Major Emergency Surgery Research Articles

Anticoagulant Management After Emergency Surgery or Major Bleeding in Anticoagulated Patients—Results of the Prospective RADOA Registry

Background: Major bleeding or emergency surgery are the most frequently observed emergency situations in patients anticoagulated with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). The restart of anticoagulation after these situations is a therapeutic dilemma. Methods: The prospective RADOA registry is an observational, noninterventional multicenter registry that documents the management of severe bleeding or emergency surgery in patients treated with VKAs or DOACs. In this substudy, we analyzed time point, type, and dosage of anticoagulant resumption after emergency situations. Results: Overall, 78 emergency surgery patients and 193 major bleeding patients were analyzed. Median age was similar in the VKA- and DOAC-treated groups (emergency surgery: 77 years, major bleeding: 79 years). Anticoagulants were restarted significantly earlier after emergency surgery compared to major bleeding, with no difference between the VKA and DOAC groups. While patients after cardiothoracic surgery received UFH intravenously, patients with trauma or having received abdominal surgery were mainly treated with prophylactic LMWH s.c.. After major bleeding, the majority of patients were treated with prophylactic LMWH. None of the patients in the emergency surgery group and 17% (4/24) of the major bleeding group with recurrent bleeding (12%, 24/193) experienced recurrent bleeding after restart of anticoagulation. Thromboembolism occurred rarely in both patient groups (emergency surgery: 3%, major bleeding 4%). Conclusions: Time points of restart, type, and dosage of anticoagulants are highly diverse in this high-risk patient population. Resumption of prophylactic anticoagulation is associated with a low risk of thrombosis and should be initiated as soon as possible.

Outcomes of a delirium prevention program after major abdominal emergency surgery: An interventional study.

Postoperative delirium is a common complication after emergency surgery. Delirium is associated with increased morbidity and mortality. Clinical approach varies and pharmacological treatment is ineffective. We aimed to investigate if a structured non-pharmacological multidisciplinary intervention could reduce postoperative delirium. An interventional study including all patients aged 65years or older undergoing major abdominal emergency surgery in an 8month period. The intervention consisted of improved screening, staff, patient, and family education, ward modifications and nurse-led daily motor and sensory stimulation. Data was obtained from medical records. Results were compared to an unmatched historic cohort. Primary outcome was occurrence of delirium, secondary outcomes were mortality, postoperative complications, and length of stay. 312 patients were included, 81 in the study group and 231 in the control group. Delirium occurred in 6.2% of the interventional group compared to 15.2% in the historic cohort (p=0.038). In a multivariate regression analysis, the rate of delirium was significantly reduced in the interventional group; OR 0.185 95% CI (0.04-0.81), p=0.026. The 90day mortality was 14.8% in the interventional group and 8.7% in the historic cohort (p=0.116). The rate of overall medical complications was significantly lower in the study group (37% vs. 63%, p<0.001). Median length of stay was 6days in both groups. A structured cluster intervention may prevent the occurrence of postoperative delirium. The intervention did not reduce mortality or length of stay, but the need for supplementary nursing staff was eliminated.

Comparison of Clinical and Laboratory Manifestations Between Acute Appendicitis and Mesenteric Lymphadenitis in Children.

Acute appendicitis is a major causeof emergency surgery in children and adolescents. Mesenteric lymphadenitis is also one of the most common differential diagnoses in children with acute appendicitis, and despite its high prevalence, few clinical studies have examined its features. The clinical signs of mesenteric lymphadenitis in children are very similar to those of acute appendicitis. The aim of this study was to determine the clinical manifestations of acute appendicitis and mesenteric lymphadenitis in children. In this cross-sectional study, patients less than 15 years old admitted to the pediatric emergency center of Afzalipour Hospital in Kerman from 2018 to 2021 were studied, and those who had a final diagnosis of appendicitis, mesenteric lymphadenitis, or appendectomy were included in the study by census. Data collection from the records of these patients included age, sex, clinical signs, duration of emergency until diagnosis, fever, number of times of vomiting, leukocytosis, lymphocyte, neutrophil count, neutrophil-to-lymphocyte ratio, sonographic findings, and pathology findings. SPSS software and descriptive and analytical statistics were used to analyze the data. The results showed that unlike sex (p=0.11), there was a significant difference between the two groups in terms of age (p<0.001). Nausea, vomiting, anorexia, pain shift, and leukocytosis were more common in the acute appendicitis group than in the mesenteric lymphadenitis group, with a significant difference between the two groups (p<0.001). There was a significant difference between the two groups in terms of neutrophil percentage and neutrophil-to-lymphocyte ratio (p<0.001). The present study was conducted with the aim of assisting medical professionals due to the possibility of misdiagnosing mesenteric lymphadenitis with acute appendicitis. Differentiation of these two diseases is facilitated by the significant differences in their clinical signs and test results. These results can be a useful guide for physicians to better diagnose the diseases.

