JT Powell

RJ Hinchliffe

Vascular Society, College of Emergency Medicine, Royal College of Radiologists

English

PubMed

Hinchliffe, RJ

Powell, JT

Spiral - Imperial College Digital Repository

96 Ann R Coll Surg Engl 2013; 95: 96–97 LEADING ARTICLEAnn R Coll Surg Engl 2013; 95: 96–97doi 10.1308/003588413X13511609956778KEywoRDsRuptured abdominal aortic aneurysm – Emergency surgery – Vascular surgeryAccepted November 2012CoRREspoNDENCE ToRobert Hinchliffe, St George’s Vascular Institute, St George’s Healthcare NHS Trust, LondonE: rhinchli@sgul.ac.ukImproving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelinesRJ Hinchliffe1, JT Powell21St George’s Healthcare NHS Trust, UK2Imperial College London, UKWith increasing surgical specialisation and centralisation, some surgical emergencies can only be treated in specialist centres. In this context, guidelines for patient transfer from general to specialist hospitals can aid equity of patient ac-cess to emergency specialist surgical care. Guidelines have existed for some time on the early management and trans-fer of patients with head injury but for many surgical emer-gencies there have been no such guidelines.Consequently, publication of joint Vascular Society of Great Britain and Ireland, College of Emergency Medi-cine and Royal College of Radiologists guidelines and audit standards on the diagnosis, early management and transfer of patients with ruptured abdominal aortic aneurysm (rAAA) from general hospitals is welcome.1 If widely adopted, the guidelines will optimise patient care and have the potential to save lives. Unfortunately, guidelines have not existed for vascular emergencies such as rAAA. Data from Europe sug-gest that streamlined regional pathways do improve patient outcomes from rAAA.2 Interestingly, these guidelines were stimulated through research, when it became apparent dur-ing the IMPROVE (Immediate Management of the Patient with Ruptured aneurysm: Open Versus Endovascular re-pair) trial3 that practices to transfer patients with rAAA to a specialist centre varied widely across England. This led to a three-round Delphi consensus approach to examine the ar-eas of consensus and disagreement concerning the transfer of patients with rAAA.4RAAA is a lethal condition in which many patients die before they reach hospital. An appropriately trained vascu-lar team including experienced vascular surgeons has the potential to improve outcomes of those reaching a vascular unit alive. This is dependent, in large part, on rapid diagno-sis, appropriate early management and swift transfer. The diagnosis can be difficult, especially in the elderly with mul-tiple co-morbidities.The development of a vascular surgical specialty, with its own specialist training, and the centralisation of vascular services in the UK will result in an increasing number of hospitals being unable to provide onsite operative interven-tion for rAAA. Consequently, increasing numbers of patients will have to be assessed locally by other specialists (many of whom will not have managed patients with rAAA), who will have to institute immediate care and consider which patients they should transfer to a specialist vascular centre. However, there are changes that might contribute to pa-tient management. Emergency medicine trainees are now trained to perform abdominal ultrasonography to identify a number of key pathologies, including AAA.In the UK and elsewhere, patients have had variable quality of care, largely owing to inequality of access to spe-cialist vascular surgical assessment and treatment when they present but also owing to an absence of standardisation of preoperative assessment and early management. Gener-al hospitals that operate on just a handful of patients with rAAA each year tend to have a higher mortality rate than that of specialist vascular centres.5,6 The elderly and women have been notably discriminated against.7,8The Delphi consensus study on the transfer of patients from district general hospitals to vascular centres analysed ten areas of process of care from the diagnosis of rAAA through to the necessary conditions in the receiving hos-pital.4 The study demonstrated broad agreement about the type of patient who should be eligible for transfer but disa-greements about patient management before and during transfer. Subsequently, in collaboration with the College of Emergency Medicine and others, the guidance document rAAA LEADING ARTICLE.indd   96 12/02/2013   09:06:0497Ann R Coll Surg Engl 2013; 95: 96–97HINcHLIffE PowELL ImpRovING THE ouTComEs fRom RupTuRED AbDomINAL AoRTIC ANEuRysm: INTERDIsCIpLINARy bEsT pRACTICE GuIDELINEswas developed. This document contains six key steps, which are summarised below. They are pragmatic to ensure that patients have rapid diagnosis, appropriate immediate man-agement to prevent deterioration, and rapid and equitable access to expert vascular care.A clinical diagnosis of rAAA by an experienced emergen-cy department doctor is sufficient to transfer patients to a vascular centre. The use of ultrasonography by trained per-sonnel is useful if the presence of an AAA is suspected (but ultrasonography cannot make the diagnosis of rupture). Computed tomography (CT) is helpful in the diagnosis of rAAA but should not delay