Technical Evidence Review for Emergency Major Abdominal Operation Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Abstract

Enhanced recovery pathways (ERPs), initially developed more than 2 decades ago for colorectal operations, have been shown to improve patient outcomes for many elective procedures. 1-4 They apply standardized, evidencebased, and multidisciplinary approaches to reduce surgical stress and modify physiologic responses. 5-9 As these pathways evolve, it is evident that the key principles, including multimodal analgesia, early mobilization, patient and family engagement, and best practices for preventable harms, can benefit surgical patients broadly, including those undergoing emergency operations. Emergency general surgery (EGS) represents a growing public health burden in the US, with more than 3 million patients admitted annually for these conditions and nearly 30% requiring operation. 10 EGS patients are complex; 35% are older than 70 years and 50% have at least 1 medical comorbidity and are at higher risk for morbidity (15%) and mortality (1.2%). 10,11 Rates are even higher for complex emergency procedures, including 46.9% morbidity for bowel resections and 23.8% mortality for laparotomies. 11 Quality improvement work in EGS is challenging, limited by the urgent nature and heterogeneity in disease and patient characteristics. However, given that the success of ERPs lies in reducing perioperative stress through transdisciplinary teamwork and standardization, the benefits of ERPs might be even more pronounced in this high-risk population. The Safety Program for Improving Surgical Care and Recovery (ISCR) is a national ERP initiative implemented in 2017 through a collaboration among AHRQ (funder), American College of Surgeons, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. The ISCR program has been implemented across colorectal, orthopaedic, and gynecologic surgery services. Building on the lessons learned from earlier cohorts, the final cohort of the program will expand into EGS and include appendectomy; cholecystectomy; and emergency, nontrauma, and nonvascular major abdominal operations. The objective of this study was to evaluate the evidence for ERPs for emergency major abdominal operations and to provide a framework for developing and implementing ERPs in this patient population. METHODS Seven common EGS procedures, including appendectomy, cholecystectomy, perforated peptic ulcer repair, colectomy, CME questions for this article available at http://jacscme.facs.org

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra‐ and Postoperative Care

“…The use of antibiotic prophylaxis before surgery has been shown to reduce surgical site infection [ 80 ]. Perioperative broad spectrum intravenous antibiotics should be administered within 60 min before skin incision if the patient has not already been commenced on them, some agents such as fluoroquinolones and vancomycin require administration over 1–2 h, and therefore, administration should begin, if possible within 120 min [ 26 , 81 ]. Continuation of antibiotics should be decided according to the pathology and contamination found during surgery.…”

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

“…Therefore, opioids are often necessary in addition to other multimodal agents. Non‐steroidal anti‐inflammatory drugs (NSAIDs) are best avoided, due to the high risk of acute kidney injury (AKI) in this population, until postoperatively when renal function has normalized [44, 135, 136].…”

Effect of Comprehensive Nursing on the Recovery of Gastrointestinal Function in Patients Undergoing Abdominal Operation

“…However, current clinical evidence shows that patients who do not routinely use nasogastric tubes recover intestinal function earlier and have a lower incidence of pneumonia [ 6 – 8 ]. The concept of rapid rehabilitation surgery also requires that patients be given a small amount of water and an open liquid diet on the day after operation, and gradually increase the amount and transition to a normal diet within a relatively short period of time after operation, and stop intravenous rehydration as soon as possible [ 9 ]. However, there is a contradiction between the renewal of modern surgical ideas and clinical reality.…”