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Lasithiotakis K, Kritsotakis EI, Kokkinakis S, Petra G, Paterakis K, Karali GA, Malikides V, Anastasiadis CS, Zoras O, Drakos N, Kehagias I, Kehagias D, Gouvas N, Kokkinos G, Pozotou I, Papatheodorou P, Frantzeskou K, Schizas D, Syllaios A, Palios IM, Nastos K, Perdikaris M, Michalopoulos NV, Margaris I, Lolis E, Dimopoulou G, Panagiotou D, Nikolaou V, Glantzounis GK, Pappas-Gogos G, Tepelenis K, Zacharioudakis G, Tsaramanidis S, Patsarikas I, Stylianidis G, Giannos G, Karanikas M, Kofina K, Markou M, Chrysos E. The Hellenic Emergency Laparotomy Study (HELAS): A Prospective Multicentre Study on the Outcomes of Emergency Laparotomy in Greece. World J Surg 2023; 47:130-139. [PMID: 36109368 PMCID: PMC9483423 DOI: 10.1007/s00268-022-06723-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). METHODS This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. RESULTS There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann's procedure (11.5%). 30-day post-operative mortality reached 16.3% and serious complications occurred in 10.9%. Factors associated with post-operative mortality were increasing age and ASA class, dependent functional status, ascites, severe sepsis, septic shock, and diabetes. HELAS cohort showed similarities with NELA patients in terms of demographics and preoperative risk. Post-operative utilisation of ICU was significantly lower in the Greek cohort (25.8% vs 56.8%) whereas 30-day post-operative mortality was significantly higher (16.3% vs 8.7%). CONCLUSION In this study, Greek patients experienced markedly worse mortality after emergency laparotomy compared with their British counterparts. This can be at least partly explained by underutilisation of critical care by surgical patients who are at high risk for death.
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Affiliation(s)
- Konstantinos Lasithiotakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece. .,Department of General Surgery, University Hospital of Crete, 71110, Heraklion, Greece.
| | | | - Stamatios Kokkinakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Georgia Petra
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Konstantinos Paterakis
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Garyfallia-Apostolia Karali
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Vironas Malikides
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Charalampos S. Anastasiadis
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Odysseas Zoras
- Department of Surgical Oncology, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
| | - Nikolas Drakos
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Ioannis Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Dimitrios Kehagias
- Department of Surgery, School of Medicine, University General Hospital of Patras, University of Patras, Patras, Greece
| | - Nikolaos Gouvas
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Georgios Kokkinos
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Ioanna Pozotou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Panayiotis Papatheodorou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Kyriakos Frantzeskou
- Department of Surgery, School of Medicine, General Hospital of Nicosia, University of Cyprus, Nicosia, Cyprus
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Syllaios
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ifaistion M. Palios
- Second Propaedeutic Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Nastos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Markos Perdikaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Nikolaos V. Michalopoulos
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Ioannis Margaris
- Department of Surgery, School of Medicine, University General Hospital Attikon, University of Athens, Athens, Greece
| | - Evangelos Lolis
- Department of Surgery, General Hospital of Volos, Volos, Greece
| | | | | | | | | | | | - Kostas Tepelenis
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | - Georgios Zacharioudakis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Savvas Tsaramanidis
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Patsarikas
- Department of Surgery, School of Medicine, Ippokrateio General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Georgios Giannos
- 2nd Department of Surgery, Evangelismos General Hospital, Athens, Greece
| | - Michael Karanikas
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Konstantinia Kofina
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Markos Markou
- Department of Surgery, School of Medicine, University General Hospital of Alexandroupolis, University of Thrace, Alexandroupolis, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, School of Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece
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Nagakawa K, Taniguchi K, Yukutake A, Kawaguchi Y, Matsumoto R, Akashi M, Hirayama T, Hirabaru M, Sakimura C, Minami S, Eguchi S. Predictors and preventers of postoperative bedridden status in the elderly ages over 75 after emergency general surgery: a retrospective cohort study. Acute Med Surg 2023; 10:e844. [PMID: 37207116 PMCID: PMC10190121 DOI: 10.1002/ams2.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 04/13/2023] [Indexed: 05/21/2023] Open
Abstract
Aim We investigated the proportion of bedridden patients after emergency surgery among the elderly ages over 75; defined as the latter-stage elderly in Japan, the associated factors, and interventions used to prevent it. Methods Eighty-two latter-stage elderly patients who underwent emergency surgery for non-traumatic illness between January 2020 and June 2021 in our hospital were included in the study. Backgrounds and various perioperative factors were compared retrospectively between the groups including patients who became bedridden from Performance Status Scale 0 to 3 before admission (Bedridden group) and those who did not (Keep group). Results Three cases of death and seven patients who were bedridden before admission were excluded. The 72 remaining patients were divided into the Bedridden group (n = 10, 13.9%) and the Keep group (n = 62, 86.1%). There were significant differences in the prevalence of dementia, pre- and postoperative circulatory dynamics, renal dysfunction, coagulation abnormality, length of stay in the high care unit/intensive care unit, and number of hospital days, with a relative risk of 13 (1.74-96.71), a sensitivity of 1.00, and a specificity of 0.67 for a preoperative shock index of 0.7 or higher being associated with the Bedridden group. Among patients with a preoperative shock index of 0.7 or higher, there was a significant difference in SI at 24 h postoperatively between the two groups. Conclusion Preoperative shock index may be the most sensitive predictor. Early circulatory stabilization seems to be protective against patients becoming bedridden.
