Park, Seong-Yong
(Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
,
Park, In-Kyu
(Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine)
,
Hwang, Yoo-Hwa
(Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
,
Byun, Chun-Sung
(Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
,
Bae, Mi-Kyung
(Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
,
Lee, Chang-Young
(Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine)
Background: Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. Ma...
Background: Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. Materials and Methods: 316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort. Results: Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome. Conclusion: Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.
Background: Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. Materials and Methods: 316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort. Results: Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome. Conclusion: Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.
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문제 정의
However, few studies have compared the postoperative outcomes between ICU and GTW patients to assess the efficacy of routine ICU care or to identify which patients should be admitted to the ICU. The aims of this study were to compare the postoperative outcomes between ICU and GTW patients in terms of complications and also to stratify high-risk groups who are more likely to require ICU care.
This difference may not significantly increase heterogeneity, however, because preoperative conditions, which can affect VATS selection and subsequent clinical outcomes, were adjusted extensively. The primary goal of this study was to compare the early postoperative period between ICU and GTW patients, so discordance in the VATS rate may not be an important limitation.
Patients’ characteristics and outcomes were compared. The primary goal was to determine the safety and efficacy of GTW care in selected patients. The secondary goal was to identify selection criteria for ICU care.
제안 방법
By 4：1 propensity score matching, 164 patients in the ICU group were matched with 41 patients in the GTW group. Both groups were adjusted in terms of age, sex, ASA score, CCI, expected FEV1, and cardiac and pulmonary comorbidities except for the type of incision. Rates of early complication, late complication, and mortality were not significantly different between the groups (Table 3).
The secondary goal was to identify selection criteria for ICU care. In order to evaluate the safety and efficacy of GTW care in selected patients, the outcomes of both groups were compared after 1：4 propensity score matching for variables such as age, sex, American Society of Anesthesiology (ASA) score, Charlson comorbidity index(CCI), and operative method (Fig. 1). Cardiopulmonary complication rates, significant event rates, and costs were compared between both groups, and the rate of missing significant complications in the GTW group was evaluated.
Also, caretakers were instructed to call nurses if there was an alarm or any change in the condition of the patients. Monitoring parameters, blood pressure, and chest tube drainage were checked every hour until 6 am of the first postoperative day by doctors or nurses. Three doctors and two or three nurses were on duty during the night, and no supplementary nursing staff were involved in the postoperative care of the lobectomy patients.
However, a limitation of that study was that although the authors performed propensity score matching to decrease heterogeneity, preoperative, operative and postoperative management of the two groups were wholly different. One unique and meaningful aspect of our study is that it was the first case-control study performed with a homogeneous group of patients managed by identical surgical and anesthesiologic strategies and matched by propensity score. In our study, the efficacy of GTW care was comparable with that of ICU care after lobectomy.
This study had several limitations. The first limitation is that this study is a retrospective and non-randomized study. Although the two groups were adjusted by propensity score, some patients at the extremes of the propensity scores were excluded from the analysis.
Chi-square testing for categorical variables and unpaired Students’ T-test and the Mann-Whitney test for continuous variables were applied to compare the parameters. The following variables were applied as potential risk factors for early complications, late complications, and mortality: advanced age (＞70), sex, ASA score, CCI, pulmonary comorbidity, neoadjuvant treatment, cardiac comorbidity, low expected FEV1 (＜65%), and incision type. Multiple logistic regressions were performed for multivariate analysis.
대상 데이터
8 years, and 78 patients were over the age of 70. Forty-one patients were in the GTW group, and 275 patients were in the ICU group. The two groups differed in terms of sex, ASA, CCI, cardiac comorbidity, and incision type (Table 1).
Although five patients needed transfusions, reoperation was not necessary in these patients. Nine patients were readmitted to the ICU, and the most common cause of ICU readmission was respiratory insufficiency due to postoperative pneumonia requiring mechanical ventilator support. The mean ICU readmission occurred 4.
Out of 316 patients undergoing lobectomy for NSCLC during the study period, 133 patients were female. The mean age was 63.
This study included 316 patients who underwent lobectomy or bilobectomy for the treatment of non-small cell lung cancer (NSCLC) from September 2006 to July 2008. We excluded patients undergoing pneumonectomy or extended resection, such as chest wall resection or diaphragm resection, to decrease the heterogeneity of the cohort, because pneumonectomy or extended resection could cause more severe complications than those resulting from lobectomy.
데이터처리
The following variables were applied as potential risk factors for early complications, late complications, and mortality: advanced age (＞70), sex, ASA score, CCI, pulmonary comorbidity, neoadjuvant treatment, cardiac comorbidity, low expected FEV1 (＜65%), and incision type. Multiple logistic regressions were performed for multivariate analysis. Variables included in multiple logistic regressions were selected when their p-value was less than 0.
이론/모형
Chi-square testing for categorical variables and unpaired Students’ T-test and the Mann-Whitney test for continuous variables were applied to compare the parameters.
성능/효과
1). Cardiopulmonary complication rates, significant event rates, and costs were compared between both groups, and the rate of missing significant complications in the GTW group was evaluated. In order to define the selection criteria for ICU care following lobectomy, risk factors for early and late complications were investigated.
However, few previous articles have reported or suggested guidelines for ICU admission. In this study, risk factors for early complications were low expected FEV1 and cardiac comorbidities, while those for late complications were advanced age, low expected FEV1 and cardiac comorbidities. Since most early and late complications were cardiac or pulmonary in origin, underlying cardiopulmonary comorbidities can typically predict the development of these complications.
The results of this study indicate that GTW care instead of ICU care increased neither the complication rate nor the failure of surveillance for immediate postoperative management in selected patients. In addition, GTW care is less expensive than ICU care.
참고문헌 (13)
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