Current research priorities in perioperative intensive care medicine

Planning intensive care unit admission after elective major abdominal surgery: good clinical practice document by SIAARTI-SIC-ANIARTI

Postoperative complications (PCs) are a major cause of mortality following elective major abdominal surgery (EMAS). The increasing complexity of abdominal procedures, particularly in oncology, may significantly affect patient outcomes. However, this has also introduced a higher variability in postoperative management, and the use of tailored approaches to address critical issues such as hemodynamic stabilization, infection management, and respiratory failure. While elective admission to intensive care units (ICU) is a standard practice to manage high-risk surgical patients, ICU resource allocation is often influenced by local practices and bed availability.This document presents a framework for preoperative ICU admission planning after EMAS. It focuses on the identification of patient and surgical risk factors-using established scoring systems-and provides statements to determine ICU admission. The aim is to optimize resource allocation, reduce PCs, and prevent unplanned ICU admissions. This good clinical practice statement was developed through a multidisciplinary panel formed by selected members coming from SIAARTI (Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care), SIC (Italian Society of Surgery) and ANIARTI (National Association of Critical Area Nurses).The designed scientific board developed, through a systematic literature review and a consensus methodology, a roadmap for defining the priorities of perioperative care based on the complexity of the patient and the surgical procedure. Eventually, the panel worked out statements about six voted queries that could have supported the preoperative indication to postoperative ICU admission.Evaluation of patients' characteristics, comorbidities, and surgical factors are all essential to plan ICU admission for immediate postoperative patient care after EMAS.The presence and severity of comorbidities, assessed through various severity scores, play a crucial role in predicting PCs and guiding ICU admission decisions. Tools such as the American Society of Anesthesiologists physical status, Charlson Comorbidity Index, and Rockwood Frailty Index, along with surgical risk scores and intraoperative events, help define the need for intensive care. Preoperative frailty assessment-achieved using the Clinical Frailty Scale-is essential to anticipate postoperative care needs. Finally, during the postoperative phase, continuous monitoring and reassessment in the post-anesthesia care unit are key to determine whether ICU admission is required. Establishing high-dependency units and tailored care pathways based on individual patient needs and available resources will enhance patient outcomes and optimize postoperative care.

Characteristics and Outcomes of Home-Ventilated Children Undergoing Noncardiac Surgery

OBJECTIVES

To determine the frequency of children with chronic respiratory failure (CRF) and home ventilator dependence undergoing surgery at a tertiary children's hospital, and to describe periprocedural characteristics and outcomes.

METHODS

We conducted a retrospective cohort study of patients with CRF and home ventilator dependence who underwent noncardiac surgery from January 1, 2013, to December 31, 2019. Descriptive statistics were used to report patient and procedural characteristics. Univariable and multivariable analyses were used to assess for factors associated with 30-day readmission.

RESULTS

We identified 416 patients who underwent 1623 procedures. Fifty-one percent of patients used transtracheal mechanical ventilation (trach/vent) support at the time of surgery; this cohort was younger (median age 5.5 vs 10.8 years) and more complex according to American Society of Anesthesiologists status compared with bilevel positive airway pressure-dependent patients. Postoperatively, compared with bilevel positive airway pressure-dependent patients, trach/vent patients were more likely to be admitted to the ICU with longer ICU length of stay (median 5 vs 2 days). Overall 30-day readmission rate was 12% (n = 193). Presence of chronic lung disease (adjusted odds ratio 1.65, 95% confidence interval 1.01-1.69) and trach/vent dependence (adjusted odds ratio 1.65, 95% confidence interval 1.02-2.67) were independently associated with increased odds for readmission.

CONCLUSIONS

Children with CRF use anesthetic and surgical services frequently and repeatedly. Those with trach/vent dependence have higher hospital and ICU resource utilization. Although overall mortality for these patients is quite low, underlying diagnoses, nuances of technology dependence, and other factors for frequent readmission require further study to optimize resource utilization and outcomes.

