Risk factors for postoperative mortality and morbidities in emergency surgeries

Lumboperitoneal Shunt Surgery under Spinal Anesthesia on Idiopathic Normal Pressure Hydrocephalus Patients

Since the publication of guidelines for managing idiopathic normal pressure hydrocephalus (iNPH) in 2004, an increasing number of patients with iNPH have been undergoing shunt surgery in Japan. However, shunt surgeries for iNPH can be challenging because the procedures are performed on elderly patients. General anesthesia-related risks, such as postoperative pneumonia or delirium, are higher in the elderly. To decrease these risks, we applied spinal anesthesia on a lumboperitoneal shunt (LPS). Herein, we analyzed our methods focusing on the postoperative outcomes. We retrospectively analyzed 79 patients who underwent LPS at our institution with more than one year of follow-up. The patients were divided into two groups based on the anesthetic approach, that is, 1) general anesthesia and 2) spinal anesthesia, and were examined in terms of postoperative complications, delirium, and postoperative hospital stay. In the general anesthesia group, two patients had respiratory complications after the surgery. The postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 0 (2) (median [interquartile range]), and the length of postoperative hospital stay was 11 (4) days. In the spinal anesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 0 (1), and the length of postoperative hospital stay was 10 (3) days. Although there was no significant difference regarding postoperative delirium existed, LPS under spinal anesthesia decreased respiratory complications and significantly shortened the postoperative hospital stay. LPS under spinal anesthesia could be an alternative to general anesthesia in elderly patients with iNPH and possibly lessen the general anesthesia-related risks.

Incidence and predictors of perioperative mortality in a low-resource country, Ethiopia: a prospective follow-up study

OBJECTIVE

This study aimed to assess the incidence and identify predictors of perioperative mortality among the adult age group at Tibebe Ghion Specialised Hospital.

DESIGN

A single-centre prospective follow-up study.

SETTING

A tertiary hospital in North West Ethiopia.

PARTICIPANTS

We enrolled 2530 participants who underwent surgery in the current study. All adults aged 18 and above were included except those with no telephone.

PRIMARY OUTCOME MEASURES

The primary outcome was time to death measured in days from immediate postoperative time up to the 28th day following surgery.

RESULT

A total of 2530 surgical cases were followed for 67 145 person-days. There were 92 deaths, with an incidence rate of 1.37 (95% CI 1.11 to 1.68) deaths per 1000 person-day observations. Regional anaesthesia was significantly associated with lower postoperative mortality (adjusted hazard ratio (AHR) 0.18, 95% CI 0.05 to 0.62). Patients aged ≥65 years (AHR 3.04, 95% CI 1.65 to 5.75), American Society of Anesthesiologist (ASA) physical status III (AHR 2.41, 95% CI 1.1.13 to 5.16) and IV (AHR 2.74, 95% CI 1.08 to 6.92), emergency surgery (AHR 1.85, 95% CI 1.02 to 3.36) and preoperative oxygen saturation <95% (AHR 3.14, 95% CI 1.85 to 5.33) were significantly associated with a higher risk of postoperative mortality.

CONCLUSION

The postoperative mortality rate at Tibebe Ghion Specialised Hospital was high. Age ≥65, ASA physical status III and IV, emergency surgery, and preoperative oxygen saturation <95% were significant predictors of postoperative mortality. Patients with the identified predictors should be offered targeted treatment.

Necrotising Fasciitis During the COVID-19 Pandemic: An Australian Hospital Network Experience

BACKGROUND

The clinical presentations of diseases and the provision of global healthcare services have been negatively affected by the COVID-19 pandemic. Our study aimed to determine the impact of this global pandemic on presentations of necrotising fasciitis (NF).

METHODS

A retrospective study was conducted of adult patients with NF in South West Sydney Local Health District from January 2017 to October 2022. An analysis of sociodemographic and clinical outcomes was performed comparing the COVID-19 cohort (2020-2022) and the pre-COVID-19 cohort (2017-2019).

RESULTS

Sixty-five patients were allocated to the COVID-19 cohort, and 81 patients were in the control cohort. The presentation to hospitals of the COVID-19 cohort was significantly delayed compared to the control cohort (6.1 vs. 3.2 days, P < 0.001). Patients of the age group of 40 years and younger experienced prolonged operative time (1.8 vs. 1.0 h, P = 0.040), higher number of operations (4.8 vs. 2.1, P = 0.008), and longer total length of stay (LoS) (31.3 vs. 10.3 days, P = 0.035) during the pandemic. The biochemical, clinical, or post-operative outcomes of two groups were not significantly different.

