Patients Undergoing Emergency Abdominal Surgery Research Articles

Combination of neuromuscular block monitoring and hand grip strength assessment for patients undergoing emergency abdominal surgery

Relevance. The hand grip strength measurement together with neuromuscular block monitoring played an important role during surgery. They both helped in losing less time during surgery and also facilitate the task of the surgeon. The aim of this study was to reduce time on intubation, facilitate the task of the surgeon and to limit post-surgical pain. In rehabilitation, hand grip strength helps in determining further recuperation measures after asurgery. There are three fundamental principles for an anesthesiologist to ensure that the patient after combined endotracheal anesthesia can be extubated, the first one is to ask the patient to move his head forward, the second one is to ask the patient whether the intubation tube is disturbing him in his mouth and the third most important one is to make the patient hold his wrist very firmly. Materials and Methods. Monitoring of muscle relaxant on induction, intra and post-surgery is carried out using aTOF Watch SX in coordination with handgrip strength measurement on 46 patients aged from 18 to 60 years of BMI of 18-30 kg/m² 15min before endotracheal intubation and 15min, 45min and 210min post extubation by using adynamometer “MEGEON 34090” to help us understand whether after extubation muscle strength changes and to what extent. Also, pre-anesthesiology protocol, combined endotracheal protocol, Microsoft excel advanced, monitoring of hemodynamics, ECG, PEEP, PCO2, PO2, respiratory volume using Drager Fabius. Results and Discussion. The results showed that to reach deep muscle relaxation both atracurium benzilate (FKP Kursk Biofabric company, Kursk, Russia) at TOF 0 took 258.5± 83.5 secs and Cisatracurium benzilate (ZAO Obninsk Chemical pharmaceutical company, Obninsk, Russia) at TOF0-252.4±100.1 secs in emergency patients and basically hand grip strength also was lesser as compared to planned cholecystectomy patients. Conclusion. Rehabilitation was necessary for patients undergoing massive abdominal emergency surgeries underlying the fact that on apain scale 10/10 post surgery, further treatments should be implemented to reduce pain, reduce residual neuromuscular block and muscle weakness after extubation at TOF 90-95%.

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study.

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

The Global Leadership Initiative on Malnutrition criteria for diagnosis of malnutrition and outcomes prediction in emergency abdominal surgery

ObjectivesMalnutrition has adverse postoperative outcomes, especially in emergency surgery. Among the numerous tools for nutritional assessment, this study aims to investigate malnutrition diagnosed by Global Leadership Initiative on Malnutrition criteria and the Global Leadership Initiative on Malnutrition predictive value for outcomes after emergency abdominal surgery. MethodsThis was a prospective observational study. Among the 468 patients undergoing emergency abdominal surgery admitted to a department of emergency surgery from June 2020 to December 2021, 53 patients were not eligible for enrollment, and 19 patients had missing data. Thus, the final number of participants was 396. Muscle mass was evaluated by skeletal muscle index at the third lumbar vertebra on computed tomography scans, and the lower quartile was defined as the threshold of muscle mass reduction. The associations of Global Leadership Initiative on Malnutrition, Global Leadership Initiative on Malnutrition (muscle mass reduction excluded), and skeletal muscle index with in-hospital mortality, postoperative complications, and postoperative stay were evaluated using χ2. In addition, confounding factors were screened, regression models were established, and the Global Leadership Initiative on Malnutrition predictive value was analyzed for clinical outcome. Ethical approval was obtained from the appropriate department. ResultsMalnutrition was observed in 19.9% of the total 396 patients based on the Global Leadership Initiative on Malnutrition and in 12.4% on the Global Leadership Initiative on Malnutrition (muscle mass reduction excluded). Sarcopenia by skeletal muscle index was found in 24.7% of patients. Univariate analysis indicated that in-hospital mortality, postoperative complications, infective complication rate, and postoperative hospital stay were significantly higher in malnourished and sarcopenic patients. Multivariate analysis found that malnutrition diagnosed by the Global Leadership Initiative on Malnutrition was predictive for complications, infective complications, and postoperative stay (total postoperative complications: odds ratio = 3.620; 95% CI, 1.635–8.015; P = 0.002; infective complications: odds ratio = 3.127; 95% CI, 1.194–8.192; P = 0.020; and postoperative stay: regression coefficient = 2.622; P = 0.022). The Global Leadership Initiative on Malnutrition (muscle mass reduction excluded) identified postoperative complications and postoperative stay (total postoperative complications: odds ratio = 3.364; 95% CI, 1.247–9.075; P = 0.017 and postoperative stay: regression coefficient = 3.547; P = 0.009). Sarcopenia by skeletal muscle index was a risk factor for postoperative complications (odds ratio = 3.366; 95% CI, 1.587–7.140; P = 0.002). ConclusionThe Global Leadership Initiative on Malnutrition and Global Leadership Initiative on Malnutritison (muscle mass reduction excluded) had predictive value for adverse clinical outcomes due to malnutrition in patients undergoing emergency abdominal surgery.

