title: Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement.
abstract: BACKGROUND
  Routine postoperative intensive care unit (ICU) observation of patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is driven by historically reported morbidity and mortality data. The validity of this practice and the criteria for ICU admission have not been elucidated.
  
  
  METHODS
  A prospectively maintained database of 1146 CRS/HIPEC procedures performed from December 1991 to 2014 was retrospectively analyzed. Patients with routine postoperative ICU admission were compared with patients sent directly to the surgical floor. To test the safety of non-ICU care practice, patients with less than 48 h ICU admission were compared with patients directly admitted to the floor. Demographics, primary tumor site, comorbidities, estimated blood loss (EBL), extent of CRS, Eastern Cooperative Oncology Group (ECOG) status, and overall survival were analyzed.
  
  
  RESULTS
  Complete data were available for 1064 CRS/HIPEC procedures, of which 244 cases (22.93 %) did not require ICU admission. Multivariate logistic regression identified age [odds ratio (OR) 1.024; p = 0.02], EBL (OR 1.002; p < 0.0001), number of resected organs (OR 1.308; p = 0.01) and ECOG > 2 (OR 6.387; p = 0.003) as predictive variables of postoperative ICU admission. The cohort directly admitted to the floor demonstrated less minor grade I/II morbidity (29 vs. 47 %; p < 0.0001) and similar grade III/IV major morbidity (16.5 vs. 13.4 %; p = 0.3) than the patients admitted to the ICU for less than 48 h.
  
  
  CONCLUSIONS
  ICU observation is not routinely required for all patients treated with CRS/HIPEC. Selective ICU admission based on ECOG status, nutritional status, age, EBL, and CRS extent is safe, with potential implications for hospitalization cost for these complex cases.
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: Harveshp D
authors.initials: HD
authors.lastname: Mogal
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Levine
authors.affiliation: Department of Biostatistical Sciences, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: Nora F
authors.initials: NF
authors.lastname: Fino
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: Chukwuemeka
authors.initials: C
authors.lastname: Obiora
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: Perry
authors.initials: P
authors.lastname: Shen
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA.
authors.forename: John H
authors.initials: JH
authors.lastname: Stewart
authors.affiliation: Surgical Oncology Service, Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA. kvotanop@wakehealth.edu.
authors.forename: Konstantinos I
authors.initials: KI
authors.lastname: Votanopoulos
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D010478:Chemotherapy, Cancer, Regional Perfusion; D003131:Combined Modality Therapy; D065426:Cytoreduction Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006979:Hyperthermia, Induced; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009369:Neoplasms / Q000473:pathology / Q000628:therapy*; D010343:Patient Admission / Q000592:standards* / Q000706:statistics & numerical data; D010534:Peritoneal Neoplasms / Q000556:secondary / Q000628:therapy*; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate