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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

	Abstract

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
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.

	Introduction

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
The utilization of ICUs for routine postoperative care is commonplace, often necessitated by the complex physiologic interactions resulting from underlying patient pathologic conditions and comorbidities, and anesthetic and operative interventions. For whom, and how, the ICU is utilized as part of the spectrum of services provided postoperative surgical patients can be illustrated through the evolving treatment of postcardiac surgical patients.

Postoperative ICU care for patients undergoing cardiovascular surgery has been necessitated by the need to complete recovery from anesthesia and wean from mechanical ventilation. Using standard anesthetic techniques, including high-dose narcotic induction and maintenance anesthesia, and postoperative sedation, weaning and extubation have typically not occurred until 12 to 24 h following ICU admission. Prolonged ventilatory support has been justified, in part, by its theoretical advantage of reducing stress on the myocardium consequent to decreased work of breathing and myocardial oxygen demands.¹²³

Often, the ICU admission extends beyond the immediate postextubation period to assure adequate monitoring for potential complications. These complications include hypotension, hypertension, depressed cardiac output, arterial and ventricular arrhythmias, and bleeding from chest tubes. Additionally, some have advocated prolonged intensive analgesia to reduce postoperative myocardial ischemia following coronary revascularization.⁴

The increasing economic pressure on the medical care system has required a reevaluation of traditional methods of delivering care. In cardiac surgery, this has necessitated an assessment of established practices regarding the treatment of patients undergoing open heart surgery, testing traditional dogma related to intraoperative anesthetic management and postoperative ICU care. Following the costs associated with the operating room, ICU care is the most expensive component of the cardiac surgery patient’s hospital stay.⁵

	Variability in Postoperative Cardiac Surgery Care

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
Despite the imperatives to reexamine modes of postoperative cardiac surgery care, considerable variation continues to exist in the treatment of this important patient group, estimated to include approximately 400,000 coronary artery bypass graft (CABG) procedures per year.⁶ A recently completed multicenter evaluation of care for patients undergoing CABG, undertaken by the University HealthSystem Consortium (UHC) at 39 US sites, reveals dramatic variation in current practice around important clinical milestones. For example, the dose range of operative narcotics (eg, fentanyl), routine use of pulmonary artery catheters, pacing, use of vasodilators and inotropes when leaving the operating room, postoperative intubation time, utilization of arterial blood gases, use of postoperative pain control, sedation and anxiolysis regimens, and ICU length of stay (LOS) varied significantly (Table 1).⁷

	Early Extubation, Shortened ICU Admission

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

Reports regarding more rapid postoperative extubation and shorter ICU and hospital LOS became more frequent in the early 1990s as the imperative to reduce LOS and cost for cardiac surgery mounted.¹³¹⁴¹⁵ Concurrently, improvements in anesthetic, surgical, and myocardial protection techniques, and postoperative hemostasis, made early extubation feasible.^{16171819202122} Most of these reports are evidence grade 2 or 3 according to the criteria established by the US Preventive Services Task Force.²³ There are few randomized trials.⁹²⁴²⁵

To date and to our knowledge, the most dramatic efforts are reported in Europe. Westaby et al²⁶ have reported a program by which an ICU admission is avoided entirely for most cardiac surgery patients. Postoperative patients are admitted to a cardiac recovery area staffed by nurse practitioners. Following discharge from this area, typically within 4 to 6 h, patients are admitted to a postoperative ward with continuous ECG monitoring capabilities and 13 (8 AM to 9 PM) and 16 (9 PM to 8 AM) nurse patient ratios, respectively.²⁶ Patients who develop significant postoperative difficulty are transferred to the ICU. The extent to which these approaches have been widely incorporated into US practice is unknown but < 10% of cardiac surgery programs evaluated in the UHC study referred to earlier routinely do not go the the ICU following CABG.⁷

In the most comprehensive randomized, controlled clinical trial by Reyes et al,²⁵ the authors report no difference in the incidence of major or minor complications, other than a higher rate of reintubation > 48 h after initial extubation, in the subgroup of early extubated patients. There were also reintubations in the control subgroup, albeit fewer. There were no data to support that early extubation was the cause of any deterioration in patient condition.²⁵

	Developing Method to ‘Fast Track’ Postoperative Cardiac Surgery Patients

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
Goals of programs designed to expedite care of the postcardiac surgery patient typically include the following: early extubation, decrease utilization of ICU beds, decrease ICU and hospital LOS, reduction in costs (via decreased staffing and bed needs), maintenance of quality outcomes, and patient satisfaction. Institutions implementing successful programs to hasten recovery and LOS time typically report substantial reductions in time to extubation and both ICU and hospital LOS.²⁷²⁸

The success of any program designed to minimize postoperative intubation times and ICU LOS requires a concerted program including the following: modification of operative anesthetic practice, reorientation and coordination of the ICU team, evaluation and restructuring of approaches to acute pain control, appropriate ICU discharge criteria and post-ICU resource availability, patient and family education, and monitoring of clinical outcomes and patient experiences. Ongoing, concerted, and coordinated communication and activity among the involved medical, nursing, and respiratory therapy staffs are prerequisites.

