Nursing interventions’ impact on cardiovascular complications after gastrointestinal surgery in intensive care unit: Risk factor analysis

Abstract

BACKGROUND

Cardiovascular (CV) complications are common in intensive care unit (ICU) patients after gastrointestinal surgery and are associated with increased mortality and prolonged hospital stay. The optimization of postoperative nursing interventions, particularly pain management, is crucial for reducing such complications.

AIM

To investigate the effects of enhanced recovery nursing on CV complications after gastrointestinal surgery in ICU patients and associated risk factors.

METHODS

A retrospective analysis was conducted on 78 adult patients who underwent gastrointestinal surgery in the ICU of our hospital between February 2023 and September 2024. Among them, 40 patients received standard care (control group), while 38 received enhanced recovery nursing (observation group). We compared the incidence of CV complications and nursing satisfaction between the two groups. Patients were divided into CV complication and non-complication groups based on complication occurrence, and logistic regression analysis was used to identify risk factors.

RESULTS

In the control and observation groups, the incidence of CV complications was 30.0% (12/40) and 18.4% (7/38), with a nursing satisfaction rate of 70.0% (28/40) and 92.1% (35/38), respectively. The postoperative pain score at 14 days was significantly lower in the observation group (0.27 ± 0.15) compared to the control group (1.65 ± 0.37), with all differences being statistically significant (P < 0.05). Univariate analysis indicated significant differences in age, body mass index, hypertension, diabetes, smoking history, history of heart failure, and previous myocardial infarction (P < 0.05). Multivariate logistic regression identified heart failure history, previous myocardial infarction, age, hypertension, and diabetes as independent risk factors, with odds ratios of 1.195, 1.528, 1.062, 1.836, and 1.942, respectively (all P < 0.05).

CONCLUSION

Implementing enhanced recovery nursing for ICU patients after gastrointestinal surgery is beneficial in reducing the incidence of CV complications and improving nursing satisfaction.

Key Words: Enhanced recovery nursing interventions; Intensive care unit; Gastrointestinal surgery; Cardiovascular complications; Risk factor analysis

Core Tip: Cardiovascular (CV) complications are common in intensive care unit (ICU) patients post-gastrointestinal surgery, leading to higher mortality and longer hospital stays. This study highlights the benefits of enhanced recovery nursing in reducing these complications and improving nursing satisfaction. The results indicate that key independent predictors of CV complications include a history of heart failure, previous myocardial infarction, advanced age, hypertension, and diabetes. Optimizing postoperative nursing interventions, particularly in pain management, is essential for mitigating these risks in ICU patients.

INTRODUCTION

Gastrointestinal diseases are prevalent clinical conditions with a high incidence, and many patients require surgical intervention due to the severity of their conditions[1]. Surgical treatment frequently entails considerable physiological and psychological stress[2]. In particular, patients in the intensive care unit (ICU) who are recuperating from gastrointestinal surgical procedures encounter intricate and substantial challenges[3]. The ICU functions as the primary unit for the management of critically ill patients within the hospital, thereby rendering the monitoring and treatment of postoperative gastrointestinal patients imperative[4].

During gastrointestinal surgery, anesthetic stimulation and surgical trauma have been shown to inhibit gastrointestinal motility to a certain extent, resulting in postoperative symptoms such as abdominal distension, pain, and altered bowel movements[5]. These symptoms have been demonstrated to exert a detrimental effect on patients' physical and mental well-being and they can also result in various postoperative complications, severely affecting patients' quality of life[6]. A review of the extant literature reveals that the incidence of complications following gastrointestinal surgery has been documented to range from 10-30% in clinical studies[7]. Of these complications, cardiovascular (CV) complications are particularly severe and may include myocardial infarction, heart failure, and arrhythmias[7]. These complications further increase the risk of mortality and the healthcare burden on the system.

Consequently, the implementation of clinical nursing interventions assumes paramount importance in the context of gastrointestinal surgical interventions. Typically, patients receiving intensive care following gastrointestinal surgery are subject to conventional nursing interventions, which prioritize fundamental care components such as vital sign monitoring, pain management, and wound care[8]. However, traditional nursing practices have been shown to have limitations in terms of promoting rapid recovery and preventing complications. Furthermore, the inadequate emphasis on early postoperative activity, nutritional support, and psychological interventions may result in delays in the recovery process.

