Preoperative Septic Shock Research Articles

Association of Comorbidities and Functional Level With Mortality in Geriatric Bowel Perforation

IntroductionSpontaneous bowel perforation is associated with high morbidity and mortality. This entity remains understudied in the geriatric patient. We sought to use a national surgical sample to uncover independent predictors of mortality in elderly patients undergoing emergent operation for perforated bowel. MethodsUsing the American College of Surgeons National Surgical Quality Improvement database, years 2007 to 2017, all geriatric patients (age ≥65 y) who underwent emergency surgery and who had a postoperative diagnosis of bowel perforation were included. Univariate and multivariable analyses were used to identify independent predictors of 30-d mortality. ResultsA total of 8981 patients were included. The median (interquartile range) age was 75 y (69, 82), and 59.0% were female. Twenty-one percent of patients were partially or totally dependent, and 25.2% were admitted from sources other than home. Overall, 30-d mortality rate was 22.1%. Independent predictors of mortality included the following: age 70-79 y (odds ratio [OR]: 1.59, P < 0.001), age ≥80 y (OR: 3.23, P < 0.001), American Society of Anesthesiologists ≥3 (OR: 4.74, P < 0.001), admission from chronic care facility (OR: 1.61, P < 0.001), being partially or totally dependent (OR: 1.50, P < 0.001), chronic steroid use (OR: 1.36, P < 0.001), and preoperative septic shock (OR: 3.74, P < 0.001). Having immediate fascial closure was protective against mortality (immediate fascial closure only, OR: 0.55, P < 0.001; -immediate closure of all surgical site layers, OR: 0.44, P < 0.001). ConclusionsIn geriatric patients, functional status and chronic steroid therapy play an important role in determining survival following surgery for bowel perforation. These factors should be considered during preoperative counseling and decision-making.

Analysis of Early Lower Extremity Re-amputation

Data is scarce regarding the need for early re-amputation to a higher anatomic level. This study seeks to define outcomes and risk factors for re-amputation. Patients undergoing primary major lower extremity amputation were identified within the 2012-2016 ACS-NSQIP database. Demographics, outcomes, and peri-operative characteristics were compared, and multivariable logistic regression model was used to determine association with early re-amputation. Over a 4-year period, 8306 below knee amputations and 6367 above knee amputations were identified. Thirty-day re-amputation occurred in 262 patients (1.8%) and was associated with increased length of stay (12.9 vs. 7.3 days, P < 0.001), higher rates of readmission (64.9% vs. 13.6%, P < 0.001), and overall complications (69.5% vs. 39.3%, P < 0.01). On multivariable analysis, advanced age (OR 1.02, CI 1.01-1.03), smoking (OR 1.75, CI 1.32-2.33), dialysis dependence (OR 1.67, CI 1.23-2.26), preoperative septic shock (OR 2.53, CI 1.29-4.97), and bleeding disorders (OR 1.72, CI 1.34-2.22) were associated with early re-amputation. Thirty-day re-amputation rates are low, but are associated with significant morbidity, prolonged hospitalization, and frequent readmissions.

Factors that Predict Survival From Mesenteric Ischemia in the Geriatric Patient: Not a Death Sentence.

The mortality rate from mesenteric ischemia is reported to be as high as 80%. The goal of our study was to identify demographic and clinical predictors of post-operative mortality and discharge disposition among elderly patients with mesenteric ischemia. All patients 65years and older who underwent emergency surgery (ES) for the management of mesenteric ischemia in the American College of Surgeons-National Surgical Quality Improvement Program database from 2007 to 2017 were included. Univariate analyses and logistic regressions were used to identify independent predictors of mortality and discharge disposition. A total of 2438 patients met inclusion criteria, with a median age of 77years and 60.8% being female. The 30-day mortality of the overall cohort was 31.5% and the 30-day morbidity was 65.3%. The following were the major predictors of 30-day mortality: pre-operative diagnosis of septic shock [OR: 2.46, (95% CI: 1.94-3.13)], dialysis dependence [OR: 2.05, (95% CI: 1.45-2.90)], recent weight loss [OR: 1.80, (95% CI: 1.16-2.79)], age ≥80years [OR: 1.67, (95% CI: 1.25-2.23)], and ventilator dependence [OR: 1.65, (95% CI: 1.23-2.23)]. In the absence of these predictors, survival rate was 84%. The major predictors of discharge to post-acute care (PAC) included age ≥80years [OR: 3.70, (95% CI: 2.50-5.47)] and pre-operative septic shock [OR: 2.20, (95% CI: 1.42-3.41)]. In the geriatric patient, a diagnosis of mesenteric ischemia does not equate to an automatic death sentence. The presence of certain pre-operative risk factors confers a high risk of mortality, whereas their absence is associated with a high chance of survival.

