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.     

Retrospective study on the need of intensive care unit admission after major head and neck surgery

Background : The present article aims to study the pattern and need of Intensive Care Unit admission after major head and neck operations. Methods : A retrospective study was undertaken of the hospital records of patients who underwent major head and neck operations during the period from February 1997 to February 2000 at the Division of Head and Neck Surgery, Department of Surgery, the Chinese University of Hong Kong. Results : A total of 268 consecutive elective major operations were carried out over the 3 year period. The patients’ age ranged from 14 to 82 years with a mean of 55 years. The male to female ratio was 4:1. Forty‐seven patients underwent an operation with a combination of major resection, neck dissection, flap reconstruction and tracheostomy (‘flaps group’). Two hundred and twenty‐one patients had major head and neck operations without the need of flap reconstruction (‘non‐flaps group’). Three (6.3%) out of 47 patients (flaps group) were admitted to intensive care unit (ICU) immediately after the operation. Only one patient (2.2%) out of the remaining 44 patients was admitted for emergency treatment 3 weeks post operation. All four patients recovered uneventfully. In the non‐flaps group of 221 patients, there were 12 (5.4%) planned admissions and 2 (0.96%) unplanned admissions to ICU. In the group of planned admissions, one out of the 12 patients died. The other two patients who were not planned for ICU admission died of basal meningitis that was disease‐related rather than related to the intensity of postoperative care. The overall admission rate to ICU was 18 (6.7%) out of 268 patients. The overall mortality was 1.1% (one planned, two unplanned). Conclusion : The present study showed that it is safe and cost‐effective to discharge the majority of patients after major head and neck operations back to a specialist ward for nursing care.     

Complications related to peri-operative transoesophageal echocardiography – a one-year prospective national audit by the Association of Cardiothoracic Anaesthesia and Critical Care

Previous studies on the safety of peri-operative transoesophageal echocardiography seem to suggest a low rate of associated morbidity and mortality. That said, there has been a paucity of prospective multicentre studies in this important area of clinical practice. We carried out a one-year prospective study in 2017, co-ordinated by the Association of Cardiothoracic Anaesthesia and Critical Care, to determine the rate and severity of complications associated with peri-operative transoesophageal echocardiography in anaesthetised cardiology and cardiac surgical patients. With the help of clinicians from 28 centres across the UK and Ireland, we recorded the total number of examinations conducted in anaesthetised patients during the study period. All major complications at each centre were prospectively reported and recorded. Of the 22,314 examinations, there were 17 patients diagnosed with a major complication which caused either palatal injury or gastro-oesophageal disruption. This corresponds to an incidence of 0.08% (95%CI 0.05–0.13%) or approximately 1:1300 examinations. There were seven deaths reported during the study period which were directly attributed to these complications, corresponding to an incidence of 0.03% (95%CI 0.01–0.07%) or approximately 1:3000. These figures are higher than previously reported and suggest a high probability of death following the development of a complication (~40%). Most complications occurred in patients without known risk factors for transoesophageal echocardiography associated gastro-oesophageal injury. We suggest clinicians and departments review their procedural guidelines, especially in relation to probe insertion techniques, together with the information communicated to patients when the risks and benefits of such examinations are discussed.     

A score to estimate 30-day mortality after intensive care admission after cardiac surgery

Objective

Several risk-scoring systems have been developed to predict surgical mortality and complications in cardiac surgical patients, but none of the current systems include factors related to the intraoperative period. The purpose of this study was to develop a score that incorporates both preoperative and intraoperative factors so that it could be used for patients admitted to a cardiac surgical intensive care unit (ICU) immediately after surgery.

Relationship between intra- and postoperative oxygen transport and prolonged intensive care after cardiac surgery: a prospective study

Background: Prolonged intensive care is a rare but serious complication of cardiac surgery. It is required in less than 10% of operated patients but they use more than 30% of all the intensive care resources needed for cardiac surgery. The aim of our study was to describe the clinical course of the patients who need prolonged intensive care following cardiac surgery and to assess whether the intra- and postoperative oxygen transport variables are different in these patients as compared to patients with an uncomplicated course.
Methods: The study patients were divided into two groups according to the length of stay in the intensive care unit (ICU) after the operation: Group I, n=241, ICU-stay 5 days and Group II, n=20, ICU-stay≥5 days. Hemodynamic and oxygen transport data were prospectively obtained intra- and postoperatively and postoperative organ dysfunctions were recorded.
Results: The patients in the prolonged intensive care group tended to be older, have lower ejection fraction and longer cardiopulmonary bypass time. Postoperatively, this group had significantly increased oxygen extraction rate ( P =0.035, repeated measures for ANOVA). In the logistic regression analysis, in creased oxygen extraction (31% in Group I vs. 36% in Group II, P < 0.005) at 6 hours after arrival at the intensive care unit had the strongest independent association with the need for prolonged intensive care.
Conclusions: There was no significant relationship between the factors conventionally assumed to be risk factors for prolonged intensive care. Instead, an increase in whole body oygen extraction, reflecting a mismatch between the whole body oxygen demand and supply, was associated with the need for prolonged intensive care. Oxygen extraction increased to compensate for the reduced oxygen delivery, which in turn was caused by a lower arterial oxygen content.     

