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Emergency ERAS
Folke HammarqvistPF Emergency Surgery
Karolinska University Hospital Huddinge
Is emergency Surgery a Ballot? – Whotakes the risk??
Routines and communication
4
Bukaortaaneurysm
Ileus
Abscess
Salpingit
Invagination
Pancreatit
Ulcus
DiverticulitAppendicit
Malignitet Volvulus
Tarmischemi Blödning
Njursten
Cholecystit
X
Perforation
Akuta diagnoser
Njurinfarkt Choledochussten
UVI
GBP
Ovarialtorsion
Emergency Surgery
Gaius PetroniusKejsar Neros rådgivare vad gäller lyx och extravagans.
Hans inofficiella titel var arbiter elegantiae
Vi tränade hårt, men varje gång vi började få fram fungerande grupper skulle vi omorganiseras. Jag lärde mig senare i livet att vi är benägna att möta varje ny situation genom omorganisation och också vilken underbar metod detta är för att skapa illusionen av framsteg medan den åstadkommer kaos, ineffektivitet och demoralisering.
Cytokines
Inflammation
Dehydration
Insulin resistance Capillary leakage
Translocation
Infection/sepsis
Anastomotic leakage
Catabolism
Stress response
Pain
Coagulopathy
”VISCIOUS CIRCLES”
Impaired perfusion
Organ failure
Fluid shift / oedema
Trombembolism
Metabolic effects
Increasing co-morbidities with increasing ageFrom Mike Scott
FRAILTY
AGING vs FRAILTY
The financial burden of emergency general surgery: National
estimates 2010 to 2060
S.Shafi J Trauma Acute Care Surgery 2015
© 2015 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 6
Figure 2 . Direct costs of hospitalization for EGS compared with other common conditions in the United States in 2010. *From Villaveces et al.13 **Based on the current analysis. For other diseases with no asterisk, the reported costs are from Pfuntner et al.14
The financial burden of emergency general surgery
© 2015 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 3
TABLE 2 Observed EGS Incidence per 1,000 US Population in 2010 and Projected Nationwide EGS Patients for US Population for 2020 to 2060
The financial burden of emergency general surgery
© 2015 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 5
Figure 1 . Projected percent change in total costs (2010 as baseline) for EGS patients in the United States by age group, 2015 to 2060.
The financial burden of emergency general surgery
Elective - emergent
Elective
• Is scheduled
• Patients can be prepared
• Multidisciplinaryconferences
• Controlled situation
• Stress-respons can be handled
• ”Daytime”
• Resources are available
Acute
• Not planned
• Patients can be optimized
• Information not always available
• Multifactorial effects
• The stress/inflammatoryresponse has been triggered
• 24/7
• Not always optimal resources
Ljungqvist O JPEN J Parenter Enteral Nutr
2014;0148607114523451
Copyright © by The American Society for Parenteral and Enteral Nutrition
The elective patient’s journey through the
hospital.
Ljungqvist O JPEN J Parenter Enteral Nutr
2014;0148607114523451
Copyright © by The American Society for Parenteral and Enteral Nutrition
The acute patient’s journey through the
hospital.
ERAS -
ERAS-details in emergencies
Preop
• InformInformed patient
• Prehabilitation– Non smoking
– Not alcohol
– ”Training”
• Avoid fasting
• Carbohydrate loading
• PONV profylaxis
• No bowel preparation
• Early specialist consultation
• Preoperative optimization
• Early antibiotics in abdominal sepsis
• Operation within 6 hours
Acute
ERAS-details in emergencies
• Shortacting anaesthesia
• Blockades, epidurals
• Miniinvasive (if possible)
• Modern surgical technique
• Fuid therapy
• Temperature control
Periop
• High-dependency- ICU
• Postop paintreatment
• Early enteral/oral intake– Treat PONV
– Nutritional regimens
• Mobilisation
• Avoid drains and tubes
Postop
What about ERAS in emergencysurgery?
Emergency ERAS?
• Parts of guidelines may be used in emergencies
– Colorectal
• Home-made guidelines
– Cholecystit, ileus
• Publications of smaller series of acutecolorectal surgery, perforated ulcer….
• Ongoing work on Emergency LaparotomyGuideline
Emergency ERAS?
• Parts of guidelines may be used in emergencies
– Colorectal
• Home-made guidelines
– Cholecystit, ileus
• Publications of smaller series of acutecolorectal surgery, perforated ulcer….
• Ongoing work on Emergency LaparotomyGuideline
THE TIMES - SEPT 2014
ALARM RAISED OVER DEATHS FROM EMERGENCY
SURGERY
Emergency laparotomy
• Laparotomy needed to be performed within 6 hours from admission
Emergent conditions
Perforation GI Bleeding Bowel obstruction
Contamination Bleeding Bowel ischemia
EMERGENCY LAPAROTOMY - HIGH MORTALITY
USA _ Al Temimi et al 2012
37,553 patients who had undergone emergency laparotomy from the American College of Surgeons National Surgical Quality Improvement
Program database (2005–2009) in the US.
