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Predictors of Mortality in Nonagenarian and Centenarian Emergency Surgery Patients: A Decision Making Aid
*Myriam M Martinez Aguilar, *Thomas Peponis, *Jordan D Bohnen, *Naveen F Sangji, *Anirudh R Nandan, *Kelsey Han, *Marc A DeMoya, George C Velmahos, *Dante D Yeh, *David R King, *David C Chang, Haytham M.A. Kaafarani
Massachusetts General Hospital, Boston, MA
Objective: The decision to operate in nonagenarian and centenarian emergency surgery patients (NCESPs) is complex. We sought to: 1) determine the predictors of mortality, and 2) suggest a surgical decision-making aid for NCESPs.
Design/Setting: The 2011-2012 ACS-NSQIP database was queried for all NCESPs, using the “emergent variable”. Univariate then multivariable analyses were performed to identify preoperative independent predictors of 30-day mortality. NCESPs mortality rates for different risk factors combinations were also studied.
Patients: All NCESPs
Main Outcome Measure: 30-day mortality
Results: A total of 1,186 NCESPs were included; 66.9 % were female and 30-day mortality rate was 18.8%. In multivariable analyses, independent predictors of 30-day mortality were: total functional dependence (OR 3.94, 95% CI 1.05-2.73), steroid use (OR 2.72, 95% CI 1.18-6.27), smoking within one year (OR 3.2, 95% CI 1.3-7.82), blood urea nitrogen > 40 mg/Dl (OR 1.69, 95% CI 1.05-2.73), ventilator requirement within 48 hours preoperatively (OR 3.25, 95% CI 1.22-8.68), ASA >=3 (OR 2.94, 95% CI 1.11-7.76), male gender [OR 1.46, 95% CI 1.006-2.144], sepsis (OR 2.63, 95% CI 1.59-4.34) and septic shock (OR 5.25, 95% CI 2.7-10.2). A decision-making aid reporting the mortality rates associated with combinations of risk factors is presented in Table 1. For example, all patients on steroids that were ventilator dependent preoperatively died within 30 days postoperatively.
Conclusions: NCESPs are a high-risk population with unique mortality predictors making their perioperative decision-making challenging. We present here a user-friendly decision-making tool that could prove useful for patient and family perioperative bedside discussions.
| | | | | | | | N (%) | BUN>40 | Total Functional Dependence | Preoperative Ventilator dependent | Septic Shock | Use of Steroids | Smoker within one year | | BUN>40 | 75(34%) | 11 (61%) | 8 (63%) | 35 (71%) | 7 (78%) | 4 (80%) | | Total Functional Dependence | 11 (61%) | 29 (48%) | 2 (50%) | 6(55%) | 2 (67%) | 1 (50%) | | Preoperative Ventilator dependent | 5 (63%) | 2 (50%) | 17 (59%) | 16 (69%) | 1(100%) | _ | | Septic Shock | 25(71%) | 6 (55%) | 16 (69%) | 44 (57%) | 8 (75%) | _ | | Use of steroids | 7(78%) | 6 (67%) | 1 (100%) | 8 (75%) | 16(41%) | 1 (33%) | | Smoker within one year | 4(80%) | 1 (50%) | _ | _ | 1 (33%) | 12(40%) |
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