Risk prediction models in emergency surgery: Protocol for a scoping review

BACKGROUND

Risk prediction models are used for many purposes in emergency surgery, including critical care triage and benchmarking. Several risk prediction models have been developed, and some are used for purposes other than those for which they were developed. We aim to provide an overview of the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps.

METHODS

We will conduct a scoping review on risk prediction models used for patients undergoing emergency surgery in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We will search Medline, EMBASE, and the Cochrane Library and include all study designs. We aim to answer the following questions: (1) What risk prediction models are used in emergency surgery? (2) Which variables are used in these models? (3) Which surgical specialties are the models used for? (4) Have the models been externally validated? (5) Where have the models been externally validated? (6) What purposes were the models developed for? (7) What are the strengths and limitations of the included models? We will summarize the results descriptively. The certainty of evidence will be evaluated using a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

CONCLUSION

The outlined scoping review will summarize the existing literature on risk prediction models used in emergency surgery and highlight knowledge gaps.

Perioperative Atrial Fibrillation and One-year Clinical Outcomes in Patients Following Major Emergency Abdominal Surgery

The prevalence and impact of perioperative atrial fibrillation (AF) during an admission for major emergency abdominal surgery are sparsely examined. Therefore, this study aimed to compare the 30-day and 1-year outcomes (AF-related hospitalization, stroke, and all-cause mortality) in patients with and without perioperative AF to their major emergency abdominal surgery. All patients without a history of AF who underwent major emergency abdominal surgery from 2000 to 2019 and discharged alive were identified using Danish nationwide registries. Patients with and without perioperative AF (defined as new-onset AF during the index hospitalization) were matched 1:4 on age, gender, year of surgery, and type of surgery. The cumulative incidences and hazard ratios of outcomes were assessed using a multivariable Cox regression analysis comparing patients with and without perioperative AF. A total of 2% of patients were diagnosed with perioperative AF. The matched cohort comprised 792 and 3,168 patients with and without perioperative AF, respectively (median age 78 years [twenty-fifth to seventy-fifth percentile 70 to 83 years]; 43% men). Cumulative incidences of AF-related hospitalizations, stroke, and mortality 1 year after discharge were 30% versus 3.4%, 3.4% versus 2.7%, and 35% versus 22% in patients with and without perioperative AF, respectively. The 30-day outcomes were similarly elevated among patients with perioperative AF. Perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and mortality and similar rates of stroke. These findings suggest that perioperative AF is a prognostic marker of increased morbidity and mortality in relation to major emergency abdominal surgery and warrants further investigation.

Training programmes for healthcare professionals in managing postoperative epidural analgesia: A scoping review protocol

BACKGROUND

Epidural analgesia is an effective technique advocated worldwide for postoperative analgesia after a wide range of surgical procedures. Despite the benefits of epidural analgesia for pain management, systematic education of ward nurses in managing epidural analgesia appears to be lacking.

METHODS

The aim of the proposed scoping review is to map the body of evidence and identify training programmes for healthcare professionals in the safe management of postoperative epidural analgesia. The methodology will follow the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). In addition, the five main steps set forth by Arksey and O'Malley and refined by Levac for guidance of the process will be used. The scoping review will include any study design of any date, design, setting and duration.

RESULTS

We will present results descriptively, accompanied with visual presentations as tables and graphs.

CONCLUSION

The outlined scoping review will provide an overview of existing training programmes for healthcare professionals in the safe management of postoperative epidural analgesia and map the body of available evidence on the topic. The study may support the development of a training programme for ward nurses caring for patients receiving postoperative epidural analgesia.

