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

Abstract

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.

Rethinking the role of postoperative critical care in an inequitable world

“…The fact that the investigators also included am analysis of mortality and ICU admission to treat a postoperative complication indicates that not all ICU admissions were routine. These and other issues can undermine the results and conclusions of this study (7).…”

“…The central idea behind the study was that comparison of mortality rates among cohorts of patients who were admitted to ICUs right after surgery and those who were not could provide evidence on the impact of ICU provision on the outcomes of patients. The data were analyzed at patient-and hospital-level with adjustment for some potential confounders, with further comparisons between the high income and low or middle income countries (7).…”

Implementing risk calculators: time for the Trojan Horse?

“…The potential benefits are neatly demonstrated using the example of whether to triage patients to critical care after surgery. 3,4 The jury is still out on which postoperative patients are most likely to benefit from critical care internationally 5 ; however, it is hard to argue against the hypothesis that complications could be prevented through enhanced surveillance, and in particular, more favourable nurse:patient and doctor:patient ratios. The differences in staffing provision between normal wards and critical care units are much more significant in low-and middle-income countries (LMICs), where normal wards rely heavily on patients' relatives for basic care needs, and the number of nurses and doctors per capita is a fraction of that in high-income countries (HICs).…”

“…The frequency and potential seriousness of a medication error has been well documented, 2,3 and much has been written about the techniques to reduce these errors. 4,5 However, there remains confusion about the best approach, in part because few randomised controlled trials are available, while legitimate concerns remain about implementation and the evidence base that supports it. No randomised controlled trial has ever been done specifically to test the error rate with coloured labels vs plain white labels.…”

Improving the care for elective surgical patients: post-operative ICU admission and outcome

“…In a recent issue of Intensive Care Medicine, Kahan et al (11) performed a planned secondary analysis of the ISOS data. They shed light on the relationship between provision and use of critical care resources and subsequent postoperative mortality, taking into account the income level of the countries.…”