Prog. Surg., vol. 15, pp. 37-48 (Karger, Basel 1977)
Five Years of Experience with an Intensive Care Unit Specializing in Abdominal Surgery D. FRAico and H. Βιsµurκ Centre de Réanimation de Chirurgie Digestive, Hôpital Paul Brousse, Villejuif
Contents Introduction Organization of the ICU of Digestive Surgery ICU Facilities ICU Personnel Planning of the Work in the ICU Analysis of the 5-Year Activity of the ICU Admissions for Postoperative Care Admissions for Abdominal Emergencies Admissions for Postoperative Complications Discussion Summary References
37 38 38 38 39 40 40 41 42 44 47 48
The management of critically ill or injured patients has become one of the major aspects of medicine. Advances in the knowledge of pathophysiology and in technology have enabled the development of many new lifesaving procedures. Over the past-decade intensive care medicine has been widely spread through centers for the treatment of severely ill patients. Although attempts to provide guidelines for the development and organization of these centers have been numerous, many important points remain unsettled such as who should direct these units and how specialized should they be.
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Introduction
Fτυικεο/ΒτsMnτrκ
38
In 1970, a surgical intensive care unit (ICU) was opened at the Hospital Paul Brousse as an extension of a surgical service devoted to the surgery of the liver, biliary tract and gastrointestinal tract. The creation of this ICU responded to a twofold necessity: (1) surveillance of postoperative patients following major operations, and (2) management of acute abdominal emergencies particularly in poor-risk patients. This report concerns the organization of the surgical unit. From our experience the value of the creation of specialized surgical units is discussed.
Organization of the ICU of Digestive Surgery The ICU is located in a 350-bed general hospital on the outskirts of Paris. The hospital is composed of four medical services and one surgical service, itself divided into a ward of general surgery and a 40-bed ward of surgery specialized in liver, biliary and gastrointestinal tract. The ICU is part of the latter service. Included in this hospital is also a hemodialysis center, part of the service of nephrology.
ΙCU Personnel Medical team consists of a surgeon and a medical resident both full-time and both trained in intensive care of critically ill patients, and four interns. Night coverage is under the care of residents trained in critical care medicine and three interns. At any time, 1 of the 4 surgeons specialized in liver and digestive surgery and one anesthetist are available
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ICU Facilities The surgical ICU consists of ten beds. The unit is adjacent to the operating theater. It is divided into five rooms of two beds. Facilities of each room include multiple oxygen and compressed air outlets and vacuum inlets, a set of continuous cardiac monitors with an alarm system and an artificial respirator. A mobile trolley is used to carry material for the emergency insertion of airways and chest tubes, central venous catheters and for external defibrillation and cardiopulmonary resuscitation drugs. Each room is also equipped to perform renal dialysis. There is no laboratory within the unit, but any kind of blood determinations, including blood gas analyses, and blood volume measurements can be done in the laboratory of the hospital on a 24-hour/day basis.
Intensive Care Unit Specializing in Abdominal Surgery
39
Planning of the Work in the ICU Since the patients's primary disease is concerned with abdominal surgery, it has been our policy that coordination of the work of the unit is done by the surgeon. Admission to the unit can be decided bγ any permanent member of the staff. Upon his admission, the patient is necessarily examined bγ a surgeon, the medical resident and an anesthetist in order to have immediately an initial complete examination and to define in common the priorities in diagnostic investigations and therapeutics. Clinical rounds gathering the surgeon, physician, interns and nurses take place three times a day in the morning, early afternoon and late evening. General decisions on the care of the patients are made during these rounds. Between the rounds the work is supervised by the physician and the interns. A great emphasis has been given to frequent critical analysis of the cases. To this end, two weekly sessions are organized, during which every case is presented and discussed by all members of the service. When needed, consultant advice is sought and literature pertinent to the specific subject is analyzed and exposed at these meetings. From our previous experience in the surgical service, it appeared that program-oriented approaches were of great benefit in making progress in the understanding of the patients' diseases and in the introduction of new treatments. Therefore, several prospective studies have been designed, each of them under the surveillance of one member of the staff. These studies concern the management of patients with upper gastrointestinal bleeding, the treatment of patients with hepatic failure and the nutritional needs of surgical patients with severe malnutrition. In order to facilitate the analysis of the treatments dispensed to the patients and their results, the records of each patient leaving the unit are immediately indexed according to multiple headings. Thus, the statistical figures of the unit can be easily brought up to date at frequent intervals.
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in case of any emergency necessitating surgical treatment. Consultants experienced in specific problems of critically ill patients are available within this establishment or in a nearby hospital. Nonmedical personnel include 8 nurses and 8 nurses aides under the direction of a head nurse trained in both digestive surgery and intensive care work. In addition, there is one physiotherapist and one nutritionist. The mean nurse:patient ratio is 1:2.5.
