Eliminating respiratory intensive care unit stay after gastric bypass surgery

BACKGROUND: The bariatric patient is among the most complex in general surgery. Morbid obesity and associated comorbidities create a higher likelihood for intensive care unit (ICU) services. Obstructive sleep apnea (OSA) is often unrecognized and may contribute to increased respiratory events and ICU admissions. Identifying and treating occult OSA may decrease the need for ICU utilization. This retrospective review attempts to evaluate this hypothesis. PATIENTS AND METHODS: From 1998 to 2005, 890 bariatric procedures were performed at our center: 858 primary gastric bypasses and 32 revisions. Before 2004, patients were evaluated selectively for OSA; after 2004, all patients have had a sleep study. RESULTS: A postoperative ICU stay was required in 43 patients (5%). From 1998 to 2003, when OSA evaluation was not mandatory, a respiratory-related ICU stay was necessary in 11 of 572 patients. When OSA evaluation was mandated in all patients (2004-2005), there was one respiratory related ICU stay (1/318). CONCLUSION: Multiple variables lead to a decrease in ICU stay. Our study suggests that recognizing and treating occult sleep apnea may further improve this quality metric. In our center, mandatory OSA screening and aggressive preoperative treatment have eliminated the need for respiratory-related ICU stays after bariatric surgery.     

Predictors and outcomes of extended intensive care unit length of stay in patients undergoing coronary artery bypass graft surgery

OBJECTIVE: To assess risk predictors of increased intensive care unit (ICU) length of stay in patients undergoing isolated coronary artery bypass surgery (CABG) and assess outcomes associated with increased ICU length of stay. METHODS: We conducted a nested case-control study from a 9-year hospitalization cohort with prospective data collection (N = 9869). Cases were CABG patients with ICU greater than or equal to 168 hours (N = 236) and controls were CABG patients with an ICU stay of less than 168 hours (N = 708). We examined 15 risk factors and 11 outcomes. RESULTS: Nine risk factors proved significant in predicting an increased ICU length of stay. Cases were more likely to be older, with an increased pump time, and a lower body surface area. Cases tended to be female, with COPD, hypertension, and undergoing an urgent surgical procedure. Controls tended to have hypercholesterolemia and abnormal left ventricular hypertrophy. There was no significant difference between the cases and controls for the remaining six risk factors. Five of the nine significant predictors correlated with four predictors: age, urgent surgical procedure, pump time, and chronic obstructive pulmonary disorder (COPD). Using logistic regression analysis, we found that patients undergoing CABG had an increased ICU length of stay if they were older than 70 years (OR 2.59, 95% CI 1.86 to 3.62), with longer pump time (OR 2.45, 95% CI 1.75 to 3.44), had COPD (OR 2.04, 95% CI 1.36 to 3.05), and had an urgent surgical procedure (OR 1.59, 95% CI 1.12 to 2.26). Patients with an extended ICU length of stay were also found to experience 11 additional negative outcomes. CONCLUSION: In patients undergoing CABG surgery an increased age, increased pump time, COPD, and urgent surgical procedure significantly increased the risk of an increased ICU length of stay. Patients with an increased ICU length of stay also experienced more negative outcomes.     

Preoperative prediction of prolonged stay in the intensive care unit for coronary bypass surgery.

OBJECTIVES: To construct a predictive model for a prolonged stay in the intensive care unit (ICU) for coronary artery bypass graft surgery (CABG). METHODS: Eight hundred and eighty-eight patients undergoing CABG were studied by univariate and multivariate analysis. Prolonged stay in the ICU was defined as >/=3 days stay. Stepwise selective procedure (P/=0.40 was used as cut-off point for the prognostic test. The specificity of this test for prolonged stay in the ICU was 99%; sensitivity 9%; positive predictive value 60%; and negative predictive value 89%. CONCLUSIONS: The results show that individual patients presented for CABG, can be stratified according to their risk for prolonged stay >/=3 days in the ICU.     

Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A

BACKGROUND: Operative mortality after acute aortic dissection type A is still high, and prolonged stay at the intensive care unit is common. Little has been documented about factors influencing the intensive care unit length of stay. The aim of this study was to determine such variables. METHODS: During a 10-year period, 67 patients (47 male, 20 female) were operated on for acute aortic dissection type A. In 42 patients (63%), an ascending aortic replacement was performed, 23 patients (34%) underwent a Bentall procedure, and 2 patients (3%) received a valve-sparing David type of operation. In 14 of these cases (20%), an additional partial or total arch replacement was performed. RESULTS: Hospital mortality was 9 of 67 (14%). Median postoperative intensive care unit length of stay was 5 days (range, 1 to 72 days). Intensive care unit stay was in univariate analysis significantly influenced by the following factors: age (p = 0.008), body mass index (p = 0.039), cardiopulmonary bypass time (p = 0.018), aortic cross-clamp time (p = 0.031), postoperative low cardiac output syndrome (p < 0.001), and postoperative lactate levels (p = 0.01). By multivariate analysis, age (p = 0.012), cardiopulmonary bypass time (p = 0.037), and the presence of a postoperative low cardiac output syndrome (p < 0.001) significantly influenced intensive care unit stay. CONCLUSIONS: Stay in the intensive care unit after operation for acute aortic dissection type A seems to be determined by age, cardiopulmonary bypass time, and the postoperative presence of a low cardiac output syndrome.     

Predictors of prolonged intensive care unit stay in patients undergoing coronary surgery

Background

We aimed to investigate the factors affecting the length of intensive care unit (ICU) stay in patients undergoing isolated on-pump coronary artery bypass (CABG). We also aimed to evaluate effective factors on morbidity, mortality, and survival among patients with prolonged ICU stay.

Methods

Between January 2002 and December 2009, a total of 1,657 patients underwent isolated on-pump CABG in our clinic. Prolonged ICU stay (>2 days) was present in 532 patient (32.1 %).

Results

Diabetes (OR 1.49, P?=?0.006), hypertension (OR 1.37, P?=?0.029), chronic obstructive pulmonary disease (OR 9.06, P?P?P?P?=?0.023), prolonged inotropic support (OR 40.40, P?P?=?0.022), postoperative renal insufficiency (OR 4.50, P?=?0.004), postoperative atrial fibrillation (OR 8.00, P?3 units) (OR 3.23, P?=?0.007) were the independent predictive factors of prolonged ICU stay (>2 days). Postoperative mortality rate was 7 % (n?=?37) and 2.3 % (n?=?26) in patients with length of ICU stay >2 days and length of ICU stay ≤2 days (P?2 days (P?Conclusions Postoperative mortality was higher in patients with prolonged ICU stay. Mean follow-up was shorter in patients with prolonged ICU stay.     

冠状动脉旁路移植术后ICU监护时间延长的危险因素

目的 分析冠状动脉旁路移植术后ICU监护时间延长的危险因素.方法 1997年至2009年间单纯冠状动脉旁路移植术病人1318例,按ICU监护时间分2组,ICU监护时间≤72 h l113例,ICU监护时间＞72 h 205例.对两组病人术前多项指标进行单因素和多因素分析.结果 病人平均年龄(67.4±9.4)岁,男996例(75.6%),女322例(24.4%),两组病人的ICU监护时间分别为(40.1±22.5)h和(122.6±48.7)h,院内死亡分别占13.7%和1.2%.单因素分析显示,2组病人体外循环手术的比例、体外循环时间和阻断时间、远端吻合口数、术后升压药应用、呼吸机辅助时间和院内死亡方面差异有统计学意义.年龄、心功能(NYHA分级)Ⅲ～Ⅳ级,术前左室射血分数(LVEF)＜0.40、术前肾功能不全、脑血管和(或)周围血管病、慢性阻塞性肺疾病、近期心肌梗死、介入治疗病史、左主干和三支病变是ICU监护时间延长的危险因素.多因素分析显示,年龄、心功能(NYHA分级)Ⅲ～Ⅳ级的比例、LVEF、术前肾功能不全、慢性阻塞性肺疾病、近期心肌梗死、PCI病史和三支病变是ICU监护时间延长的危险因素.结论 LVEF＜0.40、近期心肌梗死、术前肾功能不全和慢性阻塞性肺疾病是术后ICU监护时问延长的主要高危因素.

