Perioperativ optimering af akutte højrisiko ... · Perioperativ optimering af akutte højrisiko...

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

Hvem er risikopatienten?

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

?