Prolonged surgical intensive care. A useful allocation of medical resources

To determine factors related to outcome following prolonged stays in the surgical intensive care unit (ICU), we reviewed the charts of all 59 patients who required surgical ICU stays of one week or longer during 1982 (63 admissions). Overall ICU survival was 58.7% and varied inversely with acute illness severity, length of ICU stay, and hospital cost. The need for renal dialysis and prolonged mechanical ventilatory support were associated with bad outcomes. Age did not affect ICU survival. Follow-up survival was 33% of the original group or 56.8% of ICU survivors. Poor chronic health was associated with a high late mortality. The functional status of surviving patients was satisfactory, with 18 of 21 patients living independently. We conclude that there is significant survival following prolonged ICU therapy, and that, although identifiable factors related to outcome exist, none alone permit the discontinuation of therapy on an individual basis.     

What Happens After Discharge? An Analysis of Long‐Term Survival in Cardiac Surgical Patients Requiring Prolonged Intensive Care

Abstract Background: Cardiac surgical patients with postoperative complications frequently require prolonged intensive care yet survive to hospital discharge. Methods: From January 1, 2002 to December 31, 2007, 11,541 consecutive patients underwent cardiac operations at a single academic institution. Of these, 11,084 (95.9%) survived to hospital discharge and comprised the study sample. Patients were retrospectively categorized into four groups according to intensive care unit (ICU) length of stay (LOS): <3 days, three to seven days, 7 to 14 days, and >14 days. Survival at 12 months was determined using the Social Security Death Index. Kaplan–Meier (KM) survival curves and Cox proportional hazards regression modeling (hazard ratio, HR) were used to analyze group differences in survival. Results: One‐year survival among the four groups according to ICU LOS was: <3 days, 97.0% (8407/8666); three to seven days, 91.2% (1481/1625); 7 to 14 days, 87.9% (356/405); and >14 days, 68.3% (265/388) (p < 0.001). Using multivariable regression analysis, adjusted overall mortality was significantly greater in patients with ICU LOS of three to seven days (HR = 1.51), 7 to 14 days (HR = 1.40), and >14 days (HR = 1.90) compared to patients with ICU LOS <3 days. Mortality among patients who survived more than six months postsurgery was significantly greater in patients with ICU LOS of three to seven days (HR = 1.37), 7 to 14 days (HR = 1.34), and >14 days (HR = 1.63). Conclusions: Although cardiac surgery patients with major postoperative complications frequently survive to hospital discharge, survival after discharge is significantly reduced in patients requiring prolonged ICU care. Reduced survival in patients with a high risk of complications and anticipated long ICU stays should be considered when discussing surgical versus nonsurgical options. (J Card Surg 2012;27:13‐19)     

Can clinicians predict ICU length of stay following cardiac surgery?

Purpose

To determine whether a group of experienced clinicians can predict intensive care unit (ICU) length of stay (LOS) following cardiac surgery.

Methods

A cohort of 265 adult patients undergoing cardiacsurgery at St. Michael’s Hospital, Toronto, Ontario, between January 2, 1992, and June 26, 1992, were seen preoperatively by the clinicians participating in the study and ICU length of stay was predicted based on the clinicians’ preoperative assessment and/or information recorded in the patient’s chart.

Results

Five hundred and ten ICU length of stay predictions were obtained from a group of eight experienced clinicians (anaeslhetists/intensivists, cardiologists, nurses). The clinicians predicted the exact ICU length of stay (in days) correctly 51.2% of the time and were within ± 1 day 84.5% of the time. The clinicians correctly predicted short ICU stays (≤ 2 days) for 87.6% of the patients who had short ICU stays but only predicted long ICU stays (> 2 days) in 39.4% of the patients who had long ICU stays.

Conclusions

Experienced clinicians can predict preoperatively with a considerable degree of accuracy patients who will have short ICU lengths of stay following cardiac surgery. However, many patients who had long ICU stays were not correctly identified preoperatively. Unidentified preoperative risk factors or unanticipated intraoperative/postoperative events may be causing these patients to have longer than expected ICU stays.     