Predictors of mortality in elderly patients in emergency abdominal surgery: A retrospective single-center study

Background/Aim: Advancements in medical technologies and prolonged life expectancy have increased the number of surgical interventions for elderly patients. Despite this however, emergency surgical interventions remain associated with a high mortality rate. Managing an emergency abdominal surgery in elderly patients poses great challenges for both the surgeon and the anesthesiologist. However, knowing the risk factors that increase mortality may offer advantages to the clinician managing the treatment process. There are studies in the literature examining the mortality of emergency surgeries in elderly patients. However, there are very few studies that work with a specific patient group such as abdominal surgery and then analyze laboratory test results. Here, we aimed to identify the risk factors that can be used to predict mortality in elderly patients undergoing emergency abdominal surgery. Methods: The study was designed retrospectively in a single center; 100 patients over the age of 80 who underwent emergency abdominal surgery were included in the study. The patients were divided into two groups as survivor and non-survivor. Demographic, surgical, and anesthetic characteristics, laboratory tests, American Society of Anesthesiologists (ASA) physical status scores, postoperative intensive care needs, and treatments of the groups were compared using the chi-squared and Mann Whitney U-test. Determining factors were investigated with logistic regression analysis. Results: In multivariate analysis, ASA 3 and major surgery significantly increased mortality (P=0.041, P=0.011). Receiver operating characteristic (ROC) curve analysis showed that C-reactive protein with a cut-off value of >84 mg/L had a sensitivity of 58.8% and a specificity of 71.2% (AUC=0.636, P=0.004), while lactate with a cut-off value of >3.6 mmol/L had a sensitivity of 50% and a specificity of 95.5% in predicting mortality (AUC=0.776, P<0.001). Conclusion: The magnitude of surgery and the ASA score were the best predictors of mortality in elderly patients undergoing emergency abdominal surgery.

Modified Enhanced Recovery After Surgery (ERAS) Protocol Versus Non-ERAS Protocol in Patients Undergoing Emergency Laparotomy for Acute Intestinal Obstruction: A Randomized Controlled Trial.

Enhanced Recovery After Surgery (ERAS) is a multimodal approach with promising results in improving patient outcome. Only recently, is evidence emerging highlighting how similar principles of care can be applied to patients undergoing emergency abdominal surgery. A randomized controlled trial was conducted from November 2021 to April 2022 at PGIMER Chandigarh, which is a leading tertiary care hospital in northern India. 60 patients with acute intestinal obstruction requiring emergency laparotomy were randomized and assigned to ERAS or Non-ERAS group. ERAS protocol with some modifications was applied. Primary endpoints were post-operative hospital stay. Secondary end points were morbidity, 30-day readmission and mortality rate. Data analysis was done using SPSS 22.0. Independent t test or Mann-Whitney test and Chi-square or Fisher-exact test were used for analysis. A significant 3-day reduction in hospital stay was observed in ERAS compared to non-ERAS group (median (interquartile range) 5.50 (4.75-8.25) vs 8.0 (6.0-11.0) p = 0.003) with no difference in 30-day readmission rate, mortality rate and complication rate (according to Clavien-Dindo classification). ERAS group was associated with early recovery of gastrointestinal functions including time to first passage of flatus (p < 0.001), stools (p = 0.014), early ambulation (p < 0.001), time to first fluid diet (p < 0.001), solid diet (p = 0.001) and reduced nasogastric tube reinsertion rates (p = 0.01) despite its early removal. ERAS with some modifications can be applied in patients with intestinal obstruction. Thus, we can expedite post-operative recovery and early regain of gastrointestinal function with decreased hospital stay, comparable morbidity and mortality. Further studies are needed to assess ERAS role in emergency gastrointestinal surgeries. Trial registration Ctri.gov Identifier: CTRI/2022/04/042156.

