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Loftus TJ, Balch JA, Ruppert MM, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Aligning Patient Acuity With Resource Intensity After Major Surgery: A Scoping Review. Ann Surg 2022; 275:332-339. [PMID: 34261886 PMCID: PMC8750209 DOI: 10.1097/sla.0000000000005079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Develop unifying definitions and paradigms for data-driven methods to augment postoperative resource intensity decisions. SUMMARY BACKGROUND DATA Postoperative level-of-care assignments and frequency of vital sign and laboratory measurements (ie, resource intensity) should align with patient acuity. Effective, data-driven decision-support platforms could improve value of care for millions of patients annually, but their development is hindered by the lack of salient definitions and paradigms. METHODS Embase, PubMed, and Web of Science were searched for articles describing patient acuity and resource intensity after inpatient surgery. Study quality was assessed using validated tools. Thirty-five studies were included and assimilated according to PRISMA guidelines. RESULTS Perioperative patient acuity is accurately represented by combinations of demographic, physiologic, and hospital-system variables as input features in models that capture complex, non-linear relationships. Intraoperative physiologic data enriche these representations. Triaging high-acuity patients to low-intensity care is associated with increased risk for mortality; triaging low-acuity patients to intensive care units (ICUs) has low value and imparts harm when other, valid requests for ICU admission are denied due to resource limitations, increasing their risk for unrecognized decompensation and failure-to-rescue. Providing high-intensity care for low-acuity patients may also confer harm through unnecessary testing and subsequent treatment of incidental findings, but there is insufficient evidence to evaluate this hypothesis. Compared with data-driven models, clinicians exhibit volatile performance in predicting complications and making postoperative resource intensity decisions. CONCLUSION To optimize value, postoperative resource intensity decisions should align with precise, data-driven patient acuity assessments augmented by models that accurately represent complex, non-linear relationships among risk factors.
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Affiliation(s)
- Tyler J. Loftus
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Jeremy A. Balch
- Department of Surgery, University of Florida Health,
Gainesville, FL, USA
| | - Matthew M. Ruppert
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | - Patrick J. Tighe
- Departments of Anesthesiology, Orthopedics, and Information
Systems/Operations Management, University of Florida Health, Gainesville, FL,
USA
| | - William R. Hogan
- Department of Health Outcomes & Biomedical Informatics,
College of Medicine, University of Florida, Gainesville, FL, USA
| | - Parisa Rashidi
- Departments of Biomedical Engineering, Computer and
Information Science and Engineering, and Electrical and Computer Engineering,
University of Florida, Gainesville, Florida, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
| | | | - Azra Bihorac
- Department of Medicine, University of Florida Health,
Gainesville, FL, USA
- Precision and Intelligent Systems in Medicine
(Prisma), University of Florida, Gainesville, FL, USA
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Dion D, Drudi LM, Beaudoin N, Blair JF, Elkouri S. Safety of transition from a routine to a selective intensive care admission pathway after elective open aneurysm repair. Can J Surg 2021; 64:E3-E8. [PMID: 33411997 PMCID: PMC7955835 DOI: 10.1503/cjs.012518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background There is a growing trend to implement intermediate care units to avoid unnecessary costs associated with intensive care unit (ICU) admission and associated resources. We sought to evaluate the safety of transitioning from a routine to a selective policy of postoperative transfer to the ICU for elective open abdominal aortic aneurysm (AAA) repair. Methods This retrospective study included consecutive open elective AAA repair procedures performed at a single centre from Aug. 8, 2010, to Dec. 1, 2014. Patients were identified through a prospectively maintained database, and electronic charts were reviewed. Patients with interventions before Mar. 13, 2012, were routinely sent to the ICU after operation (group A). Patients treated after this date were sent directly to an intermediate care unit (group B) unless preoperative or intraoperative factors deemed them suitable for ICU admission. The primary outcome was in-hospital death; secondary outcomes were perioperative complications and length of stay. We used logistic and linear regression to determine the association between the use of an intermediate care unit and the primary and secondary outcomes after adjusting for confounders and clinically relevant covariates. Results The cohort comprised 310 patients (266 men, 44 women) with a mean age of 69.7 (standard deviation 10.1) years and a mean AAA diameter of 61.2 mm (SD 9.6 mm). Groups A and B included 118 and 192 patients, respectively. Admission to the ICU was spared in 149 patients (77.6%) in group B. Only 2 patients (1.3%) in group B were subsequently admitted to the ICU. There was no statistically significant difference in in-hospital mortality or perioperative complications between the 2 groups on multivariable logistic regression. There was a nonsignificant trend toward slightly shorter length of stay in group B. Conclusion In this single-centre experience with the majority of patients sent directly to an intermediate care unit, there was no statistically significant difference in mortality or morbidity between routine and selective ICU admission. Our results confirm the safety of a selective ICU admission pathway.
