Patient perceptive focus on recovery: An exploratory study on follow-up after major emergency abdominal surgery.

BACKGROUND: Optimal recovery can be defined as the adequate in-hospital length of stay with minimal postoperative complications and readmissions. The quality of recovery beyond the immediate postoperative period after major emergency abdominal surgery is yet to be fully described. We hypothesized that long-term measures of overall recovery were affected after surgery. The study aimed to investigate patient-focused recovery-related parameters 1 year after major emergency abdominal surgery. METHOD: This is a prospective study including patients undergoing major emergency abdominal surgery at a Danish secondary referral center. Three questionnaires were answered regarding the recovery following the procedure; Activities Assessment Scale (AAS); Quality of Recovery-15 (QoR-15), and Self-complete Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). All questionnaires were answered at postoperative days (PODs) 14, 30, 90, and 365. RESULTS: Eighty-two patients were included, and 68 were available for follow-up until 1 year after surgery. The response rates differed between the follow-up time points, with a response rate of 85% (n = 59) at POD30 and 50% (n = 36) at POD365. A decrease in the level of physical function following surgery was observed in 60% of the patients at POD14, which improved to 36% at POD365. Twenty-four patients (48%) reported postoperative pain at POD14, which declined to 9 (26%) at POD365. The maximum overall recovery was reached at POD30, which remained stable throughout the study period. CONCLUSION: One in three patients reported physical functional impairment, and one in four patients reported pain 1 year after their surgical procedure.

Validation of the preoperative score to predict postoperative mortality (POSPOM) in patients undergoing major emergency abdominal surgery.

PURPOSE: Patients undergoing major emergency abdominal surgery have a high mortality rate. Preoperative risk prediction tools of in-hospital mortality could assist clinical identification of patients at increased risk and thereby aid clinical decision-making and postoperative pathways. The aim of this study was to validate the preoperative score to predict mortality (POSPOM) in a population of patients undergoing major emergency abdominal surgery. METHODS: POSPOM was investigated in a retrospectively collected cohort of patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 to 2016. Predicted in-hospital mortality by POSPOM was compared to observed in-hospital mortality. Calibration was assessed by Hosmer-Lemeshow goodness-of-fit and calibration plot. Discrimination was assessed by area under the receiver operating characteristic curve and accuracy was assessed with Brier score. RESULTS: The study included 979 patients (513 females) with a median age of 64 (IQR 55-77) years. The majority of patients underwent open surgery (94.5%). The observed in-hospital mortality rate was 10.9%. The estimated mean in-hospital mortality rate by POSPOM was 6.7%. POSPOM showed a good discrimination [AUC 0.82 (95% CI 0.78-0.85)] and an excellent accuracy [Brier score 0.09 (95% CI 0.07-0.10)]. However, a poor calibration was found (p < 0.01) as POSPOM underestimated in-hospital mortality. CONCLUSIONS: POSPOM is not an ideal prediction model for in-hospital mortality in patients undergoing major emergency abdominal surgery due a poor calibration.

Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery.

PURPOSE: The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery. METHODS: An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge. RESULTS: A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake. CONCLUSIONS: The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.

Endothelial dysfunction and myocardial injury after major emergency abdominal surgery: a prospective cohort study.

BACKGROUND: Preoperative endothelial dysfunction is a predictor of myocardial injury and major adverse cardiac events. Non-cardiac surgery is known to induce acute endothelial changes. The aim of this explorative cohort study was to assess the extent of systemic endothelial dysfunction after major emergency abdominal surgery and the potential association with postoperative myocardial injury. METHODS: Patients undergoing major emergency abdominal surgery were included in this prospective cohort study. The primary outcome was the change in endothelial function expressed as the reactive hyperemia index from 4-24 h after surgery until postoperative day 3-5. The reactive hyperemia index was assessed by non-invasive digital pulse tonometry. Secondary outcomes included changes in biomarkers of nitric oxide metabolism and bioavailability. All assessments were performed at the two separate time points in the postoperative period. Clinical outcomes included myocardial injury within the third postoperative day and major adverse cardiovascular events within 30 days of surgery. RESULTS: Between October 2016 and June 2017, 83 patients were included. The first assessment of the endothelial function, 4-24 h, was performed 15.8 (SD 6.9) hours after surgery and the second assessment, postoperative day 3-5, was performed 83.7 (SD 19.8) hours after surgery. The reactive hyperemia index was suppressed early after surgery and did not increase significantly; 1.64 (95% CI 1.52-177) at 4-24 h after surgery vs. 1.75 (95% CI 1.63-1.89) at postoperative day 3-5, p = 0.34. The L-arginine/ADMA ratio, expressing the nitric oxide production, was reduced in the perioperative period and correlated significantly with the reactive hyperemia index. A total of 16 patients (19.3%) had a major adverse cardiovascular event, of which 11 patients (13.3%) had myocardial injury. The L-arginine/ADMA ratio was significantly decreased at 4-24 h after surgery in patients suffering myocardial injury. CONCLUSION: This explorative pathophysiological study showed that acute systemic endothelial dysfunction was present early after major emergency abdominal surgery and remained unchanged until day 3-5 after the procedure. Early postoperative disturbances in the nitric oxide bioavailability might add to the pathogenesis of myocardial injury. This pathophysiological link should be confirmed in larger studies. TRIAL REGISTRATION: clinicaltrials.gov no. NCT03010969.

