Advertisement

Predicting mortality in patients admitted to the intensive care unit after open vascular surgery

  • Pedro ReisEmail author
  • Ana Isabel Lopes
  • Diana Leite
  • João Moreira
  • Leonor Mendes
  • Sofia Ferraz
  • Tânia Amaral
  • Fernando Abelha
Original Article
  • 17 Downloads

Abstract

Purposes

Vascular surgery (VS) has a higher perioperative mortality than other types of surgery. We compared different scores for predicting mortality in patients admitted to the intensive care unit (ICU) after open VS.

Methods

Patients admitted to the ICU after open VS from 2006 to 2013 were included. We calculated the Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Preoperative Score to Predict Postoperative Mortality (POSPOM). We performed multivariate logistic regression to assess independent factors with the calculation of odds ratios (ORs) and 95% confidence intervals (CIs). We tested the predictive ability of the scores using the area under the receiver operating characteristics curve (AUROC).

Results

A total of 833 consecutive patients were included. Hospital mortality was 5.1% (1.3% after intermediate-risk and 8.4% after high-risk surgery). In the multivariate analysis, the age (OR 1.04, 95% CI 1.01–1.08, p = 0.013), smoking status (OR 2.46, 95% CI 1.16–5.21, p = 0.019), surgery risk (OR 2.92, 95% CI 1.05–8.08, p = 0.040), serum sodium level (OR 1.17, 95% CI 1.10–1.26, p < 0.001), urea (OR 1.01, 95% CI 1.01–1.02, p = 0.001) and leukocyte count (OR 1.05, 95% CI 1.01–1.10, p = 0.009) at admission were considered independent predictors. Hematocrit (0.86, 95% CI 0.80–0.93, p < 0.001) was considered an independent protective factor. The AUROC of our model was 0.860, compared to SAPS (0.752), APACHE (0.774), POSPOM (0.798) and POSSUM (0.829).

Conclusion

The observed mortality was within the predicted range (1–5% after intermediate-risk and > 5% after high-risk surgery). POSSUM and POSPOM had slightly better predictive capacity than SAPS or APACHE.

Keywords

Hospital mortality SAPS APACHE Intensive care unit Vascular surgery 

Notes

Author contribution

All authors were involved in data collection. PR was responsible for the data analysis and manuscript writing. FA coordinated the project and revised the manuscript. All authors approved the final version of the manuscript.

Compliance with ethical standards

Conflict of interest

All authors have nothing to declare.