Necrotizing Soft Tissue Infection in the Elderly: Effect of Pre-Operative Factors on Mortality and Discharge Disposition.

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressing, life-threatening diseases associated with substantial morbidity and mortality, especially in patients 65 years or older. We aimed to evaluate clinical factors associated with mortality and discharge disposition after NSTIs in elderly patients. Patients and Methods: Retrospective data were obtained from the 2007-2017 American College of Surgeons-National Surgical Quality (ACS-NSQIP) database. Patients aged 65 years or older with a post-operative diagnosis of an NSTI (defined as gas gangrene, necrotizing fasciitis, or Fournier gangrene) were included. Univariable and multivariable analyses were performed to identify independent clinical and demographic factors associated with mortality and with discharge disposition. Results: A total of 1,460 patients were included. Median age was 71 years, 43% were females. Overall, 30-day mortality was 18.5% and 30-day morbidity was 63.6%. The most important predictors of mortality included pre-operative septic shock (odds ratio [OR], 6.36; 95% confidence interval [CI], 3.61-11.18), pre-operative dialysis dependence (OR, 2.99; 95% CI, 1.77-5.05), coagulopathy (international normalized ratio [INR], >1.5, OR, 2.25; 95% CI, 1.51-3.37), hepatobiliary disease (bilirubin >1.0 mg/dL; OR, 2.05; 95% CI, 1.38-3.04) and aged 80 years or older (OR, 3.36; 95% CI, 2.08-5.44). Patients without any of these risk factors had a mortality of 7.3%. Predictors of discharge to inpatient rehabilitation or skilled care included age 80 years or older (OR, 2.49; 95% CI, 1.44-4.30), American Society of Anesthesiologists (ASA) ≥3 (OR, 2.05; 95% CI, 1.03-4.05)] and amputation as opposed to debridement (OR, 2.53; 95% CI,1.48-4.32). Conclusions: We identified several pre-operative clinical factors that were associated with increased post-operative mortality and discharge to post-acute care. The next steps should focus on determining if optimization of modifiable predictors would improve mortality.

Importance of CT-scan predicting clinical outcomes in gastro-intestinal perforation.

BackgroundGastrointestinal (GI) perforations are an acute surgical dilemma, with diagnostic workup often requiring abdominal imaging. Post-operative care for these patients may vary and oftentimes includes ICU care for sepsis, but not always. We evaluated if free fluid and air on computed tomography (CT) could be associated with sepsis, septic shock and mortality in GI perforations. The aim of our study was a correlation between a new CT-scan scoring system and septic complications in GI perforations.MethodsWe conducted an observational retrospective study about patients who underwent emergency surgery for intestinal perforation between January 2014 and June 2017. Inclusion criteria were a CT-scan positive for free fluid and air, and an intestinal perforation confirmed intraoperatively. A CT-score was created to evaluate location and extent of free fluid and air related to clinical outcome and prognosis. Univariate analysis between the CT score and the various clinical outcomes was conducted with the non-parametric Mann-Whitney test for continuous variables and with the chi-square test for categorical variables.ResultsOne-hundred and fifty-one patients were evaluated. The mortality was 23.18% and the complications were present in 45.95%. The median CT score for patients who developed complications was 3, compared with a value of 2 in the absence of complications (P=0.008). A CT score of 4 or greater had a sensitivity and specificity for predicting pre-operative sepsis of 73.33% and 64.42% respectively, and for pre-operative septic shock of 35.56% and 93.27%. Looking at post-operative sepsis, sensitivity and specificity were 57.45% and 70.19%, and for septic shock 36.17% and 85.85%. Spearman correlation analysis revealed that at higher scores at CT score corresponded higher scores at the P-POSSUM morbidity, P-POSSUM mortality and WSES Sepsis Severity Score.ConclusionsOur CT score shows a significant correlation with validated predictive scoring systems with regards to predicting sepsis, septic shock and complications—and seems to be a useful outcome predictor in GI perforation.

