Background: There are no recommendations about admission to an ICU after a major lung resection and there are considerable differences among institutions in this respect. Objectives: To audit the practice of admission to an ICU after a major lung resection and evaluate factors predicting the need for intensive care. Methods: Clinicalrecords of all patients who underwent major pulmonary resections in a 14-month period were reviewed retrospectively. The criteria for postoperative admission to the ICU were: (1) standard pneumonectomy if comorbidity index (CI) >0 and/or ASA score >1, and/or abnormal spirometry or arterial gas analysis; (2) extended pneumonectomy; (3) lobectomy if CI ≧4 and/or ASA ≧3; (4) lobectomy if FEV1 <60% of predicted; (5) lobectomy if FEV1 is between 60 and 80% and hypercapnia. Results: Among the 49 patients postoperatively admitted to the surgical ward, only 1 needed late intensive care. Among the 55 patients admitted to the ICU, 25 did not require specific intensive care and were discharged 24 h postoperatively, whereas the remaining 30 patients required specific intensive care. Multivariate analysis identified ASA score, predictive postoperative DLCO, and predictive postoperative product (PPP) as independent predictors of a need for admission to an ICU. Conclusion: This empirical protocol was useful in identifying patients not likely to need admission to the ICU. ASA score, predictive postoperative DLCO, and PPP are independent predictors of a need for admission to an ICU.
The study was aimed at assessing the influence of the elective ICU admission on the early outcome after major lung resection by analyzing the different postoperative management policies of two centers. Center A managed all patients in a dedicated ward, resorting to ICU for complications requiring invasive assisted ventilation. In center B, high-risk patients were electively transferred to ICU immediately after operation. Propensity score was used to match those patients of center B electively admitted to ICU (96 of 157), with counterparts from center A (96 of 205). The outcome of these matched pairs were then compared. There was a trend of reduced total morbidity (23% vs. 35%, respectively; P=0.06), cardiovascular (13.5% vs. 23%, respectively; P=0.09) and pulmonary complication rates (9.3% vs. 18%, respectively; P=0.09), but a longer postoperative hospital stay (11.5 vs. 9.7, respectively; P=0.015) in the patients electively admitted to ICU, compared to matched center A patients. Mortality rates were not different (7.3% vs. 7.3%; P=1). Since the elective postoperative ICU admission did not show a clear-cut outcome benefit over the management in a dedicated ward, this practice should be limited to highly selected patients in order to efficiently utilize the available resources.
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