Non-abdominal imaging: a marker of illness severity and outcome in elderly patients needing emergency abdominal surgery

Author(s):
Lavina Malhotra; Charles Adams, Jr.; Daithi Heffernan; Andrew Stephen; Eric Benoit

Background:

Sepsis is known to cause neurologic and pulmonary dysfunction, but the elderly are exceptionally susceptible due to their limited reserve in these systems. This concept is largely the basis of the qSOFA scoring system, which aims to identify patients with sepsis earlier. Many elderly patients with abdominal sepsis undergo unrevealing non-abdominal imaging on presentation and it is unknown whether this predicts illness severity or outcomes.

Hypothesis:

We hypothesize that elderly patients with abdominal sepsis that undergo extra-abdominal imaging present with a greater burden of illness.

Methods:

We conducted a 4 year retrospective review of patients greater than age 65 that underwent emergency abdominal surgery for abdominal sepsis after presenting to the emergency room. Charts were reviewed for emergency room workup and patients were divided into two groups: those with only abdominal CT imaging(abdCT) and those with abdominal CT and non-abdominal CT imaging(extraCT). Chief complaints, presenting laboratory values, qSOFA, and comorbidities were reviewed in all patients.  Indications for and results of the non-abdominal CT workups were recorded. Outcomes reviewed included time to the OR, need for the ICU, infectious complications, and mortality.

Results:

Of the 130 patients, 100 had abdCT and 30 extraCT. The abdCT and extraCT patients were similar age (75.1 vs 75.7 years; p>0.05). Chief complaints charted by the ER staff and surgical consultant were more often disparate in the extraCT group(63% vs 14%; p<0.001). Presenting WBC was higher in the extraCT group(15.9 vs 11.7; p=0.002) and qSOFA was more often positive(33% vs 7%; p<0.001). Among the 38 extraCT imaging tests, none of the head CT scans was positive, and only 2 of the chest CTs were noted to have a positive finding. Only two of 38 non-abdominal CTs did not have a clinical indication. Delivery of surgical care was unaffected as time to the operating room was similar in the two groups. Outcomes were worse  in the extraCT group with increased need for the ICU (70% vs 31%; p<0.001), higher mortality (33% vs 6%; p<0.001), and higher rate of infectious complications (46% vs 25%; p=0.04).

Conclusions:

Among elderly patients who require emergency abdominal surgery non-abdominal CT imaging may be a marker of severity of the abdominal process and indicate presence of extra-abdominal manifestations of abdominal sepsis. Additionally, it may indicate decreased neurologic and pulmonary reserve in the elderly.