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Sepsis in General Surgery: The 2005-2007 National Surgical Quality Improvement Program Perspective
Sepsis in General Surgery: The 2005-2007 National Surgical Quality Improvement Program Perspective
Objective: To document the incidence, mortality rate, for myocardial infarction. The septic-shock group had a
and risk factors for sepsis and septic shock compared with greater percentage of patients older than 60 years (no sep-
pulmonary embolism and myocardial infarction in the sis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%;
general-surgery population. P⬍ .001). The need for emergency surgery resulted in
more cases of sepsis (4.5%) and septic shock (4.9%) than
Design: Retrospective review. did elective surgery (sepsis, 2.0%; septic shock, 1.2%)
(P⬍ .001). The presence of any comorbidity increased
Setting: American College of Surgeons National Surgi- the risk of sepsis and septic shock 6-fold (odds ratio, 5.8;
cal Quality Improvement Program institutions. 95% confidence interval, 5.5-6.2) and increased the 30-
day mortality rate 22-fold (odds ratio, 21.8; 95% confi-
Patients: General-surgery patients in the 2005-2007 Na- dence interval, 17.6-26.9).
tional Surgical Quality Improvement Program data set.
Conclusions: The incidences of sepsis and septic shock
Main Outcome Measures: Incidence, mortality rate, exceed those of pulmonary embolism and myocardial in-
and risk factors for sepsis and septic shock. farction. The risk factors for mortality include age older
than 60 years, the need for emergency surgery, and the
Results: Of 363 897 general-surgery patients, sepsis oc- presence of any comorbidity. This study emphasizes the
curred in 8350 (2.3%), septic shock in 5977 (1.6%), pul- need for early recognition of patients at risk via aggres-
monary embolism in 1078 (0.3%), and myocardial in- sive screening and the rapid implementation of evidence-
farction in 615 (0.2%). Thirty-day mortality rates for each based guidelines.
of the groups were as follows: 5.4% for sepsis, 33.7% for
septic shock, 9.1% for pulmonary embolism, and 32.0% Arch Surg. 2010;145(7):695-700
P
REVENTION OF PERIOPERA - surgery patients have become standards
tive complications is a ma- of care. The issue of SSIs has been ad-
jor focus in the care of the dressed through national guidelines.2 Mini-
general-surgery patient. In mizing the occurrence of these poten-
recent years, much atten- tially preventable complications improves
tion has focused on the prevention of ve- patient outcomes and reduces health care
nous thromboembolism (postoperative costs.
deep vein thrombosis and pulmonary em- Within our institution, we have iden-
bolism [PE]), postoperative myocardial in- tified surgical sepsis to be a potentially pre-
farction (MI), and surgical site infections ventable cause of morbidity and mortal-
ity in our general-surgery patients. Severe
sepsis and septic shock are the leading
CME available online at causes of multiple organ failure and mor-
www.jamaarchivescme.com tality in noncoronary intensive care units
and questions on page 615 (ICUs).3 It is estimated that in the United
States there are 751 000 cases per year of
(SSIs). Through education and increased sepsis, with an annual cost of $17 bil-
Author Affiliations: awareness, there has been a significant re- lion.4 By 2010, it is estimated that there
Department of Surgery, The duction in the incidence of postoperative will be 934 000 cases per year.3 Unfortu-
Methodist Hospital, Weill venous thromboembolism. 1 Likewise, nately, despite tremendous basic and clini-
Cornell Medical College, preoperative cardiovascular evaluation cal research efforts, mortality from septic
Houston, Texas. and risk assessment of elective general- shock remains unchanged at greater than
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
695
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
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No. of Patients
Characteristics (n=349 570) (n=8350) (n=5977)
5000
Male sex 147 120 (42.1) 4248 (50.9) 3179 (53.2)
4000
Age, y
ⱕ19 5265 (1.5) 60 (0.7) 10 (0.2) 3000
2012
20-59 203 788 (58.3) 3975 (47.6) 1767 (29.6) (33.7%)
ⱖ60 140 517 (40.2) 4315 (51.7) 4200 (70.3) 2000 1078
(0.3%) 615
Ethnicity 1000 449
(5.4%) 98 (0.2%) 193
White 247 361 (70.8) 5982 (71.6) 4356 (72.9) (9.1%) (32.07%)
Asian or Pacific Islander 6472 (1.9) 140 (1.7) 101 (1.7) 0
Sepsis Septic Shock Pulmonary Myocardial
African American 33 548 (9.6) 1128 (13.5) 740 (12.4) Embolism Infarction
Hispanic 26 543 (7.6) 466 (5.6) 339 (5.7)
Group
American Indian 3230 (0.9) 47 (0.6) 34 (0.6)
Unknown 32 416 (9.3) 587 (7.0) 407 (6.8)
BMI b Figure. Incidence and mortality by group.
Underweight (⬍18.50) 8272 (2.4) 421 (5.0) 355 (5.9)
Normal (18.50-24.99) 95 022 (27.2) 2419 (29.0) 1744 (29.2)
Overweight (25.00-29.99) 102 841 (29.4) 2251 (27.0) 1565 (26.2) Table 3. Top 5 Operative Procedures for Sepsis
Obese (30.00-39.99) 90 532 (25.9) 2034 (24.4) 1357 (22.7) and Septic Shock
Severely obese (ⱖ40.00) 37 605 (10.8) 790 (9.5) 533 (8.9)
Unknown 15 298 (4.4) 435 (5.2) 423 (7.1)
Smoking 72 979 (20.9) 2179 (26.1) 1560 (26.1) Sepsis Septic Shock
Drinking 8875 (2.5) 335 (4.0) 301 (5.0) Partial removal of colon Partial removal of colon
Removal of small intestine Removal of small intestine
Abbreviation: BMI, body mass index (calculated as weight in kilograms Arterial bypass graft Arterial bypass graft
divided by the height in meters squared). Partial removal of pancreas Removal of colon
a Data are presented as number (percentage). Percentages may not total 100
Removal of colon Exploration of abdomen
because of rounding. P ⬍.001 for all characteristics.
b Data unavailable for 37 605 patients.
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
697
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
698
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
699
(REPRINTED) ARCH SURG/ VOL 145 (NO. 7), JULY 2010 WWW.ARCHSURG.COM
700