N. D. Martin1, S. P. Patel1, K. Chreiman1, J. Pascual1, D. N. Holena1, B. Braslow1, P. M. Reilly1, L. Kaplan1 1University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA
Introduction: Critically ill patients in extremis are often evaluated for an intra-abdominal catastrophe. With or without a pre-operative diagnosis, abdominal exploration is often performed despite the subjectively high incidence of morbidity and mortality. We hypothesis that: 1) abdominal exploration for patients in extremis leads to an inordinately high mortality and thus may be inefficacious, and 2) common physiologic measures at laparotomy predict mortality.
Methods: All patients undergoing laparotomy while in extremis by the Acute Care Surgery (ACS) service at a mature academic medical center during a 4-year period were reviewed. Surgery in extremis was defined by American Society of Anesthesiologists (ASA) score of 4 or 5 or if surgery was a bedside laparotomy (BSL) in an ICU. Outcomes were stratified by patient demographics, primary service, surgical findings, physiology at operation, and mortality. Comparisons were by made using the Chi Squared and Students t-test as appropriate.
Results: 144 patients had surgery performed in extremis (45 BSL and 99 in the operating room (OR)). Overall mortality was 55.6% (77.8% for BSL and 45.5% for OR, p<0.001). Primary services and mortality rates included cardiac [71.4% (n=42)], medicine [70.0% (n=30)], ACS [42% (n=50)], and other [36.4% (n=22)]. At laparotomy, significant differences in survival were noted for Lactate level (2.7 vs. 8.5mmol/L, p<0.001), vasopressor use (62.5% vs. 97.5%, p< 0.001), acute kidney injury (51.6% vs. 72.5%, p<0.01), leukocytosis (53.1% vs. 71.3%, p<0.04), and anemia (45.3% vs. 71.3%, p<0.01). Operative findings at BSL revealed a mortality rate of 53.3% without identified abdominal pathology and 90% with any pathology (p<0.01).
Conclusion: Therapeutic BSL has an extremely high mortality rate and thus likely represents futile care. OR procedures for patients in extremis also carries significant mortality that may be predicted by physiology at operation. This data suggests that surgical consultation for patients in extremis should be scrutinized for efficacy prior to offering surgical intervention.