819 ELLIPSE: Electrical Impedance Analysis in Patients Undergoing Emergency Abdominal Surgery

Abstract Introduction An ageing population represents greater operative risk; therefore, preoperative risk stratification is required to allow patients to make an informed decision. One method of risk stratification is bioelectrical impedance analysis (BIA) which can provide information such as muscle and fat mass, providing a proxy for patient metabolic health. Aim Metabolic health is intrinsically linked to outcomes following surgery. We hypothesised that BIA is a feasible method of assessing patients undergoing emergency abdominal surgery and predicting postoperative outcomes. Method A BIA analyser was used to measure patients body composition. All adult patients who met the National Emergency Laparotomy Audit (NELA) inclusion criteria were prospectively recruited and followed up until 30 days postoperatively. These patients had serial BIA measurements and compared with a healthy population. The phase angle (PA) is a raw variable which can be standardised to a healthy reference population and matched for age and gender. In summary, a higher phase angle is associated with improved outcomes. Results 31 patients were recruited and BIA analysis in patients undergoing emergency abdominal surgery was feasible. Patients with a phase angle lower than the reference population had a greater incidence of complications (p = 0.03) and had more severe complications (p = 0.023). Furthermore, the same patients also had a significantly higher NELA morbidity percentage (p = 0.022). Conclusions Our study shows that conducting BIA analysis in patients undergoing emergency abdominal surgery is feasible. The presence and severity of complications correlates with the phase angle. This represents a successful proof of concept study of BIA to predict postoperative outcomes.

Effects of Body Mass Index on Postoperative Outcomes and Complications for Patients Undergoing Emergency Abdominal Surgery: A NSQIP Review

Introduction: Body mass index (BMI) is closely related to morbidity and mortality, and emergency general surgery is an independent risk factor for postoperative complications and death. Study Design: This was a retrospective analysis of NSQIP data from 2018 evaluating outcomes for patients undergoing urgent or emergent abdominal surgery, based on BMI. We first analyzed the impact of patient demographics and comorbidities, including obesity (BMI ≥30), on multiple postoperative outcomes. We then stratified patients by WHO BMI classification and analyzed the same variables. Results: In the first analysis, obesity was found to increase the risk of superficial and deep surgical site infection and decrease the risk of pneumonia. The most prevalent risk factor was open surgery, which increased the risk of most postoperative complications. After stratification, we did not identify the previously described “obesity paradox.” We found no protective factors for overweight patients or those with mild obesity. However, patients at the extremes of BMI tended toward worse outcomes, including longer operative times and hospital stays. Furthermore, patients with class II or III obesity were typically at higher risk for organ space infection, pulmonary embolism, return to the operating room, and 30-day mortality. Conclusion: Body mass index clearly impacts postoperative outcomes in patients undergoing urgent or emergent abdominal surgery. While the obesity paradox was not identified in this study, outcomes generally fared worse for patients at BMI extremes. The most prevalent risk factor across all BMI classifications, for multiple postoperative complications and outcomes including 30-day mortality, was open versus laparoscopic surgery.