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Affiliation(s)
- Kantoku Nagakawa
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
| | - Ken Taniguchi
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Aki Yukutake
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Yuta Kawaguchi
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Ryo Matsumoto
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Momoko Akashi
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | | | | | - Chika Sakimura
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Shigeki Minami
- Department of SurgeryNagasaki Harbor Medical CenterNagasakiJapan
| | - Susumu Eguchi
- Department of SurgeryNagasaki University Graduate School of Biomedical SciencesNagasakiJapan
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Not all is lost: Functional recovery in older adults following emergency general surgery. J Trauma Acute Care Surg 2022; 93:66-73. [PMID: 35319547 DOI: 10.1097/ta.0000000000003613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although functional decline and death are common long-term outcomes among older adults following emergency general surgery (EGS), we hypothesized that patients' post-discharge function may wax and wane over time. Periods of fluctuation in function may represent opportunities to intervene to prevent further decline. Our objective was to describe the functional trajectories of older adults following EGS admission. METHODS This was a population-based retrospective cohort study of all independent, community-dwelling older adults (age ≥ 65) in Ontario with an EGS admission (2006-2016). A multistate model was used to examine patients' functional trajectories over the five years following discharge. Patients were followed as they transitioned back and forth between functional independence, use of chronic home care (in-home assistance for personal care, homemaking, or medical care for at least 90 days), nursing home admission, and death. RESULTS We identified 78,820 older adults with an EGS admission (mean age 77, 53% female). In the 5 years following admission, 32% (n = 24,928) required new chronic home care, 21% (n = 5,249) of whom had two or more episodes of chronic home care separated by periods of independence. The average time spent in chronic home care was 11 months, and 50% (n = 12,679) of chronic home care episodes ended with a return to independence. For patients requiring chronic home care at any time, the probability of returning to independent living over the subsequent five years ranged from 36-43% annually. CONCLUSIONS Not all is lost for older adults who experience functional decline following EGS admission. Half of those who require chronic home care will recover to independence, and one-third will have a durable recovery, remaining independent after five years. Fluctuations in function in the years following EGS may represent a unique opportunity for interventions to promote rehabilitation and recovery among older adults. LEVEL OF EVIDENCE Level III, epidemiological.
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Ramsay EA, Carter B, Soiza RL, Duffy S, Moug SJ, Myint PK. Frailty is associated with increased waiting time for relevant process-of-care measures; findings from the Emergency Laparoscopic and Laparotomy Scottish audit (ELLSA). Br J Surg 2021; 109:172-175. [PMID: 34750619 DOI: 10.1093/bjs/znab371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/23/2021] [Indexed: 11/13/2022]
Abstract
This paper using Scottish audit data found that frailty was associated with longer waiting times at almost all stages of the preoperative emergency general surgical pathway. Frailty and ASA fitness grade were also good indicators of mortality in this cohort.