CONCLUSION

This multi-centre study showed that the COVID-19 pandemic delayed presentations of NF but did not result in any significant overall changes in operative time, ICU admissions, LoS, and mortality rate. Patients aged less than 40 years in the COVID-19 group were likely to experience prolonged operative time, higher number of operations, and greater LoS.

Association of Preoperative Blood Transfusion on Postoperative Outcomes in Emergency General Surgery

INTRODUCTION

Emergency general surgery (EGS) patients often present with anemia, in which preoperative transfusions are performed to mitigate anemia-associated risks. However, transfusions have also been noted to cause worse postoperative outcomes. This study examined how transfusion-associated outcomes vary at different levels of anemia.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2019 was used to identify patients who had undergone any of 12 major EGS procedures using Current Procedural Terminology codes. Patients were divided into two cohorts based on receipt of preoperative transfusion. Cohorts were subdivided into anemia severity levels and propensity score-matched within each using patient demographic and comorbidity variables. We analyzed 30-day postoperative outcomes, including morbidity, mortality, and return to odds ratio (OR), using univariate Chi-squared tests, Wilcoxon signed-rank tests, and multivariate logistic regression analyses.

RESULTS

595,407 EGS cases were identified. Receiving preoperative transfusion were 44.45% (n = 3058) of severely anemic, 10.94% (n = 9076) of moderately anemic, 1.34% (n = 1370) of mildly anemic, and 0.174% (n = 704) of no anemia patients. Transfusion resulted in an increased overall morbidity in the severe (OR 1.54), moderate (OR 1.50), mild (OR 1.71), and no anemia (OR 1.85) groups. Mortality increased in the moderate (OR 1.27), mild (OR 1.61), and no anemia (OR 1.76) subgroups. In severe anemia, transfusion status and mortality were not significantly associated.

CONCLUSIONS

Transfusion is associated with higher morbidity and mortality rates in those with higher hematocrit levels, even after controlling for pre-existing comorbidities. A restrictive transfusion strategy should be considered to avoid risks for those with a hematocrit level more than 24%.

Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience

INTRODUCTION

As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status.

MATERIALS AND METHODS

We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed.

RESULTS

Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36).

CONCLUSIONS

At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.

Advances in Management of Fournier's Gangrene by Coupling Intensive Hospital Treatment With Innovative Post-discharge Hyperbaric Oxygen Therapy Rehabilitation: A Case Report

Fournier's gangrene (FG) is a rare form of necrotizing soft tissue infection characterized by an acute, aggressive, and rapidly progressive course. In this case report, we describe advanced therapy combining critical care, surgery, pharmacotherapy, extended biochemical/cellular blood diagnostics, and post-discharge hyperbaric oxygen therapy rehabilitation. Such an intervention resulted in survival and improved health status and quality of life of the patient with FG and septic shock.

Risk factor analysis of postoperative complications in patients undergoing emergency abdominal surgery

Purpose

To investigate the relationship between intraoperative anesthesia-related factors and postoperative complications in patients undergoing emergency abdominal surgery, and to identify risk factors for these postoperative complications.

Methods

We retrospectively analyzed 942 emergency surgery patients who underwent general anesthesia and emergency abdominal operations at Jiangsu Province Hospital during the period September 2015 to December 2016. Logistic regression analysis was performed to analyze the association between preoperative or intraoperative parameters and postoperative complications.

Results

Among the 942 patients whose data were analyzed, 226 (24.0%) had major postoperative complications within 30 days after surgery. The most common postoperative complications were respiratory complications (31.8% of those experiencing complications). After adjusting for the role of multiple confounding factors, multivariable analysis showed that the independent risk factors for postoperative complications were patient age (OR 1.648; 95% CI 1.352-2.008), the ASA classification (OR 3.220; 95% CI 2.492-4.162), intraoperative hypotension lasting more than 20 min (OR 2.031; 95% CI 1.256-3.285), intraoperative tachyarrhythmias (OR 2.205; 95% CI 1.114-4.365), and the surgical level (i.e. type and difficulty level) [OR 1.895; 95% CI 1.306-2.750].

