Critical care after major surgery: a systematic review of risk factors for unplanned admission

Critical care admission may be necessary for surgical patients requiring organ support or invasive monitoring in the peri-operative period. Unplanned critical care admission poses a potential risk to patients and pressure on services. Existing guidelines base admission criteria on predicted risk of 30-day mortality; however, this may not provide the best predictor of which patients would benefit from this service, and how unplanned admission might be avoided. A systematic review of MEDLINE, Embase, CINAHL, Web of Science, the Cochrane database and the grey literature identified 44 studies assessing risk factors for unplanned critical care admission in adult populations undergoing non-cardiac, non-thoracic and non-neurological surgery. Comparative, quantitative analysis of the admission criteria was not feasible due to heterogeneity in study design. Age, anaemia, ASA physical status, body mass index, comorbidity burden, emergency surgery, high-risk surgery, male sex, obstructive sleep apnoea, increased blood loss and operative duration were all independent risk factors for unplanned critical care admission. Age, body mass index, comorbidity extent and emergency surgery were the most common independent risk factors identified in the USA, UK, Asia and Australia. These risk factors could be used in the development of a risk tool or decision tree for determining which patients might benefit from planned critical care admission. Future work should involve testing the sensitivity and specificity of these measures, either alone or in combination, to guide planned critical care admission, reduce patient deterioration and unplanned admissions.     

Multivariate analysis of factors associated with renal dysfunction in patients with obstructive jaundice

BACKGROUND: The aim was to evaluate the factors determining preoperative renal dysfunction in patients with obstructive jaundice. METHODS: In a prospective cross-sectional observational study, 63 patients, 27 with benign and 36 with malignant obstructive jaundice, were investigated at admission and compared with 25 healthy control subjects. Variables analysed included extracellular body water (ECW) compartment, plasma levels of aldosterone, renin, atrial natriuretic peptide, vasopressin, nitric oxide, endothelin (ET) 1 and prostaglandin E2 (PGE2), urinary nitric oxide and PGE2, serum albumin and renal function. RESULTS: The metabolic profile of obstructive jaundice was characterized by a depletion of the ECW (P = 0.004), and increased plasma levels of atrial natriuretic peptide (P < 0.001), ET-1 (P = 0.044), vasopressin (P = 0.017), aldosterone (P = 0.005) and renin (P = 0.001). Increased plasma (P < 0.001) and urinary (P = 0.001) PGE2 levels were also found. Fifty-four per cent of patients had a creatinine clearance of less than 70 ml/min. In multivariate analysis, serum bilirubin, renin, ET-1, PGE2, decreased urinary sodium excretion and age were identified as predictors of renal dysfunction. CONCLUSIONS: Renal dysfunction in patients with obstructive jaundice was associated with the degree of biliary obstruction, age of the patient and reduced urinary sodium excretion. These alterations were closely related to derangements in sodium- and water-regulating hormones.     

胸科手术后非计划二次插管的危险因素

目的分析和探讨胸科手术后患者接受非计划二次插管的危险因素。方法本研究为病例-对照研究。将2014—2018年北京协和医院所有胸科手术后因气道原因接受非计划二次插管的患者与对照组患者进行1∶4配对。采用单因素和多因素分析的方法评估非计划二次插管的危险因素及预后情况。结果 5年间共完成全麻下胸科手术7 711例,其中12例(0.16%)因气道原因接受了术后非计划二次插管。选择48例患者为对照组。Logistic多因素回归分析显示,年龄≥65岁(OR=22.81,95%CI 1.41～367.97,P=0.028)、麻醉时间每延长10 min(OR=1.24,95%CI 1.07～1.43,P=0.003)、纵隔手术(OR=79.16,95%CI 2.95～2122.85,P=0.009)和术前SpO_295%(OR=92.28,95%CI 1.17～7311.58,P=0.043)是造成胸科手术后非计划二次插管的独立危险因素。结论年龄≥65岁、麻醉时间延长、纵隔手术、术前SpO_295%为胸科手术的患者术后非计划二次插管的危险因素。     

