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Davis H, Tseng S, Chua W. Oncology Intensive Care Units: Distinguishing Features and Clinical Considerations. J Intensive Care Med 2024:8850666241268857. [PMID: 39175394 DOI: 10.1177/08850666241268857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.
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Affiliation(s)
- Hugh Davis
- Division of Pulmonary and Critical Care, City of Hope National Medical Center, Duarte, USA
| | - Steve Tseng
- Division of Pulmonary and Critical Care, City of Hope National Medical Center, Duarte, USA
| | - Weijia Chua
- Division of Pulmonary and Critical Care, Cedars Sinai Medical Center, Los Angeles, USA
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Sutton TL, Potter KC, O'Grady J, Aziz M, Mayo SC, Pommier R, Gilbert EW, Rocha F, Sheppard BC. Intensive care unit observation after pancreatectomy: Treating the patient or the surgeon? J Surg Oncol 2022; 125:847-855. [DOI: 10.1002/jso.26800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/21/2021] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas L. Sutton
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon USA
| | | | | | - Michael Aziz
- Department of Anesthesiology and Perioperative Medicine OHSU Portland Oregon USA
| | - Skye C. Mayo
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Rodney Pommier
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Erin W. Gilbert
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon USA
| | - Flavio Rocha
- Division of Surgical Oncology OHSU Department of Surgery Portland Oregon USA
| | - Brett C. Sheppard
- Department of Surgery Oregon Heath and Science University (OHSU) Portland Oregon 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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Cerullo M, Gani F, Chen SY, Canner JK, Dillhoff M, Cloyd J, Pawlik TM. Routine intensive care unit admission among patients undergoing major pancreatic surgery for cancer: No effect on failure to rescue. Surgery 2019; 165:741-746. [DOI: 10.1016/j.surg.2018.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/29/2018] [Accepted: 11/13/2018] [Indexed: 12/13/2022]
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abularrage CJ, Sheridan MJ, Mukherjee D. Endovascular versus “Fast-Track” Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2016; 39:229-36. [PMID: 15920651 DOI: 10.1177/153857440503900303] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 ±0.13 vs 6.1 ±0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 ±7.4 vs 158 ±6.8 minutes, p<0.0001), with a greater volume of blood (1.8 ±0.29 vs 0.32 ±0.24 units, p=0.0005), colloid (565 ±89 vs 32 ±22 cc, p<0.0001), and crystalloid transfusions (4,625 ±252 vs 2,627 ±170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 ±0.08 vs 1.8 ±0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 ±0.10 vs 0.87 ±0.10 days, p=0.01), but floor (2.1 ±0.23 vs 2.6 ±0.21 days, p=0.17), and total hospital lengths of stay (2.8 ±0.32 vs 3.4 ±0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track ($10,205 ±$736 vs $20,640 ±$1,206, p<0.0001) leading to greater overall hospital earnings ($6,141 ±$1,280 vs $107 ±$1,940, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.
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Fast-track in Abdominal Aortic Surgery: Experience in Over 1,000 Patients. Ann Vasc Surg 2015; 29:1151-9. [DOI: 10.1016/j.avsg.2015.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 02/05/2015] [Accepted: 02/05/2015] [Indexed: 01/05/2023]
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Sim YS, Lee JH, Chang JH, Ryu YJ. Clinical Outcome and Prognosis of Patients Admitted to the Surgical ICU after Abdomen Surgery. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Singh S, Maldonado Y, Taylor MA. Optimal perioperative medical management of the vascular surgery patient. Anesthesiol Clin 2014; 32:615-637. [PMID: 25113724 DOI: 10.1016/j.anclin.2014.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. β-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.
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Affiliation(s)
- Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA.
| | - Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
| | - Mark A Taylor
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, 2570 Haymaker Road, Pittsburgh, PA 15146, USA
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Vandy FC, Campbell D, Eliassen A, Rectenwald J, Eliason JL, Criado E, Escobar G, Upchurch GR. Specialized vascular floors after open aortic surgery: cost containment while preserving quality outcomes. Ann Vasc Surg 2013; 27:45-52. [PMID: 23257073 DOI: 10.1016/j.avsg.2012.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 09/01/2012] [Accepted: 09/07/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Postoperative care of open abdominal aortic surgery (OAAS) traditionally involves the intensive care unit (ICU). We hypothesized that in patients without an indication for postoperative ICU admission, admission to a specialized vascular floor unit (hemodynamic monitoring, 2:1 nursing) offers cost savings to both payer and institution without compromising care. METHODS The electronic medical record was used to collect perioperative data for patients who underwent OAAS between July 2007 and July 2011. The university's cost accounting system provided information on revenue, total margin, and professional billing. Patients with ICU indications (spinal drain, Swan-Ganz monitoring, vasopressors, intubation, or blood product resuscitation) were excluded. Comparative cost and outcome analysis was performed on vascular ward and ICU admissions using the Fisher's exact test for dichotomous categorical variables and the Student's t-test for continuous variables. Long-term survival comparison was calculated using Kaplan-Meier survival estimates. RESULTS One hundred thirty of 215 patients were included for analysis (85 excluded, 51 floor, 79 ICU). Perioperative data amongst the floor and ICU cohorts were similar. Day of operation professional billing fees were comparable (ICU $13,365 vs. floor $12,626; P = 0.18); however, postoperative professional fees were significantly higher in the ICU cohort (ICU $3,258 vs. floor $2,101; P = 0.001) primarily because of intensivist billing. The hospital generated an average of 8.7% more revenue from the ICU cohort (ICU $37,770 vs. floor $34,756; P = 0.023). This was offset by greater expenses in the ICU cohort (ICU $30,756 vs. floor $25,144; P = 0.02), yielding a hospital profit margin of 107.5% favoring floor admission (ICU $2,858 vs. floor $5,931; P = 0.19). Duration of stay was similar (ICU 8.0 days vs. floor 7.8 days; P = 0.86). Kaplan-Meier survival analysis was not significantly different between cohorts (ICU 10.1%, median follow-up, 1,070 days vs. floor 0%, median follow-up, 405 days; P = 0.13). CONCLUSIONS Postoperative admission to the ICU is not always necessary after OAAS. Specialized vascular floors offer a financial savings to both payer and institution, which allows for simultaneous cost containment while preserving quality outcomes.
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Affiliation(s)
- Frank C Vandy
- University of Michigan Cardiovascular Center, Ann Arbor, MI, USA
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Shum S, Tanzola R, McMullen M, Hopman WM, Engen D. How well are prebooked surgical step-down units utilized? J Clin Anesth 2013; 25:202-8. [PMID: 23523574 DOI: 10.1016/j.jclinane.2012.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 10/04/2012] [Accepted: 10/06/2012] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To evaluate the utilization of the surgical step-down unit (SSDU) by a sample of patients who were preoperatively booked for admission to the unit, and to identify those patient characteristics and perioperative variables that are associated with an intervention in the unit. DESIGN Retrospective chart review. SETTING Canadian tertiary-care facility. MEASUREMENTS Data from 133 elective surgery patients with prebooked SSDU beds were recorded, including comorbidities, Surgical Risk Scale (SRS), Surgical Apgar Score (SAS), and number and nature of interventions and events occurring in the SSDU. MAIN RESULTS Of the 133 patients scheduled for SSDU admission, 60 (45.1%) were actually admitted and the other 73 (54.9%) were admitted directly to the surgical ward or else discharged. Of the patients admitted to the SSDU, 48.3% had an intervention during their stay. In logistic regression, the SRS was a significant predictor (P < 0.001) of SSDU use, while the SAS was a significant predictor (P = 0.034) of the need for an intervention or the likelihood of an event while in the SSDU. CONCLUSIONS Less than half of patients identified were actually admitted to the SSDU postoperatively; of those, less than half required an intervention. The Surgical Apgar Score, a score based on intraoperative factors, predicted the need for an intervention during SSDU admission. Consideration should be given to the development of a predictive score that emphasizes intraoperative factors and early postoperative factors to optimize allocation of this scarce resource.