Predictive value of total psoas muscle index for postoperative physical functional decline in older patients undergoing emergency abdominal surgery

BackgroundOlder individuals increasingly require emergency abdominal surgeries. They are susceptible to surgical stress and loss of independence in performing daily activities. We hypothesized that the psoas muscle volume would be significantly associated with postoperative functional decline (FD) in older patients undergoing emergency abdominal surgery and aimed to evaluate the use of the psoas muscle volume on computed tomography (CT) scans.MethodsA retrospective, single-center study of patients aged ≥ 65 years who had undergone emergency abdominal surgery between January 2019 and June 2021 was performed. We assessed patients’ activities of daily living using the Barthel Index. FD was defined as a ≥ 5-point decrease between preoperative and 28-day postoperative values. The psoas muscle volume was measured by CT, which was used for diagnosis, and normalized by height to calculate total psoas muscle index (TPI). We evaluated associations between FD and TPI using receiver operating characteristics (ROC) analysis and multiple logistic regression analysis.ResultsOf 238 eligible patients, 71 (29.8%) had clinical postoperative FD. Compared to the non-FD group, the FD group was significantly older and had a higher proportion of females, higher Charlson Comorbidity Index, lower body mass index, higher American Society of Anesthesiology score, lower serum albumin level, and lower TPI. ROC analyses revealed that TPI had the highest area under the curve (0.802; 95% confidence interval [CI], 0.75–0.86). A multivariable logistic regression model revealed that low TPI was an independent predictor of postoperative FD (odds ratio, 0.14; 95% CI, 0.06–0.32).ConclusionsTPI can predict postoperative FD due to emergency abdominal surgery. Identification of patients who are at high risk of FD before surgery may be useful for enhancing the regionalized system of care for emergency general surgery.

Risk factor analysis of postoperative complications in patients undergoing emergency abdominal surgery

PurposeTo investigate the relationship between intraoperative anesthesia-related factors and postoperative complications in patients undergoing emergency abdominal surgery, and to identify risk factors for these postoperative complications. MethodsWe retrospectively analyzed 942 emergency surgery patients who underwent general anesthesia and emergency abdominal operations at Jiangsu Province Hospital during the period September 2015 to December 2016. Logistic regression analysis was performed to analyze the association between preoperative or intraoperative parameters and postoperative complications. ResultsAmong the 942 patients whose data were analyzed, 226 (24.0%) had major postoperative complications within 30 days after surgery. The most common postoperative complications were respiratory complications (31.8% of those experiencing complications). After adjusting for the role of multiple confounding factors, multivariable analysis showed that the independent risk factors for postoperative complications were patient age (OR 1.648; 95% CI 1.352–2.008), the ASA classification (OR 3.220; 95% CI 2.492–4.162), intraoperative hypotension lasting more than 20 min (OR 2.031; 95% CI 1.256–3.285), intraoperative tachyarrhythmias (OR 2.205; 95% CI 1.114–4.365), and the surgical level (i.e. type and difficulty level) [OR 1.895; 95% CI 1.306–2.750]. ConclusionProlonged intraoperative hypotension (>20 min) and the occurrence of tachyarrhythmias are independent risk factors for postoperative complications in patients who undergo emergency abdominal surgery. During hemodynamic management of these patients, systolic blood pressure should be controlled to within 20% of the baseline value to reduce the risk of postoperative complications. In addition, a higher patient age, higher ASA grade, and a higher surgical classification level also significantly increase the risk of postoperative complications.

Sex-Based Differences in Survival Among Patients with Acute Abdomen Undergoing Surgery in Malawi: A Propensity Weighted Analysis.

Sex disparities in access to health care in low-resource settings have been demonstrated. Still, there has been little research on the effect of sex on postoperative outcomes. We evaluated the relationship between sex and mortality after emergency abdominal surgery. We performed a retrospective cohort study using the acute care surgery database at Kamuzu Central Hospital (KCH) in Malawi. We included patients who underwent emergency abdominal surgery between 2013 and 2021. We created a propensity score weighted Cox proportional hazards model to assess the relationship between sex and inpatient survival. We included 2052 patients in the study, and 76% were males. The most common admission diagnosis in both groups was bowel obstruction. Females had a higher admission shock index than males (0.91 vs. 0.81, p < 0.001) and a longer delay from admission until surgery (1.47 vs. 0.79days, p < 0.001). Females and males had similar crude postoperative mortality (16.3% vs. 15.3%, p = 0.621). The final Cox proportional hazards regression model was based on the propensity-weighted cohort. The mortality hazard ratio was 0.65 among females compared to males (95% CI 0.46-0.92, p = 0.014). Our results show a survival advantage among female patients undergoing emergency abdominal surgery despite sex-based disparities in access to surgical care that favors males. Further research is needed to understand the mechanisms underlying these findings.