The Assessment of Risk in Cardiothoracic Intensive Care (ARCtIC): prediction of hospital mortality after admission to cardiothoracic critical care

The models used to predict outcome after adult general critical care may not be applicable to cardiothoracic critical care. Therefore, we analysed data from the Case Mix Programme to identify variables associated with hospital mortality after admission to cardiothoracic critical care units and to develop a risk‐prediction model. We derived predictive models for hospital mortality from variables measured in 17,002 patients within 24 h of admission to five cardiothoracic critical care units. The final model included 10 variables: creatinine; white blood count; mean arterial blood pressure; functional dependency; platelet count; arterial pH; age; Glasgow Coma Score; arterial lactate; and route of admission. We included additional interaction terms between creatinine, lactate, platelet count and cardiac surgery as the admitting diagnosis. We validated this model against 10,238 other admissions, for which the c index (95% CI) was 0.904 (0.89–0.92) and the Brier score was 0.055, while the slope and intercept of the calibration plot were 0.961 and ?0.183, respectively. The discrimination and calibration of our model suggest that it might be used to predict hospital mortality after admission to cardiothoracic critical care units.     

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37–3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7–17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2–10 [0–335]) days, and time to tracheal extubation was 20 (12–48 [0–2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2–7 [1–1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6–26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.     

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Background: I.V. patient-controlled analgesia (PCA) with morphine is oftenused for postoperative analgesia after thoracic surgery, butthe required doses may increase postoperative respiratory disorders.Adjunction of ketamine could reduce both doses and related respiratoryside-effects. Methods: The main objective of this prospective, randomized double-blindedstudy was to evaluate the influence of adding ketamine to PCAon morphine consumption and postoperative respiratory disorders.Consecutive patients undergoing lobectomy (n = 50) were randomlyassigned to receive, during the postoperative period, eitheri.v. morphine 1 mg ml^–1 or morphine with ketamine 1 mgml^–1 for each. Morphine consumption was evaluated by cumulativedoses every 12 h for the three postoperative days. Postoperativerespiratory disorders were assessed by spirometric evaluationand recording of nocturnal desaturation. Results: The adjunction of ketamine resulted in a significant reductionin cumulative morphine consumption as early as the 36th postoperativehour [43 (SD 18) vs 32 (14) mg, P = 0.03] with a similar visualanalogue scale. In the morphine group, the percentage of timewith desaturation < 90% was higher during the three nights[1.80 (0.21–6.37) vs 0.02 (0–0.13), P < 0.001;2.15 (0.35–8.65) vs 0.50 (0.01–1.30), P = 0.02;2.46 (0.57–5.51) vs 0.55 (0.21–1.00), P = 0.02].The decrease in forced expiratory volume in 1 s was less markedin the ketamine group at the first postoperative day [1.04 (0.68–1.22)litre vs 1.21 (1.10–0.70) litre, P = 0.039]. Conclusions: Adding small doses of ketamine to morphine in PCA devices decreasesthe morphine consumption and may improve respiratory disordersafter thoracic surgery.     

Evaluation of an enhanced recovery after lung surgery (ERALS) program in lung cancer lobectomy: An eight-year experience

IntroductionEnhanced recovery after lung surgery (ERALS) protocols have proven useful in reducing postoperative stay (POS) and postoperative complications (POC). We studied the performance of an ERALS program for lung cancer lobectomy in our institution, aiming to identify which factors are associated with a reduction of POC and POS.MethodsAnalytic retrospective observational study conducted in a tertiary care teaching hospital involving patients submitted to lobectomy for lung cancer and included in an ERALS program. Univariable and multivariable analysis were employed to identify factors associated with increased risk of POC and prolonged POS.ResultsA total 624 patients were enrolled in the ERALS program. The median POS was 4 days (range 1–63), with 2.9% of ICU postoperative admission. A videothoracoscopic approach was used in 66.6% of cases, and 174 patients (27.9%) experienced at least one POC. Perioperative mortality rate was 0.8% (5 cases). Mobilization to chair in the first 24 h after surgery was achieved in 82.5% of cases, with 46.5% of patients achieving ambulation in the first 24 h. Absence of mobilization to chair and preoperative FEV1% less than 60% predicted, were identified as independent risk factors for POC, while thoracotomy approach and the presence of POC predicted prolonged POS.ConclusionsWe observed a reduction in ICU admissions and POS contemporaneous with the use of an ERALS program in our institution. We demonstrated that early mobilization and videothoracoscopic approach are modifiable independent predictors of reduced POC and POS, respectively.