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Perioperativ optimering af akutte højrisiko
abdominalkirurgiske patienter
Erfaringer med en systematisk tilgang til kvalitetsforbedring
Line Toft Tengberg
PhD og læge
Kirurgisk afdeling
Sjællands Universitetshospital Køge
The AHA study group • Nicolai Bang Foss • Morten Bay-Nielsen • Morten Lauritsen • Janne Orbæk • Lena Veyhe • Mirjana Cihoric • Hans Jørgen Nielsen • Thue Bisgaard • Lars Lindgaard
Dagsorden
• Baggrund
• Studie I-III
• Konklusion
• Diskussion
Sygelighed og dødelighed efter akut
abdominalkirurgi
Abdominalkirurgi
Abdominalkirurgi
Why should we focus on emergency surgery patients?
• High mortality rates
• Multiple postoperative complications
• Prolonged hospital stay
Vulnerable population
Saunders et al 2012
Saunders et al 2012
Variation i 30 dages dødeligheden i UK efter akut laparotomi på 4-40%
British Journal of Surgery 2015 January
PULP studiet
Scandinavian Journal of Gastroenterology. 2013; 48: 168-175
Patients undergoing
Acute
High-risk
Abdominal
surgery
Including both primary operations and reoperations
AHA patients
All patients >18 years having an emergency laparotomy or laparoscopy due to major gastrointestinal pathology Does not include appendectomies, diagnostic laparoscopies/laparotomies, cholecystectomies, simple herniotomies without bowel resections, sub-acute internal hernias after Roux-en-Y gastric bypass surgery, sub-acute surgery for inflammatory bowel diseases, and sub-acute colorectal cancer-surgery. We excluded pregnant women, traumas, as well as urogenital, gynaecological and vascular pathology, except for mesenteric ischemia
Abdominal catastrophes
Most common abdominal catastrophes
Perforated viscus Bowel obstruction
+ ”others”:
3.000-4.000 / year
30 day mortality: 15-25%
Perspective: Elective high risk procedures
Colorectal resection: 1-4 % Coronary by-pass surgery 2-5 %
Skyhigh mortality – Why?
The patients:
Elderly
Comorbid
Frail
Acute physiologically deranged
”Needle in the haystack”
Unplanned admittance 24-7: Challenge
logistics and capacity
SEPSIS
Sepsis is the body’s overwhelming and life-threatening response to infection
Tissue damage
Organ failure
death
Kvalitetsforbedring
1. Identificere problemet
2. Kvantificere problemet
3. Identificere løsningen
4. Implementere løsningen
5. Måle effekten
Identifikation
-Det er desværre ikke kun patienten der er problemet
Poor ”traditional” care of emergency
surgery patients
Surgical delay – logistics
Prolonged fasting
Prolonged immobilization
Perioperative resuscitation lacking
Opioid pain management (– if any)
HDU/ICU: restricted capacity
Medical optimization – badly defined
Absence of multidisciplinary care
No standardized care
Our responsibility
Overview of 30-day mortality, reported in patients undergoing subcategories
of AHA surgery in Denmark
Papers Inclusion criteria, year n 30-day mortality, %
Sørensen et al
Journal of Gastrointestinal Surgery,
2007
Open abdominal surgery including
appendectomies and cholecystectomies, 1995-
1998
1867 13.8
Svenningsen et al
Danish Medical Journal, 2014
Primary explorative laparotomy, 2010-2011 131 Overall: 23.7
<75 years: 10.6
≥75 years: 47.8
Vester-Andersen et al
British Journal of Anaesthesia, 2014
Patients undergoing AHA surgery
+ umbilical and ventral hernia without
strangulation, 2009-2010
2904 Overall: 18.5
>80 years: 38.1
Danish Clinical Register
of Emergency Surgery,
period of registration:
Inclusion criteria n 30-day
