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Predisposed to failure? The challenge of rescue in the medical intensive care unit

Briggs, Alexandra MD; Handzel, Robert M. MD; Kutcher, Matthew E. MD; Peitzman, Andrew B. MD; Forsythe, Raquel M. MD

Journal of Trauma and Acute Care Surgery: October 2019 - Volume 87 - Issue 4 - p 774–781
doi: 10.1097/TA.0000000000002411
AAST 2018 PODIUM PAPERS
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CME

BACKGROUND Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases.

METHODS All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality.

RESULTS Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p < 0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86–59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11–23.77).

CONCLUSION Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk.

LEVEL OF EVIDENCE Prognostic and epidemiological, level III

From the Division of Trauma and General Surgery, University of Pittsburgh Medical Center (A.B., R.H., A.B.P., R.M.F.), Pittsburgh, Pennsylvania; Division of Trauma and Acute Care Surgery, Dartmouth Hitchcock Medical Center (A.B.), Lebanon, New Hampshire; and Department of Surgery, University of Mississippi Medical Center (M.E.K.), Jackson, Mississippi.

Submitted: Semptember 7, 2018, Revised: May 30, 2019, Accepted: June 1, 2019, Published online: June 13, 2019.

Presentation: Oral Presentation at the 77th Annual Meeting of the American Association for the Surgery of Trauma, September, 2018 in San Diego, California.

Address for reprints: Alexandra Briggs, MD, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756; email: Alexandra.Briggs@hitchcock.org.

Online date: June 24, 2019

© 2019 Lippincott Williams & Wilkins, Inc.