A presentation by Nicolai Bang Foss at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Implementing
perioperative
pathways in
emergency surgery in
the elderly
Nicolai Bang Foss, MD, DMSc
Head of GI & orthopaedic anaesthesia
associate professor
Department of Anaesthesiology
Hvidovre University Hospital
Copenhagen, Denmark
Gerontoanasthesiologist

3. Laparotomy or -scopy except appendectomy,
cholescystectomy or diagnostic

4. Emergency elderly surgical patients
The Cindarellas of surgery?
Hip fractures: 10% 30-day mortality
Emergency laparotomy:
15-40% 30 day mortality
in the elderly Danish NIP database
Clarke, Eur j anaesth 2011

5. Frailty – is age a surrogate?
Partridge. Age & Ageing 2012

6. Traditional care for elderly emergency patients
Delay for surgery – logistics
Prolonged fasting /NPO
Medical optimization – badly defined
Perioperative resuscitation lacking
Opioid pain management – if any
HDU/ICU restricted capacity
Prolonged immobilization
Absence of multidisciplinary care

7. With just a few
days
of perioperative care

8. Perioperative care
and anaesthesia
Extrapolation
of research
Will survive in spite of:
Delay to surgery
Morphine pain management
Overresuscitation with crystalloids
Anaemia & hypovolamia
Immobilization
Starvation

9. Perioperative care
and anaesthesia

10. Strategy Tactics
Manage
- Logistics
- Pain
- Perfusion
Anaesthesia method -
outcome mainly dependent
on above factors?
Emergency surgery perioperative
protocols -how to do it?

11. Fast track
Optimized surgery
Enhanced recovery (ERAS)
Rapid recovery
Evidence based surgery…??
Organized surgery…..!!
- Frail / elderly patients cannot
tolerate disorganized surgery

13. Challenges in optimizing
perioperative pathway
Triage for surgery – palliative care?
Optimized logistics to minimize surgical delay
Preoperative observation / HDU / ICU
Preoperative optimization – AB / Fluids/flow / analgesia
Specialists in theater
Intra/perioperative flow optimization – Fluids / inotropics
Triage postoperative observation / HDU / ICU / PACU
Postoperative optimization – Fluids/flow / analgesia
Specialized wards
Mobilization
Nutrition
Multidisciplinary team (surgeon/anaesthesia/geriatrics)

14. Standardized pathways
Early surgery (<6/24 hrs)
Standardized approach to resuscitation
Standardized perioperative care (Specialized unit/HDU/ICU)
Does not prevent standardized individualization

15. Proposed multidisciplinary
perioperative care in emergency
surgery in the elderly
Special
Admission
to surgery
Surgery
Postoperative phase
stable organ function
Rehabilitation
to discharge
Anaesthesiologists
Geriatricians
Surgeons and nurses
Physiotherapists

16. Surgery
Reoperations ≤ 6 months account for 27% of overall
hospitalization time
Foss. Injury 2006
New algorithm for surgical procedure and supervision
Reoperation rate Before After p
Number of patients 1000 1000
Reoperation rate 18% 12% 0.001
Estimated saved beddays : 890
Palm. Acta Orthop 2012

17. Analysis of 13.343 hip fracture patients > 65
years from Michigan Hospitals
Nurse staffing in individual hospitals measured
FullTimeEquivalents-nurse / patient day
Additional FTE-nurse Mortality decrease
In hip fractures 16% (p=0.03)
Other medical and surgical 6%
Schilling. Clin Orthop relat res 2011
Hip fractures
and nurse staffing

19. AHA-project
Optimized pathway for Acute High-risk
Abdominal Surgery
Tengberg BJS 2017

20. AHA definition
AKUT Acute
HØJRISIKO High-risk
ABDOMINAL-KIRURGISK Abdominal
surgery
= ”AHA”
Perforated viscus
Intestinal obstruction
Gut ischaemia
Intraabdominal bleeding
Both primary surgery and reoperations
after elective surgery
30 day
mortality
DK > 20%

