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