mortality, %
2011/2012
2012/2013
2013/2014
2014/2015
Patients undergoing laparoscopic
or open repair of perforated
peptic ulcer
333
384
272
276
22
21
14
22
Copenhagen University Hospital Hvidovre A giant non-trauma emergency unit
Catchment area: 515.000 inhabitants
Admittances:
n = 67.000/year
Copenhagen University Hospital Hvidovre A giant non-trauma emergency unit
Data from Søren Neermark
85% emergency
15% elective
Gastro Unit, surgical division 2012/13
Data from Morten Bay-Nielsen
9.000-10.000 emergency admittances pr. year Approximately 1/5 undergo emergency surgery
30-40 AHA surgery patients every month
Study I - III
Study I – Identification and quantification
High incidence of complications after emergency laparotomy beyond the immediate postoperative period
Anaesthesia. 2016 Nov 3. [Epub ahead of print]
Study I – Aim
To investigate mortality rate and complications following AHA surgery in the Capitol Region of
Denmark
DATA DRIVES CHANGE
Capitol Region of Denmark 2012
• 4 Hospitals: 1.62 million inhabitants
• n = 1139 patients
• 4 Hospitals: 1.62 million inhabitants
• n = 1139 patients
• Median age: 70 years
• ASA>2 : 46%
Capitol Region of Denmark 2012
• 4 Hospitals: 1.62 million inhabitants
• n = 1139 patients
• Median age: 70 years
• ASA>2 : 46%
• Diagnoses: Obstruction (47%)
Perforated viscus (40 %)
Other (13%)
Capitol Region of Denmark 2012
• 4 Hospitals: 1.62 million inhabitants
• n = 1139 patients
• Median age: 70 years
• ASA>2 : 46%
• Diagnoses: Obstruction (47%)
Perforated viscus (40 %)
Other (13%)
8 %: documented severe sepsis/septic shock (pre-op)
24%: no documentation of vital parameters (pre-op)
Capitol Region of Denmark 2012
• 71%
had complications
Capitol Region of Denmark 2012
• 71%
had complications
• 47%
had a major complication
(CDC>2)
Capitol Region of Denmark 2012
• 71%
had complications
• 47%
had a major complication
(CDC>2)
• 25%
went to ICU
Capitol Region of Denmark 2012
Complications
Most common non-GI complications: • Pulmonary: 19.3%
• Cardiac: 8.3%
- complications
All patients
+ complications
Kaplan-Meier plot: survival analysis illustrating the correlation
between having complications and an increased risk of death
- complications
All patients
+ complications
Kaplan-Meier plot: survival analysis illustrating the correlation
between having complications and an increased risk of death
30 day mortality:
• 20%
- complications
All patients
+ complications
Kaplan-Meier plot: survival analysis illustrating the correlation
between having complications and an increased risk of death
30 day mortality:
• 20%
1 year mortality:
• 34%
- complications
All patients
+ complications
Kaplan-Meier plot: survival analysis illustrating the correlation
between having complications and an increased risk of death
30 day mortality:
• 20%
1 year mortality:
• 34%
Complications are
indisputably associated with
postoperative death
- complications
All patients
+ complications
Kaplan-Meier plot: survival analysis illustrating the correlation
between having complications and an increased risk of death
30 day mortality:
• 20%
1 year mortality:
• 34%
Complications are
indisputably associated with
postoperative death
Early deaths: 40 % of all deaths (within 30 days) occured within 72 hours postoperatively.
Median age: 78 years. 94 % : ASA≥3. 94 % primary operations, 98%
laparotomies. 46% had bowel ishemia, in more than half of these a decision
to end active treatment was made peroperatively.