Preoperative risk prediction models for acute kidney injury after noncardiac surgery: an independent external validation cohort study

BACKGROUND

Numerous models have been developed to predict acute kidney injury (AKI) after noncardiac surgery, yet there is a lack of independent validation and comparison among them.

METHODS

We conducted a systematic literature search to review published risk prediction models for AKI after noncardiac surgery. An independent external validation was performed using a retrospective surgical cohort at a large Chinese hospital from January 2019 to October 2022. The cohort included patients undergoing a wide range of noncardiac surgeries with perioperative creatinine measurements. Postoperative AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Model performance was assessed in terms of discrimination (area under the receiver operating characteristic curve, AUROC), calibration (calibration plot), and clinical utility (net benefit), before and after model recalibration through intercept and slope updates. A sensitivity analysis was conducted by including patients without postoperative creatinine measurements in the validation cohort and categorising them as non-AKI cases.

RESULTS

Nine prediction models were evaluated, each with varying clinical and methodological characteristics, including the types of surgical cohorts used for model development, AKI definitions, and predictors. In the validation cohort involving 13,186 patients, 650 (4.9%) developed AKI. Three models demonstrated fair discrimination (AUROC between 0.71 and 0.75); other models had poor or failed discrimination. All models exhibited some miscalibration; five of the nine models were well-calibrated after intercept and slope updates. Decision curve analysis indicated that the three models with fair discrimination consistently provided a positive net benefit after recalibration. The results were confirmed in the sensitivity analysis.

CONCLUSIONS

We identified three models with fair discrimination and potential clinical utility after recalibration for assessing the risk of acute kidney injury after noncardiac surgery.

Views of health care professionals on the implementation of preoperative advance care planning in older patients with head and neck cancer: Q methodology

Objective

To investigate the views of health care professionals in a head and neck surgical department toward the implementation of advance care planning prior to surgery for older patients with head and neck cancer.

Method

Q methodology was used to explore and analyze participants' views by combining quantitative and qualitative methods. Participants were asked to rank 35 Q statements generated via semi-structured interviews and a literature review and to explain the reasons for their ranking in subsequent interviews. The data was then analyzed and used to develop a factor series to illustrate participants' views.

Results

This study surveyed 15 health care professionals, including eight doctors and seven nurses. The views of health care professionals toward preoperative implementation of advance care planning discussions were varied and could be categorized into three types: defending the autonomy of patients, patients' knowledge and the Chinese traditional cultural context hinder the implementation of preoperative advance care planning, and lack of confidence in performing preoperative advance care planning.

Conclusions

Although the health care professionals in the head and neck surgical department in this study recognized the benefits of preoperative discussions regarding advance care planning, patients' knowledge level, traditional Chinese values, inadequate capacity among health care professionals, and unsound legal policies have caused these professionals to have misgivings about preoperative counseling and discussing advance care planning with patients. Further studies should be conducted, and strategies to overcome barriers to discussions of preoperative advance care planning should be developed.

Pulmonary function testing in preoperative high-risk patients

BACKGROUND

Postoperative respiratory failure is the most frequent complication in postsurgical patients. The purpose of this study is to assess whether pulmonary function testing in high-risk patients during preoperative assessment detects previously unknown respiratory impairments which may influence patient outcomes.

METHODS

A targeted patient screening by spirometry and the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) was implemented in the anesthesia department of a tertiary university hospital. Patients of all surgical disciplines who were at least 75 years old or exhibited reduced exercise tolerance with the metabolic equivalent of task less than four (MET < 4) were examined. Clinical characteristics, history of lung diseases, and smoking status were also recorded. The statistical analysis entailed t-tests, one-way ANOVA, and multiple linear regression with backward elimination for group comparisons.

