Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : UC05 - UC08 Full Version

Incidence of Postoperative Intensive Care Admissions in Elective Surgical Patients with High-risk Anaesthesia Consent Preoperatively


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48558.15164
Ramyavel Thangavelu, Sagiev Koshy George

1. Associate Professor, Department of Anaesthesia, Pondicherry Institute of Medical Sciences, Puducherry, India. 2. Professor and Head, Department of Anaesthesia, Pondicherry Institute of Medical Sciences, Puducherry, India.

Correspondence Address :
Dr. Ramyavel Thangavelu,
Associate Professor, Department of Anaesthesia, Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet-605041, Puducherry, India.
E-mail: ramyavel1988@gmail.com

Abstract

Introduction: Surgical patients who require high-risk anaesthesia consent are often at risk of developing perioperative complications and morbidity often warranting postoperative Intensive Care Unit (ICU) admissions.

Aim: To study the incidence of postoperative ICU admissions among surgical patients who require high-risk anaesthesia consent preoperatively.

Materials and Methods: A retrospective study using chart analysis of 64 patients who required high-risk consent for elective surgery over a period of 18 months from January 2018 to July 2019 was done. The details on demographics, the American Society of Anaesthesiologists (ASA) class, the reason for obtaining high-risk consent, type of anaesthesia administered, intraoperative events, duration of surgery and reason for shifting to Intensive Care Unit (ICU) was collected and recorded. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) software, version 20.0. Multiple logistic regressions were performed to determine the predictors of postoperative ICU admissions.

Results: Out of 64 high-risk patients, 35.9% of patients were shifted to ICU postoperatively, with the most common reason for ICU admission being metabolic/haemodynamic instability intraoperatively (47.8%). Among the various preoperative factors (presence of cardiovascular, respiratory diseases with poor reserve or functional impairment, chronic kidney disease, morbid obesity) for obtaining high-risk consent, anticipated long duration surgery with blood loss was associated with a 3.9 {95% CIs of 1.25 and 12.22} times higher odds of being shifted to ICU postoperatively.

Conclusion: About one-third of elective surgical patients who required high-risk anaesthesia consent preoperatively required ICU admission postoperatively. In addition, anticipated long duration surgery with blood loss was found to be an independent predictor of ICU requirement postoperatively.

Keywords

Elective surgical procedure, Informed consent, Intensive care unit, Surgical blood loss

Due to a growing threat of litigation and medico-legal issues, a large number of surgeries are being conducted under high-risk anaesthesia consent (1),(2). Data on characteristics and outcome of postoperative follow-up of these patients who require high-risk anaesthesia consent preoperatively are often limited and inadequate (3),(4). A fraction of these patients are often shifted to ICU postoperatively. In a study, 12.3% high-risk surgical population was detected, which constituted to 83% deaths, however of these only 15% were admitted to ICU postsurgery suggesting inadequate critical care provision and reservations (5). Thus, a better preoperative identification and preparedness for high-risk patients is required.

Though some scoring systems such as Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) are used to identify patients who require ICU admissions following surgery, there are no universally followed criteria for admitting surgical patients to the ICU (6). It is often difficult to determine which patients are at risk of developing postoperative complications. At the same time, it might not be possible to do preoperative ICU bed reservation for all high-risk anaesthesia patients. Hence, an appropriate triage of these patients for elective ICU reservation based on evidence is warranted especially in a resource limited setting.

Many a time, it is seen that patient’s relatives are provided with either inadequate or too much information containing medical jargons in an attempt to obtain high-risk consent which may be counter-productive and lead to confusion (7). Evidence on postoperative ICU requirement in patients who required high-risk anaesthesia consent preoperatively might help the anaesthesiologist in future to facilitate patient surrogates to have a better understanding of the significance of signing a high-risk consent form and making a balanced decision.

The aim of the study was to study the incidence of postoperative ICU admissions among patients who required preoperative high-risk anaesthesia consent for elective surgery.

Material and Methods

The retrospective observational study was performed in Pondicherry Institute of Medical Sciences after obtaining Institutional Ethical Committee Clearance (Ref No. IEC:RC/18/108). Retrospective chart analysis of patients who required high-risk consent for elective surgery from January 2018 to July 2019 was performed with the data retrieved from the Medical Records Department.

Inclusion and Exclusion criteria: All patients from the record who required high-risk anaesthesia consent were included in the study. Patients who underwent cardiothoracic surgery and patients already in ICU preoperatively were excluded from the study as these patients were invariably shifted to ICU as per institute protocol. In addition, patients undergoing emergency surgical procedures were also excluded.

