PREOPERATIVE INTENSIVE-CARE UNIT ADMISSION AND HEMODYNAMIC MONITORINGIN PATIENTS SCHEDULED FOR MAJOR ELECTIVE NONCARDIAC SURGERY - A RETROSPECTIVE REVIEW OF 95 PATIENTS

Objective: To review experience with preoperative intensive care unit (ICU) admission and hemodynamic monitoring to determine which patients benefited and how. Design: Retrospective review over 32-month period (1991 to 1994). Setting: Surgical ICU of a university teaching hospita l. Participants: Ninety-five patients admitted to the surgical ICU bef ore a major elective noncardiac, nonthoracic surgical procedure. Inter ventions: All patients underwent hemodynamic monitoring with a pulmona ry artery catheter (PAC). Interventions were made at the discretion of the ICU attending and attending surgeon, based on a general algorithm . Patients were categorized based on history or hemodynamics. The hist oric classification was as follows: group I, patients with cardiac dis ease documented by history and cardiac imaging, n = 37; group II, pati ents with cardiac disease documented by history, but not cardiac imagi ng, n = 24; group III, patients without documented cardiac disease, bu t with other significant medical problems, n = 34. Hemodynamic classif ication considered patients to have subnormal parameters if the cardia c index was <2.5 L/min/m(2), the mixed venous oxygen saturation was <6 5%, or the oxygen delivery index was <350 ml/min/m(2) (n = 45), and no rmal parameters if greater than these (n = 50). Main Results: There we re no differences in APACHE II scores. Group I patients had greater Go ldman Cardiac Risk Indices than group III patients (7.4 +/- 4.8 v 5.0 +/- 3.0). Patients in group I had a significantly greater incidence of subnormal initial hemodynamic values (63%) than patients in group II (47%) or group III (32%). The incidence of postoperative cardiovascula r complications among groups was not different. Fifty patients (52%) h ad normal hemodynamics initially; two (4%) developed postoperative car diovascular complications compared with 10 patients (22%) of the 45 wi th subnormal initial hemodynamic values. Of these 45 patients, 24 (52% ) had their hemodynamic parameters corrected preoperatively with cryst alloids, packed red blood cells, inotropes, and/or afterload reduction . Two of these 24 patients (8%) experienced postoperative cardiovascul ar complications, compared with 8 of the remaining 21 patients who had no attempt to normalize their hemodynamic values preoperatively other than maintaining a normal pulmonary artery occlusion pressure. Conclu sions: Patients who had normal initial preoperative hemodynamic parame ters or abnormal initial parameters that were normalized preoperativel y experienced significantly fewer perioperative cardiovascular complic ations than those with abnormal initial values that were not normalize d preoperatively. These results suggest that there may be benefit to t he practice of preoperative ICU admission, hemodynamic monitoring with a PAC, and ''optimization'' of cardiac function in selected patients undergoing major elective noncardiac surgery. Further studies are need ed to better delineate the most appropriate patient populations and ef fective therapeutic protocol. Copyright (C) 1998 by WB. Saunders Compa ny.