Improving Outcomes for Elderly Patients Following Emergency Surgery: a Cutting-edge Review

Purpose of Review The aim of this review is to explore the consequence of emergency general surgery in the elderly, and to summarise recent developments in the pre-, peri- and postoperative management of these patients, in order to improve outcomes. Recent Findings Preoperatively, accurate risk assessment is vital to ensure the right patients undergo emergency surgery. Perioperatively, there are multiple interventions specific to elderly patients that have been shown to improve outcomes. Postoperatively, elderly patients must be cared more in an appropriate setting in order to avoid failure to rescue and promote return to function. Summary This review of contemporary evidence identifies multiple pre-, peri- and postoperative interventions that can improve outcomes for elderly patients after emergency general surgery. These evidence-based recommendations should help direct care of elderly patients undergoing emergency surgery and foster further quality improvement measures and research investigations.

1118 The Role of Emergency Surgery in Diverticular Strictures of Those Who Were Initially Managed Conservatively

Aim The presence of diverticulosis can lead to several different complications including formation of strictures. However, the literature concerning management of diverticular strictures is poor. The purpose of this study is to evaluate the patients who were initially treated non surgically and had to undergo emergency surgery. Method A retrospective study was performed using a cohort of patients between 2016 and 2020 where 84 patients with diverticular strictures were identified and followed up. Data on the management of diverticular stricture was captured using the hospital’s electronic medical records. Results Out of 84 patients with diverticular strictures, 9 had elective surgery without any medical treatment while 75 had medical treatment first. Out of the 75 patients who were medically treated, 12 underwent emergency surgery while 2/75 underwent elective surgery after receiving medical treatment due to ongoing symptoms. Out of the 12 patients that underwent emergency surgery, 9 patients presented with obstruction while 3 had a bowel perforation. 6 patients had Hartmann’s procedure, 5 had defunctioning colostomy and 1 patient had adhesiolysis. No patient deaths were recorded at 12 months. Conclusions Although medical management remains the preferred method of managing diverticular strictures in the UK, it is not without its complications. 1 in 5 patients had an acute surgical admission requiring emergency surgery. This raises the importance of a good ‘safety net’ in those managed non-surgically, to reduce delays associated with seeking medical advice. We also appreciate the importance of carrying out more extensive studies to establish the best way to manage diverticular strictures.

Multiple thrombosis associated with Cytomegalovirus enterocolitis in an immunocompetent patient: a case report

Background Cytomegalovirus (CMV) is reported to have thrombogenic characteristics that activate factor X in vitro and stimulate the production of factor VIII and von Willebrand factor (vWF). Thrombosis associated with CMV infection is prevalent among immunocompromised patients and predominantly presents as a solitary large thrombus in the deep vein, pulmonary artery, splanchnic arteriovenous ducts, or other similar sites. Multiple thrombi, however, are rarely observed in such cases. Here, we report about an immunocompetent man with multiple microthrombi associated with CMV infection. Case presentation A 72-year-old Japanese man who complained of abdominal pain was hospitalized with multiple colonic stenosis. He was later diagnosed with CMV enterocolitis and treated with ganciclover from Day 27 post-admission. During hospitalization, the patient developed thrombi in his fingers. He was initially treated with anticoagulant therapy (rivaroxaban); however, the therapy was discontinued owing to a prolonged activated thromboplastin time and an elevated international normalized ratio of prothrombin time. Instead, vitamin K and fresh-frozen plasma were administered. Nevertheless, his coagulation profile remained abnormal. Eventually, he developed colonic perforation and had to undergo emergency surgery. An intraoperative specimen showed several microthrombi in the middle and small arteriovenous ducts of his small and large intestines. The patient’s coagulopathy improved preoperatively, and his overall condition improved postoperatively. Since the activation of ADAMTS13 was reduced remarkably, the thrombotic tendency was determined to be a thrombotic microangiopathy-like condition owing to increased vWF. We could not attribute the coagulopathy to any other cause except CMV infection; therefore, we concluded that this was a case of multiple thrombosis associated with CMV. Conclusions We present an extremely rare case of a patient with multiple thrombotic microangiopathy-like microthrombosis caused by CMV infection. Our findings suggest that CMV infection may be considered as a differential diagnosis for immunocompetent individuals who present with thrombosis of unspecified cause.

