Futility Thresholds for Emergency General Surgery in the Post-Cardiac Intensive Care Unit

Gastrointestinal complications requiring emergency general surgery (EGS) after cardiac surgery are associated with high morbidity and mortality. Identifying predictors of 30-d mortality and intuitive preoperative laboratory-based futility thresholds may enhance risk stratification and clinical decision-making.

We conducted a single-center retrospective cohort study of adults aged 18-90 y who underwent cardiac surgery between 2013 and 2023. Patients requiring EGS intervention for gastrointestinal complications during their index cardiac surgery hospitalization were included. Exclusion criteria were intraoperative EGS consultations and consults without surgical intervention. Preoperative laboratory-based futility thresholds and independent predictors of 30-d mortality were identified using multivariable logistic regression.

Ninety-five patients met inclusion criteria; 30-d mortality was 51%. Ischemic bowel was the most common diagnosis (56%). Nonsurvivors had higher rates of obesity (body mass index ≥ 30: 42% versus 17%, P = 0.008), elevated Sequential Organ Failure Assessment (SOFA) scores (median [interquartile range]: 13 [11-14] versus 10 [7-11], P < 0.001), and end-stage renal disease (60% versus 19%, P < 0.001). They also had higher lactate (7.5 versus 3.4 mmol/L, P < 0.001) and lower platelet counts (83 versus 134 × 10³/μL, P < 0.001). Laboratory thresholds associated with 100% 30-d mortality included platelet count < 95 × 10³/μL, white blood cell count < 4.3 × 10³/μL, lactate > 3.4 mmol/L, and total bilirubin > 3.9 mg/dL. Independent predictors of mortality were SOFA ≥ 11.5 (adjusted odds ratios [aOR] 3.2, P = 0.04), body mass index ≥ 30 (aOR 4.0, P = 0.04), and platelets <100 × 10³/μL (aOR 5.9, P = 0.02).

Post-cardiac surgery patients involving EGS intervention have high 30-d mortality. Elevated SOFA scores, obesity, and thrombocytopenia are critical predictors, offering opportunities for improved risk stratification and targeted management strategies.