Conclusion

Prolonged intraoperative hypotension (>20 min) and the occurrence of tachyarrhythmias are independent risk factors for postoperative complications in patients who undergo emergency abdominal surgery. During hemodynamic management of these patients, systolic blood pressure should be controlled to within 20% of the baseline value to reduce the risk of postoperative complications. In addition, a higher patient age, higher ASA grade, and a higher surgical classification level also significantly increase the risk of postoperative complications.

Results of emergency colectomy in nonagenarians and octogenarians previously labeled as prohibitive surgical risk

PURPOSE

There are no standardized criteria for what constitutes prohibitive risk for emergency abdominal surgery.

METHODS

A retrospective review was performed comparing two groups of patients having emergent colectomy. One group had previously been labeled as being prohibitive surgical risk and the other was a contemporary, non-prohibitive risk group also requiring emergency colectomy. All operations were performed by a single surgeon.

RESULTS

There were 27 prohibitive risk patients and 81 non-prohibitive risk (control group) patients. The average age of the prohibitive risk group was 85 years (range 78-99) compared to the control group mean age of 52 years (18-79, p < 0.00001). Prohibitive risk was due to extremes of age combined with congestive heart failure in 44%, followed by chronic obstructive pulmonary disease combined with heart failure in 19%. The groups were closely matched by the type of colectomy performed. The total complication rate was much higher in the prohibitive risk group compared to the non-prohibitive risk patients (81% versus 48%, p 0.005). But the 30-day mortality rate was similar between groups (7% versus 4%, p 0.6).

CONCLUSION

Patients who are labeled as prohibitive surgical risk may be inaccurately assessed in the majority of cases. Additional research will need to be performed to evaluate the presence of quantifiable high-risk physiological conditions, and not just comorbidities, that place a patient at high risk of death after abdominal surgery. Until then, elderly patients should not be denied colectomy based upon comorbidities alone.

The impact of operative time on the outcomes of necrotizing soft tissue infections: a multicenter cohort study

Background

The primary aim of this study was to identify if there is an association between the operative time of the initial debridement for necrotizing soft tissue infections (NSTIs) and the mortality corrected for disease severity.

Methods

A retrospective multicenter study was conducted of all patients with NSTIs undergoing surgical debridement. The primary outcome was the 30-day mortality. The secondary outcomes were days until death, length of intensive care unit (ICU) stay, length of hospital stay, number of surgeries within first 30 days, amputations and days until definitive wound closure.

Results

A total of 160 patients underwent surgery for NSTIs and were eligible for inclusion. Twenty-two patients (14%) died within 30 days and 21 patients (13%) underwent an amputation. The median operative time of the initial debridement was 59 min (IQR 35–90). In a multivariable analyses, corrected for sepsis just prior to the initial surgery, estimated total body surface (TBSA) area affected and the American Society for Anesthesiologists (ASA) classification, a prolonged operative time (per 20 min) was associated with a prolonged ICU (β 1.43, 95% CI 0.46–2.40; p = 0.004) and hospital stay (β 3.25, 95% CI 0.23–6.27; p = 0.035), but not with 30-day mortality. Operative times were significantly prolonged in case of NSTIs of the trunk (p = 0.044), in case of greater estimated TBSA affected (p = 0.006) or if frozen sections and/or Gram stains were assessed intra-operatively (p < 0.001).

Conclusions

Prolonged initial surgery did not result in a higher mortality rate, possible because of a short duration of surgery in most studied patients. However, a prolonged operative time was associated with a prolonged ICU and hospital stay, regardless of the estimated TBSA affected, presence of sepsis prior to surgery and the ASA classification. As such, keeping operative times as limited as possible might be beneficial for NSTI patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01456-0.

OUP accepted manuscript

The purpose of this study was to determine the impact of coronavirus disease 2019 (COVID-19) on the delayed presentation of necrotising fasciitis (NF). A retrospective study was conducted of adult patients (≥16 years old) diagnosed with NF at a hospital from 2017 to 2020. A quantitative comparative analysis for the COVID-19 group and control group between 2017 and 2019. Structured interviews were conducted to examine the impact of COVID-19 on patients. There were 6 patients in the COVID-19 group and 10 patients in the control group. The COVID-19 group had a longer mean onset of symptoms till hospital presentation of 4.1 days and a longer mean operative time. The COVID-19 group was more likely to be admitted to intensive care unit. Three patients in the COVID-19 group did not survive compared to survival in the counterparts. Participant responses indicated the COVID-19 pandemic did not prevent them from presenting to ED.

