An evaluation of the charlson co-morbidity score for predicting sepsis after elective major surgery
Peter A. Hampshire, Arpan Guha, Ann Strong, Dawn Parsons, Patricia Rowan
Charlson score, predictors, sepsis
Citation Information :
Hampshire PA, Guha A, Strong A, Parsons D, Rowan P. An evaluation of the charlson co-morbidity score for predicting sepsis after elective major surgery. Indian J Crit Care Med 2011; 15 (1):30-36.
Background and Aims: Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care. Materials and Methods: We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery. Results: Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016). Conclusions: Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.
Veltkamp SC, Kemmeren JM, van der Graaf Y, Edlinger M, van der Werken C. Prediction of serious complications in patients admitted to a surgical ward. Br J Surg 2002;89:94-102.
Madbouly KM, Senagore AJ, Remzi FH, Delaney CP, Waters J, Fazio VW. Perioperative blood transfusions increase infectious complications after ileoanal pouch procedures (IPAA). Int J Colorectal Dis 2006;21:807-13.
Vamvakas EC, Carven JH, Hibberd PL. Blood transfusion and infection after colorectal cancer surgery. Transfusion 1996;36:1000-8.
Torchia MG, Danzinger RG. Perioperative blood transfusion and albumin administration are independent risk factors for the development of postoperative infections after colorectal surgery. Can J Surg 2000;43:212-6.
Cullen DJ, Apolone G, Greenfield S, Guadagnoli E, Cleary P. ASA Physical Status and age predict morbidity after three surgical procedures. Ann Surg 1994;220:3-9.
Behrman SW, Zarzaur BL. Intra-abdominal sepsis following pancreatic resection: Incidence, risk factors, diagnosis, microbiology, management, and outcome. Am Surg 2008;74:572-9.
Wichmann MW, Inthorn D, Andress HJ, Schildberg FW. Incidence and mortality of severe sepsis in surgical intensive care patients: The influence of patient gender on disease process and outcome. Intensive Care Med 2000;26:167-72.
Mokart D, Leone M, Sannini A, Brun JP, Tison A, Delpero JR, et al. Predictive perioperative factors for developing severe sepsis after major surgery. Br J Anaesth 2005;95:776-81.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;40:373-83.
Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister DG, Shah JP. Factors associated with complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg 1999;103:403-11.
Ouellette JR, Small DG, Termuhlen PM. Evaluation of charlson-age comorbidity index as predictor of morbidity and mortality in patients with colorectal carcinoma. J Gastrointest Surg 2004;8:1061-7.
Nuttall M, van der Meulen J, Emberton M. Charlson scores based on ICD-10 administrative data were valid in assessing comorbidity in patients undergoing urological cancer surgery. J Clin Epidemiol 2006;59:265-73.
D′Agata EM, Mount DB, Thayer V, Schaffner W. Hospital-acquired infections among chronic dialysis patients. Am J Kidney Dis 2000;35:1083-8.
Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery risk factors and outcomes. J Bone Joint Surg 2006;88:1705-12.
Bader MS. Staphyloccocus aureus bacteraemia in older adults: Predictors of 7-day mortality and infection with a methicillin-resistant strain. Infect Control Hosp Epidemiol 2006;27:1219-25.
Zavascki AP, Barth AL, Fernandes JF, Moro AL, Gonçalves AL, Goldani LZ. Reappraisal of Pseudomonas aeruginosa hospital-acquired pneumonia mortality in the era of metallo-beta-lactamase-mediated multidrug resistance: A prospective observational study. Crit Care 2006;10:R114.
NHS Connecting for Health, Great Britain: Department of Health, Health and Social Care Information Centre. OPCS Classification of Interventions and Procedures, Version 4.3. London, UK: The Stationery Office; 2006.
Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee: American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-55.
Ahlers O, Nachtigall I, Lenze J, Goldmann A, Schulte E, Höhne C, et al. Intraoperative thoracic epidural anaesthesia attenuates stress-induced immunosuppression in patients undergoing major abdominal surgery. Br J Anaesth 2008;101:781-7.
Yokoyama M, Itano Y, Katayama H, Morimatsu H, Takeda Y, Takahashi T, et al. The effects of continuous epidural anesthesia and analgesia on stress response and immune function in patients undergoing radical esophagectomy. Anesth Analg 2005;101:1521-7.
Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: A systematic update of the evidence. Anesth Analg 2007;104:689-702.
Pittet D, Rangel-Frausto S, Li N, Tarara D, Costigan M, Rempe L, et al. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock: Incidence, morbidities and outcomes in surgical ICU patients. Intensive Care Med 1995;21:302-9.
Offner PJ, Moore EE, Biffl WL. Male gender is a risk factor for major infections after surgery. Arch Surg 1999;134:935-40.
Esper AM, Moss M, Lewis CA, Nisbet R, Mannino DM, Martin GS. The role of infection and comorbidity: Factors that influence disparities in sepsis. Crit Care Med 2006;34:2576-82.
Leone M, Honstettre A, Lepidi H, Capo C, Bayard F, Raoult D, et al. Effect of sex on Coxiella burnetii infection: Protective role of 17beta-estradiol. J Infect Dis 2004;189:339-45.
Fariñas-Alvarez C, Fariñas MC, Fernández-Mazarrasa C, Llorca J, Casanova D, Delgado-Rodríguez M. Analysis of risk factors for nosocomial sepsis in surgical patients. Br J Surg 2000;87:1076-81.
Rotstein C, Ferguson R, Cummings KM, Piedmonte MR, Lucey J, Banish A. Determinants of clean surgical wound infections for breast procedures at an oncology center. Infect Control Hosp Epidemiol 1992;13:207-14.
Ferraz EM, Bacelar TS, Aguiar JL, Ferraz AA, Pagnossin G, Batista JE. Wound infection rates in clean surgery: A potentially misleading risk classification. Infect Control Hosp Epidemiol 1992;13:457-62.
Haller G, Myles PS, Wolfe R, Weeks AM, Stoelwinder J, McNeil J. Validity of unplanned admissions to an intensive care as a measure of patient safety in surgical patients. Anesthesiol 2005;103:1121-9.
Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL. Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med 2006;34:2517-29.
Miller NH, Benefield E, Hasting L, Carry P, Pan Z, Erickson MA. Evaluation of high-risk patients undergoing spinal surgery: A matched case series. J Pediatr Orthop 2010;30:496-502.
Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay: A randomised, controlled trial. Crit Care 2005;9:R687-93.
Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, et al. Reducing the risk of major elective surgery: Randomised controlled trial of preoperative optimization of oxygen delivery. BMJ 1999;318;1099-103.
Bennett ED. Advances in protocolising management of high risk surgical patients. Crit Care 2006;10:124.
Bellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 2004;32:916-21.