Overnight Intensive Recovery: Elective Open Aortic Surgery Without a Routine ICU Bed

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.

Basic principles of donor management for multiorgan removal

Prime quality organs are a scarce resource best fostered by widespread education of critical care physicians in the principles of donor management, and by the provision of expert donor teams (two surgeons, one anesthetist, one nurse) to set consistent high standards of care during organ retrieval.

Mortality during intensive care after orthotopic liver transplantation

The postoperative course of 335 adult patients who underwent orthotopic liver transplantation from 1968-1987 was reviewed retrospectively to identify patients who died in the intensive care unit and the causes of death. Forty-four percent of all deaths occurred in the intensive care unit. The mortality rate in the intensive care unit peaked in 1984 (48%), but decreased to 11% in 1987. The main causes for death in the intensive care unit were infection (55%) and haemorrhage (19%). The patients who died spent more time in the intensive care unit, had a longer period of tracheal intubation and received a larger intra-operative blood transfusion than patients who died in other locations.

The prevention of renal impairment in patients undergoing orthotopic liver grafting by infusion of low dose dopamine

Administration of low dose dopamine (2.0 micrograms/kg/minute) begun before surgery in patients undergoing liver transplantation decreases the incidence of postoperative renal impairment. Thirty-four consecutive patients in the Cambridge/King's College Hospital liver transplantation series were studied. Nineteen patients (21 transplant operations) received prophylactic low dose dopamine throughout the operative and early postoperative period, while 15 patients (15 transplant operations) received dopamine only when clinically indicated for incipient renal failure or as an inotropic agent. In the prophylactic dopamine group, only two transplant operations (9.5%) were complicated by renal impairment, whereas in the other group, 10 patients (67%) developed renal impairment (p = 0.001); of these, four developed acute renal failure (27%). Comparison of seven pairs of patients, matched for age, sex, diagnosis, operative blood loss and operative hypotension (one group receiving dopamine, the other not), revealed a significantly higher urine output in the first 24 hours and creatinine clearance 24-48 hours after surgery (p less than 0.05) in those treated prophylactically. In view of these findings, we would recommend that consideration be given to the prophylactic use of dopamine in patients undergoing orthotopic liver transplantation.

Autotransfusion, an experience of seventy six cases

The use of autotransfusion with a centrifugal cell washer in a series of 76 cases is reviewed. The requirement for bank blood is reduced in patients with major operative haemorrhage, although it does not appear to be able to provide the main source of blood replacement in such cases. The major impact of autotransfusion may lie in reducing the amount of blood that needs to be crossmatched for elective operations. Nevertheless in certain cases its use can be life saving.

Anesthesia for hepatic transplantation: cardiovascular and metabolic alterations and their management

We studied the cardiovascular and metabolic changes occurring during orthotopic liver transplantation in nine patients. The operative management of these patients can be divided into an initial dissection phase, an anhepatic phase when the hepatic artery, portal vein, and inferior vena cava are cross-clamped, and the phase after the release of these clamps. On clamping the inferior vena cava, the systolic arterial pressure decreased from 134 +/- 9 to 104 +/- 8 mm Hg, the pulmonary artery pressure decreased from 25 +/- 4 to 17 +/- 4 mm Hg, the mean pulmonary wedge pressure decreased from 11.9 +/- 1.9 to 6.8 +/- 1.2 mm Hg, and cardiac index decreased from 5.3 +/- 0.3 to 2.7 +/- 0.2 L X min-1 X m-2. There were compensatory increases in systemic vascular resistance from 806 +/- 52 to 1448 +/- 109 dyne X cm X sec-5 and in pulmonary vascular resistance from 78 +/- 13 to 122 +/- 25 dyne X cm X sec-5. Removal of these clamps was followed by an initial depression in cardiac output that returned to preclamping values. Profound metabolic alterations were encountered during these phases. Hydrogen ion concentration increased from a mean of 39 +/- 2 to 45 +/- 2 nmol/L during cross-clamping, with a further increase to 55 +/- 3 nmol/L after the initial perfusion of the new liver. Serum potassium levels increased significantly only on release of the clamps, from a mean of 3.8 +/- 0.3 to a peak of 5.3 +/- 0.6 mmol.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidural morphine in the elderly. A controlled trial after upper abdominal surgery

