Anesthesia Quality Improvement and Patients With Planned ICU Admission

Study Overview
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Brief Summary
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Intensive care unit (ICU) is an important part of perioperative management for high-risk patients but is associated with higher medical costs. Improper ICU admission may produce overtreatment without beneficial effects. In clinical practice, delayed recovery after general anesthesia is a common indication for ICU admission after surgery. The concept of Enhanced Recovery After Surgery recommends early extubation. The investigators suppose that, for patients with planned ICU admission after elective surgery, implementing anesthesia quality improvement including extubation in the operating room will reduce the rate of ICU admission after surgery without increasing complications.

Detailed Description
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Intensive care unit (ICU) is an important part of perioperative management for high-risk patients but is associated with higher medical costs. Improper ICU admission may produce overtreatment without beneficial effects. Studies found that immediate ICU admission after surgery did not reduce the perioperative mortality. Some authors suggested that the indication of ICU admission should be the occurrence of postoperative complications, which will reasonably reduce the use of medical resources. In clinical practice, delayed recovery after general anesthesia is a common indication for ICU admission after surgery. Old age, high ASA grade, respiratory complications, long duration surgery, large-volume fluid infusion, and use of vasopressors were main factors associated with delayed recovery. The concept of Enhanced Recovery After Surgery recommends early extubation after surgery. Studies showed that, for patients after organ transplantation, immediate extubation in the operating room can shorten hospital stay and reduce medical costs, without increasing mortality. The investigators suppose that, for patients with planned ICU admission after elective surgery, implementing anesthesia quality improvement including extubation in the operating room will reduce the rate of ICU admission after surgery without increasing postoperative complications.

Official Title
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Effects of Anesthesia Quality Improvement on Outcomes of Patients With Planned ICU Admission: a Prospective Pre-post Intervention Study

Conditions
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Anesthesia, Extubation, Intensive Care Unit, Postoperative Complications

Intervention / Treatment
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* Other: Routine anesthesia care
* Other: Improved anesthesia care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Age ≥18 years. Scheduled to undergo elective surgery. Planned ICU admission after surgery. Exclusion Criteria: Refused to participate in the study. ICU admission before surgery. Unexpected ICU admission. Other conditions that are considered unsuitable for study participation.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Non-Randomized
Intervention Model: Sequential Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Routine anesthesia care<br>• Implementing anesthesia management according to current routine practice. | Other: Routine anesthesia care<br>* • Implementing anesthesia management according to current routine practice.<br>|
| Experimental: Improved anesthesia care<br>Encourage regional anesthesia or combined regional-general anesthesia. Encourage goal-directed fluid therapy, lung-protective ventilation, and active warming during surgery. Encourage extubation in the operating room at the end of surgery. Encourage multimodal analgesia after surgery. Encourage strict indication for ICU admission after surgery. | Other: Improved anesthesia care<br>* Encourage regional anesthesia or combined regional-general anesthesia. Encourage goal-directed fluid therapy, lung-protective ventilation, and active warming during surgery. Encourage extubation in the operating room at the end of surgery. Encourage multimodal analgesia after surgery. Encourage strict indication for ICU admission after surgery.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Incidence of postoperative complication | Postoperative complications are defined as newly occurred medical conditions that are considered harmful to patients' recovery and require therapeutic intervention, that is grade II or higher on Clavin-Dindo classification. | Up to 30 days after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of ICU admission | Rate of ICU admission | On the 1 day of surgery | 
| Incidence of postoperative delirium | Delirium is assessed with the Three-dimensional Confusion Assessment Method (3D-CAM) twice daily (8:00-10:00 am and 18:00-20:00 pm). | Up to 5 days after surgery | 
| Rate of delayed neurocognitive recovery | Cognitive function is assessed with the Montreal Cognitive Assessment (MoCA) before surgery and at discharge. A decrease of 2 points or more is defined as the development of delayed neurocognitive recovery. | up to 7 days after surgery | 
| Length of stay in hospital after surgery | Length of stay in hospital after surgery | Up to 30 days after surgery | 
| Medical costs during hospitalization | Medical costs during hospitalization | Up to 30 days after surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Anesthesia management, Early extubation, Intensive care unit admission, Postoperative Complications