SCORING SYSTEMS DO NOT ACCURATELY PREDICT OUTCOME FOLLOWING ABDOMINAL AORTIC ANEURYSM REPAIR

Benchmarking a Center of Excellence in Vascular Surgery: Using Acute Physiology and Chronic Health Evaluation II to Validate Outcomes in a Tertiary Care Institute

OBJECTIVE

The Society of Vascular Surgery (SVS) has made it a top priority to implement verification of vascular "centers of excellence". Our institutional aortic network was established in 2008 in order to standardize care of patients with suspected acute aortic pathology. The implementation and success of this program has been previously reported. We sought to use our experience as a benchmark for which to develop prognostic modeling to quantify clinical status upon admission and help predict outcomes. Our objective was to validate the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system using a cohort of aortic emergencies transferred by an organized transfer network.

METHOD

This was a retrospective, single institution review of patients transferred through an institutional aortic network for acute aortic pathology from 2017-2018. Demographics, comorbidities, aortic diagnosis, APACHE II score, as well as 30-day mortality were recorded. Associations with 30-day mortality were evaluated using two-sample t-tests, ANOVA models, Pearson chi-square tests and Fisher exact tests. Receiver operating characteristic (ROC) curves were fit overall and by pathology to predict 30-day mortality by Apache II total score.

RESULTS

There were 395 consecutive transfers were identified. The mean age was 64.7 years. Diagnoses included Type A Dissection (n = 134), Type B (n = 81), Aortic Aneurysm (n = 122), and PAU/IMH (n = 27). Mean APACHE II score on arrival was 12. Overall there were 53 deaths (13.4%) in the cohort. Patients that died had significantly higher Apache II total scores (11.3 vs 16.5, P < .001). The area under the receiver operator characteristic (ROC) curve (AUC) was .66 for the full cohort, indicating a poor clinical prediction test.

CONCLUSION

APACHE II score is a poor predictor of 30-day mortality in a large transfer network accepting all aortic emergencies. The authors believe further refining a prognostic model for diverse population will not only help in predicting outcomes but to objectively quantify illness severity in order to have a basis for comparison among institutions and verification of "centers of excellence".

After-Hours Urgent and Emergent Surgery in the Elderly: Outcomes and Prognostic Factors

Surgeons are becoming increasingly involved in the care of elderly patients. The purpose of this project was to evaluate contemporary outcomes of emergent surgeries performed after hours in elderly patients and to determine any risk factors for poor outcome. We retrospectively reviewed patients 80 years or older undergoing an urgent or emergent surgery at our medical center from 6 pm to 6 am from October 2006 through July 2009. Comparisons were made between survivors and nonsurvivors using Wilcoxon rank sum and Fisher exact test when indicated. P < 0.05 was considered significant. During the study period, 59 patients met inclusion criteria; the average age was 84 years (range, 80 to 102 years). A total of 70 procedures were performed; the most common were colectomy (18), small bowel resection (13), lysis of adhesions (9), and gastric surgery (8). The majority of patients were female (68%) with 47 per cent and 53 per cent of patients undergoing emergent and urgent surgery, respectively. Sixty-seven complications occurred in 38 patients; the morbidity rate was 64 per cent, and the mortality rate was 25 per cent. The only studied factors significantly associated with mortality were higher American Society of Anesthesiologists score ( P = 0.004), increased intravenous fluids ( P = 0.03), decreased intraoperative urine output ( P = 0.03), and the need for intraoperative blood ( P = 0.003). After-hours urgent and emergent surgery in the elderly has a high morbidity and mortality rate. We identified several risk factors for a poor prognosis that may be useful to the surgeon when discussing the patient's prognosis with the family.