Abstract：

Objective To describe the preoperative factors of prolonged intensive care unit length of stay after coronary artery bypass grafting. Methods From 1997 to 2009, 1318 patients underwent isolated CABG in our hospital. Retrospective analysis was performed on these cases. Univariate and multivariate analyses for preoperative risk factors were performed. Prolonged length of ICU stay was defined as initial admission to ICU exceeding 72 h. Results The mean age of patients ( 322women and 996 men) was (67.4±9.4) years. Of 1318 patients undergoing isolated CABG from 1997 to 2009, 205 experienced prolonged length of ICU stay. The length of ICU stay was (40.1 ± 22.5 ) hours and ( 122.6 ± 48.7 ) hours separately.Overall in-hospital mortality was higher among these 205 patients ( 13.7% vs. 1.2%, P ＜0.05 ). The overall mortality was 3.1%. In univariate analyses, there were statistically significant differences with respect to the percentage of CPB, total bypass time, cross-clamp time, number of distal anastomoses, use of pressor agent, use of intro-aortic balloon pump,time of ventilation and hospital mortality. The significant risk factors were age, NYHA class Ⅲ/Ⅳ, left ventricular ejection fraction(LVEF) ＜0.40, renal failure, cerebrovascular and/or peripheral vascular disease, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, left main stenosi, three-vessels disease. The variables entered into the multivariate logistic regression were age, NYHA class Ⅲ/Ⅳ, LVEF ＜0.40, renal failure, chronic obstructive pulmonary disease, recent acute myocardial infarction, prior percutaneous coronary intervention, three-vessels disease. According to the outcome of multivariate logistic regression, we can conclude the model of probability forecast and create a new variable named Pre. The area under ROC curve of the new variable Pre was larger than other variables. Conclusion The main risk factors of prolonged ICU length of stay were LVEF ＜ 0.40, recent acute myocardial infarction, renal failure and chronic obstructive pulmorary disease. The AUC of variable Pre was higher than other' s , which indicated that new variable Pre combining each variable was more valuable than single variable with respect to prediction. A predicted probability of 0. 754 was used as cut-off point for the prognostic test.     

Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting

Objective  

Patients who have prolonged stay in intensive care unit (ICU) are associated with adverse outcomes. Such patients have cost implications and can lead to shortage of ICU beds. We aimed to develop a preoperative risk prediction tool for prolonged ICU stay following coronary artery surgery (CABG).     

Predicted clinical factors associated with the intensive care unit length of stay after total cavopulmonary connection

Objectives

A longer length of stay (LOS) in the intensive care unit (ICU) after the total cavopulmonary connection (TCPC) is thought to be a predictive sign of late Fontan failure. This study was performed to determine the clinical risk factors for ICU LOS.

Survival and functional outcome after prolonged intensive care unit stay

OBJECTIVE: To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA: The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS: All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS: For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996). CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.     