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Affiliation(s)
- Serena Shum
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, ON K7L 2V7, Canada
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Kim SH, Lee JG, Kwon SY, Lim JH, Kim WO, Kim KS. Is close monitoring in the intensive care unit necessary after elective liver resection? JOURNAL OF THE KOREAN SURGICAL SOCIETY 2012; 83:155-61. [PMID: 22977762 PMCID: PMC3433552 DOI: 10.4174/jkss.2012.83.3.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/14/2012] [Accepted: 07/14/2012] [Indexed: 02/06/2023]
Abstract
Purpose Many surgical patients are admitted to the intensive care unit (ICU), resulting in an increased demand, and possible waste, of resources. Patients who undergo liver resection are also transferred postoperatively to the ICU. However, this may not be necessary in all cases. This study was designed to assess the necessity of ICU admission. Methods The medical records of 313 patients who underwent liver resections, as performed by a single surgeon from March 2000 to December 2010 were retrospectively reviewed. Results Among 313 patients, 168 patients (53.7%) were treated in the ICU. 148 patients (88.1%) received only observation during the ICU care. The ICU re-admission and intensive medical treatment significantly correlated with major liver resection (odds ratio [OR], 6.481; P = 0.011), and intraoperative transfusions (OR, 7.108; P = 0.016). Patients who underwent major liver resection and intraoperative transfusion were significantly associated with need for mechanical ventilator care, longer postoperative stays in the ICU and the hospital, and hospital mortality. Conclusion Most patients admitted to the ICU after major liver resection just received close monitoring. Even though patients underwent major liver resection, patients without receipt of intraoperative transfusion could be sent to the general ward. Duration of ICU/hospital stay, ventilator care and mortality significantly correlated with major liver resection and intraoperative transfusion. Major liver resection and receipt of intraoperative transfusions should be considered indicators for ICU admission.
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Affiliation(s)
- Sung Hoon Kim
- Department of Surgery, Wonju Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010:CD006632. [PMID: 20238347 DOI: 10.1002/14651858.cd006632.pub2] [Citation(s) in RCA: 294] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.
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Affiliation(s)
- Thomas Rotter
- Department of Public Health, Dresden Medical School, University of Dresden, Dresden, Germany, D-01307
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Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2-49. [PMID: 19786250 DOI: 10.1016/j.jvs.2009.07.002] [Citation(s) in RCA: 453] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Elliot L Chaikof
- Department of Surgery, Emory University, Atlanta, Ga 30322, USA.
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Reduced access aortic exposure (RAAE) technique for infrarenal abdominal aortic aneurysm (AAA) repair. Int J Surg 2009; 7:159-62. [PMID: 19268645 DOI: 10.1016/j.ijsu.2008.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 12/07/2008] [Accepted: 12/15/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A reduced access aortic exposure (RAAE) technique for repair of infrarenal AAA repair has been evaluated and the short-term surgical outcomes are compared with conventional open repair (OPEN). METHODS All consecutive patients having repair of infrarenal AAA over a period of 3 years were included in this study. A group of these patients had AAA repair using the RAAE technique with a small midline incision (<8 cm). Patient characteristics and peri-operative outcomes were compared with the other group treated with the traditional full-length midline incision (OPEN). RESULTS Sixty patients underwent AAA repair in this study (38 in the RAAE group and 22 in the OPEN group). The age, sex distribution and co-morbidities were similar across the two groups (median age 76 and 75 years respectively). The RAAE group had a significantly shorter Intensive care stay (2 vs. 4 days, p=0.041) and a shorter total hospital stay (9 vs. 14 days, p=0.004). Significant postoperative chest infection was recorded in 13% (5/38) in the RAAE group as compared to 41% (9/21) in the OPEN group (p=0.025). CONCLUSIONS The RAAE technique for infra renal AAA repair is feasible and safe, and allows quicker postoperative recovery with comparable morbidity and mortality to the conventional technique.
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Weissman C, Klein N. Who receives postoperative intensive and intermediate care? J Clin Anesth 2008; 20:263-70. [PMID: 18617123 DOI: 10.1016/j.jclinane.2007.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Revised: 11/02/2007] [Accepted: 11/19/2007] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVES To examine the effects of preoperative and intraoperative factors that determine whether to provide postoperative intensive or intermediate care. DESIGN Prospective observational study. SETTING Tertiary-care university hospital. PATIENTS 3,066 ASA physical status I, II, III, and IV adult patients, 1,233 of whom were transferred to floor or the ambulatory surgery unit after a short postoperative recovery room stay (group 1), whereas the other 1,883 were admitted to intermediate and intensive care areas (group 2). INTERVENTIONS None. MEASUREMENTS Demographic and clinical information including preoperative medical history, extent of intraoperative care, and postoperative course were collected. Intraoperative activities were examined with the Operative Complexity Score and the Intraoperative Therapeutic Intensity Score. RESULTS Almost all patients undergoing complex surgery (cardiac surgery and neurosurgery) received postoperative intermediate or intensive care, even if they had no significant underlying systemic diseases (ASA physical status I and II). Patients with severe underlying diseases (ASA physical status III and IV), but who underwent less extensive surgery, tended to receive intensive and intermediate care. Postoperative mechanical ventilation was associated with receipt of intensive rather than intermediate care. Interestingly, 10% of the elective surgery patients in group 2 unexpectedly received intensive or intermediate care because of intraoperative and immediate postoperative complications. CONCLUSIONS Receipt of postoperative intermediate and intensive care is associated with distinct patterns of preoperative and intraoperative factors.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel.