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Affiliation(s)
- Euan A Ramsay
- Ageing, Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Roy L Soiza
- Ageing, Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Siobhan Duffy
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - Susan J Moug
- Department of Surgery, Royal Alexandra Hospital, Paisley, UK
| | - Phyo K Myint
- Ageing, Clinical and Experimental Research Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Long-term survival in high-risk older adults following emergency general surgery admission. J Trauma Acute Care Surg 2021; 91:634-640. [PMID: 34252059 DOI: 10.1097/ta.0000000000003346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) conditions are increasingly common among nursing home residents. While such patients have a high risk of in-hospital mortality, long-term outcomes in this group are not well described, which may have implications for goals of care discussions. In this study, we evaluate long-term survival among nursing home residents admitted for EGS conditions. METHODS We performed a population-based, retrospective cohort study of nursing home residents (65 years or older) admitted for one of eight EGS diagnoses (appendicitis, cholecystitis, strangulated hernia, bowel obstruction, diverticulitis, peptic ulcer disease, intestinal ischemia, or perforated viscus) from 2006 to 2018 in a large regional health system. The primary outcome was 1-year survival. To ascertain the effect of EGS admission independent of baseline characteristics, patients were matched to nursing home residents without an EGS admission based on demographics and baseline health. Kaplan-Meier analysis was used to evaluate survival across groups. RESULTS A total of 7,942 nursing home residents (mean age, 85 years) were admitted with an EGS diagnosis and matched to controls. One quarter of patients underwent surgery, and 18% died in hospital. At 1 year, 55% of cases were alive, compared with 72% of controls (p < 0.001). Among those undergoing surgery, 61% were alive at 1 year, compared with 72% of controls (p < 0.001). The 1-year survival probability was 57% in patients who did not require mechanical ventilation, 43% in those who required 1 to 2 days of ventilation, and 30% in those who required ≥3 days of ventilation. CONCLUSION Although their risk of in-hospital mortality is high, most nursing home residents admitted for an EGS diagnosis survive at least 1 year. While nursing home residents presenting with an EGS diagnosis should be cited realistic odds for the risk of death, long-term survival is achievable in the majority of these patients. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Sunnybrook Health Sciences Centre (M.P.G., BWT, ABN, BH); Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., R.S., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons (A.B.N.), Chicago, Illinois; and ICES (A.B.N., R.S., S.E.B., A.H., B.H.), Toronto, Ontario, Canada
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6
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Guttman MP, Tillmann BW, Nathens AB, Saskin R, Bronskill SE, Huang A, Haas B. Alive and at home: Five-year outcomes in older adults following emergency general surgery. J Trauma Acute Care Surg 2021; 90:287-295. [PMID: 33502146 DOI: 10.1097/ta.0000000000003018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes in this population. Our objective was to evaluate the relationship between EGS admission and the probability of an older adult being alive and residing in their own home 5 years later. We also examined the extent to which specific EGS diagnoses, need for surgery, and frailty modified this relationship. METHODS We performed a population-based, retrospective cohort study of community-dwelling older adults (age, ≥65 years) admitted to hospital for one of eight EGS diagnoses (appendicitis, cholecystitis, diverticulitis, strangulated hernia, bowel obstruction, peptic ulcer disease, intestinal ischemia, or perforated viscus) between 2006 and 2018 in Ontario, Canada. Cases were matched to controls from the general population. Time spent alive and at home (measured as time to nursing home admission or death) was compared between cases and controls using Kaplan-Meier analysis and Cox models. RESULTS A total of 90,245 older adults admitted with an EGS diagnosis were matched with controls. In the 5 years following an EGS admission, cases experienced significantly fewer months alive and at home compared with controls (mean time, 43 vs. 50 months; p < 0.001). Except for patients operated on for appendicitis and cholecystitis, all remaining patient subgroups experienced reduced time alive and at home compared with controls (p < 0.001). Cases remained at elevated risk of nursing home admission or death compared with controls for the entirety of the 5-year follow-up (hazard ratio, 1.17-5.11). CONCLUSION Older adults who required hospitalization for an EGS diagnosis were at higher risk for death or admission to a nursing home for at least 5 years following admission compared with controls. However, most patients (57%) remained alive and living in their own home at the end of this 5-year period. LEVEL OF EVIDENCE Epidemiological, level III.