Validation of the NELA risk prediction model in emergency abdominal surgery

Risk prediction models are frequently used to identify high-risk patients undergoing emergency laparotomy. The National Emergency Laparotomy Audit (NELA) developed a risk prediction model specifically for emergency laparotomy patients, which was recently updated. In this study, we validated the updated NELA model in an external population. Furthermore, we compared it with three other risk prediction models: the original NELA model, the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) model, and the American Society of Anesthesiologists Physical Status (ASA-PS). We included adult patients undergoing emergency laparotomy at Zealand University Hospital, from March 2017 to January 2019, and Herlev Hospital, from November 2017 to January 2020. Variables included in the risk prediction models were collected retrospectively from the electronic patient records. Discrimination of the risk prediction models was evaluated with area under the curve (AUC) statistics, and calibration was assessed with Cox calibration regression. The primary outcome was 30-day mortality. Out of 1226 included patients, 146 patients (11.9%) died within 30 days. AUC (95% confidence interval) for 30-day mortality was 0.85 (0.82-0.88) for the updated NELA model, 0.84 (0.81-0.87) for the original NELA model, 0.81 (0.77-0.84) for the P-POSSUM model, and 0.76 (0.72-0.79) for the ASA-PS model. Calibration showed underestimation of mortality risk for both the updated NELA, original NELA and P-POSSUM models. The updated NELA risk prediction model performs well in this external validation study and may be used in similar settings. However, the model should only be used to discriminate between low- and high-risk patients, and not for prediction of individual risk due to underestimation of mortality.

Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA): A consortium initiative for perioperative research

Evidence in perioperative care is insufficient. There is an urgent need for large perioperative research programmes, including pragmatic randomised trials, testing daily clinical treatments and unanswered question, thereby providing solid evidence for effects of interventions given to a large and growing number of patients undergoing surgery and anaesthesia. This may be achieved through large collaborations. Collaboration for Evidence-based Practice and Research in Anaesthesia (CEPRA) is a novel collaborative research network founded to pursue evidence-based answers to major clinical questions in perioperative medicine. The aims of CEPRA are to (1) improve clinical treatment and outcomes and optimise the use of resources for patients undergoing anaesthesia and perioperative care, and (2) disseminate results and inform caretakers, patients and relatives, and policymakers of evidence-based treatments in anaesthesia and perioperative medicine. CEPRA is inclusive in its concept. We aim to extend our collaboration with all relevant clinical collaborators and patient associations and representatives. Although initiated in Denmark, CEPRA seeks to develop an international network infrastructure, for example, with other Nordic countries. The work of CEPRA will follow the highest methodological standards. The organisation aims to structure and optimise any element of the research collaboration to reduce economic costs and harness benefits from well-functioning research infrastructure. This includes successive continuation of trials, harmonisation of outcomes, and alignment of data management systems. This paper presents the initiation and visions of the CEPRA network. CEPRA aims to be inclusive, patient-focused, methodologically sound, and to optimise all aspects of research logistics. This will translate into faster research conduct, reliable results, and accelerated clinical implementation of results, thereby benefiting millions of patients whilst being cost and labour-saving.

Intra-operative blood transfusion in elderly patients on antithrombotic therapy

BACKGROUND

Many elderly patients are receiving antithrombotics, which may increase intra-operative blood loss. We aimed to assess whether chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in patients at least 80 years of age undergoing elective procedures.

METHODS

We performed a secondary analysis of the prospective, observational European multicentre study entitled POSE (peri-interventional outcome study in the elderly) including 9497 surgical patients aged 80 years and older in 177 centres from October 2017 to December 2018. In this secondary analysis we included POSE patients who underwent elective procedures and with available data on chronic antithrombotic therapy. The primary outcome was intra-operative transfusion of packed red blood cells and results were analysed using multiple logistic regression model. We adjusted for the following predetermined explanatory variables: Age, sex, body mass index, American Society of Anaesthesiologists Physical Status Classification System, baseline haemoglobin concentration, disseminated cancer, and type and severity of surgery.

RESULTS

A total of 7174 patients were included of whom 4073 (56.8%) were on antithrombotic therapy. Among patients on antithrombotic therapy 191 (4.7%) received intra-operative blood transfusion compared with 98 (3.2%) of patients not on chronic antithrombotic therapy (crude odds ratio: 1.51, 95% CI 1.18-1.94). Following multiple logistic regression analysis, the adjusted odds ratio was 0.98; 0.73-1.32. We found that chronic antithrombotic therapy was associated with intra-operative transfusion of packed red blood cells in elderly patients undergoing elective procedures in an unadjusted analysis, but not in a multivariate adjusted model.

Use of vasoactive agents in non-cardiac surgery: Protocol for a scoping review

BACKGROUND

An increasing number of patients undergo surgical procedures worldwide each year, and despite advances in quality and care, morbidity and mortality rates remain high. Perioperative hypotension is a well-described condition, and is associated with adverse outcomes. Both fluids and vasoactive agents are commonly used to treat hypotension, however, whether one vasoactive agent is preferable over another has yet to be explored.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement, we plan to conduct a scoping review of studies assessing the use of vasoactive agents in patients undergoing non-cardiac surgery. We will provide an overview of indications, agents used and outcomes assessed. We will assess and report the certainty of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

We will provide descriptive analyses of the included studies accompanied by tabulated results.