The impact of timing of antibiotics on in-hospital outcomes after major emergency abdominal surgery.

BACKGROUND: Patients undergoing major open emergency abdominal surgery experience high morbidity and mortality rates and often have sepsis at admission. The purpose of this study was to evaluate the association between antibiotic timing and in-hospital outcomes such as complications, need for reoperation, length of stay, and 30-day mortality. METHODS: This retrospective observational cohort study was conducted between January 2010 and December 2015 including patients that were triaged through the emergency department for subsequent major open abdominal surgery. All relevant perioperative data were extracted from medical records. The outcomes of interest were development of in-hospital postoperative complications, reoperations, length of stay, and 30-day mortality, all in association with antibiotic timing, categorized according to 0-6, 6-12, or > 12 h from triage. Multivariate logistic regression was performed to evaluate adjusted outcomes associated with antibiotic timing. RESULTS: A total of 408 patients were included, of whom 107 (26.2%) underwent at least one reoperation and 55.4% had at least one postoperative complication. These complications consisted of 26% surgical complications and 74% medical complications. Of the surgical complications, 73% were Clavien-Dindo ≥ 3. The median length of stay was 9 days and the overall 30-day mortality was 17.9%. The data showed that the development of complications, need for reoperation, 30-day mortality, and the length of stay were significantly correlated to delayed antibiotic administration of more than 12 h from admission. CONCLUSIONS: Antibiotic administration more than 12 h from triage was associated with a significantly increased risk of postoperative complications, need for reoperation, 30-day mortality, and a prolonged length of stay, when compared to patients that received antibiotic treatment 0-6 h and 6-12 h after triage. Our data suggest that prophylactic antibiotics should be administered to all patients undergoing major open emergency abdominal surgery; however, the dose and duration cannot be concluded on the basis of our data and should be further examined.

The impact of blood type on transfusion after major emergency abdominal surgery.

BACKGROUND: ABO dependent variation in von Willebrand factor (vWF) and factor VIII have an impact on hemostasis. Several contradictory studies have investigated the influence of ABO blood type in surgical hemorrhage. Emergency surgery is associated with an increased risk of perioperative hemorrhage leading to inferior clinical outcomes. The aim of this study was to investigate if patients with blood type O received more transfusions with blood components compared with non-O patients after major emergency abdominal surgery. STUDY DESIGN AND METHODS: This retrospective observational study combined perioperative data including hemoglobin with transfusion data in patients undergoing emergency surgery at a university hospital between January 2010 and October 2016. The primary outcome was postoperative transfusion stratified into early transfusion, within 24 hours after surgery, and late transfusion from 24 hours to 7 days (POD7) after surgery. RESULTS: A total of 869 patients were included, 363 patients with blood type O (42.0%) and 501 (58.0%) with blood type non-O. We found no difference in the need for transfusion with 42 (11.6%) patients with blood type O and 66 (13.2%) patients with blood type non-O receiving early transfusion and 39 (13.4%) and 48 (11.9%) of O and non-O patients, respectively, receiving late transfusion. Multivariate logistic regression analysis showed an adjusted OR of 0.915 (95% CI 0.569-1.471) for early transfusion and an adjusted OR of 1.307 (95% CI 0.788-2.169) for late transfusion in patients with blood type O. Likewise, no difference was seen with respect to the change in hemoglobin levels before and after surgery as well as transfused volume. CONCLUSION: We did not find an association between transfusion or perioperative changes in hemoglobin with respect to blood type ABO.

[Sparse knowledge about patient-reported outcomes after major emergency abdominal surgery].

Little is known about patient-reported outcomes after major emergency abdominal surgery. Studies on patients undergoing major elective abdominal surgery and patients in the intensive care unit report significant challenges with chronic pain, functional impairment, quality of life, depression and post-traumatic stress disorder (PTSD). Approximately one out of three patients experience chronic pain and functional impairment after major emergency abdominal surgery. The magnitude of depression and PTSD after major emergency abdominal surgery have not been studied before.