RESULTS

Among 256 included patients, 230 fulfilled the test quality criteria. Eighty-one (35.2%) patients presented obstructive ventilatory disorders, out of which 65 were previously unknown. 38 of the newly diagnosed obstructive disorders were mild, 18 moderate, and 9 severe. One hundred forty-five DLCO measurements revealed 40 (27.6%) previously unknown gas exchange impairments; 21 were mild, 17 moderate, and 2 severe. The pulmonary function parameters of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly lower than the international reference values of a healthy population. Patients with a lower ASA class and no history of smoking exhibited higher FVC, FEV1, and DLCO values. Reduced exercise tolerance with MET < 4 was strongly associated with lower spirometry values.

CONCLUSIONS

Our screening program detected a relevant number of patients with previously unknown obstructive ventilatory disorders and impaired pulmonary gas exchange. This newly discovered sickness is associated with low metabolic equivalents and may influence perioperative outcomes. Whether optimized management of patients with previously unknown impaired lung function leads to a better outcome should be evaluated in multicenter studies.

TRIAL REGISTRATION

German Registry of Clinical Studies (DRKS00029337), registered on: June 22nd, 2022.

Intensive care utilisation after elective surgery in Australia and New Zealand: A point prevalence study

Objective

We aimed to describe the characteristics, outcomes and resource utilisation of patients being cared for in an ICU after undergoing elective surgery in Australia and New Zealand (ANZ).

Methods

This was a point prevalence study involving 51 adult ICUs in ANZ in June 2021. Patients met inclusion criteria if they were being treated in a participating ICU on he study dates. Patients were categorised according to whether they had undergone elective surgery, admitted directly from theatre or unplanned from the ward. Descriptive and comparative analysis was performed according to the source of ICU admission. Resource utilisation was measured by Length of stay, organ support and occupied bed days.

Results

712 patients met inclusion criteria, with 172 (24%) have undergone elective surgery. Of these, 136 (19%) were admitted directly to the ICU and 36 (5.1%) were an unplanned admission from the ward. Elective surgical patients occupied 15.8% of the total ICU patient bed days, of which 44.3% were following unplanned admissions. Elective surgical patients who were an unplanned admission from the ward, compared to those admitted directly from theatre, had a higher severity of illness (AP2 17 vs 13, p<0.01), require respiratory or vasopressor support (75% vs 44%, p<0.01) and hospital mortality (16.7% vs 2.2%, p < 0.01).

Conclusions

ICU resource utilisation of patients who have undergone elective surgery is substantial. Those patients admitted directly from theatre have good outcomes and low resource utilisation. Patient admitted unplanned from the ward, although fewer, were sicker, more resource intensive and had significantly worse outcomes.

Intensive care utilisation after elective surgery in Australia and New Zealand: getting the balance right

Of the total intensive care unit (ICU) admissions in Australia and New Zealand, 36.6% occur following an elective surgical procedure. How best to use ICU services in this setting is not clear, despite this being an expensive and resource-intensive method of care delivery. The literature relating to this area has not demonstrated a clear association between improved outcomes and routine ICU utilisation. It has, however, demonstrated that methods of care delivery in this setting vary at the local, national and international level. There is now an increased interest in how we can offer safe, efficient care to patients who need ICU-level support after elective surgery, as well as where and when that care can be offered. We had previously performed a literature review relating to ICU utilisation in the elective surgical post-operative setting. This perspective piece arises from this literature review as well as extensive clinical experience from the authors. We discuss the need for a move towards an evidence-based indication for ICU admission and how this may be achieved. We then move on to the various alternative models of care that could be offered, briefly discussing their positives and potential drawbacks. We finish by outlining the research priorities and how these might be implemented in clinical practice. Getting the balance right between ICU admission and higher acuity ward-level care for post-operative elective surgical patients is difficult. However, this is an important challenge that we as a healthcare community must be working to answer.

