acute high-risk abdominal surgery improving outcome
TRANSCRIPT
Acute high-risk abdominal surgery –
improving outcome through organizational changes of patient
pathwayNicolai Bang Foss, MD, DMSc
Head of GI & orthopaedic anaesthesiaassociate professor
Department of Anaesthesiology Hvidovre University HospitalCopenhagen, Denmark
Laparotomy or -scopy except appendectomy,
cholescystectomy or diagnostic
Emergency elderly surgical
patients
The Cindarellas of surgery?
Hip fractures: 10% 30-day mortality
Emergency laparotomy:
15-40% 30 day mortality
in the elderly
Danish NIP database
Clarke, Eur j anaesth 2011
Traditional care for elderly emergency patients
Delay for surgery – logistics
Prolonged fasting /NPO
Medical optimization – badly defined
Perioperative resuscitation lacking
Opioid pain management – if any
HDU/ICU restricted capacity
Prolonged immobilization
Absence of multidisciplinary care
Challenges in optimizing
perioperative pathway
Triage for surgery – palliative care?
Optimized logistics to minimize surgical delay
Preoperative observation / HDU / ICU
Preoperative optimization – AB / Fluids/flow / analgesia
Specialists in theater
Intra/perioperative flow optimization – Fluids / inotropics
Triage postoperative observation / HDU / ICU / PACU
Postoperative optimization – Fluids/flow / analgesia
Specialized wards
Mobilization
Nutrition
Multidisciplinary team (surgeon/anaesthesia/geriatrics)
Proposed multidisciplinary
perioperative care in emergency
surgery in the elderly
Specialist involvement in care
Admission
to surgery
Surgery
Postoperative phase
stable organ function
Rehabilitation
to discharge
Anaesthesiologists
Geriatricians
Surgeons and nurses
Physiotherapists
Surgery
Reoperations ≤ 6 months account for 27% of overall
hospitalization time
Foss. Injury 2006
New algorithm for surgical procedure and supervision
Reoperation rate Before After p
Number of patients 1000 1000
Reoperation rate 18% 12% 0.001
Estimated saved beddays : 890
Palm. Acta Orthop 2012
AHA-project
Optimized pathway for Acute High-risk
Abdominal Surgery
Tengberg BJS 2017
AHA definition
AKUT Acute
HØJRISIKO High-risk
ABDOMINAL-KIRURGISK Abdominal surgery
= ”AHA”
Perforated viscus
Intestinal obstruction
Gut ischaemia
Intraabdominal bleeding
Both primary surgery and reoperations
after elective surgery
30 day
mortality
DK > 20%
• 4 hospitals: BBH, HEH, HVH, HiH
• 1.6 million inhabitants
• 1139 AHA patients in a year
AHA surgery Greater Copenhagen 2012
AHA surgery Region Hovedstaden 2012
• 71%
Complications
• 47%
Serious (CDC>2)
• 25%
ICU at some point
Tengberg Anaesthesia 2017
Complications
•Pulmonary: 19.3%
•Cardiac: 8.3%
Tengberg Anaesthesia 2017
- complications
All patients
+ complications
30 day mortality:
•20%
1 year mortality:
•34%
Complication associated
w long term mortality
AHA Surgery Region Hovedstaden 2012
Tengberg Anaesthesia 2017
• Patients physiologic
derangement and potential
catastrophy defines the
population rather than the
individual surgical pathology or
procedure
Southern Copenhagen
730 beds
5500 staff
83.000 admission/y
12 ICU beds
Largest GI surgical dept. In
Denmark
”general GI surgery”
No thoracic or liver surgery
AHA Intervention:Common language: ”AHA” – focus
Continuous education: All staff groups in surgery, anaesthesia, ER and radiology
Optimized diagnostic logistics: CT abdomen
Early antibiotics: Administered on suspicion of pathology
Perioperative perfusion optimization: SV guided fluid and inotropic therapy
preop and 24 hrs postoperatively
Standardized anaesthesia: TIVA + Epidural - epi from preop – 3 days postop
Preventive perioperative intermediary therapy: triage for 24 h obligatory care in PACU
Standardized care plans on surgical wards (physiotherapy)
Decisions and handling on consultant level
Suspected pathology
AHA pathway
PACU/HDU
Oxygen / sat > 94%
Ringer 1000 ml
High dose Antibiotics
NG tube
PACU/HDU
If ASA 3-4 or APGAR 0-5
- minimum 24 hours stay
Abdominal CT < 2 hours
Admittance papers
OR advised
Conference
between senior
surgeon and
anaesthetist - triage
CT
If diagnostics
indicated
Patient taken to
specialized ward
Standardized
care
Surgery < 6 hoursGDT : SV / SVV
pulsecontour
analysis
Perioperatively
Until 24 hrs
postop
Epidural catheter
Arterial line
Intervention
• High level of monitoring
• High level staff
• Focus on time and resuscitation
• Complication prevention
• Joint venture
AHA study: Design
2 predefined cohorts
Interventions: AHA as standard
600 consecutive patients from june 2013
Vs
Historic control:
600 consecutive patients from january 2011
At Hvidovre, Gastroenheden, Denmarks biggest GI dept.