Associations between surgical start time (regular vs after hours) and morbidity and mortality during hospitalization in dogs and cats

OBJECTIVE

To examine the relationship between after-hours (ie, nights and weekends) emergency general surgery and morbidity or mortality in dogs and cats during hospitalization.

DESIGN

Cross-sectional study from September 1, 2013 to May 31, 2017.

SETTING

University teaching hospital.

ANIMALS

Four hundred seventy-four dogs and 66 cats that underwent emergency general surgery (gastrointestinal, hepatobiliary, urogenital, soft tissue traumatic injury, splenectomy/excision of bleeding abdominal tumor, surgical revision, and negative exploratory categories) with the emergency surgery service. All patients were required to have complete medical records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Study animals were grouped as exposed or not exposed to after-hours emergency surgery. They were further classified as either postoperatively dead or suffering morbidity (yes or no). Additional exposure factors (eg, age, sex, American Society of Anesthesiology [ASA] status) were investigated. Multivariable logistic regression was used to identify and quantify any associations with mortality or morbidity. In dogs, exposure to after-hours emergency general surgery was not associated with mortality or morbidity. In dogs, both mortality and morbidity were associated with ASA status. In cats, mortality was not examined because the number of dead cats was small (n = 5). The odds of morbidity were 3.4 times lower (1/0.29) in cats having emergency surgery after hours, compared to cats admitted during regular hours (odds ratio [OR], 0.29; 95% Confidence Interval (CI), 0.09-0.93; P = 0.03). No other investigated exposure factors were associated with morbidity in study cats.

CONCLUSIONS

After-hours emergency surgery in dogs was not associated with increased risk of mortality and morbidity at the study facility. Feline patients having emergency surgery during regular hospital hours had a higher risk of morbidity; further investigation of modifiable risk factors is warranted.

Impact of frailty on clinical outcomes and resource use following emergency general surgery in the United States

Background

Frailty has been recognized as an independent risk factor for inferior outcomes, but its effect on emergency general surgery (EGS) is understudied.

Objective

The purpose of the present study was to define the impact of frailty on risk-adjusted mortality, non-home discharge, and readmission following EGS operations.

Methods

Adults undergoing appendectomy, cholecystectomy, small bowel resection, large bowel resection, repair of perforated ulcer, or laparotomy within two days of an urgent admission were identified in the 2016–2017 Nationwide Readmissions Database. Frailty was defined using diagnosis codes corresponding to the Johns Hopkins Adjusted Clinical Groups frailty indicator. Multivariable regression was used to study in-hospital mortality and non-home discharge by operation, and Kaplan Meier analysis to study freedom from unplanned readmission at up to 90-days follow-up.

Results

Among 655,817 patients, 11.9% were considered frail. Frail patients most commonly underwent large bowel resection (37.3%) and cholecystectomy (29.2%). After adjustment, frail patients had higher mortality rates for all operations compared to nonfrail, including those most commonly performed (11.9% [95% CI 11.4–12.5%] vs 6.0% [95% CI 5.8–6.3%] for large bowel resection; 2.3% [95% CI 2.0–2.6%] vs 0.2% [95% CI 0.2–0.2%] for cholecystectomy). Adjusted non-home discharge rates were higher for frail compared to nonfrail patients following all operations, including large bowel resection (68.1% [95% CI 67.1–69.0%] vs 25.9% [95% CI 25.2–26.5%]) and cholecystectomy (33.7% [95% CI 32.7–34.7%] vs 2.9% [95% CI 2.8–3.0%]). Adjusted hospitalization costs were nearly twice as high for frail patients. On Kaplan-Meier analysis, frail patients had greater unplanned readmissions (log rank P<0.001), with 1 in 4 rehospitalized within 90 days.

Conclusions

Frail patients have inferior clinical outcomes and greater resource use following EGS, with the greatest absolute differences following complex operations. Simple frailty assessments may inform expectations, identify patients at risk of poor outcomes, and guide the need for more intensive postoperative care.