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Affiliation(s)
- Matthew P Guttman
- From the Institute of Health Policy, Management, and Evaluation (M.P.G., B.W.T., A.B.N., S.E.B., B.H.), Department of Surgery (M.P.G., A.B.N., B.H.), and Interdepartmental Division of Critical Care Medicine, Department of Medicine (B.W.T., B.H.), University of Toronto; Evaluative Clinical Sciences, Sunnybrook Research Institute (A.B.N., S.E.B., B.H.), Toronto, Ontario, Canada; American College of Surgeons, Trauma Quality Improvement Program (A.B.N.), Chicago, Illinois; and ICES Central, ICES (R.S., S.E.B., A.H.), Toronto, Ontario, Canada
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7
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Olotu C. ["Emergency anesthesia" in geriatric patients]. Med Klin Intensivmed Notfmed 2019; 115:16-21. [PMID: 31832699 DOI: 10.1007/s00063-019-00635-5] [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: 09/09/2019] [Revised: 10/23/2019] [Accepted: 11/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term. OBJECTIVES Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented. METHODS Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews. CONCLUSION Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.
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Affiliation(s)
- Cynthia Olotu
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 22051, Hamburg, Deutschland.
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Shah A, Palmer AJR, Fisher SA, Rahman SM, Brunskill S, Doree C, Reid J, Sugavanam A, Stanworth SJ. What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis. Perioper Med (Lond) 2018; 7:30. [PMID: 30559962 PMCID: PMC6290500 DOI: 10.1186/s13741-018-0109-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023] Open
Abstract
Background Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery. Methods We followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events. Results Three RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I 2 = 9%) or in the Hb concentration at 'short-term' (≤ 7 days) follow-up (mean difference - 0.32 g/L, 95% CI - 3.28 to 2.64, I 2 = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I 2 = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms. Conclusion We found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted. Trial registration This systematic review was registered on PROSPERO (CRD42018096288).
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Affiliation(s)
- Akshay Shah
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK
| | - Antony J R Palmer
- 2Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sheila A Fisher
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Shah M Rahman
- 3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK
| | - Susan Brunskill
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Carolyn Doree
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Jack Reid
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Anita Sugavanam
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Simon J Stanworth
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK.,3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK.,4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
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Stevens CL, Brown C, Watters DAK. Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator. World J Surg 2017; 42:1981-1987. [DOI: 10.1007/s00268-017-4418-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Bampoe S, Odor PM, Ramani Moonesinghe S, Dickinson M. A systematic review and overview of health economic evaluations of emergency laparotomy. Perioper Med (Lond) 2017; 6:21. [PMID: 29204269 PMCID: PMC5702212 DOI: 10.1186/s13741-017-0078-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/31/2017] [Indexed: 12/30/2022] Open
Abstract
Background Little is known about the economic impact of emergency laparotomy (EL) surgery in healthcare systems around the world. The aim of this systematic review is to describe the primary resource utilisation, healthcare economic and societal costs of EL in adults in different countries. Methods MEDLINE, EMBASE, ISI Web of Knowledge, Cochrane Central Register Controlled Trials, Cochrane Database of Systematic Reviews and CINAHL were searched for full and partial economic analyses of EL published between 1 January 1991 and 31 December 2015. Quality of studies was assessed using the Consensus on Health Economic Criteria (CHEC) checklist. Results Sixteen studies were included from a range of countries. One study was a full economic analysis. Fifteen studies were partial economic evaluations. These studies revealed that emergency abdominal surgery is expensive compared to similar elective surgery when comparing primary resource utilisation costs, with an important societal impact. Most contemporaneous studies indicate that in-hospital costs for EL are in excess of US$10,000 per patient episode, rising substantially when societal costs are considered. Discussion EL is a high-risk and costly procedure with a disproportionate financial burden for healthcare providers, relative to national funding provisions and wider societal cost impact. There is substantial heterogeneity in the methodologies and quality of published economic evaluations of EL; therefore, the true economic costs of EL are yet to be fully defined. Future research should focus on developing strategies to embed health economic evaluations within national programmes aiming to improve EL care, including developing the required measures and infrastructure. Conclusions Emergency laparotomy is expensive, with a significant cost burden to healthcare and systems and society worldwide. Novel strategies for reducing this econmic burden should urgently be explored if greater access to this type of surgery is to be pursued as a global health target. Trial registration PROSPERO registration no. 42015027210.
