Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study

Gillies, Michael; Harrison, Ewen M; Pearse, Rupert M; Garrioch, Sweyn; Haddow, Catriona; Smyth, Lorraine; Parks, Rowan W.; Walsh, Timothy; Lone, Nazir

doi:10.1093/bja/aew396

Cited by 78 publications

(65 citation statements)

References 22 publications

(20 reference statements)

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“…However, these values were not censored in the linear regression model used to estimate the association whilst high-risk patient groups undergoing non-cardiac surgery are often not provided with this level of care despite a much higher mortality rate [8,11,12]. Overall rates of postoperative admission to critical care remain low, even amongst high-risk patients [8][9][10]. The findings of an analysis of a large US Medicare dataset exploring the association between mortality, length of hospital stay, and healthcare costs with critical care admission for patients over 65 years of age undergoing one of five major surgical procedures did not identify any benefit of critical care admission [20,21].…”

Section: Discussionmentioning

confidence: 99%

“…Estimates from high income countries suggest that postoperative complications occur in up to 20% of patients [6,7], and short-term mortality may vary from 1 to 4% [8][9][10][11][12][13][14][15][16]. While effective perioperative care is considered essential to the safe provision of surgical treatments [17], the optimal level of such care has not been defined.…”

Section: Introductionmentioning

confidence: 99%

“…The value of routine admission of highrisk patients to a critical care unit after surgery is hotly debated. In developed nations, there is some evidence that this resource is not allocated to patients at greatest need [8][9][10]. The findings of healthcare registry studies of postoperative critical care admission in the UK are complex and inconsistent [18,19].…”

Section: Introductionmentioning

confidence: 99%

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Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

et al. 2017

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Purpose: As global initiatives increase patient access to surgical treatments, there is a need to define optimal levels of perioperative care. Our aim was to describe the relationship between the provision and use of critical care resources and postoperative mortality.Methods: Planned analysis of data collected during an international 7-day cohort study of adults undergoing elective in-patient surgery. We used risk-adjusted mixed-effects logistic regression models to evaluate the association between admission to critical care immediately after surgery and in-hospital mortality. We evaluated hospital-level associations between mortality and critical care admission immediately after surgery, critical care admission to treat life-threatening complications, and hospital provision of critical care beds. We evaluated the effect of national income using interaction tests. .21]; p < 0.001). This association may differ with national income (high income countries OR 2.50 vs. low and middle income countries OR 4.68; p = 0.07). At hospital level, there was no association between mortality and critical care admission directly after surgery (p = 0.26), critical care admission to treat complications (p = 0.33), or provision of critical care beds (p = 0.70). Findings of the hospital-level analyses were not affected by national income status. A sensitivity analysis including only high-risk patients yielded similar findings. Results Conclusions:We did not identify any survival benefit from critical care admission following surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

et al. 2017

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“…27 Unplanned admissions to critical care represented a small but important minority (n¼86) and were associated with worse survival outcomes than planned admissions, as previously reported. 7,10,28 The European Surgical Outcomes Study 2 identified that 73% of inpatient deaths were never admitted to critical care after operation, with 43% of those who died having been discharged from critical care; the authors highlighted a systematic failure in allocation of critical care resources. Unplanned admission to critical care can be because of an acute deterioration in an existing clinical condition (potentially preventable), or a serious, unexpected adverse event with a non-modifiable outcome.…”

Section: Discussionmentioning

confidence: 99%

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

McLean¹,

Glasbey²,

Borakati³

et al. 2019

British Journal of Anaesthesia

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Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

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“…Recently, the value of routine ICU admission after elective surgery has been questioned, given its costs and the lack of robust evidence supporting it [3,4]. Moreover, identification of patients at highest risk, who might benefit from ICU admission, remains a major challenge leading to unacceptable inequity in resource distribution [5].…”

mentioning

confidence: 99%

Do we really need postoperative ICU management after elective surgery? No, not any more!

2017

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Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study

Abstract: UKCRN registry no. 15761.

Cited by 78 publications

References 22 publications

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

Do we really need postoperative ICU management after elective surgery? No, not any more!

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