Variables affecting mortality rates in patients undergoing emergency abdominal surgery: A retrospective cross-sectional study.

Patients operated under emergency conditions have a higher risk of death and complications than those per-formed under elective conditions. Especially the patient group with high comorbidity needs to be evaluated more specifically. Accord-ing to the surgical risk and American Society of Anesthesiologists (ASA) scoring, the perioperative risk should be determined quickly, and the relatives of the patients should be informed. This study aimed to evaluate the factors affecting mortality and morbidity in patients undergoing emergency abdominal surgery. A total of 1065 patients aged 18 years and older who underwent emergency abdominal surgery in 1 year were included in the study. The primary aim of this study was to determine the mortality rates in the first 30 days and 1 year and the variables af-fecting these rates. Of 1065 patients, 385 (36.2%) were female and 680 (63.8%) were male. The most common procedure was appendectomy (70.8%), followed by diagnostic laparotomy (10.2%), peptic ulcus perforation (6.7%), herniography (5.5%), colon resection (3.6%), and small bowel resection (3.2%). There was a significant difference between the age of the patients and mortality (p<0.05). There is no statistically significant relationship between gender and mortality. A statistically significant correlation was found between ASA scores, perioperative complication, perioperative blood product use, reoperation, intensive care unit admission, hospitalization time, periop-erative complication, and 30-day mortality and 1-year mortality. There is a significant relationship between trauma and only 30-day mortality (p=0.030). The morbidity and mortality of patients operated on under emergency conditions increased compared to elective surgical operations, especially those over age 70. The 30-day mortality rate of patients who underwent emergency abdominal surgery is 3%, while the 1-year mortality rate is 5.5%. Mortality rates are higher in patients with a high ASA risk score. However, mortality rates in our study were found to be higher than the mortality rates in ASA risk scoring.

Predictors of mortality in patients undergoing emergency abdominal surgery: a prospective study

Predictors of mortality in patients undergoing emergency abdominal surgery: a prospective study

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.

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques.

Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality. To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients. This retrospective study includes 297 patients 70years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU). For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points. Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling. Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

Prevalence and Factors Associated with Acute Postoperative Pain after Emergency Abdominal Surgery

Objective: This study aimed to assess the prevalence and associated factors of acute postoperative pain after emergency abdominal surgery in the first 24 postoperative hours among adult patients. Methods: An institutional-based cross-sectional study was conducted on adult patients undergoing emergency abdominal surgery at the University of Gondar Comprehensive Specialized Hospital from March 1 to May 30, 2020. Data were collected by delivering questionnaires through interviews and reviewing the patients’ charts. Data were entered into Epi Info software, version 7.2, and analyzed by SPSS version 20. Logistic regression was applied to point out independent risk factors for postoperative acute pain. Variables with a p-value of &lt; 0.05 were taken as significant. Results: 165 patients participated in the study with a response rate of 98.2%. Among these, 75.8% [95% CI: (69.8%, 82.3%)] of patients experienced moderate to severe acute postoperative pain. Female gender [AOR:3.9, 95%CI: (1.22,12.5)], preoperative anxiety[AOR:4.4,95%CI:(1.74,11.1)],moderate to severe preoperative pain[AOR:5.79,95%CI:(2.08,16.1)], and incision length ≥10cms [AOR: 4.86, 95%(CI:1.88,12.5)], were significantly associated with moderate to severe acute postoperative pain. Conclusions and Recommendations: The prevalence of immediate postoperative pain following emergency abdominal surgery was found to be high in this study. Acute postoperative pain was substantially linked to the female sex, preoperative anxiety, preoperative pain, and an incision length of ≥10 cm. The prevalence of moderate-to-severe acute postoperative pain as well as the factors that contribute to it can be used to develop particular preventive strategies to reduce patient suffering.