21. • 4 hospitals: BBH, HEH, HVH, HiH
• 1.6 million inhabitants
• 1139 AHA patients in a year
AHA surgery Greater Copenhagen 2012

22. AHA surgery Region Hovedstaden 2012
• 71%
Complications
• 47%
Serious (CDC>2)
• 25%
ICU at some point
Tengberg Anaesthesia 2017

23. Complications
•Pulmonary: 19.3%
•Cardiac: 8.3%
Tengberg Anaesthesia 2017

24. - complications
All patients
+ complications
30 day mortality:
•20%
1 year mortality:
•34%
Complication associated
w long term mortality
AHA Surgery Region Hovedstaden 2012
Tengberg Anaesthesia 2017

26. • Patients physiologic
derangement and potential
catastrophy defines the
population rather than the
individual surgical pathology or
procedure

27. Southern Copenhagen
730 beds
5500 staff
83.000 admission/y
12 ICU beds
Largest GI surgical dept. In
Denmark
”general GI surgery”
No thoracic or liver surgery

28. AHA Intervention:
Common language: ”AHA” – focus
Continuous education: All staff groups in surgery, anaesthesia, ER and radiology
Optimized diagnostic logistics: CT abdomen
Early antibiotics: Administered on suspicion of pathology
Perioperative perfusion optimization: SV guided fluid and inotropic therapy
preop and 24 hrs postoperatively
Standardized anaesthesia: TIVA + Epidural - epi from preop – 3 days postop
Preventive perioperative intermediary therapy: triage for 24 h obligatory care in PACU
Standardized care plans on surgical wards (physiotherapy)
Decisions and handling on consultant level

29. Suspected pathology
AHA pathway
PACU/HDU
Oxygen / sat > 94%
Ringer 1000 ml
High dose Antibiotics
NG tube
PACU/HDU
If ASA 3-4 or APGAR 0-5 -
minimum 24 hours stay
Abdominal CT < 2 hours
Admittance papers
OR advised
Conference
between senior
surgeon and
anaesthetist - triage
CT
If diagnostics
indicated
Patient taken to
specialized ward
Standardized
care
Surgery < 6 hours
GDT : SV / SVV
pulsecontour
analysis
Perioperatively
Until 24 hrs
postop
Epidural catheter
Arterial line

30. Intervention
• High level of monitoring
• High level staff
• Focus on time and resuscitation
• Complication prevention
• Joint venture

31. AHA study: Design
2 predefined cohorts
Interventions: AHA as standard
600 consecutive patients from june 2013
Vs
Historic control:
600 consecutive patients from january 2011
At Hvidovre, Gastroenheden, Denmarks biggest GI dept.
Tengberg BJS 2017

32. Inclusion in analysis
All patients surgically treated at the hospital
included in analysis regardless of actual
perioperative treatment given

33. 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
Tengberg BJS 2017

34. Control Intervention
n
Age (median)
600
68
600
68
ASA>2 274 242
WHO/Zubrod score >1
(%)
121 156
Pathology
Perforation
obstruction
Other
236
284
80
233
274
93
Cardiovascular
comorbidity
289 283
Pulmonary comorbidity 108 114
Laparoscopic surgery 53 87
Peritonitis 225 216
Comparative comorbidity
Tengberg BJS 2017

35. 24 h PACU stay
Postoperative: 24 h PACU?
AHA
directly ICU 67
Not 24 h PACU – protocol breach 23
Yes, Surg apgar 0-4 or ASA 3-4 208
No, not indicated 302
AHA
GDT preoperatively 460
GDT postoperatively 500
GDT with SV monitoring

37. Mortality
Control
n=600
AHA
n=600
30 day (%) 131
(21.8)
93 (15.5) 0.005
180 day
(%)
177
(29.5)
133
(22.2)
0.004
Adjusted mortality risk
AHA: 0.56 (0.39-0.82)
Adjusted for age, ASA, Zubrod, malignancy,
perforation/obstruction, laparocopic surgery
Tengberg BJS 2017

38. Length of stay
Hospital
ICU
Control
10
n=131
AHA
11 ns
n=146
ICU-LOS
median
5 3 p=0.02

39. ICU LOS

40. 0.0
0.2
0.4
0.6
0.0 0.2 0.4 0.6
observed
expected
kohorte
AHA
KONTRO
Observed vs. expected mortality in AHA project
Which
patients
does it help?

