Postoperative ICU management of vascular surgery patients

Analysis of a Large 19-Year Database in Vascular Surgery in Southern Iran: Evaluation of Trends and Limitations

BACKGROUND

Large databases with data elements of clinical interest are essential for carrying out high-quality observational studies. Such databases have become increasingly popular for clinical research in fields like vascular surgery. Our goal is to create a solid and reliable database of the patients who have been admitted and undergone different vascular surgery procedures over 19 years and to provide surgeons with the current trends and limitations in managing patients with vascular disease.

METHODS

The database of patients operated in Namazi Hospital, the referral center for vascular surgery in Southern Iran, from 2001 to 2019, was retrieved and patients undergoing vascular procedures were parted. Demographic and perioperative data were evaluated and patients were categorized into subgroups based on the type and cause of operation. All data were analyzed with SPSS version 26.0 (IBM, NY, USA).

RESULTS

During the period of our study, a total of 226,051 operations were performed at the Namazi Hospital. Among these operations, 6,386 (2.82%) vascular surgery-related operations were entered into our study. The average age of the patients in our study was 53.22 ± 18.92 years (range: 1 day old-97 years) and 4,061 (63.6%) were male. Furthermore, 147 (2.3%) were operated by multiple surgeons. Moreover, 798 (12.5%) of the patients were admitted postoperatively to the intensive care unit, while the rest (5,588; 87.5%) in the common surgery ward. The cause of operation in 609 (9.5%) of the cases was trauma. Based on wound categorization, 5,132 (80.4%) were type I (clean). The most frequent operation performed in our center was arterial reconstruction and limb revascularization (31.4%), followed by hemodialysis access (31.3%). The most frequent surgery in the age group of less than 18 years was fasciotomy, in the 19-40 years group was tumor (56.8%) and varicose veins (52.9%), and in the 41-60 years group was implantation of ventral venous port catheter (47%). Only carotid and thoracic outlet syndrome surgeries were significantly higher in females. The remaining operations were all significantly higher among male patients. Finally, carotid body tumor surgery was the most frequent operation requiring intensive care unit monitoring.

CONCLUSIONS

We demonstrated, for the first time, an overview of vascular surgeries performed in a referral tertiary center in Southwest Iran. There is an increase in the number of surgical procedures in the field of vascular surgery, and large databases will be a valuable tool for addressing critical problems in this field and also the healthcare system.

Critical Care of the Vascular Surgery Patient

Patients that require major vascular surgery suffer from widespread atherosclerosis and have multiple comorbidities that place them at increased risk for postoperative complications and require admission to the intensive care unit (ICU). Postoperative critical care of these patients is focused on hemodynamic optimization, and early identification and management of complications to improve outcomes.

Postoperative Intensive Care Management of Aortic Repair

Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

Intraoperative hypotension and complications after vascular surgery: A scoping review

BACKGROUND

Intraoperative hypotension during major surgery is associated with adverse health outcomes. This phenomenon represents a potentially important therapeutic target for vascular surgery patients, who may be uniquely vulnerable to intraoperative hypotension. This review summarizes current evidence regarding the impact of intraoperative hypotension on postoperative complications in patients undergoing vascular surgery, focusing on potentially modifiable procedure- and patient-specific risk factors.

METHODS

A scoping review of the literature from Embase, MEDLINE, and PubMed databases was conducted from inception to December 2019 to identify articles related to the effects of intraoperative hypotension on patients undergoing vascular surgery.

RESULTS

Ninety-two studies met screening criteria; 9 studies met quality and inclusion criteria. Among the 9 studies that defined intraoperative hypotension objectively, there were 9 different definitions. Accordingly, the reported incidence of intraoperative hypotension ranged from 8% to 88% (when defined as a fall in systolic blood pressure of >30 mm Hg or mean arterial pressure <65). The results demonstrated that intraoperative hypotension is an independent risk factor for longer hospital length of stay, myocardial injury, acute kidney injury, postoperative mechanical ventilation, and early mortality. Vascular surgery patients with comorbid conditions that confer increased vulnerability to hypoperfusion and ischemia appear to be susceptible to the adverse effects of intraoperative hypotension.

CONCLUSION

There is no validated, consensus definition of intraoperative hypotension or other hemodynamic parameters associated with increased risk for adverse outcomes. Despite these limitations, the weight of evidence suggests that intraoperative hypotension is common and associated with major postoperative complications in vascular surgery patients.

Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence

Frailty is presumably associated with an elevated risk of postoperative mortality and adverse outcome in vascular surgery patients. The aim of our review was to identify possible methods for risk assessment and prehabilitation in order to improve recovery and postoperative outcome. The literature search was performed via PubMed, Embase, OvidSP, and the Cochrane Library. We collected papers published in peer-reviewed journals between 2001 and 2018. The selection criterion was the relationship between vascular surgery, frailty and postoperative outcome or mortality. A total number of 52 publications were included. Frailty increases the risk of non-home discharge independently of presence or absence of postoperative complications and it is related to a higher 30-day mortality and major morbidity. The modified Frailty Index showed significant association with elevated risk for post-interventional stroke, myocardial infarction, prolonged in-hospital stays and higher readmission rates. When adjusted for comorbidity and surgery type, frailty seems to impact medium-term survival (within 2 years). Preoperative physical exercising, avoidance of hypalbuminemia, psychological and cognitive training, maintenance of muscle strength, adequate perioperative nutrition, and management of smoking behaviours are leading to a reduced length of stay and a decreased incidence of readmission rate, thus improving the effectiveness of early rehabilitation. Pre-frailty is a dynamically changing state of the patient, capable of deteriorating or improving over time. With goal-directed preoperative interventions, the decline can be prevented.

Eosinopenia and post-hospital outcomes in critically ill non-cardiac vascular surgery patients

BACKGROUND AND AIMS

Eosinopenia is a marker for acute inflammation. We hypothesized that eosinopenia at Intensive Care Unit (ICU) admission in vascular surgery patients who receive critical care, would be associated with increased mortality following hospital discharge.

METHODS AND RESULTS

We performed a two-center observational cohort study of critically ill, non-cardiac adult vascular surgery patients who received treatment in Boston between 1997 and 2012 and survived hospital admission. The consecutive sample included 5083 patients (male 57%, white 82%, mean age [SD] 61.6 [17.4] years). The exposure was Absolute eosinophil count measured within 24 h of admission to the ICU and categorized as ≤10 cells/μL, 11-50 cells/μL, 51-100 cells/μL, 101-350 cells/μL (normal range), and >350 cells/μL. The primary outcome was all-cause mortality within 90 days of hospital discharge. The secondary outcome was discharge to home following hospitalization. 90-day post-discharge mortality was 6.7%, and 12.9% of patients were readmitted within 30 days. After multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 90-day post-discharge mortality OR of 1.97 (95%CI 1.42, 2.73; P < 0.001) relative to patients with an absolute eosinophil count of 101-350 cells/μL. Further, after multivariable adjustment, patients with eosinopenia (≤10 cells/μL) have a 25% lower odds of discharge to home compared to patients with an absolute eosinophil count of 101-350 cells/μL [OR = 0.71 (CI 95% 0.59-0.85); P < 0.001].

CONCLUSION

Eosinopenia at ICU admission is a robust predictor of increased mortality and lower likelihood of discharge to home in vascular surgery patients treated with critical care who survive hospitalization.

Enhanced Recovery after Vascular Surgery

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.

A systematic review and meta-analysis of factors for delirium in vascular surgical patients

BACKGROUND

Delirium is a common syndrome responsible for a large burden of morbidity and mortality. In surgical settings, research into risk factors for postoperative delirium has largely focused on elective orthopedic patients. We performed a systematic review and meta-analysis to evaluate the evidence surrounding risk factors for delirium in vascular surgical populations.

METHODS

Two independent reviewers searched five databases (MEDLINE, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO) from January 1987 to December 2015. We included primary research studies for incident delirium that used validated delirium assessment tools in exclusively vascular surgical populations.

RESULTS

We identified 16 studies (3817 patients) that met the inclusion criteria. There was substantial clinical heterogeneity in the populations included under a heading of "vascular surgery." Studies were high quality, with an average Newcastle-Ottawa Scale score of 6.9. Summary incidence of delirium was 23.4% (range, 4.8%-39%). Across all studies, 157 separate risk factors were examined. Ten of the included studies used multivariable models in their analysis of risk factors. Meta-analysis of risk factors with data from more than three studies identified the following factors as conferring an increased risk of delirium: American Society of Anesthesiologists score >2 (odds ratio [OR], 3.44), renal failure (OR, 2.09), previous stroke (OR, 1.87), history of neurologic comorbidity (OR, 1.57), and male sex (OR, 1.30). Delirious patients were older (mean difference [MD], +4.99 years), had lower preoperative hemoglobin levels (MD, -0.66 g/dL), and stayed longer in intensive care units (MD, +1.06 days).

