15th June 2018

Rural SIG Meeting, Ayers Rock

Jeremy Fernando

Anaesthetist and Intensive Care Specialist

Rockhampton Hospital, QLD

Emergency Laparotomy

Conflicts

Conflicts

Nil

Overview

Resuscitation

Resuscitation

Risk Assessment

Resuscitation

Risk Assessment

Anaesthesia

Resuscitation

Risk Assessment

Anaesthesia

Surgery

Resuscitation

Risk Assessment

Anaesthesia

Surgery

Recovery

Resuscitation

Definition of

Sepsis

SIRS = 2 or more of the following:

Temp > 38 or < 36ºC

Heart rate > 90

Resp rate > 20 or PaCO2 < 30 mmHg

WCC > 12 or < 4

Sepsis = SIRS with identified organism

Severe sepsis = sepsis with organ dysfunction

- hypoperfusion – lactate >4 or impaired mentation

- hypotension – SBP < 90, MAP < 65, drop of 40mmHg from baseline

Septic shock = sepsis with hypotension after adequate fluid resuscitation

Old Sepsis Definitions (1992, 2001)

SIRS = 2 or more of the following:

Temp > 38 or < 36ºC

Heart rate > 90

Resp rate > 20 or PaCO2 < 30 mmHg

WCC > 12 or < 4

Sepsis = SIRS with identified organism

Severe sepsis = sepsis with organ dysfunction

- hypoperfusion – lactate >4 or impaired mentation

- hypotension – SBP < 90, MAP < 65, drop of 40mmHg from baseline

Septic shock = sepsis with hypotension after adequate fluid resuscitation

Old Sepsis Definitions (1992, 2001)

SIRS = 2 or more of the following:

Temp > 38 or < 36ºC

Heart rate > 90

Resp rate > 20 or PaCO2 < 30 mmHg

WCC > 12 or < 4

Sepsis = SIRS with identified organism

Severe sepsis = sepsis with organ dysfunction

- hypoperfusion – lactate >4 or impaired mentation

- hypotension – SBP < 90, MAP < 65, drop of 40mmHg from baseline

Septic shock = sepsis with hypotension after adequate fluid resuscitation

Old Sepsis Definitions (1992, 2001)

Sepsis = life threatening organ dysfunction caused

by a dysregulated host response to infection.

Organ dysfunction quantified by Sequential Organ

Failure Assessment (SOFA).

New Sepsis Definitions (2016)

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810

Sepsis Quick SOFA Score (qSOFA)

2 or more:

RR ≥ 22/min

Altered mentation

SBP ≤ 100mmHg

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810

Hospital Mortality = 10%

Septic Shock

Vasopressor requirement

post fluid resuscitation

Lactate > 2mmol/L

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis – 3) – Singer et al, JAMA 2016;315(8):801-810

Hospital Mortality = 40%

qSOFA does not replace SIRS in the definition of sepsis – Vincent et al, Critical Care 2016 20:210

More specific

Clinically more helpful

Doesn’t require lab tests

Facilitates earlier recognition

Greater consistency with

research and trials

IV antibiotics –

when?

Well + qSOFA score < 2: sample first?

qSOFA ≥ 2 or Septic Shock: within 1 hour

Well + qSOFA score < 2: sample first?

qSOFA ≥ 2 or Septic Shock: within 1 hour

Duration of hypotension before the initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock – Kumar et al , Critical Care Medicine 2006 Jun;34(6):1589-96

For every hour

a patient with

septic shock is

without

appropriate

antibiotic

therapy, their

mortality rate

increases by

7.6%

IV cannula in

Blood cultures out

Appropriate empiric antibiotics in

IV cannula in

Blood cultures out

Appropriate empiric antibiotics in

All in one

motion

IV antibiotics –

what?

IV antibiotics –

what?

“Triples”

Ampicillin + Gentamicin + Metronidazole OR

Piperacillin-Tazobactam (Pip-taz) OR

Ticarcillin+clavulanate (Timentin)

Penicillin allergic (mild reaction/rash)

Ceftriaxone/Cefuroxime + Metronidazole

Penicillin allergic (anaphylaxis)

Gentamicin + Clindamycin

Ampicillin + Gentamicin + Metronidazole OR

Piperacillin-Tazobactam (Pip-taz) OR

Ticarcillin+clavulanate (Timentin)

Penicillin allergic (mild reaction/rash)

Ceftriaxone/Cefuroxime + Metronidazole

Penicillin allergic (anaphylaxis)

