National Audit of Small Bowel Obstruction

NASBO logo

The following is taken from a presentation of results from the Royal Liverpool Hospital focused upon NASBO results in this region. The original inception and protocols can be found here:

http://nasbo.org.uk/project-hub/

Background

Laparotomy for small bowel obstruction (SBO) accounted for 49% of emergency laparotomies in the first NELA report. Approximately 12,000 emergency laparotomies for SBO between 2015 – 2016. It is well known that delays in surgery or prolonged conservative management are associated with poor outcomes. There is a significant mortality risk with laparotomies for SBO as 13% of patients die within 3 months of surgery.

SBO is associated with malnutrition as patients present with underlying malignancy and possibly recurrent adhesive SBO managed conservatively. Their nutritional status may fluctuate and postoperatively develop post op ileus. This would involve the patient being nil by mouth and having a nasogastric tube inserted for several days. The need for nutritional support is agreed but the optimum timing and regimens are not clear. NICE guidance recommends the use of parenteral nutrition in those with >5 days of starvation or high nutrient losses.

Aims

To assess outcomes and impact of guidelines for malnourished patients in small bowel obstruction

Objectives

  • To audit use of malnutrition tools in patients with bowel obstruction.
  • To audit whether patients at a high risk of malnutrition receive appropriate management in line with national guidelines.
  • To audit outcomes in patients with small bowel obstruction and feed-back findings at unit level.
  • To audit outcomes of patients with small bowel obstruction and identify outcomes in patients who are malnourished.

Protocol

  • Prospective multicentre audit
  • Audit registered locally
  • Site profile form completed
  • Consultant questionnaires completed
  • 16th January 2017 – 13th March 2017 – prospective identification of patients
  • Snapshot data at days 1,3,5 and 7 of admission
  • Identification of outcomes and management
  • 30 day readmission rate (if discharged during study period)
  • Data inputted onto REDcap secure data system
  • Data independently validated

Audit standards

Picture1

Steering Committee

Ms Vicky Fretwell Audit registration and data collection
Mr Fraser Smith Consultant supervisor
Mr Kulbir Mann Validator
Mr Eyas Mohamed Data Collection
Ms Andrea Sheel Data Collection
Ms Hannah Lennon Data Collection

Results – Overview

  • 23 patients, 2 exclusions (resolved SBO within 24 hours)→Total analysed = 21 (10 men 11 women)
  • Median age 65 years (range 21 – 92) Nationally median age 71 (18-101)
  • 1 Nursing home resident, 20 independent

Co-morbidities: IHD n=4, Haematological malignancy n=1, Severe liver disease n=1, COPD n=2, Diabetes n=1, Solid tumour n=3, Metastatic tumour n=5, PUD n=2, No co-morbidities n=7

  • Referral source
    Emergency department 13 (65.2%) 68% nationally
    General practitioner 4 (17.4%) 18% nationally
    From other inpatient team 4 (17.4%) 12% nationally
  • 19 patients were seen by surgeons within 24 hours of admission
  • 1 patient waited 4 days (under medics, palliative)
  • 1 patient waited 92 days (under medics, necrotising enterocolitis with stricture)
  • Initial management strategy
    Non-operative 10 (48%) 69% nationally
    Operative (decision <24 hours from admission) 9 (43%) 28% nationally
    Palliative 2 (9.5%) 3% nationally
  • 3 patients (14%) went from non-operative to operative approach Nationally 1/3 failed conservative management, 2 patients with adhesions, 1 patient managed for Crohns stricture which turned out to be right colon cancer with peritoneal mets

Results – Radiology

  • AXR was performed in 17 patients (81%) 84% nationally
  • 88% of AXR’s were within 24 hours of admission
  • CT was performed in 14 patients (71.4%) 80% nationally
  • Median time from admission to CT 1.5 days 2.2 days nationally
  • 10 patients had an AXR and CT (47%) Nationally 65%
  • Oral / Rectal gastrografin was never administered with purely therapeutic intent alone (i.e. only given prior to CT)
  • 50% of our strangulated hernias underwent a CT

Results – Patient outcomes

  • Mean WCC on admission (x109/L) = 11.62 (range 1.7 to 24.6)
  • Mean CRP (mg/L) = 83.2 (range <5 to 271)
  • Mean albumin level (g/dL) = 39.57 (range 27 to 51)
  • 4 patients (19%) had an AKI on admission (22% nationally)
  • 3 deaths (14%) within 30 days of admission Nationally 8%
  • 1 of these was post operative therefore post operative death rate = 8.3%
  • Mean duration of stay was 13.5 days (1-93) nationally 10.7 days (1-100)
  • 15 (71%) patients were discharged within 48 hours of being “medically fit”