Financial toxicity part II: A practical guide to measuring and tracking long-term financial outcomes among acute care surgery patients.

Acute care surgery (ACS) patients are frequently faced with significant long-term recovery and financial implications that extend far beyond their hospitalization. While major injury and emergency general surgery (EGS) emergencies are often viewed solely as acute moments of crisis, the impact on patients can be lifelong. Financial outcomes after major injury or emergency surgery have only begun to be understood. The Healthcare Economics Committee from the American Association for the Surgery of Trauma previously published a conceptual overview of financial toxicity in ACS, highlighting the association between financial outcomes and long-term physical recovery. The aims of second-phase financial toxicity review by the Healthcare Economics Committee of the American Association for the Surgery of Trauma are to (1) understand the unique impact of financial toxicity on ACS patients; (2) delineate the current limitations surrounding measurement domains of financial toxicity in ACS; (3) explore the "when, what and how" of optimally capturing financial outcomes in ACS; and (4) delineate next steps for integration of these financial metrics in our long-term patient outcomes. As acute care surgeons, our patients' recovery is often contingent on equal parts physical, emotional, and financial recovery. The ACS community has an opportunity to impact long-term patient outcomes and well-being far beyond clinical recovery.

Association between reduced physical performance measures and short-term consequences after major emergency abdominal surgery: a prospective cohort study

BackgroundMajor emergency abdominal surgery is associated with high morbidity with outcomes worse than for similar elective surgery, including complicated physical recovery, increased need for rehabilitation, and prolonged hospitalisation.PurposeTo investigate whether low physical performance test scores were associated with an increased risk of postoperative complications, and, furthermore, to investigate the feasibility of postoperative performance tests in patients undergoing major emergency abdominal surgery. We hypothesize that patients with low performance test scores suffer more postoperative complications.MethodsThe study is a prospective observational cohort study including all patients who underwent major abdominal surgery at the Department of Surgery at Zealand University Hospital between 1st March 2017 and 31st January 2019. Patients were evaluated with De Morton Mobility Index (DEMMI) score, hand grip strength, and 30-s chair-stand test.ResultsThe study included 488 patients (median age 69, 50.6% male). Physiotherapeutic evaluation including physical performance tests with DEMMI and hand grip strength in the immediate postoperative period were feasible in up to 68% of patients undergoing major emergency abdominal surgery. The 30-s chair-stand test was less viable in this population; only 21% of the patients could complete the 30-s chair-stand test during the postoperative period. In logistic regression models low DEMMI score (< 40) and ASA classification and low hand grip strength (< 20 kg for women, < 30 kg for men were independent risk factors for the development of postoperative severe complications Clavien–Dindo (CD) grade ≥ 3.ConclusionsIn patients undergoing major emergency surgery low performance test scores (DEMMI and hand grip strength), were independently associated with the development of significant postoperative complications CD ≥ 3.

Postoperative pulmonary complications with high versus standard FiO2 in adult patients undergoing major abdominal surgery: A noninferiority trial