Postoperative Critical Care Admission Was Not Associated with Improved Postoperative Outcomes in Elective Colorectal Surgery: Secondary Analysis Of POWER Trial

BACKGROUND

The efficacy of routine admission of high-risk patients to a critical care unit after surgery is not clear. The aim of our study was to investigate the association between critical care admission after scheduled colorectal surgery and postoperative complications, 30-day mortality, and length of stay in hospital.

METHODS

A pre-defined secondary substudy of POWER study was performed. POWER study was a prospective multicenter observational study of patients undergoing elective primary colorectal surgery during a single period of two months of recruitment between September and December 2017.

RESULTS

A total of 2084 patients from 80 Spanish hospitals were included, of which 722 (34.6%) were admitted to critical care unit (CCU) after elective surgery. After adjusting for confounding factors in the multivariate analysis, postoperative CCU admission was independently associated with a higher incidence of moderate-to-severe postoperative complications (adjusted OR 1.951, 95% CI 1.570, 2.425; p < 0.001). Regarding secondary outcomes, postoperative critical care admission was independently associated with higher 30-day mortality (adjusted OR 6.736; 95% CI 2.507, 18.101; p < 0.001) and independently associated with an increased hospital length of stay (adjusted OR 1.143, 95% CI 1.112, 1.175; p < 0.001).

CONCLUSIONS

Direct admission to CCU after scheduled colorectal surgery was not associated with a reduction in moderate-to-severe postoperative complications.

Trends in major intensive care medicine journals: A machine learning approach

PURPOSE

Intensive care medicine (ICM) has the particularity of being a multidisciplinary specialty and its literature reflects this multidisciplinarity. However, the proportion of each field in this literature and its trend dynamics are not known. The objective of this study was to analyze the ICM literature, extract latent topics and search for the presence of research trends.

MATERIAL AND METHODS

Abstracts of original articles from the top ICM journals, from their inception until December 31st, 2019, were included. This corpus was fed into a structural topic modeling algorithm to extract latent semantic topics. The temporal distribution was then analyzed and the presence of trends was searched by Mann-Kendall trends tests.

RESULTS

Finally, 49,276 articles from 10 journals were included. After topic modeling analysis and experts' feedback, 124 research topics were selected and labeled. Topics were categorized into 19 categories, the most represented being respiratory, fundamental and neurological research. Increasing trends were observed for research on mechanical ventilation and decreasing trends for cardiopulmonary resuscitation.

CONCLUSIONS

This study reviewed all articles from major ICM journals in a comprehensive way. It provides a better understanding of ICM research landscape by analyzing the temporal evolution of latent research topics in the ICM literature.

Intraoperative protective mechanical ventilation in patients requiring emergency abdominal surgery: the multicentre prospective randomised IMPROVE-2 study protocol

IntroductionEmergency abdominal surgery is associated with a high risk of postoperative complications. One of the most serious is postoperative respiratory failure (PRF), with reported rates up to 20%-30% and attributable 30-day mortality that can exceed 20%.Lung-protective ventilation, especially the use of low tidal volume, may help reducing the risk of lung injury. The role of positive end-expiratory pressure (PEEP) and recruitment manoeuvre (RM) remains however debated. We aim to evaluate whether a strategy aimed at increasing alveolar recruitment by using higher PEEP levels and RM could be more effective at reducing PRF and mortality after emergency abdominal surgery than a strategy aimed at minimising alveolar distension by using lower PEEP levels without RM.

METHODS AND ANALYSIS

The IMPROVE-2 study is a multicentre randomised, parallel-group clinical trial of 680 patients requiring emergency abdominal surgery under general anaesthesia. Patients will be randomly allocated in a 1:1 ratio to receive either low PEEP levels (≤5 cm H2O) without RM or high PEEP levels individually adjusted according to driving pressure in addition to RM, stratified by centre and according to the presence of shock and hypoxaemia at randomisation. The primary endpoint is a composite of PRF and all-cause mortality by day 30 or hospital discharge. Data will be analysed on the intention-to-treat principle and a per-protocol basis.

