Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit.
- Resource Type
- Academic Journal
- Authors
- Javanmard-Emamghissi H; Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK. Hannah.javanmard-emamghissi@nottingham.ac.uk.; Doleman B; Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.; Lund JN; Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.; Frisby J; Department of Palliative Care Medicine, Royal Derby Hospital, Derby, UK.; Lockwood S; Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK.; Hare S; Department of Anaesthesia, Medway Maritime Hospital, Kent, UK.; Moug S; Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK.; Tierney G; Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK.
- Source
- Publisher: Springer-Verlag Italia Country of Publication: Italy NLM ID: 9613614 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1128-045X (Electronic) Linking ISSN: 11236337 NLM ISO Abbreviation: Tech Coloproctol Subsets: MEDLINE
- Subject
- Language
- English
Background: Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database.
Methods: A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori.
Results: Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85).
Conclusions: Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.
(© 2023. The Author(s).)