Overnight Intensive Recovery: Elective Open Aortic Surgery Without a Routine ICU Bed

Different but Equal: Outcomes of Prolonged Postanesthesia Care Unit Stay After Trauma Laparotomy

INTRODUCTION

Hospital overcrowding is common and can lead to delays in intensive care unit (ICU) admission, resulting in increased morbidity and mortality in medical and surgical patients. Data on delayed ICU admission are limited in the postsurgical trauma cohort. Damage control laparotomy with temporary abdominal closure (DCL-TAC) for severely injured patients is often followed by an aggressive early resuscitation phase, usually occurring in the ICU. We hypothesized that patients who underwent DCL-TAC with initial postanesthesia care unit (PACU) stay would have worse outcomes than those directly admitted to ICU.

METHODS

A retrospective chart review identified all trauma patients who underwent DCL-TAC at a level 1 trauma center over a 5 y period. Demographics, injuries, and resuscitation markers at 12 and 24 h were collected. Patients were stratified by location after index laparotomy (PACU versus ICU) and compared. Outcomes included composite morbidity and mortality. Multivariable logistic regression was performed.

RESULTS

Of the 561 patients undergoing DCL-TAC, 134 (24%) patients required PACU stay due to ICU bed shortage, and 427 (76%) patients were admitted directly to ICU. There was no difference in demographics, injury severity score, time to resuscitation, complications, or mortality between PACU and ICU groups. Only 46% of patients were resuscitated at 24 h; 76% underwent eventual primary fascial closure. Under-resuscitation at 24 h (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.31-0.95, P = 0.03), increased age (AOR 1.04; 95% CI 1.02-10.55, P < 0.0001), and increased injury severity score (AOR 1.04; 95% CI 1.02-1.07, P < 0.0001) were associated with mortality on multivariable logistic regression. The median time in PACU was 3 h.

CONCLUSIONS

PACU hold is not associated with worse outcomes in patients undergoing DCL-TAC. While ICU was designed for the resuscitation of critically ill patients, PACU is an appropriate alternative when an ICU bed is unavailable.

Association of reintubation and hospital costs and its modification by postoperative surveillance: A multicenter retrospective cohort study

OBJECTIVE

We estimated hospital costs associated with postoperative reintubation and tested the hypothesis that prolonged surveillance in the post-anesthesia care unit (PACU) modifies the hospital costs of reintubation.

DESIGN

Retrospective observational research study.

SETTING

Two tertiary care academic healthcare networks in the Bronx, New York and Boston, Massachusetts, USA.

PATIENTS

68,125 adult non-cardiac surgical patients undergoing general anesthesia between 2016 and 2021.

INTERVENTIONS

The exposure variable was unplanned reintubation within 7 days of surgery.

MEASUREMENTS

The primary outcome was direct hospital costs associated with patient care related activities. We used a multivariable generalized linear model based on log-transformed costs data, adjusting for pre- and intraoperative confounders. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS). In the key secondary analysis, we examined if prolonged postoperative surveillance, defined as PACU utilization (≥4 h) modifies the association between reintubation and costs of care.

MAIN RESULTS

1759 (2.6%) of patients were re-intubated within 7 days after surgery. Reintubation was associated with higher direct hospital costs (adjusted model estimate 2.05; 95% CI: 2.00-2.10) relative to no reintubation. In the HCUP-NIS matched cohort, the adjusted absolute difference (ADadj) in costs amounted to US$ 18,837 (95% CI: 17,921-19,777). The association was modified by the duration of PACU surveillance (p-for-interaction <0.001). In patients with a shorter PACU length of stay, reintubation occurred later (median of 2 days; IQR 1, 5) versus 1 days (IQR 0, 2; p < .001), and was associated with magnified effects on hospital costs compared to patients who stayed in the PACU longer (ADadj of US$ 23,444, 95% CI: 21,217-25,799 versus ADadj of US$ 17,615, 95% CI: 16,350-18,926; p < .001).

CONCLUSION

Postoperative reintubation is associated with 2-fold higher hospital costs. Prolonged surveillance in the recovery room mitigated this effect. The cost-saving effect of longer PACU length of stay was likely driven by earlier reintubation in patients who needed this intervention.

