Who Needs to Be Allocated in ICU after Thoracic Surgery? An Observational Study

Criteria for continuous neuraxial analgesia associated with reduced mortality in patients undergoing thoracotomy

INTRODUCTION

Both thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia.

METHOD

1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates.

RESULTS

Continuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01).

CONCLUSIONS

Neuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.

Enhanced recovery after surgery pathway leads to decreased length of stay for patients undergoing minimally invasive lung resection

Background

Enhanced recovery after surgery (ERAS) protocols in thoracic surgery have been demonstrated to impact length of stay (LOS), complication rates, and postoperative opioid use. However, ERAS protocols for minimally invasive lung resections have not been well described. Given most lung resections are now performed minimally invasively, there is a gap in the literature regarding the efficacy of ERAS protocols in this setting. In this study, we analyzed patient outcomes following implementation of an ERAS protocol for minimally invasive lung resections.

Methods

Outcome data was retrospectively collected for 442 patients undergoing minimally invasive lung resections between January 1st, 2015 and October 26th, 2021. Patients were divided into either a pre-ERAS (n=193) or ERAS (n=249) group. Primary outcomes included LOS, postoperative complications, intensive care unit (ICU) admission status, 30-day hospital readmissions, and 30-day mortality. Secondary outcomes included common postoperative complications required for the Society for Thoracic Surgeons (STS) database.

Results

We observed an overall decrease in median LOS (4.0 vs. 3.0 days, P=0.030) and ICU admission status (15% vs. 7.6%, P=0.020) after implementation of our ERAS protocol. The difference in LOS was significantly lower for anatomic lung resections, but not non-anatomic resections. There was no difference in 30-day readmissions and a 0% mortality rate in both groups. Overall, there was a low complication rate that was similar between groups.

Conclusions

The implementation of an ERAS protocol led to decreased LOS and decreased ICU admission in patients undergoing minimally invasive lung resection. Process standardization optimizes performance by providers by decreasing decision fatigue and improving decision making, which may contribute to the improved outcomes observed in this study.

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Is intensive care necessary after major thoracic surgery? A propensity score-matched study

Background

This study aims to compare the surgical results, complications, mortality rates, and inpatient costs in two patient groups followed, whether in the intensive care unit or general ward after a major thoracic procedure and to examine clinical and surgical factors related to the development of complications.

Methods

Between January 2018 and June 2021, a total of 485 patients (150 males, 335 females; mean age: 58.3±13.2 years; range, 22 to 86 years) who underwent a major thoracic surgery in our clinic were retrospectively analyzed. The patients were divided into two groups as the intensive care unit patients (n=254) and general ward patients (n=231). In the former group, the patients were followed in the intensive care unit for a day, while in the general ward group, the patients were taken directly to the ward. The groups were compared after propensity score matching. All patients were analyzed for risk factors of morbidity development.

Results

After propensity score matching, 246 patients were enrolled including 123 patients in each group. There was no statistically significant difference between the groups in any features except for late morbidity, and inpatient costs were higher in the intensive care unit group (p<0.05). In the multivariate analysis, age, American Society of Anesthesiologists Class 3, and secondary malignancy were found to be associated with morbidity (p<0.05).

Conclusion

In experienced centers, it is both safe and costeffective to follow almost all of the major thoracic surgery patients postoperatively in the general ward.

The impact of the COVID-19 pandemic on the decrease in the use of intensive care units in the postoperative period of anatomic lung resections. A retrospective analysis

OBJECTIVE

COVID-19 pandemic required optimization of hospital institutional flow, especially regarding the use of intensive care unit (ICU) beds. The aim of this study was to assess whether the individualization of the indication for postoperative recovery from pulmonary surgery in ICU beds was associated with more perioperative complications.

METHOD

retrospective analysis of medical records of patients undergoing anatomic lung resections for cancer in a tertiary hospital. The sample was divided into: Group-I, composed of surgeries performed between March/2019 and February/2020, pre-pandemic, and Group-II, composed of surgeries performed between March/2020 and February/2021, pandemic period in Brazil. We analyzed demographic data, surgical risks, surgeries performed, postoperative complications, length of stay in the ICU and hospital stay. Preventive measures of COVID-19 were adopted in group-II.

