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Wilson I, Rahman S, Pucher P, Mercer S. Laparoscopy in high-risk emergency general surgery reduces intensive care stay, length of stay and mortality. Langenbecks Arch Surg 2023; 408:62. [PMID: 36692646 PMCID: PMC9872062 DOI: 10.1007/s00423-022-02744-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/26/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Emergency general surgery patients undergoing laparoscopic surgery are at reduced risk of mortality and may require reduced length of critical care stay. This study investigated the effect of laparoscopy on high-risk patients' post-operative care requirements. METHODS Data were retrieved for all patients entered into the NELA database between 2013 and 2018. Only high-risk surgical patients (P-POSSUM predicted mortality risk of ≥ 5%) were included. Patients undergoing laparoscopic and open emergency general surgical procedures were compared using a propensity score weighting approach. Outcome measures included total length of critical care (level 3) stay, overall length of stay and inpatient mortality. RESULTS A total of 66,517 high-risk patients received emergency major abdominal surgery. A laparoscopic procedure was attempted in 6998 (10.5%); of these, the procedure was competed laparoscopically in 3492 (49.9%) and converted to open in 3506 (50.1%). Following inverse probability treatment weighting adjustment for patient disease and treatment characteristics, high-risk patients undergoing laparoscopic surgery had a shorter median ICU stay (1 day vs 2 days p < 0.001), overall hospital length of stay (11 days vs 14 days p < 0.001) and a lower inpatient mortality (16.0% vs 18.8%, p < 0.001). They were also less likely to have a prolonged ICU stay with an OR of 0.78 (95% CI 0.74-0.83, p < 0.001). CONCLUSION The results of this study suggest that in patients at high risk of post-operative mortality, laparoscopic emergency bowel surgery leads to a reduced length of critical care stay, overall length of stay and inpatient mortality compared to traditional laparotomy.
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Affiliation(s)
- Iain Wilson
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, PO3 6LY, UK
| | - Saqib Rahman
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, PO3 6LY, UK
| | - Philip Pucher
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, PO3 6LY, UK
| | - Stuart Mercer
- Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, PO3 6LY, UK.
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Shah V, Ahuja A, Kumar A, Anstey C, Thang C, Guo L, Shekar K, Ramanan M. Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand. J Cardiothorac Vasc Anesth 2022; 36:4313-4319. [PMID: 36207199 DOI: 10.1053/j.jvca.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand. DESIGN A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019. SETTING One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database. PARTICIPANTS Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve + coronary artery surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days = 3.21, 95% CI 2.88-3.58, p < 0.001). CONCLUSIONS Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.
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Affiliation(s)
- Vikram Shah
- Intensive Care Unit, Sunshine Coast University Hospital, Queensland, Australia
| | - Abhilasha Ahuja
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Logan, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Christopher Thang
- School of Medicine, Griffith University, Queensland, Australia; Department of Anaesthesia, Sunshine Coast University Hospital, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Linda Guo
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Kiran Shekar
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia; Critical Care Division, George Institute for Global Health, Level 5, Newtown, New South Wales, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia.
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El-Sayed Ahmad A, Bayram A, Salamate S, Sirat S, Amer M, Bakhtiary F. Percutaneous versus surgical femoral access in minimally invasive cardiac operations. Eur J Cardiothorac Surg 2022; 61:1348-1354. [PMID: 35445255 DOI: 10.1093/ejcts/ezab520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/15/2021] [Accepted: 10/03/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Both surgical and percutaneous femoral accesses for the establishment of extracorporeal circulation are used in minimally invasive cardiac surgeries. The goal of this study was to compare the outcomes with the MANTA vascular closure device after percutaneous arterial decannulation via the surgical approach. METHODS Between November 2018 and January 2021, a total of 490 consecutive patients underwent minimally invasive cardiac operations at our institution. Cannulation and decannulation of femoral vessels were under direct vision surgically or percutaneously. The MANTA system was used to close the femoral artery in all patients with percutaneous cannulation. Demographic, clinical and procedural data were collected retrospectively. RESULTS Surgical cut-down and suture closure of the femoral artery was performed in 222 patients (45.3%); percutaneous access and closure with the MANTA system was used in 268 patients (54.7%). The surgical group presented a significantly higher incidence of any access site complication compared to the percutaneous group [18 patients (8.1%) vs 6 patients (2.2%); P = 0.003]. Lymph fistula and wound healing disorders occurred more frequently in the surgical group (3.2% vs 0% [P = 0.004] and 3.6% vs 0% [P = 0.002], respectively). Median procedural duration and stays in the intensive care unit were significantly lower in the percutaneous group {127 [interquartile range (IQR) 97-158] min vs 150 (IQR 117-185) min (P < 0.001) and 1 (IQR 1-2) day vs 2 (IQR 1-3) days (P = 0.008), respectively}. CONCLUSIONS Percutaneous access and closure with the MANTA system are feasible, safe and associated with lower incidences of all-cause access site complications and shorter stays in the intensive care unit compared to surgical access and closure in minimally invasive cardiac surgeries.