The Impact on 30-Day Mortality From a Brief Focused Ultrasound-Guided Management Protocol Immediately Before Emergency Noncardiac Surgery in Critically Ill Patients: A Multicenter Randomized Controlled Trial

OBJECTIVE

To determine whether brief ultrasound-guided treatment of hemodynamic shock and respiratory failure immediately before emergency noncardiac surgery reduced 30-day mortality.

DESIGN

Parallel, nonblinded, randomized trial with 1:1 allocation to control and intervention groups.

SETTING

Twenty-eight major hospitals within China.

PARTICIPANTS

Six-hundred sixty patients ≥14 years of age, scheduled for emergency noncardiac surgery with evidence of shock (heart rate >120 beat/min, systolic blood pressure< 90 mmHg or requiring inotrope infusion), or respiratory failure (Pulse Oxygen Saturation <92%, respiratory rate >20 beat/min, or requiring mechanical ventilation).

INTERVENTIONS

A brief (<15 minutes) focused ultrasound of ventricular filling and function, lung, and peritoneal spaces, with predefined treatment recommendation based on the ultrasound was performed before surgery or standard care.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was 30-day mortality. Secondary outcomes included changes in medical or surgical diagnosis and management due to ultrasound, intensive care unit, and hospital stay and cost, and Short Form-8 quality-of-life scores. Although there were frequent changes in diagnosis (82%) and management (49%) after the ultrasound, mortality at 30 days was not different between groups (50 [15.7%] v 53 [16.3%]; odds ratio 1.05, 0.69-1.6, p = 0.826). There were no differences in the secondary outcomes of the days spent in the hospital (mean 13.8 days, 95% confidence interval [CI] 12.1-15.6 v 14.4 d, 11.8-17.1, p = 0.718) or intensive care unit (mean 9.3 days, 95% CI 7.7-11.0 v 8.7 d, 7.2-10.2, p = 0.562), hospital cost (USD$14.5K, 12.2-16.7 v 13.7, 11.5-15.9, p = 0.611) or Short Form-8 scores at one year (mean 80.9, 95% CI 78.4-83.3 v 79.7, 76.9-82.5, p = 0.54) between participants allocated to the ultrasound and control groups.

CONCLUSIONS

In critically ill patients with hemodynamic shock or respiratory failure, a focused ultrasound-guided management did not reduce 30-day mortality but led to frequent changes in diagnosis and patient management.

Blood transfusion in major emergency abdominal surgery

BACKGROUND

Major emergency abdominal surgery is associated with excess mortality. Transfusion is known to be associated with increased morbidity and emergency surgery is an independent risk factor for perioperative transfusion. The primary objectives of this study were to identify risk factors for transfusion, and secondarily to investigate the influence of transfusion on clinical outcomes after major emergency abdominal surgery.

STUDY DESIGN AND METHODS

This study combined retrospective observational data including intraoperative, postoperative, and transfusion data in patients undergoing major emergency abdominal surgery from January 2010 to October 2016 at a Danish university hospital. The primary outcome was a transfusion of any kind from initiation of surgery to postoperative day 7. Secondary outcomes included 7-, 30-, 90-day and long-term mortality (median follow-up = 34.6 months, IQR = 13.0-58.3), lengths of stay, and surgical complication rate (Clavien-Dindo score ≥ 3a).

RESULTS

A total of 1288 patients were included and 391 (30%) received a transfusion of any kind. Multivariate logistic regression identified age, hepatic comorbidity, cardiac comorbidity, post-surgical anemia, ADP-receptor inhibitors, acetylsalicylic acid, anticoagulants, and operation type as risk factors for postoperative transfusion. 60.1% of the transfused patients experienced a serious surgical complication within 30 days of surgery compared with 28.1% of the non-transfused patients (p < 0.001). Among patients receiving a postoperative transfusion, unadjusted long-term mortality was increased with a hazard ratio of 3.8 (95% CI 2.9-5.0), p < 0.01. Transfused patients had significantly higher mortality at 7-, 30-, 90- and long-term, as well as a longer hospital stay but in the multivariate analyses, transfusion was not associated with mortality.