Results – Operative management

  • 12 patients (52.2%) underwent an operation for the SBO (48% nationally)
    ASA1 2 (16.7%)
    ASA2 5 (41.7%)
    ASA3 2 (16.7%)
    ASA4 3 (25.0%)
    Open midline 9 (75.0%)
    Open groin 2 (16.7%)
    Laparoscopic converted to open 1 (8.3%)
  • Median length of time from admission to procedure 2 days.  33% of patients waited longer than 2 days median time nationally 1 day but 20% waited >4 days
  • Nationally 14% were attempted laparoscopically with a 50% conversion rate
Type of procedure Number of patients Mean time to surgery
Hernia repair
  • 4 (33.3%)
  • With Small bowel resection + anastomosis = 3
1.25 days (1-2)
Small bowel resection
  • 3 (25 %)
  • Adhesional SBO = 2
  • Septic emboli (IVDU) stoma formed = 1
27.3 days (2-49)
Large bowel resection 1 (8%) stoma formed 1 day
Formation of ileostomy
  • 2 (16.6%)
  • De-functioning for widespread malignancy = 2
28.5 day (7-50)
Other
  • 2 (16.7%)
  • De-volve small bowel = 1
  • Appendicectomy (phlegmon causing SBO) = 1
1.5 days (1-2)

Results – Nutritional management

Length of time between last enteral intake and admission to hospital (days)
< 24 hours 12
2 days 1
3 days 7
1 week 1
  • 18 (85%) patients were assessed using a nutritional assessment tool (eg MUST) 98% nationally
  • 11 patients (47.8%) were identified as being malnourished or at risk of malnourishment during their admission 32% nationally
  • 64% of these patients were identified within 48 hours
  • 12 (52.2%) patients were assessed by a dietitian during admission
  • 75% of these patients were seen within 48 hours
  • 9 patients (43%) were unable to eat properly for 5 days or more.  Nationally 49%
  • 12 (52.2%) patients were assessed by a dietitian during admission
  • 5 within 24 hours of admission
  • 2 within 48 hours of admission
  • 2 at 3 days and 1 at 6 days
  • 2 patients were reviewed within 48 hours despite not being deemed “at risk”
  • 7 (30.4%) patients were started on oral supplements (eg fortisips) during their admission 26% nationally
  • No patients were NG/NJ fed
  • TPN was commenced in 5 patients (21.7%) 14% nationally, all via PICC line, with no reported line infections
  • 4 (80%) of these patients were in the operative group
  • Mean duration of TPN was 15.6 days (range 7 – 35 days)

Conclusions – Summary

  • Higher proportion of our patients go straight to surgery and fewer fail conservative management than nationally – Our initial management decisions seem appropriate
  • We are operating in line with national averages (52% of our patients operated, 48% national average). Hernias are being operated on in timely fashion – Arguably we should look at this one in hours rather than days since admission and need to consider why we are performing CT for strangulated hernia?
  • Imaging is happening in a timely fashion – We could consider using gastrograffin as therapeutic agent more frequently
  • Lower than the national average in unplanned HDU admissions, CVS complications, delirium, and return for additional operations – But higher VTE events (small number could be skewing this)
  • 3 deaths – All predictable / expected

Conclusions – Summary

  • 85% of our patients had a MUST assessment documented
  • All patients identified at risk of malnutrition were seen by a dietitian
  • 75% of these patients were seen within 48 hours
  • We are using more nutritional supplements / TPN than the national averages

National Recommendations

  • Early use of CT scanning to confirm diagnosis and for prognostic info
  • Water soluble contrast should be embedded in clinical management for prognostic and therapeutic purposes
  • Early assessment of nutritional status is essential and involvement of specialist nutritional services should be considered in all patients.  Nutritional support should be planned from diagnosis and tailored to the individual patient requirements
  • Patients on conservative management should be reviewed regularly and if SBO not resolving surgery should be carried out within 72 hours to optimise outcomes
  • Patients undergoing surgery for SBO need risk assessment to ensure high and moderate risk patients are proactively admitted to critical care facilities
  • There may be benefit in applying the principals of enhanced recovery to patients with SBO managed both conservatively and operatively
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