Outcome following unplanned critical care admission after lung resection

Abstract

Objectives: Patients undergoing lung resection are at risk of perioperative complications, many of which necessitate unplanned critical care unit admission in the postoperative period. We sought to characterize this population, providing an up-to-date estimate of the incidence of unplanned critical care admission, and to assess critical care and hospital stay, resource use, mortality, and outcomes.

Methods: A multicenter retrospective cohort study of patients undergoing lung resection in participating UK hospitals over 2 years. A comprehensive dataset was recorded for each critical care admission (defined as the need for intubation and mechanical ventilation and/or renal replacement therapy), in addition to a simplified dataset in all patients undergoing lung resection during the study period. Multivariable regression analysis was used to identify factors independently associated with critical care outcome.

Results: A total of 11,208 patients underwent lung resection in 16 collaborating centers during the study period, and 253 patients (2.3%) required unplanned critical care admission with a median duration of stay of 13 (4-28) days. The predominant indication for admission was respiratory failure (68.1%), with 77.8% of patients admitted during the first 7 days following surgery. Eighty-seven (34.4%) died in critical care. On multivariable regression, only the diagnosis of right ventricular dysfunction and the need for both mechanical ventilation and renal-replacement therapy were independently associated with critical care survival; this model, however, had poor predictive value.

Conclusions: Although resource-intensive and subject to prolonged stay, following unplanned admission to critical care after lung resection outcomes are good for many patients; 65.6% of patients survived to hospital discharge, and 62.7% were discharged to their own home.

Keywords: ACTACC, UK Association of Cardiothoracic Anaesthesia and Critical Care; ARDS, acute respiratory distress syndrome; LRTI, lower respiratory tract infection; RV, right ventricular; critical care; lung resection; thoracic surgery.

Graphical abstract

Outcomes following unplanned critical care admission in 253 patients across 16 UK centers.

Figure 1

Number of critical care admissions per day in 253 patients admitted unplanned to critical care following lung resection. Both survivors and nonsurvivors demonstrate a characteristic bimodal distribution with the most admissions occurring on the day of surgery (postoperative day zero) and a second peak occurring on day 2-3. There was no difference in day of admission between survivors and non-survivors (P = .06, univariate regression). Data smoothing by 348-point cubic spline plot.

Figure 2

Critical care mortality as a function of number of unplanned postoperative critical care admissions by center. Each data point represents 1 of 16 UK thoracic surgical centers. Red line represents mean ICU mortality across all centers, warning limits are plotted at 2 and 3 standard deviations from the mean. Funnel plots have been shared with all participating centers for local audit/quality improvement purposes. ICU, Intensive care unit.

Figure 3

Receiver operating characteristic curve demonstrating the predictive value of a multivariate model for critical care mortality following unplanned critical care admission following lung resection. Final model composed of need for both mechanical ventilation and renal replacement therapy and the presence/absence of right ventricular dysfunction (Table 4). Area under the receiver operating characteristic curve = 0.64, 95% confidence interval, 0.56-0.72.