Outcomes of Intensive Care Unit admissions after elective cancer surgery

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Abstract

Background

Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU).

Objective

To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses.

Methods

We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012.

Results

28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8–1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0–4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcimoma 2.0%).

Conclusion

Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.

Introduction

Although more and more potentially curative cancer treatment-strategies are of multidisciplinary nature, surgical removal of the tumor is still a key component. To achieve long term survival aggressive surgical procedures are not unusual, making direct postoperative management a significant aspect of cancer treatment.1, 2 A subgroup of cancer patients is admitted to the Intensive Care Unit (ICU) for direct postoperative care, which is related to the type of malignancy and the nature and extent of the surgical procedure. As cancer incidence is increasing by age, also elderly patients are now subject to multimodality strategies with curative intent. These patients are more vulnerable to postoperative complications at least in part due to more comorbidity of cardiovascular, pulmonary and/or metabolic origin.3 As such, there is a need to obtain insight into the incidence and extent of acute complications and into hospital outcomes after major elective cancer surgery requiring postoperative ICU care.

Although many studies have reported on postoperative morbidity and mortality in unselected patient populations,4, 5, 6, 7, 8 few previous investigations examined the specific characteristics of cancer patients in the ICU after major elective surgery. In a large observational study evaluating the outcomes of 88,504 surgical patients admitted to the ICU in Austria during an 11-year period, 9.8% were reported to have a malignant non-metastatic process as comorbid condition.8 Of these, a total of 6987 patients were admitted to the ICU after elective surgery. ICU and hospital mortality of all surgical patients were 7.6% and 11.8% respectively; logistic regression analysis identified non-metastatic cancer as an independent risk factor for postoperative hospital mortality (odds ratio 1.20), but this analysis did not discriminate between elective and emergency surgery or different types of surgical procedures.8 Of importance, whereas postoperative mortality of elective cancer surgery has been the topic of many investigations, none specifically addressed postoperative care on the ICU in this patient group.9, 10, 11, 12, 13, 14, 15

Considering the limited data on postoperative care of cancer patients in the ICU published to date, we here sought to analyze the characteristics and outcome of patients after ICU admission following elective cancer surgery. For this we analyzed all ICU admissions in the Netherlands collected in the National Intensive Care Evaluation (NICE) registry16 from January 2007 through January 2012 and extracted data from all elective surgical cancer patients.

Section snippets

Patient data and selection

The database of the Dutch National Intensive Care Evaluation (NICE) registry was used in this observational study.16 The participating ICUs provide information on all ICU admissions. For each ICU admission variables are collected that among others describe patient characteristics, severity of illness and acute comorbidities during the first 24 h of ICU admission, and the ICU and in-hospital mortality and length of stay. The data are encrypted such that all patient-identifying information are

Patients

321,493 patients were admitted to the participating ICUs between January 2007 and January 2012. Of these, 28,973 patients (9.0%) were admitted after a planned surgical procedure for cancer (Table 1). Overall, 77% of ICU admissions after elective cancer surgery were planned before the start of surgery; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent operated malignancies were colorectal carcinoma, followed by lung carcinoma and tumors

Background and main results

Knowledge of the specific characteristics of cancer patients in the ICU after major elective surgery is limited. As a consequence of advances in cancer treatment, ICU physicians can be expected to be confronted with increasing numbers of oncology patients directly following aggressive surgical treatments. Surgical procedures for different malignancies vary considerably, each carrying their own specific risks during the acute postoperative care.

This study focused on the acute postoperative ICU

Estimation of proportion of patients per cancer diagnosis admitted to ICU after elective surgery

One of four patients admitted to the ICU after elective cancer surgery was operated for colorectal carcinoma. This patient group had the highest ICU and hospital mortality (2.2% and 8.0% respectively). Our investigation does not provide insight into how many patients were operated for colorectal carcinoma in total. Indeed, many patients are transferred to a general surgical ward after elective colorectal cancer surgery. Comparing data from the Netherlands Cancer Registry, which provides data on

Conclusion

This multicenter five-year observational study conducted in 80 general ICUs shows that the most frequent cancer types admitted to the ICU after elective surgery are colorectal carcinoma, lung carcinoma and head and neck carcinoma. The median length of stay in the ICU was less than one day for almost all cancers, while postoperative care for esophageal carcinoma typically is longer (median two days). In addition, overall ICU mortality was low in this patient population, with highest mortality

Conflict of interest statement

The authors declare no conflict of interest.

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