Actual 30-day Mortality Research Articles

FP7.8 - Perioperative risk prediction for Emergency Laparotomy in Adults, using the National Emergency Laparotomy Audit (NELA) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools – an Eastern European perspective

Abstract Background Worldwide, emergency laparotomy (EL) is one of the most common procedures. Having an actual 30-day mortality (30-dm) of 10 to 15%, EL has a high mortality rate, particularly in patients >70 years old. Preoperative risk assessment and stratification can improve outcomes. The American-College-of-Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and the National Emergency Laparotomy Audit (NELA) risk prediction tools are the most used risk calculators, but both can under or overpredict. Methods This is a single-center, retrospective, cohort study that looked at the correlation between actual and predicted 30-dm using NELA and ACS-NSQIP in adults ≥18, following EL, over 2 years, in a single-tertiary-center from Romania. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. Statistical analysis was performed using GraphPad-Prism 10.1.1. and Stata18. Results 207 cases were analyzed. Male/female ratio was 1.49; age 65 years (50;77); BMI 26.25kg/m² (23.01;28.35); preoperative lactate 1.8 mmol/L (1.5;3.4); ASA grade 3 (2;4) clinical frailty score 4 (3;4); and Charlson Comorbidity Index 5 (3;8). Actual 30-dm was 31.4% with NELA and ACS-NSQIP predicted 30-dm of 5.78% (1.84;21.48) and 5.5% (1.2;24.2) respectively. NELA and ACS-NSQIP predicted 30-dm expressed a strong positive correlation, R²=0.88; p<0.0001. Both NELA and ACS-NSQIP predicted 30-dm showed a significant positive correlation with actual 30-dm: R²=0.33, p<0.0001; and R²=0.41, p<0.0001 respectively. All data is presented as Median + IQR. Conclusion In a Romanian setting both ACS-NSQIP and NELA risk calculators underpredicted 30-dm, despite expressing a strong positive correlation with actual 30-dm.

30-Day Mortality Rates in Fractured Neck of Femur: Nottingham Hip Fracture Score vs Surgical Outcome Risk Tool

Objectives: The Nottingham hip fracture score (NHFS) and the Surgical outcome risk tool (SORT) are both validated scoring systems used to predict mortality rates in patient with Fractured neck of femur (FnF). The primary aim of this study was to compare the accuracy of the predicted 30-day mortality rates between NHFS and SORT in patients with FnF. The secondary aim was to investigate the influence of patient and surgical factors on 30-day mortality. Methods: The NHFS and SORT score was collected from 212 patients admitted with FnF. Variables including hip fracture type, surgical procedure and peri-operative haemoglobin, gender and ASA grade were also collected and further analysed to assess their influence on 30-day mortality rates. Results: Overall actual 30-day mortality rate for the study population was 11.3% (n=24). There was a significant difference between the mean predicted 30-day mortality for the NHFS (8.0%) and the SORT score (7.0%, p=0.006). The was no difference in mortality rates between the different fracture types (p=0.889). There was a significant difference in mortality rates when comparing surgical procedures (p=0.031). Patients who had a notable fall in haemoglobin peri-operatively had significantly higher mortality rates (p<0.001). Males had significantly higher mortality rates compared to females (20.0% vs 8.6% respectively, p=0.027). Higher ASA grades also had significantly higher mortality rates (p=0.003). Conclusion: NHFS was found to be significantly more accurate at calculating 30-day mortality rates compared to the SORT score in patients with FnF. Surgical procedure and patient factors including gender, ASA grade and peri-operative haemoglobin also significantly influenced mortality rates but fracture type did not.

Surgical risk calculators in veterans following lower extremity amputation

ObjectiveTo evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation. MethodsThe actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective. ResultsThe overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST. ConclusionRisk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.

Is using intracerebral hemorrhage scoring systems valid for mortality prediction in surgically treated patients?