Conclusion
High mortality and a protracted postoperative course
dominated by multiple complications
Strategies for prevention, treatment and rescue of
complications are urgently needed
Study II – The solution
Reduced mortality after implementation of a multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. –The AHA study
Accepted in British Journal of Surgery
Study II – Aim
To investigate the effect of an optimised multidisciplinary perioperative treatment in
patients undergoing AHA surgery in Hvidovre Hospital
Fokus i Gastroenheden Hvh på AHA-patienterne
• Vi vil forbedre outcome
• Vi vil øge det tværfaglige samarbejde
• Vi vil standardisere behandlingen
• Vi vil øge fokus på og viden om den udsatte
patientgruppe
• Vi vil tage ansvaret for at allokere ressourcer til dem der har det største behov
AHA Projektet Finansieret af Region Hovedstaden
Joint venture med Anæstesiologisk Afdeling
Samarbejdsaftaler med Funktions- og Billeddiagnostisk Afdeling samt Fysio- og Ergoterapeutisk Afdeling
AHA: Fra videnskab til daglig praksis
-Den videnskabelig proces, et ledelsesværktøj? • Et solidt videnskabeligt
projekt som bølgebryder for ændringer i kliniske klinisk praksis på tværs af afdelinger
• En passioneret forskningsgruppe bestående af både læger og sygeplejersker som bannerførere
Udfordringer og gevinster – Set fra et ledelsesperspektiv
• Økonomi • Tværfagligt samarbejde
• Organisation
• Konflikthåndtering
Økonomi
- Allokering af resourcer helt afgørende for implementering
• PhD projekt
• Uddannelse af personale
• Nye behandlingsmuligheder - Indkøb af udstyr
• Etablering af database
• Daglig drift: Inklusion og opfølgning
Poor ”traditional” care of emergency
surgery patients
Surgical delay – logistics
Prolonged fasting
Prolonged immobilization
Perioperative resuscitation lacking
Opioid pain management (– if any)
HDU/ICU: restricted capacity
Medical optimization – badly defined
Absence of multidisciplinary care
No standardized care
Challenge no. 1:
Designing a perioperative protocol from the existing evidence
Challenge no. 1:
Designing a perioperative protocol from the existing evidence
Very limited evidence
Pragmatic approach
+
Multidisciplinary COLLABORATION
Methods
• Single-center prospective controlled study in the largest department in Denmark
• Intervention: 600 consecutive patients after the implementation of the AHA perioperative protocol as standard treatment (2013-2015)
• Control: 600 consecutive patients from the same department before implementation (2011-2012)
All patients undergoing AHA surgery were analysed, regardless of compliance to the
protocol
Methods
Primary outcome: 30 day mortality
Secondary outcomes: 180 day mortality Length of stay Length of stay in the intensive care unit Complications
All procedures January 1, 2011 – September 12, 2012
n=9.035
Non-elective procedures n=5.328
AHA procedures
Control n=600
Emergency, non-AHA n= 4.911 Abscess incision or wound debridement (n=1.760) Appendectomies and laparoscopies with negative findings (n=1336) Endoscopies (n=929) Hernia repairs (n=171) Internal hernia due to gastric bypass surgery (n=134) Cholecystectomies, acute and subacute (n=253) Other minor procedures (n=328) Repeating surgery on the same patient in the study period (n=27)
Emergency, non-AHA n= 4.714 Abscess incision or wound debridement (n=1.786) Appendectomies and laparoscopies with negative findings (n=1.154) Endoscopies (n=901) Hernia repairs (n=139) Internal hernia due to gastric bypass surgery (n=149) Cholecystectomies, acute and subacute (n=227) Other minor procedures (n=358) Repeating surgery on the same patient in the study period (n=14)
All procedures June 1, 2013 – February 21, 2015
n=10.150
Non-elective procedures n=5.538
AHA procedures Intervention
n=600
elective procedures n=3.707
elective procedures n=4.612
Study profile
New standards – welldefined standards
Key Elements of the Protocol
• evaluation of patient by senior surgeon and anesthesiologist
• early preoperative nasogastric tube, arterial catheter and high dose intravenous
broad-spectrum antibiotics
• surgery within 6 hours after indication to operate
• intermediate care/intensive care lead by a senior anesthesiologist, or operation
theater, if available, immediately after the decision to operate.
• Stroke volume guided hemodynamic optimization pre-, per- and postoperative
(Pulse contour analysis) carried out in the PACU/operation theater
• standardized anesthesia protocol (TIVA/epidural)
• postoperative intermediate care
• postoperative standard nursing care map with optimal pain treatment, early
nutrition and mobilization
• High level of monitoring
• Consultant-led care 24-7!
