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The 30-day Impact of Intraoperative Adverse Events: What Happens In The OR Does Not Stay In The OR!
Jordan D. Bohnen, MD, MBA1; Michael N. Mavros, MD2; Elie P. Ramly, MD3; Myriam M. Martinez Aguilar, MD1; Thomas Peponis, MD1; Yuchiao Chang, PhD1; Jarone Lee, MD, MPH1,4; D. Dante Yeh, MD1; Marc de Moya, MD1; David R. King, MD1; Kathryn Butler, MD1; George C. Velmahos, MD, PhD1; Haytham M.A. Kaafarani, MD, MPH1,4
1Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA 2Department of Surgery, MedStar Washington Hospital Center, Washington, DC, 3Department of Surgery, Oregon Health & Science University, Portland, OR 4Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA

Background:
The clinical sequelae of intraoperative adverse events (iAEs) remain largely unknown. We sought to study the independent impact of iAEs on 30-day postoperative outcomes in abdominal surgery. Methods: The 2007-2012 institutional ACS-NSQIP and administrative databases for abdominal surgeries were matched then screened for iAEs using the ICD-9-CM-based Patient Safety Indicator “Accidental Puncture/Laceration”. A review of flagged charts was performed to confirm occurrence of iAEs. Univariate then multivariable logistic regression models were constructed to assess the independent impact of iAEs on 30-day mortality and morbidity, controlling for preoperative/intraoperative variables (e.g. age; co-morbidities; ASA; wound classification), procedure type (e.g. laparoscopic vs. open; intestinal, foregut, hepatopancreaticobiliary vs. abdominal wall procedure) and complexity (e.g. adhesions; relative value units [RVUs]).

Results:
9288 cases were included; 183 had iAEs. Most injuries were addressed intraoperatively (92%) with 31% requiring tissue/organ resection and/or significant impact on/incompletion of the procedure; 8% were initially missed and required re-operation. In multivariable analyses, iAEs were independently associated with increased 30-day mortality [OR=3.19, 95% CI:1.52–6.71,p=0.002] and morbidity [OR=2.68(1.89–3.81),p<0.001], including increased risk of deep/organ-space surgical site infection [OR=1.94(1.20–3.14),p=0.007], sepsis [OR=2.14(1.32-3.47),p=0.002], pneumonia [OR=2.18(1.11–4.26),p=0.023], failure to wean off the ventilator>48 hours [OR=3.88(2.17–6.95),p<0.001], and prolonged postoperative LOS (?7 days) [OR=1.85(1.27–2.70),p=0.001] (Figure 1).

Conclusions:
iAEs, even when recognized and repaired intraoperatively, were independently associated with increased postoperative mortality, LOS, and a wide range of postoperative morbidities.





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