Schreiber Joerg, Nierhaus Axel, Vettorazzi Eik, Braune Stephan A, Frings Daniel P, Vashist Yogesh, Izbicki Jakob R, Kluge Stefan
Crit Care. 2014 Jun 16;18(3):R123. doi: 10.1186/cc13925.
The prognoses of critically ill patients with a requirement for emergency laparotomy and severe respiratory and/or hemodynamic instability precluding transport to the operating room (OR) are often fatal without surgery. Attempting emergency surgery at the bedside might equally result in an adverse outcome. However, risk factors and predictors that could support clinical decision making have not been identified so far. This study describes the clinical characteristics, indicative pathophysiology and outcomes in patients undergoing resuscitative laparotomy in the intensive care unit (ICU).
This was a retrospective observational study of all critically ill adult patients undergoing resuscitative laparotomy in the ICUs of a German university hospital from January 2005 to July 2013. Clinical characteristics, risk factors, and treatments were compared between survivors and non-survivors. The primary endpoint was 28-day survival.
A total of 41 patients with a median age of 64 (21 to 83) were included. The most frequent reasons for ICU admission were sepsis, pneumonia, and pancreatic surgery. All patients were mechanically ventilated, receiving vasopressors, and were in multiple organ failure. Twenty-nine patients (70.7%) were on renal replacement therapy and two patients (4.9%) on extracorporeal membrane oxygenation. The main reasons for surgery were suspected intra-abdominal bleeding (39.0%), suspected intestinal ischemia (24.4%) or abdominal compartment syndrome (24.4%). Twenty-eight-day, ICU and hospital mortalities were 75.6%, 80.5%, and 82.9%, respectively. In six out of ten patients (60%) who survived surgery for more than 28 days, bedside laparotomy was rated as a life-saving procedure by an interdisciplinary group of the investigators.
These findings suggest that in selected critically ill patients with a vital indication for emergency laparotomy and severe cardiopulmonary instability precluding transport to the OR, a bedside resuscitative laparotomy in the ICU can be considered as a rescue procedure, even though very high mortality is to be expected.
对于需要进行急诊剖腹手术且存在严重呼吸和/或血流动力学不稳定而无法转运至手术室（OR）的危重症患者，若不进行手术，其预后往往是致命的。尝试在床边进行急诊手术同样可能导致不良后果。然而，目前尚未确定可支持临床决策的风险因素和预测指标。本研究描述了在重症监护病房（ICU）接受复苏性剖腹手术患者的临床特征、指示性病理生理学及预后。
这是一项对2005年1月至2013年7月在德国一家大学医院ICU接受复苏性剖腹手术的所有成年危重症患者进行的回顾性观察研究。比较了幸存者和非幸存者的临床特征、风险因素及治疗情况。主要终点为28天生存率。
共纳入41例患者，中位年龄为64岁（21至83岁）。入住ICU最常见的原因是脓毒症、肺炎和胰腺手术。所有患者均接受机械通气、血管升压药治疗，且存在多器官功能衰竭。29例患者（70.7%）接受肾脏替代治疗，2例患者（4.9%）接受体外膜肺氧合治疗。手术的主要原因是怀疑腹腔内出血（39.0%）、怀疑肠缺血（24.4%）或腹腔间隔室综合征（24.4%）。28天、ICU和医院死亡率分别为75.6%、80.5%和82.9%。在手术存活超过28天的10例患者中，有6例（60%）被研究人员的跨学科小组评为床边剖腹手术为挽救生命的手术。
这些发现表明，对于某些有急诊剖腹手术的重要指征且存在严重心肺不稳定而无法转运至手术室的危重症患者，即使预期死亡率很高，在ICU进行床边复苏性剖腹手术也可被视为一种挽救措施。
