Intensive Care Unit Stay of More than 14 Days after Cardiac Surgery is Associated with Non-cardiac Organ Failure

Risk factors associated with prolonged intensive care unit stay following surgery for total anomalous pulmonary venous connection: a retrospective study

BACKGROUND

Prolonged intensive care unit (ICU) stays consume medical resources and increase medical costs. This study identified risk factors associated with prolonged postoperative intensive care unit (ICU) stay in children with total anomalous pulmonary venous connection (TAPVC).

METHODS

The medical records of 85 patients who underwent surgical repair of TAPVC were retrospectively analyzed. The patients were divided into prolonged-stay and standard-stay groups. The prolonged stay group included all patients who exceeded the 75th percentile of the ICU stay duration, and the standard stay group included all remaining patients. The effects of patient variables on ICU stay duration were investigated using univariate and logistic regression analyses.

RESULTS

Patient median age was 41 (18-103) days, and median weight was 3.80 (3.30-5.35) kg.Postoperative duration of ICU stay was 11-68 days in the prolonged stay group (n = 23) and 2-10 days in the standard stay group (n = 62). Lower preoperative pulse oximetry saturation (SpO2), higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay. Preoperative SpO2 < 88.5%, highest plasma lactate value > 4.15 mmol/L, and postoperative mechanical ventilation duration was longer than 53.5 h, were associated with increased risk of prolonged ICU stay. Young age, low body weight, subcardiac type, need for vasoactive drug support, emergency surgery, long anesthesia time, low SpO2 after anesthesia induction, long cardiopulmonary bypass (CPB) and aortic clamp times, high lactate level, low temperature, large volume of ultrafiltration during CPB, large amounts of chest drainage, large red blood cells (RBCs) and plasma transfusion, and postoperative cardiac dysfunction may be associated with prolonged ICU stay.

CONCLUSIONS

Lower preoperative SpO2, higher intraoperative plasma lactate levels, and prolonged postoperative mechanical ventilation were independent risk factors for prolonged ICU stay in children with TAPVC. When SpO2 was lower than 88.5%, the highest plasma lactate value was more than 4.15 mmol/L, and the postoperative mechanical ventilator duration was longer than 53.5 h, the risk of prolonged ICU stay increased. Improved clinical management, including early diagnosis and timely surgical intervention to reduce hypoxia time and protect intraoperative cardiac function, may reduce ICU stay time.

Extended intensive care correlates with worsening of surgical outcome after elective abdominal aortic reconstruction

BACKGROUND

The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment.

METHODS

The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival.

RESULTS

Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, p=.0498; OR 4.42 (0.94-20.84)) and the rate of acute kidney injury (82.5% vs. 57.1%, p=.0352; OR 3.55 (1.20-0.46)) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, p=.0281; OR 0.27 (0.09- 0.84)) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (p=.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a body mass index (BMI) of <25, chronic renal insufficiency (CRI), and coronary artery disease (CAD). Endovascular therapy was a positive predictive factor of short ICU stay of ≤3 days.

CONCLUSIONS

The outcome after extended intensive care following elective aortic surgery is strongly dependent on the length of ICU stay.

Postoperative Cardiac Arrest in Cardiac Surgery-How to Improve the Outcome?

Background

In the early postoperative period after cardiac surgery the heart may be temporarily dysfunctional and prone to arrhythmias due to the phenomenon of myocardial stunning, vasoplegic syndrome, systemic inflammatory response syndrome (SIRS), electrolyte disturbances, operative trauma and myocardial edema. Most cases of cardiac arrest after cardiac surgery are reversible.

Objective

To analyse the factors that may influence the outcome of cardiac arrest after adult and pediatric cardiac surgery.