Study Procedure

Data was collected by the researchers and organised by the primary author. For each patient, demographic details, the ASA class, the reason for obtaining high-risk consent, type of anaesthesia administered, intraoperative events (requirement of inotropes, blood and invasive monitoring), duration of surgery, reason for shifting to ICU and number of days of ICU stay was recorded.

Sample size calculation was done from a previous similar study (5) taking incidence of postoperative ICU admissions among high-risk surgical patients (15%) as the primary outcome. A minimum of 51 patients would be required in the present study to determine a similar proportion with a power of 80% and an alpha error of 0.05.

Statistical Analysis

Statistical analysis was performed with the SPSS software, version 20.0. Categorical variables were summarised as frequencies and percentages and continuous variables were summarised as mean and standard deviation. Univariate logistic regression analysis was conducted to determine the association between the odds of being shifted to ICU postoperatively and the potential independent variables. Only those variables which showed trend level association (p-value <0.2) on univariate analysis were entered into the equation of multiple logistic regression analyses. Chi-square test was done to detect the association between type of anaesthesia and various intraoperative interventions (namely inotropes, blood transfusion and invasive monitoring) with postoperative ICU admission. Association between duration of surgery and postoperative ICU admission was evaluated using Spearman correlation analysis.

Results

During the study period of 18 months, a total of 64 patients required high-risk anaesthesia consent preoperatively among the patients undergoing elective surgical procedures. The mean age of study population was 60.56±15.86 with 81.25% of patients belonging to ASA II and III (Table/Fig 1).

The major reasons for obtaining high-risk consent were presence of preoperative cardiovascular disorder (51.6%) and presence of more than one systemic condition preoperatively (51.6%). Majority of risk consent preoperatively were administered general anaesthesia as compared with regional or peripheral nerve blocks (Table/Fig 1), (Table/Fig 2).

Out of 64 high-risk patients, 23 patients were shifted to ICU (35.9%) with the most common reason for ICU admission being haemodynamic/metabolic instability intraoperatively (Table/Fig 3), (Table/Fig 4). Anticipated long duration of surgery was found to be correlated with postoperative intensive care (rho coefficient 0.384, p-value 0.002).

Regression analysis was conducted to find the independent predictors of ICU admission among high-risk patients. Only those variables which showed trend level association (p-value <0.2) on univariate analysis were entered into the equation of multiple logistic regression analysis. Univariate logistic regression analysis revealed age (OR 0.96, 95% CI 0.93-0.99, p-value 0.04) and preoperative anticipated long duration surgery with blood loss (OR 4.62, 95% CI 1.52-13.99, p-value 0.007) to have a significant association with patients being shifted to ICU postoperatively (Table/Fig 5). Multivariate logistic regression analysis revealed anticipated long duration of surgery remained significant after adjusting for age (OR 3.90 CI 1.25-12.21, p=0.019) (Table/Fig 5). The model had 67.2% of correct classification rate and explained about 20.3% of the variance (Nagelkerke r2=0.203).

The mean postoperative ICU stay was 2.87±1.79 days with 0.67±0.65 ventilator days. The mean duration of surgery and intraoperative requirement of inotropes, blood and invasive monitoring were significantly high in patients shifted to ICU (Table/Fig 6).

Discussion

A report by the American Medical Association reveals over 57% of physicians in surgical specialities have been sued. It was seen that a majority of legal suits imposed by the patient on the anaesthesiologists have been due to lack of adequate information provided about the complications of anaesthesia or their expected postoperative outcomes (8). Identifying which of the patients are at risk of developing complications or require ICU admission postoperatively often remains difficult (4). Hence, it becomes mandatory to obtain a high-risk anaesthesia consent in a patient who is likely to be at high-risk of developing perioperative complications related to anaesthesia and surgery.

When the reasons for obtaining high-risk anaesthesia consent were analysed in the study retrospectively, it was found that high-risk consent was obtained from patients having cardiovascular disorders (Ischaemic heart disease, structural heart diseases with poor cardiac reserve/functional impairement, respiratory diseases, neurological (cerebrovascular disease, Alzheimer’s, Parkinson’s disease) and renal disorders (chronic kidney disease). The most common reason among them, was presence of cardiovascular disorder (51%) which included presence of coronary artery diseases, valvular lesions and other cardiac disorders likely to worsen or derange under anaesthesia.

In this study, 35.9% of the elective surgical patients who required high-risk anaesthesia consent preoperatively were shifted to ICU postoperatively while the remaining patients were shifted to post anaesthesia care unit.