While intracerebral hemorrhage (ICH) scoring systems provide mortality and morbidity prediction, the actual mortality rates seem to be lower than those predicted by scoring systems in our clinical impression. To assess the validity of the ICH score and the Surgical Swedish ICH (SwICH) score, we retrospectively reviewed surgically treated ICH patients between 2012 and 2019. Uni- and multivariate analyses were performed to identify variables in predicting 30-day mortality. We identified 203 patients (mean ICH score 2.7; mean SwICH score 2.0). The actual 30-day mortality was 7%, which was significantly lower than those predicted by the ICH and the SwICH scores (55% and 16%, respectively; p < 0.001). Both scores were strongly correlated with the modified Rankin scale (mRS) at discharge (correlation coefficient 0.97 and 0.98; critical value 0.81). The only significant prognostic factors for the 30-day mortality by multivariate analysis were anisocoria (p = 0.03) and preoperative Glasgow Coma Scale (p = 0.03). These two factors also predicted mRS at discharge (p < 0.001). After discharge, 15% of patients improved regarding mRS and 29% of wheelchair-bound patients gained the ability to ambulate. No significant relationship existed between the degree of recovery after discharge and preoperative ICH score (p = 0.25). The ICH and SwICH scores were more valid in predicting morbidity, rather than mortality after surgical intervention for ICH. Anisocoria and Glasgow Coma Scale < 7 were the only two factors that predicted 30-day mortality and morbidity at discharge.

Trauma-registry survival outcome follow up: 30 days is mandatory and appears sufficient

IntroductionThirty-day in-hospital mortality is a common outcome measure in trauma-registry research and benchmarking. However, this does not include deaths after hospital discharge before 30 days or late deaths beyond 30 days since the injury. To evaluate the reliability of this outcome measure, we assessed the timing and causes of death during the first year after major blunt trauma in patients treated at a single tertiary trauma center. MethodsWe used the Helsinki Trauma Registry to identify severely injured (NISS ≥ 16) blunt trauma patients during 2006 to 2015. The Population Register center of Finland provided the mortality data for patients and Statistics Finland provided the cause of death information from death certificates. Disease, work-related disease, medical treatment, and unknown cause of death were considered as non-trauma related deaths. We divided the 1-year study period into the following three categories: in-hospital death before 30 days (Group 1), death after discharge but within 30 days (Group 2), and death 31 to 365 days since admission (Group 3). ResultsWe included 3557 patients with a median NISS of 29. Altogether, 21.8% (776/3557) patients died during the first year since the injury. Of these non-survivors, 12.7% (450) were in Group 1, 4.0% (141) in Group 2, and 5.2% (185) in Group 3. Non-traumatic deaths not directly related to the injury increased substantially as the time from the injury increased and were 2.0% (9/450) in Group 1, 13.5% (19/141) in Group 2, and 35.7% (66/185) in Group 3. ConclusionThirty-day mortality is a proper outcome that measures survival after severe blunt trauma. However, applying only in-hospital mortality instead of actual 30-day mortality may exclude non-survivors who die at another facility before day 30. This could result in over-optimistic benchmarking results. On the other hand, extending the follow-up period beyond 30 days increases the rate of non-traumatic deaths. By combining data from different registries, it is possible to address this challenge in current trauma-registry research caused by lack of follow up.

External validation of a prognostic scoring system for percutaneous endoscopic gastrostomy (PEG)

IntroductionThere is a significant mortality associated with PEG. The Sheffield Gastrostomy Score (SGS) was devised to try and improve outcomes following this procedure by predicting 30-day mortality. After prospectively collecting...

External validation of a prognostic scoring system for percutaneous endoscopic gastrostomy (PEG)

Introduction There is a significant mortality associated with PEG. The Sheffield Gastrostomy Score (SGS) was devised to try and improve outcomes following this procedure by predicting 30-day mortality. After prospectively collecting demographic, biochemical and outcome data from a cohort of patients having a new PEG inserted (Hospital A, n = 403), multivariate analysis identified that age and albumin were determinants of 30-day mortality (p 35, 25–34 and Methods Four local district general hospitals were used to externally validate the SGS. Demographic, biochemical and outcome data was obtained from all patients undergoing PEG insertion between June 2006 and June 2009. χ 2 analysis was used to compare actual 30-day mortality rates in the external cohort to the rate predicted by the SGS. Results A total of 679 new PEGs were inserted during this period in these four hospitals. Complete records were obtained from 88% (597/679) and analysed (median age 71, 322 male). The 30-day mortality for this external validation cohort was 13.6%. The main indications for PEG insertion were stroke (33.7%), oropharyngeal malignancy (32.3%) and neurodegenerative diseases (17.4%). Univariate analysis predictors of 30-day mortality in this external cohort were: increasing age, low serum albumin and stroke. There were no significant differences between the observed and the predicted mortality (p ≤ 0.05) in the external validation cohort using the SGS. Conclusion Our results suggest that the SGS can accurately stratify patients into different risk categories, with higher scores correlating with significantly lower survival. We feel that the SGS could have an important role in those patients where the benefits and risks of gastrostomy are unclear.