BackgroundDespite the possible clinical benefit of high intraoperative oxygen therapy on surgical site infection, the effect on postoperative respiratory function is debatable. However, it remains yet to be elucidated whether hyperoxia due to a high fraction of inspired oxygen used in conjunction with lung protective ventilation can lead to increased incidence of postoperative pulmonary complications. MethodsIn this noninferiority randomized trial, an intraoperative high fraction of inspired oxygen of 0.8 (group H) was compared to a standard fraction of inspired oxygen of 0.3 to 0.4 (group S) in adult patients undergoing major elective or emergency surgery. A lung protective ventilation strategy was employed in all patients, including volume control ventilation with a tidal volume of 6 to 8 mL/kg of predicted body weight, respiratory rate of 12 beats per minute, and positive end-expiratory pressure of 5 to 8 cm H2O. Postoperative pulmonary complications were assessed on postoperative days 3 and 5 by the Melbourne group scale. ResultsIn this trial, n = 226 patients were randomized; among them, 130 patients underwent routine surgery, and 96 patients underwent emergency surgery. The median (interquartile range) of the patients was 48 (35–58) years, and 47.3% were female. Melbourne group scale scores at postoperative day 3 (median [interquartile range] 2 [1–4] in group S vs 2 [1–3] in group H; the difference in median [95% confidence interval] 0 [0, –1]; P = .13) and day 5 (median [interquartile range] 1 (0–3) in group S vs 1 [0–3] in group H; the difference in median [95% confidence interval] 0 [0, 0.5]; P = .34) were statistically similar in both the groups and the upper margin was within the predefined margin of 1. Incidence of surgical site infection (P = .46), postoperative hospital stay (P = .29), and days alive without antibiotic therapy at postoperative day 28 (P = .95) were similar in both groups. ConclusionHigh intraoperative fiO2 was noninferior to standard fiO2 in postoperative pulmonary complications in adult patients undergoing major surgery.

Preoperative shock index in major abdominal emergency surgery.

Major abdominal emergency surgery (MAES) patients have a high risk of mortality and complications. The time-sensitive nature of MAES necessitates an easily calculable risk-scoring tool. Shock index (SI) is obtained by dividing heart rate (HR) by systolic blood pressure (SBP) and provides insight into a patient's haemodynamic status. We aimed to evaluate SI's usefulness in predicting postoperative mortality, acute kidney injury (AKI), requirements for intensive care unit (ICU) and high-dependency monitoring, and the ICU length of stay (LOS). We retrospectively reviewed 212,089 MAES patients from January 2013 to December 2020. The cohort was propensity matched, and 3960 patients were included. The first HR and SBP recorded in the anaesthesia chart were used to calculate SI. Regression models were used to investigate the association between SI and outcomes. The relationship between SI and survival was explored with Kaplan-Meier curves. There were significant associations between SI and mortality at 1 month (odds ratio [OR] 2.40 [1.67-3.39], P<0.001), 3 months (OR 2.13 [1.56-2.88], P<0.001), and at 2 years (OR 1.77 [1.38-2.25], P<0.001). Multivariate analysis revealed significant relationships between SI and mortality at 1 month (OR 3.51 [1.20-10.3], P=0.021) and at 3 months (OR 3.05 [1.07-8.54], P=0.034). Univariate and multivariate analysis also revealed significant relationships between SI and AKI (P<0.001), postoperative ICU admission (P<0.005) and ICU LOS (P<0.001). SI does not significantly affect 2-year mortality. SI is useful in predicting postopera-tive mortality at 1 month, 3 months, AKI, postoperative ICU admission and ICU LOS.

SP10.16 Impact of joint surgical and medical management on outcomes in inflammatory bowel disease. A retrospective review of medical management and surgical outcomes in a District General

Abstract Aim A combined medical and surgical team approach for management of inflammatory bowel disease (IBD) facilitates optimized medical and surgical management through dedicated MDTs and clinics. These benefits were delivered during the COVID-19 pandemic impacting planned medical care. Method Data was collected for all IBD patients undergoing resection surgery over 16 years of age covering a 2-year period before and a 2-year period after the impact of COVID-19 pandemic and start of a combined IBD practice. It included demographics, immune-suppression and planned and unplanned surgery between January 2018 to September 2021. Results 62 patients underwent major resection surgery. Six were excluded for non-IBD related indication (malignancy, infective colitis and volvulus). Of the remaining 56 patients, 20 (35.7%) had Crohn’s Disease, 35 (62.5%) had Ulcerative colitis and one (1.8%) with indeterminate colitis on histopathology. The median age was 43.6 years (16 to 80) with 64.3% females. In the first 2-year period, 73.7% (14) underwent surgery with high perioperative immunosuppression. This reduced to 26.3% (5) in the combined IBD period. Proportion of patients undergoing emergency surgery declined from 59% to 12.5%. Use of biologics increased from 29% to 50% of patients with the average of 0.71 vs 2.13 failed biologics use before surgical intervention. Conclusion Combined medical and surgical IBD practice offers optimised care through timely escalation of medical treatment and reduces risks associated with major emergency surgery. Despite the restrictions to planned surgical treatment during the COVID-19 pandemic, improved outcomes were achieved with combined practice for IBD patients.

