The Impact of the Time interval from the decision to operate to Anaesthesia induction for Patients with Acute Traumatic Abdominal Conditions at Kenyatta National Hospital

Abstract

Background: The provision of emergency surgical care to patients with acute surgical abdominal conditions is one of the cornerstones of general surgical practice. As most interventions are time critical, the intra-hospital time interval between diagnosis and the actual operation influences the outcome in these patients. This time-interval can be modified, unlike other factors which also influence post-operative outcomes. This study sought to investigate the association between the time-to surgery and the patient’s outcome. Objective: To determine the effect of the time interval on post-operative wound dehiscence, wound sepsis, length of hospital stay and mortality in patients with acute traumatic abdominal conditions at Kenyatta National Hospital (KNH). Patients and methods: A prospective analysis of consecutive patients presenting with acute traumatic abdominal surgical conditions at the Accident and Emergency Department of KNH, between December 2012 and April 2013, was conducted. The time interval between T1 (decision to operate) and T2 (induction of anesthesia) was recorded. The main outcome measures were the in-patient hospital stay, wound dehiscence, wound sepsis and mortality. This follow-up was done in the general surgical and pediatric surgical wards. The data was collected using a standard form, entered and verified using Microsoft Excel. Analysis of the data collected was performed by Statistical Package for Social Sciences version 17 (SPSS 17.0) and graphs, pie-charts and tables were used to present the results. Results: A total of 73 patients admitted to KNH with acute traumatic abdominal injuries were included in this study. The average age of the patients with abdominal injuries was 28 years (SD 8.8) and the age range was from 12 years to 51 years. The percentage of males presenting with abdominal injuries was 91.8% and this was significantly higher than that of female patients (8.2%), difference = 83.6% (95% CI 60.6-100), p < 0.001. Most (72.6%) patients presented with penetrating abdominal injuries and the remaining 27.4% presented with blunt abdominal injuries. Stab injuries were the most common cause of abdominal injury accounting for 56.2% of all admissions. Road Traffic Accidents (RTA) were the second most common cause of abdominal injuries (26%). Other important causes of injuries were gunshot wounds (16.4%). Approximately sixty-three percent (63%) of all operations were performed within 6 hours of presentation to KNH. Thirty percent (30%) of operations were performed between 7 and 12 hours of admission and the remaining 6.9% conducted 13-24 hours postadmission. The duration of inpatient stay ranged from 2 days to 49 days with a median length of stay of 7 days (IQR 6-9 days). The most common adverse outcome was superficial surgical site infection (SSI) documented in 24 (32.9%) patients. Wound dehiscence and deep SSI occurred in 9.6% and 8.2% of patients, respectively. A total of 4 deaths occurred among the 73 patients with abdominal injuries giving an overall mortality rate of 5.5%. Comparison of post-operative hospital stay according to preoperative time interval showed that there was no statistically significant difference in median duration of stay among patients operated within 6 hours (median = 7 days), 7-12 hours (median = 7 days) or 13-24 hours (median = 8 days) from the time the decision to operate was made (Kruskall-Wallis p value = 0.88). There were no significant differences in the percentage of patients with superficial SSI within the different pre-operative time intervals (35% versus 32% and 20%), p = 0.92. Similarly the occurrence of deep SSI (p = 0.46) and wound dehiscence (p = 0.41) was not significantly influenced by the pre-operative time interval. Mortality rates reported in the groups of patients undergoing operation 0-6 hours and 7-12 hours after admission were 6.5% and 4.6% while no death occurred among the 5 patients operated 13-24 hours post admission (p = 0.99).The pre-operative time interval was not significantly associated with mortality. Conclusion In this study the time interval was not significantly associated with morbidity outcomes and mortality. The null hypothesis of the study was accepted. The male predominance, the most affected age bracket of 20 to 29 years, the higher frequency of penetrating acute abdominal injuries compared to blunt abdominal injuries was consistent with other previous studies.