title: Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room.
abstract: BACKGROUND
  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).
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.forename: Joerg
authors.initials: J
authors.lastname: Schreiber
authors.forename: Axel
authors.initials: A
authors.lastname: Nierhaus
authors.forename: Eik
authors.initials: E
authors.lastname: Vettorazzi
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Braune
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Frings
authors.forename: Yogesh
authors.initials: Y
authors.lastname: Vashist
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.forename: Stefan
authors.initials: S
authors.lastname: Kluge
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care / Q000379:methods*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007422:Intestines / Q000098:blood supply; D059325:Intra-Abdominal Hypertension / Q000601:surgery; D007511:Ischemia / Q000601:surgery; D007813:Laparotomy; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000601:surgery; D009873:Operating Rooms; D019095:Point-of-Care Systems; D012189:Retrospective Studies; D012307:Risk Factors; D014187:Transportation of Patients; D016896:Treatment Outcome; D055815:Young Adult