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Teli M, Morris-Stiff G, Rees JR, Woodsford PV, Lewis MH. Vascular surgery, ICU and HDU: a 14-year observational study. Ann R Coll Surg Engl 2008; 90:291-6. [PMID: 18492391 DOI: 10.1308/003588408x241980] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Mary Teli
- Department of Surgery, Royal Glamorgan Hospital, Ynysmaerdy, Llantrisant, UK
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Weissman C, Klein N. The importance of differentiating between elective and emergency postoperative critical care patients. J Crit Care 2008; 23:308-16. [PMID: 18725034 DOI: 10.1016/j.jcrc.2007.10.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 10/05/2007] [Accepted: 10/11/2007] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of the study is to demonstrate the importance of separately analyzing data on elective and emergency surgery patients admitted postoperatively to intensive and intermediate care units. MATERIALS AND METHODS A prospective observational study was performed in a tertiary care university hospital to assess the demographic and clinical differences between emergency and elective surgical patients (>14 years old). Group 1 included patients transferred to a floor bed or the ambulatory surgery unit for discharge home after a short stay (<12 hours) in the postanesthesia care unit. Group 2 patients were admitted to the cardiothoracic intensive care unit (ICU), neurosurgical ICU, general ICU, or for an extended intermediate care postanesthesia care unit stay (>12 hours). RESULTS In groups 1 (n = 1059), there were significant differences between the elective and emergency patients. Emergency, as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting illnesses (ie, had higher American Society of Anesthesiology classifications), underwent different and shorter operations, required prolonged postoperative mechanical ventilation, required longer ICU stays, and had higher mortality. CONCLUSIONS Substantial differences between elective and emergency surgery patients have important implications when conducting and reporting research on the nature, extent, and outcome of postoperative ICU care.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine, Hadassah-Hebrew University Medical Center, Hebrew University-Hadassah School of Medicine, Jerusalem, Israel
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Keegan MT, Whalen FX, Brown DR, Roy TK, Afessa B. Acute Physiology and Chronic Health Evaluation (APACHE) III outcome prediction after major vascular surgery. J Cardiothorac Vasc Anesth 2008; 22:713-8. [PMID: 18922428 DOI: 10.1053/j.jvca.2008.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system in patients admitted to the intensive care unit (ICU) after major vascular surgery. DESIGN Retrospective cohort study. SETTING A tertiary referral center. PARTICIPANTS Three thousand one hundred forty-eight patients who underwent major vascular surgery between October 1994 and March 2006. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were abstracted from an institutional APACHE III database. Standardized mortality ratios (SMRs) (with 95% confidence intervals) were calculated. The area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow C statistic were used to assess discrimination and calibration, respectively. The mean age of 3,148 patients studied was 70.5 years (+/- standard deviation 9.6). The mean Acute Physiology Score and the APACHE III score on the day of ICU admission were 31.0 (+/- 17.5) and 45.1 (+/- 18.8), respectively. The mean predicted ICU and hospital mortality rates were 3.2% (+/- 7.8%) and 5.0% (+/- 9.5%), respectively. The median (and interquartile range) ICU and hospital lengths of stay were 4.3 (3.6-5.1) and 14 days (11.9-16.8 days), respectively. The observed ICU mortality rate was 2.4% (75/3, 148 patients) and hospital mortality rate was 3.7% (116/3,148). The ICU and hospital SMRs were 0.74 (0.58-0.91) and 0.74 (0.61-0.88), respectively. The AUC of APACHE III-derived prediction of hospital mortality was 0.840 (95% confidence interval, 0.799-0.880), indicating excellent discrimination. The Hosmer-Lemeshow C statistic was 28.492, with a p value <0.01, indicating poor calibration. CONCLUSIONS The APACHE III scoring system discriminates well between survivors and nonsurvivors after major vascular surgery, but calibration of the model is poor.
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Affiliation(s)
- Mark T Keegan
- Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN 55905, USA.
