SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting

Timan, Terje Jansson; Sernert, Ninni; Karlsson, Ove; Prytz, Mattias

doi:10.1186/s13104-020-05030-4

Cited by 8 publications

(7 citation statements)

References 16 publications

(33 reference statements)

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“…It is therefore of great importance to further study this group of patients. Our results present the first part of the SMASH project [ 21 ], an ongoing study at the Northern Älvsborg County Hospital (NÄL), NU-Hospital Group (Trollhättan, Sweden) exploring whether or not the introduction of a standardised perioperative protocol for high-risk abdominal surgery can affect outcome in a Swedish context.…”

Section: Discussionmentioning

confidence: 99%

Mortality following emergency laparotomy: a Swedish cohort study

et al. 2021

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Background Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. Methods Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014–2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort. Results A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification. Conclusions In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies. Trial registration: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).

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Section: Discussionmentioning

confidence: 99%

Mortality following emergency laparotomy: a Swedish cohort study

et al. 2021

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“…Encouraged by these changes, in 2017 the NU Hospital Group (Vastra Gotaland County in southwestern Sweden) developed a protocol for standardized management. The SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study started in February 2018 17 . The aim of the study was to investigate whether standardized perioperative management improved postoperative outcomes after emergency laparotomy in a Swedish context.…”

Section: Introductionmentioning

confidence: 99%

Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study

Timan

Karlsson

Sernert

et al. 2023

British Journal of Surgery

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Background Acute high-risk abdominal surgery is common, as are the attendant risks of organ failure, need for intensive care, mortality, or long hospital stay. This study assessed the implementation of standardized management. Methods A prospective study of all adults undergoing emergency laparotomy over an interval of 42 months (2018–2021) was undertaken; outcomes were compared with those of a retrospective control group. A new standardized clinical protocol was activated for all patients including: prompt bedside physical assessment by the surgeon and anaesthetist, interprofessional communication regarding location of resuscitation, elimination of unnecessary factors that might delay surgery, improved operating theatre competence, regular epidural, enhanced recovery care, and frequent early warning scores. The primary endpoint was 30-day mortality. Secondary endpoints were duration of hospital stay, need for intensive care, and surgical complications. Results A total of 1344 patients were included, 663 in the control group and 681 in the intervention group. The use of antibiotics increased (81.4 versus 94.7 per cent), and the time from the decision to operate to the start of surgery was reduced (3.80 versus 3.22 h) with use of the new protocol. Fewer anastomoses were performed (22.5 versus 16.8 per cent). The 30-day mortality rate was 14.5 per cent in the historical control group and 10.7 per cent in the intervention group (P = 0.045). The mean duration of hospital (11.9 versus 10.2 days; P = 0.007) and ICU (5.40 versus 3.12 days; P = 0.007) stays was also reduced. The rate of serious surgical complications (grade IIIb–V) was lower (37.6 versus 27.3 per cent; P = <0.001). Conclusion Standardized management protocols improved outcomes after emergency laparotomy.

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“…Looking forward, there is obviously a drive to reduce morbidity and mortality and lead to a better outcome by raising awareness and implementing change. The SMASH trial from Sweden is ongoing, seeks to determine whether a new standardised perioperative protocols consisting of rapid start of operation in emergency abdominal surgical procedures leads to a better outcome compared with the present standard in Swedish routine health-care [25]. In China, the Abdominal Pain Center model has been in place for several years and has demonstrated a better management and in-hospital clinical outcomes of patients with abdomen.…”

Section: Discussionmentioning

confidence: 99%

Association of onset-to-surgery time with morbidity and mortality among patients with perforated peptic ulcer: an observational cohort study

Tan

Heng

et al. 2022

Preprint

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Background: Rapid surgery is recommended to improve outcomes after peptic ulcer perforation (PPU), but understanding of the optimal onset-to-surgery time for PPU is limited. The purpose of this study was to assess the optimal time of onset to surgery for PPU that improved patient outcomes. Methods: Data of eligible patients with PPU at three hospitals from 2019 to 2021 were retrospectively reviewed. Patients were categorized as a onset-to-surgery time of ≤ 12 h (early surgery [ES]) or > 12 h (late surgery [LS]). The primary outcome was 30-day sepsis morbidity. Secondary outcomes included 30-day postoperative morbidity and 30-day mortality. Patients’ characteristics and surgical outcomes were also compared. A P value of < 0.05 is considered as statistically significant. Results: Of 245 patients, 231 (94.3%; mean [SD] age, 62.6 [18.2] years; 153 [70.5%] male)were included in the final analysis. Among the remaining cases, 50.7% underwent ES and 49.3% underwent LS. LS was associated with increased sepsis morbidity within 30 days (ORadj 5.71, 95% CI 2.02-16.10, P = 0.001). In secondary analyses, LS was associated with an increased risk of postoperative morbidity (ORadj 1.93, 95% CI 1.06-3.53, P = 0.032). The 30-day mortality was 0.9% in the ES group and 4.7% in the LS group (ORadj 3.93, 95% CI 0.43-36.05, P = 0.227). In addition, the estimated blood loss during ES was significantly less than that during LS (P = 0.004). The operative time and hospital stay were shorter in the ES group (both P < 0.005). Moreover, patients in the LS group were more likely to need for ICU admission (39.3% vs 22.7%, P = 0.008). Conclusions: This cohort study found evidence that more favorable outcomes were achieved when surgery was performed within 12 hours after the onset of severe abdominal pain among patients with PPU. These findings provide more clarity around the optimal time of onset to surgery for patients with PPU. However, more well powered researches are needed to confirm the findings.

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SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting

Cited by 8 publications

References 16 publications

Mortality following emergency laparotomy: a Swedish cohort study

Mortality following emergency laparotomy: a Swedish cohort study

Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study

Association of onset-to-surgery time with morbidity and mortality among patients with perforated peptic ulcer: an observational cohort study

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