Preoperative and Intraoperative Risk Factors for Prolonged Intensive Care Unit Stay After Aortic Arch Surgery

doi:10.1053/j.jvca.2009.05.028

Journal of Cardiothoracic and Vascular Anesthesia

Volume 23, Issue 6, December 2009, Pages 789-794

https://doi.org/10.1053/j.jvca.2009.05.028 Get rights and content

Objective

The present study was performed to evaluate preoperative and intraoperative risk factors for prolonged intensive care unit (ICU) stay after aortic arch surgery.

Design

A retrospective study. Prolonged ICU stay was defined as >5 days (120 hours).

Setting

Cardiovascular operating rooms and the ICU.

Participants

Adults requiring aortic arch surgery with deep hypothermic circulatory arrest plus antegrade selective cerebral perfusion.

Interventions

None.

Measurements and Main Results

After 11 patients who underwent 1-stage total or subtotal aortic replacement were excluded, 298 patients were enrolled in the study. The average age of patients was 44.9 ± 10.7 years with male predominance (74.8%). Sixty-one patients (20.5%) stayed longer than 5 days in the ICU. Univariate analyses found age, body mass index, New York Heart Association classification, preoperative serum creatinine, creatinine clearance, emergency, inotropes, cardiopulmonary bypass time, myocardial ischemia time, and fresh-frozen plasma transfused intraoperatively were significantly associated with prolonged ICU stay (p < 0.05). Independent risk factors for prolonged ICU stay were found to be New York Heart Association classification (class III and IV), emergency, inotropes used intraoperatively, and prolonged cardiopulmonary bypass time (p < 0.05).

Conclusion

The authors identified 4 preoperative and intraoperative risk factors for prolonged ICU stay. This is helpful to identify patients with increased risk for prolonged ICU stay, implement specific strategies, and allocate medical resources.

Section snippets

Methods

With the approval of the Institutional Review Committee, 309 consecutive adult patients undergoing aortic arch surgery between January 2005 and December 2007 were reviewed retrospectively. Eleven patients who had 1-stage total or subtotal aortic replacement were excluded because of different surgical incisions and cardiopulmonary bypass (CPB) procedures.

General anesthesia was standardized for all patients. Patients were premedicated with morphine, 0.1 mg/kg, and scopolamine, 0.005 mg/kg,

Results

All surgical procedures of the 298 patients involved aortic arch repair with total aortic arch replacement predominance (79.2%). Two hundred seventy patients (90.6%) needed ascending aortic replacement. The breakdown of aortic surgical procedures is summarized in Table 1. The average age of overall patients was 44.9 ± 10.7 years. The age is significantly different between men and women (44.1 ± 10.1 years v 47.5 ± 11.8 years, p < 0.05). The majority of this cohort was male (74.8%). Two hundred

Discussion

The costs in the ICU are very high for patients undergoing cardiovascular surgery not only in developing countries but also in developed countries. As a special subset of cardiovascular surgery, thoracic aortic surgery commonly has been performed in a lot of cardiovascular centers. Early prediction of patients requiring prolonged ICU stay after aortic surgery could help allocate medical resources effectively.

There is currently no recognized definition for prolonged ICU stay after cardiovascular

Conclusions

In conclusion, a prolonged ICU stay after aortic arch surgery with DHCA plus ASCP was common. After excluded postoperative variables, the present study identified 4 preoperative and intraoperative risk factors associated with prolonged ICU stay after aortic arch surgery. This may help clinicians to identify patients with an increased risk for prolonged ICU stay earlier, implement specific strategies, and allocate medical resources.

References (40)

G.T. Christakis et al.
Impact of preoperative risk and perioperative morbidity on ICU stay following coronary bypass surgery
Cardiovasc Surg
(1996)
O.V. Hein et al.
Prolonged intensive care unit stay in cardiac surgery: Risk factors and long-term survival
Ann Thorac Surg
(2006)
J.G. Augoustides et al.
Clinical predictors for prolonged intensive care unit stay in adults undergoing thoracic aortic surgery requiring deep hypothermic circulatory arrest
J Cardiothorac Vasc Anesth
(2006)
Q. Lei et al.
Predictors of prolonged mechanical ventilation after aortic arch surgery with deep hypothermic circulatory arrest plus antegrade selective cerebral perfusion
J Cardiothorac Vasc Anesth
(2009)
J.J. Appoo et al.
Perioperative outcome in adults undergoing elective deep hypothermic circulatory arrest with retrograde cerebral perfusion in proximal aortic arch repair: Evaluation of protocol-based care
J Cardiothorac Vasc Anesth
(2006)
J.G. Augoustides et al.
Major clinical outcomes in adults undergoing thoracic aortic surgery requiring deep hypothermic circulatory arrest: Quantification of organ-based perioperative outcome and detection of opportunities for perioperative intervention
J Cardiothorac Vasc Anesth
(2005)
J.G. Augoustides et al.
Renal dysfunction after thoracic aortic surgery requiring deep hypothermic circulatory arrest: Definition, incidence, and clinical predictors
J Cardiothorac Vasc Anesth
(2006)
F. Bakhtiary et al.
Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients
Ann Thorac Surg
(2008)
A. Della Corte et al.
Aortic arch surgery: Thoracoabdominal perfusion during antegrade cerebral perfusion may reduce postoperative morbidity
Ann Thorac Surg
(2006)
C.H. Hsing et al.
Induction of interleukin-19 and interleukin-22 after cardiac surgery with cardiopulmonary bypass
Ann Thorac Surg
(2006)