Tengberg BJS 2017
Inclusion in analysis
All patients surgically treated at the hospital
included in analysis regardless of actual
perioperative treatment given
Control Interventio
n
n
Age (median)
600
68
600
68
ASA>2 274 242
WHO/Zubrod score >1 (%) 121 156
Pathology
Perforation
obstruction
Other
236
284
80
233
274
93
Cardiovascular
comorbidity
289 283
Pulmonary comorbidity 108 114
Laparoscopic surgery 53 87
Peritonitis 225 216
Comparative comorbidity
Tengberg BJS 2017
Mortality
Control
n=600
AHA
n=600
30 day (%) 131 (21.8) 93 (15.5) 0.005
180 day (%) 177 (29.5) 133 (22.2) 0.004Adjusted mortality risk
AHA: 0.56 (0.39-0.82)
Adjusted for age, ASA, Zubrod, malignancy,
perforation/obstruction, laparocopic surgery
Tengberg BJS 2017
Length of stay
Hospital
Control
10
n=131
AHA
11 ns
n=146
ICU-LOS 5 3 p=0.02
AHA-project:
Breaking a trend at Hvidovre
Perioperative immobilization
PainPONV Hypovolaemia
Muscle
wasting
Anaemia
Thromboembolic
complications
Respiratory
complications
Pressure
ulcers
Fatigue
Sedation
Immobilization
Postoperative functional performance
•Thigh-worn accelerometer: ActivPAL
50 patients, mean age 61 y
Primarily restricting factors
•Pain, Motor blockade, Dizziness, Exhaustion, Nausea and vomiting, Acute
cognitive dysfunction, Respiratory problems, Unconscious, Patient declines,
Logistics, Monitoring equipment, Other.
Functional performance following
emergency high-risk abdominal surgery
– a prospective cohort study
Results
Dependent in mob. Independently mob.Median (25-75%) Median (25-75%) p-value
Sit/Lie (h)
Day 2 23.94 (23.80-23.99) 22.51 (22.33-23.25) <0.001
Day 4 23.96 (23.70-23.99) 22.69 (21.20-23.18) <0.001
Day 7 23.81 (23.50-23.95) 22.52 (21.60-23.36) <0.001
Stand/steps (h)
Day 2 0.06 (0.01-0.20) 1.49 (0.75-1.66) <0.001
Day 4 0.04 (0.01-0.31) 1.31 (0.82-2.80) <0.001
Day 7 0.19 (0.05-0.51) 1.49 (0.64-2.41) <0.001
Patients were in bed or sitting approximately 23
hours and 30 minutes each day during the first week
Results
Factors restricting mobilization for
patients not independently mobilized
Day 2 Day 4 Day 7
How is life in the elderly after
major abdominal emergency
surgery???
Prospective, consecutive cohort
Patients & relatives
Interview & questionnaire
52 elderly patients
1 week + 6 months after surgery
Tengberg Dan med J 2017
1 week postoperative interview
”Hvad do you recall from the time before the surgery?”
Pain - 52%
”Did you consider refusing surgery?”
7 %
”Do you recall being asked about your wishes in regards to”:
- Resuscitation in the case of cardiac arrest?
- Intensive care or respirator treatment?
Yes / 14 %
6 months postoperatively questionnaire:
Status at preoperative admission: 91% from own home
No patients from nursing homes alive at 6 months!
”How do you assess your overall quality of life after the surgery”
”Good” / 75%
”Would you agree to have similar surgery again if your life depended on it”
Yes / 73%
6 months postop.; Are you active and about > ½ the day
- 100%
Knowledge
ImplementationLogistics
Training
Outcome
Implementation time line
Analyse
Teach
Staggered implementation
Frontline leadership
Re-analyse
Adapt
Teach
Cultural change
Document
Actioncards stating
intent and overall plan
-Overall plan and flowchart – perioperative
-Surgical actioncard
-Surgical – Radiological collaboration
agreement
-Anaesthesia preop actioncard
-Anaesthesia standard plan
-Triage decision chart postop.
-Postop. Ward care plan
Triage timeline!
Futile surgery?
Preop. Optimization?
Where to postop.
Ward/HDU/ICU
When to step down?
Diagnostic triage
Knowledge
ImplementationLogistics
Training
Outcome