M. Dasari1, A. B. Peitzman1, J. W. Marsh1, D. Mohan1, M. R. Rosengart1, R. M. Forsythe1, J. L. Sperry1, M. E. Kutcher2 1University Of Pittsburgh Medical Center,Pittsburgh, PA, USA 2University Of Mississippi Medical Center,Jackson, MS, USA
Introduction: 'Surgical rescue' is defined as the surgical management of an acute complication of a surgical, interventional, or endoscopic procedure, and is a key pillar of Acute Care Surgery (ACS). We compared complications, interventions, and outcomes between surgical patients who were successfully 'rescued' after a procedural complication and those who 'failed to rescue', defined by death in-hospital or within 30 days of discharge following a surgical complication.
Methods: A prospective ACS database at an urban academic center was reviewed for acute surgical complications using an ICD-9 code-based screen, and linked with Social Security Death Index long-term mortality data. Failure-to-rescue (FTR) was defined as in-hospital mortality or death within 30 days of discharge.
Results: Of 2,301 ACS patients screened from 1/2013 to 5/2014, 321 (14%) had an acute complication of a surgical (85%), endoscopic (8%), or interventional (7%) procedure; most commonly, wound complications (31%), uncontrolled sepsis (19%), and bowel obstruction (15%). 206 patients (63%) required operative intervention. The most common rescue measures were bowel resection (22%), wound debridement (18%), and surgeon-guided resuscitation (17%). Forty-four patients (14%) died in-hospital or within 30 days of discharge (FTR). FTR patients were significantly older than rescued patients (55±15 vs. 67±14y, p<0.01), more commonly male (64% vs. 46%, p=0.03), and had more frequent pre-existing coronary disease (48% vs. 16%, p<0.01). Lowest albumin and hemoglobin, as well as highest creatinine and lactate, were significantly higher in FTR patients (all p<0.01). Bowel ischemia (20% vs. 12%, p<0.01) and perforation (18% vs. 6%, p<0.01) were more common complications in FTR patients, and more than twice as many FTR patients required bowel resection compared to successfully rescued patients (43% vs. 20%, p<0.01; Table 1). The FTR rate was higher in consult and transfer patients (17%) compared to primary ACS service patients (8%; p=0.02).
Conclusion: Systematic study of failure to rescue in Acute Care Surgery identifies patients with significant comorbidities, critical physiological derangements, and frequent intestinal compromise; many are referred to an acute care surgeon specifically for rescue after a procedural complication. Rapid assessment of frailty, appropriate goals-of-care discussion, and careful operative planning are critical in this high-risk population.