As contemporary healthcare models undergo continuous evolution, the clinical demand for nursing has undergone a gradual shift from a myopic focus on disease treatment to an integrated model encompassing health maintenance, rehabilitation, and prevention[9]. The concept of enhanced recovery nursing has emerged in this context, originating in Europe and the United States in the 1990s. The emphasis on utilizing scientific methodologies prior to, during, and following surgical procedures aims to mitigate surgical stress responses, reduce the risk of complications, and accelerate postoperative recovery[10,11]. This approach involves a comprehensive assessment of the patient's condition, the development of personalized nursing plans, and enhanced rehabilitation training post-surgery. The efficacy of these interventions in positively impacting postoperative recovery and prognosis has been demonstrated through empirical evidence.

In recent years, China has gradually adopted the concept of enhanced recovery nursing for postoperative rehabilitation care for gastrointestinal diseases, achieving notable outcomes[12,13]. However, there remains a paucity of in-depth and systematic research on the specific effects of enhanced recovery nursing on CV complications in ICU patients following gastrointestinal surgery, as well as an analysis of the associated risk factors. Furthermore, by thoroughly analyzing the risk factors for CV complications in ICU patients’ post-gastrointestinal surgery, targeted measures can be implemented to reduce the risk of complications and improve clinical outcomes for patients.

This study aims to explore the impact of enhanced recovery nursing on CV complications after gastrointestinal surgery in ICU patients and to analyze related risk factors, with a view to providing strong support for optimizing nursing strategies and improving the quality of postoperative recovery in ICU patients after gastrointestinal surgery.

MATERIALS AND METHODS

Study subjects

This study retrospectively selected the clinical data of 78 adult patients who underwent gastrointestinal surgery in the ICU of our hospital from February 2023 to September 2024. The study population included 40 patients receiving conventional care, who were assigned to the control group, and 38 patients receiving enhanced recovery nursing, who were assigned to the observation group. The incidence of CV complications and nursing satisfaction between the two groups were compared. Based on the occurrence of CV complications, patients were divided into the CV complications group and the non-CV complications group, and data were collected for logistic regression analysis to determine the risk factors for CV complications. Given the retrospective nature of the study, a formal sample size calculation was not conducted. The study adhered to institutional privacy and security policies to ensure the protection and security of patient data during data sourcing, cleansing, scrubbing, normalization, and acquisition.

Ethics approval

This study was approved by the Clinical Research Ethics Committee of our hospital and was conducted by the principles of the Helsinki Declaration.

Inclusion and exclusion criteria

Inclusion criteria[14]: (1) Underwent gastrointestinal surgery in the ICU; (2) Diagnosed with colorectal cancer, gastric cancer, or rectal cancer; and (3) Normal consciousness, mental status, and communication ability.

Exclusion criteria: (1) Poor compliance with nursing; (2) Coagulation disorders; (3) Severe major organ dysfunction; (4) Received preoperative chemotherapy or radiotherapy; and (5) Gastrointestinal obstruction.

Nursing methods

Control group: The control group implemented conventional nursing[15]: (1) Preoperative assessment: Evaluate the patient's general condition, specialty status, psychological state, nutritional status, and potential complications. Specialty assessment includes checking for abdominal masses, tenderness, distension, acid reflux, loss of appetite, and other gastrointestinal symptoms; (2) Preoperative care: Timely alleviate the patient's negative emotions, answer questions, and explain the surgical methods and precautions. Complete routine checks, coagulation function tests, assessments of major organ functions, and specialized examinations such as gastrointestinal endoscopy and abdominal computed tomography. Instruct patients to avoid gas-producing foods for 2 days before surgery, switch to a liquid diet 1 day before surgery, fast for 12 hours before surgery, and restrict water intake for 4-6 hours before surgery. Prepare for routine preoperative preparations such as skin preparation and blood preparation. For laparoscopic surgery patients, ensure the cleanliness of the umbilical incision. Administer antibiotics orally according to individual circumstances 3 days before surgery, and perform a cleansing enema on the morning of the surgery or the day before; (3) Intraoperative care: Assist the surgical team with drainage, suturing, and other procedures, and adjust the operating room's temperature and humidity; and (4) Postoperative care: Closely monitor the patient's vital signs, and provide routine pain relief, dietary guidance, and rehabilitation training. Ensure nutritional support after surgery, observe the patient's consciousness, and check for dehydration, electrolyte imbalances, or gastrointestinal reactions. Regularly test blood lipids, blood glucose, and liver and kidney functions. Monitor for complications such as nausea, vomiting, and abdominal pain, and provide symptomatic treatment promptly.