CONCLUSION

The outlined scoping review will provide a summary of the body of evidence on the use of vasoactive agents in the non-cardiac surgical population.

Rehospitalizations, repeated aortic surgery, and death in initial survivors of surgery for Stanford type A aortic dissection and the significance of age – a nationwide registry-based cohort study

Background

All patients with type A aortic dissections, regardless of age, are recommended urgent aortic surgery. However, studies exploring long term outcomes in survivors are sparse, and especially, the significance of age on long-term outcomes remain unclear.

Purpose

We described and compared incidences across age groups of post-discharge readmission, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection.

Methods

Using data from Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections from 2006–2018. Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (Figure 1). Using cumulative incidence plots taking death into account as a competing risk and Cox regression analysis, we described long-term outcomes (rehospitalizations, repeated aortic surgery, and death) and compared different age groups. The diagnosis of type A aortic dissection in the registries used, was validated from 191 clinical records to have a positive predictive value of 94.8%.

Results

Of 606 initial survivors of surgery and hospitalization with type A aortic dissection, 236 (38.9%) were <60 years old (group I), 194 (32.0%) were 60–69 years old (group II), and 176 (29.1%) were >69 years old (group III). Figure 2 shows cumulative incidences of outcomes according to age. During the first year, 62.5% were re-hospitalized (median number of days hospitalized was 2 days (IQR 1–8 days) and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P=0.68 and P=0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P=0.04). After 10 years of follow up, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P=0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P=0.01). In adjusted analyses, no age differences were found in one-year outcomes, while age >69 years (group III) compared with age <60 years (group I) was associated with a lower rate of repeated aortic surgery (hazard ratio 0.17, 95% confidence interval 0.04–0.78) and a higher rate of all-cause mortality (hazard ratio 2.44, 95% confidence interval 1.37–4.34) in the 10-years analysis.

Conclusion

Among survivors of type A aortic dissections, rehospitalizations the first year after discharge were common among all age groups, but survival was high. Repeated aortic surgery was rare, and significantly more common among younger than older patients. Evaluations of quality of life in survivors of type A aortic dissections are needed.

Funding Acknowledgement

Type of funding sources: None.

Perioperative atrial fibrillation in major emergency abdominal surgery: does it affect postoperative outcome?

Background

Atrial fibrillation (AF) in relation to surgery remains a clinical challenge. Major emergency abdominal surgery (e.g. ileus, perforation) is associated with postoperative complications and mortality. However, the prevalence and impact of perioperative AF in this setting is not well examined.

Purpose

We compared 30-days and 1-year outcomes (i.e. hospitalization of any causes, AF-related hospitalization, thromboembolic events and all-cause mortality) in patients who did and did not develop perioperative AF (POAF) in relation to their major emergency abdominal surgery.

Methods

We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000–2018) and discharged alive. Patients who developed POAF during hospitalization were matched in a 1:3 ratio on age, sex, year of surgery and category of surgery with those without POAF. Starting follow up at discharge, we examined the rates of outcomes at 30-days and 1-year post-discharge. The cumulative incidences and ratios of outcomes were assessed with the Aalen Johanson estimator together with Kaplan-Meier estimator and multivariable Cox regression analysis, respectively.

Results

We identified 891 patients with POAF and 64,914 patients without POAF. The matched cohort were composed of 889 patients with POAF and 2667 patients without POAF with a median age of 79 years [25th-75th percentile; 72–84 years] and 45.2% males. In general, patients with POAF had higher comorbid burden compared with patients without POAF. The cumulative incidences of a hospitalization of any cause after 30-days post-discharge were 31.2% and 22.3% in patients with and without POAF, respectively. The corresponding numbers for AF-related hospitalization were 20.8% and 1.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of hospitalization of any causes together with AF-related hospitalization (Figure 1 and 2).

