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Abstract

Introduction: Acute care surgeons are often called to evaluate critically ill patients in extremis to rule out an abdominal catastrophe when no other source of decompensation is identifiable. Occasionally, these patients are deemed too unstable for travel to an operating room. Bedside Laparotomy (BSL) in the Intensive Care Unit (ICU) is often the only diagnostic and potentially therapeutic option, but is associated with significant mortality. Herein, we attempt to characterize BSL in extremis as either effective care or surgical futility. Methods: All patients who had a BSL by our emergency surgery service (ESS) at our quaternary-care, university-based medical center during a 22 month period (2011-2013) were included. Data was acquired retrospectively from our prospectively collected ESS registry and the electronic medical record. Patient demographics, physiology, and timing & nature of operative procedures were abstracted and analyzed against mortality using fisher's exact test. Results: 32 patients met inclusion criteria. 23 were male (72%), 24 died (75%), and average age was 64 years, (65 in the mortality group vs. 60, p=NS). 12 patients had their initial laparotomy at the bedside, whereas the remainder had a subsequent BSL. All but 3 patients had multiple operations. At the time of bedside laparotomy, no patients had mental capacity for decision making. Of those that died, 16 (67%) had bedside explorations within one day of death, often within hours. No significant pathology was found in 25% of laparotomies in the mortality group vs. 37.5% in the survivor group, p=NS. Of the deaths with operative findings (n=18), 11 (61%) had globally ischemic viscera and no intervention was performed. Post laparotomy, 15 of 24 (63%) were made Do Not Resuscitate prior to death. On univariate analysis, lactate level at time of BSL had the strongest association with mortality, 12.3 vs. 1.9, p<0.002. When compared to emergent laparotomies in a formal theatre, BSL resulted in significantly higher mortality, 75% vs. 31.0%, p<0.0001. Conclusions: When bedside laparotomy is performed, it is often non-diagnostic, but more frequently, also non-therapeutic. Death ensues often in short order. Surgical futility should be discussed with patient families and intensivists to more appropriately address goals of care in this patient cohort.