Emergency laparotomy clinical outcome according to patient characteristics, level of postoperative care and time of surgery

Introduction

Emergency laparotomies have poor outcomes with variable postoperative critical care provision [1–3]. All patients requiring an emergency laparotomy with an estimated risk of death of >10% should go to critical care. Time of surgery should not affect standard of care [3, 4]. In advance of the National Emergency Laparotomy Audit (NELA) results [2], our objective was to see whether the level of postoperative care and time of surgery affect outcome.

Methods

Retrospective data were collected across the Imperial NHS trust for all emergency laparotomies over 3 months in 2014: length of stay in days (LOS); mortality; age; ASA; surgery time and postoperative care level, that is ward (L1), high dependency (L2), or ICU (L3). Statistical tests: Mann-Whitney, Pearson correlation (PCC) and multilinear regression analysis.

Results

Seventy-one patients underwent surgery. Overall mortality was 13% and 70% of patients went to a L2/3 bed. More ASA 1/2 patients went to L1 and all ASA 4/5 went to L2/3. Median (IQR) for age was 61 (44 to 67) for L1, 65 (48 to 73) for L2/3 (P = 0.11), LOS was 10 (7 to 16) for L1, 19 (12 to 57) for L2/3 (P = 0.002), and mortality (%) was 0 for L1 and 18 for L2/3. For surgery between 08:00 and 17:59, 14 went to L1, 28 to L2/3. Mortality was 5% and LOS 15 (9 to 24). Between 18:00 and 21:59, two went to L1, 10 to L2/3. Mortality was 17% and LOS 22 (8 to 34). Between 22:00 and 07:59, five went to L1, 12 to L2/3. Mortality was 29% and LOS 15 (9 to 36). ASA strongly predicted mortality (P = 0.006, PCC 0.32). There was a negative correlation between postoperative destination and mortality with all deaths happening in those who went to L2/3 (P = 0.038 and PCC -0.25); however, sicker patients may have gone here. There was a strong correlation between mortality and time of surgery, night surgery being a strong predictor of mortality (PCC 0.31, P = 0.008). LOS can be predicted by a combination of ASA, age and care level (P = 0.027); the postoperative care regression coefficient was negative (-18.04, SE 10.41) with prolonged LOS in patients admitted to L2/3, which could also be explained by illness severity.

Conclusion

Trust mortality is similar to that in the Emergency Laparotomy Network audit [1]. Higher ASA patients are appropriately going to L2/3 care. Baseline health status and time of surgery are the strongest predictors of mortality in emergency laparotomy patients.