Enhanced Recovery After Surgery (ERAS) program in dogs undergoing emergency abdominal surgery

Abstract

Emergency abdominal surgery carries high morbidity and mortality rates in people and is has been an ideal focus for quality improvement programs implementation. However, there is less evidence characterising the outcome of these surgeries as a single group in dogs. Enhance Recovery After Surgery (ERAS) protocols have been largely applied in human medicine to reduce morbidity and mortality of several surgical procedures. ERAS protocols highlight the importance of establishing a specific pathway for the patients focusing on preoperative, intraoperative and postoperative components which comprehend a multidisciplinary approach. Reports of use of these protocols in emergency veterinary surgery are absent but the first indication to build a specific ERAS protocol is to individuate the critical points of the procedure in order to act on them to ameliorate the outcome. This study aimed to characterise the clinical course, associated complications and outcome of dogs undergoing emergency abdominal surgery and to create a specific ERAS program to decrease mortality and postoperative complications in this population. The first part of the study consists in a retrospective study of dogs that underwent emergency abdominal surgery in two institutions. Logistic regression analysis was performed to identify variables correlated with death and complication Then, a multidisciplinary team was created, and a perioperative program for optimizing the management of these patients was developed. The second part of the study consist in a prospective study with the implementation of the program in this population of dogs in the same institutions. Patients of the retrospective study were classified as control group and cases from the prospective study after the protocol implementation were classified as ERAS group. The comparison of variables between groups was performed using Fisher's exact test and the results were reported as Odd Ratio (OR). Eighty-two dogs were included in the first part of the study (control group). The most common reason for surgery was a gastrointestinal foreign body. Overall, the 15-day mortality rate was 20.7% (17/82). The median (range) length of hospitalization was 3 (0.5–15) days. Of the 82 patients, 24 (29.3%) developed major complications and 66 (80.5%) developed minor complications. Perioperative factors significantly associated with death included tachycardia (p < 0.001), hypothermia (p < 0.001), lactate acidosis (p < 0.001), shock index > 1 (p < 0.001), leukopenia (p < 0.001) and thrombocytopenia (p < 0.001) at admission, as well as intraoperative hypotension (p < 0.001) and perioperative use of blood products (p < 0.001). Fifty-nine patients were included in the ERAS group. Surgical procedures were different between ERAS and control group and more patients in ERAS groups had lower comorbidity index (CI). The rest of demographic and laboratory and physical examination findings on arrival were similar between groups. Compared with control group, ERAS group had reduced mortality (20.7% vs 5%, p = 0.01, OR 4.88) and postoperative minor complications (80.5% vs 45.8%, p = 0.0001, OR 4.71). The overall number of patients that did not experience postoperative complications was significantly higher in the ERAS group compared with control group (45.8% vs 17%, p = 0.0003, OR 0.24). The rate of postoperative major complications and the overall length of hospital stay was similar between groups. ERAS significantly improved use of locoregional anaesthesia (p < 0.0001), antiemetic prophylaxis (p < 0.0001) and time from surgery to start oral intake (p < 0.0001). Implementation of this perioperative program and demonstration of improved outcomes in two different hospitals provides evidence of external validity of the use of this approach to reduce mortality and complications after emergency laparotomy in dogs. Further work assessing the potential of selected program items in these patients are needed to identify factors that may improve outcome.