Salvage intensive care following initial recovery from pulmonary resection: is it justified?

Risk Factors for Postoperative Pulmonary Complications in Patients Undergoing Thoracotomy for Indications Other than Primary Lung Cancer Resection: A Multicenter Retrospective Cohort Study from the German Thorax Registry

Background: Postoperative pulmonary complications (PPCs) are the most common complications following lung surgery and can lead to increased postoperative mortality. In this study, we examined the incidence of PPCs, the in-hospital mortality rate, and the risk factors associated with PPCs in patients undergoing open thoracotomy lung resection (OTLR) for reasons other than primary lung cancer. Methods: Data from this multicenter, retrospective study involving 1.368 patients were extracted from the German Thorax Registry and analyzed using univariate and multivariable statistical methods. Results: In total, 278 patients showed at least one PPC. The presence of PPCs was associated with a significantly higher in-hospital mortality rate (7.2% vs. 1.5%; p = 0.000). Multivariable stepwise logistic regression analysis showed absolute age (OR 1.02) and BMI ≤ 19 (OR 2.6) as independent patient-specific risk factors. Significant preoperative risk factors included re-thoracotomy (OR 4.0) and FEV1 < 60% (OR 2.5). Procedure-related independent risk factors for PPCs included a surgical duration surpassing 195 min (OR 2.7), the continuation of invasive ventilation post-surgery (OR 3.8), and an intraoperative infusion of crystalloids greater than 6 mL/kg/h (OR 1.8). Conclusions: Optimizing intraoperative fluid therapy and on-table extubation when possible may reduce the incidence of PPCs and associated mortality.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased In-Hospital Mortality in Patients Undergoing Thoracotomy for Primary Lung Cancer Resection: A Multicentre Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications (PPCs) represent the most frequent complications after lung surgery, and they increase postoperative mortality. This study investigated the incidence of PPCs, in-hospital mortality rate, and risk factors leading to PPCs in patients undergoing open thoracotomy lung resections (OTLRs) for primary lung cancer. The data from 1426 patients in this multicentre retrospective study were extracted from the German Thorax Registry and presented after univariate and multivariate statistical processing. A total of 472 patients showed at least one PPC. The presence of two PPCs was associated with a significantly increased mortality rate of 7% (p < 0.001) compared to that of patients without or with a single PPC. Three or more PPCs increased the mortality rate to 33% (p < 0.001). Multivariate stepwise logistic regression analysis revealed male gender (OR 1.4), age > 60 years (OR 1.8), and current or previous smoking (OR 1.6), while the pre-operative risk factors were still CRP levels > 3 mg/dl (OR 1.7) and FEV1 < 60% (OR 1.4). Procedural independent risk factors for PPCs were: duration of surgery exceeding 195 min (OR 1.6), the amount of intraoperative blood loss (OR 1.6), partial ligation of the pulmonary artery (OR 1.5), continuing invasive ventilation after surgery (OR 2.9), and infusion of intraoperative crystalloids exceeding 6 mL/kg/h (OR 1.9). The incidence of PPCs was significantly lower in patients with continuous epidural or paravertebral analgesia (OR 0.7). Optimising perioperative management by implementing continuous neuroaxial techniques and optimised fluid therapy may reduce the incidence of PPCs and associated mortality.

Outcome following unplanned critical care admission after lung resection

OBJECTIVES

Patients undergoing lung resection are at risk of perioperative complications, many of which necessitate unplanned critical care unit admission in the postoperative period. We sought to characterize this population, providing an up-to-date estimate of the incidence of unplanned critical care admission, and to assess critical care and hospital stay, resource use, mortality, and outcomes.

METHODS

A multicenter retrospective cohort study of patients undergoing lung resection in participating UK hospitals over 2 years. A comprehensive dataset was recorded for each critical care admission (defined as the need for intubation and mechanical ventilation and/or renal replacement therapy), in addition to a simplified dataset in all patients undergoing lung resection during the study period. Multivariable regression analysis was used to identify factors independently associated with critical care outcome.

RESULTS

A total of 11,208 patients underwent lung resection in 16 collaborating centers during the study period, and 253 patients (2.3%) required unplanned critical care admission with a median duration of stay of 13 (4-28) days. The predominant indication for admission was respiratory failure (68.1%), with 77.8% of patients admitted during the first 7 days following surgery. Eighty-seven (34.4%) died in critical care. On multivariable regression, only the diagnosis of right ventricular dysfunction and the need for both mechanical ventilation and renal-replacement therapy were independently associated with critical care survival; this model, however, had poor predictive value.

CONCLUSIONS

Although resource-intensive and subject to prolonged stay, following unplanned admission to critical care after lung resection outcomes are good for many patients; 65.6% of patients survived to hospital discharge, and 62.7% were discharged to their own home.

Impact of regional analgesia techniques on the long-term clinical outcomes following thoracic surgery

Continuous monitoring of clinical outcomes after thoracotomy is very important to improve medical services and to reduce complications. The use of regional analgesia techniques for thoracotomy offers several advantages in the perioperative period including effective pain control, reduced opioid consumption and associated side effects, enhanced recovery, and improved patient satisfaction. Postthoracotomy complications, such as chronic postthoracotomy pain syndrome, postthoracotomy ipsilateral shoulder pain, pulmonary complications, recurrence, and unplanned admission to the intensive care unit are frequent and may be associated with poor outcomes and mortality. The role of regional techniques to reduce the incidence of these complications is questionable. This narrative review aims to investigate the impact of regional analgesia on the long-term clinical outcomes after thoracotomy.

