Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery

Shaheed Merani, Judd Payne, Raj S Padwal, Darren Hudson, Sandy L Widder, Rachel G Khadaroo, Shaheed Merani, Judd Payne, Raj S Padwal, Darren Hudson, Sandy L Widder, Rachel G Khadaroo

Abstract

Introduction: With the increasing aging population demographics and life expectancies the number of very elderly patients (age ≥ 80) undergoing emergency surgery is expected to rise. This investigation examines the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity.

Methods: A retrospective study of patients aged 80 and above undergoing emergency surgery between 2008 and 2010 at a tertiary care facility in Canada was conducted. Demographics, comorbidities, surgical indications, and perioperative risk assessment data were collected. Outcomes included length of hospitalization, discharge destination, and in-hospital mortality and morbidity. Multivariable logistic regression was used to identify predictors of in-hospital mortality and complications.

Results: Of the 170 patient admissions, the mean age was 84 years and the in-hospital mortality rate was 14.7%. Comorbidities were present in 91% of this older patient population. Over 60% of the patients required further services or alternate level of care on discharge. American Society of Anesthesiologist Physical Status (ASA) Classification (OR 5.30, 95% CI 1.774-15.817, p = 0.003) and the development of an in-hospital complications (OR 2.51, 95% CI 1.210-5.187, p = 0.013) were independent predictors of postoperative mortality. Chronological age or number of comorbidities was not predictive of surgical outcome.

Conclusions: Mortality, complication rates and post-discharge care requirements were high in very elderly patients undergoing emergency general surgery. Advanced age and medical comorbidities alone should not be the limiting factors for surgical referral or treatment. This study illustrates the importance of preventing an in-hospital complication in this very vulnerable population. ASA class is a robust tool which is predictive of mortality in the very elderly population and can be used to guide patient and family counseling in the emergency setting.

Keywords: Acute care; Elderly; Emergency; Morbidity; Mortality; Surgery.

Figures

Figure 1
Figure 1
Multivariable Logistic regression analysis demonstrated statistically significant factors predictive of in-hospital mortality. Development of in-hospital complication is predictive of in-hospital mortality (A), and increasing ASA class is predictive of in-hospital mortality (B).

References

    1. Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges ahead. Lancet. 2009;374:1196–1208.
    1. Abbas S, Booth M. Major abdominal surgery in octogenarians. N Z Med J. 2003;116:U402.
    1. Rosenberg M, Moore E. The health of Canada’s elderly population: current status and future implications. Can Med Assoc J. 1997;157:1025–1032.
    1. Canadian Institute for Health Information. Health Care in Canada, 2011: A Focus on Seniors and Agingle. 2011.
    1. Statistics Canada. Population Projections for Canada, Provinces and Territories, 2009 to 2036. 2011.
    1. Bettelli G. Preoperative evaluation in geriatric surgery: comorbidity, functional status and pharmacological history. Minerva Anestesiol. 2011;77:637–646.
    1. Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48:78–83.
    1. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865–877.
    1. Story DA, Finkf M, Myles KLPS, Yap SJ, Beavistt V, Kerridgeii R-K, Mcnicol PL. Perioperative mortality risk score using pre- and postoperative risk factors in older patients. Anaesth Intensive Care. 2009;37(3):392–398.
    1. Robinson TN, Wallace JI, Wu DS, Wiktor A, Pointer LF, Pfister SM, Sharp TJ, Buckley MJ, Moss M. Accumulated frailty characteristics predict postoperative discharge institutionalization in the geriatric patient. J Am Coll Surg. 2011;213:34–37.
    1. Louis D, Hsu A, Brand M, Saclarides T. Morbidity and Mortality in Octogenarians and Older Undergoing Major Intestinal Surgery. Dis Colon Rectum. 2009;1:59–63.
    1. Devon KM, Urbach DR, McLeod RS. Postoperative disposition and health services use in elderly patients undergoing colorectal cancer surgery: a population-based study. Surgery. 2011;149:705–712.
    1. Akinbami F, Askari R, Steinberg J, Panizales M, Rogers SO. Factors affecting morbidity in emergency general surgery. Am J Surg. 2011;201:456–462.
    1. Pelavski AD, Lacasta A, Rochera MI, De Miguel M, Roige J. Observational study of nonogenarians undergoing emergency, non-trauma surgery. Br J Anaesth. 2011;106(November 2010):189–193.
    1. Alcock M, Chilvers CR. Emergency surgery in the elderly: a retrospective observational study. Anaesth Intensive Care. 2012;40:90–94.
    1. Inouye SK. Prevention of delirium in hospitalized older patients: risk factors and targeted intervention strategies. Ann Med. 2000;32:257–263.
    1. Evans DC, Cook CH, Christy JM, Murphy CV, Gerlach AT, Eiferman D, Lindsey DE, Whitmill ML, Papadimos TJ, Beery PR, Steinberg SM, Stawicki SP. Comorbidity-Polypharmacy Scoring Facilitates Outcome Prediction in Older Trauma Patients. J Am Geriatr Soc. 2012;60(8):1465–1470.
    1. Population Division US Census Bureau. Projections of the Population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12) 2008.
    1. Gazala S, Tul Y, Wagg A, Widder S, Khadaroo RG. Quality of life and long-term outcomes of octo- and nonagenarians following acute care surgery: a cross sectional study. World J Emerg Surg. 2013;8:23.
    1. Hilmer SN, Perera V, Mitchell S, Murnion BP, Dent J, Bajorek B, Matthews S, Rolfson DB. The assessment of frailty in older people in acute care. Australas J Ageing. 2009;28:182–188.
    1. Minne L, Ludikhuize J, De Jonge E, De Rooij S, Abu-hanna A. Prognostic models for predicting mortality in elderly ICU patients: a systematic review. Intensive Care Med. 2011;37:1258–1268.
    1. Keats AS. The ASA classification of physical status–a recapitulation. Anesthesiology. 1978;49:233–236.
    1. Wolters U, Wolf T, Stützer H, Schröder T, Pichlmaier H. Risk factors, complications, and outcome in surgery: a multivariate analysis. Eur J Surg. 1997;163:563–568.

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