Observation group: The observation group implemented enhanced recovery nursing[16]: (1) Preoperative care: (a) Preoperative Assessment: Assess the patient's psychological state, nutritional status, and potential complications based on specific conditions and general status, and conduct specialized evaluations; (b) Preoperative education: Introduce the methods, processes, precautions, and adverse reactions of gastrointestinal surgery to patients through WeChat public accounts, group video sharing, etc., and provide dietary guidance before and after surgery. Present the postoperative rehabilitation exercise plan, focusing on demonstrating the movements and precautions for getting out of bed and turning over in bed. Arrange for specially trained nursing staff to provide personalized psychological counseling for patients with significant negative emotions; and (c) Bowel preparation: Provide a liquid diet 1 day before surgery and instruct patients to take oral intestinal lubricants. Restrict water intake for 4 hours and food intake for 8 hours before surgery, and perform a cleansing enema on the morning of the surgery. For gastric surgery patients, a gastric tube is placed; for intestinal surgery patients, a gastric tube may not be necessary; (2) Intraoperative care: Upon entering the operating room, immediately adjust the temperature and humidity. Heat intravenous fluids and irrigation solutions used during the procedure to 38 °C. Decide whether to place a nasogastric tube and abdominal drainage tube based on the patient's actual condition during surgery; monitor the patient's vital signs during transfer and ensure warmth is maintained; and (3) Postoperative care: (a) Multimodal pain management: Preemptive analgesia with oral celecoxib 400 mg 2 hours preoperatively. Postoperatively, thoracic epidural analgesia with continuous infusion of 0.2% ropivacaine and fentanyl 2 μg/mL (basal rate 6 mL/hour, patient-controlled bolus 4 mL/20 minute). Concurrently, enhance analgesic efficacy with intravenous acetaminophen 1 g every 6 hours and pregabalin 75 mg twice daily. For non-pharmacological interventions, apply transcutaneous electrical nerve stimulation (frequency 80Hz, duration 30 minutes, 4 times daily) to the surgical area to help alleviate postoperative pain; (b) Goal-directed nutritional support: After the patient regains consciousness, initially provide small amounts of warm water to moisten the mouth, continuing for 5 hours, with an initial diet consisting mainly of liquid foods. 6-8 hours postoperatively, the physician will auscultate for abdominal bowel sounds; upon confirmation of their presence, initiate feeding with an initial administration of 30-50 mL of 5% dextrose sodium chloride injection, maintained for 24 hours. If the patient experiences no discomfort, gradually advance to a full liquid diet, with a daily intake controlled between 1000-1500 mL, while monitoring their dietary intake and physical condition. Gradually transition to a semi-liquid diet, eventually progressing to a normal diet; and (c) Activity and exercise: Begin in-bed exercises (turning, limb movements) after anesthesia recovery. Ambulate with assistance on postoperative day 1; stand and walk by day 3, increasing intensity/duration based on recovery.

Observation indicators

CV complications[17]: This includes new-onset severe arrhythmias, recurrent angina, recurrent heart failure, repeat revascularization, in-stent stenosis, myocardial infarction, and cardiogenic death.

Postoperative pain scores[18]: The Visual Analog Scale (VAS) is used to assess pain, with scores categorized as follows: 0 indicates no pain, 1-3 represents mild pain, 4-6 indicates moderate pain, 7-9 signifies severe pain, and 10 denotes unbearable severe pain.

Nursing satisfaction[19]: This study observed and compared nursing satisfaction levels. A nursing satisfaction questionnaire (score range: 0-100), developed by our hospital, was utilized to assess patient satisfaction and compare nursing satisfaction scores across different groups. The questionnaire's content and evaluation criteria were designed by our team, categorizing scores of satisfied, basically satisfied, and dissatisfied into ranges of 100-85, 60-84, and below 60, respectively. The formula to calculate satisfaction is: Satisfaction = (number of satisfied cases + number of basically satisfied cases)/total cases × 100%.

Identification of risk factors for CV complications: Logistic regression analysis will be used to determine the risk factors associated with CV complications.

Statistical analysis

Statistical analysis was conducted using IBM SPSS Statistics software, version 26.0 (SPSS Inc., Chicago, IL, United States). Descriptive statistics were expressed as means and standard deviations for continuous variables, while categorical variables were expressed as counts and percentages. Odds ratios (ORs) and 95% confidence intervals (95%CIs) were used to evaluate risk factors impacting CV complications. The study subjects were divided into two groups based on the occurrence of CV complications, and factors with P < 0.05 from the univariate analysis were included in the multifactorial logistic regression analysis using the forward method. A two-tailed P < 0.05 was considered statistically significant.