Intraoperative Surgical Strategy in Abdominal Emergency Surgery.

Emergency abdominal surgery is associated with a high rate of postoperative complications and death. Pre- and immediate postoperative bundle-care strategies have improved outcome, but so far, no standardized intraoperative strategies have been proposed. We introduced a quality improvement model of specific intra- and postoperative strategies for the heterogenous group of patients undergoing emergency abdominal surgery. The objective was to evaluate a quality improvement strategy, using an intraoperative, multidisciplinary time-out model in emergency abdominal surgery to apply one of three surgical strategies; definitive-palliative-or damage control surgery. All patients scheduled for any gastrointestinal emergency procedure were stratified dynamically according to standardized criteria for performing definitive-palliative-or damage control surgery. Pre- intra- and postoperative data were collected according to the intraoperative strategy applied. Postoperative complications were displayed according to the Clavien-Dindo-score and the CCI (Comprehensive Complication Index). 30-90-day- and 1-year mortality was presented. We included 436 consecutive patients undergoing emergency laparotomy or laparoscopy in 2019. Intraoperative strategy was definitive in 326(75%)-palliative in 90(21%) and damage control approach in 20(4%) patients. CCI was 21(0,45), 30(17,54) and 78(54,100) in the definitive-, the palliative-, and the damage control group, respectively. 30-day mortality was; 11.7%, 26.7% and 30%, and the 1-year mortality was 16.9%, 56.7% and 40% in the definitive- the palliative- and the damage control group, respectively. We present a multidisciplinary, intraoperative decision-making standard as a potential quality improvement tool of ensuring individualized intra- and postoperative treatment for every emergency surgical patient and for future research-protocols.

Educational impact and recommendations from implementation of student-led clinical trial recruitment: a mixed-methods study.

Medical students have an essential role in medical research, yet often lack opportunities for involvement within randomised trials. This study aimed to understand the educational impact of clinical trial recruitment for medical students. Tracking wound infection with smartphone technology (TWIST) was a randomised controlled trial that included adult patients undergoing emergency abdominal surgery across two university teaching hospitals. All recruiters underwent prerecruitment training based on 'Generating Student Recruiters for Randomised Trials' principles, and completed prerecruitment and postrecruitment surveys. Respondent agreement with statements were assessed using 5-point Likert scales (from 1 ('strongly disagree') to 5 ('strongly agree')). Quantitative data were analysed using paired t-tests to compare differences pre-involvement and post-involvement. Thematic content analysis was performed on free-text data to generate recommendations for future student research involvement. Of 492 patients recruited to TWIST between 26 July 2016 and 4 March 2020, 86.0% (n=423) were recruited by medical students. Following introduction of student co-investigators (n=31), the overall monthly recruitment rate tripled (4.8-15.7 patients). 96.8% of recruiters (n=30/31) completed both surveys, and all respondents reported significant improvement in clinical and academic competencies. Three higher-level thematic domains emerged from the qualitative analysis: (1) engagement, (2) preparation and (3) ongoing support. Student recruitment in clinical trials is feasible and accelerates recruitment to clinical trials. Students demonstrated novel clinical research competencies and increased their likelihood of future involvement. Adequate training, support and selection of suitable trials are essential for future student involvement in randomised trials.

Financial risk of emergency abdominal surgery: a cross sectional study from Ethiopia

