The role of the intensive care unit in the management of the critically ill surgical patient

BRIAN H. CUTHBERTSON and NIGEL R. WEBSTER Academic Unit of Anaesthesia and Intensive Care, University of Aberdeen, Aberdeen, U.K. Surgical patients make up 60-70% of the work load of intensive care units in the UK. There is a recognised short fall in the resource allocation for high dependency units (HDUs) and intensive care units (ICUs) in this country, despite repeated national audits urging that this resource be increased. British ICUs admit patients later and with higher severity of illness scores than elsewhere and this leads to higher ICU mortality. How can this situation be improved? Scoring systems that allow selection of appropriate patients for admission to ICU and avoid inappropriate admission are still in development. Pre-operative admission and optimisation in ICU is rare in this country despite increasing evidence to support this practice in high risk surgical patients. Early admission to ICU, with potential improvement in outcomes, could also be achieved using multi-disciplinary medical emergency teams. These teams would be alerted by ward staff in response to set specific conditions and physiological criteria. These proposals are still under trial but may offer benefit by reducing mortality in critically ill surgical patients. Keywords: critical illness, pre-operative optimisation, medical emergency teams, scoring systems, high dependency care, intensive care
J.R.Coll.Surg.Edinb., 44, October 1999, 294-300

INTRODUCTION The critically ill surgical patient accounts for 60-70% of the workload of the general intensive care units (ICUs) in the UK.1,2,3,4 Indeed, the development of intensive care has to a large extent paralleled the increasing complexity of modern surgery in patients with high levels of physiological compromise and significant co-morbidities. Intensive care, and high dependency unit (HDU) care represent a vast use of resource in an increasingly financially constrained climate.5 So, what is the evidence to suggest that these highly technical environments offer true cost-benefit to our patients?6 Current clinical opinion and available evidence suggests that the early appropriate referral of patients to ICU can significantly reduce early, and possibly late, mortality in the critically ill.6,7,8,9 The National Confidential Enquiry into Perioperative Deaths (NCEPOD), in 1994-95, and the Scottish Audit of Surgical Mortality, in 1996, highlighted the importance in terms of poor outcome due to the under-provision of ICU and HDU beds. These two large audits questioned whether major surgery on high-risk patients should be performed in hospitals lacking appropriate 24 hour ICU facilities.1,4 The greatest challenge in supplying ICU care is deciding who would and would not benefit from ICU and, thus, who should be denied its facilities. In 1994, the cost of ICU was stated to be 1 100 per bed per day and HDU 433 per bed per day.

The knowledge that it costs twice as much to die in ICU as it does to survive, means that it is vital that patients are chosen well.10,11,12 Unfortunately, Britain has one of the smallest health care budgets amongst developed countries and spends a smaller percentage of this total on intensive care services.11 This, along with the increasing demand on ICU beds, has led to critically ill patients being denied or having delayed access to ICU. This is occurring not just for the group of patients least likely to benefit from ICU care, who may be given reduced priority, but also from an appropriately referred group of critically ill patients.9,11 Failure to admit, or non-specialist transfer of appropriately referred ICU admissions, has been demonstrably associated with an increased morbidity and mortality.7,8,13 This, along with inappropriate early discharge from ICUs, means that British ICUs contain more severely ill patients, refuse to admit or transfer more appropriately referred patients and have a higher post-ICU discharge mortality than those of many comparable countries.2,3,9,11 This situation leads to a call for higher ICU funding in an already financially restrained health system. Perhaps a more cost-effective approach would be to determine accurate admission and discharge criteria that could reduce resource wastage on patients who are too sick to benefit from intensive care and in those that are to well to show cost-benefit. In other words, concentrating provision on those most likely to benefit from the resource. This review will concentrate on issues that may help us to identify those most likely to benefit from ICU or HDU care. In further articles, current trends in the clinical management of the critically ill that are of relevance to surgical practice will be discussed. INTENSIVE CARE VERSUS HIGH DEPENDENCY CARE Intensive care and high dependency care should be closely linked. They act as step-up and stepdown units for patients of changing severity of illness. The provision of HDU also is one of the most important factors in determining the availability of ICU beds.1,2,3,11 The ability to discharge ICU patients to an appropriately equipped and staffed HDU reduces the pressure on ICU beds and reduces the rate of ICU readmission (see below). Introduction of HDU facilities have also been shown to reduce the incidence of cardiac arrest and hospital mortality.14 However, the provision of high dependency care in this country has grown very slowly over the years and in general seems to be still inadequate despite calls from NCEPOD for increased resources.1 Recent Department of Health guidelines have been published to assist clinicians and managers to decide which patients could benefit from ICU, and which services ICU and HDU should offer.5 These guidelines state that intensive care is appropriate for patients who satisfy the criteria set out in Tables 1 and 2.5 The report does not specifically state which patients should not receive ICU management, which is a more important and difficult question. Thus, these guidelines have limited value. Table 1: The characteristics of intensive and high dependency care
Intensive care is appropriate for Patients requiring or likely to High dependency care is appropriate for Patients needing support for a

