One-year mortality rates after standardized management for emergency laparotomy: results from the Swedish SMASH study.

BACKGROUND: Patients who require an emergency laparotomy suffer from high mortality and morbidity rates. Studies have shown that the standardization of perioperative management reduces complications in the short term. The aim of the present study was to report long-term mortality rates for the SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study, as well as short- and long-term outcomes for different age groups within the SMASH study. METHODS: A prospective intervention study was introduced in 2018, with the aim of investigating the introduction of a standardized protocol for emergency laparotomy. For 42 months, intervention patients were managed according to the protocol and outcomes were then compared with those of historical controls. RESULTS: A total of 1344 unique patients were included (681 in the intervention group and 663 in the control group). The 90-day mortality rate was 14.1 per cent in the intervention group and 20.8 per cent in the control group (P = 0.002) and the 1-year mortality rate in adjusted analyses was 19.7 and 27.8 per cent respectively (P =< 0.001). An age-related subgroup analysis showed that the oldest patients (76 years and older, 260 in the intervention group and 240 in the control group) had a 1-year mortality rate of 29.6 and 43.8 per cent respectively (P = 0.004) and a mean duration of hospital stay of 9.9 and 11.6 days respectively (P = 0.027). Among older adults (61-75 years), the mean duration of hospital stay was 11.7 days in the intervention group compared with 15.1 days in the control group (P = 0.009) and the mean duration of ICU care was reduced to 4.49 days compared with 7.29 days (P = 0.046). CONCLUSION: The standardized protocol associated with an emergency laparotomy appears to be beneficial, even in the long term. For elderly patients, it appears to reduce mortality rates and the durations of hospital stay and ICU care.

Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study.

BACKGROUND: Acute high-risk abdominal surgery is common, as are the attendant risks of organ failure, need for intensive care, mortality, or long hospital stay. This study assessed the implementation of standardized management. METHODS: A prospective study of all adults undergoing emergency laparotomy over an interval of 42 months (2018-2021) was undertaken; outcomes were compared with those of a retrospective control group. A new standardized clinical protocol was activated for all patients including: prompt bedside physical assessment by the surgeon and anaesthetist, interprofessional communication regarding location of resuscitation, elimination of unnecessary factors that might delay surgery, improved operating theatre competence, regular epidural, enhanced recovery care, and frequent early warning scores. The primary endpoint was 30-day mortality. Secondary endpoints were duration of hospital stay, need for intensive care, and surgical complications. RESULTS: A total of 1344 patients were included, 663 in the control group and 681 in the intervention group. The use of antibiotics increased (81.4 versus 94.7 per cent), and the time from the decision to operate to the start of surgery was reduced (3.80 versus 3.22 h) with use of the new protocol. Fewer anastomoses were performed (22.5 versus 16.8 per cent). The 30-day mortality rate was 14.5 per cent in the historical control group and 10.7 per cent in the intervention group (P = 0.045). The mean duration of hospital (11.9 versus 10.2 days; P = 0.007) and ICU (5.40 versus 3.12 days; P = 0.007) stays was also reduced. The rate of serious surgical complications (grade IIIb-V) was lower (37.6 versus 27.3 per cent; P = <0.001). CONCLUSION: Standardized management protocols improved outcomes after emergency laparotomy.

Protocol for postpartum haemorrhage including massive transfusion.

Postpartum haemorrhage (PPH) is one of the most common causes of maternal mortality worldwide. Management of PPH depends on the severity of bleeding. If the bleeding is severe, aorta compression can reduce bleeding. It should be followed by insertion of two coarse needles for intravenous access and blood sampling for haemoglobin and haemostasis. Further on, monitoring of vital parameters, as well as provision of extra oxygen and warm crystalloids, should be performed. Uterine atony is the most common cause of PPH and local guidelines for uterotonic drug selection should be followed. Patients with ongoing bleeding should immediately receive surgical care for bleeding control. During severe ongoing bleeding, haemostasis care includes early tranexamic acid, transfusion in ratio 4:4:1 (blood:plasma:platelets), and extra fibrinogen intravenously. If not severe PPH, use goal-directed therapy. During general anaesthesia and uterine atony, stop volatile anaesthesia and change to intravenous anaesthesia.