肾移植患者非计划性再入院现状及影响因素调查分析

目的了解肾移植患者非计划性再入院现状及其影响因素,为针对性干预提供参考。方法对肾移植术后1年内的424例患者进行17项相关影响因素的调查分析。结果 85例于出院1年内非计划性再入院,占20.0%;Logistic回归分析显示并发症个数、估算肾小球滤过率(eGFR)及住院期间其他手术是肾移植患者非计划性再入院的危险因素(OR=2.098～2.968;P0.05,P0.01)。结论肾移植患者术后1年内非计划性再入院不容忽视;护理人员应对出院患者进行持续随访和动态评估,及时发现风险因素进行有效干预,同时要特别加强同期行其他手术、并发症较多及eGFR低患者的管理,以降低再入院风险。     

Bariatric surgery is associated with reduced admission for aortic dissection: a nationwide case-control analysis

BackgroundAortic dissection (AD) is an uncommon but life-threatening condition associated with high morbidity and mortality. Hypertension (HTN) and hyperlipidemia (HLD) are common modifiable risk factors.ObjectivesSince bariatric surgery is associated with remission of obesity-related co-morbidities, we hypothesize that surgical weight loss might be protective against this feared aortic pathology.SettingA cross-sectional analysis was performed using the National Inpatient Sample database from 2010 to 2015.MethodsThe treatment group included bariatric patients and the control group patients with obesity (body mass index [BMI] ≥ 35kg/m²) without previous bariatric surgery. Analyzed covariates included demographics, co-morbidities, aortic diseases, and AD. A multivariate logistic regression analysis (MLRA) was performed to assess the odds of admission for AD in both groups.ResultsA total of 2,300,845 patients were identified (2,004,804 controls and 296,041 cases). The mean (SEM) age was 54.4 (.05) versus 51.9 (.05) years, for the control and treatment groups, respectively (P < .0001). Bariatric patients posed a significantly lower prevalence of type 2 diabetes (T2D), HTN, HLD, aortic aneurysm, and bicuspid aortic valve (P < .0001) than control subjects. In the control group, 1411 individuals (.070%) had AD, whereas only 94 patients (.032%) in the bariatric surgery group had such diagnosis (P < .0001). The MLRA showed that non-bariatric obese patients had a significantly higher likelihood of suffering from AD (OR = 1.8 [95%CI 1.44–2.29] P < .0001). Considering different age groups, bariatric surgery was found to be less associated with admission for AD for individuals below and above 40 years of age (OR = 2.95 [95%CI 1.09–7.99] P = .0345) and (OR = 1.75 [95%CI 1.38–2.22] P < .0001), respectively.ConclusionsBariatric surgery could be a protective factor against aortic dissection and should be considered in patients with obesity and risk factors for this cardiovascular complication.     

胃癌根治术后非计划再次手术的原因和危险因素分析

目的通过对病例资料的回顾性研究分析胃癌根治术后非计划再次手术的原因和危险因素。方法回顾性分析2012年1月至2017年12月在南京大学医学院附属鼓楼医院行胃癌根治术(包括开腹和腹腔镜)的病人资料,纳入标准:(1)年龄18～80岁;(2)胃镜病理明确诊断胃癌;(3)接受D2胃癌根治术(包括开腹和腹腔镜手术)。排除标准:(1)胃癌术中行联合脏器切除术;(2)残胃癌行胃癌根治术。共统计胃癌手术病人3 213例,其中接受非计划再次手术病人37例。按照性别、年龄进行1∶2配对,以胃癌术后未接受再次手术的病人为对照组,开展回顾性配对研究,查找非计划再次手术的原因,同时分析导致发生非计划再次手术的危险因素。结果术后行非计划再次手术的中位时间为1d(0～9d),开腹术后31例,腹腔镜术后6例。手术原因包括:腹腔出血(23例,62.2%);吻合口出血(3例,8.1%);吻合口漏(3例,8.1%);切口裂开(2例);肠梗阻(2例);十二指肠残端漏(1例);急性胆囊炎(1例);脾梗死(1例);切口感染(1例)。单因素分析结果显示,非计划再次手术组与对照组的病人在术中出血量(P=0.014)、第一助手资格(P=0.042)方面差异有统计学意义,手术时间、主刀医生资格、手术开始时间、术中输血、手术方式、手术部位等方面差异无统计学意义。多因素Logistic回归分析显示:术中出血量≥200ml是非计划再次手术的独立危险因素(OR=1.827,95%CI:1.034,3.026,P=0.024)。结论腹腔出血是胃癌根治术后非计划再次手术的最常见原因,术中出血量≥200ml是非计划再次手术的独立危险因素。     

