Early Postoperative Death in Extreme-Risk Patients: A Perspective on Surgical Futility
*Alexander Chiu, Raymond A Jean, Kevin Y Pei
Yale School of Medicine, New Haven, CT
Objective: Surgical futility is poorly defined. However, there are patients with extremely high preoperative risk who receive surgery and die in the immediate postoperative period, suggesting futile care. To explore the concept of surgical futility, we examined the incidence and factors associated with high-risk patients undergoing emergency general surgery (EGS) with early death.
Design: Retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP)
Setting: NSQIP hospitals between 2007-2015
Patients: Patients undergoing emergent colectomy, small bowel resection, control of bleeding ulcer, lysis of adhesion, and exploratory laparotomy. Extreme-risk patients were defined as an estimated mortality >75% using the NSQIP mortality-risk calculator.
Main Outcome Measures: Trends, mortality rate, and timing of death of extreme-risk patients were evaluated. Clinical factors associated with operations on extreme-risk patient who died within 48 hours were identified utilizing logistic regression.
Results: Of 94,227 EGS patients, 1.9% had a preoperative mortality risk >75% (extreme-risk). Over time, the percent of operative EGS patients who were extreme-risk has declined (2.2% 2007-2009 vs. 1.6% 2013-2015, p<.01). Among extreme-risk patients, 30-day mortality was 71.2%, with 31.6% of all extreme-risk patients dying within 48 hours. Patients who were >80 years (OR 6.2 vs. 40-65 95%CI 4.65-8.7), septic (OR 3.4 95%CI 2.4-4.6), ventilator dependent (OR 6.1 95%CI 4.6-8.0), or with ascites (OR 3.3 95%CI 2.6-4.2) had the highest odds of being extreme-risk and dying within 48 hours.
Conclusions: A significant number of EGS operations were on extreme-risk patients who suffered early death, representing essentially futile care. Future studies aimed at factors influencing these surgical decisions, as well as their implications on cost-effectiveness, are needed.
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