J. Butler et al.

Inflammatory response to cardiopulmonary bypass

Ann Thorac Surg

(1993)

P. Tassani et al.

Does high-dose methylprednisolone in aprotinin-treated patients attenuate the systemic inflammatory response during coronary artery bypass grafting procedures?

J Cardiothorac Vasc Anesth

(1999)

S. Trimarchi et al.

Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience

J Thorac Cardiovasc Surg

(2005)

S.M. Long et al.

Preoperative shock determines outcome for acute type A aortic dissection

Ann Thorac Surg

(2003)

J.V. Tu et al.

A predictive index for length of stay in the intensive care unit following cardiac surgery

CMAJ

(1994)

D.T. Wong et al.

Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track cardiac anesthesia: A new cardiac risk score

Anesthesiology

(1999)

C.A. Bashour et al.

Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care

Crit Care Med

(2000)

D.R. Lawrence et al.

Parsonnet score is a good predictor of the duration of intensive care unit stay following cardiac surgery

Heart

(2000)

J. Bucerius et al.

Predictors of prolonged ICU stay after on-pump versus off-pump coronary artery bypass grafting

Intensive Care Med

(2004)

D.P. Janssen et al.

Preoperative prediction of prolonged stay in the intensive care unit for coronary bypass surgery

Eur J Cardiothorac Surg

(2004)