Characteristics and outcomes of surgical patients admitted to an overnight intensive recovery unit: A retrospective observational study

Postoperative 'enhanced care' models that sit between critical care and ward-based care may allow for more cost-effective and efficient utilisation of resources for high-risk surgical patients. In this retrospective observational study, we describe an overnight intensive recovery model in a tertiary hospital, termed 'recovery high dependency unit', and the characteristics, treatment, disposition at discharge and in-hospital outcomes of patients admitted to this unit. We included all adult patients (≥18 years) admitted to the recovery high dependency unit for at least one hour between July 2017 and June 2020. Over this three-year period, 1257 patients were included in the study. The median length of stay in the recovery high dependency unit was 12.6 (interquartile range 9.1-15.9) hours and the median length of hospital stay was 8.3 (interquartile range 5.0-17.3) days. Hospital discharge data showed that 1027 (81.7%) patients were discharged home and that 37 (2.9%) patients died. Non-invasive ventilation was delivered to 59 (4.7%) patients and 290 (23.1%) required vasopressor support. A total of 164 patients (13.0%) were admitted to the intensive care unit following their recovery high dependency unit admission. Of the 1093 patients who were discharged to the ward, 70 patients (6.4%) had a medical emergency team call within 24 hours of discharge from the recovery high dependency unit. In this study of a recovery high dependency unit patient cohort, there was a relatively low need for intensive care unit admission postoperatively and a very low incidence of medical emergency team calls post-discharge to the ward. Other institutions may consider the introduction and evaluation of this model in the care of their higher risk surgical patients.

'Organisation of delivery of care in operating suite recovery rooms within 48 hours postoperatively and patient outcomes after adult non-cardiac surgery: a systematic review'

CONTEXT

Postoperative recovery rooms have existed since 1847, however, there is sparse literature investigating interventions undertaken in recovery, and their impact on patients after recovery room discharge.

OBJECTIVE

This review aimed to investigate the organisation of care delivery in postoperative recovery rooms; and its effect on patient outcomes; including mortality, morbidity, unplanned intensive care unit (ICU) admission and length of hospital stay.

DATA SOURCES

NCBI PubMed, EMBASE and Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Studies published since 1990, investigating health system initiatives undertaken in postoperative recovery rooms. One author screened titles and abstracts, with two authors completing full-text reviews to determine inclusion based on predetermined criteria. A total of 3288 unique studies were identified, with 14 selected for full-text reviews, and 8 included in the review.

DATA EXTRACTION

EndNote V.8 (Clarivate Analytics) was used to manage references. One author extracted data from each study using a data extraction form adapted from the Cochrane Data Extraction Template, with all data checked by a second author.

DATA SYNTHESIS

Narrative synthesis of data was the primary outcome measure, with all data of individual studies also presented in the summary results table.

RESULTS

Four studies investigated the use of the postanaesthesia care unit (PACU) as a non-ICU pathway for postoperative patients. Two investigated the implementation of physiotherapy in PACU, one evaluated the use of a new nursing scoring tool for detecting patient deterioration, and one evaluated the implementation of a two-track clinical pathway in PACU.

CONCLUSIONS

Managing selected postoperative patients in a PACU, instead of ICU, does not appear to be associated with worse patient outcomes, however, due to the high risk of bias within studies, the strength of evidence is only moderate. Four of eight studies also examined hospital length of stay; two found the intervention was associated with decreased length of stay and two found no association.

PROSPERO REGISTRATION NUMBER

This protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number CRD42018106093.

Enhanced recovery after elective open surgical repair of abdominal aortic aneurysm: a complementary overview through a pooled analysis of proportions from case series studies

OBJECTIVES

To evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) programs in elective open surgical repair (OSR) of abdominal aortic aneurysm (AAA).

BACKGROUND

Open surgical repair of AAA is associated with high morbidity and mortality, prolonged hospital stay and high costs. ERAS programs contribute to the optimization of treatment by reducing hospital stay and improving clinical outcomes.