Fππκcο/ΒτsΝτυrτ-τ
40
Table L Causes of admission to the surgical ICU for the last 5 years (1971-1975) in 1,016 patients Causes of admission
Number of patients
Abdominal emergencies
664
65.4
Postoperative complications
179
17.6
Postoperative surveillance following major operations or in poor-risk patients
173
17.0
Total
1,016
100
Analysis of the 5-Year Activity of the ICU
Admissions for Postoperative Care Postoperative care was the cause of admission in 173 cases. In 95 of the admission was due to a previous respiratory, renal or cardiac failure or to malnutrition or severe metabolic disorder. In 27 patients referal to the unit was related to intraoperative complications such as cardiac arrhythmia, myocardial infarction or bleeding disorders. 51 patients were
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During the last 5 years, 1,016 patients were admitted to the ICU. The number of admissions per year has steadily increased throughout this period, the overall increase between the first and the last year being 43%. During the same time, bed occupancy rose from 80.6 to 92%. Only 34.5% of the patients came from the local surgical service (17%) or the other services of the hospital (17.5 %). Most of the patients were referred to the unit from other hospitals because of a specific need of intensive therapy and abdominal surgery. Patients were sent to the unit mainly from hospitals of Paris and its outskirts (47.2%), but also from other large French cities (15.6%) or even foreign countries (2.7%). Patients were admitted for one of the three following conditions: (1) postoperative care after major abdominal surgery especially in poorrisk cases; (2) surgical emergencies involving the liver, bile ducts, pancreas or digestive tract, and (3) complications following abdominal surgery. Causes of admission are detailed in table I.
Intensive Care Unit Specializing in Abdominal Surgery
41
Table ΙΙ. Type of surgical emergencies in 664 patients admitted to the surgical ICU for the last 5 years (1971-1975) Type of emergency
Number of patients
Gastrointestinal hemorrhage Abdominal complications in cirrhotic patients Acute pancreatitis Cholangitis with renal failure Liver traumas and abscesses Intestinal infarction Miscellaneous
414 70
62.3 10.5
28 27 13 21 91
4.2 4.1 2.0 3.2 13.7
Total
664
62.3
100
Admissions for Abdominal Emergencies 664 patients were admitted to the unit because of a severe abdominal emergency. These cases are detailed in table II. The development of the unit has been helpful in the management of these patients and has allowed application of recent advances described in this specialized field. The permanent availability of a surgeon specializing in abdominal surgery, an anesthetist and an internist and of laboratory and X-ray facilities serve to
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admitted to the unit because the serious nature of the operation necessitated careful monitoring as patients with esophagectomy or needed a specific specialized surveillance such as liver resection particularly in cirrhotic patients or portal diversion particularly in children. The percentage of patients admitted for postoperative care slowly decreased through the period of the study from 26.5 to 9.3%. This was due to a decrease in the number of patients admitted to the unit for major operations. Postoperative care of these patients has been improved in such a way that they can now be managed in surgical wards. Mortality, in this postoperative group of patients was 19.1% and remained about the same during the 5-year period. Great age, malnutrition from advanced carcinomas of the gastrointestinal tract and abdominal or general complications in patients with chronic respiratory insufficiency were the main factors of death. This has led us to increase the indication of postoperative respiratory support and pre- and postoperative hyperalimentation by parenteral nutrition.
FRAico/BISMUTH
42
Admissions for Postoperative Complications 179 patients were referred to the unit because of postoperative complications following abdominal surgery. There were 112 external gastrointestinal fistulas, 20 cases of peritonitis, 14 localized peritoneal abscesses and 33 metabolic complications. Early experience with these patients disclosed that the two main factors of mortality were the persistence of peritoneal sepsis and malnutrition. A specific effort was then directed towards these two complications. Prevention of sepsis was attempted by better abdominal drainage when necessary. The diagnosis of peritoneal abscesses was improved by multiple abdominal taps guided by conventional X-rays of the abdomen and by scintiscans. The recent discovery of specific detection of abscesses by 67Ga scintiscans has increased the rate of diagnosis of
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quickly perform the diagnostic investigations to correct the organic failure and metabolic disorders actually present. Special interest was brought to the management of gastrointestinal hemorrhage, particularly in cirrhotic patients and patients in stress situations. The practice of early endoscopy, within 6 h of admission has lowered the rate of hemorrhage of unknown origin to less than 5% of the cases in the last year. Improvement in the techniques of blood replacement using fresh whole blood of fresh frozen plasma, packed red cell and blood fractions, and the use of special filters and blood warmers has lowered the risk inherent to massive transfusion. In addition, new procedures of hemostasis have been investigated including arterial selective or venous peripheral infusion of vasopressin and arterial and coronary venous embolizatíon. Those nonoperative techniques have proven to be valuable in the control of bleeding in patients with stress ulcers and in variced bleeders with severe hepatic failure in whom the operative risk is high. Increase in early diagnosis and introduction of new, nonoperative methods of hemostasis, as well as nonspecific care of these patients has to decreased the mortality from massive GI bleeding from 34.1% at the beginning of our experience to 26.6% at the present time. Among the 250 other emergency cases, most were referred for severe cholangitis, pancreatitis or for the occurrence of abdominal complications in cirrhotic or previously critically ill patients. The number of patients admitted for abdominal emergencies has greatly increased since the opening of the unit from 84 (49.4% of the total admissions) the first year to 188 (75.5% of the total number of admissions) the last year. The overall mortality rate in this group of patients was 30.8% and slowly decreased throughout the period of the study.
