Postoperative Complications and Outcome After Emergency Laparotomy: A Retrospective Study.

BACKGROUND: Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL. METHODS: This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications. RESULTS: A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications. CONCLUSIONS: This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.

Accuracy of dispatch and prehospital triage performance in poisonings - A retrospective study from northern Finland.

BACKGROUND: Increasing numbers of dispatches place a burden on EMS; this study sought to assess the prehospital evaluation of poisoned patients transported to hospital. The primary aim of this study was to measure dispatch centre and EMS provider performance as well as factors contributing to the recognition of poisoning among prehospital patients. The secondary aim was to compare triage performance between dispatch centres and EMS providers. METHODS: A retrospective single-centre study in Northern Finland was conducted. Patients suspected as poisonings by dispatch centres as well as other EMS-transported patients who received a diagnosis of poisoning in hospital between June 1, 2015 and June 1, 2017, were included. RESULTS: There were a total of 1668 poisoning-related EMS missions. Dispatch centres suspected poisonings with sensitivity of 79.9% (95% CI 76.7-82.9) and specificity of 98.9% (95% CI 98.9-99.0) when all EMS missions were taken into account. In a logistic regression model, decreased state of consciousness as dispatch code (OR 7.18, 95% CI 1.90-27.05) and intravenous fluid resuscitation (OR 6.58, 95% CI 1.34-32.37) were associated with EMS transport providers not recognizing poisoning. Overtriage rate appeared significantly higher (33.6%, 95% CI 28.6-39.2) for dispatch when compared with transport (17.8%, 95% CI 13.9-22.6). CONCLUSION: Dispatch centres seem to suspect poisonings fairly accurately. Poisonings unrecognized by EMS providers may be linked with intravenous fluid resuscitation and decreased patient consciousness. Overtriage appears to resolve somewhat from dispatch to transport. There were no fatal poisonings in this study population.

Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy: A retrospective study.

PURPOSE: Outcomes after emergency laparotomy (EL) are poor. These patients are often admitted to an intensive care unit (ICU). This study explored outcomes in patients who were admitted to an ICU within 48 h after EL. MATERIALS AND METHODS: This retrospective single-center registry study included all patients over 16 years of age that underwent an EL and were admitted to an ICU within 48 h after surgery in Oulu University Hospital, Finland between January 2005 and May 2015. Survival was followed until the end of 2019. RESULTS: We included 525 patients. Hospital mortality was 13.3%, 30-day mortality was 17.3%, 90-day mortality was 24.2%, 1-year mortality was 33.0%, and 5-year mortality was 59.4%. Survivors were younger (57 [45-70] years) than the non-survivors (73 [62-80] years; p < .001). According to the Cox regression model, death during the follow-up was associated with age, APACHE II-score, lower postoperative CRP levels and platelet count of the first postoperative day, and the admission from the post-anesthesia care unit (PACU) to the ICU instead of direct ICU admission. CONCLUSION: Age, high APACHE II-score, low CRP and platelet count, and admission from the PACU to the ICU associated with mortality after EL in patients admitted to an ICU within 48 h after EL.

Artificial intelligence-enhanced care pathway planning and scheduling system: content validity assessment of required functionalities.

BACKGROUND: Artificial intelligence (AI) and machine learning are transforming the optimization of clinical and patient workflows in healthcare. There is a need for research to specify clinical requirements for AI-enhanced care pathway planning and scheduling systems to improve human-AI interaction in machine learning applications. The aim of this study was to assess content validity and prioritize the most relevant functionalities of an AI-enhanced care pathway planning and scheduling system. METHODS: A prospective content validity assessment was conducted in five university hospitals in three different countries using an electronic survey. The content of the survey was formed from clinical requirements, which were formulated into generic statements of required AI functionalities. The relevancy of each statement was evaluated using a content validity index. In addition, weighted ranking points were calculated to prioritize the most relevant functionalities of an AI-enhanced care pathway planning and scheduling system. RESULTS: A total of 50 responses were received from clinical professionals from three European countries. An item-level content validity index ranged from 0.42 to 0.96. 45% of the generic statements were considered good. The highest ranked functionalities for an AI-enhanced care pathway planning and scheduling system were related to risk assessment, patient profiling, and resources. The highest ranked functionalities for the user interface were related to the explainability of machine learning models. CONCLUSION: This study provided a comprehensive list of functionalities that can be used to design future AI-enhanced solutions and evaluate the designed solutions against requirements. The relevance of statements concerning the AI functionalities were considered somewhat relevant, which might be due to the low level or organizational readiness for AI in healthcare.

