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Background: Patients undergoing emergency abdominal surgery are at high risk of post-operative complications. Although post-operative treatment at an intermediate care unit may improve early outcome, there is a lack of studies on the long-term effects of such therapy. The aim of this study was to assess the long-term effect of intermediate care versus standard surgical ward care on mortality in the Intermediate Care After Emergency Abdominal Surgery (InCare) trial.Methods: We included adult patients undergoing emergency major laparoscopy or laparotomy with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 10 or more, who participated in the InCare trial from October 2010 to November 2012. In the InCare trial, patients were randomized to either post-operative intermediate care or standard surgical ward care. The primary outcome was time to death within 6 years after surgery. We assessed mortality with Coxregression analysis.Results: A total of 286 patients were included. The all-cause 6-year landmark mortality was 52.8% (76 of 144 patients) in the intermediate care group and 47.9% (68 of 142 patients) in the ward care group. There was no statistically significant difference in mortality risk between the two groups (hazard ratio 1.06 (95% confidence interval 0.76-1.47), P = .73).Conclusion: We found no statistically significant difference in 6-year mortality between patients randomized to post-operative intermediate care or ward care after emergency abdominal surgery. However, we detected an absolute mortality risk reduction of 5% in favour of ward care, possibly due to random error. [ABSTRACT FROM AUTHOR]

Background: Myocardial injury after non-cardiac surgery occurs in a high number of patients, resulting in increased mortality in the post-operative period. The use of high inspiratory oxygen concentrations may cause hyperoxia, which is associated with impairment of coronary blood flow. Furthermore, the surgical stress response increases reactive oxygen species, which is involved in several perioperative complications including myocardial injury and death. Avoidance of hyperoxia and substitution of reactive oxygen species scavengers may be beneficial. Our primary objective is to examine the effect of oxygen and added antioxidants for prevention of myocardial injury assessed by area under the curve for troponin measurements during the first three post-operative days.Methods: The VIXIE trial (VitamIn and oXygen Interventions and cardiovascular Events) is an investigator-initiated, blinded, 2 × 2 factorial multicentre clinical trial. We include 600 patients with cardiovascular risk factors undergoing major non-cardiac surgery. Participants are randomised to an inspiratory oxygen fraction of 0.80 or 0.30 during and for 2 hours after surgery and either an intravenous bolus of vitamin C and an infusion of N-acetylcysteine or matching placebo of both. The primary outcome is the area under the curve for high-sensitive cardiac troponin release during the first three post-operative days as a marker of the extent of myocardial injury. Secondary outcomes are mortality, non-fatal myocardial infarction and non-fatal serious adverse events within 30 days.Perspective: The current trial will provide further evidence for clinicians on optimal administration of perioperative oxygen in surgical patients with cardiovascular risks and the clinical effects of two common antioxidants. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing emergency abdominal surgery are at high risk of morbidity and mortality. Accurate identification of high-risk patients is important. The Acute Physiology and Chronic Health Evaluation (APACHE) II score needs to be validated in a larger heterogeneous population before implementation. We aimed to assess the predictive value of the APACHE II score in emergency abdominal surgical patients. Furthermore, we compared the APACHE II score with the American Society of Anesthesiologists (ASA) physical status score and the Charlson Comorbidity Index (CCI).Methods: We included adult patients undergoing emergency abdominal surgery screened for enrolment in the InCare trial from October 2010 to November 2012. The APACHE II score was evaluated with area under the receiver operating characteristics curve (AUROC) statistics. The primary outcome was 30-day mortality. Secondary outcomes included 90-day mortality and admission to the intensive care unit.Results: We included a total of 885 patients. All-cause 30-day mortality was 5.0%, 90-day mortality was 8.9%, and a total of 7.9% of the patients were admitted to the intensive care unit. The AUROC (95% confidence interval) of the APACHE II score was 0.72 (0.65-0.80) for 30-day mortality, 0.70 (0.64-0.76) for 90-day mortality and 0.65 (0.59-0.71) for admission to the intensive care unit. The CCI performed better in prediction of 90-day mortality (P = .04). All other results for the ASA score and CCI were comparable with the APACHE II score.Conclusion: The APACHE II score predicted mortality moderately and admission to intensive care unit poorly in emergency abdominal surgical patients. [ABSTRACT FROM AUTHOR]

Background: Emergency abdominal surgery carries a considerable risk of mortality and post-operative complications, including pulmonary complications. In major elective surgery, epidural analgesia reduces mortality and pulmonary complications. We aimed to evaluate the association between epidural analgesia and mortality in emergency abdominal surgery.Methods: In this population-based cohort study with prospective data collection, we included adults undergoing emergency abdominal laparotomy or laparoscopy between 1 January 2009 and 31 December 2010 at 13 Danish hospitals. Appendectomies were excluded. The primary outcome was 90-day mortality. Secondary outcomes included 30-day mortality and serious adverse events. We used binary logistic regression analyses (odds ratios (ORs) with 95% confidence intervals (CIs)).Results: We included 4920 patients, of whom 1134 (23.0%) died within 90 days. Overall, 27.9% of the patients were treated with epidural analgesia perioperatively. This increased to 34.0% among patients undergoing major laparotomy. The crude and adjusted association between epidural analgesia and 90-day mortality was OR 0.99 (95%CI: 0.86-1.15, P = .94) and OR 0.80 (95%CI: 0.67-0.94; P = .01), respectively. For 30-day mortality the corresponding estimates were OR 0.90 (95% CI: 0.76-1.06, P = .21) and OR 0.75 (95% CI: 0.62-0.90, P < .01), respectively. No serious adverse events were reported.Conclusion: In this population-based cohort study of adult patients undergoing emergency abdominal surgery, we found that the use of epidural analgesia perioperatively was associated with a decreased risk of mortality in the adjusted analysis. [ABSTRACT FROM AUTHOR]

Aims and objectives To elicit knowledge of patient experiences of postoperative intermediate care in an intensive care unit and standard postoperative care in a surgical ward after emergency abdominal surgery. Background Emergency abdominal surgery is common, but little is known about how patients experience postoperative care. The patient population is generally older with multiple comorbidities, and the short-term postoperative mortality rate is 15-20%. Thus, vigilant surgeon and nursing attention is essential. The present study is a qualitative sub-study of a randomised trial evaluating postoperative intermediate care after emergency abdominal surgery, the InCare trial. Design A qualitative study with individual semi-structured interviews. Methods We analysed interviews using Systematic Text Condensation. Results Eighteen patients (nine intervention/nine controls) were strategically sampled from the InCare trial. Data analysis resulted in three distinct descriptions of intermediate care; two of standard surgical ward care. Intermediate care was described as 'luxury service' or 'a life saver.' The latter description was prevalent among patients with a perceived complicated disease course. Intermediate care patients felt constrained by continuous monitoring of vital signs as they recovered from surgery. Standard surgical ward care was described as either 'ok - no more, no less' or 'suboptimal'. Experiencing suboptimal care was related to patient perceptions of heavy staff workloads, lack of staff availability and subsequent concerns about the quality of care. Conclusion Postoperative intermediate care enhanced perceptions of quality of care, specifically in patients with a perceived complicated disease course. Patients were eager to contribute actively to their recovery; however, intermediate care patients felt hindered in doing so by continuous monitoring of vital signs. Relevance to clinical practice Intermediate care may increase patient perceptions of quality and safety of care. [ABSTRACT FROM AUTHOR]