METHODS

A review of PubMed, EMBASE and LILACS databases was conducted. As only one randomized controlled trial was found, a pooled analysis of proportions from case series was conducted, considering it a complementary overview of the topic. Inclusion criteria were case series with more than five cases reported, adult patients who underwent an elective OSR of AAA and use of an ERAS program. ERAS was compared to conventional perioperative care. The pooled proportion and the confidence interval (CI) are shown for each outcome. The overlap of the CI suggests similar effect of the interventions studied.

RESULTS

Thirteen case series studies with ERAS involving 1,250 patients were compared to six case series with conventional care with a total of 1,429 patients. The pooled, respective proportions for ERAS and conventional care were: mortality, 1.51% [95% CI: 0.0091, 0.0226] and 3.0% [95% CI 0.0183, 0.0445]; and incidence of complications, 3.82% [95% CI 0.0259, 0.0528] and 4.0% [95% CI 0.03, 0.05].

CONCLUSION

This review shows that ERAS and conventional care therapies have similar mortality and complication rates in OSR of AAA.

Successful extubation in the operating room after infratentorial craniotomy: the Cleveland Clinic experience

BACKGROUND

There is lack of information in the literature about the rate of successful extubation after infratentorial craniotomy and the risk factors associated with failed extubation. This retrospective analysis assessed the rate of successful extubation after infratentorial craniotomy in a tertiary hospital.

METHODS

Only infratentorial craniotomies for tumors, vascular malformations in the brainstem or cerebellum, and fourth ventricle cysts performed in prone position were included. Failed extubation was defined as the need for airway reintubation in the operating room (OR), postanesthesia care unit, or intensive care unit after surgery. Only those patients, in whom the primary reason for reintubation was respiratory failure, deteriorating level of consciousness, or inability to protect the airway were included in the statistical analysis. Prolonged intubation was defined as airway intubation longer than 48 hours from the initial intubation.

RESULTS

This is a retrospective study that included perioperative information from 145 adult patients. One hundred and twenty patients (82%) were primarily extubated in the OR and the rest remained intubated (18%). From the latter group, 9 (36%) and 16 (64%) were extubated in the postanesthesia care unit or intensive care unit, respectively. The rate of failed extubation within 24 hours after primary extubation in the OR was 0.83%. Patients not extubated in the OR had a statistically significant higher American Society of Anesthesiologists score, a longer length of surgery, a larger blood loss, and a longer stay in the hospital compared with those who were extubated in the OR.

CONCLUSIONS

We conclude that primary extubation in the OR after infratentorial craniotomy is feasible. However, cautions should be taken in patients with poor physical status undergoing vascular surgery and long procedures with potential significant fluid shifts.

Assessment of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Open Abdominal Aortic Aneurysm Repair

Pneumonia is a common postoperative complication, with a mortality of up to 40%. The Post-operative Pneumonia Risk Index (PPRI) was derived from a large cohort of general surgical patients but has not been validated in patients undergoing open abdominal aortic aneurysm (AAA) repair. The PPRI was applied to patients undergoing elective open AAA repair in a tertiary referral vascular unit. Pneumonia occurred in 20% of patients. Receiver operating characteristic curve analysis identified 36 as the optimum PPRI cutoff value. At this cutoff, the likelihood ratio for pneumonia was 1.35 (95% confidence interval 1.08–1.62). However, in a multivariate analysis, only weight loss in excess of 10% over the preceding 6 months was an independent predictor of postoperative pneumonia. Although the PPRI is of some value in identifying high-risk patients undergoing AAA repair, weight loss alone may be predictive, allowing targeted preventive measures in aneurysm patients at increased risk.

Atrial fibrillation following elective open abdominal aortic aneurysm repair

BACKGROUND

Atrial fibrillation is a common complication following major vascular surgery. It is often considered to be relatively benign but may represent the first sign of cardiac and non-cardiac complications. We conducted a retrospective study to determine the incidence and clinical associations of atrial fibrillation following open elective abdominal aortic aneurysm repair as well as its effect on prognosis.

METHODS

The case-notes of 200 consecutive patients undergoing open aneurysm repair were reviewed. Known pre-operative and intra-operative risk factors and potential post-operative associations with new-onset AF were recorded. Significant univariate correlates with AF were entered into a forward stepwise logistic regression model to test for independence. The effect of new-onset AF on long-term prognosis was assessed.