Life after 90: Predictors of mortality and performance of the ACS-NSQIP risk calculator in 4,724 nonagenarian patients undergoing emergency general surgery

The decision to emergently operate on nonagenarian patients (NONAs) can be complex due to the uncertainty about outcomes and goals of care at this advanced age. We sought to study: (1) the outcomes and predictors of mortality for NONAs undergoing emergency general surgery (EGS) and (2) the accuracy of ACS-NSQIP mortality risk calculator in this special population. Using the 2007 to 2015 ACS-NSQIP database, we included all patients older than 90 years of age who underwent an emergent operation with a Current Procedural Terminology (CPT) code for "digestive system." Multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality. NONAs' mortality rates for different combinations of risk factors were also studied and compared to the ACS-NSQIP calculator-predicted mortality rates. Out of a total of 4,456,809 patients, 4,724 NONAs were included. The overall 30-day patient mortality and morbidity rates were 21% and 45%, respectively. In multivariable analyses, several independent predictors of 30-day mortality were identified, including recent history of weight loss, history of steroid use, smoking, functional dependence, hypoalbuminemia and sepsis or septic shock. The mortality among NONAs with a history of steroid use and a recent history of weight loss was 100%. Similarly, the mortality of NONAs with recent history of weight loss who presented with preoperative septic shock was 93%. The ACS-NSQIP calculator significantly and consistently underestimated the risk of mortality in all NONAs undergoing EGS. Most NONAs undergoing EGS survive the hospital stay and the first 30 postoperative days, even in the presence of significant preexisting comorbidities. However, the combination of recent weight loss with either steroid use or septic shock nearly ensures mortality and should be used in the discussions with patients and families before a decision to operate is made. The ACS-NSQIP surgical risk calculator should be used with caution in these high-risk patients. Prognostic study, level III.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74-2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30-2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Influence of Staphylococcus aureus on Outcomes after Valvular Surgery for Infective Endocarditis

BackgroundAs Staphylococcus aureus (SA) remains one of the leading cause of infective endocarditis (IE), this study evaluates whether S. aureus is associated with more severe infections or worsened outcomes compared to non-S. aureus (NSA) organisms.MethodsAll patients undergoing valve surgery for bacterial IE between 1995 and 2013 at our institution were included in this study (n = 323). Clinical data were retrospectively collected from the chart review. Patients were stratified according to the causative organism; SA (n = 85) and NSA (n = 238). Propensity score matched pairs (n = 64) of SA versus NSA were used in the analysis.ResultsSA patients presented with more severe IE compared to NSA patients, with higher rates of preoperative vascular complications, preoperative septic shock, preoperative embolic events, preoperative stroke, and annular abscess. Among the matched pairs, there were no significant differences in 30-day (9.4% SA vs. 7.8% NSA, OR = 1.20, p = 0.76) or 1-year mortality (20.3% SA vs. 14.1% NSA, OR = 1.57, p = 0.35) groups, though late survival was significantly worse in SA patients. There was also no significant difference in postoperative morbidity between the two matched groups.ConclusionsSA IE is associated with a more severe clinical presentation than IE caused by other organisms. Despite the clearly increased preoperative risk, valvular surgery may benefit SA IE patients by moderating the post-operative mortality and morbidity.

Open abdomen with vacuum-assisted wound closure and mesh-mediated fascial traction in patients with complicated diffuse secondary peritonitis: A single-center 8-year experience.