Long-term survival and resource use in critically ill cardiac surgery patients: a population-based study

Purpose

Most cardiac surgery patients recover well; a substantial minority become critically ill after surgery. The epidemiology of critical illness after cardiac surgery is poorly described. We measured the association of prolonged critical illness with long-term survival and resource use after cardiac surgery.

Methods

This was a historical population-based cohort study in Ontario, Canada (2002-2013), of adult cardiac surgery patients. Validated methods were used to measure postoperative intensive care unit (ICU) length of stay (LOS). We categorized patients into short (0-2 day), moderate (3-9 day), and long (10+ day) ICU LOS groups. The adjusted associations of ICU LOS with one-year survival (primary outcome) and costs, hospital readmissions, and institutional discharge were measured using multilevel, multivariable regression. Pre-specified sensitivity analyses were performed.

Results

We included 111,740 patients having their first cardiac surgery during the study period who survived ≥ ten postoperative days. Most patients had a short ICU LOS (75.9%); 20.9% and 3.3% had moderate or long ICU LOS, respectively. The short-stay one-year mortality rate was 2.1%. Longer ICU LOS was independently associated with decreased one-year survival (moderate LOS: hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.6 to 1.94; long LOS: HR, 8.66; 95% CI, 7.93 to 9.44). Sensitivity analyses supported the findings of the primary analysis. Secondary outcomes were independently associated with longer ICU LOS. Long ICU LOS patients occupied 30% of all ICU bed days, and 55% died or were discharged to an institution.

Conclusion

Prolonged ICU LOS after cardiac surgery is associated with decreased 1-year survival and increased healthcare resource use.

     

Long-term survival and quality of life in cardiac surgical patients with prolonged intensive care unit length of stay

BACKGROUND: Patients with prolonged intensive care unit (ICU) stays after cardiac operations are labor intensive and expensive. We sought to determine whether exhaustive ICU efforts result in survival or quality-of-life benefits and whether outcome could be predicted. METHODS: We retrospectively analyzed all adult cardiac surgical patients in 1998 for ICU stays more than 14 days. Data were analyzed to create multiple organ dysfunction scores (MODS, range 0 to 24) and hospital charges. Follow-up was conducted 1 and 2 years apart for survival and quality-of-life evaluation. RESULTS: Forty-nine patients remained in the ICU more than 14 days, comprising 3.8% of our patients but 28% of total ICU bed time. This population had a 28.5% hospital mortality, which was greater than those in the ICU less than 14 days (5.3%, p < 0.05). By 2 years, 22 of the 35 discharged patients were alive, 16 of whom had a normal quality of life. Patients alive at 2 years had lower MODS at day 14 than those who died (2.6 +/- 1.4 versus 5.5 +/- 3.8; p < 0.005) as well as lower hospital costs ($223,000 +/- $128,000 versus $306,000 +/- $128,000; p < 0.05). No patient with an MODS of at least 6 at day 14 survived. CONCLUSIONS: Patients remaining in the ICU for more than 14 days suffer a higher mortality at greater expense. A MODS at day 14 may help predict those who will not enjoy long-term survival and thus aid in the decision to terminate care.     

Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit

HYPOTHESIS: Catheter-related bloodstream infection (CRBSI) in critically ill surgical patients with prolonged intensive care unit (ICU) stays is associated with a significant increase in health care resource use. DESIGN: Prospective cohort study. SETTING: Surgical ICU at a large tertiary care center. PATIENTS: Critically ill surgical patients (N = 260) with projected surgical ICU length of stay greater than 3 days. INTERVENTIONS: Central venous catheters were cultured for clinical suspicion of infection. MAIN OUTCOME MEASURES: Increases in total hospital cost, ICU cost, hospital days, and ICU days attributable to CRBSI were estimated using multiple linear regression after adjusting for demographic factors and severity of illness (APACHE III [Apache Physiology and Chronic Health Evaluation III] score). RESULTS: The incidence of CRBSI per 1000 catheter-days was 3.6 episodes (95% confidence interval [CI], 2.1-5.8 episodes). Microbiologic isolates were Gram-positive bacteria in 75%, Gram-negative bacteria in 20%, and yeast in 5%. After adjusting for demographic factors and severity of disease, CRBSI was associated with an increase of $56 167 (95% CI, $11 523-$165 735; P =.001) (in 1998 dollars) in total hospital cost, an increase of $71 443 (95% CI, $11 960-$195 628; P<.001) in ICU cost, a 22-day increase in hospital length of stay, and a 20-day increase in ICU length of stay. CONCLUSIONS: For critically ill surgical patients, CRBSI is associated with a profound increase in resource use. Prevention, early diagnosis, and intervention for CRBSI might result in cost savings in this high-risk population.     