Palliative Care in Emergency General Surgery Patients: Reduced Inpatient Mortality And Increased Discharge to Hospice

Background Admissions due to emergency general surgery (EGS) are on the rise, and patients who undergo emergency surgery are at increased risk of mortality. We hypothesized that utilization of palliative care and discharge to hospice in the EGS population have increased over time and that this is associated with a decrease in inpatient mortality. Methods Using the 2002-2011 nationwide inpatient sample and American Association for the Surgery of Trauma-defined EGS diagnosis codes, we identified patients ≥18 years old with an EGS admission. Demographics, hospitalization characteristics, mortality, use of palliative care services, and discharge to hospice were queried. All Patient Refined-Diagnosis Related Group risk of mortality was used to categorize those with an extreme likelihood of dying (ELD). Multivariable logistic regression was used to investigate the association between palliative care consult and discharge to hospice. Results Of the included patients, .3% received palliative care and .2% were discharged to hospice. Over time, rates of palliative care and hospice discharge increased while inpatient mortality decreased. In the 4% of patients with ELD, 3% received palliative care, 5% were transitioned to hospice care, and 22% suffered inpatient mortality. Controlling for patient characteristics, utilization of palliative care services was associated with increased odds of discharge to hospice compared to inpatient mortality (OR = 1.78 all patients and OR = 2.04 for ELD). Conclusions Despite the known increased risks associated with emergency surgical diagnoses, palliative care services remain infrequently utilized in the EGS population. This may be an opportunity for lessening suffering, improving patient-concordant care and outcomes, and reducing nonbeneficial and unwanted care.

A novel whole blood coagulometer for NOAC testing

Background While use of the non-vitamin K antagonist oral anticoagulants (NOACs) does not currently require routine coagulation monitoring, this can be highly desirable in at-risk patients, including those suffering major trauma or having to undergo emergency surgery, especially when a NOAC reversal agent is used. However, a point-of-care (PoC) device for the rapid measurement of clotting times in patients on NOACs is currently not available. Purpose To characterize the sensitivity of a novel PoC coagulometer to NOAC-induced anticoagulation, as well as quantify instrument precision, via venous whole blood samples freshly spiked with rivaroxaban, apixaban and edoxaban. Methods This study was conducted using healthy volunteers with normal coagulation lab values, including PT/INR and aPTT, confirmed via laboratory testing. Whole blood samples from two volunteers per NOAC were spiked with either 0 (sham), 75, 150, or 300 ng/mL of rivaroxaban, apixaban or edoxaban, in randomized order, each day for five days of testing. Each day, each spiked sample was run on five PoC coagulometers simultaneously for replicate measurement. Results PoC coagulometer clotting times exhibited a high degree of linearity spanning the measuring range, with R2 values approaching 1, and high sensitivity across NOAC concentrations tested (i.e. each concentration was statistically significantly different from the others), as well as a high level of precision across the five days of testing. Furthermore, the PoC coagulometer yielded notably low %CVs at each concentration tested, for each subject and anticoagulant, ranging from approximately 3–7% (Fig. 1, rivaroxaban and apixaban data from individual subjects shown). Conclusions These results suggest that this PoC coagulometer could be a valuable tool to assess the pharmacodynamic effects of the NOACs in emergency and other settings. The PoC coagulometer yields results within minutes at a patient's bedside, requiring only a drop of whole blood. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Perosphere Technologies Inc.

Assessing the role of the universal addition of CT thorax to CT abdomen and pelvis in the COVID era. A retrospective multicentre cohort study

Objective: The SARS-CoV2 infection is associated with high mortality for individuals who undergo emergency surgery. The United Kingdom surgical associations and Colleges of Surgeons collectively recommended the addition of CT Thorax to all emergency CT abdomen/pelvis imaging in order to help identify possible COVID-19 patients. Early identification of these patients would lead to optimal treatment strategies for the patient and protection for staff members. However, an extension of CT would be associated with increased irradiation doses for the patient, and its diagnostic relevance was unclear. Methods: This was a retrospective observational review looking at all surgical admissions that required a CT Thorax/Abdomen/Pelvis across 7 weeks during the COVID-19 pandemic, across four Scottish Hospitals. CT thorax investigations (of non-surgical patients) were also re-assessed by a single radiologist to assess the extent of pathology identified at the lung bases (and therefore would be included in a standard CT abdomen and pelvis). Results: Of 216 patients identified who had a CT thorax/Abdomen/Pelvis during the timeframe, 5 were diagnosed with COVID-19. During this timeframe, 77 patients underwent solely CT thorax. Across the entire cohort, 98% of COVID pathology was identified at the lung bases. The estimated sensitivity and specificity of CT thorax was 60 and 86.4% respectively. Conclusions: In a region with relatively low prevalence of SARS-COV2 infection, inclusion of CT Thorax in surgical admission imaging does not significantly contribute to identification and management of SARS-COV2 patients. We therefore suggest that imaging the lung bases can be sufficient to raise clinical suspicion of COVID-19. Advances in knowledge: This paper adds further evidence to that from other single UK centres that the addition of CT chest for all patients does not yield any further diagnostic information regarding coronavirus. Additionally, rapid SARS-CoV-2 testing in the UK (which is currently widely available) further demonstrates that inclusion of the entire chest during CT examination of the acute abdomen is not required.