Intensive Care Unit Specializing in Abdominal Surgery Number of patients per year 237 216 149 174
1971
1972
1973
1974
43
250
1975
localized peritoneal sepsis. An important step in the treatment of these patients has also been brought by new techniques of nutrition. Enteral nutrition via NG tube with a continuous infusion pump allowed a daily supply of 3,000-4,000 cal in patients with normal bowel function. When enteral nutrition was not possible in face of high gastrointestinal fistula or intestinal lleus, hyperalimentation was provided via the parenteral route. In a few severely malnourished patients, combined enteral and parenteral nutrition provided a daily intake of 7,000-9,000 cal. Actual surgical cure of fistulas could then be delayed until the patient was in good nutritional status. Impτovement in the techniques of nutrition has been a major factor in reversing the prognosis of gastrointestinal fistulas. The advent of hypemutrítion was directly related to a decreased mortality in this group in the last 2 years, from 62% before to 36% at the present time. Besides the specific advances in the treatment of surgical patients with abdominal conditions, special attention was paid to the treatment of various organic failures. 313 patients had respiratory insufficiency on admission and 70% of them were treated by mechanical respiratory support. Acute renal failure complicated the course of 229 patients and required peritoneal dialysis in 14% of them and hemodialysis in another 21%. Cardiac failure or cardiac arrhythmia was a predominant feature
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Fig. 1. Yearly mortality in 1,016 patients admitted to the surgical ICU during the last 5 years. The overall mortality for the 5-year period was 30.2%.
FπΑκεο/ΒτsΝτυτκ
44
in 178 patients and cardiac monitoring was utilized for various periods of time in about 80% of the patients. 307 patients died during their hospitalization in the unit, an overall mortality rate of 30.2%. These figures steadily improved during the 5year period of the study from 35.3% the first year to 26.9% the last year (fig. 1).
The complexity of care and the expense of the material needed for adequate treatment of critically ill patients has led to the development of centers specializing in the care of the severely ill. These ICUs offer to the patients everything that is necessary to deal with any organic failure, all around the clock. This necessitates to gather in one area the physicians and nurses trained in resuscitation techniques and the equipment needed for monitoring of vital signs and treatment of life-threatening organic failures, such as respiratory or renal insufficiencies, cardiac failure or cardiac arrhythmia and shock. The general guidelines for the organization of such units have been well defined elsewhere. For the last 10 years many ICU have been created in European and North American countries. This has often led to the dispersion into multiple critical care centers even within a single hospital of the experienced medical and nonmedical personnel and equipment. For this reason, the recent general tendency, as expressed by SAFAR and GRENVICK [5] and WEIL and SHUBIN [9] has been to gather in a single center within each hospital all the critically ill patients, whatever their primary disease was. This seemed to be further justified by the fact that, in any case, most of these patients presented with the same symptoms and required the same care whether they first had renal or lung disease, or medical or surgical complications. For SAFAR and GRENVICK [6], the creation of small ICUs specializing in the treatment of a single organ failure such as respiratory unit or in surgical patients was questionable. This attitude would favor the development of multidisciplinary critical care centers regrouping, under the direction of anesthetists, all the patients of one or several hospitals necessitating intensive care. We would stress that such an organization would tend to overemphasize the importance of resuscitation at the expense of the patients primary disease. WEIL and S~umν [8] have already underlined this risk. With this
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Discussion
45
in mind we created, 5 years ago, an ICU specializing in the treatment of critically ill patients with abdominal conditions. The results obtained have been promising. Many advances have been done in the management of these patients ending to an improvement in their prognosis and a decrease of mortality. As a consequence, the referral of patients from other hospitals and especially from other multidisciplinary ICUs has been constantly increasing. The need of intensive care for patients with abdominal surgical diseases is obvious. Most of the large general ICUs are overloaded with patients presenting with abdominal conditions. There is no doubt that the occurrence of complications following abdominal surgery is fraught with a high risk of multiorganic failures such as septic shock, pulmonary insufficiency and renal failure. Furthermore, it appears that many patients with abdominal surgical emergencies may benefit from intensive care either because those emergencies are severe or because they arise in poorrisk patients. The advantages provided by ICU have been recently underlined by HELLERS and IØ [3] in the treatment of gastrointestinal hemorrhage and by PROSS [4] in the treatment of pancreatítis. In our surgical ICU, we have extended the indication of admission to the unit to patients with cholangitis and pancreatítis, and cirrhotic patients with abdominal sepsis. The management of critically ill surgical patients is marked off by several peculiarities: (1) Most of the patients are either postoperative or are liable to undergo emergency surgery. In that regard there must be a strong relationship between the operating room and the ICU and the unit should necessarily be set up near the operating theater. Resuscitation should be pursued from one place to the other by the same team. For example, it has been a common rule to perform the initial steps of diagnosis and treatment in patients with fulminant gastrointestinal bleeding in the operating room rather than in the unit in order to be able to operate on them promptly, should it become necessary. (2) Equal attention must be paid to nonspecific techniques of multiorganic support and to the specific surgical care. In patients with postoperative surveillance or postoperative complications, the supervision of abdominal or chest drainage, gastric aspiration, or the care of the incision have the same importance as endotracheal suction or fluid imbalance. Therefore, the personnel of the ICU must be trained in both surgical and medical intensive care.
