背景:未能营救,或者病人在手术并发症后死亡,主要发生在发生一系列术后并发症的患者中。然而,目前尚不清楚是否有特定类型的指标并发症与抢救失败密切相关,额外的继发性并发症,或其他类型的术后结果。这是一项针对在退伍军人事务医院接受非心脏手术的退伍军人的国家队列研究,使用退伍军人事务手术质量改善计划(2016年1月1日至2021年9月30日)的数据。指标并发症分为几类(心血管,静脉血栓栓塞,肺,出血/输血,肾,中枢神经系统,伤口,脓毒症,艰难梭菌结肠炎,移植,或轻微[定义为相关死亡率<1%的并发症])。指标并发症类型与抢救失败之间的关联,继发性并发症,再操作,术后住院时间采用多变量评估,分层回归,和死亡风险评估与共享脆弱模型。
结果:在574,195名患者中,5.3%有至少1例并发症(其中26.1%有继发性并发症,8.2%的人未能获救),4.5%的人再次手术。次要并发症(5.0%-61.4%)和抢救失败(0.8%-34.2%)的发生率因指标并发症的类型而异。相对于指数轻微并发症,索引性出血与继发并发症最相关(亚分布风险比1.4,95%置信区间[1.1-1.8]),心脏并发症指数与抢救失败最相关(比值比45.4[34.5-59.7]),移植并发症与再次手术最相关(比值比96.0[79.5-115.8]),和指数肺部并发症与住院时间延长2.6倍相关(发生率比2.6[2.6-2.7]).心脏和中枢神经系统并发症指数与死亡风险密切相关(心脏风险比2.45,95%置信区间[2.14-2.81];中枢神经系统风险比1.84[1.49-2.27])。
结论:不同类型的指标并发症与不同的结局特征相关。这表明手术质量改进工作不仅应针对要解决的指标并发症的类型,而且还应针对所需的结果进行调整。
BACKGROUND: Failure to rescue, or the death of a patient after a surgical complication, largely occurs in patients who develop a cascade of postoperative complications. However, it is unclear whether there are specific types of index complications that are more strongly associated with failure to rescue, additional secondary complications, or other types of postoperative outcomes. This is a national cohort study of veterans who underwent noncardiac surgery at Veterans Affairs hospitals using data from the Veterans Affairs Surgical Quality Improvement Program (January 1, 2016 to September 30, 2021). Index complications were grouped into categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, sepsis, Clostridium difficile colitis, graft, or minor [defined as complications having an associated mortality rate <1%]). The association between type of index complication and failure to rescue, secondary complications, reoperation, and postoperative length of stay was evaluated with multivariable, hierarchical regression, and risk of death assessed with shared frailty modeling.
RESULTS: Among 574,195 patients, 5.3% had at least 1 complication (of which 26.1% had secondary complications, and 8.2% had failure to rescue), and 4.5% had a reoperation. Secondary complication (5.0%-61.4%) and failure to rescue (0.8%-34.2%) rates varied by the type of index complication. Relative to index minor complications, index bleeding was most associated with secondary complication (subdistribution hazard ratio 1.4, 95% confidence interval [1.1-1.8]), index cardiac complications were most associated with failure to rescue (odds ratio 45.4 [34.5-59.7]), index graft complications were most associated with reoperation (odds ratio 96.0 [79.5-115.8]), and index pulmonary complications were associated with 2.6 times longer length of stay (incident rate ratio 2.6 [2.6-2.7]). Index cardiac and central nervous system complications were most strongly associated with risk of death (cardiac-hazard ratio 2.45, 95% confidence interval [2.14-2.81]; central nervous system-hazard ratio 1.84 [1.49-2.27]).
CONCLUSIONS: Different types of index complications are associated with different outcome profiles. This suggests surgical quality improvement efforts should be tailored not only to the type of index complication to be addressed but also to the desired outcome to improve.