RESULTS

Comparison of baseline data between the study group and control group

Control group: 26 males and 14 females; Age 27-75 years old; Mean 69.18 ± 5.32 years old; Types of surgery: Rectal surgery in 10 cases, colon surgery in 12 cases, stomach surgery in 16 cases. Observation group: 24 males and 14 females; Mean 67.35 ± 4.76 years old; Types of surgery: Rectal surgery 11 cases, colon surgery 12 cases, stomach surgery 17 cases. After statistical analysis, there was no significant difference in baseline data between the two groups (P > 0.05), which was comparable.

Incidence of CV complications

After the nursing intervention, the incidence of overall CV complications in 78 patients was 24.3% (19/78). Among them, CV complications occurred in 30.0% of patients in the control group (12/40) and 18.4% of patients in the study group (7/38). The overall incidence of CV complications in the control group was significantly higher than that in the observation group (P = 0.035). As shown in Figure 1A.

Figure 1 Comparison of cardiovascular disease complication rate, Visual Analog Scale scores time and nursing satisfaction between the two groups. A: Cardiovascular disease complication rate; B: Visual Analog Scale scores time; C: Nursing satisfaction.

Of the 19 patients who developed CV complications, there were 10 cases of severe arrhythmia (52.63%), 3 cases of angina pectoris (15.79%), 2 cases of heart failure (10.53%), 1 case of revascularization (5.26%), 1 case of stent stenosis (5.26%), 1 case of myocardial infarction (5.26%) and 1 case of cardiac death (5.26%). As shown in Table 1.

Table 1 Classification of cardiovascular diseases in 19 patients, n = 19.

Cardiovascular diseases	n (%)
Severe arrhythmia	10 (52.63)
Angina pectoris	3 (15.79)
Heart failure	2 (10.53)
Revascularization	1 (5.26)
Stent stenosis	1 (5.26)
Myocardial infarction	1 (5.26)
Cardiac death	1 (5.26)

Comparison of VAS scores between the two groups

Before the nursing intervention, the pain score of gastrointestinal surgery patients in the observation group was 4.52 ± 1.26 points, and there was no statistically significant difference compared with the control group (4.55 ± 1.07) points (P = 0.909). Pain scores (1.38 ± 0.43) and (0.27 ± 0.15) on 7 days and 14 days after surgery were lower than those of the control group (2.46 ± 0.35) and (1.65 ± 0.37), with statistical significance (P < 0.001), as shown in Figure 1B.

Comparison of nursing satisfaction between two groups

The nursing satisfaction score of patients in the observation group was 92.10% (35/38), which was significantly higher than that of the control group [70.00% (28/40)], and the difference was statistically significant (P < 0.001), as shown in Figure 1C.

Single factor analysis of CV complications risk factors

After the nursing intervention, 19 patients with CV complications were in the CV complications group, and 59 patients without CV complications were in the non- CV complications group. Univariate analysis showed that there were significant differences in age, body mass index, hypertension, diabetes, smoking history, heart failure history, and previous history of myocardial infarction (all P < 0.05; Table 2).

Table 2 Clinical and pathological characteristics of patients from cardiovascular diseases and non-cardiovascular diseases group.

Variables	Cardiovascular diseases, n = 19	Non-cardiovascular diseases, n = 59	P value
Age (mean ± SD, years)	78.3 ± 4.2	57.5 ± 3.9	< 0.001
Sex (%)			0.215
Male	12 (63.2)	38 (64.4)
Female	7 (36.8)	21 (35.6)
BMI (mean ± SD, kg/m2)	24.5 ± 3.0	21.9 ± 3.2	0.045
ASA score [n (%)]			0.253
I-II	9 (47.3)	26 (44.1)
III-IV	10 (52.6)	33 (55.9)
History of smoking [n (%)]	9 (47.3)	12 (20.3)	< 0.001
History of diabetes mellitus [n (%)]	13 (68.4)	24 (40.6)	< 0.001
History of hypertension [n (%)]	15 (78.9)	25 (42.4)	< 0.001
History of heart failure [n (%)]	7 (36.8)	6 (2.3)	0.043
History of myocardial infarction [n (%)]	5 (26.3)	5 (8.4)	0.008

BMI: Body mass index; ASA: American Society of Anesthesiologists.

Bivariate logistic regression analysis of CV complications influencing factors

With CV complications as the dependent variable (0 = no, 1 = yes), according to the univariate analysis results in Table 2, variables with statistically significant differences (P < 0.05) were analyzed by Logistic regression for independent risk factors affecting CV complications.

