Ann Thorac Surg 2002;73:718-719
© 2002 The Society of Thoracic Surgeons
Invited commentary
Marc A.A.M. Schepens, MD, PhDa
a Department of Cardiothoracic Surgery, St. Antonius Hospital, Koekoekslaan 1 3435 CE Nieuwegein, The Netherlands
e-mail: m.schepens{at}antonius.net
Doctor Hoefer and colleagues have reported on a relatively small number of patients who underwent surgery for an acute type A aortic dissection from 1991 to 2001. It is in fact amazing that few have looked at the aspect of length of stay in intensive care related to this subject until now.
The surgical results are good. Age, cardiopulmonary bypass time and postoperative low cardiac output significantly influenced intensive care unit (ICU) stay. Age cannot be controlled; patients are referred to the hospital once diagnosis is established and should be operated upon immediately irrespective of their age. Selection bias can play an important role since some surgeons refuse to operate upon octogenarians with an uncomplicated type A dissection. Apparently this was not the case here since the oldest patient was 85. Postoperative low cardiac output is ill-defined and seemingly it is difficult to explain its impact on ICU stay.
This interesting article raises many additional questions. The exact point of time of and the conditions for leaving the ICU are completely lacking. Or to put it in another way: the question, when can a patient depart from the ICU after repair for type A dissection, is not answered. If you accept patients on the ward with low dose of inotropic agents, according to Hoefer these patients still have low cardiac output. This would mean that their ICU stay is shortened but the pressure on the nurses on the ward is increased. If you accept patients with good blood gases within 24 hours of extubation on a ward where unqualified nurses are supervising patients, the ICU period will be reduced but probably the total length of hospital stay will be longer. If physician income is directly proportional to the number of days that a patient resides in the ICU, we can expect the worst. The length of stay in the ICU will be substantially decreased if there is great pressure on the cardiothoracic surgical program due to waiting lists and "routine" cardiac surgery that must go on. Furthermore, if patients are transferred barely 24 hours after extubation back to the referring center after this kind of surgery, it is obvious that patients are at high risk and surgeons and anesthesiologists dice with death. Therefore I argue strongly in favor of keeping patients in the ICU after repair for acute type A dissection not too long but certainly not too short. Actually in some countries like The Netherlands, this balance often disappears simply due to restricted intensive care facilities (shortage of beds and nurses). Cardiothoracic surgeons should control and be involved in the decision to discharge patients from the ICU and it is wrong to accept decisions because of the pressures of an exhaustive routine operative program. I regret that some of these important concerns seem to be completely forgotten in this article.
Related Article
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Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A
- Daniel Hoefer, Elfriede Ruttmann, Markus Riha, Wolfgang Schobersberger, Andreas Mayr, Guenther Laufer, and Johannes Bonatti
Ann. Thorac. Surg. 2002 73: 714-718.
[Abstract]
[Full Text]
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