Methods

Retrospective analysis that included cardiac surgical procedures (886 adult and 749 pediatric patients) performed during the 18 month period of this study at Queen Alia Heart Institute/ Amman, Jordan. All cardiac arrest events were recorded and analysed. Data was collected on Utstein style templates designed for the purpose of this study. The outcome of cardiac arrest is examined as an early outcome (ROSC or lethal outcome) and late outcome (full recovery, recovery with complications, or in-hospital mortality). Factors that may influence the outcome of cardiac arrest were recorded and statistically analysed. Ethical committee approval obtained.

Results

The overall mortality rate was 3.3%. Cardiac arrest occurred in 114 patients (6.97%). The age of patients ranged from 5 days to 82 years and constituted 66 pediatric and 48 adult patients. Most pediatric cardiac arrests manifested as non-shockable rhythms (77%). Most in-hospital cardiac arrests occurred in the intensive care unit (86.5%). The majority of patients were mechanically ventilated at the time of occurrence of arrest (62.5% and 54.5% in adult and pediatric patients, respectively). Average time of cardiopulmonary resuscitation was 32.24 minutes. Overall, CA survival was 20% higher in the paediatric sub-group (full recovery rate of 51.5%). Neurological injury was slightly lower in pediatric than adult cardiac arrest survivals. (2% vs. 3%).

Conclusion

Shockable rhythms are more common in adult cardiac arrest, while non-shockable rhythms are more frequent in the pediatric sub-population. Hemodynamic monitoring, witnessed-type of cardiac arrest, non-interrupted cardiac massage, and early recognition of cardiac tamponade are the factors associated with higher rates of survival.

The long-term effects of prolonged intensive care stay postcardiac surgery

OBJECTIVES

Short-term outcomes for those with a prolonged length of stay (LOS) in intensive care (ITU) following cardiac surgery are poor, with higher rates of in-hospital mortality and morbidity. Consequently, discharge from hospital has been considered the key measure of success. However, there has been a shift towards long-term outcomes, functional recovery and quality of life (QoL) as measures of surgical quality. The aim of this review is to compare and critique the findings of multiple studies to determine the long-term effects of prolonged ITU stay postcardiac surgery.

METHODS

A computerized literature search of CINAHL, EMBASE and Google Scholar databases, based on keywords "long-term effects," "prolonged ITU stay," "cardiac surgery," with rigorous CASP critique was undertaken.

RESULTS

The search yielded 12 papers meeting the inclusion criteria, with eight retrospective and four prospective studies. Eight of these 12 papers identified inferior long-term survival or higher mortality rates for those who had prolonged LOS in ITU in comparison to "normal" LOS or a control. The greatest burden of mortality was 6 months to 1 year postdischarge. Three papers found that quality of life was adversely affected or worse for those who had experienced prolonged LOS in ITU.

CONCLUSIONS

Further research is required to provide better quality evidence into QoL, following prolonged stay in ICU postcardiac surgery. The evidence reviewed suggests that the risk of mortality in this demographic of patients is higher, especially within the first year and, therefore, more frequent medical surveillance of these patients is recommended.

Survival, Quality of Life, and Functional Status Following Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review

OBJECTIVES

Compared with noncardiac critical illness, critically ill postoperative cardiac surgical patients have different underlying pathophysiologies, are exposed to different processes of care, and thus may experience different outcome trajectories. Our objective was to systematically review the outcomes of cardiac surgical patients requiring prolonged intensive care with respect to survival, residential status, functional recovery, and quality of life in both hospital and long-term follow-up.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science, and Dissertations and Theses Global up to July 21, 2017.

STUDY SELECTION

Studies were included if they assessed hospital or long-term survival and/or patient-centered outcomes in adult patients with prolonged ICU stays following major cardiac surgery. After screening 10,159 citations, 114 articles were reviewed in full; a final 34 articles met criteria for data extraction.

DATA EXTRACTION

Two reviewers independently extracted data and assessed risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Studies. Extracted data included the used definition of prolonged ICU stay, number and characteristics of prolonged ICU stay patients, and any comparator short stay group, length of follow-up, hospital and long-term survival, residential status, patient-centered outcome measure used, and relevant score.