Outcome in patients with long-term treatment in a surgical intensive care unit

Background

This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment.

Patients and methods

The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48?h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value.

Results

In 2?years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4?days. Sixty-seven long-term patients were compared to 152 (69.4?%) patients treated between 2 and 20?days. Overall survival after 12?months was 50.2?% (110/219), while 65.8?% (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61?% for patients treated 2–4, 5–19 and ≥20?days at the ICU. Decreased survival of patients treated for 5–19 and ≥20?days were confirmed by logrank test (p?=?0.001).

Conclusions

Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5?days but similar survival as patients which stayed between 5 and 19?days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.     

终末期肝病模型评分较高的良性终末期肝病患者肝移植疗效评价

目的 探讨终末期肝病模型(MELD)评分较高的良性终末期肝病患者的肝移植疗效.方法 回顾分析80例良性终末期肝病肝移植患者的资料,根据MELD评分的不同将患者分成两组,MELD评分≥30分的23例为高MELD评分组,MELD评分＜30分的57例为低MELD评分组.分别比较两组患者手术时间、术中无肝期、术中血液制品输入量、术后重症监护病房(ICU)治疗时间和受者1年存活率,同时比较死亡患者和存活患者的临床资料,寻找导致术后死亡的危险因素.结果 高MELD评分组的手术时间、术中血液制品输入量、ICU治疗时间以及术后3个月内的死亡率明显高于低MELD评分组,差异有统计学意义(P＜0.05),而术中无肝期和患者1年存活率,两组间的差异无统计学意义(P＞0.05).死亡者和存活者相比较,MELD评分的差异无统计学意义(P＞0.05),而术前机械通气、血清钠水平、持续性肝性脑病(重型)等方面的差异有统计学意义(P＜0.05).结论 对于良性终末期肝病患者,单纯依靠MELD评分不足以准确判断患者肝移植术后的生存状态,高MELD评分者也可获得较好的肝移植结果,术前严重的低钠血症、重度肝性脑病以及机械通气是除MELD评分以外影响患者术后生存状况的危险因素.     

Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience

Background

Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients.

Multiple organ failure and outcome of critically ill patients with haematological malignancy

BACKGROUND: The number of failing organs systems in ICU patients with haematological malignancy is associated with outcome. The objective of this study was to assess short and long-term survival in these patients with special reference to multiple organ failure reflected by the SOFA (Sequential Organ Failure Assessment) score. METHODS: Retrospective chart review of haematological patients admitted to the 10-bed intensive care unit (ICU) of a tertiary level academic teaching hospital from 1994 to 1998. Of 31 admitted patients with the diagnosis of haematological malignancy, the charts of 30 were available for analysis. RESULTS: Univariate logistic regression analysis of factors previously shown to influence survival revealed that only admission SOFA score and untreated status of haematological disease were significantly associated with survival (P < 0.05). ICU, 3-month and one-year survival rates were 57% (17/30), 23% (7/30) and 20% (6/30), respectively. If maximal SOFA score during the ICU stay was included in a multivariate model comprising treatment status and effect, admission day SOFA and APACHE II scores, mechanical ventilation, renal replacement therapy and neutropenia, the maximal SOFA score became the only independent variable. All patients with an admission SOFA score exceeding 11 died in hospital. Leave-one-out method revealed that admission SOFA scores and the status of haematological disease (untreated or not) correctly classified 83% (25 of 30) of patients to survivors or non-survivors. CONCLUSIONS: Multiple organ failure assessed as SOFA score on admission and status of disease were associated with outcome in critically ill patients with haematological malignancy.     

