Impact of implementing co-designed care bundles on the outcomes of critically ill patients after emergency exploratory laparotomy-a pre-post analysis.

Emergency exploratory laparotomy is a critical surgical procedure often performed on patients with acute abdominal conditions with an annual incidence of around one in a thousand population. Bowel obstruction and bowel perforation, along with bowel ischemia, account for the majority of the patient population. The incidences and burden of the acute surgical abdomen in India are comparable worldwide.

Given the urgency and complexity of the surgery, emergency laparotomy carries very high mortality and morbidity worldwide. Although the underlying pathology varies pre-operatively, often, the patients are elderly and very sick with sepsis and organ dysfunction. Preparing these patients for high-risk surgery consumes a meaningful amount of hospital resources, although crucial for optimizing outcomes and reducing morbidity and mortality rates. Multinational studies reported a short-term mortality of 7-21%  and an even higher (26.6%) long-term mortality, along with a significant proportion (23.8%) requiring ICU admission.

Exploratory laparotomy patients requiring ICU care have documented considerable morbidity and mortality (33%, 1-year mortality and 59.4%, 5-year mortality) along with higher resource utilization. Independent predictors of mortality were older age(>62), high APACHE-II score, peri-operative immunosuppression, and delayed admission to the ICU.

Several quality improvement initiatives have been implemented worldwide, like the UK Emergency Laparotomy Network (ELN), emergency laparotomy pathway quality improvement care (ELPQuiC), Enhanced Peri-Operative Care for High-risk Patients (EPOCH), ERAS exploratory Laparotomy 2022 etc, with mixed results.  Data on acute care in emergency exploratory laparotomy are lacking in lower-middle-income countries, especially populous countries like India.