Factors influencing length of intensive care unit stay following a bidirectional cavopulmonary shunt

 Open in a separate windowOBJECTIVESThe goal of this study was to identify the risk factors for prolonged length of stay (LOS) in the intensive care unit (ICU) after a bidirectional cavopulmonary shunt (BCPS) procedure and its impact on the number of deaths.METHODSIn total, 556 patients who underwent BCPS between January 1998 and December 2019 were included in the study.RESULTSEighteen patients died while in the ICU, and 35 died after discharge from the ICU. Reduced ventricular function was significantly associated with death during the ICU stay (P = 0.002). In patients who were discharged alive from the ICU, LOS in the ICU [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.02–1.06; P < 0.001] and a dominant right ventricle (HR 2.41, 95% CI 1.03–6.63; P = 0.04) were independent risk factors for death. Receiver operating characteristic analysis identified a cut-off value for length of ICU stay of 19 days. Mean pulmonary artery pressure (HR 1.03, 95% CI 1.01–1.05; P = 0.04) was a significant risk factor for a prolonged ICU stay.CONCLUSIONSProlonged LOS in the ICU with a cut-off value of 19 days after BCPS was a significant risk factor for mortality. High pulmonary artery pressure at BCPS was a significant risk factor for a prolonged ICU stay.     

Perturbations in laboratory values after coronary artery bypass graft surgery with cardiopulmonary bypass

OBJECTIVE: The purpose of this study was to describe the sequential changes in commonly obtained laboratory values after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: The authors examined laboratory data from 375 patients who underwent uncomplicated CABG with CPB in a multicenter clinical trial of a medication for postoperative pain. Data were obtained preoperatively, at the time of postoperative extubation, and at 4 subsequent intervals ending 14 days after extubation. Data obtained before study drug administration are reported for all patients; thereafter, only data from placebo patients without perioperative complications (n=123) are reported. RESULTS: Mean postoperative coagulation values remained within their reference ranges at the time of extubation. However, platelet counts increased to a peak value well above the reference range by the end of the study. Postoperative white blood cell counts rose above the reference range, mainly because of increased neutrophils. Serum chemistries were also altered; most patients showed a persistent postoperative hyperglycemia. Creatine kinase levels rose to nearly 4 times the upper limit of the reference range in the early postoperative period. Lactate dehydrogenase, serum aspartate aminotransferase, and alanine aminotransferase levels also increased above the reference range. Total protein and albumin values were below the reference range throughout the postoperative period. CONCLUSIONS: Laboratory values for hematology, blood coagulation, and serum chemistry change substantially after uncomplicated CABG with CPB. Recognition of these changes will facilitate the conduct of clinical research and may prevent inappropriate treatment based on abnormal laboratory findings that have no clinical significance.     

EuroSCORE predicts intensive care unit stay and costs of open heart surgery

Background

This study aimed to determine whether the preoperative risk stratification model EuroSCORE predicts the different components of resource utilization in open heart surgery.

Methods

Data for all adult patients undergoing heart surgery at the University Hospital of Lund, Sweden, between 1999 and 2002 were prospectively collected. Costs were calculated for the surgery and intensive care and ward stay for each patient (excluding transplant cases and patients who died intraoperatively). Regression analysis was applied to evaluate the correlation between EuroSCORE and costs. The predictive accuracy for prolonged postoperative intensive care unit (ICU) stay was assessed by the Hosmer-Lemeshow goodness-of-fit test. The discriminatory power was evaluated by calculating the areas under receiver operating characteristics curves.

Results

The study included 3,404 patients. The mean cost for the surgery was $7,300, in the ICU $3,746, and in the ward $3,500. Total cost was significantly correlated with EuroSCORE, with a correlation coefficient of 0.47 (p < 0.0001); the correlation coefficient was 0.31 for the surgery cost, 0.46 for the ICU cost, and 0.11 for the ward cost. The Hosmer-Lemeshow p value for EuroSCORE prediction of more than 2 days' stay in the ICU was 0.40, indicating good accuracy. The area under the receiver operating characteristics curve was 0.78. The probability of an ICU stay exceeding 2 days was more than 50% at a EuroSCORE of 14 or more.

Conclusions

In this single-institution study, the additive EuroSCORE algorithm could be used to predict ICU cost and also an ICU stay of more than 2 days after open heart surgery.