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.     

Data linkage enables evaluation of long-term survival after intensive care

Outcomes of intensive care are important to the patient and for assessment of benefit. Short-term outcomes after critical illness are well described, but less is known about long-term outcomes. This study describes the use of data linkage, combining intensive care unit (ICU) clinical data with administrative morbidity and mortality data, to assess long-term outcomes after treatment in ICU. The hospital-based cohort study was conducted in a 22-bed general ICU in a metropolitan teaching hospital. All patient admissions admitted to ICU from 1 January 1987 to 31 December 2002 were included. The prospective ICU clinical database with patient demographics, ICU diagnoses, severity of illness, daily assessment of organ failures and common daily treatments used was linked using probabilistic methods to the state-wide hospital morbidity and mortality databases to describe long-term survival. There were 26,019 ICU admissions (22,980 patients) with 25,972 records (99.8%) linked to a hospitalization event that included the index ICU admission. Unadjusted survival was 84.7% at 1 year decreasing progressively to 50.7% at 15 years. Age, type of admission, severity of illness (measured by Acute Physiologic and Chronic Health Evaluation (APACHE) II and the presence of organ failure), ICU length of stay, comorbidity (Chronic Health Evaluation and Charlson comorbidity index) and ICU admission diagnosis, were all associated with survival at 1, 3, 5, 10, and 15 year follow-up (P<0.001 at all time points). Linkage of clinical and administrative data provides a feasible method for ascertaining long-term survival after critical illness. Age, admission severity of illness, diagnosis and comorbidity influenced long-term unadjusted survival.     

The Costs of Skull Base Surgery in the Pediatric Population

Objectives To determine the costs of endoscopic endonasal surgery (EES) for pediatric skull base lesions. Methods Retrospective chart review of pediatric patients (ages 1 month to 19 years) treated for skull base lesions with EES from 1999 to 2013. Demographic and operative data were recorded. The cost of care for the surgical day, intensive care unit (ICU), floor, and total overall cost of inpatient stay were acquired from the finance department. Results A total of 160 pediatric patients undergoing EES for skull base lesions were identified. Of these, 55 patients had complete financial data available. The average total inpatient and surgical costs of care were $34, 056 per patient. Angiofibromas were the most costly: $59,051 per patient. Fibro-osseous lesions had the lowest costs: $10,931 per patient. The average ICU stay was 1.8 days at $4,577 per ICU day. The average acute care stay was 3.4 days at $1,961 per day. Overall length of stay was 4.5 days. Three cerebrospinal fluid leaks (4%) and two cases of meningitis (3%) occurred. One tracheostomy was required (1.5%). Conclusions EES is a cost-effective model for removal of skull base lesions in the pediatric population. Costs of care vary according to pathology, staged surgeries, length of ICU stay, and need for second operations.     

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.     

Audit of intensive care unit admissions from the operating room

An audit of 265 intensive care unit (ICU) admissions from the operating room was performed for the year 1991. In a quality assurance exercise we identified 34 unanticipated ICU admissions (UIAs) by a retrospective peer review of the medical charts. Of these UIAs, 16 were deemed predictable and seven preventable. Five of the seven potentially preventable UIAs were judged to have had inappropriate intravenous fluid management. This has prompted changes in our education programme. In an assessment of our resource management, we evaluated prospectively collected data on the Apache II scores on the day of admission, the incidence of ICU-specific interventions, length of stay in ICU, and outcomes. ICU-specific interventions were not initially required in 36% of admissions and these patients had a low risk (1.1%) of eventually requiring ICU-specific interventions. In comparison with patients requiring ICU-specific interventions, they had lower Apache II scores (10.2 vs 13.1), shorter ICU stays (medians of one vs two days), lower ICU mortality (0 vs 8.2%), P < 0.05, but hospital mortality was not different (7.4 vs 15.3%). This audit has prompted re-organisation of our intensive care services, so that patients not requiring ICU-specific interventions will be managed in an intermediate care area with nurse.patient ratios of 1:3 or 4, in comparison with 1:1 or 2 ratios in the intensive care area.     

