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