RESULTS

AF developed in 20 patients (10%) post-operatively. Previous cerebrovascular disease, aneurysm size and post-operative cardiac failure were associated with post-operative AF in univariate analyses. Cerebrovascular disease and post-operative cardiac failure were independently associated with new-onset AF. AF patients had a longer hospital stay. There was no difference in survival between those patients with and without new-onset AF.

CONCLUSION

New-onset AF is a common complication of open abdominal aortic aneurysm surgery and may indicate an underlying myocardial infarction. It is associated with a longer hospital stay and an increased risk of cardiac failure. Assessed and treated appropriately, it appears to have no effect on long-term prognosis.

Vascular surgery, ICU and HDU: a 14-year observational study

INTRODUCTION

Over the course of the past decade, numerous changes have occurred in the management of patients undergoing vascular surgical operations. The introduction of high dependency units (HDUs) has meant that many patients previously requiring observation in intensive care units (ICUs) are now managed in this new environment. In addition, many vascular patients may now be suitable for management on a vascular ward immediately following their surgery. This study reports the chronological changes in resource utilisation of patients undergoing major vascular surgery in a district general hospital over a 14-year period.

PATIENTS AND METHODS

Details of all patients admitted to either the ICU or HDU under the care of a single vascular surgeon during the period 1991-2004 were extracted from a prospectively maintained anaesthetic department database. Details of the age and gender of the patients were obtained together with source of admission, place of discharge and need for re-admission. Operative details for each patient were extracted from a prospectively maintained vascular surgery database including type of procedure undertaken and degree of urgency.

RESULTS

During the 14-year period under study, there was a dramatic decrease in the use of ICU facilities for the management of vascular patients from 100% in 1991 to 36% in 2004. There was a corresponding increase in the use of HDU for major vascular cases during the same period from 0% to 66%. However, despite a significant increase in the total number of major vascular operations performed, from 67 in 1991 to 185 in 2004 as a result of sub-specialisation, overall use of all high-care facilities fell as the number of patients returned directly to the vascular ward increased from 34% in 1991 to 64% in 2004. The efficacy of the choice of management venue was confirmed by the observation that only 7.7% of those managed on ICU had been initially managed at a lower level of care. In addition, only 1.8% of patients managed on HDU had been admitted after initially being managed on the vascular ward.

CONCLUSIONS

Sub-specialisation over the past decade has meant a significantly increased major vascular work-load. Since the introduction of the HDU, there has been a significant fall in the use of ICU facilities for routine cases. These changes in resource utilisation have significant implications in terms of budget allocation. It would appear that finances, in relation to vascular surgery, should be concentrated on expanding HDU facilities and ensuring vascular surgery expertise amongst ward nursing staff.

Assessment of pre-operative delays in the management of elective abdominal aortic aneurysms

INTRODUCTION

Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays.

PATIENTS AND METHODS

Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR.

RESULTS

A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02).

CONCLUSIONS

Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.

Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery

BACKGROUND

The Estimation of Physiologic Ability and Surgical Stress (E-PASS) score was designed on the premise that the balance between the patient's physiologic reserve capacity and the surgical stress inflicted at operation was important in the occurrence of postoperative complications. The aim of this study was to assess its value in predicting mortality and morbidity after open elective abdominal aortic aneurysm (AAA) repair.

METHODS

E-PASS data items were collected prospectively in a group of 204 patients undergoing elective open AAA repair over a 6-year period. The operative morbidity and mortality rates were compared with the preoperative risk score (PRS), surgical stress score (SSS) and comprehensive risk score (CRS) of E-PASS. The group comprised 180 (88%) males and the median age was 73 (range 44 to 86) years.

RESULTS

There were 13 (6%) deaths and 121 (59%) experienced a postoperative complication. As the PRS, SSS and CRS increased, the incidence of postoperative morbidity and mortality significantly increased (P < .0001). Overall mean CRS was .52 (+/-.27). Mean CRS in the groups of patients who survived and died were .49 (+/-.24) and .98 (+/-26), respectively. PRS, SSS, and CRS all had extremely good predictive power for both mortality and morbidity as demonstrated by high areas under the receiver operator curve (range .799 to .953). CRS also showed a strong statistically significant association with the severity of postoperative complication (P < .0001) and length of hospital stay (P < .0001).

