Postoperative intensive care allocation and mortality in high-risk surgical patients: evidence from a low- and middle-income country cohort
Alocação de cuidados intensivos pós-operatórios e mortalidade em pacientes cirúrgicos de alto risco: evidências de uma coorte de países de baixa e média renda
Adriene Stahlschmidt, Sávio Cavalcante Passos, Guilherme Roloff Cardoso, Gabriela Jungblut Schuh, Paulo Corrêa da Silva Neto, Stela Maris de Jezus Castro, Luciana Cadore Stefan
Abstract
Background
The escalation of surgeries for high-risk patients in Low- and Middle-Income Countries (LMICs) lacks evidence on the positive impact of Intensive Care Unit (ICU) admission and lacks universal criteria for allocation. This study explores the link between postoperative ICU allocation and mortality in high-risk patients within a LMIC. Additionally, it assesses the Ex-Care risk model's utility in guiding postoperative allocation decisions.
Methods
A secondary analysis was conducted in a cohort of high-risk surgical patients from a 800-bed university-affiliated teaching hospital in Southern Brazil (July 2017 to January 2020). Inclusion criteria encompassed 1431 inpatients with Ex-Care Model-assessed all-cause postoperative 30-day mortality risk exceeding 5%. The study compared 30-day mortality outcomes between those allocated to the ICU and the Postanesthetic Care Unit (PACU). Outcomes were also assessed based on Ex-Care risk model classes.
Results
Among 1431 high-risk patients, 250 (17.47%) were directed to the ICU, resulting in 28% in-hospital 30-day mortality, compared to 8.9% in the PACU. However, ICU allocation showed no independent effect on mortality (RR = 0.91; 95% CI 0.68‒1.20). Patients in the highest Ex-Care risk class (Class IV) exhibited a substantial association with mortality (RR = 2.11; 95% CI 1.54–2.90) and were more frequently admitted to the ICU (23.3% vs. 13.1%).
Conclusion
Patients in the highest Ex-Care risk class and those with complications faced elevated mortality risk, irrespective of allocation. Addressing the unmet need for adaptable postoperative care for high-risk patients outside the ICU is crucial in LMICs. Further research is essential to refine criteria and elucidate the utility of risk assessment tools like the Ex-Care model in assisting allocation decisions.
Keywords
Resumo
Introdução
A escalada de cirurgias para pacientes de alto risco em países de baixa e média renda (PBMR) carece de evidências sobre o impacto positivo da admissão em unidades de terapia intensiva (UTI) e carece de critérios universais para alocação. Este estudo explora a ligação entre a alocação pós-operatória na UTI e a mortalidade em pacientes de alto risco em um PBMR. Além disso, avalia a utilidade do modelo de risco Ex-Care na orientação de decisões de alocação pós-operatória.
Métodos
Uma análise secundária foi realizada em uma coorte de pacientes cirúrgicos de alto risco de um hospital universitário com 800 leitos no Sul do Brasil (julho de 2017 a janeiro de 2020). Os critérios de inclusão abrangeram 1.431 pacientes internados com risco de mortalidade pós-operatória em 30 dias, por todas as causas, avaliado pelo modelo Ex-Care, superior a 5%. O estudo comparou os desfechos de mortalidade em 30 dias entre aqueles alocados na UTI e na Sala de Recuperação Pós-anestésica (SRPA). Os resultados também foram avaliados com base nas classes do modelo de risco Ex-Care.
Resultados
Entre 1.431 pacientes de alto risco, 250 (17,47%) foram direcionados para a UTI, resultando em 28% de mortalidade hospitalar em 30 dias, em comparação com 8,9% na SRPA. No entanto, a alocação na UTI não mostrou efeito independente na mortalidade (RR = 0,91; IC 95% 0,68-1,20). Pacientes na classe de risco Ex-Care mais alta (Classe IV) apresentaram associação substancial com mortalidade (RR = 2,11; IC 95% 1,54–2,90) e foram internados com mais frequência na UTI (23,3% vs. 13,1%).
Conclusão
Os pacientes na classe de risco Ex-Care mais alta e aqueles com complicações enfrentaram risco elevado de mortalidade, independentemente da alocação. Abordar a necessidade não atendida de cuidados pós-operatórios adaptáveis para pacientes de alto risco fora da UTI é crucial nos países de baixa e média renda. Mais pesquisas são essenciais para refinar os critérios e elucidar a utilidade de ferramentas de avaliação de risco, como o modelo Ex-Care, no auxílio às decisões de alocação.
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References
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Submitted date:
01/11/2024
Accepted date:
05/14/2024
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