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Who Goes to the ICU Postoperatively?^*

^* From the Department of Anesthesiology and Critical Care Medicine, Health Delivery and Systems Evaluation Team (HeDSET), Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Correspondence to: Carl A. Sirio, MD, FCCP, University of Pittsburgh Medical Center, 614A Scaife Hall, 200 Lothrop St, Pittsburgh, PA 15213; e-mail: sirio{at}smtp.anes.upmc.edu

Objective: To describe changes in ICU postoperative management strategies utilized for patients undergoing cardiac surgery. The treatment of these patients serves as a useful illustration of the changing patterns of ICU utilization and care associated with contemporary surgery.

Design: Evidence-based review of the clinical literature following a MEDLINE search, direct observation of rapid recovery programs following surgery, and informal inquiry of others utilizing similar approaches to postoperative cardiac surgery care.

Setting and patients: The reports reviewed are from a diverse set of hospitals providing cardiac surgery services in both Europe and the United States. Most reports focus efforts on patients undergoing coronary artery revascularization.

Measurements: Outcome measures used to gauge the effectiveness of postoperative ICU care typically include time to extubation, ICU and hospital length of stay, postoperative complications including reintubation and ICU readmission, patient satisfaction, and health resource savings.

Main results: The literature regarding current practice for postoperative ICU management in cardiac surgery consists primarily of grade 2 and 3 literature.

Conclusions: Despite the paucity of controlled data, rapid recovery, extubation, and discharge from the ICU following cardiac surgery is an approach to care that is growing in acceptance. The goals include reduction in the utilization of resources and costs associated with cardiac surgery and maintenance of quality of care and patient satisfaction. Assessment of outcomes requires a program to monitor outcomes. Success does not appear to be linked to preoperative risk for most patients but does relate directly to the anesthetic management delivered in the operating room. Few adverse consequences from this approach have been reported. Experience to date suggests that programs designed to truncate ICU admission following cardiac surgery can be implemented with the cooperation between the health delivery team including surgeon, anesthesiologist, intensivist where available, nursing, respiratory care, and patient and family. These programs can serve as useful models for reassessing the utilization and role of the ICU in the postoperative treatment of routine surgical patients.

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