References

  1. 1.
    Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139–44.CrossRefGoogle Scholar
  2. 2.
    Gupta PK, Gupta H, Sundaram A, Kaushik M, Fang X, Miller WJ, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–7.CrossRefGoogle Scholar
  3. 3.
    Ohlsson H, Winso O. Assessment of the surgical Apgar Score in a Swedish setting. Acta Anaesthesiol Scand. 2011;55(5):524–9.CrossRefGoogle Scholar
  4. 4.
    Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380(9847):1059–65.CrossRefGoogle Scholar
  5. 5.
    Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. 2005;100(1):4–10.CrossRefGoogle Scholar
  6. 6.
    Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242(3):326–41.Google Scholar
  7. 7.
    Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368–75.CrossRefGoogle Scholar
  8. 8.
    Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10(3):R81.CrossRefGoogle Scholar
  9. 9.
    Abelha FJ, Castro MA, Landeiro NM, Neves AM, Santos CC. Mortality and length of stay in a surgical intensive care unit. Rev Br Anestesiol. 2006;56(1):34–45.CrossRefGoogle Scholar
  10. 10.
    Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc. 2001;49(8):1080–5.CrossRefGoogle Scholar
  11. 11.
    Hall BL, Hamilton BH, Richards K, Bilimoria KY, Cohen ME, Ko CY. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg. 2009;250(3):363–76.Google Scholar
  12. 12.
    Weissman C. The enhanced postoperative care system. J Clin Anesth. 2005;17(4):314–22.CrossRefGoogle Scholar
  13. 13.
    Simpson JC, Moonesinghe SR. Introduction to the postanaesthetic care unit. Perioperat Med. 2013;2(1):5.CrossRefGoogle Scholar
  14. 14.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818–29.CrossRefGoogle Scholar
  15. 15.
    Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;14(2):207.CrossRefGoogle Scholar
  16. 16.
    Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. J Am Med Assoc. 1993;270(24):2957–63.CrossRefGoogle Scholar
  17. 17.
    Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med. 2004;32(6):1254–9.CrossRefGoogle Scholar
  18. 18.
    Mosquera D, Chiang N, Gibberd R. Evaluation of surgical performance using V-POSSUM risk-adjusted mortality rates. ANZ J Surg. 2008;78(7):535–9.CrossRefGoogle Scholar
  19. 19.
    Midwinter MJ, Tytherleigh M, Ashley S. Mortality and morbidity risk in Vascular Surgery using POSSUM and Portsmouth predictor equation. Br J Surg. 1999;86:471–4.CrossRefGoogle Scholar
  20. 20.
    Le Manach Y, Collins G, Rodseth R, Le Bihan-Benjamin C, Biccard B, Riou B, et al. Preoperative Score to Predict Postoperative Mortality (POSPOM): derivation and Validation. Anesthesiology. 2016;124(3):570–9.CrossRefGoogle Scholar
  21. 21.
    Liu Y, Cohen ME, Ko CY, Bilimoria KY, Hall BL. Considerations in releasing equations for the american college of surgeons NSQIP surgical risk calculator in: reply to Wanderer and Ehrenfeld. J Am Coll Surg. 2016;223(4):674–5.CrossRefGoogle Scholar
  22. 22.
    Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42.CrossRefGoogle Scholar
  23. 23.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370:1453–7.CrossRefGoogle Scholar
  24. 24.
    Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, De Hert S, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol. 2014;31(10):517–73.CrossRefGoogle Scholar
  25. 25.
    Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.CrossRefGoogle Scholar
  26. 26.
    Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. J Am Med Assoc. 2012;307(21):2295–304.CrossRefGoogle Scholar
  27. 27.
    Rhodes A, Moreno RP, Metnitz B, Hochrieser H, Bauer P, Metnitz P. Epidemiology and outcome following post-surgical admission to critical care. Intensive Care Med. 2011;37(9):1466–72.CrossRefGoogle Scholar
  28. 28.
    Weissman C, Klein N. The importance of differentiating between elective and emergency postoperative critical care patients. J Crit Care. 2008;23(3):308–16.CrossRefGoogle Scholar
  29. 29.
    Darmon M, Diconne E, Souweine B, Ruckly S, Adrie C, Azoulay E, et al. Prognostic consequences of borderline dysnatremia: pay attention to minimal serum sodium change. Crit Care. 2013;17(1):R12.CrossRefGoogle Scholar
  30. 30.
    Funk GC, Lindner G, Druml W, Metnitz B, Schwarz C, Bauer P, et al. Incidence and prognosis of dysnatremias present on ICU admission. Intensive Care Med. 2010;36(2):304–11.CrossRefGoogle Scholar
  31. 31.
