The ethics of interventional procedures for patients too ill for surgery

Cardiac risk stratification in emergency resection for colonic tumours

Background

Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

Methods

Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

Results

Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

Conclusion

This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

How to optimize critical care resources in surgical patients: intensive care without physical borders

PURPOSE OF REVIEW

Timely identification of surgery patients at risk of postoperative complications is important to improve the care process, including critical care. This review discusses epidemiology and impact of postoperative complications; prediction scores used to identify surgical patients at risk of complications, and the role of critical care in the postoperative management. It also discusses how critical care may change, with respect to admission to the ICU.

RECENT FINDING

Optimization of postoperative outcome, next to preoperative and intraoperative optimization, consists of using risk scores to early identify patients at risk of developing complications. Critical care consultancy should be performed in the ward after surgery, if necessary. ICUs could work at different levels of intensity, but remain preferably multidisciplinary, combining care for surgical and medical patients. ICU admission should still be considered for those patients at very high risk of postoperative complications, and for those receiving complex or emergency interventions.

SUMMARY

To optimize critical care resources for surgery patients at high risk of postoperative complications, the care process should not only include critical care and monitoring in ICUs, but also strict monitoring in the ward. Prediction scores could help to timely identify patients at risk. More intense care (monitoring) outside the ICU could improve outcome. This concept of critical care without borders could be implemented in the near future to optimize the local resources and improve patient safety. Predict more, do less in ICUs, and more in the ward.