• Standardized treatment
• Time matters! Prioritization
• ”AHA” -logistics
Suspected pathology
major emergency surgery pathway
-The perioperative period
PACU/HDU
Oxygen / sat > 94%
High dose Antibiotics
NG tube
PACU/HDU
If ASA 3-4 or Surgical
Apgar Score 0-4:
minimum 24 hours
postoperative stay
Abdominal “AHA” CT < 2 hours
Admittance papers
OR advised
Conference
between senior
surgeon and
anaesthetist - triage
CT
If indicated
Patient taken to
ward or ICU
Standardized
care
Surgery < 6 hours
GDT : SV + SVV
pulsecontour
analysis
LIDCO rapid
Epidural catheter
Arterial line
Rationale Early identification and resuscitation is essential for improved outcome. No exact diagnosis preoperatively We chose to calculate with optimizing ”too many”, rather than too few
Optimisation in the PACU/OR
A core element:
Senior anaesthesiologist responsible
Stroke-volume-guided hemodynamic optimisation
SOPs for every element in the pathway + actioncards
Implementation
Planning
Resources
Education of staff - Continuously
Actioncards and guidelines
Motivation
Coordination TEAMWORK
Support
8 months
Reality for me:
Living in a database
Implementeringsfasen
-Samarbejdsmøder
-Sparring kontinuerligt
-Fælles instrukser på tværs af afdelingerne
-Øget kommunikation i alle døgnets timer
-Udveksling: personalegrupper på besøg på de
forskellige afsnit – forståelse for arbejdsbelastning
og frustrationer
Tværfagligt fællesskab med patienten i centrum
Implementering
Nye rutiner tager tid – kræver tålmodighed
Compliance til protokol ændret fra 25 % til >90 %
i implementeringsperioden
Dimensionering/Kapacitet:
Den elektive patient viger for den akutte under
spidsbelastninger og kapacitetsproblemer.
-Koordination og fleksibilitet.
Compliance to protocol
kohorte
AHA KONTROL
ANTIBIOTICS
No antibiotics 10 22
peroperatively 89 289
postoperatively 7 3
preoperatively 488 286
24 hours in the PACU
Postoperative PACU? AHA cohort Directly to intensive care after surgery 67
Indicated, but not offered 23
Yes, Surgical Apgar 0-4 eller ASA 3-4 208
Not indicated according to protocol 302
AHA
preoperatively 460
postoperatively 500
Stroke-volume-guided hemodynamic optimization
PACU for 24 hours: 35 %
Stroke-volume-guided
hemodynamic optimization
in > 80 %
Results
Test of Equality over Strata
Test Chi-Square DF Pr > Chi-Square
Log-Rank 10.4 1 0.0013
Unadjusted mortality
Control
n=600
AHA
n=600
P
30-day
mortality
(%)
131 (21.8) 93 (15.5) 0.005
180-day
mortality
177 (29.5) 133 (22.2) 0.004
Risk-adjusted mortality
OR (95% CI)
Control 1
Intervention
adjusted for
• Age
• ASA
• Malignancy
• Zubrod score
• Surgical Technique (open vs lap)
• obstruction, perforation, other
0.56 (0.39-0.82)
Length of stay
Cohort n median q1 q3 sum
AHA 600 11 6 21 9902
CONTROL 600 10 5 22 10827
P = 0.783
ICU length of stay
Cohort
AHA
CONTROL
n median q1 q3 sum
146 3 1 9 1242
131 5 2 17 1622
P = 0.018
Proportion of patients with an
absence of major complications
Control: 48 %
AHA: 54 %
P-value: 0.0282
Uncomplicated cases
=
Limitations
Limitations
• Single center study with a historical control
Limitations
• Single center study with a historical control
• Multiple interventions – impossible to infer causality or to identify which elements are most important
Limitations
• Single center study with a historical control
• Multiple interventions – impossible to infer causality or to identify which elements are most important
• Hawthorne effect?
Limitations
• Single center study with a historical control
• Multiple interventions – impossible to infer causality or to identify which elements are most important
• Hawthorne effect?
• General national improvements in the period?