ETHICS AND DISSEMINATION

IMPROVE-2 trial has been approved by an independent ethics committee for all study centres. Participant recruitment began in February 2021. Results will be submitted for publication in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03987789.

The impact of the incorporation of a feasible postoperative mortality model at the Post-Anaesthestic Care Unit (PACU) on postoperative clinical deterioration: A pragmatic trial with 5,353 patients

Background

Practical use of risk predictive tools and the assessment of their impact on outcome reduction is still a challenge. This pragmatic study of quality improvement (QI) describes the preoperative adoption of a customised postoperative death probability model (SAMPE model) and the evaluation of the impact of a Postoperative Anaesthetic Care Unit (PACU) pathway on the clinical deterioration of high-risk surgical patients.

Methods

A prospective cohort of 2,533 surgical patients compared with 2,820 historical controls after the adoption of a quality improvement (QI) intervention. We carried out quick postoperative high-risk pathways at PACU when the probability of postoperative death exceeded 5%. As outcome measures, we used the number of rapid response team (RRT) calls within 7 and 30 postoperative days, in-hospital mortality, and non-planned Intensive Care Unit (ICU) admission.

Results

Not only did the QI succeed in the implementation of a customised risk stratification model, but it also diminished the postoperative deterioration evaluated by RRT calls on very high-risk patients within 30 postoperative days (from 23% before to 14% after the intervention, p = 0.05). We achieved no survival benefits or reduction of non-planned ICU. The small group of high-risk patients (13% of the total) accounted for the highest proportion of RRT calls and postoperative death.

Conclusion

Employing a risk predictive tool to guide immediate postoperative care may influence postoperative deterioration. It encouraged the design of pragmatic trials focused on feasible, low-technology, and long-term interventions that can be adapted to diverse health systems, especially those that demand more accurate decision making and ask for full engagement in the control of postoperative morbi-mortality.

[Perioperative fluid management in major abdominal surgery]

Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.

Preoperative endothelial dysfunction in cutaneous microcirculation is associated with postoperative organ injury after cardiac surgery using extracorporeal circulation: a prospective cohort study

Background

Cardiac surgery is known to induce acute endothelial dysfunction, which may be central to the pathophysiology of postoperative complications. Preoperative endothelial dysfunction could also be implicated in the pathophysiology of postoperative complications after cardiac surgery. However, the relationship between preoperative endothelial function and postoperative outcomes remains unknown. The primary objective was to describe the relationship between a preoperative microcirculatory dysfunction identified by iontophoresis of acetylcholine (ACh), and postoperative organ injury in patients scheduled for cardiac surgery using cardiopulmonary bypass (CPB).

Methods

Sixty patients undergoing elective cardiac surgery using CPB were included in the analysis of a prospective, observational, single-center cohort study conducted from January to April 2019. Preoperative microcirculation was assessed with reactivity tests on the forearm (iontophoresis of ACh and nitroprusside). Skin blood flow was measured by laser speckle contrast imaging. Postoperative organ injury, the primary outcome, was defined as a Sequential Organ Failure Assessment score (SOFA) 48 h after surgery greater than 3.

Results

Organ injury at 48 h occurred in 29 cases (48.3%). Patients with postoperative organ injury (SOFA score > 3 at 48 h) had a longer time to reach the peak of preoperative iontophoresis of acetylcholine (133 s [104–156] vs 98 s [76–139] than patients without, P = 0.016), whereas endothelium-independent vasodilation to nitroprusside was similar in both groups. Beyond the proposed threshold of 105 s for time to reach the peak of preoperative endothelium-dependent vasodilation, three times more patients presented organ dysfunction at 48 h (76% vs 24% below or equal 105 s). In multivariable model, the time to reach the peak during iontophoresis of acetylcholine was an independent predictor of postoperative organ injury (odds ratio = 4.81, 95% confidence interval [1.16–19.94]; P = 0.030).

