Study of Direct Admission of Postoperative Patients to ICU
Condition: Postoperative Complications; Comorbidities and Coexisting Conditions
MeSH terms: Postoperative Complications
Study type: Observational

Summary: 
      Background: This study assessed perioperative factors associated with planned and unplanned
      postoperative ICU admission and evaluated the outcome of the two groups. There are limited
      researches evaluating these factors. Hence, it is important to do an audit that assesses the
      perioperative factors to help creating a criteria for postoperative ICU admissions.

      Materials and methods: This retrospective study evaluated medical records of 68 patients
      above 18 years between January'2016- December'2018 that were admitted to ICU postoperatively
      in Sultan Qaboos University hospital in Oman. Both planned and unplanned admissions were
      assessed who underwent elective as well as emergency surgeries. Neurologic and cardiothoracic
      surgeries were excluded. Data collected included patient's demographics, social status like
      smoking, ASA physical status (American Society of Anesthesiologists), associated
      comorbidities, other perioperative factors and investigations, surgical and anesthesia
      details were recorded. The primary outcome studied was reasons of admission for planned
      versus unplanned postoperative ICU admissions. The secondary outcomes included mortality
      outcome and length of stay in ICU.
    

Detailed description: 
      There are 2 Levels of care available for patients who require high level of organ support and
      monitoring. First of them is the high dependency unit (HDU) where higher level organ support
      and monitoring is given (exception for mechanical ventilation) such as invasive blood
      pressure monitoring. Second one is the intensive care unit (ICU), which provides support for
      patients with multiple organ dysfunction that needs higher level of care which cannot be
      provided in the ward or the high dependency unit (HDU) and without this care the patient may
      not survive.

      ICU admission post-operatively can be either in a planned or unplanned way. The complex
      interaction between associated comorbidities, anticipated complications intra-operatively and
      high American Society of Anesthesiologists (ASA) Physical Status are major factors in
      planning for ICU admission post-operatively. ASA physical status indicates patient's health
      status and has been accepted as a determinant of comorbidity and mortality. Unplanned ICU
      admissions can be due to unpredicted surgical or anesthetic intra-operative complications or
      poor assessment of perioperative factors. After surgery, some patients are admitted to ICU
      for further management and monitoring based on their underlying low functional status and
      co-morbidities. Out of these some patients may actually need ICU interventions and others may
      not. If an ICU bed is booked for unworthy patient, this may lead to unnecessary increased
      expenditure, wastage of valuable resources as well as deny the ICU services to potentially
      survivable and worthy critically ill patient.

      This study aimed to assess perioperative factors associated with planned and unplanned
      admissions to find out the main reasons of admission to ICU at Sultan Qaboos University
      hospital (SQUH). This will help to lay guideline for guiding future admission to ICU for
      surgical patients in immediate postoperative period and help to reduce the unplanned
      admission.

      Methods

      This retrospective observational study traced all adult patients (above 18 years old) who
      underwent surgery and got admitted to ICU directly from operating theatre during the 3-year
      period: 2016-2018 at SQUH. These were segregated into planned and unplanned admissions.
      Required information was accessed using the hospital information system after receiving the
      ethical approval from Sultan Qaboos University Hospital Ethics and Research Committee
      (MREC#1937). Patients who were admitted to specialized ICU and those who underwent neurologic
      or cardiothoracic operations were excluded from this study since they are admitted
      postoperatively to ICU by default.

      Patient's data that were collected included age, gender, social status like smoking, ASA
      physical status (American Society of Anesthesiologists), associated comorbidities such as
      diabetes, hypertension, ischemic heart disease, valvular heart disease, pulmonary diseases,
      chronic kidney disease and cirrhosis. Associated factors and investigations were collected
      like dehydration, hypoxia, hypercarbia, pH changes, pulmonary complications,
      fluid/electrolyte imbalance, temperature changes, random blood sugar, sepsis, coagulopathy,
      elevated WBC, low hemoglobin, hemodynamic instability, septic shock, hypovolemic shock,
      infection, blood loss more than 20%, hypotension and cardiac arrhythmia. Type, nature and
      duration of surgery, type of anesthesia and airway issues were recorded. Patients mortality
      outcome and length of stay in ICU were included as well.

      Statistical methods: Statistical Package for the Social Sciences (SPSS) was used for
      patient's data analysis. Descriptive statistics were used to determine median, frequencies
      and percentages of the data and were presented in form of graphs and tables. For testing the
      significance between the way of ICU admission (planned/unplanned) and different variables,
      Chi-square and Fisher's exact test were used. To assess risk factors of mortality outcome and
      long ICU stay, odds ratio was used. P-value of 0.05 or less was considered to be significant.
    

Intervention name(s): Surgical procedure under anesthesia
Intervention type(s): Procedure
Intervention description(s): Different varieties of surgical procedures done under anesthesia
Intervention MeSH terms: Anesthetics
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        Adult patients (above 18 years old) who underwent surgery and got admitted to ICU directly
        from operating theatre