CONCLUSIONS

Delirium is common in vascular surgery settings. Meta-analysis has identified significant risk factors relating to the patient, the presentation, and the pathway of care. Better understanding of these risk factors may help in prediction, prevention, and early identification of delirium.

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost

OBJECTIVE

We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost.

METHODS

A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed.

RESULTS

THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012.

CONCLUSIONS

In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.

Postintubation Hypotension in General Anesthesia: A Retrospective Analysis

BACKGROUND

Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department endotracheal intubations. Study objective was to determine the incidence of PIH and its impact on outcomes following tracheal intubation in a general anesthesia population.

METHODS

Structured chart audit of adult patients intubated for a vascular surgery procedure at a tertiary care center over a 3-year period. Outcomes included in-hospital mortality, extended intensive care unit length of stay (ICU LOS), and requirement for postoperative (postop) hemodialysis or mechanical ventilation.

RESULTS

Incidence of PIH was 60% (837 of 1395). Patients who developed PIH had increased mortality (8.8% PIH vs 5.2% no-PIH; P = .014), extended ICU LOS (7.9% PIH vs 2.0% no-PIH; P < .001), and postop mechanical ventilation requirement (20.7% PIH vs 3.8% no-PIH; P < .001). When controlling for confounding factors, PIH was associated with extended ICU LOS (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.01-6.62, P = .049), postop ventilation (OR 2.43, 95% CI 1.27-4.74, P = .008), and a composite end point (OR 1.72, 95% CI 1.02-2.92, P = .043).

CONCLUSIONS

Development of PIH occurs in 60% of patients undergoing intubation for vascular surgery and was associated with adverse outcomes including extended ICU LOS and postop ventilation requirement.

Postoperative management

Most patients undergoing major aortic surgery have multiple comorbidities and are at high risk of postoperative complications that affect multiple organ systems. Different aortic pathologies and surgical repair techniques have specific impact on the postoperative course. Ischemia-reperfusion injury is the common denominator in aortic surgery and influences the integrity of end-organ function. Common postoperative problems include hemodynamic instability due to the immediate inflammatory response, renal impairment, spinal cord ischemia, respiratory failure with prolonged mechanical ventilation, and gastrointestinal symptoms such as ileus or mesenteric ischemia. Focused care bundles to establish homeostasis and a team working toward an early functional recovery determine the success of effective rehabilitation and outcomes after aortic surgery.

The use of a pro forma to improve quality in clerking vascular surgery patients

At our institution, a large tertiary referral centre for vascular surgery, patients are often admitted directly to the ward and clerked by foundation year one (FY1) doctors. We found that these clerkings frequently fell short of national record keeping standards, potentially leading to an increased risk for patients during their hospital stay. In addition, we found that junior doctors did not feel confident in clerking vascular surgery patients.

A literature review found that high quality clerkings were strongly linked to improved patient safety, and that the use of a pro forma was one method to improve compliance with documentation guidelines. We devised a clerking pro forma based on national guidelines and introduced it to the department.

We found that the use of a pro forma significantly improved documentation standards across a number of domains, including patient demographics, presenting complaint, and family and social histories (p <0.05). Examinations were significantly more comprehensive, with cardiac and vascular examination as well as peripheral pulses documented (p <0.05).

In conclusion, we found that using a pro forma helped to aid junior doctors in clerking new patients, and significantly improved the quality of their history and examinations. This leads to a potential positive impact on patient safety during their inpatient stay, and should be rolled out more widely across the hospital.

Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis

OBJECTIVE

To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients.

DESIGN

Retrospective case series.

SETTING

Single-center academic hospital.

PARTICIPANTS

The study included 1,395 adult vascular surgery patients with peripheral vascular disease.

INTERVENTIONS

Retrospective review of hospital databases.

MEASUREMENTS AND MAIN RESULTS

Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41).

CONCLUSIONS

Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.