Correspondence pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3: CD001449. 3. Gilson GJ, Kramer RL, Barada C, Izquierdo LA, Curet LB. Does labetalol predispose to pulmonary edema in severe pregnancy-induced hypertensive disease? Journal of Maternal-fetal Medicine 1998; 7: 142–7. doi: 10.1111/j.1365-2044.2012.07287.x
Variation in costs of emergency laparotomy following a multicentre national audit The recent paper by Shapter et al. [1] estimated the cost of emergency laparotomy in a single institution in the NHS, drawing on data from an extensive prospective database. They concluded that there was a significant difference between the estimated £13 000 cost per patient incurred by the Trust and that reimbursed through the payment by results (PBR) tariff that, in their institution, resulted in a shortfall of £6100 per patient. We would like to comment on these results in the light of the national multicentre audit that we recently carried out on behalf of the National Emergency Laparotomy Network [2]. Our prospective audit collected data from 1853 patients from 35 NHS hospitals who underwent emergency laparotomy over a threemonth period. The inclusion criteria were slightly different in that we included laparoscopically-assisted emergency abdominal surgery. Outcomes were not dissimilar, with a 30-day mortality of 14.9% in our study compared with 11% in Shapter’s paper at 30 days, rising to 14% for in-hospital mortality.
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Our median (IQR [range]) total length of hospital stay of 15 (9–27 [0–226]) days was very similar to Shapter et al.’s of 15 (9–28 [1–179]) days. We calculated the cost incurred per patient across all hospitals in our audit using the same methodology. We do not have figures for operating time, so have used Shapter et al.’s median value of 3 h. This provided a median (IQR [range]) cost per patient of £9282 (£6222–14 400 [£2880–144 912]). This is lower than Shapter et al.’s and may represent local differences in the provision of care. In order to provide additional insight into this cost variation, we ranked hospitals according to their median patient costs. The nine hospitals with the lowest costs had a median (IQR [range]) cost of £7223 (£5418– 11 340 [£2880–76 492) per patient; the nine hospitals with the highest costs had a cost per patient of £11 904 (£8224–17 192 [£3162–144 912]). One of the key findings in our audit was that there was a great deal of variation in the provision of care between hospitals, particularly surrounding the use of critical care. Across all hospitals, between 9.7% and 87.5% of patients were admitted to intensive care untis (ICUs), and between 0% and 74.5% were admitted to high dependency units (HDUs). Variation here will clearly affect the costs incurred by each hospital. This may not be accurately reflected if the superspell costs do not distinguish between ICU and HDU admission. We do not know whether increased spending on critical care resources leads to an overall increase in cost per patient, as early and more intensive input might
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
reduce downstream costs by reducing complications or improving length of stay. Whilst non-risk adjusted 30-day mortality varied from 3.6% to 41.6%, there was no evidence that hospitals with lower mortality incurred higher costs. Shapter et al. draw comparisons with the effort directed towards quality improvement in hip fractures. We share their concerns. With hip fractures, there is a clear radiological diagnosis; generally all patients require surgery (even if for palliation); and the service is geared towards providing surgical intervention. Of the many patients admitted with symptoms and signs of an acute abdomen, the majority do not require surgery on that admission. As a result, the initial clinical pathway is complex compared with fractured neck of femur. Despite the lack of research amongst this group of patients [3, 4], standards of care for unscheduled surgical patients have recently been published by the Royal College of Surgeons and other professional groups [5–7]. These form the basis for audit and quality improvement in patients undergoing emergency laparotomy. Shapter et al.’s paper serves to highlight the huge cost of managing patients requiring emergency major abdominal surgery and would suggest an inherent lack of investment in delivering the service at all levels within the NHS. Improvements in outcome will require a multidisciplinary approach that concentrates on all aspects of the clinical pathway. Key to this is early involvement of senior clinicians, with adequate risk stratification in order to ensure timely access to theatres, staff of appropri1173
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ate seniority, and discharge to the appropriate level of postoperative care. Shapter et al. advocated the formation of a National Emergency Laparotomy Database, and we are pleased to report that this will be available soon. In response to the Healthcare Quality Improvement Partnership (HQIP) call for new audit topics in 2011, the Emergency Laparotomy Network, in collaboration with the National Institute of Academic Anaesthesia’s Health Services Research Centre, proposed emergency laparotomy as a new topic for national audit, and subsequently contributed to the specification development [8]. Since then, we have submitted a tender to HQIP to run this audit, and are expecting a decision imminently. This raises the possibility of the first anaesthetic-led, nationally funded audit into perioperative patient care.