Open abdomen (OA) treatment in patients with peritonitis is increasing worldwide. Various temporary abdominal closure devices are being used. This study included patients with complicated diffuse secondary peritonitis, OA, and vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). The aim of this study was to describe mortality and major morbidity in terms of delayed primary fascial closure and enteroatmospheric fistula rates. This was a single-academic-center retrospective study of consecutive patients with diffuse peritonitis, OA, and VAWCM between years 2008 and 2016. Descriptive and univariate analyses were performed. Forty-one patients were identified and analyzed. Median age was 59 years, preoperative septic shock was diagnosed in 54% (n = 22), and 59% (n = 24) had a postoperative peritonitis. Mortality was 29% (n = 12), and 76% (n = 31) of patients were admitted in the intensive care unit. The median duration of OA was 7 days with a median of two dressing changes. Delayed primary fascial closure rate among survivors was 92% (n = 33), and enteroatmospheric fistulas developed in 7% (n = 3). In a subgroup analysis, patients with OA in the primary laparotomy for peritonitis (n = 27) were compared with patients with OA in the subsequent laparotomies (n = 14). There were no significant differences between groups. The VAWCM technique in patients with complicated secondary diffuse peritonitis and OA yields excellent results in terms of delayed primary fascial closure rate and a low number of enteroatmospheric fistulas. It seems to be safe to close the abdomen at the index laparotomy, if possible, even if there is a risk of a need of OA later. Therapeutic/care management study, level IV.

Variation in intraoperative and postoperative red blood cell transfusion in pediatric surgery.

Intraoperative and postoperative red blood cell (RBC) transfusions are relatively frequent events tracked in the American College of Surgeons' National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P). This study sought to quantify variation in RBC transfusion practices among hospitals. This is an observational study of children older than 28 days who underwent a general, neurologic, urologic, otolaryngologic, plastic, or orthopedic operation at 50 hospitals in participating in the ACS-NSQIP-P during 2011 to 2012. The primary outcome was whether or not a RBC transfusion was administered from incision time to 72 hours postoperatively. Transfusions of fresh-frozen plasma, cryoprecipitate, and platelets were excluded from data abstraction due the rarity of their administration. A multivariate hierarchical risk-adjustment model estimated the risk-adjusted hospital RBC transfusion odds ratio (OR) and designated hospitals by transfusion practice. The mean RBC transfusion rate was 1.5%. Five preoperative variables were associated with greater than threefold increased odds of having an intraoperative or postoperative RBC transfusion; young age; 29 days to 1 year (OR, 5.9; p < 0.001) and 1 to 2 years (OR, 3.4; p < 0.001); American Society of Anesthesiologists Class IV (OR, 3.2; p < 0.001); procedure linear risk (OR, 3.1; p < 0.001); preoperative septic shock (OR, 14.5; p < 0.001); and preoperative cardiopulmonary resuscitation (OR, 8.1; p < 0.001). Twenty-five hospitals had RBC transfusion practices significantly different than risk-adjusted mean (17 higher and eight lower). Intraoperative and postoperative RBC transfusion practices vary widely among hospitals after controlling for patient and procedural characteristics.

Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation

The above-knee amputation (AKA) is an operation of last resort with high postoperative morbidity and mortality. This study identifies preoperative risk factors predictive of both 30-day mortality and extended length of stay (LOS) in AKA patients. Two hundred ninety-five AKA patients from 2004 to 2013 from a single institution were retrospectively reviewed using a deidentified electronic medical record. Rationally selected factors potentially influencing 30-day mortality and LOS were chosen, including demographics, etiologies, vascular surgical history, lifestyle factors, comorbidities, and laboratory values. Variables trending with one of the end points on bivariate analysis (P≤0.10) were entered into multivariate forward stepwise regression models to determine independence as a risk factor (P≤0.05). Subgroup analysis of AKA patients without a traumatic, burn, or malignant etiology was similarly conducted. Within the 295 patient cohort, 60% of the patients were male, 18% were African American, mean age was 58years and mean body mass index was 28kg/m(2). The 30-day mortality rate was 9%, and mean postoperative LOS of discharged patients was 9.3days. Upon logistic regression, thrombocytopenia (platelet count<250×10(6)/mL, P<0.001, odds ratio 6.1) and preoperative septic shock (P=0.02, odds ratio 5.1) were identified as independent risk factors for 30-day mortality. Upon linear regression, burn etiology (P<0.001, B=15.8days), leukocytosis (white blood cell count>12×10(6)/mL, P<0.001, B=6.2days), and guillotine amputation (P<0.001, B=7.6days) were independently associated with prolonged LOS. Excluding patients with AKAs due to trauma, burn, or malignancy, only thrombocytopenia (platelet count<250×10(6)/mL, P<0.001, odds ratio 10.2) and leukocytosis (white blood cell count>12×10(6)/mL, P=0.01, B=5.2days) were independent risk factors for in-hospital mortality and prolonged LOS, respectively. Preoperative septic shock and thrombocytopenia are independent risk factors for 30-day mortality after AKA, while burn etiology, leukocytosis, and guillotine amputation contribute to prolonged LOS. Awareness of these risk factors may help enhance both preoperative decision making and expectations of the hospital admission.

