Risk is almost double compared to elective surgery

Patients who undergo emergency general surgery appear to have a greater risk of thromboembolism (VTE) compared to those who undergo elective surgery, researchers found.

Samuel W. Ross, MD, MPH, Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, and colleagues determined that the emergency general surgery (EGS) population had almost twice the risk for VTE.

Their study was published in JAMA Surgery.

According to Ross and colleagues, between 7% and 11% of operations are classified as emergency surgery in 7% of hospital admissions, however, these admissions account for 28% of postoperative complications, about half of postoperative deaths.

VTE is, according to the American Public Health Association, the most preventable cause of morbidity and mortality among hospitalized patients. It is also known that trauma patients have an increased risk of VTE, and that those patients, as well as patients undergoing other surgeries (cancer and bariatric surgery, for example) have increased dosing or higher frequency and duration of chemoprophylaxis because these of a higher risk of VTE due to stasis, hypercoagulability, and inflammation.

“Despite a known, well-studied association between these conditions and VTE events, little research has focused on VTE in the EGS population, which may also have these risk factors, especially inflammation,” Ross and colleagues pointed out.

Therefore, in this retrospective study, Ross and colleagues used the American College of Surgeons National Surgical Quality Improvement Program database from Jan. 1, 2005, to Dec. 31, 2016 to compile data on 3 types of operations — cholecystectomies, ventral hernia repairs (VHRs), and partial colectomies (PCs) — that are common to both emergency and elective cases.

Emergency surgeries were then compared to elective surgeries, with the primary outcome the incidence of VTE after 30 days (controlling for age, sex, body mass index, bleeding disorder, disseminated cancer, laparoscopic approach, and surgery type).

During the period of the study 604,537 adults underwent 285,847 cholecystectomies, 158,500 VHRs, and 160,190 PCs. The rate of VTE within 30 days was 1.1% for the entire population (a total of 6,624 VTEs). The complication rate was 27.0% and the mortality rate within 30 days was 1.4%.

However, the rate of VTE was 1.9% for EGS compared to 0.8% for elective surgery — a statistically significant difference — with an increased greater VTE risk with the level of invasiveness (0.5% for cholecystectomy, 0.8% for VHR, and 2.4% for PC).

In addition, patients who had emergency surgery had general and major complication rates that were 1.9 and 3.8 times higher than the rates of their elective counterparts, respectively. Reoperation and readmission rates were also higher among emergency surgery patients, while 30-day mortality was significantly higher — 9 times greater in patients with emergency (3.6%) compared to elective status (0.4%).

On multivariate analysis, emergency surgeries had almost twice the increased risk VTE compared with elective surgeries (OR, 1.70; 95% CI, 1.61-1.79). In addition, patients who underwent open surgeries had about 3 times the risk for VTE compared to patients who underwent laparoscopic surgeries.

“These findings should be a call to action for surgeons and hospitals to promote research and quality improvement processes aimed at patients undergoing EGS in an effort to prevent and mitigate VTE,” Ross and colleagues wrote. In addition, they suggested that a more aggressive thromboembolism chemoprophylaxis regimen should be considered for patients who undergo emergency general surgery.

In a commentary accompanying the study, Patrick B. Murphy, MD, MPH, MSc, Division of Acute Care Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, and Elliott R. Haut, MD, PhD, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, said the study — like all good research — “raised more questions than it answers.”

For example, how can those VTE rates in the emergency general surgery population be reduced? Are these patients being prescribed the ideal prophylaxis on admission, or are they missing doses of prescribed medications?

“To answer these questions, and many others, in the EGS population, we need to develop risk assessment tools specific to EGS, capture important process measures, and create EGS databases or registries that include patients not undergoing surgery,” wrote Murphy and Haut.

  1. Patients who undergo emergency general surgery have almost twice the risk of venous thromboembolic events compared to patients who undergo similar elective surgeries.

  2. A more aggressive approach to providing thromboembolism chemoprophylaxis should be considered for patients who undergo emergency general surgery.

Michael Bassett, Contributing Writer, BreakingMED™

Haut reported being primary investigator of contracts from the Patient-Centered Outcomes Research Institute (PCORI) and being coinvestigator of another PCORI contract; being primary investigator of a grant from the Agency for Healthcare Research and Quality and being coinvestigator of a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health; receiving research grant support from the US Army Medical Research Acquisition Activity of the Department of Defense and receiving grant support from the Henry M. Jackson Foundation; and receiving book royalties from Lippincott Williams & Wilkins and being a paid consultant to Vizient Inc for their HIIN Venous Thromboembolism (VTE) Prevention Action Network.

Cat ID: 163

Topic ID: 97,163,254,730,192,925,163