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

Abstract

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 intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), 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): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) 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.

Open and laparoscopic approaches are associated with comparable 90-day morbidity and mortality following ERAS protocol

“…Mortality is defined as any death within 90 days post operative period and morbidity included clavien-dindo grade 3 and grade 4 complications, which is similar to published data. 9,10 In our study in univariate analysis morbidity was associated significantly with higher CDC grade of surgeries, higher ASA grade, more operative time, more blood products use, more hospital stay, open surgeries,HPB surgeries and luminal surgeries(non hpb gastrointestinal surgeries) were associated with higher 90 days morbidity However on multivariate analysis no factors independently predicted morbidity.…”

“…Mortality is defined as any death within 90 days of the operation and morbidity included Clavien-Dindo grade 3 and grade 4 complications, which is similar to the published data. 9,10…”

Postoperative complications and disposition for vascular surgery

“…For instance, the STARSurg collaborative revealed no benefit in mortality with planned ICU admission postoperatively. 17 However, that study only considered liver and gastrointestinal surgery and only measured 30-day mortality. Meanwhile, the study by Gillies et al 10 demonstrated increased morbidity and mortality with unplanned postoperative ICU admissions.…”

Pre operative fitness score accurately predicts uneventful post operative course in gastrointestinal and hepatobiliary surgery

“…On univariate analysis we found that ASA score,CDC grade of surgery, more blood products used, increased operative time, open surgeries compared to laparoscopic surgeries, emergency surgeries were associated with increased morbidity and mortality in gastrointestinal and hepato-pancreatico biliary surgery.Various authors have also found similar factors associated with post operative morbidity and mortality. [1,2 34…”