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Affiliation(s)
- Sohail Bampoe
- Centre for Anaesthesia and Perioperative Medicine, University College London, Gower St, Bloomsbury, London, WC1E 6BT UK.,University College Hospital, 235 Euston Road, London, N1 2BU UK.,Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX UK
| | - Peter M Odor
- University College Hospital, 235 Euston Road, London, N1 2BU UK
| | | | - Matthew Dickinson
- University College Hospital, 235 Euston Road, London, N1 2BU UK.,Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX UK
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11
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A Comparison of Mortality Following Emergency Laparotomy Between Populations From New York State and England. Ann Surg 2017; 266:280-286. [DOI: 10.1097/sla.0000000000001964] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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12
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Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, Orbæk J, Veyhe L, Jørgen Nielsen H, Lindgaard L. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg 2017; 104:463-471. [DOI: 10.1002/bjs.10427] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery.
Methods
The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality.
Results
Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004).
Conclusion
The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L T Tengberg
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Bay-Nielsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - T Bisgaard
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M L Lauritsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark
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Eveleigh MO, Howes TE, Peden CJ, Cook TM. Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle. Anaesthesia 2016; 71:1291-1295. [PMID: 27667290 DOI: 10.1111/anae.13623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2016] [Indexed: 12/25/2022]
Abstract
Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.
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Affiliation(s)
- M O Eveleigh
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK.
| | - T E Howes
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
| | - C J Peden
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
| | - T M Cook
- Department of Anaesthesia, Royal United Hospital NHS Foundation Trust, Bath, UK
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Roque-Castellano C, Marchena-Gómez J, Fariña-Castro R, Acosta-Mérida MA, Armas-Ojeda MD, Sánchez-Guédez MI. Perioperative Blood Transfusion is Associated with an Increased Mortality in Older Surgical Patients. World J Surg 2016; 40:1795-801. [DOI: 10.1007/s00268-016-3521-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Shah AA, Latif A, Zogg CK, Zafar SN, Riviello R, Halim MS, Rehman Z, Haider AH, Zafar H. Emergency general surgery in a low-middle income health care setting: Determinants of outcomes. Surgery 2016; 159:641-9. [PMID: 26361098 DOI: 10.1016/j.surg.2015.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/26/2015] [Accepted: 08/01/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Emergency general surgery (EGS) has emerged as an important component of frontline operative care. Efforts in high-income settings have described its burden but have yet to consider low- and middle-income health care settings in which emergent conditions represent a high proportion of operative need. The objective of this study was to describe the disease spectrum of EGS conditions and associated factors among patients presenting in a low-middle income context. METHODS March 2009-April 2014 discharge data from a university teaching hospital in South Asia were obtained for patients (≥16 years) with primary International Classification of Diseases, 9(th) revision, Clinical Modification diagnosis codes consistent with an EGS condition as defined by the American Association for the Surgery of Trauma. Outcomes included in-hospital mortality and occurrence of ≥1 major complication(s). Multivariable analyses were performed, adjusting for differences in demographic and case-mix factors. RESULTS A total of 13,893 discharge records corresponded to EGS conditions. Average age was 47.2 years (±16.8, standard deviation), with a male preponderance (59.9%). The majority presented with admitting diagnoses of biliary disease (20.2%), followed by soft-tissue disorders (15.7%), hernias (14.9%), and colorectal disease (14.3%). Rates of death and complications were 2.7% and 6.6%, respectively; increasing age was an independent predictor of both. Patients in need of resuscitation (n = 225) had the greatest rates of mortality (72.9%) and complications (94.2%). CONCLUSION This study takes an important step toward quantifying outcomes and complications of EGS, providing one of the first assessments of EGS conditions using American Association for the Surgery of Trauma definitions in a low-middle income health care setting. Further efforts in varied settings are needed to promote representative benchmarking worldwide.
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Affiliation(s)
- Adil A Shah
- Department of Surgery, The Aga Khan University, Karachi, Pakistan; Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Asad Latif
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Cheryl K Zogg
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Syed Nabeel Zafar
- Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Robert Riviello
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Muhammad Sohail Halim
- Section of Critical Care, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Zia Rehman
- Department of Surgery, The Aga Khan University, Karachi, Pakistan
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Hasnain Zafar
- Department of Surgery, The Aga Khan University, Karachi, Pakistan
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Abstract
Emergency abdominal surgery has a high mortality, with an incidence of around 15% for all patients. Mortality in elderly patients is up to 25%, and 1-year mortality for emergent colorectal resection for patients over 80 years is around 50%. Patients presenting to hospital are often given low priority. Definitive surgery is not always possible and it may be more important to control the septic focus and to revisit surgery later. The literature is poor for such a common procedure, but there is evidence that a standardized pathway focusing on rapid diagnosis; resuscitation; sepsis treatment; and, if appropriate, urgent surgery followed by admission to intensive care improves outcomes.
