Enhanced Recovery After Surgery (ERAS) - The Evidence in Geriatric Emergency Surgery: A Systematic Review.

Background: Geriatric surgery is rising and projected to continue at a greater rate. There is already concern about the poor outcomes for the emergency surgery in elderly. How to manage the available resources to improve outcomes in this group of patients is an important object of debate. OBJECTIVES: We aimed to determine the feasibility and safety of applying ERAS pathways to emergency elderly surgical patients. METHOD: Two searches were undertaken for ERAS protocols in elderly patients and emergency surgery, in order to gather evidence in relation to ERAS in geriatric emergency patients. Primary outcomes were postoperative complications, mortality, hospital length of stay and readmission rates. Results: Eighteen studies were included. The majority of patients were older than 70. Elderly patients had fewer postoperative complications and a reduced hospitalization with ERAS compared to conventional care. Emergency surgical patients also had fewer postoperative complications with ERAS compared to conventional care. Hospital stay was reduced in 2 out of 3 studies for emergency surgery. Conclusions: ERAS can be safely applied to elderly and emergency patients with a reduction in postoperative complications, hospitalization and readmission rates. There is evidence to suggest that ERAS is feasible and beneficial for geriatric emergency patients.

Multimodal Rehabilitation in Geriatric Emergency Surgery.

Introduction: Perioperative application of multimodal rehabilitation pathways represents the anticipated evolution of a concept that has arisen in recent decades, initially named fast-track surgery and known today as enhanced recovery after surgery (ERAS). This concept refers to the use of standardised perioperative care protocols that are supported by evidence-based medicine and aim to reduce surgical trauma and stress. Although application of such protocols to emergency surgery has produced favourable results, the use of ERAS in the geriatric emergency surgery setting has not been widely applied, and no studies have produced results that support its use in this setting. However, ERAS could help improve outcomes in this group of patients, who already have high surgical morbidity and mortality rates. Material and Methods: In preparation for a lecture presented at the 18th European Congress of Trauma and Emergency Surgery (Bucharest, May 2017), the authors performed a literature search using the terms "ERAS", "fast-track", "emergency surgery", "emergency medicine", "multimodal rehabilitation" and "elderly patient" to gather scientific evidence with which to present suggestions in support of their opinion that ERAS could be applied successfully to improve postoperative outcomes for geriatric emergency patients. CONCLUSION: Urgent surgical treatment of elderly patients is associated with morbidity and mortality rates higher than those of younger patients, and there is room for improvement. A multimodal rehabilitation program seems to be a good working model for achieving this goal.

Enhanced Recovery after Emergency Surgery: A Systematic Review.

OBJECTIVE: To evaluate the current scientific evidence for the applicability, safety and effectiveness of pathways of enhanced recovery after emergency surgery (ERAS). METHODS: We undertook a search using PubMed and Cochrane databases for ERAS protocols in emergency cases. The search generated 65 titles; after eliminating the papers not meeting search criteria, we selected 4 cohort studies and 1 randomized clinical trial (RCT). Data extracted for analysis consisted of: patient age, type of surgery performed, ERAS elements implemented, surgical outcomes in terms of postoperative complications, mortality, length of stay (LOS) and readmission rate. RESULTS: The number of ERAS items applied was good, ranging from 11 to 18 of the 20 recommended by the ERAS Society. The implementation resulted in fewer postoperative complications. LOS for ES patients was shorter when compared to conventional care. Mortality, specifically reported in three studies, was equal or lower with ERAS. Readmission rates varied widely and were generally higher for the intervention group but without statistical significance. CONCLUSIONS: The studies reviewed agreed that ERAS in emergency surgery (ES) was feasible and safe with generally better outcomes. Lower compliance with some of the ERAS items shows the need for the protocol to be adapted to ES patients. More evidence is clearly required as to what can improve outcomes and how this can be formulated into an effective care pathway for the heterogeneous ES patient.

Thorax Trauma Severity Score: Is it reliable for Patient's Evaluation in a Secondary Level Hospital?

OBJECTIVE: To determine the predictive and diagnostic value of thorax trauma severity score (TTSS) in a population of thoracic trauma patients admitted to a secondary level trauma center. METHODS: A Retrospective analysis of patients admitted over a period of two years with IDC-9 codes related to thoracic trauma was undertaken. The association of TTSS with complications and mortality was evaluated. We also determined the predictive value of TTSS using receiver operating characteristic curve (ROC). RESULTS: 238 patients with thoracic trauma, mostly middle-aged (62.2 ± 15 years), were included. The main mechanisms of injury were falls and traffic accidents. Thirty-three patients had important extra-thoracic injuries, but only 9 presented an ISS> 15. The average ISS was 3 ± 5; Morbidity was 2.5% and mortality was 2.1% as a result of thoracic injury and these patients had significantly higher TTSS values. Each score component was analyzed separately, showing significant association with complications and mortality. The area under the curve for TTSS was significant for predicting complications (0.848) and mortality (0.856) values. TTSS with a cut off value of 8 points had a sensitivity of 66% and specificity of 94% to predict complications and 80% sensitivity and 94% specificity for predicting mortality. CONCLUSIONS: The TTSS is an appropriate and feasible tool to predict the development of complications or mortality in a population of mostly mild thoracic trauma.

Primary cutaneous mucormycosis in an immunocompetent patient.

Mucormycosis is most common in immunocompromised patients, but it can also occur in healthy hosts, most frequently as primary cutaneous mucormycosis (PCM) and predominantly as a result of skin trauma. We present an uncommon case of PCM in a healthy, young man with no previous history of local trauma. Despite rapid progression of the infection, the patient was successfully treated through surgical intervention and by administering liposomal amphotericin B and posaconazole. He made a full recovery without the need for skin grafting.