Effect of Metabolic Syndrome on Peri-Operative Outcomes Following Liver Surgery: A National Surgical Quality Improvement Project (NSQIP) Analysis

274

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS ventions, and infections for patients undergoing elective colorectal and bariatric surgery at 38 participating hospitals between 4th quarter of 2005 and 4th quarter of 2010. Results: Of the 11,633 patients (55.4615.3 yrs; 65.7% women) with a serum glucose either on the day of surgery, postoperative (POD) 1, or POD 2, 29.1% of patients were hyperglycemic. After controlling patient and clinical factors, those with hyperglycemia had a significantly increased risk of infection (OR 2.0; 95% CI 1.63-2.44), reoperative interventions (OR 1.8; 95% CI 1.412.3), anastomotic failure (OR 2.43; 95% CI 1.38-4.28), and mortality (OR 2.71; 95% CI 1.72-4.28). Those with hyperglycemia on both PODs postoperatively had the highest risk of infection (OR 3.1; 95% CI 1.725.59), and we observed increasing risk of reoperative interventions and infections with increasing glucose levels. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR 1.01; 95% CI 0.72-1.42), reoperative interventions (OR 1.29; 95% CI 0.89-1.89), or deaths (OR 1.21; 95% CI 0.61-2.42). However, 26% of patients with hyperglycemia on the day of surgery did not receive insulin. Conclusions: Perioperative hyperglycemia was associated with and adverse outcomes in patients with and without diabetes, but patients receiving insulin were not at greater risk than those with normal blood sugars. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are worthwhile QI targets. 32.5. Effect of Metabolic Syndrome on Peri-Operative Outcomes Following Liver Surgery: A National Surgical Quality Improvement Project (NSQIP) Analysis. N. H. Bhayani,2 W. Frederick,3 R. D. Schulick,1 C. L. Wolfgang,1 K. Hirose,1 B. Edil,1 M. A. Choti,1 T. M. Pawlik1; 1Johns Hopkins Hospital, Baltimore, MD; 2Legacy Good Samaritan Medical Center, Portland, OR; 3Howard University College of Medicine, Washington, DC

32.4. Importance of Perioperative Glycemic Control in General Surgery: A Report from the Surgical Care and Outcomes Assessment Program. S. Kwon,1 R. E. Thompson,1 P. Dellinger,1 T. Rogers,2 D. Flum1; 1University of Washington/Harborview Medical Center, Seattle, WA; 2 Foundation for Health Care Quality, Seattle, WA Introduction: There is limited evidence on the impact of perioperative hyperglycemia and insulin administration in patients undergoing general surgical procedureas on adverse outcomes, in patients with or without known diabetes. Methods: The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative using clinical data from over 55 hospitals. We evaluated the relationship of perioperative hyperglycemia (> 180 mg/dL) and insulin administration on mortality, operative inter-

Introduction: The problem of obesity has risen to epidemic levels in the United States. A subset of patients (pts) with obesity will have metabolic syndrome (MetS), defined as a constellation of clinical features including hypertension, elevated fasting glucose and high body mass index (BMI). the impact of MetS on outcomes following liver resection remains ill defined. We sought to examine the impact of MetS on the risk of morbidity and mortality among a large cohort of pts who underwent hepatic resection. Methods: All pts included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent hepatic resection between January 2005 and December 2008 were identified. Data on clinical characteristics, co-morbidities, operative details, as well as post-operative complications and mortality were collected and analyzed. Patients with BMI > 30 kg/m2 who also had hypertension and diabetes were defined as having MetS; the impact of MetS on morbidity and mortality was then assessed. Results: 3,973 pts who underwent a liver resection were identified. Half of pts were male (n¼1962, 49%) with a mean age of 58 yrs (range, 17-89). Overall mean BMI was 28 kg/m2; 2.5% (n¼98) pts were underweight (BMI < 18.5 kg/m2), 32% (n ¼ 1289) had a normal BMI (18.5-24.9 kg/ m2), 33% (n ¼ 1327) were overweight (25.0-29.9 kg/m2), and 31.7% (n¼1259) were obese (>30 kg/m2). of the 1259 pts who were obese, 256 (20.3%) also had both diabetes and hypertension and therefore were defined as having MetS. the mean BMI in the non-MetS group was 27.5 kg/m2 vs 35.3 kg/m2 in the MetS group (p<0.0001). Pts with MetS were less likely to have had a major hepatectomy ( hemi-hepatectomy, 36% vs. 43%; p¼0.01) but had a higher mean number of red blood cell transfusions (1.6 vs. 1; p¼0.02). Pts with MetS were more likely to have HCC (n¼75, 29%) vs non-MetS pts (n¼596, 16%) (p<0.001). the incidence of post-operative complications following hepatectomy was 23.1% (n ¼ 919). Pts with MetS had a higher risk for re-intubation (OR ¼ 1.9; p¼0.02), ventilator dependence for >48 hrs (OR¼2.0; p¼0.003), myocardial infarction (OR¼5.5; p¼0.01) and superficial surgical site infections (OR¼1.7; p¼0.01) vs. non-MetS pts. Overall, the post-operative mortality was 3%. MetS was associated with an increased risk of post-operative death (OR¼2.7; p¼0.001). Conclusions: The incidence of MetS in a large,

ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS nationally-representative cohort of pts undergoing hepatic resection was 6.4%. The presence of MetS was associated with a higher risk of peri-operative complications. In addition, pts with MetS had nearly a three-fold increase risk of death following hepatic resection.