Outcome and cost of prolonged stay in the surgical intensive care unit

We retrospectively studied 50 surgical patients who required more than 14 days of care in the intensive care unit (ICU) in terms of the admission diagnosis, reason for extended stay, complications, cost, therapeutic intervention scores, mortality, and quality of life after discharge. The morbidity, mortality, and cost were extraordinary. Survival varied inversely with the therapeutic intervention scores. The ICU and one-year mortalities were 46.0% and 74.5%, respectively. The quality of life following discharge was generally poor. Increased mortality was associated with the following criteria: multiple-organ failure, age, sepsis, cancer, the combination of infection and failure of a major organ system, the requirement for a tracheostomy for prolonged respiratory support, and the requirement for hemodialysis for renal failure. In light of the escalating demand and cost of ICU care, it is advisable to identify those factors that determine whether these patients will benefit from intensive care, to develop strategies that are cognizant of the prognosis and the cost at the outset of care.     

Septic shock due to community-acquired complicated intra-abdominal infection treated with ertapenem: outcome in 25 cases

OBJECTIVES: To assess the effectiveness of ertapenem in patients admitted to a surgical intensive care unit with septic shock due to community-acquired complicated intra-abdominal infection. PATIENTS AND METHODS: Patients undergoing emergency surgery for community-acquired complicated intra-abdominal infection were enrolled prospectively. All patients were given intravenous ertapenem at a rate of 1 g/24 h and the guidelines of the Surviving Sepsis Campaign were applied. Outcome measures were duration of antibiotic therapy, mean length of stay in the surgical intensive care unit (ICU), antibiotic failure, and death while in the surgical ICU. RESULTS: Twenty-five patients with a mean (SD) age of 74 (14) years were enrolled. The origin of infection was the colon in 56% of the cases; most patients (76%) had generalized peritonitis. The mean stay in the surgical ICU was 10 (7) days. The mean duration of antibiotic therapy was 5.8 (1.26) days. Antibiotic failure occurred in 12%. Mortality in the surgical ICU was 28%. CONCLUSIONS: Our findings suggest that patients with community-acquired intra-abdominal infection and septic shock have a good chance of survival when treated according to the guidelines of the Surviving Sepsis Campaign. Ertapenem seems to give good results when used in this setting.     

Risk factors for prolonged stay in the intensive care unit and on the ward after cardiac surgery

BACKGROUND: Prolonged length of stay (LOS) after cardiac surgery has been associated with poor outcome and a considerable expenditure of health care resources. As our patient's demographics are changing, a continuing evaluation of the preoperative and intraoperative variables affecting LOS in the intensive care unit (ICU) and on the floor remains important. METHODS: This is a prospective study examining the determinants of prolonged LOS in 426 consecutive patients after cardiac surgery. Univariate and multivariate analyses were performed for an ICU stay > or =2 days and for a stay on the floor >7 days. Secondary outcome was the incidence of postoperative complications. RESULTS: Among all patients, 27.7% had a prolonged stay in the ICU. Univariate analysis revealed 13 perioperative variables that were significantly associated with prolonged stay. Independent predictors for extended ICU LOS included an ejection fraction <40% (RR 1.83; p = 0.04), high Parsonnet score (RR 2.23; p = 0.012), history of renal failure (RR 5.39; p = 0.001), and an emergency surgery (RR 2.43; p = 0.007). Furthermore, 30.5% of patients had an extended stay on the floor with female gender (RR 1.93; p = 0.009) and age (RR 2.55; p = 0.0001) being two independent risk factors. CONCLUSIONS: In this series of 426 consecutive patients, we have identified several perioperative risk factors associated with prolonged hospitalization that can help clinicians in their preoperative patient counseling, risk stratification, and selection. However, the most obvious use of these results is in allowing decision makers to implement specific strategies that would best allocate resources depending on the risk profile of cardiac patients.     