require advanced respiratory support alone Patients requiring support of two or more organ systems (see Table 2) Patients with chronic impairment of one or more organ systems sufficient to restrict daily activities (co-morbidity) and who require support for an acute reversible failure of another system

single failing organ system, but excluding advanced respiratory support Patients who can benefit from more detailed observation than can be provided on a general ward Patients no longer needing Intensive Care but who are not yet well enough to be returned to a general ward Post-operative patients who need close monitoring for longer than a few hours

Table 2: Categories of organ system monitoring and support

1. Advanced respiratory support Mechanical ventilatory support The possibility of sudden deterioration in respiratory function requiring intubation and ventilation

2. Basic respiratory monitoring and support The need for > 40% Oxygen The possibility of progressive deterioration requiring respiratory support The need for physiotherapy >2 hourly Extubation after prolonged intubation The need for mask CPAP or non-invasive ventilation Patients who require intubation for airway protection

3. Circulatory support The need for vasoactive drugs to support cardiac output and blood pressure Circulatory instability due to hypovolaemia that is unresponsive to moderate volume replacement After resuscitation from cardiac arrest if HDU and ICU is appropriate

4. Neurological monitoring CNS depression with risk of airway compromise Invasive neurological monitoring

5. Renal support

The need for acute renal replacement

CRITERIA FOR INTENSIVE CARE ADMISSION Attempts have been made to apply specific standardised admission criteria to the breadth of patients referred for ICU admissions.9,15 Scoring systems, such as the Acute Physiological and Chronic Health Evaluation II (APACHE) and Mortality Prediction Model II (MPM), have been widely used to determine probability of ICU survival in populations of ICU admissions.1,16,17,18 It has been suggested that these scoring systems could be adaptable for use in predicting ICU survival in specific cases and, thus, be used to determine admission criteria for individual patients.19,20 However, they are designed and evaluated only for the determination of probability of survival in ICU populations and have limited applicability to individual cases.5,11,16,19 Also, the data collection and interpretation required for APACHE II is complex and time consuming, and the raw data needed is often not available in the ward setting. There has been suggestion that it is unethical to apply systems for predicting ICU survival for patients to whom ICU admission may be refused.9 The correlation of number of organ system failures and ICU mortality has lead to a crude count of that number being applied in an ad hoc fashion to justify refusal of admission to ICU.21,22 Such practice is inappropriate, although this concept has been formalised in the System for Organ Failure Assessment.23 In this system, the severity of organ system failures is scored on each organ system and a cumulative score is attained which relates to ICU survival. Once again this has not been verified as being applicable for ICU admission criteria23 and the application of this relatively simple score to ward patients with deteriorating condition on a daily basis, although appealing requires to be tested as a system to determine ICU admission. Other familiar scoring systems are the American Society of Anesthesiologists (ASA) score and the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM).24,25 Although ASA score predicts surgical risk, it is not very sensitive for the prediction of requirement for ICU admission. However, it has been shown to correlate closely with early post-operative emergencies which often lead to ICU admission.26 POSSUM, like APACHE II, predicts probability of surgical mortality for a range of surgical sub-populations, but not the need for ICU or HDU support.25,27,28 Some have suggested that the patients age should be used as a means to ration scarce health care resources, including ICU services, though many feel that this is inappropriate and, indeed, unethical. The APACHE II data does demonstrate that increasing age is related to increased ICU mortality and indeed the score is weighted for age.16 The importance of age has been shown to vary in different countries and it has been suggested that biological, rather than chronological, age may be more important.29,30,31,32 The inability of admission criteria and scoring systems to guide ICU admission in a general cohort of ICU admissions contrast with the successful use of attempts with criteria in patients