Mortality 14.9%
UK – Murray et al
UK - Emergency Laparotomy Network prospectively studied
1853 patients from 37 hospitals and found a similar 30 -day Mortality of 14.4 %
Mortality 25% in over 80 year olds
Assess,
escalate and
resuscitate
patients on
presentation
Patient is rapidly
assessed using
simple scoring
system
Escalation team
Medical team
Agreed scoring system and trigger
carried out within 15 mins
presentaion.
Triggers for escalation are known
Red flag signs/symptoms referral
pathway
Available 24/7
Protocol driven care
(fluids/antibiotics/sepsis)
Escalation pathways agreed
Further risk assessment (lactate)
Senior members available 24/7
Understand referral patterns and
timing
Familiar with red flag/lactate
directed referral pathways
Familiar with laparotomy
pathway/protocols and urgency
ELPQUICEMERGENCY LAPAROTOMY PATHWAY QUALIT Y IMPROVEMENT
CARE B JS 2 014 HU D DART ET AL
Early assessment; NEWS/MEWS > 4
Surgical assessment
Early antibiotics in patients with abdominal
sepsis
Emergent operations within 6 hours
Goal-directed fluid therapy
ICU- high dependency wards
From Mike Scott
From Mike Scott
From Mike Scott
1 – ED or Floor
1 Recognition and Resuscitation • Sepsis alert + abdominal complaint• Lactate• LTTE and fluid resuscitation (up to 30 mL/kg)• Priority CT imaging• Surgical consult within 30 minutes
Must get fluids right from the beginning!
From Mike Scott
Early assessment identification ofemergent conditions - reevaluation
Early radiology
From Bertil Leidner
2 Early delivery of antibiotics• Within 1 hour• Standardize to Zosyn• Ciprofloxacin + metronidazole for allergies• Add Vancomycin and Clindamycin for soft tissue
infections
3 Early surgery• OR prioritization• Early anesthesiology consult for surgical planning• Incision no later than 8 hours
From Mike Scott
4 Goal-directed fluid therapy• Protocolized preoperative resuscitation and LTTE
assessment• Non-invasive cardiac output monitoring (FloTrac,
esophageal doppler, SVV / PPV, LTTE)• Appropriate initiation of vasopressors
From Mike Scott
4 Goal-directed fluid therapy• Protocolized preoperative resuscitation and LTTE
assessment• Non-invasive cardiac output monitoring (FloTrac,
esophageal doppler)• Appropriate initiation of vasopressors
5 Post-operative ICU admission• STICU bed for all patients• Continue goal-directed fluid therapy• Appropriate use of vasopressors
From Mike Scott
“Enhanced Recovery for Emergency Laparotomy Surgery: Consensus Statement for Clinical Practice”
Michael Scott, Carol Peden
• Part 1) Consensus Statement for Pathway Care, Surgical and Anaesthesia Practice
• Part 2) Consensus Statement for Critical Care and Continuation of Care
• To be presented in April 2019
ERAS Emergency LaparotomyPart 1) Consensus Statement for Pathway Care, Surgical
and Anaesthesia Practice
• Patient population definition and the problem
• Early diagnosis and Intervention
• Early diagnosis, scoring, impact of comorbidities and frailty
• Early fluid resuscitation
• Early antibiotics
• Early Surgery, damage limitation, control, non surgical options
• Anesthesia management
• Analgesia management
• Fluid and hemodynamic management
ERAS Emergency LaparotomyPart 1) Consensus Statement for Pathway Care, Surgical
and Anaesthesia Practice
• ERAS Elements (As applicable to emergency surgery)
– Patient and family involvement
– Sedative medication, brain health, reducing risk of post operative delirium
– Warming
– Antibiotics (covered in other sections)
– Fluids (covered in other sections)
– Opioid sparing (covered in other sections)
– Anesthesia – NMB and reversal, BIS, Ventilation strategy
– Carbohydrate drinks
– Early feeding
ERAS Emergency LaparotomyPart 1) Consensus Statement for Pathway Care, Surgical
and Anaesthesia Practice
• Early mobilization
• Hemoglobin management
• Nasogastric tubes
• Drains
• Ileus prevention
• Discharge criteria
• Surgery – Overview, damage control
• Implementation and audit
ERAS Emergency Laparotomy
• Part 2) Consensus Statement for continuation of care / Critical Care
• Intensive care utilization – scoring & risk• Stabilization and optimization – ICU versus Floor • De-escalation of care – survivable patients• De-escalation of care – elderly with poor chance of
functional recovery• Postoperative delirium • Sarcopenia and Nutritional Therapy, TPN /enteral feeding• Diagnosis and Treatment of complications • The next 90 days –PROMs and Quality of Life Scores• Rehabilitation –patient reported and centered outcomes
That was all Folks