41. AHA-project:
Breaking a trend at Hvidovre

42. Postoperative functional performance
•Thigh-worn accelerometer: ActivPAL
50 patients, mean age 61 y
Primarily restricting factors
•Pain, Motor blockade, Dizziness, Exhaustion, Nausea and vomiting, Acute
cognitive dysfunction, Respiratory problems, Unconscious, Patient declines,
Logistics, Monitoring equipment, Other.
Functional performance following
emergency high-risk abdominal surgery
– a prospective cohort study

43. Results
Dependent in mob. Independently mob.
Median (25-75%) Median (25-75%) p-value
Sit/Lie (h)
Day 2 23.94 (23.80-23.99) 22.51 (22.33-23.25) <0.001
Day 4 23.96 (23.70-23.99) 22.69 (21.20-23.18) <0.001
Day 7 23.81 (23.50-23.95) 22.52 (21.60-23.36) <0.001
Stand/steps (h)
Day 2 0.06 (0.01-0.20) 1.49 (0.75-1.66) <0.001
Day 4 0.04 (0.01-0.31) 1.31 (0.82-2.80) <0.001
Day 7 0.19 (0.05-0.51) 1.49 (0.64-2.41) <0.001
Patients were in bed or sitting approximately 23
hours and 30 minutes each day during the first week

44. Results
Factors restricting mobilization for
patients not independently mobilized
Day 2 Day 4 Day 7

45. How is life in the elderly after
major abdominal emergency
surgery???
Janne Orbæk, Lena Veyhe, Line Toft Tengberg, Nicolai Bang Foss, Morten Lauritzen, Morten Bay-Nielsen, Tine Tjørnhøj-Thomsen
Staffmeeting 210116
Prospective, consecutive cohort
Patients & relatives
Interview & questionnaire
52 elderly patients
1 week + 6 months after surgery
Tengberg Dan med J 2017

46. 1 week postoperative interview
”Hvad do you recall from the time before the surgery?”
Pain - 52%
”Did you consider refusing surgery?”
7 %
”Do you recall being asked about your wishes in regards to”:
- Resuscitation in the case of cardiac arrest?
- Intensive care or respirator treatment?
Yes / 14 %

47. 6 months postoperatively questionnaire:
Status at preoperative admission: 91% from own home
”How do you assess your overall quality of life after the surgery”
”Good” / 75%
”Would you agree to have similar surgery again if your life depended on it”
Yes / 73%
6 months postop.; Do you consider yourself to be active and about > ½ the
day
- 100%

48. Knowledge
Implementation
Logistics
Training
Outcome

49. Implementation time line
Analyse
Teach
Staggered implementation
Frontline leadership
Re-analyse
Adapt
Teach
Cultural change
Document

51. Actioncards stating
intent and overall plan
-Overall plan and flowchart – perioperative
-Surgical actioncard
-Surgical – Radiological collaboration
agreement
-Anaesthesia preop actioncard
-Anaesthesia standard plan
-Triage decision chart postop.
-Postop. Ward care plan

53. Perioperative pain
ntermediary therapy
Acute organ instability
Cardiopulmonary failure
Surgical ward??
Immobilisation
Cardiopulmonary complications
Lengthy rehabilitation
Perioperative path – AHA
Where now?
24 hours?

54. Triage timeline!
Futile surgery?
Preop. Optimization?
Where to postop.
Ward/HDU/ICU
When to step down?
Diagnostic triage

55. Knowledge
Implementation
Logistics
Training
Outcome