急诊手术中术中不良事件的性质、模式、临床结局及经济影响。
The nature, patterns, clinical outcomes, and financial impact of intraoperative adverse events in emergency surgery.
作者信息
Ramly Elie P, Bohnen Jordan D, Farhat Maha R, Razmdjou Shadi, Mavros Michael N, Yeh Daniel D, Lee Jarone, Butler Kathryn, De Moya Marc, Velmahos George C, Kaafarani Haytham M A
机构信息
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street Suite 810, Boston, MA, 02114, USA.
出版信息
Am J Surg. 2016 Jul;212(1):16-23. doi: 10.1016/j.amjsurg.2015.07.023. Epub 2015 Oct 24.
BACKGROUND
Little is known about intraoperative adverse events (iAEs) in emergency surgery (ES). We sought to describe iAEs in ES and to investigate their clinical and financial impact.
METHODS
The 2007 to 2012 administrative and American College of Surgeons-National Surgical Quality Improvement Program databases at our tertiary academic center were: (1) linked, (2) queried for all ES procedures, and then (3) screened for iAEs using the ICD-9-CM-based Patient Safety Indicator "accidental puncture/laceration". Flagged cases were systematically reviewed to: (1) confirm or exclude the occurrence of iAEs (defined as inadvertent injuries during the operation) and (2) extract additional variables such as procedure type, approach, complexity (measured by relative value units), need for adhesiolysis, and extent of repair. Univariate and multivariate analyses were performed to assess the independent impact of iAEs on 30-day morbidity, mortality, and hospital charges.
RESULTS
Of a total of 9,288 patients, 1,284 (13.8%) patients underwent ES, of which 23 had iAEs (1.8%); 18 of 23 (78.3%) of the iAEs involved the small bowel or spleen, 10 of 23 (43.5%) required suture repair, and 8 of 23 (34.8%) required tissue or organ resection. Compared with those without iAEs, patients with iAEs were older (median age 62 vs 50; P = .04); their procedures were more complex (total relative value unit 46.7, interquartile range [27.5 to 52.6] vs 14.5 [.5 to 30.2]; P < .001), longer in duration (>3 hours: 52% vs 8%; P < .001), and more often required adhesiolysis (39.1% vs 13.5% P = .001). Patients with iAEs had increased total charges ($31,080 vs $11,330, P < .001), direct charges ($20,030 vs $7,387, P < .001), and indirect charges ($11,460 vs $4,088, P < .001). On multivariable analyses, iAEs were independently associated with increased 30-day morbidity (odds ratio, 3.56 [CI, 1.10 to 11.54]; P = .03) and prolonged postoperative length of stay (LOS; LOS >7 days; odds ratio, 5.60 [1.54 to 20.35]; P = .01]. A trend toward increased mortality did not reach statistical significance.
CONCLUSIONS
In ES, iAEs are independently associated with significantly higher postoperative morbidity and prolonged LOS.
背景
关于急诊手术（ES）中的术中不良事件（iAEs），我们所知甚少。我们试图描述急诊手术中的术中不良事件，并调查其对临床和经济的影响。
方法
我们将2007年至2012年在我们三级学术中心的行政数据库和美国外科医师学会-国家外科质量改进计划数据库进行：（1）链接，（2）查询所有急诊手术程序，然后（3）使用基于国际疾病分类第九版临床修正版（ICD-9-CM）的患者安全指标“意外穿刺/撕裂伤”筛选术中不良事件。对标记的病例进行系统回顾，以：（1）确认或排除术中不良事件的发生（定义为手术期间的意外损伤），以及（2）提取其他变量，如手术类型、入路、复杂性（通过相对价值单位衡量）、是否需要粘连松解以及修复范围。进行单变量和多变量分析，以评估术中不良事件对30天发病率、死亡率和医院费用的独立影响。
结果
在总共9288例患者中，1284例（13.8%）接受了急诊手术，其中23例发生术中不良事件（1.8%）；23例术中不良事件中有18例（78.3%）涉及小肠或脾脏，23例中有10例（43.5%）需要缝合修复，23例中有8例（34.8%）需要组织或器官切除。与未发生术中不良事件的患者相比，发生术中不良事件的患者年龄更大（中位年龄62岁对50岁；P = 0.04）；他们的手术更复杂（总相对价值单位46.7，四分位间距[27.5至52.6]对14.5[0.5至30.2]；P < 0.001），手术持续时间更长（>3小时：52%对8%；P < 0.001），并且更常需要粘连松解（39.1%对13.5%，P = 0.001）。发生术中不良事件的患者总费用增加（31080美元对11330美元，P < 0.001），直接费用增加（20030美元对7387美元，P < 0.001），间接费用增加（11460美元对4088美元，P < 0.001）。在多变量分析中，术中不良事件与30天发病率增加独立相关（比值比，3.56[置信区间，1.10至11.54]；P = 0.03）和术后住院时间延长（住院时间>7天；比值比，5.60[1.54至20.35]；P = 0.01]。死亡率增加的趋势未达到统计学显著性。
结论
在急诊手术中，术中不良事件与术后发病率显著升高和住院时间延长独立相关。
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