Conclusions

Patients who postoperatively developed organ injury (SOFA score > 3 at 48 h) had preoperatively a longer time to reach the peak of endothelium-dependent vasodilation.

Trial registration Clinical-Trials.gov, NCT03631797. Registered 15 August 2018, https://clinicaltrials.gov/ct2/show/NCT03631797

Advance Care Planning for Intensive Care Patients During the Perioperative Period: A Qualitative Study

INTRODUCTION

Patients in intensive care units (ICUs) may transition into an end-of-life phase during treatment. Advance care planning (ACP) for this population has not been studied comprehensively, and support for its implementation is insufficient.

OBJECTIVE

This study aims to clarify the ACP support needs among critical perioperative patients.

METHODS

In this qualitative descriptive study, semistructured interviews were conducted with patients previously admitted to the ICU. The survey was conducted from September to November 2019. Participants comprised 13 individuals, who were admitted to the ICU for a period of 3 months to 2 years after surgery.

RESULTS

The average age of the participants was 63.8 years. The average mechanical ventilation duration following surgery was 24.5 h. The interviews focused on the ACP needs from the preoperative period to discharge. About 90% of the patients thought about the possibility of death before surgery and considered giving advance orders (e.g., "I don't want life-sustaining treatment"). The participants discussed inheritance, work-related matters, and household issues with their families but rarely spoke about treatment and care. Although they examined the content of the advance directives, the medical staff was not informed about them. Patients revealed that they wanted to understand the distinction between life-prolonging and life-saving treatments and discuss it with the medical staff, apart from being educated on ACP. Many patients previously admitted to the ICU are unclear about the difference between life-prolonging and life-saving treatments; this is also true for medical staff.

CONCLUSION

Patients who had been admitted to the ICU after high-risk surgery thought they needed help with ACP before surgery. Therefore, patients have the right to know about treatment risks; however, medical staff believes that this is difficult to communicate. Thus, medical staff should consider ways to communicate clearly with patients, including discussing the risks associated with surgery.

Post-operative intensive care unit admission after elective non-cardiac surgery: A single-center analysis of the NSQIP database

BACKGROUND

Admission to the intensive care unit (ICU) after surgery can be associated with significant morbidity and mortality. This observational cohort study aims to identify perioperative factors associated with post-operative ICU admission in patients undergoing elective non-cardiac surgery.

METHODS

Data from the ACS NSQIP^® database at a tertiary care academic medical center were analyzed from January 2011 to September 2016. Univariable and multivariable logistic regression of patient and surgery-specific characteristics was performed to assess association with post-operative ICU admission. The Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9) billing codes, as well as associated outcomes, were reviewed.

RESULTS

Of 5254 database patient records, 1150 met our inclusion criteria. Elevated body mass index (BMI), longer procedure duration and a diagnosis of disseminated cancer were associated with post-operative ICU admission. Prostatectomy and morbid obesity were the most common CPT and ICD-9 codes identified. Patients who were admitted to the ICU after surgery had a longer hospital length of stay (LOS), had a higher frequency of readmission, re-operation, and in-hospital mortality.

CONCLUSION

Admission to the ICU after elective non-cardiac surgery is common. Our analysis of the ACS NSQIP^® database identified elevated BMI, longer duration of surgery and disseminated cancer as predictors of post-operative ICU admissions in patients undergoing elective non-cardiac surgery.