Placenta accreta spectrum-A single-center retrospective observational cohort study of multidisciplinary management over time.

OBJECTIVE: To evaluate whether the results of a previous study that showed a decrease in blood loss and transfusions with a multidisciplinary approach, including a fixed team when delivering women diagnosed with placenta accreta spectrum at Sahlgrenska University Hospital, remained low throughout time, and to investigate hospital stay and maternal and neonatal complications during a time period with varying team structure compared with previous periods. METHODS: A retrospective observational cohort study comparing data from medical records including three cohorts of women diagnosed with placenta accreta spectrum between October 2003 and December 2020. Cohort 1 consisted of women delivered before the multidisciplinary approach was introduced. Cohort 2 and cohort 3 were both managed in a multidisciplinary manner, but while cohort 2 was managed by a fixed team, cohort 3 was managed by several different senior specialists. The data were analyzed using Kruskal-Wallis test. RESULTS: Blood loss and need for transfusion were significantly lower for cohort 3 and cohort 2 compared with cohort 1. No significant difference was found between cohort 3 and cohort 2. CONCLUSION: The multidisciplinary management and surgical method employed at Sahlgrenska University Hospital have lowered blood loss and the need for transfusions, even over time.

Improving assessment of acute obstetric patients - introducing a Swedish obstetric triage system.

BACKGROUND: Failure to identify severely ill obstetric patients seeking acute care, and hence delaying treatment, can lead to maternal morbidity and mortality. Triage is the prioritization of patients seeking emergency care, based on clinical decision-making tools assessing medical urgency. While triage has been applied in general emergency medicine for 30 years, there are only a few obstetric triage systems (OTS) and obstetric triage has hitherto been unknown in Sweden. Obstetric triage is more complex than general triage since both mother and fetus require assessment, and pregnancy-related physiological changes must be taken into account. This paper aims to describe the development and an initial evaluation of the first OTS in Sweden. METHODS: A multidisciplinary team surveyed reasons to seek acute obstetric care and the current patient flow at the largest obstetric unit in Scandinavia, Sahlgrenska University Hospital, Gothenburg, Sweden, with about 10,000 deliveries/year. A semi-structured literature review on obstetric triage was undertaken. Based on the survey and the literature review the first Swedish OTS was developed and implemented. Patient satisfaction was followed by electronical questionnaires. Initial validity evaluation was performed, defined by the system's ability to identify patients with need for hospital admission, stratified by acuity level. RESULTS: The Gothenburg Obstetrical Triage System (GOTS) addresses the patient to one of five acuity levels based on both vital signs and 14 chief complaint algorithms. It entails recommendations for initial procedures of care as well as an acuity form for documentation. Initial evaluation of the system indicates good correlation between need for admission and acuity level. The implementation has provided the staff with an improved medical overview of the patients and patient flow and enabled the unit to monitor emergency care in a structured way. Implementation came along with increased patient and staff satisfaction. CONCLUSION: The GOTS is the first OTS developed in and for Sweden and implementation has improved management of obstetric patients seeking acute care. Patients are now prioritized according to level of acuity and the time to assessment and treatment of severely ill patients can be structurally evaluated. Both patients and staff express improved satisfaction with obstetric triage.

Study protocol: establishment of a multicentre pre-eclampsia database and biobank in Sweden: GO PROVE and UP MOST, a prospective cohort study.

