R. Chang1, M. Scerbo1, L. Moore1, A. Macaluso1, C. Wade1, J. Holcomb1 1University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA
Background: Although many infections can be treated with antibiotic therapy alone, intra-abdominal infections (IAI) often require surgical intervention to achieve adequate source control. Time to initiation of appropriate antibiotic therapy is a well-described quality metric in the treatment of life-threatening infections (sepsis), but time to operation for source control has not been amply investigated for surgical sources of infection. We hypothesized that decreased time to laparotomy (TTL) to achieve surgical source control was associated with improved outcomes in patients presenting with IAI.
Methods: Billing codes were used to identify adult patients who underwent laparotomy from 2011-2015 at a single center. These were screened to identify patients who presented to the emergency department (ED) with IAI, underwent laparotomy for source control, and had hospital stay >24 hours. TTL was defined as the time from ED triage to initiation of laparotomy. The SOFA score was calculated using parameters obtained in the ED. The primary outcome was survival to hospital discharge; the secondary outcome was ICU-free days. Using SOFA score as a covariate, we constructed multivariable logistic and linear regression models to test the hypothesis that decreased TTL was associated with increased survival and increased ICU-free days respectively.
Results: Of the 54 patients included for analysis, 46 (85%) survived to hospital discharge. Overall incidence of sepsis (defined as change in baseline SOFA ≥2) was 57%. Median ICU-free days was 26 with interquartile range of 15 to 30. Survivors had lower SOFA scores (median 2 vs 7, p<0.01) but similar TTL (median 16 vs 17 hours, p>0.05) compared to non-survivors. For patients with sepsis, TTL was also similar between survivors and non-survivors (median 15 vs 17 hours, p>0.05). Perforated hollow viscus accounted for 54% of infectious sources (colorectal 20%, small bowel 17%, stomach 17%), and intra-abdominal abscess accounted for 46%.
Decreased TTL was not associated with improved survival (odds ratio 1.00, 95% confidence interval [CI] 0.98 – 1.02) on multivariable logistic regression, but was significantly associated with increased ICU-free days (relative risk -0.05, 95% CI -0.10 to -0.01) on multivariable linear regression.
Conclusion: Although there was no difference in mortality, decreased TTL was associated with increased ICU-free days in patients presenting with IAI requiring laparotomy. Despite the emphasis on time to initiation of antibiotic therapy, comparatively little attention has been paid to time to surgical source control, even though both are needed to treat certain cases of IAI.