    Darmon M, Timsit JF, Francais A, Nguile-Makao M, Adrie C, Cohen Y, et al. Association between hypernatraemia acquired in the ICU and mortality: a cohort study. Nephrol Dial Transplant. 2010;25(8):2510–5.CrossRefGoogle Scholar
  32. 32.
    Waite MD, Fuhrman SA, Badawi O, Zuckerman IH, Franey CS. Intensive care unit-acquired hypernatremia is an independent predictor of increased mortality and length of stay. J Crit Care. 2013;28(4):405–12.CrossRefGoogle Scholar
  33. 33.
    Stelfox HT, Ahmed SB, Khandwala F, Zygun D, Shahpori R, Laupland K. The epidemiology of intensive care unit-acquired hyponatraemia and hypernatraemia in medical–surgical intensive care units. Crit Care. 2008;12(6):R162.CrossRefGoogle Scholar
  34. 34.
    Lindner G, Funk GC. Hypernatremia in critically ill patients. J Crit Care. 2013;28(2):216.Google Scholar
  35. 35.
    Naughton C, Feneck RO. The impact of age on 6-month survival in patients with cardiovascular risk factors undergoing elective non-cardiac surgery. Int J Clin Pract. 2007;61(5):768–76.CrossRefGoogle Scholar
  36. 36.
    Skonetzki S, Lüders F, Engelbertz C, Malyar NM, Freisinger E, Meyborg M, et al. Aging and outcome in patients with peripheral artery disease and critical limb ischemia. J Post-Acute Long-Term Care Med. 2016;17(10):927–32.Google Scholar
  37. 37.
    Maia PC, Abelha FJ. Predictors of major postoperative cardiac complications in a surgical ICU. Portug J Cardiol. 2008;27(3):321–8.Google Scholar
  38. 38.
    Abelha FJ, Botelho M, Fernandes V, Barros H. Quality of life and mortality assessment in patients with major cardiac events in the postoperative period. Rev Br Anestesiol. 2010;60(3):268–84.Google Scholar
  39. 39.
    Flores E, Lewinger JP, Rowe VL, Woo K, Weaver FA, Shavelle D, et al. Increased risk of mortality after lower extremity bypass in individuals with acute kidney injury in the vascular quality initiative. J Vasc Surg. 2017;65(4):1055–61.CrossRefGoogle Scholar
  40. 40.
    Huber M, Ozrazgat-Baslanti T, Thottakkara P, Efron PA, Feezor R, Hobson C, et al. Mortality and cost of acute and chronic kidney disease after vascular surgery. Ann Vasc Surg. 2016;30:72–81.CrossRefGoogle Scholar
  41. 41.
    Arora P, Davari-Farid S, Pourafkari L, Gupta A, Dosluoglu HH, Nader ND, et al. The effect of acute kidney injury after revascularization on the development of chronic kidney disease and mortality in patients with chronic limb ischemia. J Vasc Surg. 2015;61(3):720–7.CrossRefGoogle Scholar
  42. 42.
    O’Hare AM, Sidawy AN, Feinglass J, Merine KM, Daley J, Khuri S, et al. Influence of renal insufficiency on limb loss and mortality after initial lower extremity surgical revascularization. J Vasc Surg. 2004;39(4):709–16.CrossRefGoogle Scholar
  43. 43.
    Lobo SM, Rezende E, Knibel MF, Silva NB, Paramo JA, Nacul FE, et al. Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients. Anesth Analg. 2011;112(4):877–83.CrossRefGoogle Scholar
  44. 44.
    Chen SL, Whealon MD, Kabutey NK, Kuo IJ, Sgroi MD, Fujitani RM. Outcomes of open and endovascular lower extremity revascularization in active smokers with advanced peripheral arterial disease. J Vasc Surg. 2017;65(6):1680–9.CrossRefGoogle Scholar
  45. 45.
    Velescu A, Clará A, Cladellas M, Peñafiel J, Mateos E, Ibañez S, et al. Anemia increases mortality after open or endovascular treatment in patients with critical limb ischemia: a retrospective analysis. Eur J Vasc Endovasc Surg. 2016;51(4):543–9.CrossRefGoogle Scholar
  46. 46.
    Ad N, Holmes SD, Massimiano PS, Spiegelstein D, Shuman DJ, Pritchard G, et al. Operative risk and preoperative hematocrit in bypass graft surgery: role of gender and blood transfusion. Cardiovasc Revasc Med. 2015;16(7):397–400.CrossRefGoogle Scholar
  47. 47.
    Gupta PK, Sundaram A, MacTaggart JN, Johanning JM, Gupta H, Fang X, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg. 2013;258(6):1096–102.CrossRefGoogle Scholar
  48. 48.
    Valentijn TM, Hoeks SE, Bakker EJ, van de Luijtgaarden KM, Verhagen HJ, Stolker RJ, et al. The impact of perioperative red blood cell transfusions on postoperative outcomes in vascular surgery patients. Ann Vasc Surg. 2015;29(3):511–9.CrossRefGoogle Scholar
  49. 49.
    O’Keeffe SD, Davenport DL, Minion DJ, Sorial EE, Endean ED, Xenos ES. Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization. J Vasc Surg. 2010;51(3):616–21.CrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.São João Hospital CentrePortoPortugal
  2. 2.Faculdade de Medicina da Universidade do PortoPortoPortugal

Personalised recommendations