DATA SYNTHESIS

The definition of prolonged ICU stay varied from 2 days to greater than 14 days. Twenty-eight studies observed greater in-hospital mortality among all levels of prolonged ICU stay. Twenty-five studies observed greater long-term mortality among all levels of prolonged ICU stay. Multiple tools were used to assess patient-centered outcomes. Long-term health-related quality of life and function was equivalent or worse with prolonged ICU stay.

CONCLUSIONS

We found consistent evidence that patients with increases in ICU length of stay beyond 48 hours have significantly increasing risk of hospital and long-term mortality. The significant heterogeneity in exposure and outcome definitions leave us unable to precisely quantify the risk of prolonged ICU stay on mortality and patient-centered outcomes.

Very prolonged stay in the intensive care unit after cardiac operations: early results and late survival

BACKGROUND

Prolonged intensive care unit (ICU) stay is a surrogate for advanced morbidity or perioperative complications, and resource utilization may become an issue. It is our policy to continue full life support in the ICU, even for patients with a seemingly grim outlook. We examined the effect of duration of ICU stay on early outcomes and late survival.

METHODS

Between 1993 and 2011, 6,385 patients were admitted to the ICU after cardiac surgery. Patients were grouped according to length of stay in the ICU: group 1, 2 days or less (n = 4,631; 73%); group 2, 3 to 14 days (n = 1,423; 22%); group 3, more than 14 days (n = 331; 5%). Length of stay in ICU for group 3 patients was 38 ± 24 days (range, 15 to 160; median 31). Clinical profile and outcomes were compared between groups.

RESULTS

Patients requiring prolonged ICU stay were older, underwent more complex surgery, had greater comorbidity, and a higher predicted operative mortality (p < 0.0001). They had a higher incidence of adverse events and increased mortality (p < 0.0001). Of the 331 group 3 patients, 60% were discharged: survival of these patients at 1, 3, and 5 years was 78%, 65%, and 52%, respectively. Operative mortality as well as late survival of discharged patients was proportional to duration of ICU stay.

CONCLUSIONS

Current technology enables keeping sick patients alive for extended periods of time. Nearly two thirds of patients requiring prolonged ICU leave hospital, and of these, 50% attain 5-year survival. These data support offering full and continued support even for patients requiring very prolonged ICU stay.

Outcome in patients with long-term treatment in a surgical intensive care unit

BACKGROUND

This study aimed to evaluate the outcome of patients with abdominal, thoracic or vascular operations and long-term intensive care unit (ICU) treatment.

PATIENTS AND METHODS

The present retrospective observational cohort study was performed at the authors' surgical ICU at the Marburg University Medical Centre. All patients who stayed at the ICU longer than 48 h and underwent visceral, thoracic or vascular surgery between January 2005 and December 2006 were retrospectively analysed. Patients with an ICU stay of 20 or more days were defined as the long-term study group. Clinical variables were tested for prognostic value.

RESULTS

In 2 years, 852 patients were treated at the intensive care unit. Follow-up was available in 502 patients, with 219 patients treated for two and more days and a median of 16.4 days. Sixty-seven long-term patients were compared to 152 (69.4 %) patients treated between 2 and 20 days. Overall survival after 12 months was 50.2 % (110/219), while 65.8 % (144/219) were discharged from ICU. Older age, longer treatment at the ICU and increased simplified acute physiology score (SAPS) at admission were associated with decreased 12-month survival, while no statistical differences were observed for the underlying and malignant disease by univariate analysis. The risk of death was 29, 56 and 61 % for patients treated 2-4, 5-19 and ≥20 days at the ICU. Decreased survival of patients treated for 5-19 and ≥20 days were confirmed by logrank test (p = 0.001).