patient transfer. It is better to per-form CT in the vascular centres rather than delay transfer.An assessment of premorbid conditions (including ad-vanced directive) should be performed in all patients. It is inappropriate to transfer patients who have suffered a car-diac arrest in this illness. The other guidance is pragmatic. In very frail patients or where there are other concerns, consultant involvement in the discussion is helpful.Patients at the general hospital do not require assess-ment by a general surgeon. An experienced emergency de-partment doctor is sufficient to make the diagnosis and refer patients.All patients should have continuous vital sign monitor-ing during assessment and transfer. Investigations should not delay the transfer and none are essential. Intravenous access is the only necessary invasive procedure required. Permissive hypotension should be instituted with small bo-luses of fluids given only if necessary to maintain a systolic blood pressure of >70mmHg. Aggressive fluid resuscitation should be avoided.The transfer of the patient should be as swift as possi-ble. The next available ambulance (‘time critical transfer’) is appropriate. A paramedic crew is preferred but not es-sential. Any imaging should be transferred with the patient or electronically (not allowed to delay). No blood should be transferred with the patient (as it cannot be used at the re-ceiving vascular unit).Patients should be transferred to an area that offers critical care facilities. This will depend on the local ar-rangements and the ambulance should be informed of the destination prior to transfer. After agreement to accept the patient, the vascular consultant/senior trainee should put in place all necessary arrangements to manage the patient ex-peditiously on arrival. It is expected that formal protocols of care will exist in the vascular unit to facilitate management of patients with rAAA (although this is beyond the scope of the guidance).An audit standard has been introduced with the new guidelines. All appropriate patients with rAAA should be transferred to specialist vascular care within 30 minutes of the diagnosis of rAAA being made.RAAA is a good example of a surgical emergency where patients stand to benefit from the introduction of guidelines and audit standards.References1. Vascular Society, college of Emergency Medicine, Royal college of Radiologists. Best Practice Guidelines for the Management and Transfer of Patients with a Diagnosis of Ruptured Abdominal Aortic Aneurysm to a Specialist Vascular Centre. London: VSGBI, cEM, RcR; 2012. http://www.collemergencymed.ac.uk/Shop-floor/clinical%20Guidelines/default.asp. [cited November 2012]2. Haveman Jw, Karliczek A, Verhoeven EL et al. Results of streamlined regional ambulance transport and subsequent treatment of acute abdominal aortic aneurysms. Emerg Med J 2006; 23: 807–810.3. Powell JT. Time to IMPRoVE the management of ruptured abdominal aortic aneurysm: IMPRoVE trialists. Eur J Vasc Endovasc Surg 2009; 38: 237–238.4. Hinchliffe RJ, Ribbons T, Ulug P, Powell JT. Transfer of patients with ruptured abdominal aortic aneurysm from general hospitals to specialist vascular centres: results of a Delphi consensus study. Emerg Med J 2012 Jul 3. [Epub ahead of print.]5. Basnyat PS, Biffin AH, Moseley LG et al. Mortality from ruptured abdominal aortic aneurysm in wales. Br J Surg 1999; 86: 765–770.6. Mell Mw, callcut RA, Bech f et al. Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms. J Vasc Surg 2012; 56: 651–55.7. Anjum A, von Allmen R, Greenhalgh R, Powell JT. Explaining the decrease in mortality from abdominal aortic aneurysm rupture. Br J Surg 2012; 99: 637–645.8. filipovic M, Seagroatt V, Goldacre MJ. Differences between women and men in surgical treatment and case fatality rates for ruptured aortic abdominal aneurysm in England. Br J Surg 2007; 94: 1,096–1,099.rAAA LEADING ARTICLE.indd   97 12/02/2013   09:06:04

Annals of The Royal College of Surgeons of England

Improving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelines

Crossref

St George's Online Research Archive

Differences between women and men in surgical treatment and case fatality rates for ruptured aortic abdominal aneurysm in England.

Explaining the decrease in mortality from abdominal aortic aneurysm rupture.

Mortality from ruptured abdominal aortic aneurysm in wales.

Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms. J Vasc Surg

Results of streamlined regional ambulance transport and subsequent treatment of acute abdominal aortic aneurysms. Emerg Med J

Time to IMPRoVE the management of ruptured abdominal aortic aneurysm: IMPRoVE trialists.

Transfer of patients with ruptured abdominal aortic aneurysm from general hospitals to specialist vascular centres: results of a Delphi consensus study. Emerg Med J

Vascular Society, college of Emergency Medicine, Royal college of Radiologists. Best Practice Guidelines for the Management and Transfer of Patients with a Diagnosis of Ruptured Abdominal Aortic Aneurysm to a Specialist Vascular Centre.

http://dx.doi.org/10.1308/003588413X13511609956778

Improving the outcomes from ruptured abdominal aortic aneurysm: interdisciplinary best practice guidelines

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