Resources and use of the intensive care unit in patients who undergo surgery for ovarian carcinoma

Postoperative Admission in Critical Care Units Following Gynecologic Oncology Surgery: Outcomes Based on a Systematic Review and Authors' Recommendations

BACKGROUND/AIM

The present study aimed to evaluate the predictors of admission to the Critical Care Units (CCUs) and factors predisposing to prolonged stay in CCUs after gynecological oncology surgery.

PATIENTS AND METHODS

Studies which addressed cases of women who underwent surgery for gynecological malignancies and required postoperative CCU admission were included.

RESULTS

Seven studies with 3820 patients were included. Among them, 1680 required admission to CCU. Advanced age, higher Charlson Comorbidity Index (CCI) score, longer operative times, protracted blood loss and intestinal resection were associated with higher probability of CCU admission. Patients' age, operative times, blood loos and intestinal resection were significant predictors of prolonged stay to CCUs.

CONCLUSION

Admission to CCU and length of stay following surgery for gynecologic malignancies is driven by specific patient characteristics as well as intraoperative values. Further studies are needed to validate high risk patients who will benefit from postoperative care to CCUs to ensure favorable postoperative outcomes and cost-effectiveness.

Intensive care admissions among ovarian cancer patients treated with primary debulking surgery and neoadjuvant chemotherapy-interval debulking surgery

OBJECTIVE

Admissions to intensive care units (ICU) are costly, but are necessary for some patients undergoing radical cancer surgery. When compared to primary debulking surgery (PDS), neoadjuvant chemotherapy (NACT) with interval debulking surgery, is associated with less peri-operative morbidity. In this study, we compare rates, indications and lengths of ICU stays among ovarian cancer patients admitted to the ICU within 30days of cytoreduction, either primary or interval.

METHODS

A retrospective chart review was performed of patients with stage III-IV ovarian cancer who underwent surgical cytoreduction at two large academic medical centers between 2010 and 2014. Chi square tests, Student t-tests, and Mann-U Whitney tests were used.

RESULTS

A total of 635 patients were included in the study. There were 43 ICU admissions, 7% of patients. Compared to NACT, a higher percentage of PDS patients required ICU admission, 9.4% vs 3.9% of patients (P=0.004). ICU admission indications did not vary between PDS and NACT patients. NACT patients admitted to the ICU had comparable mean surgical complexity scores to those PDS patients admitted to the ICU, 6.2 (95%CI 5.3-7.1) vs 4.5 (95%CI 3.1-6.0) (P=0.006). Length of ICU admission did not vary between groups, PDS 2.7days (95%CI 2.3-3.2) vs 3.5days (95%CI 1.5-5.6) for NACT (P=0.936).

CONCLUSIONS

The rate of ICU admissions among patients undergoing PDS is higher than for NACT. Among patients admitted to the ICU, indications for admission, length of stay and surgical complexity were similar between patients treated with NACT and PDS.

Do critical care units play a role in the management of gynaecological oncology patients? The contribution of gynaecologic oncologist in running critical care units

Routine post-operative care in high dependency unit (HDU), surgical intensive care unit (SICU) and intensive care unit (ICU) after high-risk gynaecological oncology surgical procedures may allow for greater recognition and correct management of post-operative complications, thereby reducing long-term morbidity and mortality. On the other hand, unnecessary admissions to these units lead to increased morbidity - nosocomial infections, increased length of hospital stay and higher hospital costs. Gynaecological oncology surgeons continue to look after their patient in the HDU/SICU and have the final role in decision-making on day-to-day basis, making it important to be well versed in critical care management and ensure the best care for their patients. Post-operative monitoring and the presence of comorbid illnesses are the most common reasons for admission to the HDU/SICU. Elderly and malnutritioned patients, as well as, bowel resection, blood loss or greater fluid resuscitation during the surgery have prolonged HDU/SICU stay. Patients with ovarian cancer have a worse survival outcome than the patients with other types of gynaecological cancer. Dependency care is a part of surgical management and it should be incorporated formally into gynaecologic oncology training programme.