Quality of life in head and neck cancer patients at 5 years after free flap reconstruction: a significant decline during the follow-up.

PURPOSE: Free flap reconstructions following head and neck tumor resection are known to involve more than 50% rate of complications and other adverse events and up to 50% mortality during a 5-year follow-up. We aimed to examine the difference in the long-term quality of life (QoL) between the 2-year and 5-year assessments after free flap surgery for cancer of the head and neck. METHODS: A total of 28 of the 39 eligible patients responded to the survey. QoL was assessed at 5 years after operation and compared with the assessment performed at 2 years after the operation using RAND-36, EORTC-C30 and H&N-35, and SWAL-QOL tools. RESULTS: The criteria for poor QoL using RAND-36 tool was met in 11 (39.3%) patients in contrast to 4 (14.3%, P = 0.003) patients in the 2-year assessment. EORTC-C30 global score was decreased from 83.9 (SD16.4) to 64.6 (SD 24.0, P < 0.001) during the follow-up. In both RAND-36 and EORTC-C30 surveys, decline was found in physical and role functioning together with energy and emotional well-being domains. SWAL-QOL showed poor swallowing-related QoL in both assessments. CONCLUSION: We found a significant decline in QoL during a 5-year follow-up after free flap surgery for cancer of the head and neck.

Emergency department admission and mortality of the non-transported emergency medical service patients: a cohort study from Northern Finland.

OBJECTIVES: A high number of emergency medical service (EMS) patients are not transported to hospital by ambulance. Various non-transport protocols and guidelines have been implemented by different EMS providers. The present study examines subsequent tertiary care ED and hospital admission and mortality of the patients assessed and not transported by EMS in Northern Finland and evaluates the factors predicting these outcomes. METHODS: Data from EMS missions with a registered non-transportation code during 1 January 2018-31 December 2018 were screened retrospectively. EMS charts were retrieved from a local EMS database and data concerning hospital admission and mortality were collected from the medical records of Oulu University Hospital, Oulu, Finland. RESULTS: A total of 12 530 EMS non-transport missions were included. Of those, a total of 344 (2.7%) patients were admitted to tertiary care ED in 48 hours after the EMS contact, and 229 (1.8%) of them were further admitted to the hospital. Patients with the dispatch code 'abdominal pain', clinical presentation with fever or hyperglycaemia, physician phone consultation and a decision not to transport during night hours were associated with a higher risk of ED admission within 48 hours after EMS contact. Overall 48-hour and 30-day mortalities of non-transported patients were 0.2% (n=25) and 1.0% (n=128), respectively. CONCLUSION: In this cohort, the rate of subsequent tertiary care ED admission and mortality in the non-transported EMS patients was low. Dispatch code abdominal pain, clinical presentation with fever or hyperglycaemia, physician phone consultation and night-hours increased the risk of ED admission within 48 hours after EMS contact.

Long-term mortality after endovascular thrombectomy for stroke.

OBJECTIVES: Endovascular thrombectomy (EVT) has become the standard treatment for large vessel occlusion (LVO) in acute ischemic stroke. Stroke trials typically report clinical outcome at the three-month time point but there is a lack of studies focusing on the long-term outcome after EVT. The aim of this study is to assess the long-term mortality after EVT for stroke and to determine the factors that are associated with mortality. METHODS: Retrospective single-center analysis of 323 patients who underwent EVT for stroke between the years 2015-2019 and survived at least 30 days. Patients were followed up until the end of the year 2020. Cox regression analysis was used to identify the factors associated with mortality. RESULTS: A total of 53 (16.4%) of the 30-day survivors died during the follow-up. According to the Cox regression analysis, mortality was associated with functional dependence (modified Rankin Scale (mRS) >2, HR 2.7 (95% CI 1.2-5.9), p=0.013), comorbidity (Charlson Comorbidity Index (CCI) ≥3, HR 2.7 (95% CI 1.4-5.5), p=0.004), stroke severity at baseline (National Institutes of Health Stroke Scale (NIHSS) >8, HR 1.9 (95% CI 1.1-3.3), p=0.026), and medical complications (HR 2.4 (95% CI 1.2-4.8), p=0.011). Procedural variables did not have an impact on mortality. CONCLUSIONS: Functional dependence, stroke severity, comorbidity, and medical complications during the hospital stay were associated with the long-term mortality after EVT for stroke.