The results showed that the Diabetes history is the risk of CV complications (OR = 1.942, 95%CI: 1.826-2.139). A history of heart failure is a risk factor for CV complications (OR = 1.195, 95%CI: 1.141-1.326), and a history of hypertension is also a risk factor for CV complications (OR = 1.836, 95%CI: 1.517-2.592). Age is a risk factor for CV complications (OR = 1.062; 95%CI: 1.035-1.089); History of myocardial infarction is also a risk factor for CV complications (OR = 1.528; 95%CI: 1.456-1.872). As shown in Table 3, P < 0.05.

Table 3 Risk factors considered in this analysis.

Variable	Reference	P value	OR	95%CI
History of myocardial infarction
Yes	No	< 0.001	1.528	1.456-1.872
History of heart failure
Yes	No	0.028	1.195	1.141-1.326
Age ≥ 60, years	< 60	< 0.001	1.062	1.035-1.089
History of hypertension
Yes	No	< 0.001	1.836	1.517-2.592
Diabetes history
Yes	No	0.017	1.942	1.825-2.136

DISCUSSION

With the continuous advancement of surgical techniques, the management of postoperative complications has become increasingly important. Enhanced recovery nursing, as an emerging nursing model, emphasizes multidisciplinary collaboration, early mobilization, and personalized pain management, aiming to shorten recovery times and reduce the incidence of complications[20]. This study aims to investigate the impact of enhanced recovery nursing interventions on the incidence of CV complications in ICU patients following gastrointestinal surgery and to analyze the associated risk factors. The results indicate that patients receiving enhanced recovery nursing had a significantly lower incidence of CV complications compared to those receiving conventional care, along with a notable increase in nursing satisfaction. This finding supports the effectiveness of enhanced recovery nursing in reducing postoperative complications and improving patient satisfaction.

In this study, the incidence of CV complications in the observation group was 18.4%, while in the control group, it was 30.0%, with a statistically significant difference (P = 0.035). This result aligns with existing literature, suggesting that enhanced recovery nursing may improve patient outcomes by optimizing postoperative management and reducing the incidence of complications[21,22]. Enhanced recovery nursing emphasizes multidisciplinary collaboration, early mobilization, and pain management, which may help improve CV function and lower the risk of postoperative CV complications[23]. Furthermore, the VAS scores for pain in the observation group were significantly lower than those in the control group at both 7- and 14 days post-surgery, further indicating the advantages of enhanced recovery nursing in pain management.

The nursing satisfaction in the observation group was 92.10%, significantly higher than the control group’s 70.00% (P < 0.001). This result suggests that enhanced recovery nursing can significantly improve overall patient satisfaction, likely due to more personalized care, timely pain management, and better communication provided to patients post-surgery. The increase in nursing satisfaction not only contributes to patients' psychological well-being but may also influence their postoperative recovery speed and quality of life[24].

Both univariate analysis and logistic regression analysis revealed that a history of diabetes, heart failure, hypertension, age, and previous myocardial infarction were independent risk factors for CV complications. This is consistent with existing research, highlighting the importance of these factors in postoperative CV risk assessment[25,26]. Notably, patients with diabetes and hypertension have a significantly increased risk of CV complications, indicating that closer monitoring and management of these high-risk patients is crucial in clinical practice. Additionally, advancing age was positively correlated with the risk of CV complications, suggesting that CV health management should be prioritized in elderly patients.

Based on the risk factors identified in this study, it is crucial to develop personalized interventions for high-risk patients. For example, specialized monitoring and management programs can be implemented for patients with diabetes and hypertension to ensure early identification and management of potential CV risks. Furthermore, hospitals should address potential implementation barriers, such as resource limitations and inadequate staff training, by taking effective intervention measures, such as introducing multidisciplinary teamwork and enhancing nursing training, thereby promoting the implementation of enhanced recovery nursing in clinical practice.

CONCLUSION

The results of this study indicate that enhanced recovery nursing can effectively reduce the incidence of CV complications in ICU patients following gastrointestinal surgery and improve nursing satisfaction. A history of diabetes, heart failure, hypertension, age, and previous myocardial infarction are significant risk factors for CV complications. Screening for risk factors should be prioritized before surgery to identify high-risk patients for targeted interventions, including intensive glycemic control (maintaining HbA1c < 7% for diabetics), optimization of blood pressure (targeting systolic < 140 mmHg), and adjustment of cardioprotective medications. Enhanced recovery care protocols should feature dynamic risk monitoring, like using wearable devices to track hemodynamic stability in older patients and implementing nurse-led delirium prevention bundles. Multidisciplinary teams must work together to address modifiable risks by encouraging early postoperative mobilization for hypertensive patients and structured fluid management for those with heart failure histories. By translating these evidence-based strategies into standardized clinical pathways, providers can proactively reduce CV risk and improve surgical outcomes in high-risk populations.