Larissa C Chiulli1, Andrew H Stephen1, Daithi S Heffernan1, Thomas J Miner2. 1. Department of Surgery, Alpert Medical School, Brown University, Rhode Island Hospital, Providence, RI. 2. Department of Surgery, Alpert Medical School, Brown University, Rhode Island Hospital, Providence, RI. Electronic address: tminer@lifespan.org.
Abstract
BACKGROUND: Failure to rescue (FTR) is a key metric of perioperative morbidity and mortality. We review perioperative medical comorbidities (MCMs) to determine what factors are associated with complications and rates of FTR. STUDY DESIGN: A retrospective review of a NSQIP database including general, vascular, and surgical subspecialty patients from a tertiary referral center between March 2008 and March 2013 was performed. Demographics, MCMs, complications, 30-day mortality, and risk of FTR associated with specific complications and MCM were evaluated. RESULTS: A total of 7,763 patients were included; 52.6% had MCMs and 14% (n = 1,099) experienced a complication. Patients with complications were older (64.9 vs 55 years; p < 0.001), more likely male (54% vs 44%; p < 0.001), and had more MCMs per patient (1.6 vs 1.4; p < 0.001). Complications were also associated with renal failure (odds ratio [OR] = 1.4; 95% CI, 1.0-2.0), steroid use (OR = 1.9; 95% CI, 1.4-2.5), CHF (OR = 2.5; 95% CI, 1.2-5.1), and ascites (OR = 9.1; 95% CI, 3.7-21.7), but not diabetes, hypertension, or COPD. There were 117 (11%) deaths among patients with complications. Adjusting for age, sex, American Society of Anesthesiologists class, and number of comorbidities, FTR was associated with postoperative respiratory failure, sepsis, and renal failure, as well as comorbid CHF, renal failure, ascites, and disseminated cancer. CONCLUSIONS: Specific comorbidities are associated with higher rates of complications and FTR. Preoperative CHF, renal failure, and ascites, which were associated with FTR, can reflect a physiologic inability to tolerate complication-induced fluid shifts. Postoperative mortality was associated with signs of end organ damage, including sepsis, respiratory failure, and renal failure. Earlier recognition of these complications in at-risk patients should improve rates of FTR.
BACKGROUND: Failure to rescue (FTR) is a key metric of perioperative morbidity and mortality. We review perioperative medical comorbidities (MCMs) to determine what factors are associated with complications and rates of FTR. STUDY DESIGN: A retrospective review of a NSQIP database including general, vascular, and surgical subspecialty patients from a tertiary referral center between March 2008 and March 2013 was performed. Demographics, MCMs, complications, 30-day mortality, and risk of FTR associated with specific complications and MCM were evaluated. RESULTS: A total of 7,763 patients were included; 52.6% had MCMs and 14% (n = 1,099) experienced a complication. Patients with complications were older (64.9 vs 55 years; p < 0.001), more likely male (54% vs 44%; p < 0.001), and had more MCMs per patient (1.6 vs 1.4; p < 0.001). Complications were also associated with renal failure (odds ratio [OR] = 1.4; 95% CI, 1.0-2.0), steroid use (OR = 1.9; 95% CI, 1.4-2.5), CHF (OR = 2.5; 95% CI, 1.2-5.1), and ascites (OR = 9.1; 95% CI, 3.7-21.7), but not diabetes, hypertension, or COPD. There were 117 (11%) deaths among patients with complications. Adjusting for age, sex, American Society of Anesthesiologists class, and number of comorbidities, FTR was associated with postoperative respiratory failure, sepsis, and renal failure, as well as comorbid CHF, renal failure, ascites, and disseminated cancer. CONCLUSIONS: Specific comorbidities are associated with higher rates of complications and FTR. Preoperative CHF, renal failure, and ascites, which were associated with FTR, can reflect a physiologic inability to tolerate complication-induced fluid shifts. Postoperative mortality was associated with signs of end organ damage, including sepsis, respiratory failure, and renal failure. Earlier recognition of these complications in at-risk patients should improve rates of FTR.
Authors: Robert E Freundlich; Michael D Maile; Joseph J Sferra; Elizabeth S Jewell; Sachin Kheterpal; Milo Engoren Journal: Anesth Analg Date: 2018-07 Impact factor: 5.108
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