Abstract
Background Critically ill patients are often evaluated for an intra-abdominal catastrophe. In the absence of a preoperative diagnosis, abdominal exploration may be offered despite desperate circumstances. We hypothesize that (1) abdominal exploration for such patients is associated with a high mortality and (2) commonly obtained physiologic measures at laparotomy anticipate mortality. Methods All acute care surgery (ACS) patients undergoing emergency laparotomy at a quaternary referral center during a 3-year period were reviewed. Inclusion was defined by emergency laparotomy in the operating room (OR) in a patient with an American Society of Anesthesiologists (ASA) score ≥4 or bedside laparotomy in the ICU (BSL). Mortality was the primary endpoint and was stratified by demographics, admitting service, surgical findings, and physiology. Comparisons between OR and BSL were by Fisher's exact and Mann–Whitney tests. Results 144 patients underwent emergency laparotomy (45 BSL vs. 99 OR). Overall mortality was 55.6% (77.8% BSL vs. 45.5% OR; p < 0.001). Mortality by admitting service was cardiac 71.4% (n=42), medical 70% (n=30), ACS 42% (n=50), and other 36.4% (n=22) services. Preoperative lactate levels were higher in nonsurvivors (2.7 vs. 8.5 mmol/L, p < 0.001), as was vasopressor use (62.5% vs. 97.5%, p < 0.001), acute kidney injury (51.6% vs. 72.5%, p < 0.01), leukocytosis (53.1% vs. 71.3%, p < 0.04), and anemia (45.3% vs. 71.3%, p < 0.01). The presence of any identifiable abdominal pathology established a 90% mortality rate. Conclusions The need for BSL portends an extremely high mortality rate and is likely useful in preintervention counselling. Emergency OR laparotomy leads to mortality in nearly half of such patients and is anticipatable based on concurrent abnormal physiology.
Highlights
Ill patients are often evaluated for an intra-abdominal catastrophe
Surgical decision-making may be limited by the absence of a reliable physical examination secondary to an altered sensorium compounded by physiologic instability rendering the patient too unstable to travel for advanced imaging
Patients admitted to the acute care surgery (ACS) service either presented to the hospital with severe critical illness or became so after admission for an emergency general surgery diagnosis
Summary
Ill patients are often evaluated for an intra-abdominal catastrophe. In the absence of a preoperative diagnosis, abdominal exploration may be offered despite desperate circumstances. An intra-abdominal catastrophe may be suspected when intensive care unit (ICU) patients demonstrate rapidly progressive critical illness without an alternative diagnosis. In this setting, surgical decision-making may be limited by the absence of a reliable physical examination secondary to an altered sensorium compounded by physiologic instability rendering the patient too unstable to travel for advanced imaging. Surgical decision-making may be limited by the absence of a reliable physical examination secondary to an altered sensorium compounded by physiologic instability rendering the patient too unstable to travel for advanced imaging In these cases, emergent laparotomy may be offered regardless of age, despite an anticipated high mortality [1,2,3].
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