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Inteπsive Care Unit Specializing in Abdominal Surgery
46
The severity of disease in critically ill surgical patients is seldom related to a single pure medical complication. When isolated, and acute respiratory failure in a patient with chronic pulmonary insufficiency or postoperative cardiac arrhythmia in a patient with previous coronary disease may be treated in a pure respiratory or coronary care center. In fact, most of the life-threatening complications arising in surgical patients have a medical and surgical component. Pulmonary edema and/or renal failure occurring in patients following intestinal surgery are often an indication of anastomosis breakdown or peritoneal sepsis. The advent of such complications in patients with acute pancreatitis often means that necrosis of the pancreas is extending or has become infected. Surgical correction of these complications will thus be a major factor in the treatment of respiratory, renal or other organic failures. On the other hand, the treatment of bleeding stress ulcerations may in some cases require the correction of metabolic, respiratory or hemodynamic disorders rather than surgical hemostasis. The surgical primary disease thus constitutes an important feature in determining the evolution of the patients, and a great part of the therapeutic effort should be directed towards the surgical lesion. Α typical example of the close relationship between surgery and nonsurgical organic support is given by the treatment of cholangitis with acute renal failure as recently defined by Βisµurκ et al. [1]. Since surgical problems are essential in coping with those patients, the surgeon should be the coordinator of the work in the unit. Thus, the necessity of a spatial relationship between the operating room and the unit, and the need for medical personnel used to surgical patients, are strong arguments in favor of ICU specializing in surgery and directed by surgeons. Should every surgical unit have its own intensive care department? On a theoretical basis, this would be the best attitude and it has been recently advocated in France. However, it does not seem possible to add to every surgical unit an intensive care center many surgeons are not trained to this kind of work. To our point of view, two requisites are absolutely needed to create a surgical ICU. Firstly, it should be ascribed to surgical units specializing into one field of surgery. Surgery in critically ill patients offers multiple traps. Α diagnostic procedure or a therapeutic act that would be easily sustained in a normal patient may have a deleterious effect on a severely ill one. Thus, the choice of investigations and treatments requires an extensive surgical knowledge which could hardly be obtained without specialization. In addition, operations in these patients
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Fκaxco/Βτsιrτυrκ
Intensive Care Unit Specializing in Abdominal Surgery
47
are fraught with a high risk of operative and postoperative complications. Technical difficulties may arise in the face of multiple reoperations and of bleeding disorders often present in critically ill patients. Respiratory and renal failures are known to increase the risk of anastomosis breakdown. The least complication even at the level of the wound may lead to surgical catastrophies and to the death of the patient. The creation of specialized ICUs has been recently advocated by DENBESTEN [2] in the field of gastroenterology. Secondly, surgeons working in a surgical ICU should be familiarized with metabolic, renal, respiratory and other complications and trained with the techniques of artificial organic temporary support and of resuscitation. Such an experience can be gained only by a prolonged training in other intensive care centers. In conclusion, the creation of a surgical ICU specializing in one field of surgery has many advantages. It allows to give to the patients the newest treatments in that field. In such intensive care units are gathered the surgical and medical facilities which both are needed often at the same time by those patients, thus limiting movements of critically ill patients throughout a single hospital or from one hospital to another. Although from an economical standpoint, the development of general multiorganic ICUs may be beneficial, small specialized ICUs particularly in surgery, seem to offer a more appropriate care to each individual patient.
Centers for the treatment of critically ill patients are nowadays spreading throughout hospitals. While the basic requirements in personnel and equipment have been extensively studied, many aspects of the organization of these units still are ill-defined. The development of pure surgical intensive care centers has been recently criticized. Our own experience with an intensive care unit specializing in digestive surgery has been rewarding. It allowed us to improve the management of poor-risk patients with major surgery, of patients presenting with severe abdominal emergencies, and of those with postoperative abdominal complications. Peculiarities tied to the care and treatment of surgical patients underline the necessity to create separate surgical intensive care units. These units should depend upon surgical services and should be under the direction of surgeons.
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Summary
FRAxCO/BISMUTx
48
References
2 3 4 5 6 7 8 9
Βιsµurη, Η.; KUIrzIGER, Η., and CORLETTE, M. Β.: Cholangitis with acute renal failure. Priorities in therapeutics. Ann. Surg. 181: 881-886 (1975). DENBESTEN, L.: The gastrointestinal intensive care unit. Surgery Gynec. Obstet. 142: 404Ø5 (1976). HELLERS, G. and 1HRE, T.: Impact of change to early diagnosis and surgery in major upper gastrointestinal bleeding. Lancet ii: 1250-1251 (1975). PROs, F.: Inteπsive care in acute pancreatitis. Arch. klin. Chir. 337: 251-254 (1974). SAFAR, P. and GRENVICK, A.: Multidisciplinary intensive care. Mod. Med. 5: 92-99 (1971). SAFAR, P. and GRENVICK, A.: Critical care medicine. Organizing and staffing intensive care units. Chest 59: 535-548 (1971). Sκιnµοrn, F. D.: A review of 460 patients admitted to the intensive-therapy unit of a general hospital between 1965 and 1969. Br. J. Surg. 60: 1-16 (1973). WEIL, M. Η. and Smirni, Η.: Centers for the critically ill. Mod. Med. 5: 86-91(1971). WEI., M. Η. and SηυυΒΙΝ, Η.: Centralized hospital care for the critically ill. Clin. Anesth. 10: 127-135 (1974).
