Postoperative care and Surgical ICU

There are several issues to be considered when we think about the plan for postoperative care of noncardiac surgical patients whether or not that patient should be cared in the Surgical ICU (SICU).

First of all, the bed allocation, the SICU bed during the workday are usually not enough for the increasing demand, therefore there are some patients that they would not get the bed access, while the others who receive a permission for SICU care cancel their postoperative care plan, because the surgical procedures may be much better than the provisional plan, the bleeding was so imminent, or the surgical plan cannot be performed as plan due to the change of staging. The surgeon and anaesthetist should plan and discuss the patient care pathway together, and anaesthetist in charge of patient care in the operating theatre should have some important role in decision making about the care plan where to send the patient to depending on intraoperative course.

The diagnosis or priority setting for the patient going to SICU can be categorised as priority model; the most appropriate group means that the patient requires IPPV support, vasopressors or inotropes infusion, suitable for the care in SICU, while the least appropriate group can mean either the patient is too good or too bad to benefit for a care from SICU. The diagnosis model is grouped by the diagnosis of each organ system, such as cardiac arrest, perioperative AMI, malignant arrhythmias for cardiac diagnosis model, while pulmonary embolism with unstable haemodynamics belongs to respiratory diagnosis, and surgical diagnosis can include patient requiring haemodynamics monitoring, ruptured viscera with haemodynamics changes. While the last model is objective parameter model; such as ECG shows complete heart block, ABG shows severe metabolic disturbances suchas pH <7.1 or >7.7, hypercalcaemia from blood chemistry. These three models can be combined to consider the patient selection for SICU bed access.

In 2004 we studied the patients who stay in SICU longer than 4 days, overall the average LOS was 2.7 days, this patient subgroup was approximate 20% of the overall patients during the six-month period, the mean LOS for this group was 12 days, and overall mortality in the group was 12.1 %. The associated factors with longer stay in SICU is shown in the table here.

Factors	Odds ratio	95% CI	p value
Periop cardiac complications	12.77	4.5-36.1	<0.01
Periop RS complications	2.77	1.1-7.0	0.03
IPPV support	6.95	3.1-15.4	<0.01
Bleeding in SICU	4.85	1.3-17.6	0.02
Emergency service	2.47	1.3-4.5	<0.01
Active monitoring	2.28	1.3-4.1	<0.01
Oliguria	1.82	1.03-3.2	0.04
hypotension	2.27	1.2-4.5	0.02

The SICU patients are at risk of postoperative pulmonary complications : aspiration, ventilator associated pneumonia, acute lung injury, therefore, care should include how the predisposing factors in this patient group can be attenuated.

New approaches to acute postoperative pain control is much improved means that patient pain control is much better than the past, therefore the surgical procedures such as thoracic and vascular patients can have a good postoperative pain control resulting in a reducing care intensity in SICU.