275

porting therapy on or before postoperative day 14 are more likely to decline to operate than negotiate with such a patient.

TABLE Bivariate Analysis and Multivariate Logistic Regression of Surgeon Characteristics Associated with Negotiating for Postoperative Life Supporting Therapy

Characteristic

32.6. Do Surgeons Expect Patients to Buy-in to Postoperative Life Support Preoperatively? A National Survey of Surgeons Who Routinely Perform High Risk Operations. M. L. Schwarze,1 A. J. Redmann,2 G. C. Alexander,3 K. J. Brasel4; 1University of Wisconsin Department of Surgery, Madison, WI; 2University of Wisconsin School of Medicine and Public Health, Madison, WI; 3University of Chicago, Department of Medicine, Chicago, IL; 4Medical College of Wisconsin, Milwaukee, WI Introduction: ‘‘Surgical Buy-In’’ describes the process of surgeons negotiating or contracting with patients preoperatively for their participation in life supporting therapy postoperatively. the objective of this study is to assess whether the practice of buy-in is generalizable to a large sample of surgeons who routinely perform high risk operations. Methods: We designed a survey to determine the prevalence of surgical buy-in, the consequences of buy-in regarding withdrawal of postoperative life supporting therapy and surgeon characteristics associated with this practice. We surveyed 2100 randomly selected vascular, cardiothoracic and neurosurgeons via US mail. We used bivariate and multivariate analysis to identify surgeon characteristics associated with a) negotiating for time or creating an informal contract with the patient describing agreed upon limitations of life support and b) declining to operate on patients with a specific request to limit life support postoperatively. Results: The adjusted response rate was 56%. Of surgeons faced with a patient at moderate risk for prolonged mechanical ventilation or dialysis who had a preoperative request to limit postoperative life supporting therapy 62% would create an informal contract with the patient describing agreed upon limitations of aggressive therapy and 72% of surgeons would negotiate for a time period after which life supporting therapy could be discontinued. 60% might decline to operate on such a patient. Surgeons who favored negotiating for time were more likely to be female (84 vs. 71%, p ¼ 0.04) and reported fewer years of experience (77 vs. 66%, p ¼ 0.02). Surgeons who were willing to withdraw life support on postoperative day 14 (86% of respondents) were twice as likely to negotiate or contract preoperatively about life-supporting therapy (OR: 2.0, 95%CI: 1.3-3.0 and OR: 2.1, 95%CI: 1.4-3.2 respectively) and almost half as likely to decline to operate (OR: 0.6, 95%CI: 0.4-0.9) than surgeons who would rarely withdraw life support on postoperative day 14. Conclusions: A majority of surgeons will negotiate or contract with patients preoperatively about postoperative life supporting therapies if the patient has a specific request to limit these treatments. Surgeons who believe that it is rarely acceptable to withdraw life sup-

Gender Male Female Years of experience 0 – 10 11- 20 21 – 30 >30 Believe it is acceptable to withdraw LST POD #14 Never, rarely Sometimes, always

N

Would negotiate for time after which life supporting therapy could be discontinued Bivariate (%) P-value

832 50

71 84

196 211 232 212

77 75 67 66

127 760

57 64

0.04

0.02

<0.0001

OR (95% CI) Ref 1.6 (0.7 – 3.4)

Ref 1.6 (1.03 – 2.5) 1.4 ( 0.9 – 2.2) 0.97 (0.7 – 1.5)

Ref 2.0 (1.3 – 3.0)

32.7. Assessment of the Implementation of a Surgical Preoperative Checklist. C. E. Senter,1,2,3,5 R. B. Hawkins,1,2,3,5 S. M. Levy,1,2,3,5 J. Y. Zhao,1,2,3,5 K. A. Doody,1,2,3,5 K. P. Lally,1,2,3,5 L. S. Kao,1,2,4,5 K. Tsao1,2,3,5; 1University of Texas Medical School at Houston, Houston, TX; 2Children’s Memorial Hermann Hospital, Houston, TX; 3Department of Pediatric Surgery, Houston, Texas; 4Department of General Surgery, Houston, Texas; 5Center for Surgical Trials and Evidence Based Practice, Houston, Texas Introduction: Peri-operative checklists are mandated by many hospitals based on the reduction in morbidity and mortality seen with utilization of the World Health Organization’s (WHO) ‘‘Surgical Safety Checklist.’’ Although an adapted peri-operative checklist was implemented within our hospital system without formal system-wide training, compliance with the checklist is reported to be 100%. We hypothesize that compliance does not measure fidelity of implementation, in that all items on the checklist are not performed as intended. Methods: Over a 10 week period, a prospective study was performed evaluating the completion of the 12 pre-incision components of the surgical checklist. Pediatric surgical operations, occurring in the operating room or in neonatal and pediatric intensive care units, were randomly selected for direct observation. Emergent cases were excluded. The evaluated checkpoints include essential parties present, team members identified, patient name/procedure verified, incision site confirmed, team member concerns addressed, administration of appropriate antibiotics (if applicable), essential imaging displayed (if applicable), anticipated case length stated, anticipated risk of blood loss stated, and sterility indicator confirmed. Essential parties