Gentamicin + Clindamycin

Not a Cephalosporin

Emergency Laparotomy Microbiology

Most common organisms

E coli

B fragilis

C perfringes

Enterococcus faecalis

Microflora of Abdominal Sepsis by Locus of Infection – Walker, A.P., et al , Journal of Clinical Microbiology, 1994 Feb: 557-558

Emergency Laparotomy Microbiology

Most common organisms

E coli

B fragilis

C perfringes

Enterococcus faecalis

Microflora of Abdominal Sepsis by Locus of Infection – Walker, A.P., et al , Journal of Clinical Microbiology, 1994 Feb: 557-558

Cephalosporins

don’t cover

Enterococcus

Risk Factors

• Prolonged antibiotics

exposure

• In-hospital > 48 hours

• Infective endocarditis risk

• Immunosuppressed

Intravenous

Venous

Fluid

SAFE

SPLIT

CHEST

FEAST

FIRST

SALT-ED

SMART…

Literature Summary

SAFE

SPLIT

CHEST

FEAST

FIRST

SALT-ED

SMART…

Literature Summary

Saline: safe

SAFE

SPLIT

CHEST

FEAST

FIRST

SALT-ED

SMART…

Literature Summary

Saline: safe

Hartmans + Plasmalyte: safe but no better than Saline

SAFE

SPLIT

CHEST

FEAST

FIRST

SALT-ED

SMART…

Literature Summary

Saline: safe

Hartmans + Plasmalyte: safe but no better than Saline

Starches: renal dysfunction

SAFE

SPLIT

CHEST

FEAST

FIRST

SALT-ED

SMART…

Literature Summary

Saline: safe

Hartmans + Plasmalyte: safe but no better than Saline

Starches: renal dysfunction

Albumin: can use, but not in head injury, ?sepsis

Perioperative administration of buffered versus non-buffered crystalloid intravenous fluid to improve outcomes following adult surgical procedures – Bampoe, S. et al (2017) Cochrane Database of

Systematic Reviews, Issue 9. Art. No,: CD004089

n = 3,000

Urgent/Time critical surgery excluded

Liberal fluid

vs

Restrictive fluid

No change in disability free survival at 1 year

AKI + RRT

Surgical site infection

n = 3,000

Urgent/Time critical surgery excluded

Liberal fluid

vs

Restrictive fluid

No change in disability free survival at 1 year

AKI + RRT

Surgical site infection

n = 3,000

Urgent/Time critical surgery excluded

Liberal fluid

vs

Restrictive fluid

No change in disability free survival at 1 year

AKI + RRT

Surgical site infection

n = 3,000

Urgent/Time critical surgery excluded

Liberal fluid

vs

Restrictive fluid

No change in disability free survival at 1 year

AKI + RRT

Surgical site infection

Liberal Fluids

• 1L intraoperatively

• 200mL/hr

• Hartmans

Urgent CT scan

with contrast

RANZCR guidelines have changed in 2016

eGFR > 60

RANZCR guidelines have changed in 2016

eGFR > 60

RANZCR guidelines have changed in 2016

eGFR > 60

> 30

Resuscitation

Risk Assessment

Risk

Assessment

Elderly + MOF +

Emergency Surgery

Elderly + MOF +

Emergency Surgery

Risk Assessment

Patient

Family

Primary care

Comorbidity assessment – , IHD, heart failure, COPD

Frailty

Exercise capacity

Mobility

Independence

P-POSSUM

NSQIP

NELA

Risk Assessment

Patient

Family

Primary care

Comorbidity assessment – , IHD, heart failure, COPD

Frailty

Exercise capacity

Mobility

Independence

P-POSSUM

NSQIP

NELA

Frailty

=

a state of increased

vulnerability to stressors

Walston, J et al. (2006) - Research agenda for frailty in older adults: toward a better understanding of physiology and etiology - J Am Geriatr Soc, vol. 54, pg. 991-1001

Function

Predicting Performance Status 1 Year After Critical Illness in Patients 80 Years or Older: Development of a Multivariable Clinical Prediction Model – Heyland, D

et al (2016) – Critical Care Medicine, Vol 44, Issue 9, page 1719-1728

NELA Score

Mortality at 30 days

Critical Care Bed

Consultant present

We’ve done the risk

assessment.

Now what?