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Affiliation(s)
- Danielle Dion
- From the Division of Vascular Surgery, Centre hospitalier universitaire de Montréal, Montreal, Que
| | - Laura Marie Drudi
- From the Division of Vascular Surgery, Centre hospitalier universitaire de Montréal, Montreal, Que
| | - Nathalie Beaudoin
- From the Division of Vascular Surgery, Centre hospitalier universitaire de Montréal, Montreal, Que
| | - Jean-François Blair
- From the Division of Vascular Surgery, Centre hospitalier universitaire de Montréal, Montreal, Que
| | - Stéphane Elkouri
- From the Division of Vascular Surgery, Centre hospitalier universitaire de Montréal, Montreal, Que
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Lloyd C, Ludbrook G, Story D, Maddern G. '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'. BMJ Open 2020; 10:e027262. [PMID: 32139478 PMCID: PMC7059488 DOI: 10.1136/bmjopen-2018-027262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Courtney Lloyd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Guy Ludbrook
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - David Story
- Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Guy Maddern
- Discipline of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Lee SE, Cho WH, Lee SK, Byun KS, Son BS, Jeon D, Kim YS, Yeo HJ. Routine intensive monitoring but not routine intensive care unit-based management is necessary in video-assisted thoracoscopic surgery lobectomy for lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:129. [PMID: 31157250 DOI: 10.21037/atm.2019.02.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Evidence for immediate postoperative intensive care unit (ICU) care is still lacking in the era of minimally invasive video-assisted thoracic surgery (VATS). We evaluated the safety and feasibility of general ward (GW) care after VATS lobectomy for lung cancer. Methods A total of 451 patients who underwent VATS lobectomy for lung cancer between June 2012 and August 2017 were retrospectively studied. The patients were divided into two groups (ICU 344 vs. GW 107). We compared the postoperative complications and mortality between the two groups after propensity score matching. Furthermore, we evaluated the clinical factors associated with complications, and stratified patients according to the risk for complications. Results Immediate complications (within 24 hours after surgery) occurred in 0.4%. Non-immediate complications occurred in 18.8%. There were no differences in the incidence of complications and mortality between the two groups, after propensity matching. However, the length of postoperative stay (12.6±10.0 vs. 10.3±4.1 days, P=0.041) was significantly higher in the ICU group than in the GW group. Multivariate regression analyses revealed that chronic obstructive pulmonary disease (COPD) [odds ratio (OR) =3.00, 95% confidence interval (CI): 1.51-5.97, P=0.002], non-stage I cancer (OR =2.54, 95% CI: 1.39-4.62, P=0.002), multi-port surgery (OR =3.75, 95% CI: 2.18-6.44, P<0.001), and age ≥60 years (OR =2.12, 95% CI: 1.03-4.37, P=0.042) were associated with complications. Immediate postoperative care in GW had no influence on complications. Conclusions Immediate postoperative care after VATS lobectomy for lung cancer in GW was safe and feasible without poor outcomes. Therefore, selective intensive monitoring for high risk groups may offer cost-saving and efficient use of ICU resources.
