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Open Access

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

Sonia Anne Butterworth, Irena Zivkovic, Sandra Kim and Kourosh Afshar
CAN J SURG March 17, 2023 66 (2) E123-E131; DOI: https://doi.org/10.1503/cjs.015421
Sonia Anne Butterworth
From the Division of Pediatric Surgery, University of British Columbia, Vancouver, BC (Butterworth); BC Children’s Hospital, Vancouver, BC (Butterworth); the Faculty of Medicine, University of British Columbia, Vancouver, BC (Zivkovic); the Department of Urology, Dalhousie University, Halifax, NS; and the Department of Urology, University of British Columbia, BC Children’s Hospital, Vancouver, BC (Afshar)
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Irena Zivkovic
From the Division of Pediatric Surgery, University of British Columbia, Vancouver, BC (Butterworth); BC Children’s Hospital, Vancouver, BC (Butterworth); the Faculty of Medicine, University of British Columbia, Vancouver, BC (Zivkovic); the Department of Urology, Dalhousie University, Halifax, NS; and the Department of Urology, University of British Columbia, BC Children’s Hospital, Vancouver, BC (Afshar)
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Sandra Kim
From the Division of Pediatric Surgery, University of British Columbia, Vancouver, BC (Butterworth); BC Children’s Hospital, Vancouver, BC (Butterworth); the Faculty of Medicine, University of British Columbia, Vancouver, BC (Zivkovic); the Department of Urology, Dalhousie University, Halifax, NS; and the Department of Urology, University of British Columbia, BC Children’s Hospital, Vancouver, BC (Afshar)
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Kourosh Afshar
From the Division of Pediatric Surgery, University of British Columbia, Vancouver, BC (Butterworth); BC Children’s Hospital, Vancouver, BC (Butterworth); the Faculty of Medicine, University of British Columbia, Vancouver, BC (Zivkovic); the Department of Urology, Dalhousie University, Halifax, NS; and the Department of Urology, University of British Columbia, BC Children’s Hospital, Vancouver, BC (Afshar)
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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.AgeDiagnosisProcedureTime from booking to operating room, hTime from booking to incision, hActive bleedingShockIncreased intracranial pressureTime from operating room to death, d*
    12.5 yrMisplaced gastrostomy tubeLaparotomy, gastrostomy revision1.732.20NoNoNo> 730
    2†1.7 yrBurnBurn débridement1.472.22NoYesNo4
    30.2 moIntestinal ischemiaLaparotomy, intestinal resection1.051.77NoYesNo20
    48.5 yrIntracranial hemorrhageCraniotomy1.031.92YesNoYes39
    50 dRuptured liver tumourLaparotomy, temporary abdominal closure1.431.87YesYesNo7
    60.7 moNecrotizing enterocolitisLaparotomy2.172.30NoYesNo61
    74 moIntestinal perforationLaparotomy, stoma formation1.031.90NoYesNo643
    80.2 moCardiac tamponadeRe-exploration of chest, clot evacuation4.144.88NoYesNo10
    93.9 yrBrain tumourCraniotomy, tumour biopsy24.00§24.00§NoNoYes594
    1014.0 yrIntracranial hemorrhageCraniotomy, hematoma evacuation2.301.77YesYesYes6
    113.6 yrImmunodeficiencyIncision and drainage joints1.333.00NoNoNo45
    120.1 moMalrotationLaparotomy, intestinal resection1.422.10NoYesNo1
    135 moAirway obstructionRigid bronchoscopy1.051.28NoNoNo19
    145.0 yrBrain tumourVentriculoperitoneal shunt1.402.00NoNoYes133
    155.3 yrTraumatic brain injuryCraniotomy, hematoma evacuation1.082.00YesYesYes> 30
    160.3 moNecrotizing enterocolitisLaparotomy2.583.25NoYesNo27
    1 moIntestinal perforationLaparotomy3.624.43YesYesNo6
    17‡1 moIntestinal perforationLaparotomy1.231.95NoYesNo282
    2 moIntestinal perforationLaparotomy, intestinal resection, temporary abdominal closure1.602.52NoYesNo253
    9 moUpper gastrointestinal bleedUpper gastrointestinal gastroscopy, VAC change1.471.80YesYesNo44
    9 moRetroperitoneal bleedUpper gastrointestinal gastroscopy, variceal sclerotherapy, VAC change1.421.72YesYesNo43
    1810 moAbdominal compartment syndromeLaparotomy, intestinal resection1.501.92NoYesNo> 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.

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Canadian Journal of Surgery: 66 (2)
CAN J SURG
Vol. 66, Issue 2
31 Mar 2023
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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
CAN J SURG Mar 2023, 66 (2) E123-E131; DOI: 10.1503/cjs.015421

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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
CAN J SURG Mar 2023, 66 (2) E123-E131; DOI: 10.1503/cjs.015421
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