The cumulative incidences of a thromboembolic event after 30-days post-discharge were 2.2% and 0.9% in patients with and without POAF, respectively. The corresponding numbers for all-cause mortality were 9.7% and 3.2%, respectively. In adjusted analyses, POAF was associated with a significantly higher risk of a thromboembolic event together with all-cause mortality within 30-days of follow up as well as 1-year of follow up. However, the results regarding thromboembolic events did not reach statistical significance after 1-year of follow up (Figure 1 and 2).

Conclusions

Perioperative atrial fibrillation in relation to major emergency abdominal surgery was associated with higher 30-days and 1-year rates of hospitalizations of any causes, atrial fibrillation related hospitalization, a thromboembolic event and all-cause mortality. These findings suggest that perioperative atrial fibrillation is a strong prognostic marker of increased morbidity following major emergency abdominal surgery.

Funding Acknowledgement

Type of funding sources: None.

Rehospitalizations, repeated aortic surgery, and death in initial survivors of surgery for Stanford type A aortic dissection and the significance of age - a nationwide registry-based cohort study

AIMS

Describe and compare incidences across age groups of rehospitalization, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection.

METHODS AND RESULTS

From Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections (2006-2018). Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (n = 606, 36 (38.9%) <60 years old (group I), 194 (32.0%) 60-69 years old (group II), and 176 (29.1%) >69 years old (group III)). During the first year, 62.5% were re-hospitalized and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P = 0.68 and P = 0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P = 0.04). After 10 years, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P = 0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P = 0.01). Using multivariable Cox regression analysis, we described long-term outcomes comparing age groups. No age differences were found in one-year outcomes, while age > 69 years compared with age < 60 years was associated with a lower rate of repeated aortic surgery (hazard ratio 0.17, 95% confidence interval 0.04-0.78) and a higher rate of all-cause mortality (hazard ratio 2.44, 95% confidence interval 1.37-4.34) in the 10-years analyses.

CONCLUSIONS

Rehospitalizations the first year after discharge were common in all age groups, but survival was high. Repeated aortic surgery was significantly more common among younger than older patients.

The prognostic value of surgical delay in patients undergoing major emergency abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used.

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible.

RESULTS

Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score.

CONCLUSION

Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.

Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study

OBJECTIVE

In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general.

MATERIAL AND METHODS

All in-patients aged ≥ 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression.

RESULTS

A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding.

CONCLUSIONS

In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.

Randomized multicentre feasibility trial of intermediate care versus standard ward care after emergency abdominal surgery (InCare trial)

Background

Emergency abdominal surgery carries a considerable risk of death and postoperative complications. Early detection and timely management of complications may reduce mortality. The aim was to evaluate the effect and feasibility of intermediate care compared with standard ward care in patients who had emergency abdominal surgery.

Methods

This was a randomized clinical trial carried out in seven Danish hospitals. Eligible for inclusion were patients with an Acute Physiology And Chronic Health Evaluation (APACHE) II score of at least 10 who were ready to be transferred to the surgical ward within 24 h of emergency abdominal surgery. Participants were randomized to either intermediate care or standard surgical ward care after surgery. The primary outcome was 30-day mortality.

Results

In total, 286 patients were included in the modified intention-to-treat analysis. The trial was terminated after the interim analysis owing to slow recruitment and a lower than expected mortality rate. Eleven (7·6 per cent) of 144 patients assigned to intermediate care and 12 (8·5 per cent) of 142 patients assigned to ward care died within 30 days of surgery (odds ratio 0·91, 95 per cent c.i. 0·38 to 2·16; P = 0·828). Thirty (20·8 per cent) of 144 patients assigned to intermediate care and 37 (26·1 per cent) of 142 assigned to ward care died within the total observation period (hazard ratio 0·78, 95 per cent c.i. 0·48 to 1·26; P = 0·310).

Conclusion

Postoperative intermediate care had no statistically significant effect on 30-day mortality after emergency abdominal surgery, nor any effect on secondary outcomes. The trial was stopped prematurely owing to slow recruitment and a much lower than expected mortality rate among the enrolled patients. Registration number: NCT01209663 (http://www.clinicaltrials.gov).

Patients' experiences of postoperative intermediate care and standard surgical ward care after emergency abdominal surgery: a qualitative sub-study of the Incare trial

AIMS AND OBJECTIVES

To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery.