The analysis of the levels of plasma inflammation-related cytokines and endotoxins in patients with acute aortic dissection

OBJECTIVE: To investigate the changes in the levels of plasm interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), matrix metalloproteinase-9 (MMP-9) and endotoxins in patients with acute aortic dissection (AAD). METHODS: 55 AAD patients who were admitted and scheduled to undergo emergency surgery in our hospital from January 2017 to July 2017 were selected and retrospectively analyzed. They were divided into the survival group (n = 40) and the death group (n = 15). The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins at admission and at 6 h, 12 h and 24 h after admission (T0, T1, T2 and T3) were measured, and the correlations of inflammatory cytokines with endotoxins were analyzed. RESULTS: At T1, T2 and T3, the levels of inflammatory cytokines and endotoxins were increased. The levels of plasma IL-6, TNF-α, CRP, MMP-9 and endotoxins in the death group were significantly higher than those in the survival group at each time point (p < 0.05 in all comparisons). Neutrophil and platelet counts in the death group were higher than those in the survival group (p < 0.05). Correlation analyses indicated that the levels of IL-6, TNF-α, CRP and MMP-9 were positively correlated with the level of endotoxin. CONCLUSION: Patients with AAD are often accompanied by systemic inflammatory responses, with inflammation-related cytokines (IL-6, TNF-α, CRP and MMP-9) and endotoxins levels significantly elevated. Combined monitoring of dynamic changes in inflammatory cytokines and endotoxins, as well as early interventions, has important clinical implications for evaluating the prognosis of AAD and reducing mortality.

Parental obligation and compelled caesarean section: careful analogies and reliable reasoning about individual cases

Whether it is morally permissible to compel women to undergo a caesarean section is a topic of longstanding debate. Despite plenty of arguments against the moral permissibility of a forced caesarean section, the question keeps cropping up. This paper seeks to scrutinise a particular moral argument in favour of compulsion: the appeal to parental obligation. We present what we take to be a distillation of the basic form of this argument. We then argue that, in the absence of an exhaustive theory of parental obligation, the question of whether a labouring woman is morally obliged to undergo emergency surgery—and especially the further question of it is morally permissible for third parties to compel this—cannot be answered via ready-made theory. We propose that the most viable option for settling both questions is by analogy. We follow earlier writers in presenting an analogous case—that of fathers being compelled to undergo non-consensual invasive surgery to save their children—but expand the analogy by considering objections that appeal to the ownership of the fetus. We offer two lines of response: (1) the parthood view of pregnancy and (2) chimaera dad. We argue that it is clear in the analogous case that compulsion cannot be justified. We also offer this analogy as a useful tool for assessing whether mothers have a moral duty to undergo caesarean sections, both in general and in particular cases, even if such a duty is insufficient to warrant compulsion.

A Comparative Study of Different Techniques of Brachial Plexus Block in Upper Limb Surgery

Background: Different techniques of Brachial Plexus block in upper limb surgery depending on the site of operation the approach of the brachial plexus was chosen. For the operations around the shoulder joint interscalene approach was chosen; for the operations up to the shoulder either interscalene or supraclavicular or Infraclavicular routes were chosen and for the operations up to and around the elbow joint any one of the four approaches were tried. Objective of this study was to evaluate its clinical applications and practical utility in providing good analgesia for the upper extremity surgery in elective as well as emergency cases.Design: This was a hospital based retrospective study. Duration: One Year i.e. from June 2018 to June 2019. Participants: 80 patients.Subjects and Methods:The present study includes 80 blocks of brachial plexus by four different routes. 1. Supraclavicular approach – 20 cases. 2. Infraclavicular approach – 20 cases. 3. Axillary perivascular approach – 20 cases. 4. Interscalene – 20 cases. The cases were selected at random, who were subjected for various types of surgery of upper extremity both elective and emergency as in-patients.Results:In this series of 80 blocks, when the type of the surgery (emergency or elective) is considered, it has been that about one third of the patients underwent emergency surgery successfully with the brachial plexus block. In the remaining two-third of the patients, the surgery was planned procedure.Conclusion:Thus, our study reveals that the brachial plexus block can be equally safely employed for emergency surgery as for any elective procedure. Some-times the brachial plexus block can be the only choice with no alternatives affording a reasonable chance to a moribund patient to undergo emergency surgery. The dosage of the drug was modified according to the patient’s general condition.