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In addition, in the present study, CPB duration contributed to prolonged ICU LOS, indicating that patients with more complex conditions or undergoing complicated operations are more likely to have prolonged ICU LOS. This is consistent with previous reports [5,33,34]. In this study, the rate of prolonged ICU LOS after cardiac surgery with CPB was high, which suggests that healthcare workers should pay attention to and strengthen the management of such patients.
Patients after cardiac surgery with cardiopulmonary bypass (CPB) require a stay in the ICU postoperatively. This study aimed to investigate the incidence of prolonged length of stay (LOS) in the ICU after cardiac surgery with CPB and identify associated risk factors.
The current investigation was an observational, retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017. Data were obtained from the hospital database. Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.
Of 395 patients, 137 (34.7%) had a prolonged ICU LOS (>72.0 h), and the median ICU LOS was 50.9 h. Several variables were found associated with prolonged ICU LOS: duration of CPB, prolonged mechanical ventilation and non-invasive assisted ventilation use, PaO₂/FiO₂ ratios within 6 h after surgery, type of surgery, red blood cell infusion during surgery, postoperative atrial arrhythmia, postoperative ventricular arrhythmia (all P < 0.05).
These findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS, enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.
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Of note, the method of reporting BMI varies tremendously across studies assessing the relationship of BMI and ICU resource utilization [5, 6, 14, 15, 18, 20, 23]. Researchers often consider BMI as a dichotomous variable (eg, BMI >30 vs BMI ≤30), a simplification that does not allow for the study of curvilinear relationships between BMI and adverse outcomes [4, 6, 7, 14, 17, 19, 20], whereas others treat it as a multicategoric variable (eg, BMI 18.5 to 24.99, 25 to 29.99, or ≥30) [8–10, 12, 13, 15, 16, 22] or even a continuous variable [5, 11, 18, 21]. The inconsistency in reporting methods leads to difficulty comparing results across studies and may contribute to the conflicting findings present in the literature.
Much has been published about the effect of obesity on adverse outcomes after cardiac operations, yet little is known regarding the effect of obesity on intensive care unit (ICU) resource utilization. This study examined the effect of obesity on ICU resource utilization after cardiac operations.
All patients with a body mass index (BMI) of 18.5 kg/m² or higher who underwent a cardiac surgical procedure between 2006 and 2013 were stratified into the following weight categories: normal (BMI 18.5 to 24.99 kg/m²), preobese (BMI 25 to 29.99 kg/m²), obese class I (BMI 30 to 34.99 kg/m²), obese class II (BMI 35 to 39.99 kg/m²), and obese class III (BMI ≥40 kg/m²). Comparisons between weight categories were done, and the risk-adjusted effect of weight category on prolonged ICU stay, prolonged ventilation, and ICU readmission was determined.
Of the 5,365 included patients, 1,948 were obese. Patients with greater obesity experienced longer ICU time, longer ventilation time, and increased ICU readmission. After adjustment, increasing obesity remained independently associated with greater likelihood of prolonged ICU stay (obese class II: odds ratio [OR], 2.4; 95% confidence interval [CI], 1.55 to 3.61; obese class III: OR, 4.1; 95% CI, 2.38 to 7.05), prolonged ventilation (obese class III: OR, 3.4; 95% CI, 1.57 to 7.22), and ICU readmission (obese class II: OR, 3.0; 95% CI, 1.70 to 5.31; obese class III: OR, 2.9; 95% CI, 1.32 to 6.36).
Increasing obesity was associated with a significant increase in ICU resource utilization after cardiac operations. Further study is needed to determine the mechanisms underlying this association and how the adverse effects of obesity may be mitigated.
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4) We included the type of procedure as operative factors in the model development, and found that tricuspid valve replacement, concurrent CABG, and other cardiac surgery were associated with PrlICULOS. The reason could be that all these patients had longer cardiopulmonary bypass times, which had been previously identified as an important factor in determining the length of ICU stay by other studies [23,25]. There are several limitations in our study.
The aim of this study was to develop a preoperative risk prediction model and an scorecard for prolonged intensive care unit length of stay (PrlICULOS) in adult patients undergoing heart valve surgery.
This is a retrospective observational study of collected data on 3925 consecutive patients older than 18 years, who had undergone heart valve surgery between January 2000 and December 2010. Data were randomly split into a development dataset (n = 2401) and a validation dataset (n = 1524). A multivariate logistic regression analysis was undertaken using the development dataset to identify independent risk factors for PrlICULOS. Performance of the model was then assessed by observed and expected rates of PrlICULOS on the development and validation dataset. Model calibration and discriminatory ability were analysed by the Hosmer–Lemeshow goodness-of-fit statistic and the area under the receiver operating characteristic (ROC) curve, respectively.
There were 491 patients that required PrlICULOS (12.5%). Preoperative independent predictors of PrlICULOS are shown with odds ratio as follows: (1) age, 1.4; (2) chronic obstructive pulmonary disease (COPD), 1.8; (3) atrial fibrillation, 1.4; (4) left bundle branch block, 2.7; (5) ejection fraction, 1.4; (6) left ventricle weight, 1.5; (7) New York Heart Association class III–IV, 1.8; (8) critical preoperative state, 2.0; (9) perivalvular leakage, 6.4; (10) tricuspid valve replacement, 3.8; (11) concurrent CABG, 2.8; and (12) concurrent other cardiac surgery, 1.8. The Hosmer–Lemeshow goodness-of-fit statistic was not statistically significant in both development and validation dataset (P = 0.365 vs P = 0.310). The ROC curve for the prediction of PrlICULOS in development and validation dataset was 0.717 and 0.700, respectively.
We developed and validated a local risk prediction model for PrlICULOS after adult heart valve surgery. This model can be used to calculate patient-specific risk with an equivalent predicted risk at our centre in future clinical practice.
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Original articlePreoperative and Intraoperative Risk Factors for Prolonged Intensive Care Unit Stay After Aortic Arch Surgery

Objective

Design

Setting

Participants

Interventions

Measurements and Main Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusions

Cardiovasc Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

Ann Thorac Surg

A predictive index for length of stay in the intensive care unit following cardiac surgery

CMAJ

Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track cardiac anesthesia: A new cardiac risk score

Anesthesiology

Long-term survival and functional capacity in cardiac surgery patients after prolonged intensive care

Crit Care Med

Parsonnet score is a good predictor of the duration of intensive care unit stay following cardiac surgery

Heart

Predictors of prolonged ICU stay after on-pump versus off-pump coronary artery bypass grafting

Intensive Care Med

Preoperative prediction of prolonged stay in the intensive care unit for coronary bypass surgery

Eur J Cardiothorac Surg

Original article
Preoperative and Intraoperative Risk Factors for Prolonged Intensive Care Unit Stay After Aortic Arch Surgery