with specific conditions such as GI haemorrhage.33,34 The great diversity of diagnoses, and severity of illnesses seen in ICU admissions make the current broad criteria for admission inappropriate to apply. Indeed, the statement that ICU should be available to anyone who has reversible pathology and has a reasonable chance of returning to an acceptable quality of life, is just as appropriate and almost as specific a guideline. So ,we return to the rather poor definition of who should be admitted to ICU. The answer, at this time, is anyone who could benefit. When Should the Critically Ill Surgical Patient be Admitted to ICU? As stated above, the lack of ICU and HDU beds in the UK leads to appropriate admissions to ICU being delayed and, thus, patients are admitted to ICU later and with higher severity of illness scores.7,8,11 Although standardisation for case mix and severity of illness shows that British ICUs achieve similar outcomes to elsewhere35, this hides the fact that for individual patients this worsening of clinical condition caused by delayed ICU admission does have adverse effects on out-come. Thus, ICU in the UK is probably associated with an unnecessary excess morbidity and mortality.7,8,11 It has also been pointed out that the quality of care before admission to ICU is frequently sub-optimal.36,37 In a cohort of 100 consecutive ICU admissions, it was found that care was deemed sub-optimal in 54 of these cases. Care was said to be inadequate at the most basic levels, including airway, breathing, and circulatory management. There are three main ways in which this situation may be remedied: 1) pre-operative admission and optimisation in ICU; 2) early recognition and rapid interventions for the critically ill; 3) better staff training in critical care. Pre-Operative Admission It seems logical that early admission and timely discharge of appropriately chosen patients to ICU is desirable. The timing of admission for surgical patients is usually with regard to operative care. In a large-scale study, only 5% of surgical patients were admitted to ICU pre-operatively, and this was thought to be due, in part, to pressure on ICU beds.2,3 Most of the deaths related to surgery are at least 3 days into the postoperative period, but it has been suggested that preoperative admission to ICU and cardiovascular optimisation may reduce this post-operative mortality.11 In 1987, Shoemaker et al38 published the results of a prospective trial of supra-normalisation of cardiovascular indices in the management of high risk surgical patients (Table 3). Patients were admitted pre-operatively to a critical care area for pulmonary artery catheterisation and supranormalisation of cardiac index (>4.5l/min/m2) and oxygen delivery (>600ml/min/m2) using fluids and inotropes. Results suggested that there was a major benefit in terms of morbidity and mortality.38 These results were supported by the work of Boyd et al in the UK.38 These workers also demonstrated a significant reduction in mortality in a prospective randomised trial of preoperative supra-normalisation, continuing for up to 24 hours post-operatively, in the same high risk patients (Table 3).39 A further study of pre-operative optimisation in vascular surgery patients using a different protocol also demonstrated reduction in cardiovascular morbidity and mortality.40 The situation was made less clear by more recent studies. In orthopaedic patients, non-invasively monitored fluid filling did not seem to reduce mortality but the authors claimed it had a beneficial effect on recovery41 and, in major vascular surgery patients, two trials have

failed to show favourable effects.42,43 However, none of these studies actually supranormalised the cardiovascular indices as described by Shoemaker.38 A further recent report has again clearly demonstrated a marked improvement in mortality in high risk surgical patients undergoing preoperative optimisation and supranormalisation.44 These positive results are seen to contrast with the failure of trials of supranormalisation in the already critically ill patients who show no benefit.45,46 This would suggest that such strategies must be implemented before the insult occurs in order to show some improvement in mortality. This has lead to suggestions that aggressive pre-operative interventions may be the way forward in the management of a group of patients, whose mortality could be reduced from the quoted 17-28% down to 3-6%.38,39,44,47 Patients with severe cardiac disease for major non-cardiac surgery are a subgroup of the above mentioned high-risk group with a particularly poor outcome. Goldman et al were first to attach specific multi-factorial risks in this group pointing out the very high mortality associated with cardiac failure and recent myocardial infarction.48 Later work by Rao et al suggested that invasive monitoring and aggressive therapy throughout the operative period, including pre- and post-operative admission to ICU, could bring about very significant reductions in mortality.49 Detailed guidelines for the perioperative care of such patients now exist.50 NCEPOD tells us that 20 000 patients per year die within 30 days of surgery. Many of these patients will be true emergency patients who will not be able to benefit from extensive preoperative optimisation. However, many are elective or urgent cases in which a few hours of preoperative manipulation would be feasible. If these results are generally applicable the potential lives saved could be very significant.1 In light of the shortage of ICU beds and resources, how can this strategy be implemented? At first glance this strategy would appear to significantly increase the ICU beds usage. Undoubtedly, this would be the case even if you allowing for the promised reduction in late postoperative admissions that this policy could bring. The reduction in mortality alone could be considered adequate reason to attract new funding. Along with this, the promise of reduced hospital stays44 and avoidance of the extremely high cost that late ICU admissions could reduce the total hospital costs and possibly the total ICU costs for this large group of surgical patients. Table 3: Criteria for high risk patients, after Shoemaker

