Major morbidity and mortality associated with delays to emergent surgery in children: a risk-adjusted analysis

Sonia Anne Butterworth; Irena Zivkovic; Sandra Kim; Kourosh Afshar

doi:10.1503/cjs.015421

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Fig. 1
Distribution of cases by age.
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Fig. 2
Distribution of cases by surgical service. ANES = anesthesiology; CVS = cardiac surgery; DDS = dentistry; ENT = otolaryngology; GAST = gastroenterology; GENL = pediatric surgery; NEUR = neurosurgery; OBGY = obstetrics and gynecology; ONC = oncology; OPTH = ophthalmology; ORTH = orthopedic surgery; PLAS = plastic surgery; UROL = urology.
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Fig. 3
Outcome based on mortality risk and delay to operating room. *Two patients had 2 class 1 operations, and 1 patient had 5 class 1 operations. They were categorized as having a delay of more than 1 hour if any of their operations were delayed.

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Table 1

Pediatric patients with delayed class 1 surgery who died

Patient no.	Age	Diagnosis	Procedure	Time from booking to operating room, h	Time from booking to incision, h	Active bleeding	Shock	Increased intracranial pressure	Time from operating room to death, d^*
1	2.5 yr	Misplaced gastrostomy tube	Laparotomy, gastrostomy revision	1.73	2.20	No	No	No	> 730
2^†	1.7 yr	Burn	Burn débridement	1.47	2.22	No	Yes	No	4
3	0.2 mo	Intestinal ischemia	Laparotomy, intestinal resection	1.05	1.77	No	Yes	No	20
4	8.5 yr	Intracranial hemorrhage	Craniotomy	1.03	1.92	Yes	No	Yes	39
5	0 d	Ruptured liver tumour	Laparotomy, temporary abdominal closure	1.43	1.87	Yes	Yes	No	7
6	0.7 mo	Necrotizing enterocolitis	Laparotomy	2.17	2.30	No	Yes	No	61
7	4 mo	Intestinal perforation	Laparotomy, stoma formation	1.03	1.90	No	Yes	No	643
8	0.2 mo	Cardiac tamponade	Re-exploration of chest, clot evacuation	4.14	4.88	No	Yes	No	10
9	3.9 yr	Brain tumour	Craniotomy, tumour biopsy	24.00^§	24.00^§	No	No	Yes	594
10	14.0 yr	Intracranial hemorrhage	Craniotomy, hematoma evacuation	2.30	1.77	Yes	Yes	Yes	6
11	3.6 yr	Immunodeficiency	Incision and drainage joints	1.33	3.00	No	No	No	45
12	0.1 mo	Malrotation	Laparotomy, intestinal resection	1.42	2.10	No	Yes	No	1
13	5 mo	Airway obstruction	Rigid bronchoscopy	1.05	1.28	No	No	No	19
14	5.0 yr	Brain tumour	Ventriculoperitoneal shunt	1.40	2.00	No	No	Yes	133
15	5.3 yr	Traumatic brain injury	Craniotomy, hematoma evacuation	1.08	2.00	Yes	Yes	Yes	> 30
16	0.3 mo	Necrotizing enterocolitis	Laparotomy	2.58	3.25	No	Yes	No	27
16	1 mo	Intestinal perforation	Laparotomy	3.62	4.43	Yes	Yes	No	6
17^‡	1 mo	Intestinal perforation	Laparotomy	1.23	1.95	No	Yes	No	282
	2 mo	Intestinal perforation	Laparotomy, intestinal resection, temporary abdominal closure	1.60	2.52	No	Yes	No	253
	9 mo	Upper gastrointestinal bleed	Upper gastrointestinal gastroscopy, VAC change	1.47	1.80	Yes	Yes	No	44
	9 mo	Retroperitoneal bleed	Upper gastrointestinal gastroscopy, variceal sclerotherapy, VAC change	1.42	1.72	Yes	Yes	No	43
18	10 mo	Abdominal compartment syndrome	Laparotomy, intestinal resection	1.50	1.92	No	Yes	No	> 311

VAC = vacuum-assisted closure.
↵* If the date of death was not recorded, the date of the last documented encounter was used.
↵† Patient had second class 1 operation, with no delay to the operating room, 2 days after first class 1 operation (with delay).
↵‡ Patient had third class 1 operation, with no delay to the operating room, 6 days after second class 1 operation (with delay).
↵§ Patient arrived at operating room more than 24 hours from booking, and time was entered as 24 hours. From chart review, it appeared that the patient’s status had changed from initial booking and resulted in delay.