This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

Within the limits of the small size of the study, low-dose dopamine appeared to offer no advantage to euvolemic patients after elective abdominal aortic surgery. However, patients with acute oliguric renal failure were not included in the study.

Objective To report two cases of fatal brown snake envenomation in adults despite the use of appropriate antivenom. Clinical features Two men, aged 42 and 39, one with a history of hypertension, suffered fatal brown snake envenomation in Queensland. One believed he had been stung by a wasp. Both developed cardiorespiratory failure within one hour of the bite, followed by coagulopathy and pulmonary oedema. One patient developed fulminant multiorgan failure. Intervention Both patients died despite the administration of large doses of appropriate antivenom and full supportive care. Conclusion Brown snake bites remain extremely dangerous despite the availability of specific antivenom. In severe cases associated with myocardial depression and gross coagulopathy, death may occur rapidly despite the use of conventional doses of antivenom. In such patients the antivenom requirement may be much greater than is currently recommended.

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