RESULTS

43 patients were included, 20 in group-I and 23 in group-II. The groups did not show statistical differences regarding baseline demographic variables. In group-I, 80% of the patients underwent a postoperative period in the ICU, compared to 21% in group-II. There was a significant difference when comparing the average length of stay in an ICU bed (46 hours in group-I versus 14 hours in group-II - p<0.001). There was no statistical difference regarding postoperative complications (p=0.44).

CONCLUSIONS

the individualization of the need for ICU use in the immediate postoperative period resulted in an improvement in the institutional care flow during the COVID-19 pandemic, in a safe way, without an increase in surgical morbidity and mortality, favoring the maintenance of essential cancer treatment.

Development and Validation of a Multivariable Prediction Model for Postoperative Intensive Care Unit Stay in a Broad Surgical Population

IMPORTANCE

Despite limited capacity and expensive cost, there are minimal objective data to guide postoperative allocation of intensive care unit (ICU) beds. The Surgical Risk Preoperative Assessment System (SURPAS) uses 8 preoperative variables to predict many common postoperative complications, but it has not yet been evaluated in predicting postoperative ICU admission.

OBJECTIVE

To determine if the SURPAS model could accurately predict postoperative ICU admission in a broad surgical population.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytical model was a retrospective, observational analysis of prospectively collected patient data from the 2012 to 2018 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, which were merged with individual patients' electronic health record data to capture postoperative ICU use. Multivariable logistic regression modeling was used to determine how the 8 preoperative variables of the SURPAS model predicted ICU use compared with a model inputting all 28 preoperatively available NSQIP variables. Data included in the analysis were collected for the ACS NSQIP at 5 hospitals (1 tertiary academic center, 4 academic affiliated hospitals) within the University of Colorado Health System between January 1, 2012, and December 31, 2018. Included patients were those undergoing surgery in 9 surgical specialties during the 2012 to 2018 period. Data were analyzed from May 29 to July 30, 2021.

EXPOSURE

Surgery in 9 surgical specialties, including general, gynecology, orthopedic, otolaryngology, plastic, thoracic, urology, vascular, and neurosurgery.

MAIN OUTCOMES AND MEASURES

Use of ICU care up to 30 days after surgery.

RESULTS

A total of 34 568 patients were included in the analytical data set: 32 032 (92.7%) in the cohort without postoperative ICU use and 2545 (7.4%) in the cohort with postoperative ICU use (no ICU use: mean [SD] age, 54.9 [16.6] years; 18 188 women [56.8%]; ICU use: mean [SD] age, 60.3 [15.3] years; 1333 men [52.4%]). For the internal chronologic validation of the 7-variable SURPAS model, data from 2012 to 2016 were used as the training data set (n = 24 250, 70.2% of the total sample size of 34 568) and data from 2017 to 2018 were used as the test data set (n = 10 318, 29.8% of the total sample size of 34 568). The C statistic improved in the test data set compared with the training data set (0.933; 95% CI, 0.924-0.941 vs 0.922; 95% CI, 0.917-0.928), whereas the Brier score was slightly worse in the test data set compared with the training data set (0.045; 95% CI, 0.042-0.048 vs 0.045; 95% CI, 0.043-0.047). The SURPAS model compared favorably with the model inputting all 28 NSQIP variables, with both having good calibration between observed and expected outcomes in the Hosmer-Lemeshow graphs and similar Brier scores (model inputting all variables, 0.044; 95% CI, 0.043-0.048; SURPAS model, 0.045; 95% CI, 0.042-0.046) and C statistics (model inputting all variables, 0.929; 95% CI, 0.925-0.934; SURPAS model, 0.925; 95% CI, 0.921-0.930).

CONCLUSIONS AND RELEVANCE

Results of this decision analytical model study revealed that the SURPAS prediction model accurately predicted postoperative ICU use across a diverse surgical population. These results suggest that the SURPAS prediction model can be used to help with preoperative planning and resource allocation of limited ICU beds.