Programs reporting success in moving patients more rapidly through the ICU, with early extubation, describe anesthetic management practices that avoid traditional, high-dose narcotic regimens. Various combinations of lower-dose narcotic and benzodiazepines, inhalation agents, propofol, and short-acting muscle relaxants have been advocated. Warmer core temperatures and reduction in invasive monitoring unless indicated by clinical circumstance are employed.⁷ In addition, postoperative pain control regimens have often utilized lower-dose narcotics in conjunction with nonsteroidal anti-inflammatory agents (eg, indomethacin, ketorolac tromethamine [Toradol]) to reduce postpericardiotomy and sternotomy pain.

The surgical, nursing, and respiratory therapy teams must be reoriented toward the expeditious movement of patient to extubation, and subsequent early transfer from the ICU. Typically, this will include the utilization of standardized rapid weaning protocols, and the preauthorized implementation of ICU transfer orders unless complications ensue, necessitating longer ICU LOS. Standing protocols for the treatment of atrial fibrillation are often employed. Transfer criteria must be standardized to account for the likely complications, including respiratory and hemodynamic, which would predict likely ICU readmission.⁷

Setting patient and family expectations regarding the course of care following surgery is critical to patient acceptance and satisfaction. The educational process should include discussion of the benefit of early extubation and mobilization as well as the physical steps involved in assuring early extubation and ICU transfer. Allaying anxiety surrounding pain control, establishing expectations regarding pulmonary toilet, and providing the ongoing postoperative nursing support structures to assure quality outcomes and satisfaction must be a part of the care plan.

Criteria for early extubation vary minimally across institutions. Typically they include an assessment of consciousness and neuromuscular function, and the adequacy of oxygenation and ventilation (eg, PO₂, oxygen saturation or fraction of inspired oxygen/PaO₂ ratio, pH, PCO₂, or end-tidal CO₂). Protocols vary somewhat regarding extubation and the concurrent requirement for vasoactive drugs therapy, and the amount of tolerable postoperative bleeding. However, patient requirements for vasoactive therapy do not preclude the successful early weaning and extubation of patients.

Contraindications to the adoption of early extubation protocols appear to be few. For most patients, preoperative status does not seem to predict the postoperative course and should not preclude early efforts toward rapid weaning. Most cardiac surgical patients, presenting for either elective or emergent surgery, have adequate ventilatory function. For other types of surgery they would not require prolonged mechanical ventilation and a general rule of thumb is that if a patient was not intubated and ventilated preoperatively, there is unlikely to be a prolonged postoperative ventilatory requirement.

Importantly, patients undergoing emergent cardiac surgery typically do not behave differently when compared with elective postoperative patients. Age has not been consistantly reported to be adversely associated with early extubation. Those patients who require prolonged ICU admission or ventilatory support are similar to those who might require such support in other operative settings, including those with preexisting respiratory insufficiency, significant acute neurologic deficits, and the need for acute renal replacement therapy.²⁹

Barriers to effective introduction of the clinical processes designed to speed extubation and recovery following cardiac surgery should be few in number given the literature supporting the safety and efficacy of this approach to patient management. Nevertheless, reluctance of the medical and surgical teams to implement the necessary changes in practice can hinder the success of such efforts. Additionally, an institution must first commit the necessary resources to support patient care and education requirements outside the ICU.

	Monitoring Outcomes

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
The safety and success of any program designed to improve the flow of patients through the hospital following cardiac surgery must be monitored. Preoperative and postoperative acuity-adjusted performance measurements of importance include time to extubation, ICU and hospital LOS, reintubation rates, readmission to the ICU and hospital, and patient satisfaction.

	Conclusion

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 
The utilization of the ICU for routine postoperative cardiac surgery patient treatment is undergoing change. Efforts to truncate postoperative ventilatory times have been reported to successfully reduce ICU and hospital LOS without apparent adverse impact on clinical outcomes or patient satisfaction. Reductions in cost of care associated with cardiac surgery have similarly been reported. Such efforts require coordinated and sustained effort among all key participants in the treatment of postoperative cardiac surgery patients. These programs can serve as useful models for reassessing the utilization and role of the ICU in the postoperative treatment of routine surgical patients.

Understanding the impact of restricting patient access to ICU care (in this case via reductions in ICU LOS) is often fraught with an inability to assess the impact on those for whom care is withheld. Importantly, the evaluation of the differential outcomes associated with speedy extubation and transfer out of the ICU in cardiac surgery provides insight into the dilemma of assessing the impact of providing care for the critically ill via alternative mechanisms or in alternative settings.

	References

TOP Abstract Introduction Variability in Postoperative... Early Extubation, Shortened ICU... Developing Method to 'Fast... Monitoring Outcomes Conclusion References

 

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