The critically ill patient after hepatobiliary surgery

Abstract

We analyzed the causes and results of utilization of critical care services in the special care unit in patients after surgical procedures performed by the hepatobiliary surgical service during a 23-month period. = 0.041). Respiratory failure was the predominant component of all complications after hepatobiliary surgery. No clinically useful predictors of eventual outcome could be identified.

Background:

We analyzed the causes and results of utilization of critical care services in the special care unit in patients after surgical procedures performed by the hepatobiliary surgical service during a 23-month period.

Results:

= 0.041).

Conclusions:

Respiratory failure was the predominant component of all complications after hepatobiliary surgery. No clinically useful predictors of eventual outcome could be identified.

Introduction

]. There are no prior reports on the utilization and outcomes of critical care services required in the management of all patients who experience complications after hepatobiliary surgery at a single institution. This paper reviews the complications leading to the utilization of critical care services after all hepatobiliary procedures performed over a 23-month period by a team of specialized surgeons, nurses, anesthesiologists, and internists who comprise the Hepatobiliary Disease Management Team of the Memorial Sloan-Kettering Cancer Center.

Statistical analysis

≤ 0.05 was considered statistically significant.

Study population

Between February 2, 1994 and December 28, 1995, 1048 patients were admitted to the Hepatobiliary Surgical Service (admitting physicians LHB and YF) at Memorial Sloan-Kettering Cancer Center. Of these, 32 out of 537 patients (6.0%) undergoing surgical treatment were admitted to the SCU, whereas four out of 511 patients (0.8%) who were receiving medical treatment only were admitted to the SCU. No single surgical procedure was associated with a higher frequency of SCU utilization than other procedures (data not shown).

Preoperative variables

. Eighteen patients had a history of cardiac disease, 10 were jaundiced in the preoperative period, 10 underwent preoperative biliary instrumentation, nine underwent preoperative biliary drainage, five had a history of cirrhosis and/or portal hypertension, four had a history of chronic obstructive pulmonary disease, and three had a history of viral hepatitis.

).

Operative variables

). During their postoperative course, seven patients required second procedures (two drainage intraabdominal abscesses, two tracheostomies, one repair of bleeding peptic ulcer, one repair of postoperative intraabdominal bleed, one repeat pancreatic debridement), two patients required a third procedure (one repeat pancreatic debridement, one removal of intra-abdominal packing and closure of abdomen), and one patient required a fourth procedure (thoracotomy/decortication for empyema).

Postoperative variables and complications

.

High and low postoperative laboratory values

on day 9 (± 13 days).

Postoperative mortality

) appear to be associated with an increased risk of SCU death. At the time of death, eight out of the 12 patients (67%) had respiratory failure, five patients (42%) had hepatic failure, and three patients (25%) had acute renal failure. Additionally, five out of the 12 patients (42%) were septic, two patients (17%) had persistent coagulopathy and ongoing upper gastrointestinal bleeding, and two patients (17%) died of acute cardiopulmonary arrest of undetermined etiology. Overall, three out of the 12 patients (25%) had multiple organ system failure.

= 0.041). Postoperative mortality did not depend on the total postoperative duration of stay, or on the number of times a patient was taken to the operating room.

= 0.053) among patients admitted to the SCU. Multivariate analysis of those two variables revealed that neither a history of viral hepatitis and a history of cirrhosis/portal hypertension was an independent predictor of postoperative mortality among patients admitted to the SCU.

= 0.020).

= 0.009) was statistically more likely to die than patients with other complications. However, multivariate analysis of these three postoperative complications failed to disclose any independent predictor of postoperative mortality.

Discussion

There is relatively incomplete information available within the literature as to the causes and outcomes of utilization of critical care services for patients undergoing hepatobiliary surgery. In the present paper, we have reviewed the Memorial Sloan-Kettering Cancer Center experience during the period of February 2, 1994 to December 28, 1995. Firstly, this study was initiated to help to determine the causes of major morbidity and mortality after hepatobiliary surgery, such that we might alter our patient care in order to avoid similar complications in the future. Secondly, this study was initiated to help to evaluate possible predictors of survival once a major complication had arisen, such that guidance could be given to clinicians caring for such patients in determining the likelihood of ultimate survival of such events.

Over a 23-month period, 6.0% of patients operated upon by the Hepatobiliary Surgical Service at Memorial Sloan-Kettering Cancer Center required critical care services. Information on similar critical care services utilized by comparable hepatobiliary services at other institutions is not available in the surgical literature; however, this appears to be an appropriate level of care, because the mortality of patients treated postoperatively with floor care alone was only 1% (five out of 505 patients). The fact that the mortality of hepatobiliary patients, once admitted to the SCU, was 37.5% (12 out of 32 patients) may be taken to suggest that patients might have been kept for inappropriately long periods on floor care before being admitted to a critical care setting, or that the problems that arose were poorly treated in the critical care setting, or that the problems that arose were beyond the ability of critical care medicine to salvage. The latter explanation seems to be the most probable.

]. This suggests that the potential benefit of preoperative drainage of the biliary tree before surgical resection is questionable and needs to be evaluated further.

]. None of the thirty-two patients requiring postoperative SCU admission had ascites or were encephalopathic preoperatively. Therefore, preoperative prothrombin time and preoperative albumin, as well as a history of viral hepatitis and/or a history of cirrhosis with or without portal hypertension, may be taken to indicate a need for heightened alertness to the possibility of the need for critical care services after significant hepatobiliary surgery.

Once admitted to the critical care unit, postoperative mortality increased with increasing duration of stay, with patients whose SCU stays exceeded 4.5 days doing significantly worse. Beyond this association of survival and duration of SCU stay, we were unable to establish any distinct individual markers to help determine the appropriateness of continuing aggressive care of critically ill patients. However, if markers could be identified, then the determination of the time at which aggressive critical care becomes futile could be established. This would ultimately better assist the critical care staff in advising the patient or proxy as to when survival is unlikely, and all subsequent decisions about pursuing further aggressive interventions could be made with this in mind.

Acknowledgements

The authors gratefully acknowledge Ruth L Sun (Hepatobiliary Database Manager) and Frank M Lewis (Systems Development Data Administrator) for their assistance in identifying patients and collecting data from the hepatobiliary and institutional databases, respectively.

Figures and Tables

Diagnoses of those 32 patients who required critical care services during postoperative care and number of deaths by diagnosis

Type of operations performed on 32 patients admitted requiring critical care service during postoperative care and the number of postoperative deaths by type of operation

Postoperative complications in those 32 patients who required critical care services during postoperative care

Potential preoperative and intraoperative variables associated with postoperative mortality by univariate and multivariate analyses in those 32 patients who required critical care services during postoperative care

Preoperative and postoperative laboratory values in surviving and nonsurviving patients requiring critical care services during postoperative care

Values are expressed as means ± standard deviation.

Potential postoperative complications associated with postoperative mortality by univariate and multivariate analyses in those 32 patients who required critical care services during postoperative care

Values are expressed as means ± standard deviation.

Keywords

• critical care
• hepatobiliary surgery
• morbidity
• mortality
• pancreatic surgery