CONCLUSIONS

Patients with long-term ICU stay showed decreased survival than patients who are treated less than 5 days but similar survival as patients which stayed between 5 and 19 days. Malignant disease is not associated with an unfavourable 12-month survival while older age, higher SAPS index at discharge and longer stay at ICU are. Long-term ICU survivors have no increased risk to succumb after discharge from ICU.

Clinical outcomes in patients with prolonged intensive care unit length of stay after cardiac surgical procedures

BACKGROUND

Advances in critical care medicine have allowed for improved care of patients requiring prolonged intensive care unit length of stay (prICULOS) after cardiac operations, yet little is known regarding their eventual outcomes. The purpose of this study was to examine short- and long-term outcomes in patients undergoing cardiac operations with prICULOS.

METHODS

All cases of coronary artery bypass grafting (CABG), aortic valve, mitral valve, and combined CABG/valve surgical procedures performed at a single institution from July 2002 to July 2007 were identified. All-cause mortality in patients discharged alive from the hospital was determined until December 2007 through linkage with the Social Security Death Index. Patients who experienced intraoperative death or those with missing or invalid social security numbers were excluded. The definition of prICULOS was total ICULOS greater than 7 days.

RESULTS

A total of 3,478 patients met inclusion criteria. One hundred thirty-seven of three thousand four hundred seventy-eight patients (3.9%) experienced prICULOS. These patients were more likely to be older than 70 years (55.5% versus 30.5%; p<0.0001) and to have had recent myocardial infarction (28.5% versus 20.1%; p=0.02), previous cardiac operation (18.3% versus 6.9%; p<0.0001), and emergent status (9.5% versus 1.6%; p<0.0001). They experienced greater in-hospital mortality (37.2% versus 1.7%; p<0.0001) and those who were discharged alive had worse long-term survival (log-rank, p<0.0001). After risk adjustment, prICULOS emerged as a significant predictor of in-hospital death (odds ratio [OR] 20.9; 95% confidence interval [CI], 12.9-33.7) and decreased long-term survival (hazard ratio [HR] 2.9; 95% CI, 2.0-4.3).

CONCLUSIONS

Patients with prICULOS after cardiac operations have worse overall outcomes. These data may be used to inform these patients and their families of realistic expectations regarding their clinical course.

What happens after discharge? An analysis of long-term survival in cardiac surgical patients requiring prolonged intensive care

BACKGROUND

Cardiac surgical patients with postoperative complications frequently require prolonged intensive care yet survive to hospital discharge.

METHODS

From January 1, 2002 to December 31, 2007, 11,541 consecutive patients underwent cardiac operations at a single academic institution. Of these, 11,084 (95.9%) survived to hospital discharge and comprised the study sample. Patients were retrospectively categorized into four groups according to intensive care unit (ICU) length of stay (LOS): <3 days, three to seven days, 7 to 14 days, and >14 days. Survival at 12 months was determined using the Social Security Death Index. Kaplan-Meier (KM) survival curves and Cox proportional hazards regression modeling (hazard ratio, HR) were used to analyze group differences in survival.

RESULTS

One-year survival among the four groups according to ICU LOS was: <3 days, 97.0% (8407/8666); three to seven days, 91.2% (1481/1625); 7 to 14 days, 87.9% (356/405); and >14 days, 68.3% (265/388) (p < 0.001). Using multivariable regression analysis, adjusted overall mortality was significantly greater in patients with ICU LOS of three to seven days (HR = 1.51), 7 to 14 days (HR = 1.40), and >14 days (HR = 1.90) compared to patients with ICU LOS <3 days. Mortality among patients who survived more than six months postsurgery was significantly greater in patients with ICU LOS of three to seven days (HR = 1.37), 7 to 14 days (HR = 1.34), and >14 days (HR = 1.63).

CONCLUSIONS

Although cardiac surgery patients with major postoperative complications frequently survive to hospital discharge, survival after discharge is significantly reduced in patients requiring prolonged ICU care. Reduced survival in patients with a high risk of complications and anticipated long ICU stays should be considered when discussing surgical versus nonsurgical options.