Previous severe cardio-respiratory illness (acute myocardial infarction, stroke, COAD) Extensive ablative surgery planned for carcinoma (ie oesophagectomy, gastrectomy, prolonged surgery) Severe multi-trauma (ie> 2 organs or 3 systems, or opening 2 body cavities) Massive acute blood loss (> 8 units), blood volume < 1.5 l/ m2, haematocrit < 0.2 Age > 70 or evidence of limited physiological reserve of one of more organs Septicaemia, positive blood cultures or septic focus, WCC >13 000/ml, spiking fever to > 38.3oC for 48 hours Shock, MAP < 60mmHg, CVP < 15cmH2O and urine output < 20ml/hr

Respiratory failure, PaO2 < 8mmHg on FIO2 > 0.4, intrapulmonary shunt fraction > 30%, mechanical ventilation needed > 48 hours Acute abdominal catastrophe with haemodynamic instability (ie pancreatitis, gangrenous bowel, perforated viscus, GI bleeding) Acute renal failure: serum urea > 17.9 mmol/l, creatinine > 265mmol/l Late stage vascular disease involving aortic disease

Early Recognition and Intervention The principles of early admission to ICU could also involve an early recognition and rapid response system to allow early appropriate admission to ICU. The Medical Emergency Team (MET) concept was devised with the aim of reducing the incidence of in-hospital cardiopulmonary arrest.51 Cardiopulmonary arrest is a late, predictable and very poor prognostic event in a hospitalised patient.52 The known clinical antecedents of cardiac arrest suggested that most cardiac arrest could be predicted and often prevented.52 These known antecedents along with other physiological criteria and specific named conditions were used to devise criteria by which such a team should be alerted (see Table 4). This team comprised multi-disciplinary medical and nursing staff, trained in resuscitation, who could be alerted by ward nursing or medical staff when these defined criteria were met. There have also been other systems used to define those patients likely to need intensive care before the onset of cardiopulmonary arrest. Such systems include the Patient at Risk Team (PART)53,54, and the early warning scoring system (Table 5).55 So far, this approach has only been validated in relatively small studies. However, these have demonstrated a significant decrease in the incidence of cardiac arrest in those patients admitted to ICU, as well as a trend towards a decrease in overall mortality. The cost of running such a team could be met partly by allowing MET teams to supercede cardiac arrest teams, partly from existing resources and, hopefully, from the cost-benefit gained from more efficient ICU bed usage. Table 4: The Medical Emergency Team criteria

Abnormal physiology Temperature <35.5 or >39.5 Systolic BP <100 or >200 Respirations per minute <10 or >40 Pulse rate < 40 or >120 Urine output <500 ml / day Decreased level of consciousness

Surgical. Shock Hypovolaemic Anaphylactic Cardiogenic Excessive bleeding Excessive drainage

Abnormal pathology Potassium <3 or >6 Sodium <125 or >155 Blood sugar <2 or >20 Arterial pH <7.2 or >7.55 Base excess <-15 or >+10

Septic

Metabolic Acute diabetic emergency

Poisoning / trauma Near drowning Carbon monoxide poisoning Severe drug overdose

Specific conditions Cardiovascular Cardiopulmonary arrest Pulmonary oedema New major arrhythmia

Obstetric Amniotic fluid embolism Pre-eclampsia

Respiratory Neurological Acute severe asthma Acute respiratory failure Upper airway obstruction Status epilepticus Acute psychiatric disturbance (aggressive, uncontrollable)

Table 5: An early warning scoring system for detecting critical illness, developed by Morgan et al
Score HR Systolic BP Respiratory rate Temperature CNS 3 <70 2 <40 71-80 <8 <35 35.136.5 1 41-50 81-100 0 51-100 101-199 9-14 36.6-37.4 A 14-20 >37.5 V P U 1 101-110 2 3 111-130 >131 >200 21-29 >30

A- alert, V- responds to vocal stimuli, P- responds to painful stimuli, U- unresponsive THE ROLE OF THE INTENSIVE CARE UNIT IN TRAINING SURGICAL STAFF Clearly, the ICU is the best place to learn techniques to manage patients with severe physiological derangement. It should offer, therefore, a training role for staff from all relevant disciplines. The intensive care team must also be willing to be utilised for advice around the hospital on the care of sick patients who may not as yet require ICU admission, but do require aggressive ward based therapy. This could be in a formalised way such as MET systems but also

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