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Affiliation(s)
- Carol Peden
- Royal United Hospital, Combe Park, Bath BA1 3NG, UK.
| | - Michael J Scott
- Department of Anesthesia and Perioperative Medicine, Royal Surrey County Hospital NHS Foundation Trust, Surrey, Guildford GU1 7XX, UK; Surrey Perioperative Anesthesia Critical Care Research Group (SPACeR), University of Surrey, Surrey, Guildford GU2 7XH, UK
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17
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Abstract
The main problem in management of elderly patients who present to the emergency department with abdominal pain is related to difficulties in establishing a diagnosis, because of frequently impaired communication as well as to unusual clinical and laboratory presentations, resulting in delayed management. Early use of pertinent imaging may reduce this delay. Surgical procedures in the elderly do not differ from those in younger patients, but their associated morbidity is different. Assessing co-morbidities and patient frailty, as well as taking into consideration the diagnosis, patients' wishes and status should help in decision-making. Therapeutic decisions should involve surgeons, anesthesiologists and geriatricians alike, both pre- and postoperatively, with the goal of optimizing patients' rehabilitation and offering good and appropriate care while ensuring the humane, social and financial aspects.
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Shakerian R, Thomson BN, Gorelik A, Hayes IP, Skandarajah AR. Outcomes in emergency general surgery following the introduction of a consultant-led unit. Br J Surg 2015; 102:1726-32. [PMID: 26492418 DOI: 10.1002/bjs.9954] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/05/2015] [Accepted: 08/27/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients presenting with emergency surgical conditions place significant demands on healthcare services globally. The need to improve emergency surgical care has led to establishment of consultant-led emergency surgery units. The aim of this study was to determine the effect of a changed model of service on outcomes. METHODS A retrospective observational study of all consecutive emergency general surgical admissions in 2009-2012 was performed. A 2-year time frame before and after the establishment of the emergency general surgery (EGS) service was used to determine the number of admissions and operations, emergency department and hospital length of stay, as well as complication rates. RESULTS The study included 7233 acute admissions. The EGS service managed 4468 patients (61·6 per cent increase) and performed 1804 operations (41·0 per cent increase). The most common diagnoses during the EGS period included acute appendicitis (532, 11·9 per cent), biliary disease (361, 8·1 per cent) and abdominal pain (561, 12·6 per cent). Appendicectomy (536, 29·7 per cent), cholecystectomy (239, 13·2 per cent) and laparotomy (226, 12·5 per cent) were the most commonly performed procedures. In the EGS period, time in the emergency department was reduced (from 8·0 to 6·0 h; P < 0·001), as was length of hospital stay (from 3·0 to 2·0 days; P < 0·001). The number of complications was reduced by 46·8 per cent, from 172 (6·2 per cent) to 147 (3·3 per cent) (P < 0·001), with a 53 per cent reduction in the number of deaths in the EGS period, from 29 (16·9 per cent) to seven (8 per cent) (P = 0·039). CONCLUSION The establishment of a consultant-led emergency surgical service has been associated with improved provision of care, resulting in timely management and improved clinical outcomes.