D. FRANCO, MD, Centre de Réanimation de Chirurgie Digestive, Ηôpital Paul Brousse, 14, ay. Paul-Vaillant Couturier, F-94800 Villejuif (France)
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1
Five Years of Experience with an Intensive Care Unit Specializing in Abdominal Surgery D. FRAico and H. Βιsµurκ Centre de Réanimation de Chirurgie Digestive, Hôpital Paul Brousse, Villejuif
Contents Introduction Organization of the ICU of Digestive Surgery ICU Facilities ICU Personnel Planning of the Work in the ICU Analysis of the 5-Year Activity of the ICU Admissions for Postoperative Care Admissions for Abdominal Emergencies Admissions for Postoperative Complications Discussion Summary References
37 38 38 38 39 40 40 41 42 44 47 48
The management of critically ill or injured patients has become one of the major aspects of medicine. Advances in the knowledge of pathophysiology and in technology have enabled the development of many new lifesaving procedures. Over the past-decade intensive care medicine has been widely spread through centers for the treatment of severely ill patients. Although attempts to provide guidelines for the development and organization of these centers have been numerous, many important points remain unsettled such as who should direct these units and how specialized should they be.
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 2:12:42 AM
Introduction
Fτυικεο/ΒτsMnτrκ
38
In 1970, a surgical intensive care unit (ICU) was opened at the Hospital Paul Brousse as an extension of a surgical service devoted to the surgery of the liver, biliary tract and gastrointestinal tract. The creation of this ICU responded to a twofold necessity: (1) surveillance of postoperative patients following major operations, and (2) management of acute abdominal emergencies particularly in poor-risk patients. This report concerns the organization of the surgical unit. From our experience the value of the creation of specialized surgical units is discussed.
Organization of the ICU of Digestive Surgery The ICU is located in a 350-bed general hospital on the outskirts of Paris. The hospital is composed of four medical services and one surgical service, itself divided into a ward of general surgery and a 40-bed ward of surgery specialized in liver, biliary and gastrointestinal tract. The ICU is part of the latter service. Included in this hospital is also a hemodialysis center, part of the service of nephrology.
ΙCU Personnel Medical team consists of a surgeon and a medical resident both full-time and both trained in intensive care of critically ill patients, and four interns. Night coverage is under the care of residents trained in critical care medicine and three interns. At any time, 1 of the 4 surgeons specialized in liver and digestive surgery and one anesthetist are available
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 2:12:42 AM
ICU Facilities The surgical ICU consists of ten beds. The unit is adjacent to the operating theater. It is divided into five rooms of two beds. Facilities of each room include multiple oxygen and compressed air outlets and vacuum inlets, a set of continuous cardiac monitors with an alarm system and an artificial respirator. A mobile trolley is used to carry material for the emergency insertion of airways and chest tubes, central venous catheters and for external defibrillation and cardiopulmonary resuscitation drugs. Each room is also equipped to perform renal dialysis. There is no laboratory within the unit, but any kind of blood determinations, including blood gas analyses, and blood volume measurements can be done in the laboratory of the hospital on a 24-hour/day basis.
Intensive Care Unit Specializing in Abdominal Surgery
39
Planning of the Work in the ICU Since the patients's primary disease is concerned with abdominal surgery, it has been our policy that coordination of the work of the unit is done by the surgeon. Admission to the unit can be decided bγ any permanent member of the staff. Upon his admission, the patient is necessarily examined bγ a surgeon, the medical resident and an anesthetist in order to have immediately an initial complete examination and to define in common the priorities in diagnostic investigations and therapeutics. Clinical rounds gathering the surgeon, physician, interns and nurses take place three times a day in the morning, early afternoon and late evening. General decisions on the care of the patients are made during these rounds. Between the rounds the work is supervised by the physician and the interns. A great emphasis has been given to frequent critical analysis of the cases. To this end, two weekly sessions are organized, during which every case is presented and discussed by all members of the service. When needed, consultant advice is sought and literature pertinent to the specific subject is analyzed and exposed at these meetings. From our previous experience in the surgical service, it appeared that program-oriented approaches were of great benefit in making progress in the understanding of the patients' diseases and in the introduction of new treatments. Therefore, several prospective studies have been designed, each of them under the surveillance of one member of the staff. These studies concern the management of patients with upper gastrointestinal bleeding, the treatment of patients with hepatic failure and the nutritional needs of surgical patients with severe malnutrition. In order to facilitate the analysis of the treatments dispensed to the patients and their results, the records of each patient leaving the unit are immediately indexed according to multiple headings. Thus, the statistical figures of the unit can be easily brought up to date at frequent intervals.
Downloaded by: Université de Paris 193.51.85.197 - 1/12/2020 2:12:42 AM
in case of any emergency necessitating surgical treatment. Consultants experienced in specific problems of critically ill patients are available within this establishment or in a nearby hospital. Nonmedical personnel include 8 nurses and 8 nurses aides under the direction of a head nurse trained in both digestive surgery and intensive care work. In addition, there is one physiotherapist and one nutritionist. The mean nurse:patient ratio is 1:2.5.