INTRODUCTION: Pre-eclampsia, a multisystem disorder in pregnancy, is one of the most common causes of maternal morbidity and mortality worldwide. However, we lack methods for objective assessment of organ function in pre-eclampsia and predictors of organ impairment during and after pre-eclampsia. The women's and their partners' experiences of pre-eclampsia have not been studied in detail. To phenotype different subtypes of the disorder is of importance for prediction, prevention, surveillance, treatment and follow-up of pre-eclampsia.The aim of this study is to set up a multicentre database and biobank for pre-eclampsia in order to contribute to a safer and more individualised treatment and care. METHODS AND ANALYSIS: This is a multicentre cohort study. Prospectively recruited pregnant women ≥18 years, diagnosed with pre-eclampsia presenting at Sahlgrenska University Hospital, Uppsala University Hospital and at Södra Älvsborgs Hospital, Sweden, as well as normotensive controls are eligible for participation. At inclusion and at 1-year follow-up, the participants donate biosamples that are stored in a biobank and they are also asked to participate in various organ-specific evaluations. In addition, questionnaires and interviews regarding the women's and partner's experiences are distributed at follow-up. ETHICS AND DISSEMINATION: By creating a database and biobank, we will provide the means to explore the disorder in a broader sense and allow clinical and laboratory discoveries that can be translated to clinical trials aiming at improved care of women with pre-eclampsia. Further, to evaluate experiences and the psychological impact of being affected by pre-eclampsia can improve the care of pregnant women and their partners. In case of incidental pathological findings during examinations performed, they will be handled in accordance with clinical routine. Data are stored in a secure online database. Biobank samples are identified through the women's personal identification number and pseudonymised after identification in the biobank before analysis.This study was approved by the regional ethical review board in Gothenburg on 28 December 2018 (approval number 955-18) and by the Swedish Ethical Review Authority on 27 February 2019 (approval number 2019-00309).Results from the study will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN13060768.

An interrater reliability study on the Gothenburg obstetric triage system- a new obstetric triage system.

BACKGROUND: Triage, identifying patients with critical and time-sensitive disorders, is an integrated process in general emergency medicine. Obstetric triage is more specialised, requiring assessment of both woman, fetus and labour status. Failure to identify severely ill obstetric patients has repeatedly led to maternal morbidity and mortality. Reliable triage systems, adapted to obstetric patients as well as local conditions, are thus essential. The study aims to assess the interrater reliability (IRR) of the Gothenburg Obstetric Triage System (GOTS). METHODS: Midwives (n = 6) and registered nurses with no experience in managing obstetric patients (n = 7), assessed 30 paper cases based on actual real-life cases, using the GOTS. Furthermore, a reference group consisting of two midwives and two obstetricians, with extensive experience in obstetric care, determined the correct triage level in order to enable analysis of over- and undertriage. IRR was assessed, both with percentage of absolute agreement and with intra-class correlation coefficients (ICC) with 95% confidence intervals (CI). RESULTS: A total of 388 assessments were performed, comprising all five levels of acuity in the GOTS. Absolute agreement was found in 69.6% of the assessments. The overall IRR was good, with a Kappa value of 0.78 (0.69-0.87, 95% CI) for final triage level. Comparison with reference group assessments established that over- and undertriage had occurred in 9% and 21% of the cases, respectively. The main reasons for undertriage were "not acknowledging abnormal vital sign parameters" and "limitations in study design". CONCLUSION: The GOTS is a reliable tool for triaging obstetric patients. It enables a standardized triage process unrelated to the assessors' level of experience in assessing and managing obstetric patients and is applicable for triaging obstetric patients presenting for emergency care at obstetric or emergency units.

Mortality following emergency laparotomy: a Swedish cohort study.