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Marrocco-Trischitta MM, Melissano G, Chiesa R. Letter to the editor regarding "Fast track open aortic surgery: reduced post operative stay with a goal directed pathway". M.A. Murphy, T. Richards, C. Atkinson, J. Perkins and L.J. Hands. Eur J Vasc Endovasc Surg 2007;34:274-278. Eur J Vasc Endovasc Surg 2007; 35:251. [PMID: 18065246 DOI: 10.1016/j.ejvs.2007.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 10/17/2007] [Indexed: 10/22/2022]
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Callaghan CJ, Lynch AG, Amin I, Fazel M, Lindop MJ, Gaunt ME, Varty K. Overnight Intensive Recovery: Elective Open Aortic Surgery Without a Routine ICU Bed. Eur J Vasc Endovasc Surg 2005; 30:252-8. [PMID: 16061164 DOI: 10.1016/j.ejvs.2005.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2004] [Accepted: 03/03/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Most patients are managed on the intensive care unit (ICU) after elective open aortic surgery. We preoperatively identify patients suitable for extubation in theatre with overnight management in theatre recovery before discharge back to the ward (overnight intensive recovery (OIR)). The safety of this was investigated. DESIGN Retrospective case note analysis of all patients who underwent EOAS from 1998 to 2002, recording in-hospital morbidity and mortality. Physiological and operative severity score for the enUmeration of mortality and morbidity (POSSUM) data were collected prospectively. METHODS Patients were divided into those selected for OIR and those booked for elective ICU admission. Observed morbidity and mortality data were compared with predicted outcomes generated by Portsmouth-POSSUM and POSSUM equations. RESULTS Hundred and fifty-two out of 178 patients used OIR; 155 patients had abdominal aortic aneurysm (AAA) repair. The elective ICU group had significantly higher anaesthetic risk scores (ASA grade), larger AAA, greater intraoperative blood loss and longer operations. In the OIR group, ten patients (7%) needed ICU admission within 48h postoperatively. Complications occurred in 85/152, with two deaths. There was no excess morbidity or mortality in the OIR group (predicted 95% CI 83-105 and 5-17, respectively). CONCLUSION Most patients having elective open aortic surgery can be managed safely using OIR.
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Affiliation(s)
- C J Callaghan
- Cambridge Vascular Unit, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
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Abstract
Providing effective critical care to vascular surgical patients is challenging to the intensivist. These patients often have multiple significant concurrent diseases that need to be adequately managed. A selective policy for identifying patients that need ICU is recommended. Early and smooth restoration to their preoperative physiological homeostasis is crucial. Optimal pain relief, return to normothermia, and adequate intravascular volume replacement are thus key interventions. Epidurals provide excellent analgesia. Vigilant monitoring and decisive therapy of the wide range of complications that may occur in the postoperative is of paramount importance. The level of monitoring should be an extension of that done intraoperatively. Hemorrhage and thrombosis are dreaded sequelae; cardiac morbidity and mortality is significant. Respiratory complications may necessitate prolonged postoperative mechanical ventilation. Careful clinical evaluation is necessary to detect the various neurological complications that may occur. Renal and gastrointestinal complications are potentially lethal. Graft sepsis may occur later. The development of new techniques, such as endovascular repairs of aneurysms, may minimize the need for ICU.
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Affiliation(s)
- P Dean Gopalan
- Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of Natal, 719 Umbilo Road, Durban 4013, South Africa.
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Schweizer A, Khatchatourian G, Höhn L, Spiliopoulos A, Romand J, Licker M. Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery. J Clin Anesth 2002; 14:486-93. [PMID: 12477582 DOI: 10.1016/s0952-8180(02)00403-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVES To assess the impact of a new postanesthesia care unit (PACU) on intensive care unit (ICU) utilization, hospital length of stay, and complications following major noncardiac surgery. DESIGN Observational study. SETTING University hospital. PATIENTS AND MEASUREMENTS From 1992 to 1999, 915 patients underwent either abdominal aortic reconstruction (n = 448) or lung resection for cancer (n = 467). Demographic, clinical, surgical, and anesthetic data, as well as perioperative complications, were abstracted from two institutional databases. INTERVENTIONS Patients were divided in two study periods, before and after the opening of a new PACU (period 1992-1995 and period 1996-1999). MAIN RESULTS Utilization of ICU decreased from 35% to 16% for vascular patients and from 57% to less than 4% for thoracic patients during the second period. Readmission to the ICU, perioperative mortality, and respiratory complications were comparable between the two periods. Patients with congestive heart failure, chronic obstructive pulmonary disease, or renal insufficiency were more likely to be admitted to the ICU than the PACU. Following vascular surgery the frequency of cardiac complications decreased from 10.6% in 1992-1995 to 5.2% in 1996-1999 (p < 0.005), as well as the need for postoperative mechanical ventilation (25% vs. 12%; P < 0.05). CONCLUSIONS Increased availability of PACU beds resulted in reduced utilization of ICU resources without compromising patient care after major noncardiac surgery.
