Emergency Laparotomy

Emergency Laparotomy

• Common surgical procedure

• Significant associated morbidity and mortality

• Heterogenous group of conditions and presentations

• Patients often have significant physiological derangement and

multiple comorbidities

• Pose significant challenges to patients, clinicians and organisations

Indications for Laparotomy

Role of Conservative Management

Imaging Guided Interventions

Forgotten Patients

RCS 2011

Outcomes following Emergency Laparotomy

30 000 / year in UK

30-day mortality in 201214.9%(25% in patients > 80)

£88 million/year ICU costs

NCEPOD Report 2011

• Emergency surgery outcomes in the UK

worse than in the USA

Strategies to improve this

• Better identification of high-risk patients

• Improved triage and pre-assessment

• Better intraoperative care

• Increased use of critical care post-

operatively

2015

Preoperative Preparation

Preoperative Preparation

• Risk stratification through history-taking, examination and tests

Routine Investigations

• Basic blood tests

• Pregnancy test where appropriate

• Arterial or venous blood gas to include lactate measurement

• CXR

• ECG

• CT Scan

• Resuscitation must not delay

access to theatre

• Should occur simultaneously

• Aim for surgery within 6 hours

of the decision

• Aim for 2 hours in life-

threatening pathology

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P-POSSUMPhysiological and Operative Severity Score for the enUmeration of Mortality and morbidity

NELA Risk Calculator

• Estimates of the risk of death within 30 days of emergency abdominal

surgery.

• Developed using data from patients entered into the NELA database

between 2014 and 2016.

• Shown to be more accurate than the P-POSSUM calculator for

patients undergoing emergency laparotomy in the UK

• Reviewed at regular intervals for accuracy against contemporary

patient populations

Management of Anaesthesia

Management of Anaesthesia

• Rapidly securing the airway to reduce the risk of pulmonary aspiration

• Haemodynamic stability during RSI and throughout the perioperative period

• Optimum volume and type of fluid

• Protective lung ventilation strategies

• Analgesia

• Post-operative considerations

Post-operative Concerns

• Analgesia

• ICU admission

• NELA recommends patients with 10% or more predicted mortality

• ELC recommends all patients

• Collaborative decision making about extubation

• Avoidance of hyperglycaemia

• Optimising nutritional status

• Thromboprophylaxis

Impact of NELA

• 30-day mortality in 2012• 14.9% (25% in patients > 80 years old)

• 9.5% 30-day mortality in 2018 in participating hospitals• Reduced length of stay• Improved access to theatre• Improved access to critical care

NELA Ratings

Remaining challenges

• Provision of geriatrician-led care for older patients

• Timely antibiotics in patients with sepsis

• Formal pathways in hospitals

• Consultant delivered care

• Imaging and reporting

• Introduction of best-practice tariff