0.0
0.1
0.2
0.3
2011 Q
1
2011 Q
2
2011 Q
3
2011 Q
4
2012 Q
1
2012 Q
2
2012 Q
3
Control period
30 day mortality
0.0
0.1
0.2
0.3
2013 Q
2
2013 Q
3
2013 Q
4
2014 Q
1
2014 Q
2
2014 Q
3
2014 Q
4
2015 Q
1
Intervention period
30 day mortality
A B
Quarterly mortality in the cohorts
Danish Clinical Register of Emergency Surgery
30-day mortality in patients with surgically treated perforated peptic ulcer
in Denmark and Hvidovre 2011-2015.
Danish Clinical Register of Emergency Surgery
30-day mortality in patients with perforated peptic ulcer (Denmark), % (95% CI)
30-day mortality in patients with perforated peptic ulcer (Hvidovre), % (95% CI)
Overall reporting rate = patients reported/ patients registered in NPR, %
Hvidovre reporting rate = patients reported/ patients registered in NPR, %
2011/2012 22 (18-27) 24 (13-40) >90 (87-99%*) 96
2012/2013 21 (17-25)** 22 (10-39)*** <90 (83-94%*) 97
2013/2014 14 (11-19) 11 (2-29) 82 94
2014/2015 22 (17-27) 9 (1-29) 89 90
Conclusion
The AHA study protocol is associated
with a significant reduction in
mortality
The AHA study protocol is associated
with a changed pattern of use of
intermediate care and intensive care.
We have standardized the perioperativ
care in AHA surgery with a high level
of monitoring
Study III
Physical performance following acute high-risk abdominal surgery: a prospective cohort study
Det kontinuerlige kvalitetsudviklingsarbejde
Study III - Aim
To describe the physical performance and factors restricting physical performance
postoperatively in patients undergoing AHA surgery
Methods
Prospective cohort study
50 patients included consecutively from April to June 2014
During the first postoperative week:
• 7 patients died -> 43 included in analysis
• 12 were discharged
Patients still hospitalized on day 7:
• 50% (15/31) were not independently mobilized
Preoperative functional level
• New Mobility Score (NMS):
0-9, low - high functional level
Postoperative functional performance
• Thigh-worn accelerometer: ActivPAL
• Cumulated Ambulation Score (CAS):
0-6, unable - independent mobilizaton
Primarily restricting factors
• Pain, Motor blockade, Dizziness, Fatique, Nausea and vomiting, Acute cognitive dysfunction, Respiratory problems, Unconscious, Patient declines, Logistics, Monitoring equipment, Other.
Physical performance
Median number of days before being independently mobilized: 3 (1-8)
Median time laying or sitting (hours pr. day):
Day 2 23.8
Day 4 23.5
Day 7 23.4
Table 3. Differences in level of 24-hour physical activity between independently (CAS = 6) and non-independently (CAS < 6) mobilized patients within the first postoperative week
CAS < 6
Median (IQR) N
CAS = 6
Median (IQR) n p-value
Sit/Lie (h)
Day 2 23.9 (23.8-24.0) 28 22.5 (22.3-23.3) 16 < 0.001
Day 4 24.0 (23.7-24.0) 21 22.7 (21.2-23.2) 22 < 0.001
Day 7 23.8 (23.5-24.0) 15 22.5 (21.6-23.2) 15 < 0.001
Stand/steps (h)
Day 2 0.1 (0.0-0.2) 28 1.5 (0.8-1.7) 16 < 0.001
Day 4 0.0 (0.0-0.3) 21 1.3 (0.8-2.8) 22 < 0.001
Day 7 0.2 (0.1-0.5) 15 1.5 (0.8-2.4) 15 < 0.001
Data are reported in hours (h)
CAS = Cumulated Ambulation Score.
Exhaustion Pain Other
Factors restricting mobilization for patients not independently mobilized
Day 2 Day 4 Day 7
Conclusion
Patients undergoing major emergency abdominal surgery have
• Very limited postoperative functional performance
• Fatique and abdominal pain were the primarily restricting factors
The future
Perioperative pain
Intermediate therapi
Acute organ dysfunction
Standard Ward ??
Immobilization
Complications
Prolonged rehabilitation
Perioperative optimization - AHA
24 hours
Massive lack of knowledge of optimal treatment of AHA patients Increasingly grey population
The challenges
A river of unadressed opportunities for improvements
George Velmahos, Chief Surgeon (MGH) and Harvard Professor
?