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Affiliation(s)
- Ali El-Sayed Ahmad
- Division of Cardiac Surgery, Heart Centre Siegburg-Wuppertal, University Witten-Herdecke, Siegburg, Germany
| | - Ali Bayram
- Division of Cardiac Surgery, Heart Centre Siegburg-Wuppertal, University Witten-Herdecke, Siegburg, Germany
| | - Saad Salamate
- Division of Cardiac Surgery, Heart Centre Siegburg-Wuppertal, University Witten-Herdecke, Siegburg, Germany
| | - Sami Sirat
- Division of Cardiac Surgery, Heart Centre Siegburg-Wuppertal, University Witten-Herdecke, Siegburg, Germany
| | - Mohamed Amer
- Division of Cardiac Surgery, Heart Centre Siegburg-Wuppertal, University Witten-Herdecke, Siegburg, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
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Ramadori G. Albumin Infusion in Critically Ill COVID-19 Patients: Hemodilution and Anticoagulation. Int J Mol Sci 2021; 22:ijms22137126. [PMID: 34281177 PMCID: PMC8268290 DOI: 10.3390/ijms22137126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Hypercoagulation is one of the major risk factors for ICU treatment, mechanical ventilation, and death in critically ill patients infected with SARS-CoV-2. At the same time, hypoalbuminemia is one risk factor in such patients, independent of age and comorbidities. Especially in patients with severe SARS-CoV-2-infection, albumin infusion may be essential to improve hemodynamics and to reduce the plasma level of the main marker of thromboembolism, namely, the D-dimer plasma level, as suggested by a recent report. Albumin is responsible for 80% of the oncotic pressure in the vessels. This is necessary to keep enough water within the systemic circulatory system and for the maintenance of sufficient blood pressure, as well as for sufficient blood supply for vital organs like the brain, lungs, heart, and kidney. The liver reacts to a decrease in oncotic pressure with an increase in albumin synthesis. This is normally possible through the use of amino acids from the proteins introduced with the nutrients reaching the portal blood. If these are not sufficiently provided with the diet, amino acids are delivered to the liver from muscular proteins by systemic circulation. The liver is also the source of coagulation proteins, such as fibrinogen, fibronectin, and most of the v WF VIII, which are physiological components of the extracellular matrix of the vessel wall. While albumin is the main negative acute-phase protein, fibrinogen, fibronectin, and v WF VIII are positive acute-phase proteins. Acute illnesses cause the activation of defense mechanisms (acute-phase reaction) that may lead to an increase of fibrinolysis and an increase of plasma level of fibrinogen breakdown products, mainly fibrin and D-dimer. The measurement of the plasma level of the D-dimer has been used as a marker for venous thromboembolism, where a fourfold increase of the D-dimer plasma level was used as a negative prognostic marker in critically ill SARS-CoV-2 hospitalized patients. Increased fibrinolysis can take place in ischemic peripheral sites, where the mentioned coagulation proteins can become part of the provisional clot (e.g., in the lungs). Although critically ill SARS-CoV-2-infected patients are considered septic shock patients, albumin infusions have not been considered for hemodynamic resuscitation and as anticoagulants. The role of coagulation factors as provisional components of the extracellular matrix in case of generalized peripheral ischemia due to hypoalbuminemia and hypovolemia is discussed in this review.
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Affiliation(s)
- Giuliano Ramadori
- Internal Medicine University Clinic, University of Göttingen, Göttingen, Germany Robert-Koch-Strasse 40, 37075 Göttingen, Germany
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