High-risk patients need specialised care in the immediate postoperative period to minimise complications and/or deaths.1 To this aim, surgical patients are also closely monitored, although less intensively, in the intermediate care unit (IMCU) setting. The efficacy of this approach has been subject to criticism with the literature showing variable results.2
We have read with great interest the retrospective, single-centre study by Fujii et al.3 entitled ‘Life-threatening complications after postoperative intermediate care unit discharge’ that was addressing mortality and complications in postoperative patients within 7 days after discharge from the IMCU. In their study, Fujii et al.3 reported on a surprisingly good outcome; only 1.3% of the included patients had a life-threatening complication and a low hospital mortality of 0.8%, a finding that could be attributed to the high quality of care within the IMCU. Nevertheless, the above-mentioned mortality rates are very low when compared with the results of the European Surgical Outcomes study, according to which 4% of postoperative patients die in European hospitals.4 In a multicentre European study by Capuzzo et al.,5 the presence of an IMCU in a hospital was associated with a significantly reduced adjusted mortality for adults admitted to the ICU but the effect was absent in patients that were admitted for basic observation, for example, after surgery. In this main comment, we consider that there are some issues we would like to point out such as that no selection criteria of patients admitted to the IMCU were reported.
First, if we consider risk assessment, only 14.9% of the patients in the present study belonged to the high-risk ASA-PS ≥ 3 group. Of these, 17.5% were reported to have life-threatening complications and a high (12.5%) mortality rate. Consequently, the majority of the study population comprised rather healthy patients with a low predisposition for complications. Also, two key aspects are relevant: although the duration of surgery was not found to influence patients, surgical procedure-related risk was not taken into account. Postoperative complications are related to the type of surgery,5 and this could be a confounding factor. Yet, in accordance with the previous reports, emergency operation and perioperative fluid overload were found in this study to predispose to postoperative complications. Although the issue of perioperative fluid overload remains controversial, it appears that there is a close association between excessive intravascular volume and increased mortality, morbidity and length of hospital stay.6,7 The identification of fluid overload as a negative risk factor could prove valuable for future research. Surprisingly, short-term (<6 h) mechanical ventilation has also been found to be a negative predisposing factor. This could possibly reflect ‘inappropriate’ clinical judgement for early extubation as no extubation protocols are reported in the study.
In our opinion, overall, in this interesting study, very low mortality and complication rates are reported in patients discharged from the IMCU. Further research is needed to evaluate the significance of IMCU admittance in the improved outcome of surgical patient.
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1. Jhanji S, Thomas B, Ely A, et al. Mortality and utilisation of critical care resources amongst high-risk surgical patients in a large NHS trust. Anaesthesia
2. Vincent JL, Rubenfeld GD. Does intermediate care improve patient outcomes or reduce costs? Crit Care
3. Fujii T, Uchino S, Takinami M. Life-threatening complications after postoperative intermediate care unit discharge: a retrospective, observational study. Eur J Anaesthesiol
4. Pearse RM, Moreno RP, Bauer P, et al. European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Lancet
5. Capuzzo M, Volta CA, Tassinati T, et al. Hospital mortality of adults admitted to intensive care units in hospitals with and without intermediate care units: a multicentre European cohort study. Critical Care
6. Noordzij PG, Poldermans D, Schouten O, et al. Postoperative mortality in The Netherlands: a population-based analysis of surgery-specific risk in adults. Anesthesiology
7. Wei S, Tian J, Song X, et al. Association of perioperative fluid balance and adverse surgical outcomes in esophageal cancer and esophagogastric junction cancer. Ann Thorac Surg