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February 1997
Selective use of the intensive care unit after nonaortic arterial surgery.
Katz SG; Kohl RD;
J Vasc Surg 1996; 24:235-9
[ see abstract below ]
In medicine, clinical practice is quite often nothing more than following an old routine. Why do something a particular way? Frequently the answer is nothing more than "Because that's the way we do it." The reasons for instituting a particular practice may have been sound in the past, but as technology and skill progress, we must not fail to question whether the old way of doing things is still the right way.
Katz & Kohl undertook a study to determine whether the institution of a clinical protocol combining 6 hours of recovery room observation and guidelines for intensive care unit (ICU) admission would allow selected patients to be safely transferred directly to surgical floor after nonaortic arterial reconstruction. They evaluated 134 pts undergoing 154 nonaortic arterial reconstructions.
Procedures included 77 lower extremity revascularizations, 72 carotid endarterectomies, three operations for peripheral aneurysms, one renal artery reconstruction, and one upper extremity arterial revascularization. Patients requiring indwelling pulmonary artery catheters were moved to the ICU after a brief period in the postanesthetic care unit (PACU). The remaining
patients were sent to the PACU for an extended 6-hour stay.
In the recovery room those patients with hemodynamic instability, chest pain unresponsive to sublingual nitroglycerin, or respiratory distress with an oxygen saturation of less than 92% were transferred to the ICU as were patients requiring prolonged infusions of intravenous vasoactive or antiarrhythmic drugs. Those who appeared clinically stable after 6 hours were placed in monitored beds on the surgical floor.
The authors chose a 6-hour recovery room stay because this appeared to be the period during which most early perioperative complications arose. Note that a 6 hr PACU stay + room charge vs. a 1 day ICU stay may or may not be a great savings. On the stepdown unit, nurse/patient ratios were 1:4, and vital signs were taken at 2-hour intervals for 12 hours. After this time cardiac monitoring was discontinued, and patients received routine postoperative nursing care.
Perioperative hypertension was aggressively treated with a combination of sublingual calcium blockers (nifedipine 10 to 20 mg every 4 hours) and topical nitrates (transdermal nitroglycerin 0.2 to 0.4 mg/hr). Parenteral antihypertensives were used only if the previously mentioned regimen failed to control the blood pressure.
Twelve patients (7.8%) spent a total of 27 days in the ICU (range 1 to 11 days). As per their guidelines, four patients were transferred to the ICU for invasive monitoring, and four were sent to the ICU because of refractory hemodynamic instability or arrhythmia in the postanesthetic recovery room.
An additional four patients were transferred to the ICU after having been on the surgical floor for 24 to 72 hours because of the following perioperative complications: prolonged chest pain (one), pneumonia (one), heart failure
(one), and graft occlusion requiring a urokinase infusion. Carotids were least likely to need an ICU bed. Patients admitted to the ICU were more likely to have heart disease (p = 0.04) than those who were not. The 30-day mortality rate was 1.4%.
Note that no one transferred in the first 24 hours back to the ICU. The patient having prolonged chest pain transferred to the coronary care unit after having a subendocardial myocardial infarction 48 hours after operation. Cardiac complications are expected to occur after the first 24 hours and this paper highlights the fact that ICU admissions for the express purpose of preventing a cardiac complication is a low yield practice.
An important caveat is that patients undergoing vascular surgery cannot be transferred from the recovery room to a surgical floor until its nursing care has been upgraded with extensive inservicing (detailed in the body of the paper).
ICU's account for 20% of expenditures. although only accounting for 6% of hospital beds. We must continually revisit ICU admission criteria and critically analyze the use of this resource.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
Purpose: The purpose of this study was to determine whether the institution of a clinical protocol combining 6 hours of recovery room observation and guidelines for intensive care unit (ICU) admission would allow selected patients to be safely transferred directly to a surgical floor after nonaortic arterial reconstruction.
Methods: After a clinical pathway was formed, 134 consecutive patients undergoing 154 nonaortic arterial operations were prospectively enrolled in this study. Patients requiring ICU care and the responsible factors were identified. Comparisons of risk factors and demographics were made between those patients who did and did not require ICU care.
Results: Twelve (7.8%) patients spent a total of 27 days in the ICU (range 1 to 11 days). As per our guidelines four patients were transferred to the ICU for invasive monitoring, and four were sent to the ICU because of refractory hemodynamic instability or arrhythmia in the postanesthetic recovery room.
An additional four patients were transferred to the ICU after having been on the surgical floor for 24 to 72 hours because of the following perioperative complications: prolonged chest pain (one), pneumonia (one), heart failure (one), and graft occlusion requiring a urokinase infusion. Patients admitted to the ICU were more likely to have heart disease (p = 0.02) and to have had an operation other than carotid endarterectomy (p = 0.04) than those who were not. The 30-day mortality rate was 1.4%.
Conclusions: The implementation of a clinical protocol similar to the one used in this study will allow many patients undergoing nonaortic vascular surgery to avoid the use of the ICU. This approach will conserve hospital and financial resources without adversely affecting patient morbidity and mortality rates.
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