Causes of operative mortality in chronically ill geriatric patients: II. With an analysis of eighty additional consecutive autopsy records

Abstract

Eighty consecutive autopsy records in the various systems are analyzed among patients sixty years and over who died within one month after elective and emergency surgery at the Goldwater Memorial Hospital, the population of which consists chiefly of chronically ill geriatric patients who are extreme substandard surgical risks. These cases occurred between the years 1946 and 1952, when the antibiotics were available and when there was also improvement in various types of supportive therapy. The males predominated in a proportion of about 5:1, and a little less than half of all patients were in the eighth decade. In a previous communication 100 autopsies between the years 1939 and 1945, the chemotherapeutic period, have been analyzed and discussed. The pattern of the principal and contributory causes of death was similar in both groups although the mortality rate among all operated cases dropped 7 per cent in the elective and 21 per cent in the emergency cases in the antibiotic period. The outstanding principal causes of death in the present study were bronchopneumonia and peritonitis, and cardiac failure with accompanying pulmonary edema in a little over half the cases. During this same period there was a diminution in the number of deaths from cardiac failure, sepsis, and peritoneal and kidney infection. It is difficult to explain the rise in deaths from bronchopneumonia unless it can be attributed to a longer life after operation and therefore increased susceptibility to the factors which predispose to bronchopneumonia. Other important causes of death were thrombosis and embolism, and pyelonephritis. Among the impressive contributory causes of death were pyelonephritis and cystitis, metastatic carcinoma, intestinal obstruction, intraabdominal abscess, infarcts in abdominal viscera, cirrhosis of the liver, hepatitis, decubitus ulcers and pleural effusion. Most of the deaths after gastrointestinal operations were caused by bronchopneumonia, peritonitis and cardiac failure; after biliary tract operations by bronchopneumonia, cardiac failure and peritonitis; after genitourinary operations by bronchopneumonia, cardiac failure and pulmonary edema, pyelonephritis and peritonitis; and after extremity operations by thrombosis, bronchopneumonia and cardiac failure. Some of the factors which precipitated the deaths were analyzed. Among the more important was the increased risk in emergency surgery, with mortality about twice that of elective surgery, especially when patients came to operation too late. They had rapid deterioration and often irreversible changes or shock which supportive therapy could not combat. Other factors were accompanying multiple degenerative diseases, errors in diagnosis and technics and contraindicated technics. Surgical errors in chronically ill geriatric patients are costly. Their diminished homeostasis and reserve are not comparable with the better repair and vital processes and recuperative powers in younger, healthier people. Mortalities tend to increase with advancing years. Suggestions are made for possible reduction of operative mortality. These include the proper and intensive antibiotic and supportive therapy and indicated operative management. In emergency surgery, especially if the patient is in poor condition, it is safer, if possible, to do just enough to give the patient relief and tide him over until such time as his improved condition warrants additional surgical therapy.