D. Murray James Cook University Hospital Middlesbrough, UK Email:
[email protected] D. Saunders Royal Victoria Infirmary Newcastle upon Tyne, UK C. Peden Royal United Hospital Bath, UK S. Varley Manchester Royal Infirmary Manchester, UK
All authors are members of the Emergency Laparotomy Steering Group. No external funding or other competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www. anaesthesiacorrespondence.com. 1174
Correspondence
References 1. Shapter SL, Paul MJ, White SM. Incidence and estimated annual cost of emergency laparotomy in England: is there a major funding shortfall? Anaesthesia 2012; 67: 474–8. 2. Saunders D, Murray D, Pichel A, Varley S, Peden C. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. British Journal of Anaesthesia 2012 June 22; doi 10.1093 ⁄ bja ⁄ aes165. 3. Liu JLY, Wyatt JC, Deeks JJ, et al. Systematic reviews of clinical decision tools for acute abdominal pain. Health and Technology Assessment 2006; 10: 1–167, iii–iv. 4. Maggio AQ, Reece-Smith AM, Tang TY, Sadat U, Walsh SR. Early laparoscopy versus active observation in acute abdominal pain: systematic review and metaanalysis. International Journal of Surgery 2008; 6: 400–3. 5. Royal College of Surgeons of England. Emergency Surgery: standards for unscheduled care. http://www.rcseng. ac.uk/publications/docs/emergencysurgery-standards-for-unscheduled-care (accessed 16 ⁄ 06 ⁄ 2012). 6. Association of Surgeons of Great Britain and Ireland. Emergency general surgery: the future; a consensus statement. 2007. http://www.asgbi.org.uk/download. cfm?docid=3CBDAE30-8B61-492B-AABAE 209BB5780AD (accessed 16 ⁄ 06 ⁄ 2012). 7. Royal College of Surgeons of England ⁄ DoH. The higher risk general surgical patient: towards improved care for a forgotten group. http://www.rcseng. ac.uk/publications/docs/higher-risk-surgical-patient/ (accessed 16 ⁄ 06 ⁄ 2012). 8. Healthcare Quality Improvement Partnership. Emergency laparotomy audit specification development. http://www. hqip.org.uk/emergency-laparotomy-auditspecification-development/ (accessed 16 ⁄ 06 ⁄ 2012). doi: 10.1111/j.1365-2044.2012.07288.x
Sugammadex and rocuronium-induced anaphylaxis The study by Clarke et al., designed to examine whether sugammadex might attenuate rocuronium-induced anaphylaxis, appears to conclude prematurely that ‘sugammadex
is unlikely to modify significantly the clinical course of an established allergic reaction’ [1]. There have been at least six reports (references available from author) of apparent mitigation, from five countries. Before the introduction of sugammadex, the capacity to remove an allergen from the circulation so easily did not exist, and the implications for the future of allergy management with inclusion complexes (not just for rocuronium) are significant. Within the presently accepted understanding of allergic mediator release, it is difficult to understand how sugammadex could so quickly alleviate anaphylactic symptoms [2]. However, as well as the classical pathway involving IgE and its highaffinity receptor FcRI, we are just beginning to understand some mast cell activation pathways and effector mechanisms, for example, identification of an alternative pathway mediated by IgG, FccRIII, macrophages and platelet activating factor (PAF), and the previously unsuspected importance of nitric oxide, endothelial nitric oxide synthase, PAF, PI3K ⁄ Akt signalling, cytokines IL-4 and IL-13, sphingosine-1-phosphate and sphingosine kinases [3–5]. In addition, there is still much to learn about sugammadex. How, for example, does the drug interact with mast cells? Degranulation is a rapid process leading to release of potent mediators that increase capillary permeability (wheal) and vasodilation (flare). Histamine liberation and increased local blood flow begins within two minutes of allergen challenge and up to 50% of wheal size cannot be explained by histamine alone [6, 7]. Any anti-anaphylactic
Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
