S Manjula, D Lalita, R Shilpa
anaesthesia intensive care unit, perioperative morbidity, predictors of admission and outcome
S Manjula, D Lalita, R Shilpa. Analysis of Anaesthetic Intensive Care Unit Admissions: The Anaesthesiologists' Perspective. The Internet Journal of Anesthesiology. 2006 Volume 13 Number 1.
This study was conducted during the period of January 2005 to December 2006 at Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai. The aim of our study was to analyse the Anaesthesia Intensive Care Unit admissions and the challenges encountered in managing these patients. The Anaesthetic Intensive Care Unit is meant for any critically ill patient who needs observation in the perioperative period. Perioperative variables were assessed and the overall outcome of these patients was analyzed. Multiple factors influence the overall patient outcome. The factors which served as significant predictors of Anaesthesia Intensive care unit admissions were males aged more than 60 years, ASA Grading III or IV, abdominal explorations, emergency operations, history of intra operative arrhythmias, major blood loss, hypotension requiring inotropic support. These factors were also significant in predicting an unfavourable outcome which included death of patients or prolonged Intensive Care Unit stay. These factors also constituted a challenge rather than routine Intensive Unit Care.
Anaesthetic Intensive Care Unit is meant for patients who are critically ill and who need observation during their perioperative period.2 Perioperative morbidity is any anaesthesia or surgery related complication which leads to prolonged Intensive Care Unit care and stay.1
Risk of death associated with anaesthesia is known to depend on a number of factors which may be determined intra operatively.1,2,3,4,5,6 Pre anaesthetic illness of the patients, surgical practice, anaesthesia techniques, experience of surgeons and anaesthetists and duration of anaesthesia could play a vital role in the development of perioperative complications and to comment on the avoidance of such incidents with a view to improve practice.4
In recent years, there has been increasing interest in the development of risk assessment in anaesthesia. In order to improve the quality of care in anaesthetic practice by defining either the individual patient at increased risk of anaesthesia or specific areas of anaesthetic practice which account for the more common causes of morbidity and mortality.4
Multiple factors influence the overall patient outcome and risk. Early recognition of complications, timely intervention and masterly monitoring is the key to avoid unfavorable outcome. Unfavourable outcome can be prevented with more knowledge, availability of better drugs, techniques and monitoring equipments.
With this background, the present study was undertaken to analyse Intensive Care Unit Admissions and their outcome.
Aims and Objectives
To analyse the admissions and. types of complications encountered in the Anaesthesia Intensive Care Unit.
To evaluate the perioperative risk factors, predictors and outcome of Anaesthesia Intensive care Unit patients.
Recommendations on the basis of the above findings.
Material and Methods
This is a prospective study conducted during a period of two years from January 2005 to December 2006. All the patients who were admitted to Anaesthesia Intensive Care Unit were analysed.
To identify risk factors, patients were divided into three groups.
All patients who needed observation, ventilatory support in the postoperative period.
All patients who needed Anaesthesia Intensive care in view of compromised hemodynamic and metabolic status.
Patients with postoperative complications arising more than forty eight hours after primary surgery.
Postoperative review of every patient was carried out to determine the cause for post operative admission in the uninformed group. These patients were further divided into four major categories:
Unexpected depressed level of consciousnes
New cerebrovascular accident.
Prolonged hypotension requiring inotropic support
Low pO2, high pCO2
Atelectasis / Pneumonia
Observation and Results
This study involves 207 patients who were admitted to anaesthesia intensive care unit during the period of the study.
For systematic analysis, the following factors were considered:
Pre operative evaluation
Anaesthesia Intensive Care Unit admissions
Outcome of patients
Each factor was further analysed as follows:
6 patients out of 207 total patients came to Anaesthesia Intensive Care Unit after 48 hours of primary surgery for Intensive Unit Care.
Considering that India is a developing country, the cost factor in patient care is always prohibitive. The cost of stay in anaesthetic intensive care unit is 3-4 times more expensive than ward care. Hence, though we know that the value of a human life can not be measured in terms of money, we can reduce the anaesthesia intensive care unit admissions and thereby the cost of health care, by careful patient selection, so that the sophisticated care gets available to those patients who need it the most.1 Thus, the patients eligible for anaesthetic intensive care unit admission have to be carefully selected.
Pre operative patient characteristics:
Forrest et al said that the major risk factors were cardio vascular, thoracic and abdominal surgery, history of cardiac failure, myocardial infarction or hypertension, age more than 50 years, ASA physical status III or IV.5 In our study, the major risk factors were emergency and abdominal surgeries. Pederson et al have done a prospective study of mortality associated with anaesthesia and surgery – risk indicators of mortality in hospital – the risk of death associated with anaesthesia is known to depend on a number of factors which may be determined intra- or pre operatively.9 Derrington and Smith et al have studied anaesthetic risk, morbidity and mortality.2
The number of patient at increased risk of anaesthesia is reducing because of improved quality and care in anaesthetic practice. 27 patients in our study were admitted to the anaesthesia intensive care unit for intensive monitoring alone and did not receive any intervention. This is of the same order as the 20-40% incidence of low risk monitoring admissions reported by other intensive care units.10
Intermediate care area means those patients are admitted who need low risk monitoring so the occupancy of anaesthesia intensive care unit beds will be reduced and will be available for the high risk patients.12
The predictors for post operative intensive care unit admissions are (1) Males aged more than 60 years; (2) ASA grading III or IV; (3) Explorations and abdominal surgeries; (4) Emergency surgeries; (5) Intra operative arrhythmias, major blood loss, hypotension, and if patient is on inotropic support. As age advances chances of ICU admission and complications are more.
Intermediate care area is recommended for observation.
We are thankful to Dr. Neelima Kshirsagar, Dean, Seth G. S. Medical College and K.E.M Hospital for permitting us to carry out this study and publish this paper.
We are thankful to the staff members and resident doctors of Department of Anaesthesiology for their support in conducting this study.
We are thankful to Dr. Kadam, Lecturer, Dept. of Preventive and Social Medicine, K.E.M. Hospital, for helping us with performing the statistical calculations.