Early postoperative death in extreme-risk patients: A perspective on surgical futility
Early postoperative death in extreme-risk patients: A perspective on surgical futility
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DOI：
10.1016/j.surg.2019.05.002
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发表时间：
2019-09-01
期刊：
影响因子：
3.8
通讯作者：
Pei, Kevin Y.
中科院分区：
文献类型：
--
作者：
Chiu, Alexander S.;Jean, Raymond A.;Pei, Kevin Y.
背景：外科手术的无效性定义不明确。然而，有一些患者的术前风险极高，他们仍然接受手术，最终死亡，这表明护理是徒劳的。为了进一步探索手术的无效性，我们研究了极端危险的患者接受早期死亡的紧急普通手术的发生率和相关因素。方法：美国外科医生学会国家外科质量改进计划数据库回顾了2007-2015年间所有接受结肠切除、小肠切除、出血溃疡控制、粘连松解和剖腹探查的成年人。使用国家外科质量改进计划死亡率风险计算器，极端风险被定义为具有估计的死亡风险=75%。徒劳的护理被定义为手术后48小时内死亡的极端危险患者。结果：在94350例急诊普外科患者中，1.9%是极度危险的。在极端风险患者中，30天死亡率为71.2%；31.6%的极端风险患者在48小时内死亡，代表着徒劳的护理。只有5.5%的极端危险患者出院了。80岁(优势比[OR]6.25vs40-；95%可信区间[CI]4.51-8.66)、脓毒症(OR4.63；95%可信区间，3.38-6.34)或有依赖功能状态(OR2.50vs独立；95%可信区间，1.83-3.43)的患者手术失败的几率较高。结论：大量急诊普外科手术是在早期死亡的极端危险患者身上进行的，这可能表明护理无效。当外科医生被要求进行可能徒劳的手术时，他们面临着许多相互矛盾的压力。需要对这些病例的决策过程进行更多的研究，以了解为什么外科医生在如此可怕的情况下手术，以及他们是否应该这样做。(C)2019 Elsevier Inc.保留所有权利。
Background: Surgical futility is poorly defined. However, there are patients with extremely high preoperative risk who still undergo surgery and ultimately die, suggesting futile care. To further explore surgical futility, we examined the incidence and factors associated with extreme-risk patients undergoing major emergency general surgery with early death.Methods: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for all adults undergoing colectomy, small bowel resection, control of bleeding ulcer, lysis of adhesion, and exploratory laparotomy between 2007 and 2015. Extreme-risk was defined as having an estimated mortality risk >= 75% using the National Surgical Quality Improvement Program mortality-risk calculator. Futile care was defined as extreme-risk patients who died within 48 hours of an operation. The incidence of, and clinical factors associated with, futile surgery were identified.Results: Of 94,350 emergency general surgery patients, 1.9% were extreme-risk. Among extreme-risk patients, 30-day mortality was 71.2%; 31.6% of extreme-risk patients died within 48 hours, representing futile care. Only 5.5% of extreme-risk patients were discharged home. Patients who were >80 years (odds ratio [OR] 6.25 vs 40-64; 95% confidence interval [CI], 4.51-8.66), septic (OR 4.63; 95% CI, 3.38 -6.34), or had a dependent functional status (OR 2.50 vs independent; 95% CI, 1.83-3.43]) had higher odds of having a futile operation.Conclusion: A significant number of emergency general surgery operations were on extreme-risk patients who suffered early death, which may indicate futile care. Surgeons face numerous conflicting pressures when asked to perform potentially futile surgery. Additional research in the decision-making process in these cases is needed to understand why surgeons operate in such dire circumstances and whether they should. (C) 2019 Elsevier Inc. All rights reserved.