Bronchopleural fistula after lung cancer surgery. Multivariate analysis of risk factors

BACKGROUND: To elucidate retrospectively the risk factors for bronchopleural fistulae after lung cancer surgery. METHODS: The subjects were 1,177 patients with lung cancer who underwent surgery between 1983 and 1997. Twenty-two clinical factors were examined by logistic analysis. RESULTS: Bronchopleural fistulae were observed in 35 patients (32 males, 3 females) with a mean age of 64 years. Eighteen (51%) of 35 patients died of BPF-related complications. The significant risk factors obtained by univariate analysis were male gender, heavy smoking, current smoking, low level of %FVC, metastases to lymph nodes, squamous cell carcinoma, increased WBC, decreased albumin, advanced postsurgical stage, sleeve lobectomy, and resection of the right lower lobe or middle and lower lobe. The significant risk factors noted by multivariate analysis were heavy smoking (30 or more pack/years), current rather than past smoking, metastases to lymph nodes, decreased albumin (3.5 mg/dl or less), and resection of the right lower lobe or middle and lower lobe. CONCLUSIONS: The above risk factors must be taken into account before surgical techniques followed by adequate perioperative management are selected.     

Multivariable analysis of factors associated with hospital readmission after intestinal surgery

BACKGROUND: Readmission rates after major abdominal surgery have a significant impact on hospital costs and quality of care. Identification of risk factors for readmission may improve postoperative care and discharge plans. METHODS: One hundred fifty consecutive patients readmitted within 30 days of discharge after intestinal surgery (RD) were compared with matched nonreadmitted patients. Patient-related (demographic, comorbidity, medications), disease-related (diagnosis, type of surgery), and perioperative course variables were collected for logistic regression analysis. RESULTS: RD was associated with chronic obstructive pulmonary disease (odds ratio [OR] 7.12 and 95% confidence interval [CI] 1.4-37.6), worse functional capacity class (OR 2.02 and CI 1.15-3.56), previous anticoagulant therapy (OR 4.85 and CI 1.2-19.7), steroid treatment, and discharge to a facility other than home (OR 4.35 and CI 0.97-20.0, P = .055). In patients with intestinal perforation, RD rate was decreased (OR 0.3 and CI 0.1-0.9), but this was associated with a longer primary hospital stay (median 8 vs. 6 days, P = .12). RD causes included surgical site septic complications (33%), ileus and/or small-bowel obstruction (23%), medical complications (24%), and others (20%). CONCLUSIONS: Functional capacity, chronic obstructive pulmonary disease, previous anticoagulant therapy, perioperative steroids, and discharge destination are independent predictors of RD. Disease-related factors have minor impact on RD rates. Improving functional status before surgery, decreasing the adverse impact of steroids, and/or stratifying perioperative anticoagulant use may decrease unexpected readmissions in this patient population.     

影响腹腔镜下保留肾单位术后肾功能的多因素分析

目的 探讨影响腹腔镜下保留.肾单位手术术后肾功能的因素. 方法 前瞻性总结50例肾癌腹腔镜下保留肾单位手术患者临床资料.采用99 Tcm-二乙三胺五乙酸肾动态显像检测术前术后分肾肾小球滤过率(GFR)值的变化.采用相关和多元回归模型分析与术后.肾功能损害有关的因素,包括患者年龄、肿瘤大小、术前血肌酐值、术中肾血管阻断时间及术中出血量,确定影响术后肾功能的危险因素.随访其中20例,比较术前、术后1周及术后3个月 GFR值,明确肾脏热缺血安全时间;同时观察肾功能恢复情况. 结果 50例患者手术前后GFR平均值分别为(45.86土5.14)、(34.52+5.89)ml/min,术后减少约24%.多元回归分析显示肾血管阻断致肾脏热缺血时间长短是决定术后肾功能损害的独立危险因素.肾脏热缺血时间≤30 min和＞30 rain组,术前术后1周的GFR值分别为(45.38±6.19)和(38.54土5.18)、(46.11±4.62)和(32.51士6.26)ml/min,前者GFR值降低程度低于后者,差异有统计学意义(P＜0.01)}随访观察20例患者,肾脏热缺血时间≤30 min组术后3个月GFR值(44.38+5.59)ml/min,与术前相比,P＞0.05,差异无统计学意义;年龄＞70岁、肾脏热缺血时间＞30 min或肾脏热缺血时间＞60 rain的患者术后3个月GFR值恢复缓慢.结论影响腹腔镜下保留肾单位术后肾功能的关键因素为肾脏热缺血时间,肾脏热缺血时间≤30min者术后肾功能可以完全恢复;肾脏热缺血时间＞30 min且年龄＞70岁或肾脏热缺血时间＞60min者术后肾功能有一定程度的损害.     