SP1.1 Comparison of major abdominal emergency surgery outcomes across different organisational models of emergency surgical care: analysis of the UK NELA national database

Abstract Aims Emergency General Surgery (EGS) admissions are high risk and account for 14000 intensive care admissions costing over £88 million per year. This aim of this study is to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. Methods Data was obtained from the NELA database. Patients were dichotomised into either EGS hospital or non - EGS Hospital. EGS hospital is defined as a hospital where &amp;gt;5 % of the in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in – hospital mortality. Secondary outcomes were ITU length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. Results 115,509 patients were included in the final analysis. Patient characteristics were similar between the 2 groups. Following propensity score weighting, mean SMD reduced from 0.034 to &amp;lt;0.001. In-hospital mortality was similar (10.8% vs 11.1%, p=0.094), with mean length of stay (16.7 vs 16.1 days, p&amp;lt;0.001) and ITU stay (2.8 vs 2.6 days, p&amp;lt;0.001) persistently longer in patients treated in EGS systems. Conclusions There is no significant association between the emergency surgery hospital model of care and in – hospital mortality in emergency laparotomy patients, suggesting the emergency surgery model of care can be utilised effectively without adversely affecting patient outcomes. There is, however, a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the UK.

Comparison of major abdominal emergency surgery outcomes across organizational models of emergency surgical care: Analysis of the UK NELA national database.

Emergency general surgery (EGS) admissions account for a large proportion of surgical care and represent the majority of surgical patients who suffer in-hospital mortality. Health care systems continue to experience growing demand for emergency services: one way in which this is being increasingly addressed is dedicated subspecialty teams for emergency surgical admissions, most commonly termed "emergency general surgery" in the United Kingdom. This study aims to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. Data was obtained from the National Emergency Laparotomy Audit database. Patients were dichotomized into EGS hospital or non-EGS hospital. Emergency general surgery hospital is defined as a hospital where >50% of in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in-hospital mortality. Secondary outcomes were intensive therapy unit (ITU) length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. There were 115,509 patients from 175 hospitals included in the final analysis. The EGS hospital care group included 5,789 patients versus 109,720 patients in the non-EGS group. Following propensity score weighting, mean standardized mean difference reduced from 0.055 to <0.001. In-hospital mortality was similar (10.8% vs. 11.1%, p = 0.094), with mean length of stay (16.7 days vs. 16.1 days, p < 0.001) and ITU stay (2.8 days vs. 2.6 days, p < 0.001) persistently longer in patients treated in EGS systems. No significant association between the emergency surgery hospital model of care and in-hospital mortality in emergency laparotomy patients was seen. There is a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the United Kingdom. Prognostic and Epidemiological; Level III.

The Impact of Depression in Patients Undergoing Emergency Abdominal Surgery: An Exploratory Study.

Depression is associated with poorer outcomes in many disease states. However, its significance in abdominal surgery is unknown. This study investigated rates of depression in emergency abdominal surgery patients and its effects on outcomes. A retrospective cohort study was conducted across two UK sites and included all adult patients undergoing emergency abdominal surgery. Primary outcome was the complication rate in depressed patients, including the incidence of post-operative delirium. Secondary outcomes included mortality, time to oral intake and analgesia. Two hundred and ten patients were identified. The commonest indication for surgery was appendicitis (53.3%) followed by small bowel obstruction (9.5%). There was a 17% (n = 36) incidence of depression amongst patients, most of whom (n = 26, 72.2%) were taking antidepressants. Depression was associated with male sex (M:F 27:9 p = 0.003), higher median BMI (28 vs. 25 p = 0.013) and previous surgery (47.2% vs. 28.7% p = 0.032). Despite a higher incidence of post-operative delirium, increased time to oral analgesia and greater 30-day readmission rates in the depression cohort, multivariate analyses showed depression was not a significant independent predictor of these (OR 2.181, 95%CI 0.310-15.344; p = 0.433, OR 0.07, 95%CI 0.499-1.408; p = 0.348 and OR 1.367, 95%CI 0.102-18.34, respectively). Complication and mortality rates between depressed and non-depressed individuals were similar. Significant numbers of patients undergoing emergency abdominal surgery have depression, but this did not adversely affect post-operative outcomes. The study included relatively small numbers of participants undergoing procedures with straightforward recovery. Larger population studies are therefore required and should focus on investigating the association between major emergency surgeries with post-operative delirium and uncontrolled pain.

Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index

BackgroundMajor abdominal emergency surgery (MAES) has a high risk of postoperative mortality and a high complication rate. The aim of this study was to evaluate whether the implementation of a perioperative care bundle reduced long-term mortality and the Comprehensive Complication Index (CCI) after MAES.MethodsThis study was a single-centre retrospective cohort study. Data in the intervention group were collected prospectively and compared with a historical cohort from the same centre. It includes adult patients undergoing MAES. We implemented a care bundle under the name Abdominal Surgery Acute Protocol (ASAP). We initiated fast-track initiatives and standardised optimised care in before, during and after surgery. Data were analysed using survival analysis and multiple regression.ResultsWe included 120 patients in the intervention cohort and 258 in the historical cohort. The one-year mortality rate was 21.7% in the intervention cohort compared to 28.3% in the standard care cohort. Adjusted odds ratio of one-year mortality 0.81 (CI95% 0.41–1.56). The 30-day mortality was lowered from 19.0 to 6.7% (p = 0.003). The CCI in the intervention cohort was 8.7 (IQR 0–34) compared to 21 (IQR 0–36) in the control cohort (p = 0.932) The length of stay increased by two days (p = 0.021). Most cases had 71–80% protocol compliance.ConclusionImplementing bundle care in major abdominal emergency surgery lowered the 30-day postoperative mortality. The difference in mortality was preserved over time although not significant after one year. The changes in the Comprehensive Complication Index were not statistically significant.

Compliance with the World Health Organization’s surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia

BackgroundMinistry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications.MethodsHealth institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software.ResultsIn 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603).ConclusionsSurgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications.

Gastrointestinal complications (gangrene or perforation) after corona virus disease 2019 - A series of ten patients.

During the recent second wave of corona virus disease 2019 (COVID-19) pandemic in India, we managed a series of gastrointestinal complications in patients with COVID-19. We aim to highlight the key presentation and clinical course and emphasize the lessons we learnt from our series of such patients. A case review of ten consecutive patients with either bowel gangrene or perforation who were managed at our centre from March 20, 2021 to June 10, 2021. Clinical-demographic details, possible etiology, radiological findings, management and outcomes have been described. Of the 10 patients, 2 presented with bowel gangrene and 8 with perforation. In our series, all these patients were diagnosed with the help of computed tomography (CT) abdomen during the 3rd week after diagnosis of COVID-19. All had received steroid medication. Both patients with bowel gangrene and 4 of 8 patients with perforation underwent surgery, while 4 were managed non-operatively. Barring one patient, all the operated patients succumbed within 5 days of surgery after rapid clinical deterioration. Non-operative management in selected patients with perforation including placement of percutaneous drains, bowel rest and antibiotics was successful. Emergency surgery for COVID-19 related intestinal gangrene or perforation was associated with high mortality in our series. Non-operative management which avoids the added stress of a major emergency surgery particularly in patients just recovering from COVID-19 may be considered in stable patients in whom perforation appears to be contained.

Reversal of dabigatran with IDARUCIZUMAB in Hospital Tengku Ampuan Rahimah, Klang: Case series

Dabigatran is a direct thrombin inhibitor used in non-valvular atrial fibrillation(NVAF), deep venous thrombosis(DVT)/pulmonary embolism(PE) and venous thromboembolism(VTE) prophylaxis. Idarucizumab is specific reversal agent for dabigatran which have been shown to be useful in situations such as major bleeding or emergency surgery .We are reporting the use of idarucizumab in a tertiary centre.

Feasibility of laparoscopy and factors associated with conversion to open in minimally invasive emergency major abdominal surgery: population database analysis.

