• Michael J Nabozny, Amber E Barnato, Paul J Rathouz, Jeffrey A Havlena, Amy J Kind, William J Ehlenbach, Qianqian Zhao, Katie Ronk, Maureen A Smith, Caprice C Greenberg, and Margaret L Schwarze.
• 1Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI. 2Department of Medicine, University of Pittsburgh, Pittsburgh, PA. 3Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI. 4Department of Medicine, University of Wisconsin, Madison, WI. 5VA Geriatrics Research Education and Clinical Center, William S. Middleton VA Hospital, Madison, WI. 6Department of Population Health Sciences, University of Wisconsin, Madison, WI. 7Department of Family Medicine, University of Wisconsin, Madison, WI. 8Department of Medical History and Bioethics, University of Wisconsin, Madison, WI.
• Crit. Care Med. 2016 Jun 1; 44 (6): 1091-7.

ObjectivesSurgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation.DesignRetrospective cohort study.SettingHospitals throughout the United States.PatientsFive percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009.InterventionsNone.Measurements And Main ResultsWe identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized.ConclusionsOlder patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk of mortality and high burdens of treatment. This difficult trajectory should be considered in surgical decision making and has important implications for surgeons, intensivists, and patients.

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