Is day case surgery in urology associated with high admission rates?

The nature of the procedures and patients in urological day surgery may lead to high admission rates. A retrospective audit was performed over 8 years (1988 to 1996) to determine admission rates in a urological day surgical unit and examine reasons for and methods of decreasing admissions. The overall admission rate was 9.3%. Higher rates were associated with cystoscopic procedures, with 46% of admissions after bladder tumour cystosurveillance and a further 18% after urethroscopic surgery for urethral strictures. There was a surgical indication for admission in 72% of cases, with an anaesthetic indication in 17%. The study demonstrates that admission rates accompanying urological day surgery are higher than the 3% proposed by The Royal College of Surgeons of England. Achieving a rate of 3% may require restrictive patient selection that will deprive some patients the benefits associated with urological day surgical care.     

Factors independently associated with increased risk of pain development after ophthalmic surgery

BACKGROUND AND OBJECTIVE: Little has been documented about the development of pain after ophthalmic surgery. This study was designed to assess the incidence and severity of postoperative pain following ophthalmic surgery, and to identify key factors independently associated with development of such pain. METHODS: In a prospective, observational cohort study, 500 patients undergoing elective ophthalmic surgery were examined by assessing numerical analogue scales and analgesic requirements. RESULTS: Depending on anatomical location of surgery, operations could be classified into creating 'more severe' or 'less severe pain'. Patients undergoing posterior segment, corneal and muscle surgery exhibited the highest numerical analogue scale scores (risk ratio 4.5, 95% CI 3.01-6.79, P < 0.0001). Anterior segment surgery, which per se did not create much pain, resulted in significantly more pain when performed under general anaesthesia compared to regional anaesthesia (risk ratio 6.52, 95% CI 2.33-18.2, P < 0.0001). No other factors independently associated with an increased risk of developing serious postoperative pain could be identified. CONCLUSIONS: Patients undergoing certain ophthalmic operations, especially if performed under general anaesthesia, are more likely to experience serious postoperative pain.     

Embolic factors associated with cardiac surgery

Macro and microemboli can both cause significant neurologic dysfunction. The traditional belief in cardiac surgery was that the damage perpetrated by an embolus was caused by the occlusion of an arterial branch, resulting in an ischemic event and subsequent infarction. However, ongoing research has demonstrated that the mere passage of a deformable embolus (air, lipid, or semi-solid clot) will disrupt the endothelium as it is extruded through the vessel. A cascade of events follows endothelial irritation. In the closed environment of the brain, a disruption of the blood-brain barrier has been demonstrated after the passage of lipid microemboli. A significant breakdown of the blood-brain barrier causes marked brain swelling, increased intracranial hypertension, and a possible increase in the size of the lesions associated with larger occlusive emboli. Gaseous microemboli are also a well-documented endothelial irritant and can cause significant brain dysfunction. It is important to avoid delivering emboli of any size or composition to the cerebral vasculature in order to reduce the impact of cardiac surgery on the brain.     

Multivariate analysis of risk factors for surgical site infection after laparoscopic colorectal surgery

Background

Surgical site infection (SSI) and incisional hernia (IH) are among the most common complications after colorectal surgery. While many risk factors for these complications are unavoidable, evidence suggests that use of Pfannenstiel incisions for specimen extraction during laparoscopic procedures may reduce their incidence. The objectives of this study were to identify risk factors for extraction site SSI (primary objective) and IH (secondary objective) in patients undergoing laparoscopic colorectal surgery.