CONCLUSION

Peri- and postoperative transfusion in relation to major emergency abdominal surgery was associated with an increased risk of postoperative complications. The potential benefits and harms of blood transfusion and clinical significance of pre- and postoperative anemia after major emergency abdominal surgery should be further studied in clinical prospective studies.

Predisposed to failure? The challenge of rescue in the medical intensive care unit

BACKGROUND

Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases.

METHODS

All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality.

RESULTS

Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p < 0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86-59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11-23.77).

CONCLUSION

Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level III.

Risk factors of emergency reoperations

Background

Emergency reoperation is considered to be a quality indicator in surgery. We analyzed the risk factors for emergency reoperations.

Methods

Patients who underwent emergency operations from January 1, 2017, to December 31, 2017, at our hospital were reviewed in this retrospective study. Multivariate logistic regression was performed for the perioperative risk factors for emergency reoperation.

Results

A total of 1,481 patients underwent emergency operations during the study period. Among them, 79 patients received emergency reoperations. The variables related to emergency reoperation included surgeries involving intracranial and intraoral lesions, highest mean arterial pressure ≥ 110 mmHg, highest heart rate ≥ 100 beats/min, anemia, duration of operation >120 min, and arrival from the intensive care unit (ICU).

Conclusions

The type of surgery, hemodynamics, hemoglobin values, the duration of surgery, and arrival from ICU were associated with emergency reoperations.

Impact of acute care surgery on timeliness of care and patient outcomes: a systematic review of the literature

Background

Dedicated emergency general surgery (EGS) service models were developed to improve efficiency of care and patient outcomes. The degree to which the EGS model delivers these benefits is debated. We performed a systematic review of the literature to identify whether the EGS service model is associated with greater efficiency and improved outcomes compared to the traditional model.

Methods

We searched MEDLINE, Embase, Scopus and Web of Science (Core Collection) databases from their earliest date of coverage through March 2017. Primary outcomes for efficiency of care were surgical response time, time to operation and total length of stay in hospital. The primary outcome for evaluating patient outcomes was total complication rate.

Results

The EGS service model generally improved efficiency of care and patient outcomes, but the outcome variables reported in the literature varied.

Conclusion

Development of standardized metrics and comprehensive EGS databases would support quality control and performance improvement in EGS systems.

Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis

Background

Although the phrase “time is fascia” is well acknowledged in the case of necrotizing soft tissue infections (NSTIs), solid evidence is lacking. The aim of this study is to review the current literature concerning the timing of surgery in relation to mortality and amputation in patients with NSTIs.

Methods

A systematic search in PubMed/MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Controlled Register of Trials (CENTRAL) was performed. The primary outcomes were mortality and amputation. These outcomes were related to the following time-related variables: (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. For the meta-analysis, the effects were estimated using random-effects meta-analysis models.

Result

A total of 109 studies, with combined 6051 NSTI patients, were included. Of these 6051 NSTI patients, 1277 patients died (21.1%). A total of 33 studies, with combined 2123 NSTI patients, were included for quantitative analysis. Mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (OR 0.43; 95% CI 0.26–0.70; 10 studies included). Surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed over 6 h. Also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (OR 0.41; 95% CI 0.27–0.61; 16 studies included). Patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. None of the time-related variables assessed significantly reduced the amputation rate. Three studies reported on the duration of the first surgery. They reported a mean operating time of 78, 81, and 102 min with associated mortality rates of 4, 11.4, and 60%, respectively.

Conclusion

Average mortality rates reported remained constant (around 20%) over the past 20 years. Early surgical debridement lowers the mortality rate for NSTI with almost 50%. Thus, a sense of urgency is essential in the treatment of NSTI.

Emergency Surgery Mortality (ESM) Score to Predict Mortality and Improve Patient Care in Emergency Surgery

Background

Emergency surgery has poor outcomes with high mortality. Numerous studies have reported the risk factors for postoperative death in order to stratify risk and improve perioperative care; nevertheless, a predictive model based upon these risk factors is lacking.

Objective

We aimed to identify the risk factors of postoperative mortality and to construct a new model for predicting mortality and improving patient care.

Methods

We included adult patients undergoing emergency surgery at Srinagarind Hospital between January 2012 and December 2014. The patients were randomized: 80% to the Training group for model construction and 20% to the Validation group. Patient data were extracted from medical records and then analyzed using univariate and multivariate logistic regression.