BACKGROUND

Emergency abdominal surgery is common, but little is known about how patients experience postoperative care. The patient population is generally older with multiple comorbidities, and the short-term postoperative mortality rate is 15-20%. Thus, vigilant surgeon and nursing attention is essential. The present study is a qualitative sub-study of a randomised trial evaluating postoperative intermediate care after emergency abdominal surgery, the InCare trial.

DESIGN

A qualitative study with individual semi-structured interviews.

METHODS

We analysed interviews using Systematic Text Condensation.

RESULTS

Eighteen patients (nine intervention/nine controls) were strategically sampled from the InCare trial. Data analysis resulted in three distinct descriptions of intermediate care; two of standard surgical ward care. Intermediate care was described as 'luxury service' or 'a life saver.' The latter description was prevalent among patients with a perceived complicated disease course. Intermediate care patients felt constrained by continuous monitoring of vital signs as they recovered from surgery. Standard surgical ward care was described as either 'ok - no more, no less' or 'suboptimal'. Experiencing suboptimal care was related to patient perceptions of heavy staff workloads, lack of staff availability and subsequent concerns about the quality of care.

CONCLUSION

Postoperative intermediate care enhanced perceptions of quality of care, specifically in patients with a perceived complicated disease course. Patients were eager to contribute actively to their recovery; however, intermediate care patients felt hindered in doing so by continuous monitoring of vital signs.

RELEVANCE TO CLINICAL PRACTICE

Intermediate care may increase patient perceptions of quality and safety of care.

Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study

BACKGROUND

Emergency major gastrointestinal (GI) surgery carries a considerable risk of mortality and postoperative complications. Effective management of complications and appropriate organization of postoperative care may improve outcome. The importance of the latter is poorly described in emergency GI surgical patients. We aimed to present mortality data and evaluate the postoperative care pathways used after emergency GI surgery.

METHODS

A population-based cohort study with prospectively collected data from six Capital Region hospitals in Denmark. We included 2904 patients undergoing major GI laparotomy or laparoscopy surgery between January 1, 2009, and December 31, 2010. The primary outcome measure was 30 day mortality.

RESULTS

A total of 538 patients [18.5%, 95% confidence interval (CI): 17.1-19.9] died within 30 days of surgery. In all, 84.2% of the patients were treated after operation in the standard ward, with a 30 day mortality of 14.3%, and 4.8% were admitted to the intensive care unit (ICU) after a median stay of 2 days (inter-quartile range: 1-6). When compared with 'admission to standard ward', 'admission to standard ward before ICU admission' and 'ICU admission after surgery' were independently associated with 30 day mortality; odds ratio 5.45 (95% CI: 3.48-8.56) and 3.27 (95% CI: 2.45-4.36), respectively.

CONCLUSIONS

Mortality in emergency major GI surgical patients remains high. Failure to allocate patients to the appropriate level of care immediately after surgery may contribute to the high postoperative mortality. Future research should focus on improving risk stratification and evaluating the effect of different postoperative care pathways in emergency GI surgery.

Surgical delay is a critical determinant of survival in perforated peptic ulcer

Background

Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. Surgical delay is a well established negative prognostic factor, but evidence derives from studies with a high risk of bias. The aim of the present nationwide cohort study was to evaluate the adjusted effect of hourly surgical delay on survival after PPU.

Methods

This was a cohort study including all Danish patients treated surgically for PPU between 1 February 2003 and 31 August 2009. Medically treated patients and those with a malignant ulcer were excluded. The associations between surgical delay and 30-day survival are presented as crude and adjusted relative risks (RRs) with 95 per cent confidence intervals (c.i.).

Results

A total of 2668 patients were included. Their median age was 70·9 (range 16·2–104·2) years and 55·4 per cent (1478 of 2668) were female. Some 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases and 45·6 per cent had an American Society of Anesthesiologists fitness grade of III or more. A total of 708 patients (26·5 per cent) died within 30 days of surgery. Every hour of delay from admission to surgery was associated with an adjusted 2·4 per cent decreased probability of survival compared with the previous hour (adjusted RR 1·024, 95 per cent c.i. 1·011 to 1·037).

Conclusion

Limiting surgical delay in patients with PPU seems of paramount importance.

Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial

Background

Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients.

Methods and design

The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power.

Discussion

This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care.