Treatment profile and long-term outcome of intensive care unit-admitted patients with liver cirrhosis or other liver disease in relation to alcohol consumption.

OBJECTIVE: To examine the impact of alcohol consumption on the treatment profile, mortality and causes of death in intensive care unit (ICU)-admitted patients with liver cirrhosis and other liver disease. METHODS: Data on liver disease and ICU treatment of patients with previously diagnosed liver disease between 2015 and 2017 were retrospectively collected from medical records at Oulu University Hospital, Finland. The median follow-up was 367 days. The causes of death were obtained from Statistics Finland. RESULTS: From 250 patients, high-risk alcohol consumption was present in 74.7% (71 of 95) cirrhotic patients and 43.2% (67 of 155) patients in the other liver disease group. Gastrointestinal causes were the most common admission causes. Despite the higher SOFA scores in the alcoholic liver cirrhosis patients compared with the non-alcoholic cirrhosis, there were no differences in the need for organ support, length of ICU stay or outcome between the groups or the subgroups. There were no differences in 1-year mortality between the cirrhosis groups (alcoholic cirrhosis 43.7% versus non-alcoholic cirrhosis 45.8%, p = 1.0) or between the other liver disease groups (patients with alcohol consumption 37.3% versus patients without alcohol consumption 36.4%, p = 1.0). The patients with high-risk alcohol consumption died more often due to liver disease, whereas the patients without high-risk alcohol consumption died often due to malignancies. CONCLUSIONS: We report no significant impact of alcohol consumption on the ICU treatment profile or mortality of patients with cirrhosis or other liver disease. The high mortality underlines the importance of preventive measures after ICU admission.

Medical complications and outcome after endovascular therapy for acute ischemic stroke.

AIM: Endovascular therapy (EVT) in acute stroke is an effective but invasive treatment which is frequently followed by various complications. The aim of the present study was to examine the rate of medical complications and other adverse events following EVT. METHODS: Retrospective single-center study of 380 consecutive stroke patients who received EVT between the years 2015-2019. RESULTS: A total of 234 (61.6%) patients had at least one recorded medical complication. The most common complication was pneumonia in 154 (40.5%) patients, followed by acute cardiac insufficiency in 134 (35.3%), and myocardial infarction in 22 (5.8%) patients. In multivariate analysis, the need for general anesthesia (OR 3.8 (1.9-7.7)), Charlson Comorbidity Index >3 (OR 1.3 (1.1-1.5)), male gender (1.9 (1.1-1.3)) and high National Institutes of Health Stroke Scale (NIHSS) score at admission (1.1 (1.0-1.2)) were associated with medical complications. CONCLUSION: Medical complications are common among unselected stroke patients undergoing EVT. Both comorbidity and stroke severity have an influence on medical complications. Early recognition of complications is essential, because vast majority of patients encountering medical complications have a poor short-term outcome.

Early impact of the COVID-19 pandemic and social restrictions on ambulance missions.

BACKGROUND: The SARS-CoV-2 coronavirus disease 2019 (COVID-19) has had a major impact on health care services globally. Recent studies report that emergency departments have experienced a significant decline in the number of admitted patients in the early phase of the pandemic. To date, research regarding the influence of COVID-19 on emergency medical services (EMS) is limited. This study investigates a change in the number and characteristics of EMS missions in the early phase of the pandemic. METHODS: All EMS missions in the Northern Ostrobothnia region, Finland (population 295 500) between 1 March to 30 June 2020 were screened and analyzed as the study group. A control group was composed from the EMS calls between the corresponding months in the years 2016-19. RESULTS: A total of 74 576 EMS missions were screened for the study. Within the first 2 months after the first COVID-19 cases in the study area, the decline in the number of EMS missions was 5.7-13% compared with the control group average. EMS time intervals (emergency call to dispatch, dispatch, en-route, on-scene and hospital handover) prolonged in the COVID-19 period. Dispatches concerning mental health problems increased most in the study period (+1.2%, P < 0.001). Only eleven confirmed COVID-19 infections were encountered by EMS in the study period. CONCLUSION: Our findings suggest that the present COVID-19 pandemic and social restrictions lead to changes in the EMS usage. These preliminary findings emphasize the importance of developing new strategies and protocols in response to the oncoming pandemic waves.

Perioperative Risk Factors for One-Year Mortality in Patients With Free-Flap Reconstruction Due to Cancer of the Head and Neck.

