Readmission to the Cardiac Surgery Intensive Care Unit

Abstract

We read with interest the recent article by Holaubek et al.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar that described the perioperative risk factors associated with intensive care unit (ICU) readmission after cardiac surgery. The authors delineated respiratory failure and cardiac decompensation as the leading causes of readmission in their single-center retrospective analysis.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar Nevertheless, it may be difficult to separate cardiac and respiratory readmission in a retrospective study, as discussed by Vohra et al.2Vohra HA Goldsmith IR Rosin MD et al.The predictors and outcome of recidivism in cardiac ICUs.Eur J Cardiothorac Surg. 2005; 27: 508-511Google Scholar Quantification of the duration of mechanical ventilation and the incidence of low-cardiac-output syndrome during the initial ICU admission may have proved useful in distinguishing patients who were readmitted from those who were not. Indeed, the authors reported that readmitted patients had a longer median ICU stay, which could have resulted from a greater need for circulatory and respiratory support.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google ScholarSecond, the authors argued that their heterogeneous patient population was a strength of the study,1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar but they did not include the cardiopulmonary bypass and aortic cross-clamp times between the groups. Lee et al. identified cardiopulmonary bypass time as an independent risk factor for 30-day readmission, in a retrospective analysis of 3,654 consecutive cardiac surgical patients at their institution.3Lee R Homer N Andrei AC et al.Early readmission for congestive heart failure predicts late mortality after cardiac surgery.J Thorac Cardiovasc Surg. 2012; 144: 671-676Google Scholar Van Diepen et al. further emphasized the importance of the intraoperative and postoperative factors in determining the risk of readmission in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry.4Van Diepen S Graham MM Nagendran J et al.Predicting cardiovascular intensive care unit readmission after cardiac surgery: Derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases.Crit Care. 2014; 18: 651Google ScholarThird, the authors should be congratulated for their recognition that perioperative optimization potentially can attenuate preventable ICU readmission. However, the definition and the incidence of preventable readmission remain debatable,5Wang HJ Gao Y Qu SN et al.Preventable readmission to intensive care unit in critically ill cancer patients.World J Emerg Med. 2018; 9: 211-215Google Scholar particularly when cardiac tamponade emerges as the third leading cause for readmission in the index analysis.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar The timing of readmission also may be important in identifying preventable readmission. Bettex and Rudiger6Bettex D Rudiger A. Length of ICU stay after cardiac surgery: Too long or too short?.J Cardiothorac Vasc Anesth. 2018; 32: 2692-2693Google Scholar stressed that the readmissions within 48 hours after transfer might be a quality indicator, but the later readmissions are more closely related to the preoperative comorbid profile.7Brown SE Ratcliffe SJ Halpern SD. An empirical derivation of the optimal time interval for defining ICU readmissions.Med Care. 2013; 51: 706-714Google ScholarConflict of InterestNone. We read with interest the recent article by Holaubek et al.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar that described the perioperative risk factors associated with intensive care unit (ICU) readmission after cardiac surgery. The authors delineated respiratory failure and cardiac decompensation as the leading causes of readmission in their single-center retrospective analysis.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar Nevertheless, it may be difficult to separate cardiac and respiratory readmission in a retrospective study, as discussed by Vohra et al.2Vohra HA Goldsmith IR Rosin MD et al.The predictors and outcome of recidivism in cardiac ICUs.Eur J Cardiothorac Surg. 2005; 27: 508-511Google Scholar Quantification of the duration of mechanical ventilation and the incidence of low-cardiac-output syndrome during the initial ICU admission may have proved useful in distinguishing patients who were readmitted from those who were not. Indeed, the authors reported that readmitted patients had a longer median ICU stay, which could have resulted from a greater need for circulatory and respiratory support.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar Second, the authors argued that their heterogeneous patient population was a strength of the study,1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar but they did not include the cardiopulmonary bypass and aortic cross-clamp times between the groups. Lee et al. identified cardiopulmonary bypass time as an independent risk factor for 30-day readmission, in a retrospective analysis of 3,654 consecutive cardiac surgical patients at their institution.3Lee R Homer N Andrei AC et al.Early readmission for congestive heart failure predicts late mortality after cardiac surgery.J Thorac Cardiovasc Surg. 2012; 144: 671-676Google Scholar Van Diepen et al. further emphasized the importance of the intraoperative and postoperative factors in determining the risk of readmission in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry.4Van Diepen S Graham MM Nagendran J et al.Predicting cardiovascular intensive care unit readmission after cardiac surgery: Derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases.Crit Care. 2014; 18: 651Google Scholar Third, the authors should be congratulated for their recognition that perioperative optimization potentially can attenuate preventable ICU readmission. However, the definition and the incidence of preventable readmission remain debatable,5Wang HJ Gao Y Qu SN et al.Preventable readmission to intensive care unit in critically ill cancer patients.World J Emerg Med. 2018; 9: 211-215Google Scholar particularly when cardiac tamponade emerges as the third leading cause for readmission in the index analysis.1Holaubek C Winter F Lesjak A et al.Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery [e-pub ahead of print].J Cardiothorac Vasc Anesth. 2021 Nov 7; (November 08, 2021)https://doi.org/10.1053/j.jvca.2021.10.044Google Scholar The timing of readmission also may be important in identifying preventable readmission. Bettex and Rudiger6Bettex D Rudiger A. Length of ICU stay after cardiac surgery: Too long or too short?.J Cardiothorac Vasc Anesth. 2018; 32: 2692-2693Google Scholar stressed that the readmissions within 48 hours after transfer might be a quality indicator, but the later readmissions are more closely related to the preoperative comorbid profile.7Brown SE Ratcliffe SJ Halpern SD. An empirical derivation of the optimal time interval for defining ICU readmissions.Med Care. 2013; 51: 706-714Google Scholar Conflict of InterestNone. None. Perioperative Risk Factors for Intensive Care Unit Readmissions and Mortality After Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 36Issue 8PreviewThe aim of this study was to identify perioperative risk factors associated with intensive care unit readmission and in-hospital death after cardiac surgery. Full-Text PDF Open Access