Fππκcο/ΒτsΝτυrτ-τ
40
Table L Causes of admission to the surgical ICU for the last 5 years (1971-1975) in 1,016 patients Causes of admission
Number of patients
Abdominal emergencies
664
65.4
Postoperative complications
179
17.6
Postoperative surveillance following major operations or in poor-risk patients
173
17.0
Total
1,016
100
Analysis of the 5-Year Activity of the ICU
Admissions for Postoperative Care Postoperative care was the cause of admission in 173 cases. In 95 of the admission was due to a previous respiratory, renal or cardiac failure or to malnutrition or severe metabolic disorder. In 27 patients referal to the unit was related to intraoperative complications such as cardiac arrhythmia, myocardial infarction or bleeding disorders. 51 patients were
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During the last 5 years, 1,016 patients were admitted to the ICU. The number of admissions per year has steadily increased throughout this period, the overall increase between the first and the last year being 43%. During the same time, bed occupancy rose from 80.6 to 92%. Only 34.5% of the patients came from the local surgical service (17%) or the other services of the hospital (17.5 %). Most of the patients were referred to the unit from other hospitals because of a specific need of intensive therapy and abdominal surgery. Patients were sent to the unit mainly from hospitals of Paris and its outskirts (47.2%), but also from other large French cities (15.6%) or even foreign countries (2.7%). Patients were admitted for one of the three following conditions: (1) postoperative care after major abdominal surgery especially in poorrisk cases; (2) surgical emergencies involving the liver, bile ducts, pancreas or digestive tract, and (3) complications following abdominal surgery. Causes of admission are detailed in table I.
Intensive Care Unit Specializing in Abdominal Surgery
41
Table ΙΙ. Type of surgical emergencies in 664 patients admitted to the surgical ICU for the last 5 years (1971-1975) Type of emergency
Number of patients
Gastrointestinal hemorrhage Abdominal complications in cirrhotic patients Acute pancreatitis Cholangitis with renal failure Liver traumas and abscesses Intestinal infarction Miscellaneous
414 70
62.3 10.5
28 27 13 21 91
4.2 4.1 2.0 3.2 13.7
Total
664
62.3
100
Admissions for Abdominal Emergencies 664 patients were admitted to the unit because of a severe abdominal emergency. These cases are detailed in table II. The development of the unit has been helpful in the management of these patients and has allowed application of recent advances described in this specialized field. The permanent availability of a surgeon specializing in abdominal surgery, an anesthetist and an internist and of laboratory and X-ray facilities serve to
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admitted to the unit because the serious nature of the operation necessitated careful monitoring as patients with esophagectomy or needed a specific specialized surveillance such as liver resection particularly in cirrhotic patients or portal diversion particularly in children. The percentage of patients admitted for postoperative care slowly decreased through the period of the study from 26.5 to 9.3%. This was due to a decrease in the number of patients admitted to the unit for major operations. Postoperative care of these patients has been improved in such a way that they can now be managed in surgical wards. Mortality, in this postoperative group of patients was 19.1% and remained about the same during the 5-year period. Great age, malnutrition from advanced carcinomas of the gastrointestinal tract and abdominal or general complications in patients with chronic respiratory insufficiency were the main factors of death. This has led us to increase the indication of postoperative respiratory support and pre- and postoperative hyperalimentation by parenteral nutrition.
FRAico/BISMUTH
42
Admissions for Postoperative Complications 179 patients were referred to the unit because of postoperative complications following abdominal surgery. There were 112 external gastrointestinal fistulas, 20 cases of peritonitis, 14 localized peritoneal abscesses and 33 metabolic complications. Early experience with these patients disclosed that the two main factors of mortality were the persistence of peritoneal sepsis and malnutrition. A specific effort was then directed towards these two complications. Prevention of sepsis was attempted by better abdominal drainage when necessary. The diagnosis of peritoneal abscesses was improved by multiple abdominal taps guided by conventional X-rays of the abdomen and by scintiscans. The recent discovery of specific detection of abscesses by 67Ga scintiscans has increased the rate of diagnosis of
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quickly perform the diagnostic investigations to correct the organic failure and metabolic disorders actually present. Special interest was brought to the management of gastrointestinal hemorrhage, particularly in cirrhotic patients and patients in stress situations. The practice of early endoscopy, within 6 h of admission has lowered the rate of hemorrhage of unknown origin to less than 5% of the cases in the last year. Improvement in the techniques of blood replacement using fresh whole blood of fresh frozen plasma, packed red cell and blood fractions, and the use of special filters and blood warmers has lowered the risk inherent to massive transfusion. In addition, new procedures of hemostasis have been investigated including arterial selective or venous peripheral infusion of vasopressin and arterial and coronary venous embolizatíon. Those nonoperative techniques have proven to be valuable in the control of bleeding in patients with stress ulcers and in variced bleeders with severe hepatic failure in whom the operative risk is high. Increase in early diagnosis and introduction of new, nonoperative methods of hemostasis, as well as nonspecific care of these patients has to decreased the mortality from massive GI bleeding from 34.1% at the beginning of our experience to 26.6% at the present time. Among the 250 other emergency cases, most were referred for severe cholangitis, pancreatitis or for the occurrence of abdominal complications in cirrhotic or previously critically ill patients. The number of patients admitted for abdominal emergencies has greatly increased since the opening of the unit from 84 (49.4% of the total admissions) the first year to 188 (75.5% of the total number of admissions) the last year. The overall mortality rate in this group of patients was 30.8% and slowly decreased throughout the period of the study.