Editorial commentPrognostic information in administrative co-morbidity data following coronary artery bypass grafting

The European System for Cardiac Operative Risk Evaluation (EuroSCORE) was developed by surgeons in Europe to provide a tool to predict early mortality of patients undergoing heart surgery [1]. EuroSCORE is being used in a number of ways since its introduction in 1998. One important feature is its usefulness in counselling individual patients and their families about the risks of a suggested operation and to choose the best treatment option for patients with complicated medical histories. For instance, EuroSCORE and Society of Thoracic Surgeons (STS) scores are being used to select patients for new percutaneous valve techniques. EuroSCORE can also be used as an indicator for quality of care when comparing the score with the actual outcome. It provides a risk stratification system that gives meaning to comparing different units, surgeons or countries that otherwise may not be comparable. It is fundamental that the risk stratification system is objective, precise and resistant to manipulation to ensure that conclusions drawn from such comparisons are valid. EuroSCORE has been investigated thoroughly and some shortcomings are known. In an effort to improve the systems, new data sets from all over Europe will be collected in the near future (http:// www.euroscore.org). The article by Abildstrom and co-workers on behalf of the Danish Heart Register in this issue of EJCTS aims at using administrative data from the Danish National Patient Register to calculate a co-morbidity index [2]. Information about disease codes in discharge letters of all admissions up to 1 year prior to coronary artery bypass grafting (CABG) forms the basis of the register. The register contained information about severity of heart disease and comorbidities (malignancy, diabetes with complications, cerebrovascular disease, acute or chronic renal failure and chronic obstructive pulmonary disease). In addition, age, gender and information about isolated CABG and acute surgery were included. The prognostic power of the co-morbidity index with regard to actual 30-day mortality was compared to the simple additive EuroSCORE and found equal. The authors conclude that a co-morbidity index based on administrative data allowed meaningful comparison of institutional performance equal to the additive EuroSCORE registered in a clinical database. The comorbidity index performed well in the current study in patients undergoing coronary surgery. The results presented by Abildstrom and co-workers are interesting from a scientific point of view. However, this approach has serious drawbacks, limiting its use for comparison of institutional performance. Although comorbidities are an important part of the EuroSCORE, the EuroSCORE contains much more: for example, information on unstableangina,endocarditisorcriticalpreoperativestate.In some groups of patients, the co-morbidity score is bound to perform badly, for example, in type A-dissections or acute endocarditis. These patients may have no or few prior admissions. Nevertheless, they carry a high perioperative risk. Cardiac surgical units operating on many dissections, etc., will inevitably perform poorer, compared with units where only elective coronary surgery is being performed. In addition,diagnosiscodingforthesakeofthedischargeletteris often performed by junior doctors or administrators without quality control. By contrast, in our unit, coding for the EuroSCORE is performed by surgeons or cardiac anaesthetists priorto surgery and quality controlledin a three-stepprocess, before data are collected in the institutional database. The informationfrominstitutionaldatabasesofallcardiacsurgical unitsispassedontoourNorwegiannationaldatabaseresulting in a reliable basis for quality control. The author believes that such a process should be the minimum requirement for data used for comparisonof institutional performance. Moreover, a national database of diagnostic codes where patients can be identified would probably violate privacy laws in a number of countries.

Death After Colectomy

Clinical outcomes are increasingly subject to objective assessment and professional accountability. Informed consent relies on accurate estimation of operative risk. Current scoring systems for assessment of operative mortality after colorectal surgery (CRS) almost uniformly report 30-day mortality and may not represent true risk. Prospective cohort. University-affiliated Veterans Affairs Medical Center. All patients who underwent resections of the colon and/or rectum (as the principal operation) at a single hospital whose data are captured in the Veterans Affairs National Surgical Quality Improvement Program (VA-NSQIP) database from January 1, 2000, through December 31, 2006. Mortality at 30 days and 90 days. The VA-NSQIP cohort included 186 patients who underwent CRS, including 148 patients who underwent elective procedures (79.6%) and 38 patients who underwent emergency procedures (20.4%). All but 8 patients were men, with a median age of 67 years (range, 26-92 years). Laparoscopic operations comprised 24.2% and open operations comprised 75.8%. Most (60.8%) were performed for neoplasms. The actual 30-day mortality rates (all, elective, and emergency procedures) were 4.3%, 1.4%, and 15.8%, respectively. These rates closely mirrored the calculated VA-NSQIP risk-adjusted observed-to-expected ratio for 30-day mortality (4.8%, 1.8%, and 18.2%, respectively). However, mortality at 90 days increased substantially to 9.1%, 4.1%, and 28.9%, respectively. The 30-day mortality significantly underreports the true risk of death after CRS. The 90-day mortality rate should be included as a standard outcome measure after CRS because it serves as a better estimation of risk for counseling patients.

