Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population- Based Retrospective Cohort Study

Transcription

1 P2054 Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population- Based Retrospective Cohort Study Chia-Lun Chou 1, Woan-Ruoh Lee 1,2, Chun-Chieh Yeh 3,4, Chun-Chuan Shih 5, Ta-Liang Chen 2,6,7, Chien-Chang Liao 2,6,7,8 1 Department of Dermatology, Shuan Ho Hospital, Taipei Medical University, Taipei, Taiwan 2 School of Medicine, Taipei Medical University, Taipei, Taiwan 3 Department of Surgery, China Medical University Hospital, Taichung, Taiwan 4 Department of Surgery, University of Illinois, Chicago, USA 5 School of Chinese Medicine for Post-Baccalaureate, I-Shou University, Kaohsiung, Taiwan 6 Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan 7 Health Policy Research Center, Taipei Medical University Hospital 8 School of Chinese Medicine, China Medical University, Taichung, Taiwan

2 Disclosure of commercial support None

3 Background and methods Background: This study evaluated the association between preoperative pressure ulcer and adverse events after major surgeries. Methods: Using reimbursement claims from Taiwan s National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of patients with preoperative pressure ulcer receiving major surgery in With propensity score matching procedure, surgical patients without pressure ulcer were selected for comparison. Eight major surgical postoperative complications and 30-day postoperative mortality were evaluated among patients with pressure ulcer of varying severity.

4 Results (I) Table 1 shows demographic characteris4cs of pa4ents with and without preopera4ve pressure ulcer who underwent major surgeries. Table 1. Characteristics of surgical patients with or without pressure ulcer* No PU (N=17391) PU (N=17391) n (%) n (%) P Age, years (2.3) 397 (2.3) (3.1) 541 (3.1) (5.1) 883 (5.1) (8.7) 1515 (8.7) (14.1) 2454 (14.1) (33.6) 5845 (33.6) (29.0) 5041 (29.0) (4.1) 715 (4.1) Sex 1.00 Female 7987 (45.9) 7987 (45.9) Male 9404 (54.1) 9404 (54.1) Low income 1100 (6.3) 1100 (6.3) 1.00 Urbanization 1.00 Low 5369 (30.9) 5369 (30.9) Moderate 4312 (24.8) 4312 (24.8) High 4326 (24.9) 4326 (24.9) Very high 3384 (19.5) 3384 (19.5) Operation in teaching hospital (90.7) (90.7) 1.00 Type of surgery 1.00 Skin 1854 (10.7) 1854 (10.7) Breast 49 (0.3) 49 (0.3) Musculoskeletal 7856 (45.2) 7856 (45.2) Respiratory 775 (4.5) 775 (4.5) Cardiovascular 927 (5.3) 927 (5.3) Digestive 2381 (13.7) 2381 (13.7) Kidney, ureter, bladder 1278 (7.4) 1278 (7.4) Delivery, CS, abortion 50 (0.3) 50 (0.3) Neurosurgery 1679 (9.7) 1679 (9.7) Eye 78 (0.5) 78 (0.5) Others 464 (2.7) 464 (2.7)

5 Results (I) Table 1. Characteristics of surgical patients with or without pressure ulcer* No PU PU (N=17391) (N=17391) n (%) n (%) P Type of anesthesia 1.00 General (69.5) (69.5) Epidural or spinal 5306 (30.5) 5306 (30.5) Coexisting medical conditions Hypertension 5924 (34.1) 5924 (34.1) 1.00 Mental disorders 5119 (29.4) 5119 (29.4) 1.00 Diabetes 4990 (28.7) 4990 (28.7) 1.00 COPD 3660 (21.1) 3660 (21.1) 1.00 Stroke 2856 (16.4) 2856 (16.4) 1.00 Hip fracture 2104 (12.1) 2104 (12.1) 1.00 Ischemic heart disease 1929 (11.1) 1929 (11.1) 1.00 Congestive heart failure 658 (3.8) 658 (3.8) 1.00 Renal dialysis 526 (3.0) 526 (3.0) 1.00 Spinal cord injury 340 (2.0) 340 (2.0) 1.00 Hyperlipidemia 307 (1.8) 307 (1.8) 1.00 Liver cirrhosis 269 (1.6) 269 (1.6) 1.00 Peripheral vascular disease 123 (0.7) 123 (0.7) 1.00 A<er propensity score matching, there were no significant differences in periopera4ve characteris4cs between surgical pa4ents with and without pressure ulcer, including sex, age, types of surgery and anesthesia, opera4on in a teaching hospital or not, low- income status, and coexis4ng medical condi4ons. CS, caesarian section; COPD, chronic obstructive pulmonary disease; PU, pressure ulcer. *Surgical patients with and without decubitus ulcer were matched with propensity score by age, sex, low income, urbanization, operation in teaching hospital, type of surgery, type of anesthesia and coexisting medical conditions.

6 Results (II) Table 2. Adverse events after surgeries in patients with preoperative pressure ulcer Postoperative complications No PU, % PU, % RR (95% CI)* Pneumonia ( ) Septicemia ( ) Stroke ( ) Urinary tract infection ( ) Acute renal failure ( ) Deep wound infection ( ) Acute myocardial infarction ( ) Postoperative bleeding ( ) Pulmonary embolism ( ) Any of the above ( ) 30-day in-hospital mortality ( ) ICU stay ( ) Prolonged length of hospital stay ( ) Increased medical expenditure ( ) CI, confidence interval; PU, pressure ulcer; ICU, intensive care unit; RR, rate ratio. *Adjusted for age, sex, low income, urbanization, operation in teaching hospital, types of anesthesia, types of surgery and coexisting diseases. Pa4ents with pressure ulcer showed higher risks of postopera4ve complica4ons, including pneumonia, sep4cemia, stroke, urinary tract infec4on, acute renal failure, and acute myocardial infarc4on. Preopera4ve pressure ulcer was associated with a significant increase in 30- day postopera4ve mortality, admission to ICU, prolonged length of hospital stay, and medical expenditures.

