Easterlin Molly Crimmins, Chang David C, Wilson Samuel Eric
Department of Surgery, University of California San Diego, San Diego, CA 92103-8400, USA.
Ann Vasc Surg. 2013 Oct;27(7):909-17. doi: 10.1016/j.avsg.2012.06.030. Epub 2013 Jun 20.
Patients at risk of mortality after amputation have not been well identified. We sought to devise a clinical index predicting 30-day mortality after amputation that would allow stratification of intensity of postoperative care.
The National Surgical Quality Improvement Program (NSQIP) database (2005-2009) was analyzed for patients who had above- or below-knee amputations. An additive risk index was created based on logistic regression that examined patient demographics, comorbidities, and operative characteristics. A threshold score for clinical action was identified as the score at which the gain in certainty was maximized. The primary outcome measure was 30-day mortality.
Among 9244 patients analyzed, there were 744 deaths (8.1%) at 30 days, with 280 occurring after hospital discharge (37.9%). The final index includes 11 components with a total score range of 0-13: age (60-79 or ≥80 years), history of congestive heart failure, chronic obstructive pulmonary disease, or major cardiac surgery, using steroid medications, having dependent functional status, dyspnea, being on dialysis, having impaired sensorium, or preoperative sepsis. This index has a c-statistic of 0.7391, and the score at which clinical action should be taken is ≥5. The observed probability of 30-day mortality increased from 1.06% at a score of 1 to 10% at 5 and 38.5% at a score of 10.
More than one-third of deaths within 30 days of major amputation occur after discharge from acute care. A novel index to predict 30-day mortality after major amputation is described. Patients receiving a score ≥5 face a substantial risk of mortality and should be held in the hospital longer or, if discharged, receive closer postoperative follow-up.
截肢术后有死亡风险的患者尚未得到很好的识别。我们试图设计一种临床指标来预测截肢术后30天死亡率，以便对术后护理强度进行分层。
对国家外科质量改进计划（NSQIP）数据库（2005 - 2009年）中接受膝上或膝下截肢的患者进行分析。基于逻辑回归创建了一个累加风险指数，该指数考察了患者的人口统计学特征、合并症和手术特征。将临床行动的阈值分数确定为确定性增益最大化时的分数。主要结局指标是30天死亡率。
在分析的9244例患者中，30天时有744例死亡（8.1%），其中280例（37.9%）发生在出院后。最终指数包括11个组成部分，总分范围为0 - 13分：年龄（60 - 79岁或≥80岁）、充血性心力衰竭病史、慢性阻塞性肺疾病、重大心脏手术史、使用类固醇药物、依赖性功能状态、呼吸困难、接受透析、意识障碍或术前败血症。该指数的c统计量为0.7391，应采取临床行动的分数为≥5分。观察到的30天死亡率概率从分数为1时的1.06%增加到分数为5时的10%和分数为10时的38.5%。
在急性护理出院后，超过三分之一的大截肢术后30天内死亡发生。描述了一种预测大截肢术后30天死亡率的新指数。得分≥5分的患者面临着相当大的死亡风险，应在医院留院时间更长，或者如果出院，应接受更密切的术后随访。