Endometrial cancer in morbidly obese women: do racial disparities affect surgical or survival outcomes?

OBJECTIVE

Endometrial cancer mortality disproportionately affects black women and whether greater prevalence of obesity plays a role in this disparity is unknown. We examine the effect of race on post-surgical complications, length of stay, and mortality specifically in a morbidly obese population.

METHODS

Black and white women with endometrial cancer diagnosed from 1996 to 2012 were identified from the University Pathology Group database in Detroit, Michigan, and records were retrospectively reviewed to obtain clinicopathological, demographic, and surgical information. Analysis was limited to those with a body mass index of 40kg/m(2) or greater. Differences in the distribution of variables by race were assessed by chi-squared tests and t-tests. Kaplan-Meier and Cox regression analyses were performed to examine factors associated with mortality.

RESULTS

97 white and 89 black morbidly obese women were included in this analysis. Black women were more likely to have type II tumors (33.7% versus 15.5% of white women, p-value=0.003). Hypertension was more prevalent in black women (76.4% versus 58.8%, p-value=0.009), and they had longer hospital stays after surgery despite similar rates of open vs minimally invasive procedures and lymph node dissection (mean days=5.4) compared to whites (mean days=3.5, p-value=0.036). Wound infection was the most common complication (16.5% in whites and 14.4% in blacks, p-value=0.888). Blacks were more likely to suffer other complications, but overall the proportions did not differ by race. In univariate analyses, black women had higher risk of endometrial cancer-related death (p-value=0.090). No racial differences were noted in adjusted survival analyses.

CONCLUSION

A more complete investigation, incorporating socio-demographic factors, is warranted to understand the effects of morbid obesity and race on endometrial cancer.

Outcomes of Critically Ill Gynecological Cancer Patients Admitted to Intensive Care Unit

Purpose:

To assess the characteristics of critically ill patients with gynecological cancer, and to evaluate their prognosis.

Methods:

Fifty-two critically ill patients with gynecological cancer admitted to intensive care unit (ICU) were included. Univariate and multivariate logistic regressions were used to identify factors associated with hospital mortality.

Results:

Thirty-five patients (67.3%) had carcinoma of the cervix uteri and 11 (21.2%) had ovarian cancer. The mortality rate in the ICU was 17.3% (9 of 52) and hospital mortality rate were 23%(12 of 52). In the multivariate analysis, independent prognostic factors for hospital mortality were vasopressor use (odds ratio [OR] = 8.60, 95% confidence interval [CI] 2.05-36; P = .03) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR = 1.43, 95% CI 1.01-2.09; P = .048).

Conclusions:

The independent prognostic factors for hospital mortality were the need for vasopressors and the APACHE II score.

Derivation and validation of automated electronic search strategies to extract Charlson comorbidities from electronic medical records

OBJECTIVE

To develop and validate automated electronic note search strategies (automated digital algorithm) to identify Charlson comorbidities.

PATIENTS AND METHODS

The automated digital algorithm was built by a series of programmatic queries applied to an institutional electronic medical record database. The automated digital algorithm was derived from secondary analysis of an observational cohort study of 1447 patients admitted to the intensive care unit from January 1 through December 31, 2006, and validated in an independent cohort of 240 patients. The sensitivity, specificity, and positive and negative predictive values of the automated digital algorithm and International Classification of Diseases, Ninth Revision (ICD-9) codes were compared with comprehensive medical record review (reference standard) for the Charlson comorbidities.

RESULTS

In the derivation cohort, the automated digital algorithm achieved a median sensitivity of 100% (range, 99%-100%) and a median specificity of 99.7% (range, 99%-100%). In the validation cohort, the sensitivity of the automated digital algorithm ranged from 91% to 100%, and the specificity ranged from 98% to 100%. The sensitivity of the ICD-9 codes ranged from 8% for dementia to 100% for leukemia, whereas specificity ranged from 86% for congestive heart failure to 100% for leukemia, dementia, and AIDS.