In one of the retrospective studies done by Uzmaan S et al., on postoperative patients admitted to ICU, it was found that haemodynamic/metabolic instability constituted to 41% of the reasons for ICU admissions postoperatively (2). The above findings are similar to our study where haemodynamic/metabolic instability constituted to 47% of patients who required postoperative ICU stay. In a prospective, observational study done by Patel SK et al., on 240 patients admitted to surgical ICU postoperatively revealed, anticipated blood loss and anticipated mechanical ventilation were responsible for majority of planned admissions whereas unexpected intraoperative hypotension was the principal cause of unplanned admissions into the ICU (9).

Routine postoperative care in ICU after high-risk surgical procedures may allow for greater recognition and correct management of postoperative complications, thereby reducing long term mortality and morbidity (3). However, due to limited number of ICU beds worldwide, it becomes difficult to reserve ICU bed/shift all high-risk patients to ICU postoperatively (10). Also, there is wide difference in nature and practice of triage decision for postoperative patients (4),(11).

The characteristics and outcomes of high-risk patients shifted to ICU vs not shifted to ICU were studied and it was found that the ASA classification had no impact/association with patients being shifted or not shifted to ICU. There was no statistically significant difference in ASA class between the two groups. ASA classification is one of the known scoring systems used preoperatively to assess postoperative outcomes and takes into account the patient’s premorbid status (12). Several retrospective studies have demonstrated a correlation between ASA classification and perioperative mortality and suggested its usefulness as a predictor of patient outcome (13),(14). However in the present study, the primary outcome studied was the need for ICU admission postoperatively and it was found that ICU admission was not associated with high ASA scores. This could be explained by the fact ASA classification does not determine individual patient risk and surgical procedure. Moreover, literature determining the association between ASA scores and requirement of ICU postoperatively is scarce. It shows a poor ability to identify individuals likely to experience complications in the postoperative period or predicting ICU requirement because the outcome of shifting to ICU is often a complex interplay of patient’s preoperative status, type of anaesthesia, anaesthesia complications and the type of surgery performed (15),(16). Thus, the scoring system is insufficient for predicting postoperative outcomes.

Reasons for obtaining high-risk consent were analysed to find if there were any significant association between preoperative parameters and requirement of ICU postoperatively. Anticipated long duration of surgery with blood loss was associated with a 3.9 times higher odds of being shifted to ICU postoperatively, suggesting it to be an independent predictor/determinant of ICU admission postoperatively.

In a UK perspective audit of patients having inpatient surgery, it was found that the patients having preoperative cardiovascular disease (IHD, arrhythmias and heart failure) had a major 30 day mortality compared to other patients (17). A number of preoperative risk indices (RCRI, Lee’s cardiac index) also include presence of Cardiovascular System (CVS) disease to be a major factor in predicting mortality (18),(19). In this study, presence of CVS disorder constituted a major fraction of patients who required high-risk consent (51.6%), however mere presence of CVS disease failed to establish association with ICU requirement postoperatively. Only 36.3% of CVS patients were shifted to ICU. Adequate preoperative optimisation and intraoperative careful anaesthetic management in these patients especially in an elective setting could have been the probable reason for not requiring ICU postoperatively. However, they are more prone to develop arrhythmias and sepsis related complications in the late postoperative period which was not followed-up and assessed in the present study.

In the present study, patients shifted to ICU had more frequently received general anaesthesia (91.3%), with long duration of surgery (rho coefficient 0.384, p 0.002) and greater intraoperative interventions (p-value<0.05). Uzmann S et al., retrospectively analysed postoperative patients admitted to ICU and found 85.8% patients had received general anaesthesia in comparison to only 14.2% regional anaesthesia suggesting a wide use of general anaesthesia in high-risk patients likely to be shifted to ICU postoperatively (2).

Though, it is mandatory to obtain informed high-risk anaesthesia consent from patients with known cardiovascular, respiratory or renal disorders with poor systemic reserve and/or functional impairment, elective ICU reservation might not be practically feasible for all the patients (20). In the present study, patients in whom a long duration surgery was anticipated and obtained a high-risk consent preoperatively, there was higher odds of being shifted to ICU postoperatively compared to other reasons suggesting it to be a strong predictor of ICU requirement postoperatively. Hence, elective ICU reservations for such patients are warranted.

The main strength of this study lies in the fact that it reflects the existing practices of postoperative ICU admissions in a clinical setting. Due to the broad nature of inclusion criteria, the results are generalisable to a wide variety of elective surgical patients from various surgical disciplines.

Limitation(s)

Due to the retrospective nature of study, it was not possible to have predefined criteria for obtaining high-risk consent or for shifting to ICU postoperatively. Details on postadmission follow-up data in regard to ICU morbidity, mortality or discharge was not assessed in the present study.

