Emergency Laparotomy

Emergency abdominal surgery is associated with high mortality rates from 14% to 19% in 3 large retrospective studies in the UK, US and Denmark. This rises to over 24% in patients over 80 years of age.

“Significant changes in both the use of goal-directed fluid therapy and admission to ICU were found across almost all of the participating sites. These two elements of the [ELPQuiC] bundle may have the greatest impact in reducing mortality in other hospitals and healthcare systems where these standards of care are not met routinely.” (Huddart et al. 2014)

Emergency abdominal surgery is associated with high mortality rates from 14% to 19% in 3 large retrospective studies in the UK, US and Denmark. This rises to over 24% in patients over 80 years of age.

This vulnerable group responds well to a standardisation of care, and with clear guidelines both mortality and morbidity can be reduced, length of stay reduced and cost savings made.

2 recent studies using the LiDCO have shown a reduction in complications and length of stay when used to guide fluid and drug management as part of a pathway in emergency abdominal patients.

Guide fluid and drug management to maintain the optimal circulation and reducing the risks of complications.

Either passive leg raise or stroke volume/pulse pressure variation should be used to see if the patient is fluid responsive or not.

A fluid challenge guided by the response in the stroke volume should be used when fluids are given to prevent overfilling the patient.

If the patient is unresponsive to fluids with a low blood pressure then the appropriate drug can be used.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Patient Population
Emergency Laparotomy Surgery.

LiDCO Monitor
LiDCOrapid as part of an evidence-based care bundle.

Trial Design
Before v after a care bundle introduction.

Outcome Impact
Reduced mortality – 5.97 more lives per 100 patients were saved.

BACKGROUND
Emergency laparotomies in the UK, USA, and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care.

METHODS
The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model.

RESULTS
Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6.47 in the baseline interval (299 patients included) to 12.44 after implementation (427 patients included) (P < 0.001). The overall case mix-adjusted risk of death decreased from 15.6 to 9.6 per cent (risk ratio 0.614, 95 per cent c.i. 0.451 to 0.836; P = 0.002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0.197 and 0.223 before and after implementation respectively; P = 0.395).

CONCLUSION
Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Emergency Laparotomy Collaborative

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LiDCOrapid – Hemodynamic Monitoring in Action

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“Significant changes in both the use of goal-directed fluid therapy and admission to ICU were found across almost all of the participating sites. These two elements of the [ELPQuiC] bundle may have the greatest impact in reducing mortality in other hospitals and healthcare systems where these standards of care are not met routinely.”
Huddart et al. 2014

The LiDCOunity monitor is a single platform which combines both the LiDCOplus and LiDCOrapid functions. This provides a single solution to monitoring needs throughout the hospital. The clinician can choose which mode is most appropriate to the clinical situation. The LiDCOunity can be used non-invasively, minimally invasively with a radial arterial line and can be calibrated with the lithium dilution technique.  Find out more

The LiDCOplus hemodynamic monitor provides a continuous, reliable and accurate assessment of the hemodynamic status of critical care and surgery patients.  The LiDCOplus is comprised of two technologies: a continuous arterial waveform analysis system (PulseCO™) coupled to a single point lithium indicator dilution calibration system.  Find out more

The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management.  The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR). The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight.  Find out more