Impact of targeted preoperative optimization on clinical outcome in emergency abdominal surgeries: A prospective randomized trial

Abstract

Background:Perforation peritonitis continues to be one of the most common surgical emergencies that need a surgical intervention most of the times. Anesthesiologists are invariably involved in managing such cases efficiently in perioperative period.Aims:The assessment and evaluation of Acute Physiology and Chronic Health Evaluation II (APACHE II) score at presentation and 24 h after goal-directed optimization, administration of empirical broad-spectrum antibiotics, and definitive source control postoperatively. Outcome assessment in terms of duration of hospital stay and mortality in with or without optimization was also measured.Settings/Design:It is a prospective, randomized, double-blind controlled study in hospital setting.Materials and Methods:One hundred and one patients aged ≥18 years, of the American Society of Anesthesiologists physical Status I and II (E) with clinical diagnosis of perforation peritonitis posted for surgery were enrolled. Enrolled patients were randomly divided into two groups. Group A is optimized by goal-directed optimization protocol in the preoperative holding room by anesthesiology residents whereas in Group S, managed by surgery residents in the surgical wards without any fixed algorithm. The assessment of APACHE II score was done as a first step on admission and 24 h postoperatively. Duration of hospital stay and mortality in both the groups were also measured and compared.Statistical Analysis:Categorical data are presented as frequency counts (percent) and compared using the Chi-square or Fisher's exact test. The statistical significance for categorical variables was determined by Chi-square analysis. For continuous variables, a two-sample t-test was applied.Results:The mean APACHE II score on admission in case and control groups was comparable. Significant lowering of serial scores in case group was observed as compared to control group (P = 0.02). There was a significant lowering of mean duration of hospital stay seen in case group (9.8 ± 1.7 days) as compared to control group (P = 0.007). Furthermore, a significant decline in death rate was noted in case group as compared to control group (P = 0.03).Conclusion:Goal-directed optimized patients with perforation peritonitis were discharged early as compared to control group with significantly lesser mortality as compared with randomly optimized patients in the perioperative period.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

“…Preoperative goal-directed fluid therapy was used in two of the multimodal cohort studies which showed significant reduction in mortality [ 3 , 29 ]. Another small study used a goal-directed fluid optimization protocol in the preoperative holding room in patients with perforated peptic ulcer and showed reduced length of stay and mortality compared with a usual management control group [ 47 ]. Lactate guided resuscitation of patients with septic shock has been shown to reduce mortality [ 46 ] and may be beneficial in patients undergoing emergency laparotomy.…”

Meta‐analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery

“…Full preoperative counselling, which is known to reduce post-operative stress, pain and anxiety [24], may not be possible in emergency setting; nevertheless, information such as details of procedure, possible perioperative complications, need for creation of stoma and length of hospitalisation can be communicated with patients and their family before the procedure. On the other hand, although complete optimisation of medical conditions cannot be achieved in emergency setting, objective intravenous fluid and antibiotic resuscitation in emergency major abdominal surgery are crucial and feasible [25]. Apart from these, the rest of intraoperative and post-operative components of ERAS protocols [26][27][28][29][30][31] are achievable in emergency settings.…”

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

“…The impact of preoperative optimization on clinical outcome following emergency laparotomy has recently been studied in a prospective randomized trial of 94 patients with generalized peritonitis due to gastrointestinal perforation[19]. This study demonstrated a shorter length of hospital stay and a lower rate of postoperative death in patients receiving standardized, algorithmic management in the preoperative holding room – where central venous cannulation was performed and goal-directed optimization was done.…”