BACKGROUND: Emergency laparotomy (EL) is a central, high-risk procedure in emergency surgery. Patients in need of an EL present an acute pathology in the abdomen that must be operated on in order to save their lives. Usually, the underlying condition produces an affected physiology. The perioperative management of this critically ill patient group in need of high-risk surgery and anaesthesia is challenging and related to high mortality worldwide. However, outcomes in Sweden have yet to be studied. This retrospective cohort study explores the perioperative management and outcome after 710 ELs by investigating mortality, overall length of stay (LOS) in hospital, need for care at the intensive care unit (ICU), surgical complications and a general review of perioperative management. METHODS: Medical records after laparotomy was retrospectively analysed for a period of 38 months (2014-2017), the emergency cases were included. Children (< 18 years), aortic surgery, second look and other expected reoperations were excluded. Demographic, management and outcome data were collected after an extensive analysis of the cohort. RESULTS: A total of 710 consecutive operations, representing 663 patients, were included in the cohort (mean age 65.6 years). Mortality (30 days/1 year) after all operations was 14.2% and 26.6% respectively. The mean LOS in hospital was 12 days, while LOS in the ICU was five days. Of all operations, 23.8% patients were admitted at any time to the ICU postoperatively and the 30-day mortality seen among ICU patients was 37.9%. Mortality was strongly correlated to existing comorbidity, high ASA classification, ICU care and faecal peritonitis. The mean/median time from notification to operate until the first incision was 3:46/3:02 h and 87% of patients had their first incision within 6 h of notification. CONCLUSIONS: In this present Swedish study, high mortality and morbidity were observed after emergency laparotomy, which is in agreement with other recent studies. TRIAL REGISTRATION: The study has been registered with ClinicalTrials.gov (NCT03549624, registered 8 June 2018).

Signs of neuroaxonal injury in preeclampsia-A case control study.

BACKGROUND: Cerebral injury is a common cause of maternal mortality due to preeclampsia and is challenging to predict and diagnose. In addition, there are associations between previous preeclampsia and stroke, dementia and epilepsy later in life. The cerebral biomarkers S100B, neuron specific enolase, (NSE), tau protein and neurofilament light chain (NfL) have proven useful as predictors and diagnostic tools in other neurological disorders. This case-control study sought to determine whether cerebral biomarkers were increased in cerebrospinal fluid (CSF) as a marker of cerebral origin and potential cerebral injury in preeclampsia and if concentrations in CSF correlated to concentrations in plasma. METHODS: CSF and blood at delivery from 15 women with preeclampsia and 15 women with normal pregnancies were analysed for the cerebral biomarkers S100B, NSE, tau protein and NfL by Simoa and ELISA based methods. MRI brain was performed after delivery and for women with preeclampsia also at six months postpartum. RESULTS: Women with preeclampsia demonstrated increased CSF- and plasma concentrations of NfL and these concentrations correlated to each other. CSF concentrations of NSE and tau were decreased in preeclampsia and there were no differences in plasma concentrations of NSE and tau between groups. For S100B, serum concentrations in preeclampsia were increased but there was no difference in CSF concentrations of S100B between women with preeclampsia and normal pregnancy. CONCLUSION: NfL emerges as a promising circulating cerebral biomarker in preeclampsia and increased CSF concentrations point to a neuroaxonal injury in preeclampsia, even in the absence of clinically evident neurological complications.

Jaw exercise therapy for the treatment of trismus in head and neck Cancer: a prospective three-year follow-up study.

PURPOSE: This study aims to examine effects of jaw exercise on trismus 3 years following completion of a post-radiotherapy jaw exercise intervention. METHODS: Prospective study including 50 patients with head-and-neck cancer receiving radiotherapy and/or chemotherapy, plus a matched control group. The intervention group underwent 10 weeks of jaw exercise training. Patients were followed pre-and postintervention and 3 years postintervention completion. Outcome measures were maximal interincisal opening (MIO), trismus-related symptoms, and health-related quality-of-life as measured by Gothenburg Trismus Questionnaire, EORTC QLQ-C30, and EORTC QLQ-H&N35. RESULTS: The intervention group had a statistically significantly higher mean MIO compared with the control group (40.1 mm and 33.9 mm, respectively, p < 0.001), reported less trismus-related problems and had an improved health-related quality-of-life when compared with the control group at the 3-year follow-up. These differences were all statistically significant. CONCLUSION: Jaw exercise therapy resulted in increased MIO, less trismus-related symptoms, and improved health-related quality-of-life. Jaw exercise therapy should be initiated early, in a structured manner and continued long-term.

SMASH standardised perioperative management of patients operated with acute abdominal surgery in a high-risk setting.

