Published online Jun 5, 2020. doi: 10.5492/wjccm.v9.i2.20
Peer-review started: December 26, 2019
First decision: April 9, 2020
Revised: May 8, 2020
Accepted: May 14, 2020
Article in press: May 14, 2020
Published online: June 5, 2020
Perioperative hypotension is one of the most common complications after cardiac surgery and this may adversely affect clinical outcomes. However, data is limited in the literature regarding the actual prevalence of hypotension that develops shortly after the transfer of patients to the intensive care unit (ICU) after cardiac surgery. Hypotensive patients usually require administration of vasopressor boluses prior to or during the transfer from the operating room (OR) to the ICU as a temporizing measure. The hypotension and necessity for use of vasopressors have been previously associated with increased hospital length of stay as well as mortality, relative to the patients who maintained hemodynamic stability.
Given the proposed discrepancy between the clinical occurrence and limited data on rate of hypotension starting shortly after the anesthesia to ICU transfer, we aimed to evaluate its prevalence and also how this may relate to the pertinent clinical outcomes.
We hypothesized that the occurrence of initial hypotension in the ICU is more frequent complication among post-cardiac surgery ICU patients than previously reported and that patients who experience this complication would have adverse clinical outcomes. We also aimed to better assess the association between the occurrence of initial hypotension in the ICU and the use of vasopressor bolus administered immediately prior to or during the transfer from the OR to the ICU.
We conducted a retrospective study of adult patients undergoing cardiac surgery in a 2-year period. The primary independent variable was the development of hypotension within the first 30 min upon transfer from the OR (“ICU hypotension”). We abstracted demographic and baseline characteristics, comorbidities, and all pertinent clinical variables, as well as presence of hypotension in the OR (“OR hypotension”). A vasopressor bolus use was abstracted from the electronic chart documentation by the provider. All data were manually extracted from an electronic medical record. The anesthesia notes during the surgery were extracted partially from plotted diagrams and partially from nominal data.
We have demonstrated that hypotension in the initial 30 min upon ICU admission after adult cardiac surgery occurs more frequently than previously reported and this may be associated with adverse clinical outcomes. The results of our study have important implications for anesthesia and ICU practitioners. Given that the patients with ICU hypotension may experience worse clinical outcomes, it is necessary to address potentially modifiable factors. More than half of patients received boluses of short-acting vasopressors during the transfer from the OR to the ICU. Why this may be important? Frequently, ICU receiving team may not be aware of use of vasopressor boluses during the transfer and the development of hypotension soon after the anesthesia drop-off is not anticipated, which leads to delayed and reactive treatment strategy that may be suboptimal. This is currently subject of qualitative improvement and patient safety initiatives spanning both anesthesiology and ICU providers at our institution, as the current process of care needs to be improved. The main study limitation lies in its retrospective design. We relied on abstraction of data from the electronic medical records. The study was done at the single academic medical center and since we excluded the patients who underwent transplantation surgery, these factors limit the generalizability of our findings to the certain extent. Nevertheless, despite the above limitations, the high proportion of patients who were hypotensive immediately upon transfer from the OR to the ICU dictates the need for novel strategies and protocol implementations to assure the safest transition of care between the anesthesiology and ICU teams, which in turn may improve overall patient outcomes.
We have demonstrated that the occurrence of hypotension in the initial 30 min upon OR to ICU transfer is frequent and substantially more so than previously reported. Our findings have important implications for the anesthesia and ICU care teams as the occurrence of hypotension have been associated with adverse clinical outcomes. Administration of any medications during the actual transfer of the patient from the OR to the ICU should be readily communicated to the receiving ICU team.
It is suggested that there is a room for improvement in the OR to ICU hand off process and renewed strategies that assure smooth transition of care and patient’s safety are needed.