BackgroundThe Lancet Commission on Global Surgery suggested six indicators every country should use to measure their surgical systems. One of these indicators, catastrophic expenditure (CE), is defined as money paid for service which amounts to more than 10% of the patient’s total annual expenditure, or more than 40% of annual non-food household expenditure. Ethiopian Ministry of Health has set a target of 100% protection from CE by 2030. However, so far there is lack of studies that assess financial risk of surgery.MethodsUsing a cross sectional study design, financial risk assessment was carried out on 142 patients from Yekatit 12 and Zewditu Memorial hospitals in Addis Ababa, Ethiopia from May 15 to September 15, 2021.ResultsAppendectomy (69.0%), emergency laparotomy (26.1%) and cholecystectomy (4.9%) resulted in mean direct medical expenditures of 111.7USD, 200.70USD and 224.60USD, respectively. Medications and imaging accounted for 60.8 and 13.9% of total treatment cost. By applying the two definitions of catastrophic expenditure, 67.6 and 62.7% of patients sustained CE, respectively Overall rates of CE across procedures were 67.3 and 59.1% for appendectomy, 70.2 and 70.2% for laparotomy, 57.0 and 71.2% for cholecystectomy. Thirty-five (24.6%) patients had some form of insurance, with Community Based Health Insurance being the most common form (57%). Insured patients were less likely to sustain CE with both definitions (AOR 0.09, p = 0.002 and AOR 0.10, p = 0.006 respectively).Conclusion and recommendationsSubstantial proportion of patients undergoing emergency abdominal surgery sustain CE in Addis Ababa. Medications and imaging take major share of total cost mainly because patients have to acquire them from private set ups. Policy makers should work on availing medications and imaging in public hospitals as well as expand insurance and other forms of surgical care financing to protect patients from CE.

Evaluation of pre-operative albumin in the prediction of outcomes of emergency laparotomy

Background: Hypoalbuminemia has been established indicator of nutritional status, which may and may not be clinically apparent, but is linked to a significantly higher risk of morbidity and mortality. Objective: To assess the post-operative morbidity with relation to pre-operative albumin status in patients undergoing emergency abdominal surgery. Methods: It was a hospital based observational study, 100 patients undergoing emergency abdominal surgery at Tertiary care Hospital was included. Hypoalbuminemia was diagnosed if serum albumin level was less than 3.5 gm/dl. Study period was between May 2021 to April 2022. The Statistical software namely SPSS 11.0 and Systat 8.0 were used for the analysis. Results: Pre-operatively, 60 patients had hypoalbuminemia (serum albumin &lt;3.5 g/dl) and 40 patients had normal albumin levels (≥3.5 g/dl). Out of 100 patients, 41 (41%) developed complications postoperatively. 32 patients (50%) out of 60 patients with hypoalbuminemia (with serum albumin&lt;3.5 g/dl) had complications. 9 patients (17.5%) with albumin level ≥3.5 g/dl had complications. Mean length of hospital stay was found to be higher i.e. 9.70±4.75 days in patients with hypoalbuminemia, compared to 6.45±3.31 days with those having albumin level ≥3.5 g/dl. Conclusions: Preoperative albumin is a useful low-cost prognostic predictor for predicting surgery outcome.

Inter-hospital Transfer Delays to a Tertiary Referral Center and Postoperative Outcomes in Patients with Abdominal Surgical Emergencies in Malawi.

In low-income countries (LICs), patients with abdominal surgical emergencies often initially present to primary or district hospitals and are transferred to referral hospitals for surgical management. The transfer process introduces a delay to care, but the relationship between transfer time and outcomes has not been studied in LICs. We sought to evaluate the effect of transfer delays on postoperative outcomes among patients undergoing emergency abdominal surgery in Malawi. This is a retrospective analysis of the acute care surgery database at Kamuzu Central Hospital (KCH), a referral hospital in Malawi. Patients were eligible for inclusion if transferred from another facility to KCH for emergency abdominal surgery. We used logistic regression modeling to evaluate the relationship between transfer time and postoperative complications and mortality. The study included 2037 patients. Female patients, patients transferred from district hospitals, and patients with bowel obstructions were most likely to spend over three days at a referring facility before transfer. On regression modeling, each additional day until transfer was associated with an 18% increase in odds of developing a postoperative complication (OR 1.18, 95% CI 1.05-1.31, p = 0.005) and a 19% increase in odds of postoperative mortality (OR 1.19, 95% CI 1.08-1.31, p < 0.001). Among patients requiring emergency abdominal surgery in Malawi, transfer delays are associated with higher postoperative complications and mortality rates. Further research should focus on identifying the factors causing delays so that interventions aimed at improving the transfer process can be developed.