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Affiliation(s)
- Alexandre Schweizer
- Department of Anesthesiology, Pharmacology and Surgical Intensive Care, Clinic of Cardiovascular Surgery, and Division of Thoracic Surgery, University Hospital, Geneva, Switzerland
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Meurette G, Hamy A, Bizouarn P, Lehur PA. [Intensive care unit hospitalization after colorectal surgery]. ANNALES DE CHIRURGIE 2002; 127:356-61. [PMID: 12094418 DOI: 10.1016/s0003-3944(02)00772-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Intensive care units (ICU) support critically ill patients during the perioperative period. Few studies exist focusing on ICU hospitalisation after colorectal surgery. The objective of the study was to 1) detect predictive factors of mortality and length of stay in ICU after colorectal procedures, and 2) compare the autonomy status of the patients before and 30 days after their ICU stay. PATIENTS AND METHODS This study followed a prospective non randomized cohort in our colorectal surgery unit. During a period of one year (January 1st to December 31th, 2000) 351 colorectal procedures were performed and 54 patients were admitted to ICU after surgery. For each patient, 37 parameters were collected on a standardized register. Predictive factors of mortality (30 days after the procedure) and ICU stay (up to 3 days) were studied by univariate and multivariate statistical analysis. Self autonomy before surgery and 30 days after was also investigated. RESULTS "Multiple-intervention" was the only independent factor influencing mortality. Both "low autonomy status before surgery" and "pulmonary comorbidity" increased the length of stay. Regarding the 48 survivors, 45 (94%) recovered the same autonomy index as in the preoperative period 30 days after the procedure. CONCLUSION This study highlights the poor predictive factors influencing mortality during or after ICU stay following colorectal surgery, and emphasizes two preoperative parameters increasing the length of stay up to 3 days. This should guide the informations given to the patients families. Finally, this study confirms the good quality of self-sufficiency after ICU stay even for a long time (over 3 days).
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Affiliation(s)
- G Meurette
- Clinique chirurgicale II, pôle digestif, CHU Hôtel-Dieu, 1, place A. Ricordeau, 44093 Nantes, France
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Aquino RV, Jones MA, Zullo TG, Missig-Carroll N, Makaroun MS. Quality of Life Assessment in Patients Undergoing Endovascular or Conventional AAA Repair. J Endovasc Ther 2001. [DOI: 10.1583/1545-1550(2001)008<0521:qolaip>2.0.co;2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Aquino RV, Jones MA, Zullo TG, Missig-Carroll N, Makaroun MS. Quality of life assessment in patients undergoing endovascular or conventional AAA repair. J Endovasc Ther 2001; 8:521-8. [PMID: 11718412 DOI: 10.1177/152660280100800515] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare health-related quality of life outcomes in a cohort of abdominal aortic aneurysm (AAA) patients treated concurrently with either a conventional or endoluminal intervention. METHODS Between December 1997 and April 1999, 51 AAA patients treated by either open or endovascular techniques were enrolled in this prospective study. Conventional therapy was performed in 26 patients (19 men; mean age 70.4 +/- 6.0 years) with anatomical features unsuitable for the endovascular approach. Twenty-five patients (23 men; mean age 70.7 +/- 7.2 years) underwent endoluminal AAA exclusion using either the Ancure or bifurcated Enduring stent-grafts. The Medical Outcomes Study Short-Form 36-item health survey was administered preoperatively and at 1, 4, 8, and > or = 52 weeks after discharge. RESULTS At 1 week, both groups showed significant reductions (p < 0.001) in mean scores compared to baseline in 4 dimensions (physical function, social function, role-physical, and vitality), but the decline was more pronounced in patients having open repair. Endoluminal patients returned to their baseline scores by the 4th postoperative week, whereas complete recovery to baseline in the conventional patients was delayed to the 8th week. CONCLUSIONS Patients treated endoluminally exhibit better physical and functional scores as early as 1 week after discharge; they also return to baseline status significantly earlier than the conventional group. These findings document the perceived advantage of endovascular therapy over conventional AAA treatment.
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Affiliation(s)
- R V Aquino
- Department of Surgery, School of Nursing, University of Pittsburgh Medical Center, Pennsylvania 15213, USA
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