Abstract
Summary statement: In non-cardiac surgical patients, respiratory failure index and intensivists’ (expert) opinion predicted postoperative mortality and respiratory failure. Intermediate risk patients allocated to postoperative ICU care vs. surgical high intensity care demonstrated increasing lengths of hospital stay. Background: No guidance exists for allocating post-operative ICU resources for patients undergoing non-cardiac surgery. We determined the predictive value of preoperative risk sores and “expert opinion” in predicting postoperative mortality and complications. Methods: A cohort study involving 403 adults undergoing elective noncardiac surgery and being assessed in a preoperative clinic within a university affiliated tertiary care hospital. Postoperative outcomes included 30-day mortality, respiratory failure at 48-hours, unplanned intubation, cardiac composite score, hospital length of stay, hypotension, hypertension, and delirium. Results: Preoperative respiratory failure index (PRFI) predicted 30-day mortality (OR 1.11, 95% CI 1.04 to 1.19). An intensivist’s opinion predicted respiratory failure 48-hour postoperatively (OR 28.70, 95% CI 7.44 to 110.70). Patients with an equivalent PRFI risk had a longer hospital stay (17.2 v. 8.9 days, P = 0.01), increased respiratory failure risk (P = 0.009), hypertension (P = 0.009), hypotension (P = 0.005) and delirium (P = 0.05) if allocated to an ICU bed versus a high-intensity bed. Conclusions: PRFI predicts 30-day postoperative mortality and cardiac events. A decision to allocate an ICU bed predicted the development of postoperative respiratory failure. Patients with an intermediate PRFI risk and allocated to an ICU demonstrated increasing lengths of hospital stay and morbidity.
Highlights
The aging of the United States population in the two decades will increase the burden of acute and chronic illness and the demand for critical care services [1]
Preoperative respiratory failure index (PRFI) predicted 30-day mortality
If the “expert opinion” of the intensivist deemed that the patient required the assignment to an intensive care unit (ICU) bed, the surgery was not undertaken unless an ICU bed was available on the morning of the planned surgery
Summary
The aging of the United States population in the two decades will increase the burden of acute and chronic illness and the demand for critical care services [1]. In 2004, 33% of Medicare hospitalizations had intensive care unit (ICU) or coronary care unit care representing an annual increase in costs of 36% to $32.3 billion from 1994 [2]. Several statistical models have been validated to risk stratify patients undergoing noncardiac surgery and using both cardiac and respiratory outcomes [4,5]. Two of the most robust models include the preoperative respiratory failure risk index (PRFI) and the revised cardiac risk index (RCRI) [6,7]. Despite large numbers of patients undergoing noncardiac operations worldwide, there are no randomized trials demonstrating the effectiveness of ICU care for subgroups of noncardiac surgical patients [10]
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