PURPOSE: Head and neck cancer requiring free-flap reconstruction is associated with relatively high mortality. We aimed to evaluate perioperative risk factors for 1-year mortality in this patient group. METHODS: This is a single-center retrospective analysis of 204 patients operated during 2008 to 2018. RESULTS: A total of 47 (23.0%) patients died within 1 year. In univariate analysis, there were no differences in the intraoperative course between 1-year survivors and nonsurvivors. Among the 1-year nonsurvivors, preoperative albumin level was lower (39 [36 to 43] vs 42 [39 to 44], P = .032) and the Sequential Organ Failure Assessment admission score was higher (4 [3 to 5] vs 3 [2 to 4], P = .003) than those of the 1-year survivors. Among the nonsurvivors, the preoperative and postoperative levels of leukocytes were higher (7.6 [6.7 to 9.5] vs 6.9 [5.5 to 8.4], P = .002; 11.4 [9.0 to 14.2] vs 8.7 [7.2 to 11.3], P < .001). The highest odds ratios for 1-year mortality in multivariate analysis were American Society of Anesthesiologists A classification greater than 2 (3.9 CI 1.4 to 10.5), male gender (4.0 CI 1.5 to 11), and increase in leukocyte count (1.3 CI 1.1 to 1.5). CONCLUSIONS: One-year nonsurvivors had higher American Society of Anesthesiologists classification and were more often men. The postoperative inflammatory markers were higher in nonsurvivors, while the intraoperative course did not have a significant impact on the 1-year mortality.

Causes of nutrition deficit during immediate postoperative period after free flap surgery for cancer of the head and neck.

PURPOSE: The aim of the present of study was to examine nutrition deficit during the immediate postoperative in-hospital period following free flap surgery for cancer of the head and neck (HNC). Underfeeding and malnutrition are known to be associated with impaired short- and long-time recovery after major surgery. METHODS: This single-center retrospective cohort study included 218 HNC patients who underwent free flap surgery in Oulu University Hospital, Finland between the years 2008 and 2018. Nutrition delivery methods, the adequacy of nutrition and complication rates were evaluated during the first 10 postoperative days. RESULTS: A total of 131 (60.1%) patients reached nutritional adequacy of 60% of calculated individual demand during the follow-up period. According to multivariate analysis, nutrition inadequacy was associated with higher ideal body weight (OR 1.11 [1.04-1.20]), whereas adequate nutrition was associated with higher number of days with oral food intake (OR 0.79 [0.67-0.93]). CONCLUSION: Inadequate nutrition is common after HNC free flap surgery. The present results suggest that more adequate nutrition delivery might be obtained by the early initiation of oral food intake and close monitoring of nutrition support.

Swallowing-related quality of life after free flap surgery due to cancer of the head and neck.

PURPOSE: Treatment of head and neck cancers (HNC) often leads to impairment in speech and swallowing functions. This study evaluated swallowing problems and the impact of complications on swallowing-related QOL after free flap surgery for HNC. METHODS: Swallowing-related QOL was assessed using MDADI and SWAL questionnaires. RESULTS: Of 45 assessed patients, 25 (45.5%) had at least one postoperative complication. Patients reported less than < 86 points in 8/9 SWAL-QOL domains. The SWAL-QL total score or MDADI composite scores were not related to surgical complications. Those with medical complications had lower scores in SWAL-QOL domains of mental health (82.8 (21.8) vs 65.5 (24.2), p = 0.024) and sleep (77.6 (23.0) vs 52.3 (24.3), p = 0.003). CONCLUSIONS: In conclusion, swallowing related QOL is significantly impaired after 2 years of the tumor resection and free flap reconstruction for cancer of the head and neck, when using the cut-off value of 86 points in SWAL-QOL assessment tool. Surgical complications did not have an impact on swallowing-related QOL but medical complications were related to impairment in general QOL-related domains.

Quality of life after free flap surgery for cancer of the head and neck in patients with or without postoperative complications.

BACKGROUND: Despite advances in surgical techniques, postoperative complications are frequent after free flap surgery for cancer of the head and neck. The present study assessed quality of life (QOL) in patients with and without postoperative complications. METHODS: QOL was evaluated using RAND-36, EORTC-C30 and H&N-35, and UW-QOL questionnaires. RESULTS: Of 53 assessed patients, 29 (54.7%) had at least one complication. Those with medical complications (n = 12, 22.6%) had significantly lower QOL in all domains of RAND-36 except emotional well-being. They also reported lower scores in EORTC-C30 domains of financial difficulties, pain, and insomnia and UW-QOL domains of pain, activity, and recreation. The QOL for patients without complications was comparable to the general population. CONCLUSION: QOL after free flap surgery for cancer of the head and neck is reduced in patients with postoperative medical complications.