7 Results (III) Table 3. Risk of 30-day postoperative in-hospital mortality associated with preoperative characteristics of pressure ulcer Characteristics of pressure ulcer within 30-day postoperative mortality preoperative 24 months n DeathsMortality, % RR(95% CI)* Controls without pressure ulcer (reference) Patients with pressure ulcer Antibiotics total quantity, mg Low ( ) Moderate ( ) High ( ) Very high ( ) Medical expenditure of antibiotics Low ( ) Moderate ( ) High ( ) Types of antibiotics Without antibiotics ( ) With first-line antibiotics (stage 2) ( ) With second-line antibiotics (stage 2) ( ) Pressure ulcer with local infection No ( ) Yes (stage 2) ( ) Pressure ulcer with cellulitis No ( ) The significant 30- day postopera4ve mortality compared with surgical pa4ents without pressure ulcer was found in pa4ents who had pressure ulcer with high total quan4ty of an4bio4cs and high medical expenditure on an4bio4cs. Preopera4ve moderate- to- severe pressure ulcer was also associated with increased 30- day mortality a<er surgery. Yes (stage 2) ( )

8 Results (III) Table 3. Risk of 30-day postoperative in-hospital mortality associated with preoperative characteristics of pressure ulcer Characteristics of pressure ulcer within 30-day postoperative mortality preoperative 24 months n Deaths Mortality, % RR(95% CI)* Preoperative hospitalized care for PU No ( ) Yes (stage 2) ( ) Pressure ulcer with wound No ( ) Yes (stage 2) ( ) Pressure ulcer with debridement No ( ) Yes (stage 3) ( ) Pressure ulcer with change dressing No ( ) Yes (stage 2) ( ) Compared with surgical pa4ents without pressure ulcer, pa4ents with pressure ulcer were more likely to have significantly higher postopera4ve mortality with debridement, celluli4s, wound, and treatment by change dressing, hospitalized care, and an4bio4cs. Moderate-to-severe pressure ulcer No (stage=1) ( ) Yes (stage 2) ( ) CI, confidence interval; PU, pressure ulcer; RR, rate ratio. *Adjusted for age, sex, low income, urbanization, coexisting medical conditions, operation in teaching hospital, types of anesthesia and types of surgery. Antibiotics total quantity was categorized into low (non-antibiotics users and lowest quartile), moderate (second quartile), high (third quartile), and very high (highest quartile). Medical expenditure of antibiotics was categorized into low (non-antibiotics users and lowest quartile), moderate (second quartile), and high (third quartile and highest quartile) Based on the criteria of The National Pressure Ulcer Advisory Panel, the stage of pressure ulcer was categorised by clinical physicians in and previous investigations. Patients with pressure have at least one of characteristics, such as debridement, local infection, cellulitis, wound, change dressing, use of antibiotics, and hospitalized care.

9 Discussion (I) To our knowledge, this investigation is the first study investigating adverse events after surgery in patients with preoperative pressure ulcer. This nationwide population-based, propensity score-matched cohort study showed that patients with preoperative pressure ulcer had increased risk of postoperative 30-day in-hospital mortality and complications such as septicemia, pneumonia, stroke, urinary tract infection and acute renal failure. Patients with pressure ulcer receiving debridement, or having local infection, cellulitis or treatment with antibiotics had significantly higher 30-day postoperative mortality.

10 Discussion(II) To reduce the confounding errors, such as old age, types of surgeries and coexisting medical conditions, we adjusted these covariates using propensity score-matched procedure and then controlled these factors in the multivariate Poisson regression models. In the present study, preoperative pressure ulcer was associated with postoperative mortality in both sexes and all age groups, confirming the association between pressure ulcer and postoperative mortality.

11 Discussion (III) possible explanations First, the major predisposing factor of pressure ulcer is immobilization, which also impairs the ability to clear bronchial secretions, and can eventually result in atelectasis and hypostatic pneumonia. Second, pressure ulcer may cause several complications, including localized abscess, cellulitis, bacteremia, sepsis and osteomyelitis. Such infection can be life-threatening when complicated by bacteremia, sepsis, endocarditis and meningitis.

12 Discussion (III) possible explanations Third, chronic pressure ulcer features persistent chronic inflammation with leukocyte infiltration and release of proinflammatory cytokines. Repetitive pressure and relief also lead to cutaneous ischemia -reperfusion injury, causing infiltration of inflammatory cells, deleterious cellular reactions and tissue damage by reactive free oxygen radicals. These biochemical cascades in pressure ulcer lead to repetitive chronic inflammation, endothelial cell dysfunction and microvasculature system thrombosis that may contribute to stroke and ischemic renal injury. Finally, presence of pressure ulcers may indicate inadequate services, poor nutrition or insufficient family support for the patients. Regarding nutritional deficiency in particular, fewer scavengers to remove free oxygen radicals would result in reactive vasoconstriction and increased cell damage.

13 Conclusion This nationwide, propensity score-matched, retrospective cohort study is the first report investigating increased adverse events after surgery in patients with preoperative pressure ulcer. Because significant postoperative mortality was found in those with various severities of pressure ulcer, the study suggests the urgency of prevention, assessment and integrated care for this population.