There is limited evidence regarding the overall feasibility and success rates of the laparoscopic approach in major emergency surgery, despite its potential to improve outcomes. This study aims to investigate the association between patient, procedural, and surgical factors and likelihood of successful laparoscopic completion in emergency major surgery and derive a predictive model to aid clinical decision-making. All patients recorded in the NELA emergency laparotomy database 1 December 2013-31 November 2018 who underwent laparoscopically attempted surgery were included. A retrospective cohort multivariable regression analysis was conducted for the outcome of conversion to open surgery. A predictive model was developed and internally validated. Of 118,355 patients, 17,040 (7.7%) underwent attempted laparoscopic surgery, of which 7.915 (46.4%) were converted to open surgery. Procedure type was the strongest predictor of conversion (compared to washout as reference, small bowel resection OR 25.93 (95% CI 20.42-32.94), right colectomy OR 6.92 (5.5-8.71)). Diagnostic [free pus, blood, or blood OR 3.67 (3.29-4.1)] and surgeon [subspecialist surgeon OR 0.56 (0.52-0.61)] factors were also significant, whereas age, gender, and pre-operative mortality risk were not. A derived predictive model had high internal validity, C-index 0.758 (95% CI 0.748-0.768), and is available for free-use online. Surgical, patient, and diagnostic variables can be used to predict likelihood of laparoscopic success with a high degree of accuracy. This information can be used to inform peri-operative decision-making and patient selection.

EFFECT OF HYPOALBUMINEMIA IN WOUND HEALING AND ITS RELATED COMPLICATIONS IN SURGICAL PATIENTS.

This prospective study used hypoalbuminemia as one of the indicator of nutritional status for patients who are admitted for elective or emergency surgery. It will be invaluable to have the predictors that can assess the complication before the operation procedure,so that deciet factors can be corrected in order to reduce wound healing complications (like wound infection,wound dehiscence and anastomotic leak). Effect of Hypoalbuminemia in wound healing and AIM: related complications in surgical patients. MATERIAL AND METHODS:This study conducted on patients admitted in surgery deparment of Dr. PDMMC &amp; Hospital Amravati,for major elective or emergency surgery between 1Jan2021 to 30Aug2021 over 100 patients. Pati RESULT: ents with hypoalbuminemia are more tends to develop wound related complications than patients with normal albumin level. Serum albumin levels can be consider CONCLUSION: one of best predictor for wound related complication.

A critical decision point: Short- and long-term outcomes of older surgical patients admitted to a Queensland intensive care unit.

Critical care admission is a pivotal juncture for older patients undergoing surgery. We aimed to identify the in-hospital and postdischarge outcomes of older postsurgical patients (≥65years) admitted to the intensive care unit (ICU). We collected clinical, morbidity and survival data on all patients aged ≥65years postsurgically admitted to a tertiary metropolitan ICU between 2014 and 2019. Within this older cohort (n=370), the oldest patients (≥85years) had the highest 1-year mortality (RR: 4.00; P<0.001). Major surgery (RR: 5.67; P<0.001), emergency surgery (RR: 2.89; P<0.001) and APACHE III score ≥50 (RR: 2.63; P<0.001) were associated with reduced 1-year survival. APACHE III score and surgery subtype are strong predictors of post-ICU mortality and may be useful to preoperatively stratify whether surgery and subsequent ICU admission are in patients' best interests. These data may also inform prospective discussions regarding end-of-life care and advanced care planning.

The effect of hemoadsorption on rivaroxaban blood plasma concentration in emergency cardiac surgery

Hemoadsorption was used in a 59-year-old patient with an acute type A aortic dissection, who was on rivaroxaban and dual antiplatelet therapy with clopidogrel and acetylsalicylic acid. Our aim was to expeditiously remove rivaroxaban preoperatively. After 8 h of hemoadsorption, the rivaroxaban blood plasma concentration (RBPC) did not decrease below 42.1 μg/l. Intraoperatively, hemoadsorption was repeated during extracorporeal circulation. Sixteen hours after surgery and a total of 13 h of hemoadsorption, the RBPC was 40.1 μg/l. Thereafter, the RBPC spontaneously decreased to 24.7 μg/l within 14 h. In our patient, hemoadsorption may have enhanced rivaroxaban removal at higher RBPC (cutoff value 40–50 μg/l). At lower RBPC, the removal of rivaroxaban may depend solely on the natural drug elimination process. The evolution of the RBPC under hemoadsorption in vivo warrants a thorough investigation. Further clinical studies are required to assess the effectiveness and limitations of hemoadsorption to preclude a fatal bleeding event in patients with rivaroxaban in need of major emergency surgery.

The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis

Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery. The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome. From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I2=0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN. EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.