CONCLUSION

Our results suggest that search strategies that use automated electronic search strategies to extract Charlson comorbidities from the clinical notes contained within the electronic medical record are feasible and reliable. Automated digital algorithm outperformed ICD-9 codes in all the Charlson variables except leukemia, with greater sensitivity, specificity, and positive and negative predictive values.

Predictors of intensive care unit utilization in gynecologic oncology surgery

OBJECTIVES

The objectives of the study were to examine factors predicting intensive care unit (ICU) admission after surgery for gynecologic cancer and to determine the impact of ICU admission on survival.

METHODS

This was a retrospective study of women undergoing laparotomy for staging and debulking of gynecologic cancer at an academic hospital with tertiary ICU facilities from July 2000 through June 2003. Data on clinicopathologic factors, comorbidities, operative outcomes, and survival were obtained from medical records and institutional cancer registry. The χ analysis, Kaplan-Meier analysis, and Cox regression methods were used for analyses.

RESULTS

Two hundred fifty-five patients met our inclusion criteria, 43 of whom had a postoperative admission to the ICU. Factors predicting ICU admission on univariate analysis included age 60 years or older, hematocrit of 30% or less, albumin of 3.5 g/dL or less, and Charlson Comorbidity Index (CCI) score greater than 8; after multivariate analysis, CCI score of greater than 8 (hazard ratio, 2.5; confidence interval, 1.11-5.69) and albumin of 3.5 or less (hazard ratio, 3.8; confidence interval, 1.66-8.85) were associated with an increased risk of ICU admission. After adjusting for albumin and CCI score, ICU admission did not have a significant effect on survival.

CONCLUSIONS

The ability to predict ICU admission helps in appropriate counseling of patients and identification of institutional resource utilization.

Surgical care of young women diagnosed with ovarian cancer: a population-based perspective

OBJECTIVE

To characterize primary surgical care for women with ovarian cancer aged </=50 years versus > 50 years.

METHODS

A statewide hospital discharge database was used to identify women undergoing primary surgery for ovarian cancer from 1990 to 2000. Logistic regression models were used to evaluate differences in demographic characteristics and short-term outcomes comparing women </=50 years versus >50 years.

RESULTS

Women </=50 years comprised 30.2% (n=731) of 2417 identified cases. The 30-day mortality rate was 54% lower among women </=50 years (1.2% vs. 2.6%, P=0.0100). Women </=50 years were less likely to be managed by high-volume surgeons versus women >50 years (47.1% vs. 59.5%, P<0.0001). Younger women managed by high-volume surgeons had longer lengths of stay (5.7 days vs. 7.7 days, P<0.0001), longer ICU stays (0.2 days vs. 0.5 days, P=0.0020), more billed procedures (4.2 vs. 5.5, P<0.0001), higher adjusted cost of hospital-related care ($46,590 vs. $97,538, P<0.0001) and more comorbidities (1.0 vs. 1.6, P<0.0001) than those treated by lower-volume surgeons. Women </=50 years were as likely to be managed at high volume centers as low volume centers (57.7% vs. 61.3% P=0.0968). A similar trend in outcomes was observed in younger women treated at high-versus low-volume hospitals as high-versus low-volume surgeons.

CONCLUSION

Primary surgical care for ovarian cancer in women </=50 years is often performed by low-volume providers at low-volume centers. In light of positive volume-outcome data for malignancies treated with complex operative procedures, further efforts to characterize the surgical care of young women with ovarian cancer are warranted.

Predictors of extended intensive care unit resource utilization following surgery for ovarian cancer

OBJECTIVE

To identify perioperative variables associated with length of stay in the surgical intensive care unit (SICU), and overall cost of hospitalization in order to optimize resource utilization among patients undergoing surgery for ovarian cancer.

