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