Selective use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair

Aim. Abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). This paper reports on an experience of using preoperative medical criteria and a list of intraoperative factors for selective use of the ICU. These criteria were evaluated in relation to their impact on the safety and short term results after open AAA repair. Methods. All elective open infrarenal AAA repairs during a 9 year period (1994-2003), following a specific algorithm towards selective use of the ICU, were retrospectively evaluated. Patients were clinically evaluated, before the operative procedures, and divided into categories according to their medical risk (cardiac and pulmonary status). Patients with an ejection fraction <30% and a FVC or FEV1 <50% of the predicted value were transferred immediately from the operating room to the ICU. A list of intraoperative factors: 1) prolonged operative time; 2) prolonged aortic clamping time; 3) suprarenal clamping; 4) quantity of blood transfusion; 5) intraoperative acute renal failure; 6) intraoperative hemodynamic instability; 7) intraoperative cardiac dysfunction were also considered criteria for transfer from the operating room to the ICU. Patients who did not meet any of the above criteria were extubated and transferred to the surgical floor. Results. Elective AAA repair was performed on 602 patients, among whom, 551 (91.5%) were extubated in the operating room and thereafter treated in the surgical floor and 51 (8.5%) were transferred from the operating room to the ICU. However, later transfer from the floor to the ICU was required in 7 more patients (1.1%), increasing the total percentage of patients treated in the ICU to 9.6%. (51 patients initially and 7 later on). The total postoperative 30 days mortality rate was 0.7% (4 patients) and the morbidity rate was 18.8% in this series. The mean length of in-hospital stay was 9.9 days and the mean ICU length of stay Was 4.2 days. Conclusion. Elective AAA repair with selective use of the ICU can be a considerable safe policy in a single high volume hospital. It can reduce resource use without a negative impact on the quality of care.