METHODS

A retrospective analysis of patients admitted to the SICU immediately after surgery for ovarian cancer between 1/1/94 and 6/30/04 was performed. Patients admitted to the SICU were categorized in two groups. Those admitted for < 48 h were compared patients requiring a SICU stay > or = 48 h. Perioperative variables were compared across the two groups by univariate and multivariate logistic regression analysis.

RESULTS

A total of 95 patients were admitted to the SICU immediately after surgical management for ovarian cancer, with 57% requiring a stay > or = 48 h. Patient age = 63 years was associated with an increase risk of admission to the SICU for > or = 48 h (OR: 5.9, 95% CI: 1.72-20.50, p=0.005). Patients with administration of > or = 5 l of crystalloid solution during surgery were 8 times more likely to have prolonged admission to the SICU (95% CI: 2.34-27.57, p=0.001). Furthermore, a preoperative serum albumin level > or = 3.5 g/dl was associated with a reduction in the risk of prolonged admission to the SICU (OR: 0.23, 95% CI: 0.07-0.77, p=0.02). The average cost of hospitalization per patient was $33,086. Cost of hospital care was strongly associated with SICU length of stay (p=0.005).

CONCLUSION

Extensive fluid resuscitation during surgery, poor nutritional status, and > or = 63 years are associated with a prolonged postoperative SICU stay. These data may facilitate a reduction in unnecessary ICU admissions for patients without these risk factors and thereby optimize resource utilization following surgery for ovarian cancer.

Outcomes of gynecologic oncology patients admitted to the intensive care unit following surgery: a university teaching hospital experience

The objective of this study was to determine the outcomes of gynecological oncology patients requiring intensive care unit (ICU) admission following surgery. A computerized database identified postsurgical ICU admissions from January 1, 1999 to December 31, 2004 at a university hospital. Abstracted data included: demographics, preoperative diagnosis, reason(s) for ICU admission, consultations, interventions, length of stay (LOS), Acute Physiology and Chronic Health Evaluation (APACHE) II score, and 30-day mortality. Statistical analysis was performed with the Student's t-test. A total of 185 surgical gynecological oncology ICU patients was identified. Median age was 60 years (range, 21-92 years), and 63% of patients were white. Only 72% of patients had ovarian, endometrial, or cervical cancer. The most common indications for ICU admission were volume resuscitation (108 patients) and respiratory insufficiency (80 patients). Median ICU LOS was 1 day (range, 1-55 days). Patients surviving their hospital admission had a mean APACHE II score of 11.5 (range, 2-37) compared to a mean of 21.2 (range, 13-44) for patients who died prior to hospital discharge (P < 0.001). The overall mortality rate was 12%. A substantial number of gynecological oncology patients will be admitted to the ICU following surgery. Patient outcomes are favorable if APACHE II scores are low and ICU LOS is short.

A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research

The Charlson index is commonly used for risk adjustment in critical care health services research. However, the literature supporting this methodology has not been thoroughly explored. We systematically reviewed the literature related to administrative database adaptations of the Charlson index. Our review has 3 major findings. First, 2 studies compared Canadian administrative databases with chart review for obtaining Charlson comorbidity data. Agreement between the database and chart review was substantial (kappa > 0.70), and mortality prediction did not differ. Second, 5 database adaptations were identified with the Deyo and Dartmouth-Manitoba adaptations being most popular. Three studies directly compared these 2 popular adaptations and demonstrated substantial agreement (kappa > 0.70) and similar predictive ability for mortality. Third, one study validated the Charlson index for critically ill patients but demonstrated that APACHE (Acute Physiology and Chronic Health Evaluation) II better discriminates inhospital mortality (area under curve 0.67 vs 0.87). Time and cost barriers prevent widespread use of physiology-based risk adjustment in population-based research. The decreased predictive ability of the Charlson index must be weighed against the advantages of using this instrument for population-based research. Future research should focus on updating the Charlson index for recent changes in the prognosis of comorbid diseases and introduction of International Statistical Classification of Diseases, 10th Revision coding of discharge abstracts.