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Affiliation(s)
- R Shakerian
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - B N Thomson
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A Gorelik
- Melbourne EpiCentre, Centre for Clinical Epidemiology, Biostatistics and Health Services Research, (University of Melbourne and Melbourne Health), The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - I P Hayes
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
| | - A R Skandarajah
- Department of General Surgical Specialties, University of Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Victoria, Australia
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Quiney N, Huddart S, Peden C, Dickinson M. Use of a care bundle to reduce mortality following emergency laparotomy. Br J Hosp Med (Lond) 2015; 76:358-62. [DOI: 10.12968/hmed.2015.76.6.358] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- N Quiney
- Consultant in Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey GU2 7XX
| | - S Huddart
- Senior Registrar in Anaesthesia, St George's Hospital, London
| | - C Peden
- Associate Medical Director for Quality Improvement, Royal United Hospital Bath
| | - M Dickinson
- Consultant Anaesthetist, Royal Surrey County Hospital, Guildford
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20
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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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21
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Predictors of in-hospital mortality amongst octogenarians undergoing emergency general surgery: A retrospective cohort study. Int J Surg 2014; 12:1157-61. [DOI: 10.1016/j.ijsu.2014.08.404] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 06/29/2014] [Accepted: 08/26/2014] [Indexed: 11/21/2022]
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Davis P, Hayden J, Springer J, Bailey J, Molinari M, Johnson P. Prognostic factors for morbidity and mortality in elderly patients undergoing acute gastrointestinal surgery: a systematic review. Can J Surg 2014. [PMID: 24666459 DOI: 10.1503/cjs.006413] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Elderly patients undergoing acute gastrointestinal (GI) surgery experience increased morbidity and mortality compared with younger and elective patients. Prognostic factors can be used to counsel patients of these risks and, if modifiable, to minimize them. We reviewed the literature on prognostic factors for adverse outcomes in elderly patients undergoing acute GI surgery. METHODS We searched PubMed and Embase using a strategy developed in collaboration with an expert librarian. Studies examining independent associations between prognostic factors and morbidity or mortality in patients aged 65 and older undergoing acute GI surgery were selected. We extracted data using a standardized form and assessed study quality using the QUIPS tool. RESULTS Nine cohort studies representing 2958 patients satisfied our selection criteria. All studies focused on postoperative mortality. Thirty-four prognostic factors were examined, with significant variability across studies. There was limited or conflicting evidence for most prognostic factors. Meta-analysis was only possible for the American Society of Anesthesiologists (ASA) score, which was found to be associated with mortality in 4 studies (pooled odds ratio 2.77, 95% confidence interval 0.92-8.41). CONCLUSION While acute GI surgery in elderly patients is becoming increasingly common, the literature on prognostic factors for morbidity and mortality in this patient population lags behind. Further research is needed to help guide patient care and potentially improve outcomes.
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Affiliation(s)
- Philip Davis
- The Faculty of Medicine, Departments of Emergency Medicine Dalhousie University, Halifax, NS
| | - Jill Hayden
- Community Health and Epidemiology and Dalhousie University, Halifax, NS
| | - Jeremy Springer
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Jonathon Bailey
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Michele Molinari
- The Division of General Surgery, Dalhousie University, Halifax, NS
| | - Paul Johnson
- The Division of General Surgery, Dalhousie University, Halifax, NS
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Affiliation(s)
- D. Murray
- James Cook University Hospital; Middlesbrough 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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Affiliation(s)
- R T Keays
- Chelsea and Westminster Hospital, London, UK.
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Stoneham M, Murray D, Foss N. Emergency surgery: the big three - abdominal aortic aneurysm, laparotomy and hip fracture. Anaesthesia 2013; 69 Suppl 1:70-80. [DOI: 10.1111/anae.12492] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2013] [Indexed: 01/23/2023]
Affiliation(s)
- M. Stoneham
- Nuffield Division of Anaesthetics; Oxford University Hospitals NHS Trust; Oxford UK
| | - D. Murray
- James Cook University Hospital; Middlesbrough UK
| | - N. Foss
- Department of Anaesthesia; Hvidovre University Hospital; Copenhagen Denmark
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Huddart S, Peden C, Quiney N. Emergency major abdominal surgery--'the times they are a-changing'. Colorectal Dis 2013; 15:645-9. [PMID: 23795746 DOI: 10.1111/codi.12198] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- S. Huddart
- Royal Surrey County Hospital NHS Foundation Trust; Guildford; UK
| | - C. Peden
- Royal United Hospital Bath NHS Trust; Bath; UK
| | - N. Quiney
- Royal Surrey County Hospital NHS Foundation Trust; Guildford; UK
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Patel S, Lutz JM, Panchagnula U, Bansal S. Anesthesia and perioperative management of colorectal surgical patients - specific issues (part 2). J Anaesthesiol Clin Pharmacol 2012; 28:304-13. [PMID: 22869934 PMCID: PMC3409937 DOI: 10.4103/0970-9185.98321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Colorectal surgery carries significant morbidity and mortality, which is associated with an enormous use of healthcare resources. Patients with pre-existing morbidities, and those undergoing emergency colorectal surgery due to complications such as perforation, obstruction, or ischemia / infarction are at an increased risk for adverse outcomes. Fluid therapy in emergency colorectal surgical patients can be challenging as hypovolemic and septic shock may coexist. Abdominal sepsis is a serious complication and may be diagnosed during pre-, intra-, or postoperative periods. Early suspicion and recognition of medical and / or surgical complications are essential. The critical care management of complicated colorectal surgical patients require collaborative and multidisciplinary efforts.