The effectiveness of epidurally administered morphine in the relief of pain after upper abdominal surgery was assessed in a controlled study involving 20 patients aged 61 to 78 years. Analgesia provided by epidural morphine was comparable to that obtained in matched patients given an intramuscular regime. The total dose required by the epidural route was less than one-fifth that required intramuscularly, and sedation was correspondingly reduced. Postoperative respiratory mechanics, however, were not significantly improved and delayed respiratory depression was observed in one patient. It is concluded that in elderly patients undergoing upper abdominal surgery the risks related to the use of morphine by the epidural route outweigh the marginal advantages it may offer over conventional analgesic techniques.

Early reversal of postoperative hypoxemia

Peridural analgesia was combined with the respiratory-stimulant effect of doxapram for intermittent hyperinflation of the lungs to reverse early postoperative (PO) hypoxemia following inhalation anesthesia for upper abdominal operations. Twenty unpremedicated men undergoing upper abdominal operations were studied for 5 hours in the recovery room. Ten of these patients received doxapram plus peridural analgesia; the other 10, doxapram plus morphine analgesia. Rectal temperature, PaO2, PaCO2, respiratory rate, exhaled minute ventilation (VE), tidal volume (VT), and blood pressure and pulse were measured. The mean increase from control for VE was 9.6 L/min and for VT, 356 ml/breath during doxapram therapy for the morphine group. Corresponding values for the peridural group were 14.4 L/min for VE and 660 ml/breath for VT. Mean PaO2 for the morphine group decreased significantly from the corresponding preoperative value (p less than 0.005). Lack of significant change between preoperative and PO values for PaO2 for the peridural group would indicate that under the conditions of this study, early PO hypoxemia can be reversed by the combination of peridural analgesia with doxapram therapy.

Pethidine revisited: plasma concentrations and effects after intramuscular injection

Plasma concentrations of pethidine following i.m. gluteal injection were measured in surgical patients and volunteers. The mean plasma concentrations tended to be higher in the patients than in the volunteers; this may be a result of a slower initial absorption rate. At least 80% of the dose was absorbed from the injection site over the 6-hr period of the study. Fluctuations in plasma pethidine concentration were observed, probably caused by variations in local and systemic blood flow. This effect was more noticeable in the patient group. In general, the time-course of subjective effects in volunteers could be related to maximum plasma pethidine concentrations. However, patients appeared to be less sensitive to these effects at similar plasma drug concentrations, possibly because of catecholamine-mediated stimulus, suggesting that plasma concentrations may be a poor guide to the clinical response in patient-volunteer comparison.

Meperidine kinetics in man. Intravenous injection in surgical patients and volunteers

The plasma concentration-time profiles of meperidine following intravenous injection in surgical patients and volunteers were investigated by reference to a classical two-compartment open model. Physiologic characteristics of the subject and variables associated with the surgery and anesthesia were screened as determinants of the kinetic patterns observed. When meperidine administration preceded induction of anesthesia, induction was consistently followed by an increase in venous plasma concentrations that prevented classical kinetic analysis. To facilitate calculations in subsequent studies in patients, meperidine injections were made following induction of anesthesia. Type of anesthesia or premedication, patients' sex, or cigarette smoking did not appear to be important factors in this evaluation. Increasing alcohol consumption was associated with increasing volumes of distribution. Increasing age was associated with increasing fraction of drug unbound in plasma. These factors may relate directly to clinical observations that heavy alcohol consumers tend to be more refractory to central nervous system (CNS) depressants and that elderly patients are more susceptible to respiratory depression from narcotics.