OBJECTIVE OF THE STUDY: Emergency laparotomy and other high-risk acute abdominal surgery procedures have a high mortality rate. The perioperative management of these patients is complex and poses several challenges. The objective of the study is to implement and evaluate the outcome of protocol-based standardised care for patients in need of acute abdominal surgery in a Swedish setting. NÄL is a large county hospital in Sweden serving a population of approximately 270,000 inhabitants. The study seeks to determine whether standardised protocol-based perioperative management in emergency abdominal surgical procedures leads to a better outcome measured as short- and long-term mortality and postoperative complications compared with the present standard in Swedish routine care. The study is ongoing, and this article describes the methodology used in the study and discusses the benefits and limitations the study design. RESULTS: There are no results so far. The inclusion rate for the first 22 months is as expected; 404 patients have been included and protocols have been followed and reviewed according to the study plan. 25 patients have been missed and demographic data and outcome data for these patients will be collected and analysed.

Striking decrease in blood loss with a urologist-assisted standardized multidisciplinary approach in the management of abnormally invasive placenta.

OBJECTIVE: The aim of this study was to investigate the outcome of a standardized multidisciplinary approach using a modified surgical technique in the management of abnormally invasive placenta (AIP), with special reference to blood loss and the need for transfusion. MATERIALS AND METHODS: Data were collected retrospectively in women managed with a recently adopted multidisciplinary strategy using a modified surgical approach, involving a urologist (study group: 10 patients). Women managed before the introduction of this standardized management served as a control group (nine patients). Comparisons were made between the study group and the control group. The main outcome measures were blood loss and the need for transfusion in the two groups. RESULTS: Standardized multidisciplinary management, involving a modified surgical technique performed by a urologist, decreased blood loss in the study group compared with the control group [median 1400 ml (range 400-3000 ml) vs median 8000 ml (2300-40000 ml); p < .001]. It also decreased postoperative complications and the need for transfusion of blood products. CONCLUSIONS: Standardized multidisciplinary management of patients with AIP, using a modified surgical technique, reduces the risks of massive obstetric hemorrhage, the need for massive transfusion and the risk of postoperative complications. Involving an experienced urologist appears to be of paramount importance in the management of AIP.

Experience of Point-of-Care Devices in Obstetrical Care.

During pregnancy and puerperium, there are pronounced hemostatic changes characterized by increased coagulability and decreased fibrinolysis. In addition, hemostasis can change dramatically during obstetric complications. Several reports have described substandard management of hemostatic defects in this setting and state the need for guidelines and better care. Point-of-care devices can assess hemostatic status and are especially suitable in perioperative settings. Using point-of-care devices, no time is required for transportation, allowing faster availability of results and providing potential for better care of the patient. This article will demonstrate the use of a viscoelastic method in six different patients; five with impaired hemostasis, and where the use of viscoelastic method contributes or should have contributed to better care. The cases represent patients with normal delivery; postpartum hemorrhage (PPH); PPH with low fibrinogen; placental abruption; preeclampsia with hemolysis, elevated liver enzymes, low platelet count syndrome; and finally, one patient with sepsis. This article also shows the need for good practices and good supervision to implement the devices in patient care.

Cerebrospinal fluid levels of insulin, leptin, and agouti-related protein in relation to BMI in pregnant women.

OBJECTIVE: During pregnancy, metabolic interactions must be adapted, though neuroendocrine mechanisms for increased food intake are poorly understood. The objective of this study was to characterize differences in insulin, leptin, and agouti-related protein (AgRP) levels in serum and cerebrospinal fluid (CSF) in pregnant women with normal weight (NW) and pregnant women with overweight (OW) or obesity (OB). Placenta as a source for increased peripheral AgRP levels during pregnancy was also investigated. METHODS: Women were recruited at admission for elective cesarean section. Insulin, AgRP, and leptin were measured in serum and CSF from 30 NW, 25 OW, and 21 OB at term. Serum during pregnancy and placenta at term were collected for further AgRP analysis. RESULTS: Immunohistology showed placental production of AgRP and serum AgRP levels increased throughout pregnancy. CSF AgRP, leptin, and insulin levels were higher in OW and OB than NW. Serum leptin and insulin levels were higher and AgRP lower in OB than NW. CONCLUSIONS: High serum AgRP levels might protect from the suppressive effects of leptin during pregnancy. Pregnant women with OB and OW might further be protected from the suppressive effect of leptin by high CSF AgRP levels. Evidence was found, for the first time, of human placental AgRP production mirrored by levels in the circulation.

