk procedures. Increased availability of blood, improved perioperative monitoring, and early intervention could be part of a solution to reduce the POMR.
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Affiliation(s)
- Jenny Löfgren
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden.
| | - Daniel Kadobera
- School of Public Health, Iganga/Mayuge Health and Demographic Surveillance Site, Iganga, Uganda
| | - Birger C Forsberg
- Department of Public Health Sciences, Karolinska Institute, Solna, Sweden
| | | | - Andreas Wladis
- Department of Clinical Science and Education (KI SÖS), Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Pär Nordin
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, Umeå, Sweden
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Gruenewald M, Renner J. Do we need to monitor cardiac output in spontaneously breathing patients? Anaesthesia 2015; 70:122-5. [PMID: 25583187 DOI: 10.1111/anae.12951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- M Gruenewald
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany.
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Søreide K, Desserud KF. Emergency surgery in the elderly: the balance between function, frailty, fatality and futility. Scand J Trauma Resusc Emerg Med 2015; 23:10. [PMID: 25645443 PMCID: PMC4320594 DOI: 10.1186/s13049-015-0099-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 01/21/2015] [Indexed: 12/15/2022] Open
Abstract
Becoming old is considered a privilege and results from the socioeconomic progress and improvements in health care systems worldwide. However, morbidity and mortality increases with age, and even more so in acute onset disease. With the current prospects of longevity, a considerable number of elderly patients will continue to live with good function and excellent quality of life after emergency surgical care. However, mortality in emergency surgery may be reported at 15-30%, doubled if associated with complications, and notably higher in patients over 75 years. A number of risks associated with death are reported, and a number of scores proposed for prediction of risk. Frailty, a decline in the physiological reserves that may make the person vulnerable to even the most minor of stressful event, appears to be a valid indicator and predictor of risk and poor outcome, but how to best address and measure frailty in the emergency setting is not clear. Futility may sometimes be clearly defined, but most often becomes a borderline decision between ethics, clinical predictions and patient communication for which no solid evidence currently exists. The number and severity of other underlying condition(s), as well as the treatment alternatives and their consequences, is a complex picture to interpret. Add in the onset of the acute surgical disease as a further potential detrimental factor on function and quality of life – and you have a perfect storm to handle. In this brief review, some of the challenging aspects related to emergency surgery in the elderly will be discussed. More research, including registries and trials, are needed for improved knowledge to a growing health care challenge.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Kari F Desserud
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
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Macdonald J, Klein AA, Ferguson K. Rumsfeld revisited: knowns and unknowns affecting the right heart. Anaesthesia 2014; 70:13-7. [PMID: 25489610 DOI: 10.1111/anae.12950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J Macdonald
- Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen, UK.
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40
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Huddart S, Peden CJ, Swart M, McCormick B, Dickinson M, Mohammed MA, Quiney N. Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy. Br J Surg 2014; 102:57-66. [PMID: 25384994 PMCID: PMC4312892 DOI: 10.1002/bjs.9658] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/05/2014] [Accepted: 08/21/2014] [Indexed: 02/06/2023]
Abstract
Background Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care. Methods The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model. Results Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395). Conclusion Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.
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Affiliation(s)
- S Huddart
- Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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Griffiths R, Beech F, Brown A, Dhesi J, Foo I, Goodall J, Harrop-Griffiths W, Jameson J, Love N, Pappenheim K, White S. Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2014; 69 Suppl 1:81-98. [PMID: 24303864 DOI: 10.1111/anae.12524] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2013] [Indexed: 12/17/2022]
Abstract
Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions about the utility of surgery and/or resuscitation. The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.
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