Expanding the Donor Pool: Lung Transplantation With Donors 55 Years and Older

The scarcity of donor organs is one of the major limitations to lung transplantation. This has led to a progressive expansion of criteria for donor selection in lung transplantation. This study evaluated the outcome of recipients of lungs from donors ≥55 years. We performed a retrospective analysis of 212 consecutive lung transplantations. Recipients were divided into two groups, those receiving lungs from donors ≥55 years (older donor group) and those receiving lungs from donors <55 years (younger donor group). Recipient baseline characteristics, time in the intensive care unit (ICU), early mortality, and long-term survival (Kaplan–Meier) were compared between the groups. Forty-one donors (19%) were ≥55 years. Mean recipient age in the older donor group was higher than in the younger donor group (52 ± 8 vs. 47 ± 12 years; P = .015). Indication for transplantation did not differ between the groups. ICU stay was comparable between the two groups (6 ± 12 vs. 7 ± 11 days; P = .64). Actual 30-day mortality (10.8% vs. 6.4%; P = .32), 1-year mortality (17.1 vs. 19.6%; P = .50), and cumulative long-term survival (65% and 62% at 5 years, P = 1.00) did not differ between the older and younger donor group. This study indicated that transplantation of lungs from selected donors aged ≥55 years did not impair short-or long-term results. The use of lungs from elderly donors may help to increase the number of donor organs for lung transplantation.

Early mortality in coronary bypass surgery: the EuroSCORE versus The Society of Thoracic Surgeons risk algorithm

Background We compare two widely used risk algorithms for coronary bypass surgery: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) and The Society of Thoracic Surgeons (STS) risk stratification algorithm. Methods Risk factors for all adult patients undergoing heart surgery at the University Hospital of Lund between 1996 and 2001 were collected prospectively at preoperative admission. Predictive accuracy for 30-day mortality was assessed by comparing the observed and the expected mortality for equal-sized quintiles of risk by using the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power was evaluated by calculating the areas under receiver operating characteristics (ROC) curves. Results The study included 4497 coronary artery bypass-only operations. The average age was 66.4 ± 9.3 years (range 31 to 90 years). Most patients were men (77.0% versus 23.0%). The actual 30-day mortality was 1.89%. The Hosmer-Lemeshow goodness-of-fit test gave a p value of 0.81 (EuroSCORE) and 0.83 (STS), which indicates a good accuracy of both models. The area under the ROC curve was 0.84 (95% confidence interval [CI] 0.80 to 0.88) for EuroSCORE and 0.71 (95% CI 0.66 to 0.77) for STS. The discriminatory power (area under the ROC curve) was significantly larger for EuroSCORE compared with STS ( p < 0.00005). Conclusions In this large, single institution study the additive EuroSCORE algorithm had a significantly better discriminatory power to predict 30-day mortality than the STS risk algorithm for patients undergoing coronary artery bypass.

Early treatment with verapamil or diltiazem in patients with acute myocardial infarction: safety and possible beneficial effects.

While dihydropyridine calcium antagonists may be harmful in the immediate peri-infarction period, the effect of verapamil or diltiazem in these circumstances in uncertain. We utilized the GUSTO-1 formula to calculate the predicted 30-day mortality risk in a cohort of 352 patients with acute myocardial infarction presenting < 6 hours after onset of symptoms, with ECG changes consistent with eligibility for thrombolysis. All patients were treated with an intravenous bolus dose of verapamil followed by oral verapamil (240-360 mg/day) or diltiazem (180-360 mg/day), in the absence of specific contraindications. Predicted 30-day mortality risk was then compared with the actual 30-day mortality rate of the cohort. The actual 30-day mortality of the cohort was 3.7% (95% CI: 2.0,6.3); this was significantly lower than that predicted by the GUSTO-1 formula (7%). A similarly significantly lower mortality (7.5% vs 19.3%) was observed in a "high risk" subset of patients. Of the 13 patients who died, only 4 developed cardiogenic shock. It is concluded that verapamil and diltiazem can be administered safely in a selected patients with evolving acute transmural myocardial infarction. While the current data suggest that this form of treatment may be beneficial, definitive conclusions in this regard should await further randomized studies.