O impacto da Pandemia de COVID-19 na diminuição do uso de Unidade de Terapia Intensiva em pós-operatório de ressecções pulmonares anatômicas. Uma análise retrospectiva

RESUMO Introdução: a pandemia de COVID-19 exigiu otimização dos fluxos institucionais hospitalares, especialmente quanto ao uso de leitos de unidade de terapia intensiva (UTI). O objetivo deste estudo foi avaliar se a individualização da indicação de recuperação pós-operatória de cirurgias pulmonares em leitos de UTI associou-se a mais complicações perioperatórias. Método: análise retrospectiva de prontuários dos pacientes submetidos a ressecções pulmonares anatômicas por câncer em hospital terciário. A amostra foi dividida em dois grupos: Grupo-I, composto pelas cirurgias realizadas entre março/2019 e fevereiro/2020, pré-pandemia, e Grupo-II, composto pelas cirurgias realizadas entre março/2020 e fevereiro/2021, período de pandemia no Brasil. Analisamos dados demográficos, riscos cirúrgicos, cirurgias realizadas, complicações pós-operatórias, tempo de UTI e de internação hospitalar. Foram adotadas medidas preventivas de COVID-19 no grupo-II. Resultados: foram incluídos 43 pacientes, 20 no grupo-I e 23 no grupo-II. Os grupos não apresentaram diferenças estatísticas quanto às variáveis demográficas basais. No grupo-I 80% dos pacientes fizeram pós-operatório em UTI, comparados a 21% do grupo-II. Houve diferença significativa na comparação de tempo médio de permanência em leito de UTI (46 horas no grupo-I versus 14 horas no grupo-II - p<0,001). Não houve diferença estatística quanto a complicações pós-operatórias entre grupos (p=0,44). Conclusões: a individualização da necessidade do uso de UTI no pós-operatório imediato de cirurgias pulmonares resultou em melhora no fluxo assistencial institucional durante a pandemia de COVID-19, de maneira segura, sem aumento na morbimortalidade cirúrgica, favorecendo a manutenção do tratamento oncológico essencial.

"Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection"

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

Perioperative management in thoracic surgery

Thoracic surgery has undergone significant advances in recent years related to anesthetic and surgical techniques and the prevention and management of complications related to the procedure. This has allowed improvements in patient clinical outcomes in surgeries of this kind. Despite the above, thoracic surgery, especially related to pulmonary resection, is not without risk, and is associated to considerable morbidity and mortality. Fast track or enhanced recovery after anesthesia protocols, minimally invasive surgery, and intraoperative anesthetic management improve the prognosis and safety of thoracic surgery. Patients in the postoperative period of major thoracic surgery require intensive surveillance, especially the first 24-72hours after surgery. Admission to the ICU is especially recommended in those patients with comorbidities, a reduced cardiopulmonary reserve, extensive lung resections, and those requiring support due to life-threatening organ failure. During the postoperative period, intensive cardiorespiratory monitoring, proper management of thoracic drainage, aggressive pain control (multimodal analgesia and regional anesthetic techniques), nausea and multimodal rehabilitation are key elements for avoiding adverse events. Medical complications include respiratory failure, arrhythmias, respiratory infections, atelectasis and thromboembolic lung disease. The most frequent surgical complications are hemothorax, chylothorax, bronchopleural fistula and prolonged air leakage. The multidisciplinary management of these patients throughout the perioperative period is essential in order to ensure the best surgical outcomes.

Perioperative Factors for Predicting the Need for Postoperative Intensive Care after Major Lung Resection

Postoperative management after major lung surgery is critical. This study evaluates risk factors for predicting mandatory intensive care unit (ICU) admission immediately after major lung resection. We retrospectively reviewed patients for whom the surgeon requested an ICU bed before major lung resection surgery. Patients were classified into three groups. Univariable and multivariable logistic regression analyses were performed, and a clinical nomogram was constructed. Among 340 patients, 269, 50, and 21 were classified into the no need for ICU, mandatory ICU admission, and late-onset complication groups, respectively. Predictive postoperative diffusion capacity of the lung for carbon monoxide (47.2 (interquartile range (IQR) 43.3–65.7)% versus vs. 67.8 (57.1–79.7)%; p = 0.003, odds ratio (OR) 0.969, 95% confidence interval (CI) 0.95–0.99), intraoperative blood loss (400.00 (250.00–775.00) mL vs. 100.00 (50.00–250.00) mL; p = 0.040, OR 1.001, 95% CI 1.000–1.002), and open thoracotomy (p = 0.030, OR 2.794, 95% CI 1.11–7.07) were significant predictors for mandatory ICU admission. The risk estimation nomogram demonstrated good accuracy in estimating the risk of mandatory ICU admission (concordance index 83.53%). In order to predict the need for intensive care after major lung resection, preoperative and intraoperative factors need to be considered.

