Post-operative Intensive Care Unit admission and patient outcomes at Moi Teaching and Referral Hospital

Abstract

Background: Post-operative patients experience surgery and anesthesia-related morbidity of varying degrees which may lead to either planned or unplanned intensive care unit (ICU) admission. There is increased demand for ICU care without reciprocating increase in bed space thus demanding detailed pre-operative planning to ensure the availability of ICU services when needed. Routine post-surgical ICU admission, with debatable outcome benefit, contribute to limited bed space for unplanned admissions who often have adverse outcomes. Moi Teaching and Referral Hospital (MTRH) ICU admission protocol suggest routine admission for major elective surgeries while the facility still experiences a high burden of unplanned admissions. Objectives: To describe and compare peri-operative adverse events among postsurgical ICU admitted patients, determine risk factors associated with unplanned postoperative ICU admissions and determine post-surgical ICU patient outcomes at MTRH. Methods: A prospective comparative observational study was carried out in MTRH ICU from October 2021 to September 2022. A sample size of 352 participants, 176 participants in both planned and unplanned post-operative ICU admission type, who underwent surgery at MTRH and were admitted to MTRH ICU post-operatively was recruited through consecutive sampling. Patient treatment records and interviews with the participant or their next of kin were used to collect patient and surgery-related data. Participants were followed up while in ICU and up to 28 days after admission to ICU in case they were discharged from ICU in less than 28 days to determine patient outcome. Results: The median patient age was 35 (IQR 19.5, 52) years with 205(58.2%) of admissions being male. Majority of admissions were American Society of Anesthesiologist (ASA) class III 176(50.1%) with a 27.3% overall comorbidity incidence. Majority, 193(54.8%), had emergency surgery with neurosurgery as leading admission specialty at 209(59.9%) of admissions. Pulmonary complications were the leading indication for ICU admission, 128(36.4%), and occurred more among unplanned admissions (P=0.001). The single commonest complication leading to ICU admission was poor anesthesia reversal, 58(16.5%). Ear Nose and Throat (ENT), maxillofacial, obstetric and orthopedic specialties (P=0.006), emergency surgery (P=0.008) and post-operative complications (P<0.001) were associated with unplanned admission. The median ICU length of stay was 3(IQR 2,5) days. In-ICU mortality was 23.3% while 28-day mortality was 29.3%. Unplanned admission was associated with mechanical ventilation, in-ICU and 28-day mortality, P<0.001. Advanced age, emergency surgery and low pre-operative Glasgow coma scale (GCS) were predictors of 28-day mortality (aOR>1). Conclusion: Pulmonary and neurological complications are the commonest complications leading to post-operative ICU admission in MTRH. ENT, maxillofacial, obstetric and orthopedic specialties, type of surgery and time of complication are associated with unplanned admission. Age, type of surgery and preoperative GCS are predictors of 28-day mortality. Recommendation: Surgeons and anesthesiologists to improve on pre-operative evaluation to reduce incidence of unplanned admissions. Audit cases of poor reversal of anesthesia in MTRH to identify areas of improvement. Use of age, surgery type and pre-operative GCS in ethical dilemma when deciding probability of clinical benefit from ICU admission