Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts2Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Surg. 2016 Jul 20;151(7):e160789. doi: 10.1001/jamasurg.2016.0789.
Emergency general surgery (EGS) patients have a disproportionate burden of death and complications. Chronic liver disease (CLD) increases the risk of complications following elective surgery. For EGS patients with CLD, long-term outcomes are unknown and risk stratification models do not reflect severity of CLD.
To determine whether the Model for End-Stage Liver Disease (MELD) score is associated with increased risk of 90-day mortality following intensive care unit (ICU) admission in EGS patients.
DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study of patients with CLD who underwent an EGS procedure based on International Classification of Diseases, Ninth Revision (ICD-9) procedure codes and were admitted to a medical or surgical ICU within 48 hours of surgery between January 1, 1998, and September 20, 2012, at 2 academic medical centers. Chronic liver disease was identified using ICD-9 codes. Multivariable logistic regression was performed. The analysis was conducted from July 1, 2015, to January 1, 2016.
The primary outcome was all-cause 90-day mortality.
A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98).
In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.
急诊普通外科（EGS）患者的死亡和并发症负担不成比例。慢性肝病（CLD）会增加择期手术后并发症的风险。对于患有 CLD 的 EGS 患者，长期预后尚不清楚，风险分层模型也不能反映 CLD 的严重程度。
确定终末期肝病模型（MELD）评分是否与 ICU 入院后 90 天死亡率增加相关，以评估 EGS 患者的死亡率。
设计、设置和参与者：我们进行了一项回顾性队列研究，纳入了 1998 年 1 月 1 日至 2012 年 9 月 20 日期间在 2 所学术医疗中心接受 EGS 手术的 CLD 患者，这些患者的手术基于国际疾病分类第 9 版（ICD-9）手术编码，并在术后 48 小时内入住内科或外科 ICU。使用 ICD-9 代码确定慢性肝病。进行多变量逻辑回归分析。分析于 2015 年 7 月 1 日至 2016 年 1 月 1 日进行。
主要结局为全因 90 天死亡率。
共有 13552 例 EGS 患者接受了重症监护；其中 707 例（5%）（入院时平均[SD]年龄为 56.6[14.2]岁；64%为男性；79%为白人）患有 CLD，且 ICU 入院时可确定 MELD 评分。中位 MELD 评分为 14（四分位距，10-20）。总体 90 天死亡率为 30.1%。MELD 评分每增加 10 分，90 天死亡率的调整比值比为 1.63（95%CI，1.34-1.98）。ICU 入院后 48 小时内 MELD 评分下降超过 3 分，90 天死亡率降低 2.2 倍（比值比=0.46；95%CI，0.22-0.98）。
在这项研究中，MELD 评分与 CLD 患者接受 EGS 后 90 天死亡率相关。MELD 评分可作为该患者人群的预后因素，并应纳入术前风险预测模型以及在对 EGS 患者进行手术干预的风险和获益咨询中。