CONCLUSIONS

The E-PASS model appears to be a promising method of predicting death and the development of postoperative complications in patients undergoing elective open AAA surgery. It requires further validation in arterial surgery at different geographical locations.

POSSUM models in open abdominal aortic aneurysm surgery

OBJECTIVES

This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Portsmouth (P) POSSUM and Vascular (V) POSSUM. The primary aim was to assess the validity of these scoring systems in a population of patients undergoing elective and emergency open AAA repair. The secondary intention was in the event that these equations did not fit all patients with an aneurysm; a new model would be developed and tested using logistic regression from the local data (Cambridge POSSUM).

METHODS

POSSUM data items were collected prospectively in a group of 452 patients undergoing elective and emergency open AAA repair over an eight-year period. The operative mortality rates were compared with those predicted by POSSUM, P-POSSUM, V-POSSUM and Cambridge POSSUM.

RESULTS

All models except V-POSSUM (physiology only) showed significant lack of fit when predicting mortality after open AAA surgery. It was found that the locally generated single unified model (Cambridge POSSUM) could successfully describe both elective and ruptured AAA mortality with good discrimination (chi(2)=9.24, 7 d.f., p=0.236, c-index=0.880).

CONCLUSIONS

POSSUM, V-POSSUM and P-POSSUM may not be robust tools for comparing mortality between populations undergoing elective and emergency open AAA repair as once thought. The development and successful validation of Cambridge POSSUM provides a unified model to describe both elective and emergency AAAs together and should be validated in other geographical settings.

VBHOM, a data economic model for predicting the outcome after open abdominal aortic aneurysm surgery

Background

Vascular Biochemistry and Haematology Outcome Models (VBHOM) adopted the approach of using a minimum data set to model outcome. This study aimed to test such a model on a cohort of patients undergoing open elective and non-elective abdominal aortic aneurysm (AAA) repair.

Methods

A binary logistic regression model of risk of in-hospital mortality was built from the 2002–2004 submission to the UK National Vascular Database (NVD) (2718 patients). The subset of NVD data items used comprised serum levels of urea, sodium and potassium, haemoglobin, white cell count, sex, age and mode of admission. The model was applied prospectively using Hosmer–Lemeshow methodology to a test data set from the Cambridge Vascular Unit.

Results

The validation set contained 327 patients, of whom 208 had elective AAA repair and 119 had emergency repair of a ruptured AAA. Outcome following elective and non-elective AAA repair could be described accurately using the same model. The overall mean predicted risk of death was 14·13 per cent, and 48 deaths were predicted. The actual number of deaths was 53 (χ2 = 8·40, 10 d.f., P = 0·590; no evidence of lack of fit). The model also demonstrated good discrimination (c-index = 0·852).

Conclusion

The VBHOM approach has the advantage of using simple, objective clinical data that are easy to collect routinely. The VBHOM data items potentially allow prediction of risk in an individual patient before aneurysm surgery.

Elective surgery for aortic abdominal aneurysm: comparison of English outcomes with those elsewhere

INTRODUCTION

The aim of this study was to quantify mortality after elective repair of abdominal aortic aneurysm (AAA) in England, and to compare English case fatality rates (CFRs) with those reported in the literature.

PATIENTS AND METHODS

English Hospital Episode Statistics (HES) for the financial years 1998/9 to 2001/2, linked to death data, were analysed. A systematic literature search was undertaken to identify studies reporting CFRs after elective AAA surgery. The CFR in England was compared with these studies by using confidence intervals on the CFRs and funnel plot techniques.

RESULTS

In the English study, elective repair of AAA was performed on 11,338 patients of whom 771 died within 30 days after surgery (6.8%). The literature search found 66 studies: 34 reported mortality rates that were within the 99% confidence limits of the English rates, 31 below, and one study above.

DISCUSSION

The CFR after elective surgical repair in England within 30 days of operation (6.8%) was higher than expected from the literature. Differences between England and other countries in quality of care is one possible explanation for the findings, but other explanations are possible and are discussed.