Results

We recruited 758 patients, and the mortality rate was 14.5%. The Training group comprised 596 patients, and the Validation group comprised 162. Based upon a multivariate analysis in the Training group, we constructed a model to predict postoperative mortality-an Emergency Surgery Mortality (ESM) score based on the coefficient of each risk factor from the multivariate analysis. The ESM score comprised 7 risk factors, i.e., coagulopathy, ASA class 5, bicarbonate <15 mEq/L, heart rate >100/min, systolic blood pressure <90 mmHg, renal comorbidity, and general surgery, for a total score of 11. An ESM score ≥4 was predictive of postoperative mortality with an AUC of 0.83. The respective sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, negative predictive value, and accuracy for an ESM score ≥4 predictive of postoperative mortality was 70.2%, 94.9%, 13.8, 0.3, 69.4%, 95.1%, and 91.4%. The performance of the ESM score in the Validation group was comparable.

Conclusions

An ESM score comprises 7 risk factors for a total score of 11. An ESM score ≥4 is predictive of postoperative mortality with a high AUC (0.83), sensitivity (70.2%), and specificity (94.9%). Four risk factors are preoperatively manageable for decreasing the probability of postoperative mortality and improving quality of patient care.

Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP

Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11–1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.

Predicting Postoperative Complications for Acute Care Surgery Patients Using the ACS NSQIP Surgical Risk Calculator

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator has been used to assist surgeons in predicting the risk of postoperative complications. This study aims to determine if the risk calculator accurately predicts complications in acute care surgical patients undergoing laparotomy. A retrospective review was performed on all patients on the acute care surgery service at a tertiary hospital who underwent laparotomy between 2011 and 2012. The preoperative risk factors were used to calculate the estimated risks of postoperative complications in both the original ACS NSQIP calculator and updated calculator (June 2016). The predicted rate of complications was then compared with the actual rate of complications. Ninety-five patients were included. Both risk calculators accurately predicted the risk of pneumonia, cardiac complications, urinary tract infections, venous thromboembolism, renal failure, unplanned returns to operating room, discharge to nursing facility, and mortality. Both calculators underestimated serious complications (26% vs 39%), overall complications (32.4% vs 45.3%), surgical site infections (9.3% vs 20%), and length of stay (9.7 days versus 13.1 days). When patients with prolonged hospitalization were excluded, the updated calculator accurately predicted length of stay. The ACS NSQIP risk calculator underestimates the overall risk of complications, surgical infections, and length of stay. The updated calculator accurately predicts length of stay for patients <30 days. The acute care surgical population represents a high-risk population with an increased rate of complications. This should be taken into account when using the risk calculator to predict postoperative risk in this population.

Morbidity and mortality rates after emergency abdominal surgery: an analysis of 4346 patients scheduled for emergency laparotomy or laparoscopy

PURPOSE

Emergency abdominal surgery results in a high rate of post-operative complications and death. There are limited data describing the emergency surgical population in details. We aimed to give a detailed analyses of complications and mortality in a consecutive group of patients undergoing acute abdominal surgery over a 4-year period.

METHODS

This observational study was conducted between 2009 and 2013 at Copenhagen University Hospital Herlev, Denmark. All patients scheduled for emergency laparotomy or laparoscopy were included. Pre-, intra-, and post-operative data were collected from medical records. Complications were registered according to the Clavien-Dindo classification. Cox regression analysis was performed to identify risk factors for mortality.

RESULTS

A total of 4,346 patients underwent emergency surgery, of whom 14 % had surgical complications and 23 % medical complications. The overall 30-day mortality was 8 % with 50 % of those in this group over 80 years of age. The 30-day mortality rates were 0.8 % (95 % CI 0.5-1.1) and 17 % (95 % CI 15.5-18.9), respectively, for the laparoscopy and the laparotomy groups. The overall death rate within 24 h of surgery was 21 %. Several risk factors for 30- and 90-day mortality were identified: age, ASA ≥3 (American Society of Anaesthesiologists physical status classification), performance score (Zubroed/WHOclassification), cirrhosis of the liver, chronic nephropathy, several medical conditions, and malignancy.

CONCLUSION

Almost one in five patients died after emergency laparotomy, of whom one in five died within 24 h of surgery. Predictors for poor outcome were identified.

