Emergency Laparotomy in the Critically Ill: Futility at the Bedside

Area of Science:

• Critical Care Medicine
• Surgical Outcomes
• Emergency Surgery

Background:

• Critically ill patients often require evaluation for intra-abdominal catastrophes.
• Abdominal exploration may be necessary without a definitive preoperative diagnosis in emergent situations.

Purpose of the Study:

• To determine the mortality associated with abdominal exploration in critically ill patients.
• To assess if physiological measures at laparotomy can predict mortality.

Main Methods:

• A review of acute care surgery patients undergoing emergency laparotomy over 3 years.
• Inclusion criteria: emergency laparotomy in the operating room (OR) with American Society of Anesthesiologists (ASA) score ≥4 or bedside laparotomy in the ICU (BSL).
• Mortality was stratified by demographics, service, surgical findings, and physiology.

Main Results:

• Overall mortality was 55.6% (77.8% for BSL vs. 45.5% for OR).
• Higher mortality was observed in cardiac and medical services compared to acute care surgery.
• Nonsurvivors had higher lactate levels, increased vasopressor use, acute kidney injury, leukocytosis, and anemia.

Conclusions:

• Bedside laparotomy in the ICU is associated with extremely high mortality.
• Emergency OR laparotomy has a nearly 50% mortality rate.
• Abnormal concurrent physiology can anticipate mortality in these patients.