Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room

Abstract

IntroductionThe prognoses of critically ill patients with a requirement for emergency laparotomy and severe respiratory and/or hemodynamic instability precluding transport to the operating room (OR) are often fatal without surgery. Attempting emergency surgery at the bedside might equally result in an adverse outcome. However, risk factors and predictors that could support clinical decision making have not been identified so far. This study describes the clinical characteristics, indicative pathophysiology and outcomes in patients undergoing resuscitative laparotomy in the intensive care unit (ICU).MethodsThis was a retrospective observational study of all critically ill adult patients undergoing resuscitative laparotomy in the ICUs of a German university hospital from January 2005 to July 2013. Clinical characteristics, risk factors, and treatments were compared between survivors and non-survivors. The primary endpoint was 28-day survival.ResultsA total of 41 patients with a median age of 64 (21 to 83) were included. The most frequent reasons for ICU admission were sepsis, pneumonia, and pancreatic surgery. All patients were mechanically ventilated, receiving vasopressors, and were in multiple organ failure. Twenty-nine patients (70.7%) were on renal replacement therapy and two patients (4.9%) on extracorporeal membrane oxygenation. The main reasons for surgery were suspected intra-abdominal bleeding (39.0%), suspected intestinal ischemia (24.4%) or abdominal compartment syndrome (24.4%). Twenty-eight-day, ICU and hospital mortalities were 75.6%, 80.5%, and 82.9%, respectively. In six out of ten patients (60%) who survived surgery for more than 28 days, bedside laparotomy was rated as a life-saving procedure by an interdisciplinary group of the investigators.ConclusionsThese findings suggest that in selected critically ill patients with a vital indication for emergency laparotomy and severe cardiopulmonary instability precluding transport to the OR, a bedside resuscitative laparotomy in the ICU can be considered as a rescue procedure, even though very high mortality is to be expected.

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

“…Accordingly, abdominal exploration is often considered as both diagnostic and potentially therapeutic for those with acute severe critical illness without a well-defined alternate etiology. Hemodynamically unstable patients who are unsafe to transport to the OR for whom an intra-abdominal catastrophe is believed to be the underpinning etiology may be explored at the bedside in the ICU [ 8 , 9 ]. Unsurprisingly, such patients are believed to have a rather poor outcome either with or without intervention, leaving exploration as an “intervention of last resort.” There is no well-defined metric by which the postoperative outcome may be predicted with sufficient certainty to inform surrogate decision makers, as well as the surgeon, in deciding on the advisability of undertaking bedside exploration with regard to outcome and quality of life.…”

Intra-abdominal hypertension complicating pancreatitis-induced acute respiratory distress syndrome in three patients on extracorporeal membrane oxygenation

“…Schreiber et al [12] describe a retrospective review from a single centre. Forty-two patients underwent a laparotomy in the ICU as they were deemed too unstable to be transferred to the operating room.…”

Secondary ARDS Following Acute Pancreatitis: Is Extracorporeal Membrane Oxygenation Feasible or Futile?

“…A decompressive laparotomy can be an option and should be indicated at the bedside by an interdisciplinary team approach [ 22 ]. Mostly, decompressive laparotomy is performed as rescue bedside laparotomy in the ICU because patients are not suitable for in-house transport to the operating room [ 22 , 23 ]. Most decompressive laparotomies are required due to abdominal conditions, with acute pancreatitis being one of the most common causes [ 24 ].…”