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Affiliation(s)
- Seung Eun Lee
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Woo Hyun Cho
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Sang Kwon Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Ki Sup Byun
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Doosoo Jeon
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
| | - Hye Ju Yeo
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan-si, Gyeongsangnam-do 626-770, Republic of Korea
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Cagini L, Andolfi M. N-terminal pro B-type natriuretic peptide and the risk of acute kidney injury after lung cancer surgery. J Thorac Dis 2019; 10:6430-6431. [PMID: 30746182 DOI: 10.21037/jtd.2018.11.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lucio Cagini
- Unit of Thoracic Surgery, University of Perugia Medical School, Perugia, Italy
| | - Marco Andolfi
- Unit of Thoracic Surgery, AOU Ospedali Riuniti di Ancona, Ancona, Italy
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Acute kidney injury after lung cancer surgery: Incidence and clinical relevance, predictors, and role of N-terminal pro B-type natriuretic peptide. Lung Cancer 2018; 123:155-159. [PMID: 30089588 DOI: 10.1016/j.lungcan.2018.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/25/2018] [Accepted: 07/07/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) frequently occurs in several medical and surgical settings, and it is associated with increased morbidity and mortality. In patients undergoing lung cancer surgery, AKI has not been fully investigated. We prospectively evaluated the incidence, clinical relevance, and risk factors of AKI in patients undergoing lung cancer surgery. Moreover, we estimated the accuracy of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the prediction of AKI. METHODS Patients undergoing lung cancer surgery were included in the study. Plasma NT-proBNP was measured before and soon after surgery. Postoperative AKI was defined according to the Acute Kidney Injury Network (AKIN) classification. RESULTS A total of 2179 patients were enrolled. Of them, 222 (10%) developed AKI and had a more complicated in-hospital clinical course (overall complication rate: 35% vs. 16%; P < 0.0001), and a longer hospital stay (10 ± 7 vs. 7 ± 4 days; P < 0.0001). The incidence of AKI increased in parallel with the extent of lung resection. Among the independent predictors of AKI, serum creatinine (area under the curve [AUC] 0.70 [95% CI 0.67-0.74]) and NT-proBNP (AUC 0.71 [95% CI 0.67-0.74]) provided the highest predictive accuracy, and their combination further significantly improved AKI prediction (AUC 0.74 [95% CI 0.71-0.77]). No difference in AKI prediction was observed between preoperative and postoperative NT-proBNP (P = 0.84). CONCLUSIONS Acute kidney injury occurs in 10% of patients undergoing lung cancer surgery, and it is associated with a high incidence of postoperative complications. The risk of AKI can be accurately predicted by the combined evaluation of preoperative serum creatinine and NT-proBNP.
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Meert AP, Grigoriu B, Licker M, Van Schil PE, Berghmans T. Intensive care in thoracic oncology. Eur Respir J 2017; 49:49/5/1602189. [DOI: 10.1183/13993003.02189-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.
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8
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Kose I, Zİncircioglu C, Çakmak M, Cabbaroglu G, Senoglu N, Gonullu M. Postoperative patients in the intensive care unit: Identifying those who do not really need it. J Crit Care 2015; 30:1295-8. [DOI: 10.1016/j.jcrc.2015.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/28/2015] [Accepted: 08/20/2015] [Indexed: 11/29/2022]
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Decreasing the Length of Stay in Phase I Postanesthesia Care Unit: An Evidence-Based Approach. J Perianesth Nurs 2015; 30:116-23. [DOI: 10.1016/j.jopan.2014.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/28/2014] [Accepted: 05/16/2014] [Indexed: 11/19/2022]
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10
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Lalani SB, Ali F, Kanji Z. Prolonged-Stay Patients in the PACU: A Review of the Literature. J Perianesth Nurs 2013; 28:151-5. [DOI: 10.1016/j.jopan.2012.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/30/2012] [Accepted: 06/19/2012] [Indexed: 10/26/2022]
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Osinaike BB, Akinyemi OA, Sanusi AA. ICU Cutilization by Cardio-Thoracic Patients in a Nigerian Teaching Hospital: Any Role for HDU? Niger J Surg 2012; 18:75-9. [PMID: 24027398 PMCID: PMC3762008 DOI: 10.4103/1117-6806.103108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The underlying pathological conditions in cardio-thoracic patients, anesthetic and operative interventions often lead to complex physiological interactions that necessitate ICU care. Our objectives were to determine the intensive care unit (ICU) utilization by cardio-thoracic patients in our centre, highlight the common indications for admission; and evaluate the interventions provided in the ICU and the factors that determined outcome. Materials and Methods: The intensive care unit (ICU) records of University College Hospital, Ibadan for a period of 2 years (October 2007 to September 2009) were reviewed. Data of cardio-thoracic patients were extracted and used for analysis. Information obtained included the patient demographics, indications for admission, interventions offered in the ICU and the outcome. Results: A total of 1, 207 patients were managed in the ICU and 206 cardio-thoracic procedures were carried out during the study period. However, only 96 patients were admitted into the ICU following cardio-thoracic procedures, accounting for 7.9% of ICU admissions and 46.6% of cardio-thoracic procedures done within the review period. The mean length of stay and ventilation were 5.71 ± 5.26 and 1.30 ± 2.62 days. The most significant predictor of outcome was endotracheal intubation (P = 0.001) and overall mortality was 15%. Conclusion: There is a high utilization of the ICU by cardio-thoracic patients in our review and post-operative care was the main indication for admission. Some selected cases may be managed in the HDU to reduce the burden on ICU resources. We opine that when endotracheal intubation is to continue in the ICU, a 1:1 patient ratio should be instituted.