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Affiliation(s)
- Santosh Patel
- Department of Anesthesia, The Pennine Acute NHS Trust, Rochdale and Honorary Lecturer, School of Biomedicine, University of Manchester, United Kingdom
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Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth 2012; 109:368-75. [PMID: 22728205 DOI: 10.1093/bja/aes165] [Citation(s) in RCA: 267] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Emergency laparotomy is a common intra-abdominal procedure. Outcomes are generally recognized to be poor, but there is a paucity of hard UK data, and reports have mainly been confined to single-centre studies. METHODS Clinicians were invited to join an 'Emergency Laparotomy Network' and to collect prospective non-risk-adjusted outcome data from a large number of NHS Trusts providing emergency surgical care. Data concerning what were considered to be key aspects of perioperative care, including thirty-day mortality, were collected over a 3 month period. RESULTS Data from 1853 patients were collected from 35 NHS hospitals. The unadjusted 30 day mortality was 14.9% for all patients and 24.4% in patients aged 80 or over. There was a wide variation between units in terms of the proportion of cases subject to key interventions that may affect outcomes. The presence of a consultant surgeon in theatre varied between 40.6% and 100% of cases, while a consultant anaesthetist was present in theatre for 25-100% of cases. Goal-directed fluid management was used in 0-63% of cases. Between 0% and 68.9% of the patients returned to the ward (level one) after surgery, and between 9.7% and 87.5% were admitted to intensive care (level three). Mortality rates varied from 3.6% to 41.7%. CONCLUSIONS This study confirms that emergency laparotomy in the UK carries a high mortality. The variation in clinical management and outcomes indicates the need for a national quality improvement programme.
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Affiliation(s)
- D I Saunders
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK
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Shapter SL, Paul MJ, White SM. Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 2012; 67:474-478. [PMID: 22493955 DOI: 10.1111/j.1365-2044.2011.07046.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Significant recent interest has focussed on improving outcomes after emergency laparotomy. This retrospective database analysis estimated the annual incidence and associated inpatient costs of emergency laparotomy in England. Demographic, process and outcome data were collected for all patients undergoing emergency laparotomy in Brighton for two calendar years (2009-2010). Cost analysis assumed £16 per minute theatre time, and £282 per day ward bed and £1382 per day critical care bed costs. National incidence was confirmed from Hospital Episode Statistics and Office of National Statistics mid-year population data. In total, 768 patients underwent 850 emergency laparotomies. The incidence of emergency laparotomy was estimated as ∼1:1100 population. Thirty-six percent (276 patients) were admitted for a median (IQR [range]) of 5 (3-11 [1-76]) days of critical care. Postoperative median (IQR [range]) length of stay was 13 (8-24 [1-176]) days. Our estimated annual inpatient cost of emergency laparotomy for Brighton was ∼£5 million, equivalent to ∼£13 000 per patient, and for England, an annual estimated cost of ∼£650 million. However, 'Payment by Results' reimbursement amounted to a mean (SD) hospital income of just £6905 (2639) per patient, a net financial loss of ∼£6100 per patient, equivalent to a reimbursement shortfall nationally of ∼£300 million. We also found that patients > 70 years (46%) had significantly higher 30-day postoperative mortality (18% vs 6%, p < 0.0001), significantly prolonged median (IQR [range]) length of stay (15 (10-26 [1-123]) days vs 12 (7-22 [1-176]) days, p < 0.001) and incurred higher costs (median (IQR [range]) £9667 (6620-15 732 [1920-103 624]) vs £7467 (4975-14 251 [1178-118 060]), p < 0.001). Emergency laparotomy is a common procedure associated with considerable cost, particularly among elderly patients. A National Emergency Laparotomy Database will help provide an evidence base on which to improve clinical outcome and cost efficiency.
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Affiliation(s)
- S L Shapter
- Royal Sussex County Hospital, Brighton, East Sussex, UK
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