Methods

Patients who underwent laparoscopic colorectal resections at The Ohio State University Wexner Medical Center between January 2006 and October 2012 were included. In addition to reviewing medical records, data were gathered from patient questionnaires with a focus on two end points: extraction site SSI and IH. Univariate logistic regression analysis was performed to identify significant associations between the two end points and the following variables: age, gender, ASA (American Society of Anesthesiologists) score, cancer, inflammatory bowel disease (IBD), body mass index (BMI), diabetes, chronic obstructive pulmonary disease, use of immunosuppressant medications, chemotherapy, radiation therapy, smoking, surgical history, surgery duration, duration of follow-up, use of hand-assistance, and utilization of Pfannenstiel incisions for specimen extraction. Multivariate analysis was performed for significant variables.

Results

A total of 419 patients met the inclusion criteria. The incidence of SSI was 10.3 %. Higher BMI, presence of IBD, younger age, and hand-assisted procedures were associated with a significantly higher risk of SSI. Use of Pfannenstiel extraction sites was associated with lower infection rates; however, this association was not statistically significant. IBD, BMI, and hand-assistance were statistically significant on multivariate analysis. Odds ratios for SSI with IBD, hand-assistance and BMI (per unit increase) were 3.3, 2.2, and 1.06, respectively.

Conclusion

Alterations in surgical technique and specimen extraction site can reduce wound-related complications after laparoscopic colorectal resections. Remaining risk factors are largely nonmodifiable from a surgeon’s perspective.     

Postdischarge unplanned admission in ambulatory surgery—a prospective study

Background

Postdischarge recovery continues at home and some patients will need admission if complications occur.

Objective

To analyze the postdischarge unplanned admission rate in a hospital-based ambulatory surgery unit.

Method

Prospective non-comparative study. Patients admitted in the first 30 days postdischarge were included.Univariate analysis was performed to identify independent predictive factors for these admissions.

Results

The postdischarge unplanned admission rate was 1%. Urology, gynaecology and general surgery, patients 90 years or older and epidural anaesthesia were significant risk factors for postdischarge unplanned admission.

Conclusion

The postdischarge unplanned admission rate was very low.     

Hospital management and clinical factors associated with ophthalmic involvement in Toxic Epidermal Necrolysis

Background

Toxic Epidermal Necrolysis (TEN) is characterized by an exfoliative rash resembling widespread burns. It is often considered on the same spectrum of disease as Stevens Johnson Syndrome but is distinguished by epidermal detachment of >30% of total body surface area (TBSA). Ocular involvement of TEN may result in complications requiring intensive topical, systemic or operative treatment. This study aimed to identify the current hospital management of, and factors associated with, ophthalmic involvement in adult TEN patients.

Methods

All adult TEN patients admitted to the Victorian Adult Burns Service over an 12-year period were included. Retrospective data analyzed included patient demographics, site of TEN involvement, % TBSA, complications, duration of ocular follow up and visual outcomes.

Results

TEN patients with and without ocular involvement were compared. Cutaneous involvement of the head and neck was found to be significantly associated with ocular involvement of TEN. Age, TBSA involvement, presence of a prodrome, and presence of comorbidities were not found to be significantly associated with ocular involvement. Management of ophthalmic involvement of TEN varied between patients.

Conclusions

Clinicians should have a high index of suspicion for ocular involvement when exfoliation of the head and neck is present and should seek ophthalmological advice early in the course of disease.     

Paediatric day-case surgery: an audit of unplanned hospital admission Royal Hospital for Sick Children, Glasgow

Audit of unplanned hospital admission provides information to guide quality improvement measures and is a crude indicator of quality of care in ambulatory surgery. Our objectives were to re-audit factors relating to this outcome. Previous audit conducted in this unit revealed an unplanned admission rate of 3.7%. Data were collected between April 2000-March 2004. Of 13 592 day surgery patients, 238 (1.8%) unplanned admissions occurred. The admission rate displayed a falling trend and represented a significant improvement over the previous audit (p < 0.001). Unplanned admissions were most commonly caused by nausea/vomiting 23.5% (n = 56), postoperative bleeding 13.9% (n = 34), and unexpected extent/difficulty of procedure 11.8% (n = 28). Of all admissions, 18.5% (n = 44) were following orchidopexy, 16.4% (n = 39) following circumcision, and 12.6% (n = 30) following dental extraction. This audit shows that the unplanned admission rate is low and falling, and compares favourably with other units. Measures have been implemented targeting patients at high risk of admission.