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Affiliation(s)
- Babatunde B Osinaike
- Department of Anaesthesia, College of Medicine, University of Ibadan, Ibadan, Nigeria
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Lalani SB, Kanji Z, Ali F. Experiences of nurses related to prolonged-stay patients in a postanesthesia care unit in Karachi, Pakistan. J Perianesth Nurs 2012; 27:26-36. [PMID: 22264619 DOI: 10.1016/j.jopan.2011.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 06/28/2011] [Accepted: 10/30/2011] [Indexed: 11/17/2022]
Abstract
The role of the postanesthesia care unit (PACU) is to provide short-term monitoring of patients after surgery until recovery from anesthesia. The transfer of patients from the PACU to their designated units, however, may be delayed for various reasons. A qualitative descriptive approach was used to explore the experiences of six nurses working in the PACU at a tertiary care hospital in Pakistan. Data were collected using semistructured interviews. The data were grouped into categories and subcategories. An overarching theme that was derived from the content analysis was that of the factors impacting quality patient care. The content analysis generated a broad category of "general effects" and subcategories that included patients, families, and PACU nurses. The findings highlight the effects of prolonged PACU stays on patients, their families, and PACU nurses.
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Park SY, Park IK, Hwang Y, Byun CS, Bae MK, Lee CY. Immediate Postoperative Care in the General Thoracic Ward Is Safe for Low-risk Patients after Lobectomy for Lung Cancer. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:229-35. [PMID: 22263157 PMCID: PMC3249308 DOI: 10.5090/kjtcs.2011.44.3.229] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 12/30/2010] [Accepted: 05/10/2011] [Indexed: 11/23/2022]
Abstract
Background Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. Materials and Methods 316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort. Results Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome. Conclusion Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.
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Affiliation(s)
- Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Korea
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Grade M, Quintel M, Ghadimi BM. Standard perioperative management in gastrointestinal surgery. Langenbecks Arch Surg 2011; 396:591-606. [PMID: 21448724 PMCID: PMC3101361 DOI: 10.1007/s00423-011-0782-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 03/08/2011] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The outcome of patients who are scheduled for gastrointestinal surgery is influenced by various factors, the most important being the age and comorbidities of the patient, the complexity of the surgical procedure and the management of postoperative recovery. To improve patient outcome, close cooperation between surgeons and anaesthesiologists (joint risk assessment) is critical. This cooperation has become increasingly important because more and more patients are being referred to surgery at an advanced age and with multiple comorbidities and because surgical procedures and multimodal treatment modalities are becoming more and more complex. OBJECTIVE The aim of this review is to provide clinicians with practical recommendations for day-to-day decision-making from a joint surgical and anaesthesiological point of view. The discussion centres on gastrointestinal surgery specifically.
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Affiliation(s)
- Marian Grade
- Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - B. Michael Ghadimi
- Department of General and Visceral Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
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Licker M, Cartier V, Robert J, Diaper J, Villiger Y, Tschopp JM, Inan C. Risk factors of acute kidney injury according to RIFLE criteria after lung cancer surgery. Ann Thorac Surg 2011; 91:844-50. [PMID: 21353011 DOI: 10.1016/j.athoracsur.2010.10.037] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 10/13/2010] [Accepted: 10/18/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Perioperative acute kidney injury (AKI) is associated with increased mortality and morbidity. Our aim was to evaluate the incidence and determinants of AKI using the risk, injury, failure, loss of function, and end-stage kidney disease (RIFLE) criteria in thoracic surgical patients. METHODS We retrospectively analyzed a cohort of patients undergoing lung cancer surgery from 1996 to 2009. Patient management was protocol-driven, and postoperative complications were prospectively collected. The primary outcome was AKI within 3 days after surgery. A variety of patient comorbidities and operative characteristics were evaluated as potential predictors of AKI using a multiple logistic regression model. RESULTS Complete data were obtained from 1,345 patients, and the incidence of AKI was 6.8%. Four independent risk factors for AKI were identified: American Society of Anesthesiologists classes 3 and 4 (odds ratio [OR] 2.60, 95% confidence interval [CI]: 1.03 to 6.55), forced expiratory volume in 1 second (OR 0.55, 95% CI: 0.32 to 0.96), the use of vasopressors (OR 1.015, 95% CI: 0.998 to 1.035), and the duration of anesthesia (OR 1.044, 95% CI: 1.001 to 1.008). Patients who experienced AKI were more frequently admitted to the intensive care unit (24.2% versus 3.5% for patients without AKI, p < 0.05); they had increased mortality (19.8% versus 1.1%, p < 0.05) and a threefold to fourfold higher incidence of cardiopulmonary complications. CONCLUSIONS The RIFLE classification is a valuable tool to assess AKI after lung cancer surgery. The severity of perioperative renal impairment is associated with increased mortality and morbidity.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital, University of Geneva, Geneva, Switzerland.