The Extended Postoperative Care-Score (EXPO-Score)-An Objective Tool for Early Identification of Indication for Extended Postoperative Care

Extended postoperative care and intensive care unit capacity is limited and efficient patient allocation is mandatory. This study aims to develop an effective yet simple score to predict indication for extended postoperative care, as there is a lack of objective criteria for early prediction of admission to extended care in surgical patients. This prospective observational study was divided into two periods (Period 1: Extended Postoperative Care-Score (EXPO)-Score generation; Period 2: EXPO-Score validation) and it was performed at a tertiary university center in Germany. A total of 4042 (Period 1) and 2198 (Period 2) adult patients ≥ 18 years old receiving elective or emergency surgery were included in this study. After identifying patient- and surgery-related risk factors by an expert panel, the EXPO-Score was developed through logistic regression from data of Period 1 and validated in Period 2. Three risk factors are sufficient for generating a reliable predictive EXPO-Score: (1) the American Society of Anesthesiologists’ (ASA) physical status, (2) cardiopulmonary physical exercise status expressed in metabolic equivalents (MET), and (3) the type of surgery. The score threshold (0.23) has a sensitivity of 0.87, a specificity of 0.91, and an accuracy of 0.90 for predicting indication for extended postoperative care. The EXPO-Score provides a validated, early collectable, and easy-to-use tool for predicting indication of extended postoperative care in adult surgical patients.

Perioperative intensive care medicine

Surgery represents one of the main therapeutic references in the world, affording greater survival and life expectancy for many patients. In general, the estimated postoperative mortality is low (around 1-4%). Thirteen percent of the surgical procedures have a high risk of complications, accounting for 80% of all postoperative deaths. Recently, there have been significant advances related to organizational aspects, new anesthetic and surgical techniques, prognostic scales, perioperative management and greater participation and involvement of the patient. This new series of Medicina Intensiva will address fundamental aspects of how Departments of Intensive Care Medicine can add value to the surgical process, in a coordinated manner with other services. Institutional policies are required to ensure the detection of patients at risk in hospitalization wards, with early admission to the ICU of those patients in whom admission is indicated, adapting the treatment in the ICU and optimizing the criteria for discharge. The detection and prevention of post-ICU syndrome in patients and relatives, and the follow-up of ICU discharge and hospitalization in a multidisciplinary manner can reduce the sequelae among critical surgical patients, improving the outcomes and quality of life, and restoring the patient to society. In future publications of this series directed to the surgical patient, updates will be provided on the perioperative management of some of the most complex surgeries.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Association Between Positive Cultures During Admission and 1-Year Mortality in Patients With Cancer Receiving Perioperative Intensive Care

The number of patients with cancer being admitted to intensive care units (ICUs) is increasing worldwide, and these patients are vulnerable to infection. This study aimed to address the long-term impact of positive cultures during admission on 1-year mortality among patients with cancer who received perioperative intensive care. This retrospective cohort study enrolled adult patients with cancer who were admitted to ICUs and received surgery during 2011 to 2016 at a tertiary hospital in central Taiwan. Cancer-related data were retrieved from the cancer registry, and data during ICU admissions were obtained from the electronic medical records. We compared the survival curves between patients with and without positive clinical cultures using log-rank test and used a multivariable Cox proportional hazards regression model to evaluate the influence of positive clinical cultures on 1-year mortality. A total of 638 patients were included for analyses, and 37.9% of them had positive cultures during the index admission. In-hospital mortality was 9.1%, while 1-year mortality was 21.0%. Compared with patients who survived, patients who died were significantly more likely to have positive cultures (59.7% vs 32.1%), to have a higher Acute Physiology and Chronic Health Evaluation II scores (median 21.8 vs 19.0), and to receive mechanical ventilation (86.6% vs 77.4%). Survival analysis found that positive cultures of blood, the respiratory tract, the urinary tract, or the skin and soft tissue were associated with an increased 1-year mortality. Multivariable Cox proportional hazards regression analysis found that positive cultures of blood, the respiratory tract, the urinary tract, or the skin and soft tissue (hazard ratio: 1.621; 95% confidence interval: 1.087-2.419) were significantly associated with 62.1% increased hazards of death within 1 year after the ICU admission. A positive culture during admission was associated with a worsened long-term survival among patients with cancer who received perioperative intensive care. Further studies are needed to confirm this association.