Health information: what can mobile phone assessments add?

In healthcare, pain assessment is a key factor in effectively treating postoperative pain and reducing the risk of developing chronic pain. The overall aim of this study was to investigate whether a mobile phone support system can be used as a basis to continuously document patients' health information in real time and provide conditions for optimal, individual pain management after cholecystectomy and hysterectomy procedures.In this pilot study, two randomly selected groups of patients provided information about their pain for one week postoperatively. One group responded via cell phones, and the other, a control group, responded using paper-based questionnaires.The mobile phone system was found to provide a fast and safe basis for reporting pain postoperatively in real time. The results indicate that on days 3 and 4 the mobile phone group reported significantly higher levels of pain than the control group, and the cholecystectomy patients reported significantly more pain at movement on days 3 and 4 than the hysterectomy patients.The mobile phone approach is an adaptation to modern technology and the mobility of individuals. This technology is user friendly and requires minimal support. However, as the sample size was small (n = 37), further studies are needed before additional conclusions can be drawn.

Prospective longitudinal study of thromboelastography and standard hemostatic laboratory tests in healthy women during normal pregnancy.

BACKGROUND: Hemostatic disorders are common in obstetric complications. Thromboelastography (TEG®) simultaneously measures coagulation and fibrinolysis within 10 to 20 minutes. Our primary aim in this prospective longitudinal study was to obtain knowledge about physiological changes in TEG® variables during normal pregnancy and 8 weeks postpartum. The secondary aims were to compare TEG® variables during pregnancy with TEG® variables 8 weeks postpartum and gestational weeks 10 to 15 and to correlate TEG® variables to standard laboratory analyses. METHODS: Blood samples were collected from 45 healthy pregnant women at gestational weeks 10 to 15, 20 to 22, 28 to 30, and 38 to 40, and at 8 weeks postpartum. The following TEG® analyses were performed: time until start of clotting (TEG®-R), time until 20-mm clot firmness (TEG®-K), angle of clotting (TEG®-Angle), maximum amplitude (TEG®-MA), and lysis after 30 minutes (TEG®-LY30). Activated partial thromboplastin time, prothrombin time, soluble fibrin, antithrombin, D-dimer, and platelet count were analyzed. RESULTS: Compared to 8 weeks postpartum TEG®-R was at least 0.9 minutes shorter (upper limit 99% confidence intervals) until gestational weeks 28 to 30 and the mean reduction varied between 23%-26%. TEG®-K was at least 0.1 minutes shorter throughout pregnancy and the mean reduction varied between 18%-35%. TEG®-Angle was at least 2.5 degrees greater during pregnancy and the mean increase varied between 12%-20%. TEG®-MA was also at least 0.4 mm greater during pregnancy and the mean increase varied between 6%-8%. TEG®-LY30 was at least 0.03% lower during gestational weeks 28 to 30 and 38 to 40 and the mean reduction varied between 67%-73%. The routine coagulation laboratory values were within normal pregnant limits. There were no or weak correlations between TEG® and the laboratory variables. CONCLUSIONS: TEG® demonstrates increased coagulability and decreased fibrinolysis during pregnancy. There was a faster initiation of hemostasis, with a minor increase in clot strength. Fibrinolysis decreased during late pregnancy. Alternative cutoff limits for TEG® variables may be required during pregnancy. Standard hemostatic laboratory tests were as expected during pregnancy. Future studies are needed to ascertain whether viscoelastic methods are preferable to standard hemostatic tests for the diagnosis of coagulopathy during obstetric hemorrhage.