Ward versus intensive care management of high-risk surgical patients.
BACKGROUND
Selection of high-risk surgical patients for preoperative and perioperative admission to an intensive therapy unit (ITU) for enhancement of oxygen delivery may reduce postoperative morbidity and mortality rates. Limited resources may prevent admission of all suitable patients. This audit study examined whether it is possible to select patients most at risk and thus reduce surgical morbidity and mortality rates when ITU services are limited.


METHODS
This was a retrospective audit comparing the actual outcomes of complications and death with predicted outcomes using the POSSUM score (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) for 101 general surgical and vascular patients who would have fulfilled previously suggested criteria for preoperative admission to the ITU. Main outcome measures were the number of preoperative ITU admission criteria, American Society of Anesthesiologists (ASA) and POSSUM scores, preoperative oxygen delivery values, intravenous fluid therapy, length of ITU stay, length of hospital stay, postoperative complications and 28-day mortality.


RESULTS
Medical staff allocated patients appropriately. There was a lower mortality rate than predicted from individual POSSUM scores. Patients who were admitted to the ITU before operation had the highest ASA scores, admission criteria and POSSUM scores; they also had significantly lower mortality and morbidity rates than predicted by the POSSUM scoring system.


CONCLUSIONS
Patients with the greatest reduction in mortality and morbidity rates were admitted to the ITU before operation and had cardiovascular physiology 'optimized' before surgery.
Anaesthetic Department, St George's Hospital, London, UK.
J E
JE
Curran
R M
RM
Grounds
D000368:Aged; D003422:Critical Care / Q000706:statistics & numerical data*; D005260:Female; D005440:Fluid Therapy / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007430:Intraoperative Care / Q000706:statistics & numerical data; D008131:London; D008297:Male; D008485:Medical Audit; D010100:Oxygen / Q000627:therapeutic use; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D011300:Preoperative Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000401:mortality* / Q000706:statistics & numerical data
D010100:Oxygen