Intensive Care Unit Specializing in Abdominal Surgery Number of patients per year 237 216 149 174
1971
1972
1973
1974
43
250
1975
localized peritoneal sepsis. An important step in the treatment of these patients has also been brought by new techniques of nutrition. Enteral nutrition via NG tube with a continuous infusion pump allowed a daily supply of 3,000-4,000 cal in patients with normal bowel function. When enteral nutrition was not possible in face of high gastrointestinal fistula or intestinal lleus, hyperalimentation was provided via the parenteral route. In a few severely malnourished patients, combined enteral and parenteral nutrition provided a daily intake of 7,000-9,000 cal. Actual surgical cure of fistulas could then be delayed until the patient was in good nutritional status. Impτovement in the techniques of nutrition has been a major factor in reversing the prognosis of gastrointestinal fistulas. The advent of hypemutrítion was directly related to a decreased mortality in this group in the last 2 years, from 62% before to 36% at the present time. Besides the specific advances in the treatment of surgical patients with abdominal conditions, special attention was paid to the treatment of various organic failures. 313 patients had respiratory insufficiency on admission and 70% of them were treated by mechanical respiratory support. Acute renal failure complicated the course of 229 patients and required peritoneal dialysis in 14% of them and hemodialysis in another 21%. Cardiac failure or cardiac arrhythmia was a predominant feature
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Fig. 1. Yearly mortality in 1,016 patients admitted to the surgical ICU during the last 5 years. The overall mortality for the 5-year period was 30.2%.
FπΑκεο/ΒτsΝτυτκ
44
in 178 patients and cardiac monitoring was utilized for various periods of time in about 80% of the patients. 307 patients died during their hospitalization in the unit, an overall mortality rate of 30.2%. These figures steadily improved during the 5year period of the study from 35.3% the first year to 26.9% the last year (fig. 1).
The complexity of care and the expense of the material needed for adequate treatment of critically ill patients has led to the development of centers specializing in the care of the severely ill. These ICUs offer to the patients everything that is necessary to deal with any organic failure, all around the clock. This necessitates to gather in one area the physicians and nurses trained in resuscitation techniques and the equipment needed for monitoring of vital signs and treatment of life-threatening organic failures, such as respiratory or renal insufficiencies, cardiac failure or cardiac arrhythmia and shock. The general guidelines for the organization of such units have been well defined elsewhere. For the last 10 years many ICU have been created in European and North American countries. This has often led to the dispersion into multiple critical care centers even within a single hospital of the experienced medical and nonmedical personnel and equipment. For this reason, the recent general tendency, as expressed by SAFAR and GRENVICK [5] and WEIL and SHUBIN [9] has been to gather in a single center within each hospital all the critically ill patients, whatever their primary disease was. This seemed to be further justified by the fact that, in any case, most of these patients presented with the same symptoms and required the same care whether they first had renal or lung disease, or medical or surgical complications. For SAFAR and GRENVICK [6], the creation of small ICUs specializing in the treatment of a single organ failure such as respiratory unit or in surgical patients was questionable. This attitude would favor the development of multidisciplinary critical care centers regrouping, under the direction of anesthetists, all the patients of one or several hospitals necessitating intensive care. We would stress that such an organization would tend to overemphasize the importance of resuscitation at the expense of the patients primary disease. WEIL and S~umν [8] have already underlined this risk. With this
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Discussion
45
in mind we created, 5 years ago, an ICU specializing in the treatment of critically ill patients with abdominal conditions. The results obtained have been promising. Many advances have been done in the management of these patients ending to an improvement in their prognosis and a decrease of mortality. As a consequence, the referral of patients from other hospitals and especially from other multidisciplinary ICUs has been constantly increasing. The need of intensive care for patients with abdominal surgical diseases is obvious. Most of the large general ICUs are overloaded with patients presenting with abdominal conditions. There is no doubt that the occurrence of complications following abdominal surgery is fraught with a high risk of multiorganic failures such as septic shock, pulmonary insufficiency and renal failure. Furthermore, it appears that many patients with abdominal surgical emergencies may benefit from intensive care either because those emergencies are severe or because they arise in poorrisk patients. The advantages provided by ICU have been recently underlined by HELLERS and IØ [3] in the treatment of gastrointestinal hemorrhage and by PROSS [4] in the treatment of pancreatítis. In our surgical ICU, we have extended the indication of admission to the unit to patients with cholangitis and pancreatítis, and cirrhotic patients with abdominal sepsis. The management of critically ill surgical patients is marked off by several peculiarities: (1) Most of the patients are either postoperative or are liable to undergo emergency surgery. In that regard there must be a strong relationship between the operating room and the ICU and the unit should necessarily be set up near the operating theater. Resuscitation should be pursued from one place to the other by the same team. For example, it has been a common rule to perform the initial steps of diagnosis and treatment in patients with fulminant gastrointestinal bleeding in the operating room rather than in the unit in order to be able to operate on them promptly, should it become necessary. (2) Equal attention must be paid to nonspecific techniques of multiorganic support and to the specific surgical care. In patients with postoperative surveillance or postoperative complications, the supervision of abdominal or chest drainage, gastric aspiration, or the care of the incision have the same importance as endotracheal suction or fluid imbalance. Therefore, the personnel of the ICU must be trained in both surgical and medical intensive care.