ICU readmission after cardiac surgery.

OBJECTIVES: The increasing cost of intensive care unit (ICU) care and limited resources lead us to evaluate predictors of ICU readmission in a large group of patients undergoing coronary artery bypass surgery (CABG) at one institution. METHODS: Two thousand one hundred and seventeen consecutive patients undergoing CABG surgery between January 1999 and August 2001 were reviewed retrospectively. The reasons for readmission were determined by reviewing the physician's progress notes, the nurse's progress notes and the discharge summary. RESULTS: A total of 75 patients were readmitted to ICU during the study period for a readmission rate of 3.6%. Eight of these were readmitted a second time, and three a third time, for a total of 86 readmissions. Forty-seven patients died, for a mortality of 2% among patients that were not readmitted to the ICU, compared to 17% among those who were readmitted (P<0.0001). Median hospital length of stay was 6 days for patients not readmitted and 23 days for those readmitted (P<0.0001). The most common reason for readmission was respiratory failure, accounting for 47% of readmissions (n=40). Multivariate analysis using a stepwise logistic regression analysis revealed that preoperative renal failure (odds ratio 2.13; CI 1.03-4.41) and prolonged mechanical ventilation of >24 h (odds ratio 10.52; CI 6.18-17.91) were the only independent predictors for readmission to the ICU after CABG. CONCLUSIONS: Identification of patients that have preoperative renal failure or that required initial ventilation for more than 24 h after CABG may help to identify patients at risk of ICU readmission. Preemptive strategies designed to optimize these high-risk patients may improve outcomes.     

The predictors and outcome of recidivism in cardiac ICUs.

OBJECTIVE: Reinstitution of step-up care (recidivism) following cardiac surgery may be associated with increased mortality. This has, however, not been widely reported. METHODS: We, therefore, studied 8113 consecutive patients who underwent coronary artery bypass grafting (CABG), valve replacement/repair or combined valve+CABG surgery between January 1996 and December 2003 to determine the reasons for readmission to the intensive care unit (ICU) and their outcomes in terms of length of stay in (i) the ICU (ii) hospital and (iii) the in-hospital mortality following recidivism. RESULTS: Of the 7717 patients discharged out of the ICU, 2.3% (182) of patients [mean age 70.4+/-8.35 years (range 30-90 years); 65.4% (119) males] required step-up care. Recidivism was 1.8% (101 of 5633) following coronary artery by-pass grafting (CABG) and 3.9% (81 of 2084) following valve replacement/repair+/-CABG (P<0.05). The mean interval from ICU discharge to ICU recidivism was 6.6+/-8.4 days (range 6h to 28 days). The principal reasons for recidivism were (i) respiratory failure requiring reintubation and ventilation in 54.9% (n=100) of patients (ii) cardiovascular instability (including that secondary to dysrhythmias) and heart failure in 23.1% (n=42) (iii) renal failure requiring haemofiltration in 6.6% (n=12) (iv) sepsis in 1.1% (n=2) (v) cardiac tamponade/bleeding requiring re-exploration in 7.7% (n=14) and (vi) gastro-intestinal complications requiring laparotomy in 6.0% (n=11) patients. Multivariate analysis showed that, during primary ICU stay, respiratory complications, low cardiac output state, dysrhythmias, renal failure requiring haemofiltration and re-exploration for bleeding were independent predictors of recidivism. Following recidivism (i) the mean length of stay in the ICU was 6.65+/-6.2 days (range 4h to 51 days), (ii) mean hospital stay was 19.2+/-17.3 days (10-60 days) and (iii) the 30-day in-hospital mortality was 32.4%. CONCLUSIONS: Patients are more likely to require recidivism following valve surgery+/-CABG than CABG alone. Whilst respiratory complications were the most common reasons for recidivism in our study, patients who required mechanical supports to maintain vital functions following surgery were most prone to recidivism. Hence, efforts should be made to treat cardio-respiratory problems early in this group of patients to reduce ICU recidivism.