E. Lagazzi1, M. Abiad1, W. Rafaqat1, I. Nzenwa1, V. Panossian1, A. Hoekman1, S. Arnold1, K. Ghaddar1, C. Luckhurst1, J. J. Parks1, G. C. Velmahos1, H. M. Kaafarani1, J. O. Hwabejire1 1Massachusetts General Hospital, Division Of Trauma, Emergency Surgery, And Surgical Critical Care, Boston, MA, USA
Introduction:
Emergent surgical conditions are widely prevalent in the geriatric population and often require performing major operative procedures on frail and polymorbid patients. In this framework, knowing the patient’s risk profile holds paramount importance during surgical decision-making and for effective communication with both the patient and family.
Methods:
We queried NSQIP 2015-2019 for all patients ≥65 years undergoing an emergent exploratory laparotomy for emergency general surgery (EGS) conditions. All patients with disseminated cancer were excluded. Our primary outcome was 30-day mortality. Univariable analysis was performed to analyze patient baseline characteristics. Stepwise logistic regression was used to identify pre- and intraoperative predictors of mortality that were then included in a multivariable logistic regression model. Mortality rates were calculated using combinations of independent predictors to identify the patients at the highest risk of mortality.
Results:
We included 41,029 patients, of which 5,589 (13.62%) died within 30 days of admission. Following the multivariate analysis, we identified as the highest preoperative predictors of mortality the following characteristics: American Society of Anesthesiologists (ASA) status 5 (aOR 10.43, 95% confidence interval [CI], 7.21-15.07, p<0.001), preoperative septic shock (aOR 3.43, 95% CI, 2.99-3.93, p<0.001), and modified 5-item frailty index (mFI-5) >0.75 (aOR 2.16, 95% CI, 1.63-2.86, p<0.001). The operative procedures associated with the highest mortality risk were small bowel resection (aOR 2.09, 95% CI, 1.38-3.19, p<0.001) and colectomy (aOR 2.06, 95% CI, 1.39-3.05, p<0.001). Patients who did not have any of the highest preoperative risk factors had a mortality rate of 8.67%. Among these low-risk patients, the mortality following a colectomy or a small bowel resection was of 12.13% and 10%. However, frail patients with an mFI-5 >0.75, an ASA of 5, and preoperative septic shock had a mortality rate of 80% and 100% when undergoing a colectomy or a small bowel resection, respectively.
Conclusion:
In elderly patients who need urgent or emergent exploratory laparotomy, frailty index, ASA status, preoperative septic shock, and operative procedure type can help predict futility of surgical intervention. These clinical variables can be used to individualize goals of care and facilitate informed decision-making between surgical teams and families prior to operative management.
