Acute Care Surgery and Surgical Rescue: Expanding the Definition

Jose J. Diaz, University of Maryland School of Medicine, Baltimore, MD.
Stephen Barnes, Department of Surgery, University of Missouri, Columbia, MO.
Lindsay O'Meara, University of Maryland Medical Center, Baltimore, MD.
Robert Sawyer, Western Michigan University School of Medicine: Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI.
Addison May, Atrium Health / Carolinas Medical Center, Charlotte, NC.
Daniel Cullinane, Maine Health, Portland, ME.


BACKGROUND: Surgical Rescue (SR) is the recovery of patients with surgical complications. Patients transferred (TP) for surgical diagnoses to higher-level care or inpatients (IP) admitted to nonsurgical services may develop intra-abdominal infection (IAI) and require emergency surgery (ES). The aims were to characterize the SR population by the site of ES consultation, open abdomen (OA), and risk of mortality. STUDY DESIGN: Secondary analysis of an international, multi-institutional prospective observational study of patients requiring ES for IAI. Laparotomy before the transfer was an exclusion criterion. Patients were divided into groups: Clinic/ED (C/ED), IP, or TP. Data collected included demographics, the severity of illness (SOI), procedures, OA, and # of laparotomies. The primary outcome was mortality. Multivariable logistic regression models were constructed. RESULTS: There were 752 study patients [C/ED (63.8%), vs. TP (23.4%), & IP (12.8%)], with mean age of 59 and 43.6% female. IP had worse SOI scores (CCI, ASA, and SOFA). The most common procedures were small and large bowel (77.3%). IP and TP had similar rates of OA (IP 52.1% & TP 52.3 %) vs. C/ED (37.7%) (p<0.001) and IP had more relaparotomies (3-4). The unadjusted mortality rate was as highest in IP (n=24,25.0%) vs TP (n=29, 16.5%), and C/ED (n=68, 14.2%) (p=0.03). Adjusting for age and SOI, only SOI had an impact on the risk of mortality. [AUC of 86%]. CONCLUSIONS: IP had the highest unadjusted mortality after ES for IAI and was followed by the TP; SOI drove the risk of mortality. SR must be extended to IP for timely recognition of the IAI.