Trial registration

Clinicaltrials.gov identifier: NCT01209663

Long-term mortality following peptic ulcer perforation in the PULP trial. A nationwide follow-up study

OBJECTIVE

Morbidity and mortality following perforated peptic ulcer (PPU) remain substantial. In the recently published PULP trial, 30-day mortality in patients surgically treated for PPU decreased from 27% to 17% following the implementation of a perioperative care protocol based on The Surviving Sepsis Guidelines. The objective of the present study was to evaluate long-term mortality in the PULP trial intervention and control cohort.

DESIGN

nationwide follow-up study of a multicenter, non-randomized, clinical trial with external controls.

SETTING

Danish patients surgically treated for PPU between 1 January 2008 and 31 December 2009.

PATIENTS

117 patients in the intervention group and 512 in the control group.

INTERVENTION

a perioperative care protocol based on The Surviving Sepsis Guidelines.

OUTCOME MEASURES

60-day, 90-day, 180-day, 1-year, and 2-year mortality rates.

STATISTICAL ANALYSIS

survival statistics.

RESULTS

Baseline characteristics, clinical, and perioperative data were in general, similar in the intervention and control group. Sixty days postoperatively, the originally observed difference in 30-day mortality had diminished (25% vs. 30%, p = 0.268). After 180 days, the mortality difference was reduced additionally (31% vs. 33%, p = 0.645), and one year postoperatively, a mortality difference was no longer present (36% in both groups, p = 0.993). Two years postoperatively, the mortality rate in the intervention group was 44%, as compared to 40% in the control group (p = 0.472).

CONCLUSIONS

The survival benefit associated with a perioperative care protocol in patients treated for PPU decreases progressively after 30 days and is no longer present after one year.

REGISTRATION NUMBER

NCT00624169 ( http://www.clinicaltrials.gov ).

Accuracy of clinical prediction rules in peptic ulcer perforation: an observational study

OBJECTIVE

The aim of the present study was to compare the ability of four clinical prediction rules to predict adverse outcome in perforated peptic ulcer (PPU): the Boey score, the American Society of Anesthesiologists (ASA) score, the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and the sepsis score.

DESIGN

an observational multicenter study.

PARTICIPANTS AND SETTINGS

a total of 117 patients surgically treated for PPU between 1 January 2008 and 31 December 2009 in seven gastrointestinal departments in Denmark were included. Pregnant and breastfeeding women, non-surgically treated patients, patients with malignant ulcers, and patients with perforation of other organs were excluded.

PRIMARY OUTCOME MEASURE

30-day mortality rate.

STATISTICAL ANALYSIS

the ability of four clinical prediction rules to distinguish survivors from non-survivors (discrimination ability) was evaluated by the area under the receiver operating characteristic curve (AUC), positive predictive values (PPVs), negative predictive values (NPVs), and adjusted relative risks.

RESULTS

Median age (range) was 70 years (25-92 years), 51% of the patients were females, and 73% of the patients had at least one co-existing disease. The 30-day mortality proportion was 17% (20/117). The AUCs: the Boey score, 0.63; the sepsis score, 0.69; the ASA score, 0.73; and the APACHE II score, 0.76. Overall, the PPVs of all four prediction rules were low and the NPVs high.

CONCLUSIONS

The Boey score, the ASA score, the APACHE II score, and the sepsis score predict mortality poorly in patients with PPU.

Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients

The modified Mallampati score is used to predict difficult tracheal intubation. We have conducted a meta-analysis of published studies to evaluate the Mallampati score as a prognostic test. A total of 55 studies involving 177 088 patients were included after comprehensive electronic and manual searches. The pooled estimates from the meta-analyses were calculated based on a random-effects model and a summary receiver operating curve. Meta-regression analyses were performed to explore sources of possible heterogeneity between the studies. The summary receiver operating curve demonstrated an area under the curve of 0.75. The pooled odds ratio for a difficult intubation with a modified Mallampati score of III or IV was 5.89 [95% confidence interval (CI), 4.74-7.32]. The pooled estimates of the specificity and sensitivity were 0.91 (CI, 0.91-0.91) and 0.35 (CI, 0.34-0.36), respectively. The pooled positive and negative likelihood ratios were 4.13 (CI, 3.60-4.66) and 0.70 (CI, 0.65-0.75), respectively. The meta-analyses had statistical and clinical heterogeneity ranging from 87.2% to 99.4%. Meta-regression analyses did not identify any significant explanation of the heterogeneity. We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.