The impact of pre-operative sepsis on patients undergoing emergency general surgery

Author(s):
Anahita Jalilvand; Holly Baselice; Alex Helkin; Jon Wisler

Background:

Sepsis is one of the leading causes of death for patients admitted to the hospital. While development of sepsis following surgical procedures has been shown to increase morbidity and mortality, the impact of preoperative sepsis on outcomes has not been clearly delineated. Therefore, this study aimed to evaluate the association between preoperative sepsis status and overall morbidity and mortality following emergency general surgery.

Hypothesis:

Patients undergoing emergency general surgery with pre-operative sepsis will experience worsened short and long-term outcomes compared to non-septic patients

Methods:

We conducted a retrospective review of patients admitted through the emergency department who underwent emergency general surgery within 6 hours of presentation (n=483) at a single large-volume academic center. Patients were grouped based on whether they presented with sepsis (n=100) or not (n=383) using Sepsis III criteria. Baseline demographic and clinical characteristics were compared between groups. Primary outcome measures included in-hospital and 90-day mortality, discharge disposition, and overall post-operative complication rate. A p value <0.05 was considered statistically significant.

Results:

Baseline age, sex, racial distribution, and insurance status were similar between septic and non-septic groups. Patients who presented with sepsis were less likely to be employed compared to the non-septic cohort (12.1% vs 22.7%, p = 0.01) and more likely to be transferred from an extended care facility (62.5% vs 46.0%, p = 0.006). Septic patients were more likely to undergo surgery within 1 hour of presentation (64.7% vs 47.0%, p = 0.004) compared to the control cohort. Compared to non-septic patients, those with sepsis demonstrated higher overall complication rate (67.0% vs 33.9%, p <0.0001), in-house mortality (25% vs 6.5%, p<0.001), were less likely to be discharged home (17.33% vs 48.8%, p <0.001), and demonstrated a 68% increase in the risk of 90-day mortality.

Conclusions:

This study demonstrates that preoperative sepsis confers substantial risk to patients requiring emergency general surgery in terms of mortality and functional status. This risk appears to extend beyond discharge, suggestive of post-sepsis chronic illness. In our data, the majority of septic patients originated from an extended care facility, which may indicate that frailty plays a role in these outcomes. Further studies are required to determine how to mitigate this risk in the perioperative setting, as well as improve post-discharge care or follow-up to address the higher long-term mortality.