Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts2Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts3Division of Respiratory and Critical Care Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota.
JAMA Surg. 2015 Jan;150(1):65-73. doi: 10.1001/jamasurg.2014.1795.
Little empirical evidence exists on how a first (index) complication influences the risk of specific subsequent secondary complications. Understanding these risks is important to elucidate clinical pathways of failure to rescue or death after postoperative complication.
To understand patterns of secondary complications in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
DESIGN, SETTING, AND PARTICIPANTS: Matched analysis using a cohort of 890 604 patients undergoing elective inpatient surgery from January 1, 2005, through December 31, 2011, identified in the NSQIP Participant Use Data File. Five index complications were studied: pneumonia, acute myocardial infarction, deep space surgical site infection, bleeding or transfusion event, and acute renal failure. Each patient with an index complication was matched to a control patient based on propensity for the index event and the number of event-free days. Outcomes were compared using conditional logistic regression.
Rates of 30-day secondary complications and 30-day mortality.
Five cohorts were developed, each with 1:1 matching to controls, which were well balanced. Index pneumonia (n = 7947) was associated with increased odds of 30-day reintubation (odds ratio [OR], 17.1; 95% CI, 13.8-21.3; P < .001), ventilatory failure (OR, 15.9; 95% CI, 12.8-19.8; P < .001), sepsis (OR, 7.3; 95% CI, 6.2-8.6; P < .001), and shock (OR, 13.0; 95% CI, 10.4-16.2; P < .001). Index acute myocardial infarction was associated with increased rates of secondary bleeding or transfusion events (OR, 4.3; 95% CI, 3.3-5.8; P < .001), pneumonia (OR, 5.1; 95% CI, 2.6-10.2; P < .001), cardiac arrest (OR, 12.0; 95% CI, 7.5-19.2; P < .001), and reintubation (OR, 11.7; 95% CI, 8.4-16.3; P < .001). Deep space surgical site infection was associated with dehiscence (OR, 30.4; 95% CI, 19.9-46.5; P < .001), sepsis (OR, 13.1; 95% CI, 10.2-16.7; P < .001), shock (OR, 10.6; 95% CI, 6.4-17.7; P < .001), kidney injury (OR, 8.6; 95% CI, 3.9-18.8; P < .001), and acute renal failure (OR, 10.5; 95% CI, 3.8-29.3; P < .001). Index acute renal failure was associated with increased odds of cardiac arrest (OR, 25.3; 95% CI, 9.3-68.6; P < .001), reintubation (OR, 11.3; 95% CI, 7.4-17.1; P < .001), ventilatory failure (OR, 12.4; 95% CI, 8.2-18.8; P < .001), bleeding or transfusion events (OR, 11.3; 95% CI, 6.3-20.5; P < .001), and shock (OR, 11.2; 95% CI, 7.2-17.3; P < .001).
This investigation quantified the effect of index complications on patient risk of specific secondary complications. The defined pathways merit investigation as unique targets for quality improvement and benchmarking.
关于首次（索引）并发症如何影响特定后续次要并发症的风险，实证证据很少。了解这些风险对于阐明术后并发症后抢救失败或死亡的临床途径很重要。
了解美国外科医师学会国家手术质量改进计划（NSQIP）中继发并发症的模式。
设计、设置和参与者：使用从 2005 年 1 月 1 日至 2011 年 12 月 31 日在 NSQIP 参与者使用数据文件中确定的 890604 例择期住院手术患者的队列进行匹配分析。研究了五种索引并发症：肺炎、急性心肌梗死、深部空间手术部位感染、出血或输血事件以及急性肾衰竭。每个索引并发症患者都根据索引事件的倾向和无事件天数与对照患者进行匹配。使用条件逻辑回归比较结果。
30 天内继发性并发症和 30 天死亡率的发生率。
共建立了五个队列，每个队列都与对照组进行了 1:1 匹配，并且都很好地平衡了。索引性肺炎（n=7947）与 30 天再插管（比值比[OR]，17.1；95%置信区间[CI]，13.8-21.3；P<0.001）、通气衰竭（OR，15.9；95%CI，12.8-19.8；P<0.001）、败血症（OR，7.3；95%CI，6.2-8.6；P<0.001）和休克（OR，13.0；95%CI，10.4-16.2；P<0.001）的继发性再发风险增加相关。索引性急性心肌梗死与继发性出血或输血事件（OR，4.3；95%CI，3.3-5.8；P<0.001）、肺炎（OR，5.1；95%CI，2.6-10.2；P<0.001）、心脏骤停（OR，12.0；95%CI，7.5-19.2；P<0.001）和再插管（OR，11.7；95%CI，8.4-16.3；P<0.001）的发生率增加相关。深部空间手术部位感染与裂开（OR，30.4；95%CI，19.9-46.5；P<0.001）、败血症（OR，13.1；95%CI，10.2-16.7；P<0.001）、休克（OR，10.6；95%CI，6.4-17.7；P<0.001）、肾损伤（OR，8.6；95%CI，3.9-18.8；P<0.001）和急性肾衰竭（OR，10.5；95%CI，3.8-29.3；P<0.001）的发生率增加相关。索引性急性肾衰竭与心脏骤停（OR，25.3；95%CI，9.3-68.6；P<0.001）、再插管（OR，11.3；95%CI，7.4-17.1；P<0.001）、通气衰竭（OR，12.4；95%CI，8.2-18.8；P<0.001）、出血或输血事件（OR，11.3；95%CI，6.3-20.5；P<0.001）和休克（OR，11.2；95%CI，7.2-17.3；P<0.001）的风险增加相关。
本研究量化了索引并发症对患者特定继发性并发症风险的影响。定义的途径值得作为质量改进和基准测试的独特目标进行研究。