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Inteπsive Care Unit Specializing in Abdominal Surgery
46
The severity of disease in critically ill surgical patients is seldom related to a single pure medical complication. When isolated, and acute respiratory failure in a patient with chronic pulmonary insufficiency or postoperative cardiac arrhythmia in a patient with previous coronary disease may be treated in a pure respiratory or coronary care center. In fact, most of the life-threatening complications arising in surgical patients have a medical and surgical component. Pulmonary edema and/or renal failure occurring in patients following intestinal surgery are often an indication of anastomosis breakdown or peritoneal sepsis. The advent of such complications in patients with acute pancreatitis often means that necrosis of the pancreas is extending or has become infected. Surgical correction of these complications will thus be a major factor in the treatment of respiratory, renal or other organic failures. On the other hand, the treatment of bleeding stress ulcerations may in some cases require the correction of metabolic, respiratory or hemodynamic disorders rather than surgical hemostasis. The surgical primary disease thus constitutes an important feature in determining the evolution of the patients, and a great part of the therapeutic effort should be directed towards the surgical lesion. Α typical example of the close relationship between surgery and nonsurgical organic support is given by the treatment of cholangitis with acute renal failure as recently defined by Βisµurκ et al. [1]. Since surgical problems are essential in coping with those patients, the surgeon should be the coordinator of the work in the unit. Thus, the necessity of a spatial relationship between the operating room and the unit, and the need for medical personnel used to surgical patients, are strong arguments in favor of ICU specializing in surgery and directed by surgeons. Should every surgical unit have its own intensive care department? On a theoretical basis, this would be the best attitude and it has been recently advocated in France. However, it does not seem possible to add to every surgical unit an intensive care center many surgeons are not trained to this kind of work. To our point of view, two requisites are absolutely needed to create a surgical ICU. Firstly, it should be ascribed to surgical units specializing into one field of surgery. Surgery in critically ill patients offers multiple traps. Α diagnostic procedure or a therapeutic act that would be easily sustained in a normal patient may have a deleterious effect on a severely ill one. Thus, the choice of investigations and treatments requires an extensive surgical knowledge which could hardly be obtained without specialization. In addition, operations in these patients
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Fκaxco/Βτsιrτυrκ
Intensive Care Unit Specializing in Abdominal Surgery
47
are fraught with a high risk of operative and postoperative complications. Technical difficulties may arise in the face of multiple reoperations and of bleeding disorders often present in critically ill patients. Respiratory and renal failures are known to increase the risk of anastomosis breakdown. The least complication even at the level of the wound may lead to surgical catastrophies and to the death of the patient. The creation of specialized ICUs has been recently advocated by DENBESTEN [2] in the field of gastroenterology. Secondly, surgeons working in a surgical ICU should be familiarized with metabolic, renal, respiratory and other complications and trained with the techniques of artificial organic temporary support and of resuscitation. Such an experience can be gained only by a prolonged training in other intensive care centers. In conclusion, the creation of a surgical ICU specializing in one field of surgery has many advantages. It allows to give to the patients the newest treatments in that field. In such intensive care units are gathered the surgical and medical facilities which both are needed often at the same time by those patients, thus limiting movements of critically ill patients throughout a single hospital or from one hospital to another. Although from an economical standpoint, the development of general multiorganic ICUs may be beneficial, small specialized ICUs particularly in surgery, seem to offer a more appropriate care to each individual patient.
Centers for the treatment of critically ill patients are nowadays spreading throughout hospitals. While the basic requirements in personnel and equipment have been extensively studied, many aspects of the organization of these units still are ill-defined. The development of pure surgical intensive care centers has been recently criticized. Our own experience with an intensive care unit specializing in digestive surgery has been rewarding. It allowed us to improve the management of poor-risk patients with major surgery, of patients presenting with severe abdominal emergencies, and of those with postoperative abdominal complications. Peculiarities tied to the care and treatment of surgical patients underline the necessity to create separate surgical intensive care units. These units should depend upon surgical services and should be under the direction of surgeons.
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Summary
FRAxCO/BISMUTx
48
References
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Βιsµurη, Η.; KUIrzIGER, Η., and CORLETTE, M. Β.: Cholangitis with acute renal failure. Priorities in therapeutics. Ann. Surg. 181: 881-886 (1975). DENBESTEN, L.: The gastrointestinal intensive care unit. Surgery Gynec. Obstet. 142: 404Ø5 (1976). HELLERS, G. and 1HRE, T.: Impact of change to early diagnosis and surgery in major upper gastrointestinal bleeding. Lancet ii: 1250-1251 (1975). PROs, F.: Inteπsive care in acute pancreatitis. Arch. klin. Chir. 337: 251-254 (1974). SAFAR, P. and GRENVICK, A.: Multidisciplinary intensive care. Mod. Med. 5: 92-99 (1971). SAFAR, P. and GRENVICK, A.: Critical care medicine. Organizing and staffing intensive care units. Chest 59: 535-548 (1971). Sκιnµοrn, F. D.: A review of 460 patients admitted to the intensive-therapy unit of a general hospital between 1965 and 1969. Br. J. Surg. 60: 1-16 (1973). WEIL, M. Η. and Smirni, Η.: Centers for the critically ill. Mod. Med. 5: 86-91(1971). WEI., M. Η. and SηυυΒΙΝ, Η.: Centralized hospital care for the critically ill. Clin. Anesth. 10: 127-135 (1974).
D. FRANCO, MD, Centre de Réanimation de Chirurgie Digestive, Ηôpital Paul Brousse, 14, ay. Paul-Vaillant Couturier, F-94800 Villejuif (France)
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