Quality of life after free flap reconstruction for the cancer of the head and neck: Comparison between five-year survivors and non-survivors.

BACKGROUND: Free flap surgery due to the cancer of the head and neck includes high risk of postoperative complications and a five-year mortality up to 50%. We aimed to study the relation between the quality of life (QoL) reported two years after the operation and the mortality during a next three-year follow-up. We aimed to study the relation between the quality of life (QoL) reported two years after the operation and the mortality during a next three-year follow-up. METHODS: The QoL of 53 patients was assessed using RAND-36, UW-QOL, EORTC-C30 and H&N-35 tools two years after the operation. The assessed QoL was compared between the five-year survivors and the non-survivors. RESULTS: A total of 14 (26.4%) patients died during the follow-up. The RAND-36 scores of the deceased were lower in domains "general health", "energy", "emotional role functioning" and "emotional well-being". In UW-QOL tool, the domains "swallowing" and "mood", as well as experienced QoL were lower in the non-survivors. In EORTC QLQ assessment the non-survivors reported lower QoL in domains "global health status", "physical functioning", "role functioning", "swallowing", and "felt ill". CONCLUSION: Based on our results, poor long-term survival is related to poor QoL reported two years after surgery. The difference was found in general domains of QoL tools indicating that poor QoL is a surrogate of chronic health problems having an impact on the long-term survival.

Nutrition delivery after emergency laparotomy in surgical ward: a retrospective cohort study.

PURPOSE: Adequate nutrition after major abdominal surgery is associated with less postoperative complications and shorter hospital length of stay (LOS) after elective procedures, but there is a lack of studies focusing on the adequacy of nutrition after emergency laparotomies (EL). The aim of the present study was to investigate nutrition adequacy after EL in surgical ward. METHODS: The data from 405 adult patients who had undergone emergency laparotomy in Oulu University Hospital (OUH) between years 2015 and 2017 were analyzed retrospectively. Nutrition delivery and complications during first 10 days after the operation were evaluated. RESULTS: There was a total of 218 (53.8%) patients who were able to reach cumulative 80% nutrition adequacy during the first 10 postoperative days. Patients with adequate nutrition (> 80% of calculated calories) met the nutritional goals by the second postoperative day, whereas patients with low nutrition delivery (< 80% of calculated calories) increased their caloric intake during the first 5 postoperative days without reaching the 80% level. In multivariate analysis, postoperative ileus [4.31 (2.15-8.62), P < 0.001], loss of appetite [3.59 (2.18-5.93), P < 0.001] and higher individual energy demand [1.004 (1.003-1.006), P = 0.001] were associated with not reaching the 80% nutrition adequacy. CONCLUSIONS: Inadequate nutrition delivery is common during the immediate postoperative period after EL. Oral nutrition is the most efficient way to commence nutrition in this patient group in surgical ward. Nutritional support should be closely monitored for those patients unable to eat. TRIAL REGISTRATION NUMBER: Not applicable.

Long-term Outcomes After Emergency Laparotomy: a Retrospective Study.

BACKGROUND: Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL. METHODS: We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up. RESULTS: A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]). CONCLUSIONS: Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.

Goal-directed fluid management in free flap surgery for cancer of the head and neck.

BACKGROUND: Goal-directed fluid management using stroke volume variation (SVV) analysis is not well studied in free flap reconstruction surgery in patients with head and neck cancer. METHODS: Patients operated due to cancer of the head and neck with free flap reconstruction during 2008-2010 and 2012-2014 in Oulu University Hospital were retrospectively evaluated to determine the impact of SVV-guided fluid management on perioperative fluid balance, postoperative complications and hospital length of stay (LOS). RESULTS: A total of 104 patients were included in the study and in 48 of them SVV was used to guide intraoperative fluid management. The SVV-guided fluid management led to significant reduction in intraoperative fluid load (6070 mL vs. 8185 mL) and hospital length of stay (11.5 vs. 14.0 days). There was no difference in the number of postoperative complications between the groups. CONCLUSIONS: The SVV-guided fluid management reduces fluid administration in free flap reconstruction surgery with head and neck cancer.