Abstract 18859: Staphylococcus aureus Infective Endocarditis is Associated with Worsened Clinical Characteristics than Non-Staphylococcus aureus Organisms

Background: Staphylococcus aureus remains a leading cause of IE, but it is unknown whether S. aureus is associated with more severe infections or worsened outcomes compared to other bacterial organisms. The primary purpose of this study was to compare the clinical characteristics and mortality in S. aureus (SA) versus non-S. aureus (NSA) IE patients undergoing valvular surgery. Methods: All patients undergoing valvular surgery for bacterial IE between 1995 and 2013 at our institution were included in this study. Clinical data were retrospectively collected from chart review. Patients were categorized according to causative organism: 1) SA: n=85, and 2) NSA: n=238, composed of coagulase-negative staphylococci (23%), streptococci (12% viridans; 19% non-viridans), enterococci (17%), and other (51%). Results: SA patients had a higher severity of illness compared to NSA patients due to higher rates of preoperative vascular complications (58.8% vs. 39.4%, p = 0.002), preoperative septic shock (23.5% vs. 13.9%, p = 0.039), preoperative embolic events (33.3% vs. 20.7%, p = 0.02), preoperative stroke (27.1% vs. 13.5%, p = 0.004), and annular abscess (44.7% vs. 27.3%, p = 0.003). There were no statistically significant differences in 30-day (9.4% vs. 8.0%, p = 0.68, OR = 1.20) or 1-year (20% vs. 14.3%, p = 0.22, OR = 1.50) post-operative mortality between SA and NSA IE patients, respectively. However, length of hospital stay, and 30-day post-operative development of new renal failure were higher in SA patients. There was a trend to more post-operative embolic events in SA patients. Conclusions: SA IE is associated with higher morbidity on presentation, such as pre-operative embolic events, stroke and annular abscess, compared to IE caused by other bacterial organisms, but does not lead to increased mortality after surgery. Further research is needed to investigate the differences in post-operative complications among patients.

Factors affecting the early mortality of patients with nontraumatic colorectal perforation.

We attempted to identify the factors associated with the early mortality of patients with nontraumatic colorectal perforation. Eighty patients who underwent surgery for nontraumatic colorectal perforation between May 1986 and December 1999 were retrospectively reviewed. Age, sex, cause of perforation, duration of symptoms, associated preoperative septic shock, concomitant disorders (including cardiac disease, chronic obstructive pulmonary disease, hemodialysis, and steroid treatment), operative findings (such as the site of perforation and the degree of peritonitis), and results of preoperative laboratory blood tests (such as the white blood cell count and platelet count) were analyzed for their association with early outcome using univariate and multivariate analyses. Fourteen of the 80 patients died during hospitalization. According to the univariate analysis, advanced age, preoperative septic shock, concomitant disabling cardiac disease, hemodialysis, diffuse peritonitis, and a low preoperative platelet count were more frequent in the patients who died during hospitalization. According to the logistic regression analysis, preoperative septic shock (odds ratio 8.443, 95% confidence interval (CI) 1.625-43.873), concomitant end-stage renal failure (odds ratio 13.641, 95% CI 1.643-113.244), and diffuse peritonitis (odds ratio 13.212, 95% CI 1.441-121.102) were the most significant factors related to in-hospital mortality. Early diagnosis before the patient's general condition deteriorates is a key to improving the early mortality associated with nontraumatic colorectal perforation, especially in patients with concomitant end-stage renal failure.