The STOP-BANG questionnaire and the risk of perioperative respiratory complications in urgent surgery patients: A prospective, observational study

INTRODUCTION

The STOP-BANG (SB) questionnaire, a tool originally proposed for identifying patients at risk of obstructive sleep apnoea, may also identify patients at increased risk of perioperative complications (when>3). Perioperative complications, including respiratory ones, are more frequent in emergency surgery. This study aimed at evaluating whether the SB is predictive of perioperative respiratory complications in urgent surgery.

METHODS

Consecutive adult patients admitted for an urgent surgery under general anaesthesia were included. The STOP-BANG questionnaire was completed before anaesthesia. Perioperative respiratory complications were prospectively recorded during surgery and in the postoperative care unit (PACU).

RESULTS

One hundred and eighty-nine patients were included (women 46%, median age 60 [43-78] years old) of which 104 (55%) were SB+. Diabetes mellitus and arrhythmia were more frequent in the SB+ patients than in SB-. The ASA class was higher in SB+ patients compared with SB-, but type and duration of surgery were statistically similar. The incidence of respiratory complications was higher in SB+ patients both during surgery (21% versus 6%, P<0.002) and in the PACU (57% versus 34%, P=0.0015). Furthermore, SB+ patients had a prolonged length of hospital stay (6 [3-12] versus 4 [2-7] days, P=0.0002). In a multivariate analysis, the STOP-BANG score was independently associated with respiratory complications (OR [CI 95%]=1.44 [1.03-2.03], P=0.03).

CONCLUSIONS

An elevated STOP-BANG score (≥ 3) is associated with an increased risk of perioperative respiratory complications and with prolonged length of stay in urgent surgery patients.

Characteristics of 1-day postoperative mortality: a comparison with 2- to 7-day postoperative mortality

BACKGROUND

The purpose of this study was to determine causes and characteristics of early postoperative mortality focusing on postoperative day 1 (POD 1).

METHODS

We reviewed the electronic medical records of patients who died within 7 days after surgery under anesthesia at a tertiary university hospital from January 2004 to December 2014. Postoperative mortalities were divided into POD 1 group and POD 7 group, which included death that occurred from days 2 to 7 after surgery. Characteristics of POD 1 group were compared with those of POD 7 group.

RESULTS

The mortality rates of POD 1 and POD 7 groups were 3.6 and 7.8 per 10,000 anesthesia, respectively. The incidence of POD 1 mortality is higher than any other day of the week of surgery. The incidences of massive transfusion, intraoperative cardiac arrest, and intraoperative use of epinephrine were higher in POD 1 group than in POD 7 group. In adults, the proportion of emergency operations was higher in POD 1 group than in POD 7 group. The leading cause of death in POD 1 group was hypovolemic and cardiogenic shock, whereas that in POD 7 group was distributive shock. Human factor-related mortality was more frequent in POD 1 group (15.3%) compared with POD 7 group (6.1%).

CONCLUSIONS

The characteristics of POD 1 mortality were different from those of POD 2-7 mortality. A large proportion of early postoperative deaths were due to POD 1 mortality. Human factor-related causes were more associated with POD 1 mortality, indicating much room for improvement.

Screening of Hepatitis G and Epstein-Barr Viruses Among Voluntary non Remunerated Blood Donors (VNRBD) in Burkina Faso, West Africa

In most sub-Saharan countries screening of blood-transmitted infections includes mainly HIV, HBV, HCV and syphilis. Many viruses such as Hepatitis G (HGV) and Epstein-Barr virus (EBV) which also carry a risk of transmission by blood transfusion raise the question of the extent of screening for these pathogens. This work aims to evaluate the prevalence of HGV and EBV in first-time blood donors in Ouagadougou.

The prevalence of HGV and EBV in 551 blood donors was 7.4% and 5.4% respectively. HGV prevalence was significantly higher in blood donors with hepatitis B antigens and positive for HCV compared to donors negative for HCV and no hepatitis B antigens (respectively p<0.001 and p=0.004). EBV prevalence was higher among blood donors of < 20 years age group. HBV and HCV positive individuals are not eligible for blood donation.

This study shows significant results with regard to the prevalence of HGV and EBV prevalence in blood donors in Burkina Faso and emphasizes the need for a general screening.