Preoperative intensive care unit admission and hemodynamic monitoring in patients scheduled for major elective noncardiac surgery: A retrospective review of 95 patients☆

Objective: To review experience with preoperative intensive care unit (ICU) admission and hemodynamic monitoring to determine which patients benefited and how. Design: Retrospective review over 32-month period (1991 to 1994). Setting: Surgical ICU of a university teaching hospital. Participants: Ninety-five patients admitted to the surgical ICU before a major elective noncardiac, nonthoracic surgical procedure. Interventions: All patients underwent hemodynamic monitoring with a pulmonary artery catheter (PAC). Interventions were made at the discretion of the ICU attending and attending surgeon, based on a general algorithm. Patients were categorized based on history or hemodynamics. The historic classification was as follows: group I, patients with cardiac disease documented by history and cardiac imaging, n = 37; group II, patients with cardiac disease documented by history, but not cardiac imaging, n = 24; group III, patients without documented cardiac disease, but with other significant medical problems, n = 34. Hemodynamic classification considered patients to have subnormal parameters if the cardiac index was <2.5 L/min/m2, the mixed venous oxygen saturation was <65%, or the oxygen delivery index was <350 mL/min/m2 (n = 45), and normal parameters if greater than these (n = 50). Main Results: There were no differences in APACHE II scores. Group I patients had greater Goldman Cardiac Risk Indices than group III patients (7.4 ± 4.8 v 5.0 ± 3.0). Patients in group I had a significantly greater incidence of subnormal initial hemodynamic values (63%) than patients in group II (47%) or group III (32%). The incidence of postoperative cardiovascular complications among groups was not different. Fifty patients (52%) had normal hemodynamics initially; two (4%) developed postoperative cardiovascular complications compared with 10 patients (22%) of the 45 with subnormal initial hemodynamic values. Of these 45 patients, 24 (52%) had their hemodynamic parameters corrected preoperatively with crystalloids, packed red blood cells, inotropes, and/or afterload reduction. Two of these 24 patients (8%) experienced postoperative cardiovascular complications, compared with 8 of the remaining 21 patients who had no attempt to normalize their hemodynamic values preoperatively other than maintaining a normal pulmonary artery occlusion pressure. Conclusions: Patients who had normal initial preoperative hemodynamic parameters or abnormal initial parameters that were normalized preoperatively experienced significantly fewer perioperative cardiovascular complications than those with abnormal initial values that were not normalized preoperatively. These results suggest that there may be benefit to the practice of preoperative ICU admission, hemodynamic monitoring with a PAC, and “optimization” of cardiac function in selected patients undergoing major elective noncardiac surgery. Further studies are needed to better delineate the most appropriate patient populations and effective therapeutic protocol.