Preoperative risk factors for unexpected postoperative intensive care unit admission: A retrospective case analysis

INTRODUCTION

The purpose of this retrospective case-control study was to investigate preoperative risk factors for unexpected postoperative intensive care unit (ICU) admissions in patients undergoing non-emergent surgical procedures in a tertiary medical centre.

METHODS

A medical record review of adult patients undergoing elective non-cardiac and non-transplant major surgical procedures during the period of January 2011 through December 2015 in the operating rooms of a large university hospital was carried out. The primary outcome assessed was unexpected ICU admission, with mortality as a secondary outcome. Demographic data, length of hospital and ICU stay and preoperative comorbidities were also obtained as exposure variables. Propensity score matching was then employed to yield a study and control group.

RESULTS

The group of patients who met inclusion criteria in the study and the control group that did not require ICU admission were obtained, each containing 1191 patients after propensity matching. Patients with acute and/or chronic kidney injury (odds ratio (OR) 2.20 [1.75-2.76]), valvular heart disease (OR: 1.94 [1.33-2.85]), peripheral vascular disease (PVD) (OR: 1.41 [1.02-1.94]) and congestive heart failure (CHF) (OR: 1.80 [1.31-2.46]) were all associated with increased unexpected ICU admission. History of cerebrovascular accident (CVA) (OR: 3.03 [1.31-7.01]) and acute and/or chronic kidney injury (OR: 1.62 [1.12-2.35]) were associated with increased mortality in all patients; CVA was also associated with increased mortality (OR: 3.15 [1.21-8.20]) specifically in the ICU population.

CONCLUSIONS

CHF, acute/chronic kidney injury, PVD and valve disease were significantly associated with increased unexpected ICU admission; patients with CVA suffered increased mortality when admitted to the ICU.

Factors affecting reintubations after cardiac and thoracic surgeries in cardiac intensive care unit of a tertiary care hospital

Background

Reintubation and readmission after cardiothoracic surgeries are not uncommon, and its reasons are multifactorial. The study goal was to identify the factors that contribute reintubation after cardiac and thoracic surgery in tertiary care hospital and to compare the outcome with international benchmark.

Methodology

A prospective, observational study was planned in Cardiac Intensive Care Unit (CICU). The study included all those patients who required readmission in CICU due to endotracheal intubation following cardiac and thoracic surgeries. The study was conducted from January to December 2016. The primary focus was to identify the reasons for reintubation within 72 h of extubation after CICU discharge and its association with outcome.

Results

Out of 750 patients who shifted out from CICU following successful extubation, only 32 were readmitted and among them in 25 patients (3.33%) were reintubated and their reasons reintubation were noted. Patients underwent a coronary artery bypass grafting (CABG) with valve replacement had a higher incidence of reintubation 3/39 (7.69%) when compared with CABG 13/517 (2.51%) and 4/135 (2.96%) valve procedure alone. Single cause of endotracheal reintubation was observed in 7 patients (28%), in which 5 patients (20%) had respiratory and 2 patients had (8%) cardiac reason while 18 patients (72%) were observed with multisystem involvement, in which 7 patients (28%) had both respiratory and cardiovascular causes, and 2 (8%) had both respiratory and neurological causes. More than 70% cause of endotracheal reintubation was both respiratory and cardiovascular. The CICU stay after reintubations was 12.88 ± 16.88 days and the hospital stay prolonged to 23.84 ± 21.61 days.

Conclusion

Reasons of reintubation were mainly respiratory and cardiac. The rate of reintubations is high when multisystem involvement is there. CICU, hospital stay, and mortality are increases after reintubation.