Vohra Hunaid A, Goldsmith Ira R A, Rosin Michael D, Briffa Norman P, Patel Ramesh L
Cardio-thoracic Surgical Unit, Walsgrave Hospital, Clifford Bridge Road, Coventry CV2 2DX, UK.
Eur J Cardiothorac Surg. 2005 Mar;27(3):508-11. doi: 10.1016/j.ejcts.2004.11.016. Epub 2004 Dec 19.
Reinstitution of step-up care (recidivism) following cardiac surgery may be associated with increased mortality. This has, however, not been widely reported.
We, therefore, studied 8113 consecutive patients who underwent coronary artery bypass grafting (CABG), valve replacement/repair or combined valve+CABG surgery between January 1996 and December 2003 to determine the reasons for readmission to the intensive care unit (ICU) and their outcomes in terms of length of stay in (i) the ICU (ii) hospital and (iii) the in-hospital mortality following recidivism.
Of the 7717 patients discharged out of the ICU, 2.3% (182) of patients [mean age 70.4+/-8.35 years (range 30-90 years); 65.4% (119) males] required step-up care. Recidivism was 1.8% (101 of 5633) following coronary artery by-pass grafting (CABG) and 3.9% (81 of 2084) following valve replacement/repair+/-CABG (P<0.05). The mean interval from ICU discharge to ICU recidivism was 6.6+/-8.4 days (range 6h to 28 days). The principal reasons for recidivism were (i) respiratory failure requiring reintubation and ventilation in 54.9% (n=100) of patients (ii) cardiovascular instability (including that secondary to dysrhythmias) and heart failure in 23.1% (n=42) (iii) renal failure requiring haemofiltration in 6.6% (n=12) (iv) sepsis in 1.1% (n=2) (v) cardiac tamponade/bleeding requiring re-exploration in 7.7% (n=14) and (vi) gastro-intestinal complications requiring laparotomy in 6.0% (n=11) patients. Multivariate analysis showed that, during primary ICU stay, respiratory complications, low cardiac output state, dysrhythmias, renal failure requiring haemofiltration and re-exploration for bleeding were independent predictors of recidivism. Following recidivism (i) the mean length of stay in the ICU was 6.65+/-6.2 days (range 4h to 51 days), (ii) mean hospital stay was 19.2+/-17.3 days (10-60 days) and (iii) the 30-day in-hospital mortality was 32.4%.
Patients are more likely to require recidivism following valve surgery+/-CABG than CABG alone. Whilst respiratory complications were the most common reasons for recidivism in our study, patients who required mechanical supports to maintain vital functions following surgery were most prone to recidivism. Hence, efforts should be made to treat cardio-respiratory problems early in this group of patients to reduce ICU recidivism.
心脏手术后强化治疗（再入院）可能与死亡率增加有关。然而，这方面尚未有广泛报道。
因此，我们研究了1996年1月至2003年12月期间连续接受冠状动脉旁路移植术（CABG）、瓣膜置换/修复或瓣膜置换/修复联合CABG手术的8113例患者，以确定再次入住重症监护病房（ICU）的原因及其在（i）ICU的住院时间、（ii）医院的住院时间和（iii）再入院后的院内死亡率方面的结局。
在7717例从ICU出院的患者中，2.3%（182例）患者[平均年龄70.4±8.35岁（范围30 - 90岁）；65.4%（119例）为男性]需要强化治疗。冠状动脉旁路移植术（CABG）后再入院率为1.8%（5633例中的101例），瓣膜置换/修复±CABG后再入院率为3.9%（2084例中的81例）（P<0.05）。从ICU出院到再次入住ICU的平均间隔时间为6.6±8.4天（范围6小时至28天）。再入院的主要原因包括：（i）54.9%（n = 100）的患者因呼吸衰竭需要重新插管和通气；（ii）23.1%（n = 42）的患者因心血管不稳定（包括继发于心律失常的不稳定）和心力衰竭；（iii）6.6%（n = 12）的患者因肾衰竭需要血液滤过；（iv）1.1%（n = 2）的患者因败血症；（v）7.7%（n = 14）的患者因心脏压塞/出血需要再次手术探查；（vi）6.0%（n = 11）的患者因胃肠道并发症需要剖腹手术。多因素分析表明，在初次入住ICU期间，呼吸并发症、低心排血量状态、心律失常、需要血液滤过的肾衰竭和出血再次手术探查是再入院的独立预测因素。再入院后：（i）在ICU的平均住院时间为6.65±6.2天（范围4小时至51天）；（ii）平均住院时间为19.2±17.3天（10 - 60天）；（iii）30天院内死亡率为32.4%。
与单纯CABG相比，瓣膜手术±CABG后的患者更有可能需要再次入院。虽然呼吸并发症是我们研究中再入院的最常见原因，但术后需要机械支持以维持重要功能的患者最容易再次入院。因此，应努力在这组患者中早期治疗心肺问题，以减少ICU再入院率。