Conclusion

About one third of elective surgical patients who required high-risk anaesthesia consent preoperatively required ICU admission postoperatively. Preoperative anticipated long duration surgery with blood loss was found to be an independent predictor of ICU requirement postoperatively. Future prospective and multi-centric studies would be warranted to establish the temporal relationship between preoperative variables and postoperative ICU admissions. Development of robust evidence based criteria will help in identifying patients who would benefit most from postoperative ICU admissions.

References

1.
Onwochei DN, Fabes J, Walker D, Kumar G, Moonesinghe SR. Critical care after major surgery: A systematic review of risk factors for unplanned admission. Anaesthesia. 2020;75(Suppl 1):e62-74. [crossref] [PubMed]
2.
Uzman S, Yilmaz Y, Toptas M, Akkoc I, Gul YG, Daskaya H, et al. A retrospective analysis of postoperative patients admitted to the intensive care unit. Hippokratia. 2016;20(1):38-43.
3.
Cavaliere F, Conti G, Costa R, Masieri S, Antonelli M, Proietti R. Intensive care after elective surgery: A survey on 30-day postoperative mortality and morbidity. Minerva Anestesiol. 2008;74(9):459-68.
4.
Sobol JB, Wunsch H. Triage of high-risk surgical patients for intensive care. Crit Care. 2011;15(2):217. [crossref] [PubMed]
5.
Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care Lond Engl. 2006;10(3):R81. [crossref] [PubMed]
6.
Chieng TH, Roslan AC, Chuah JA. Risk-adjusted analysis of patients undergoing laparotomy using POSSUM and P-POSSUM score in Queen Elizabeth Hospital, Sabah. Med J Malaysia. 2010;65(4):286-90.
7.
Levine EG, Brandt LJ, Plumeri P. Informed consent: A survey of physician outcomes and practices. Gastrointest Endosc. 1995;41(5):448-52. [crossref]
8.
Wortz G. Reducing liability risk through informed consent. J Med Pract Manag MPM. 2011;26(4):203-08.
9.
Patel SK, Kacheriwala SM, Duttaroy DD. Audit of postoperative surgical intensive care unit admissions. Indian J Crit Care Med Peer-Rev Off Publ Indian Soc Crit Care Med. 2018;22(1):10-15. [crossref] [PubMed]
10.
Goldhill DR, Down JF. Are we operating as well as we can? Critical care to minimise postoperative mortality and morbidity. Anaesthesia. 2008;63(7):689-92. [crossref] [PubMed]
11.
Dahm P, Tuttle-Newhall JE, Yowell CW, Byrne RR, Price DT. Indications for surgical intensive care unit admission of postoperative urologic patients. Urology. 2000;55(3):334-38. [crossref]
12.
Kumar P, Renuka MK, Kalaiselvan MS, Arunkumar AS. Outcome of noncardiac surgical patients admitted to a multidisciplinary intensive care unit. Indian J Crit Care Med Peer-Rev Off Publ Indian Soc Crit Care Med. 2017;21(1):17-22. [crossref] [PubMed]
13.
Hackett NJ, De Oliveira GS, Jain UK, Kim JYS. ASA class is a reliable independent predictor of medical complications and mortality following surgery. Int J Surg Lond Engl. 2015;18:184-90. [crossref] [PubMed]
14.
Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111-15. [crossref] [PubMed]
15.
Grega. Is the ASA physical status classification system a good prognostic index for ICU admissions?
16.
Sankar A, Johnson SR, Beattie WS, Tait G, Wijeysundera DN. Reliability of the American Society of Anaesthesiologists physical status scale in clinical practice. Br J Anaesth. 2014;113(3):424-32. [crossref] [PubMed]
17.
Minto G, Biccard B. Assessment of the high-risk perioperative patient. Contin Educ Anaesth Crit Care Pain. 2014;14(1):12-17. [crossref]
18.
Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, et al. Perioperative cardiovascular mortality in noncardiac surgery: Validation of the Lee cardiac risk index. Am J Med. 2005;118(10):1134-41. [crossref] [PubMed]
19.
Prause G, Ratzenhofer-Comenda B, Pierer G, Smolle-Jüttner F, Glanzer H, Smolle J. Can ASA grade or Goldman’s cardiac risk index predict peri-operative mortality? A study of 16,227 patients. Anaesthesia. 1997;52(3):203-06. [crossref] [PubMed]
20.
Jhanji S, Thomas B, Ely A, Watson D, Hinds CJ, Pearse RM. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia. 2008;63(7):695-700. [crossref] [PubMed]

DOI and Others

10.7860/JCDR/2021/48558.15164

Date of Submission: Dec 13, 2020
Date of Peer Review: Mar 02, 2021
Date of Acceptance: Jun 01, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 19, 2021
• Manual Googling: Mar 22, 2021
• iThenticate Software: Jun 19, 2021 (10%)

ETYMOLOGY: Author Origin

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