Surgery

ICU/Anaesthesia

ED

I can operate

I can operate

I can resuscitate

I can operate

I can oxygenate and ventilate

I can resuscitate

SurgeonsICU/Anaesthesia

EL

ED

SurgeonsICU/Anaesthesia

EL

ED

eMDT

Post Risk Assessment Options

(1) Operate

(2) Operate with limitations

(3) Not operate + conservative/symptom

management

“Sometimes the

hardest decision is

when not to operate”

My 1st Line

“I totally support a decision to

not operate on this patient”

We are going to

operate!

Advance Resuscitation Planning

ICU – full support (+/- transfer)

ICU – limited support

Ward based care (like #NOF patient)

“Sometimes the

hardest decision is

to limit care”

My 2nd Line

“We are going to try to get you through this

operation/illness, however, if you begin to

take steps backwards and your organs

begin to shut down, we will move to

keeping you comfortable”

SurgeonsICU/Anaesthesia

EL

ED

eMDT

NELA risk of

death at 30

days = 14%

ICU intubated

Quick family meeting

(ICU/Surgery)

Extubated

Quality of Death

=

Quality of Life

Anaesthesia

Anaesthesia

ETT + IV

ETT + IV

+ Artline

+ CVL

+ Epidural

+/- RCS

+/- Q monitoring

+/- PCA

Positioning

Pain

Sepsis

Haemodynamics

Rectus Sheath

Catheters

Tudor, ECG, et al (2015) “Rectus sheath catheters provide equivalent analgesia to epidurals following laparotomy for colorectal surgery” Ann R Coll Surg Engl97:530-533

Wilkinson, K.M et al (2014) “Thoracic Epidural analgesia vs Rectus Sheath Catheters for open midline incisions in major abdominal surgery within an enhanced recovery

programme (TERSC): study protocol for a RCT” Trials, 15:400

Mostafa, A.R, et al (2016) “Postoperative analgesia of ultrasound guided rectus sheath catheters vs continuous wound catheters for colorectal surgery: A RCT” Egyptian

Journal of Anaesthesia, 32:375-383

Malchow, R. et al (2011) “Rectus Sheath Catheters for Continuous Analgesia after Laparotomy – without postoperative opioid usé” Pain Medicine, 12:1124-1129

Cornish P, Deacon A, (2007) “Rectus sheath catheters for continuous analgesia after upper abdominal surgery”ANZ J Surg, 77:84

http://www.bats.ac.nz/detail-rectus_sheath_catheters_the_quick_summary-14

Cornish, P, Deacon, A (2007) ‘Rectus sheath catheters for continuous analgesia after upper abdominal surgery’ ANZ J Surg, Jan-Feb; 77 (1-2):84

Rectus Sheath Catheters

pain (somatic)

opioid use

mobility

safety as less complex than an epidural

Lignocaine Infusion

Lignocaine infusion

pain

opioid use

LOS

ileus

chronic post-surgical pain

- cancer modulation

Bailey, M. et al (2017) “Lidocaine infusions: The golden ticket in postoperative recovery?” ANZCA Blue Book, page 186-196

Lignocaine infusion

Bolus – 1-3mg/kg

Infusion – 1-4mg/kg/hr

Length of duration; intraop, PACU, ?24hrs

Telemetry

Stop when dosing Rectus Sheath Catheters

Bailey, M. et al (2017) “Lidocaine infusions: The golden ticket in postoperative recovery?” ANZCA Blue Book, page 186-196

Surgery

Surgery

(from an Anaesthetist-

Intensivist perspective)

Surgery

Damage control surgery

Ostomy vs Anastomosis

Recovery

Recovery

ERAS

Marwah, S et al “Enhanced Recovery after Surgery (ERAS) in Emergency Laparotomy” EC Gastroenterology and Digestive System 3.3 (2017): 81-82

Recovery

Ileus is major problem (R>L)

- Distension

- Vomiting

- Aspiration

- Pain

- Respiratory failure

- Inability to wean from MV

- Nutrition

CHASM data - NSW

Marwah, S et al “Enhanced Recovery after Surgery (ERAS) in Emergency Laparotomy” EC Gastroenterology and Digestive System 3.3 (2017): 81-82

Yuan, L. et al (2018) “Prospective comparison of return of bowel function after left versus right colectomy” ANZ Journal of Surgery 88: E242-247

One final

point

http://www.surgeons.org/anzela-qi

Take home

messages

(1)

Early, appropriate

antibiotics

(2)

Risk Assessment

(3)

eMDT

(4)

Ileus

(5)

Analgesic

Options

(6)

Quality of Death

=

Quality of Life

Thank you

Thank you