Prolonged Postoperative Intensive Care Unit Research Articles

Determinants of the need for intensive care and prolonged mechanical ventilation in patients undergoing bariatric surgery.

Bariatric surgery at the upper extremes of weight can be associated with serious postoperative complications. In many cases, these complications will require the availability of critical care resources. The purpose of this study is to examine factors that increase the likelihood for prolonged postoperative intensive care unit (ICU) and extended mechanical ventilation (MV) >24 hours. A retrospective chart review was conducted of all patients undergoing bariatric surgery over a 7-year period at a tertiary care academic institution. There were 250 total patients undergoing either vertical banded gastroplasty (n=15) or Roux-en-Y gastric bypass (n=235). Age, Gender, BMI, pulmonary co-morbidity, revisional surgery (previous bariatric operations), and need for reoperation for suspected intra-abdominal complications were examined by univariate and multivariate analyses. Mean age was 43.6+/-10.6 years and mean BMI 56+/-10.6 kg/m2. Pulmonary co-morbidity was present in 123/250 patients (49%), 42/250 (17%) had revisional surgery, and 21/250 (8%) required reoperation. ICU care was required in 60 patients (24%). By univariate analysis, age >50 yrs (P=0.047), male gender (P=0.038), and need for reoperation (P <0.001) were associated with need for ICU. By multivariate analysis, BMI >60 kg/m2, odds ratio (OR) 2.25, 95% confidence Interval (CI) 1.11-4.60, P=0.04, and need for reoperation, OR 39.8, 95% CI 10.41-264.7, P <0.0001, were associated with need for ICU. MV >24 hrs was required in 44 patients (18%). By univariate analysis, BMI >60 kg/m2 (P=0.013), pulmonary co-morbidity (P=0.014), male gender (P =0.029), and reoperation (P <0.0001) were associated with need for MV. By multivariate analysis, BMI >60 kg/m2, OR 3.1, 95% CI 1.44-7.13, P=0.005, and need for reoperation, OR 22.3, 95% CI 7.4-79.2, P <0.0001, were associated with need for MV. Patients who are male, older (>50 yrs), heavier (BMI >60 kg/m2), and who have complications requiring reoperation will likely need intensive care. Additionally, males, heavier patients (BMI >60 kg/m2), pulmonary co-morbidity, and need for reoperation may warrant need for extended MV. Surgeons and hospitals should consider this when planning resources for bariatric surgery programs.

Risk factor analysis of Swedish Left Ventricular Assist Device (LVAD) patients

Background The use of left ventricular assist devices (LVADs) is established as a bridge to heart transplantation. Methods All Swedish patients on the waiting list for heart transplantation, treated with LVAD since 1993 were retrospectively collected into a database and analyzed in regards to risk factors for mortality and morbidity. Results Fifty-nine patients (46 men) with a median age of 49 years (range, 14 to 69 years), Higgins score median of 9 (range, 3 to 15), EuroScore median of 10 (range, 5 to 17) were investigated. Dominating diagnoses were dilated cardiomyopathy in 61% (n = 36) and ischemic cardiomyopathy in 18.6% (n = 11). The patients were supported with LVAD for a median time of 99.5 days (range, 1 to 873 days). Forty-five (76%) patients received transplants, and 3 (5.1%) patients were weaned from the device. Eleven patients (18.6%) died during LVAD treatment. Risk factor analysis for mortality before heart transplantation showed significance for a high total amount of autologous blood transfusions ( p < 0.001), days on mechanical ventilation postoperatively ( p < 0.001), prolonged postoperative intensive care unit stay ( p = 0.007), and high central venous pressure 24 hours postoperatively and at the final measurement ( p = 0.03 and 0.01, respectively). Mortality with LVAD treatment was 18.6% (n = 11). High C-reactive protein ( p = 0.001), low mean arterial pressure ( p = 0.03), and high cardiac index ( p = 0.03) preoperatively were risk factors for development of right ventricular failure during LVAD treatment. Conclusions The Swedish experience with LVAD as a bridge to heart transplantation was retrospectively collected into a database. This included data from transplant and nontransplant centers. Figures of mortality and morbidity in the database were comparable to international experience. Specific risk factors were difficult to define retrospectively as a result of different protocols for follow-up among participating centers.