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.

Care of the Postoperative Pulmonary Resection Patient

Patients undergoing pulmonary resection all exhibit, to some degree, a level of pulmonary dysfunction. This is due to the physiologic stress of the procedure performed, the patient’s comorbidities, and preexisting cardiopulmonary reserve. Although prognostic factors for intensive care requirement exist, to date, there is no consensus for postoperative admission. Institutional practices vary across the country, with patients often admitted to intensive care for surveillance. Guidelines published from the American Thoracic Society in 1999 emphasize that admission to the ICU be reserved for those patients requiring care and monitoring for severe physiologic instability. Admissions following pulmonary resection are typically due to respiratory complications and are an independent predictor of mortality. The following chapter will review the indications for admission to the ICU and common issues encountered following pulmonary resection and conclude with a discussion of the management of patients undergoing pulmonary transplantation.

Utilisation of Intermediate Care Units: A Systematic Review

Background. The diversity in formats of Intermediate Care Units (IMCUs) makes it difficult to compare data from different settings. The purpose of this article was to describe and quantify these different formations and utilisation. Methods. We performed a systematic review extracting geographic location, nomenclature used, admitting specialties, open (admitting specialist in charge) or closed (intensivist/generalist in charge) management format, location in hospital, number of beds, nursing workload, medical staff to patient ratios, and modalities—possibilities and limitations—implemented. Results. Nomenclature used was High Dependency Unit (56.8%) or Intermediate Care Unit (24.3%), with the latter one increasingly being used recently. The median number of beds was 6 (IQR 4–10). Location (p < 0.001) and admitting specialties (p = 0.03) were related to the management format. IMCUs integrated or adjacent to Intensive Care Units were more often capable of using single vasoactive medication (p = 0.025). The mean nurse to patient ratio was 1 to 2.5. Conclusions. IMCUs often have a specific task in a hospital, which is reflected in location, format, and utilisation. The management format depends on location and admitting specialist while incorporated supportive treatment modules reflect its function. Common IMCU denominators are continuous monitoring and respiratory support, without mechanical ventilation and multiple vasoactive medications.

The economic burden of complications occurring in major surgical procedures: a systematic review

OBJECTIVES

On the basis of a systematic review, we aimed to establish the cost and drivers of cost and/or resource use of intra- and perioperative complications occurring as a result of selected major surgical procedures, as well as to understand the relationship between costs and severity of complication and, consequently, the economic burden they represent. We also assessed the clinical and economic methodologies used to derive costs and resource use across the studies with a view to providing guidance on reporting standards for these studies.

METHODS

We searched EMBASE, MEDLINE and Econlit (from 2002 to 2012) for study publications including resource use/cost data relating to surgical complications.

RESULTS

We identified 38 relevant studies on pancreatic (n = 14), urologic (n = 4), gynaecological (n = 6), thoracic (n = 13) and hepatic surgery (n = 1). All studies showed that complications lead to higher resource use and hospital costs compared with surgical procedures without complications. Costs depend on type of complication and complication severity, and are driven primarily by prolonged hospitalisation. There was considerable heterogeneity between studies with regard to patient populations, outcomes and procedures, as well as a lack of consistency and transparency of reporting of costs/resource use. Complication severity grading systems were used infrequently.

CONCLUSIONS

The overall conclusions of included studies are consistent: complications represent an important economic burden for health care providers. We conclude that more accurate and consistent data collection is required to serve as input for good-quality economic analyses, which in turn can inform hospital decisions on cost-efficient allocation of their limited resources.

The acute physiology and chronic health evaluation III outcome prediction in patients admitted to the intensive care unit after pneumonectomy

PURPOSE

The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy.

METHODS

A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination.

RESULTS

There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (+/- standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (+/-10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction.

CONCLUSIONS

In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable.

Incidence, duration and causes of intensive care unit admission following pulmonary resection for malignancy

BACKGROUND

We assessed the overall incidence and duration of ICU admission following pulmonary resection and attempted to identify patients requiring prolonged ICU stay.

METHODS

Analysis of prospectively collected data on all patients undergoing pulmonary resection for suspected malignant disease that subsequently required ICU admission between March 2002 and October 2003.

RESULTS

Of 170 patients 52 (30%) needed intensive care post-operatively: 21 (12%) for less than 24 h and 31 (18%) for more, for which group the average length of stay was 11.3 days. There was no significant difference between the patient groups at ICU admission in terms of median APACHE II scores (12 vs. 14), gas exchange (PaO2/FIO2, 441 vs. 364 mmHg), estimated post-operative absolute FEV1 (1.62 vs. 1.31 l) or predicted percentage FEV1 (61.8% vs. 44.3%). Mean ICU cost was 1,838 sterling pounds vs. 25,974 sterling pounds per admission, respectively.

CONCLUSIONS

Following pulmonary resection some 18% of patients need a protracted ICU stay at considerable cost. Neither severity of illness scoring, indices of gas exchange at ICU admission, nor predicted post-operative FEV1 identifies such patients.