Critical care utilization following hepatobiliary surgery
Bile Duct Neoplasms
Bile Ducts, Extrahepatic
Objective: To analyze the causes and results of utilization of critical care services by patients undergoing hepatobiliary surgery. Methods: A retrospective review of all patients admitted to the Special Care Unit (SCU) of Memorial Sloan-Kettering Cancer Center following procedures performed by the Hepatobiliary Surgical Service between 2/2/94 and 12/28/95 was performed. Results: Thirty-two of 537 patients (6.0%) undergoing surgical treatment by the Hepatobiliary Surgical Service required postoperative admission to the SCU. Twenty-one patients were admitted to the SCU directly from the operating room or from the recovery room for inability to wean from the ventilator (n=10), hypovolemic shock (n=4), myocardial ischemia or infarction (n=2), sepsis (n=2), upper gastrointestinal bleeding (n=2), and acute renal failure (n=I). Eleven postoperative patients wereadmitted to the SCU from floor care for respiratory failure (n=4), cardiac dysrhythmia or infarction (n=4), sepsis (n=2), and upper gastrointestinal bleeding (n=1). After discharge from the SCU, ten patients required readmission. The median total SCU stay was 4.5 days (range 1-78) and the median postoperative hospital stay for these patients was 15.5 days (range 4-177). 38% of patients (n=12) admitted to the SCU after surgery died, compared to an overall postoperative mortality of 3.2%. A total postoperative stay in the SCU of greater than the median total length of stay of 4.5 days was the only independent predictor of postoperative mortality (p=0.041). Preoperative albumin was significantly lower (p=0.056) and postoperative prothrombin time was significantly higher (p=0.025) by univariate analysis in SCU non-survivors as compared to SCU survivors. Similarly, a clinical history of cirrhosis/portal hypertension (p=0.053) and/or viral hepatitis (p= 0.044) was associated with postoperative mortality by univariate analysis. Conclusions: Critical care utilization rates (6.0%) were low; however, mortality was high (38%) for patients requiring postoperative critical care. Respiratory failure was the most common complication leading to SCU admission. Preoperative albumin and prothrombin time, and a history of cirrhosis and viral hepatitis appear to be predictors of postoperative outcome; however, length of stay in the SCU was the only independent predictor of mortality. Possible areas of intervention to diminish the need for critical care services include avoidance of preoperative instrumentation of the biliary tree, and improved perioperative pulmonary management.