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Sobol JB, Wunsch H. Triage of high-risk surgical patients for intensive care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:217. [PMID: 21457500 PMCID: PMC3219413 DOI: 10.1186/cc9999] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Julia B Sobol
- Department of Anesthesiology, Columbia University, 622 West 168th Street, PH5-505, New York, NY 10032, USA
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Laake JH, Dybwik K, Flaatten HK, Fonneland IL, Kvåle R, Strand K. Impact of the post-World War II generation on intensive care needs in Norway. Acta Anaesthesiol Scand 2010; 54:479-84. [PMID: 19930244 DOI: 10.1111/j.1399-6576.2009.02170.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A high birth rate during the first two decades following World War II has increased the proportion of elderly people in present-day society and, consequently, the demand for health-care services. The impact on intensive care services may become dramatic because the age distribution of critically ill patients is skewed towards the elderly. We have used registry data and population statistics to forecast the demand for intensive care services in Norway up until the year 2025. METHODS Data collected by the Norwegian intensive care registry (NIR), showing the age distribution in Norwegian intensive care units (ICU) during the years 2006 and 2007, were used with three different Norwegian prognostic models of population growth for the years 2008-2025 to compute the expected increase in intensive care unit bed-days (ICU bed-days). RESULTS The elderly were overrepresented in Norwegian ICUs in 2006-2007, with patients from 60 to 79 years of age occupying 44% of ICU bed-days. Population growth from 2008 to 2025 was estimated to be from 11.1 to 26.4%, depending on the model used. Growth will be much larger in the age group 60-79 years. Other factors kept unchanged, this will result in an increase in the need for intensive care (ICU bed-days) of between 26.1 and 36.9%. CONCLUSION The demand for intensive care beds will increase markedly in Norwegian hospitals in the near future. This will have serious implications for the planning of infrastructure, education of health care personnel, as well as financing of our health care system.
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Affiliation(s)
- J H Laake
- Department of Anaesthesia and Intensive Care Medicine, Rikshospitalet Medical Centre, Oslo University Hospital, Oslo, Norway.
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Brunelli A. Risk Assessment for Pulmonary Resection. Semin Thorac Cardiovasc Surg 2010; 22:2-13. [DOI: 10.1053/j.semtcvs.2010.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2010] [Indexed: 12/20/2022]
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Solier M, Liu N, Fischler M. Enquête sur les pratiques d'analgésie après thoracotomie. ACTA ACUST UNITED AC 2004; 23:681-8. [PMID: 15324955 DOI: 10.1016/j.annfar.2004.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2003] [Accepted: 05/19/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate qualitatively and quantitatively analgesic methods used after thoracotomy. METHODS Postal questionnaire addressed to all French public (34 academic institutions, 37 public hospitals) and private hospitals (60), which routinely perform pulmonary surgery. RESULTS Analysis of the questionnaires related only to those coming from academic institutions (rate of response of 85%) and from private hospitals (60%). Intravenous patient-controlled analgesia, thoracic epidural analgesia and intrathecal analgesia are the most frequently suggested techniques of analgesia. Thoracic epidural analgesia is more frequently suggested in private hospitals than in academic institutions (77% vs. 55%, NS). There is no significant difference between academic institutions and private hospitals regarding the practised analgesic technique. Analysis of the practices of thoracic epidural analgesia and of intrathecal analgesia in particular showed limited impact of guidelines concerning preoperative administration of anticoagulants in 15-20% of the centres. Only six (in the academic institutions) to 18% (in the private hospitals) of the patients receiving thoracic epidural analgesia were hospitalised in a surgical ward. Thoracic epidural analgesia is continued generally for more than 48 h; there is however a significant difference between centres since epidural analgesia is continued longer in academic institutions than in private hospitals. CONCLUSION Intravenous patient-controlled analgesia and thoracic epidural analgesia are the most commonly analgesic techniques used after thoracotomy for pulmonary surgery. In the latter case, most centres choose to maintain these patients in high dependency units.
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Affiliation(s)
- M Solier
- Service d'anesthésie, hôpital Foch, 40, rue Worth, 92150 Suresnes, France
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