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Predictors of prolonged ICU stay after on-pump versus off-pump coronary artery bypass grafting

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Abstract

Objective

To define predictors for prolonged ICU stay in order to improve patient outcome and reduce costs.

Patients and methods

Prospective data on 10,759 patients undergoing coronary artery bypass grafting with and without use of cardiopulmonary bypass (coronary artery bypass grafting, CABG; n =8,917; off-pump coronary artery bypass grafting, OPCAB; n =765; minimally invasive direct coronary artery bypass grafting, MIDCAB; n =1,077) between April 1996 and August 2001 were subjected to univariate and, consecutively, to multivariate logistic regression analysis. Prolonged ICU stay was defined as intensive care treatment for three postoperative days and longer.

Measurements and results

Mean duration of ICU stay was 3.8±6.9 days; overall prevalence of prolonged ICU stay was 37.1%. The hospital mortality was 3.5% (ICU ≥3 days: 5.9%; ICU <3 days: 2.0%). Out of 39 selected pre- and intraoperative patient- and treatment-related variables, by univariate analysis, 32 variables having a high association with prolonged ICU stay were identified. Using a stepwise logistic regression model, 20 variables were shown to be independent predictors for prolonged ICU stay. Both OPCAB and MIDCAB surgery were identified as having a significantly lower association with prolonged ICU stay.

Conclusion

As prolonged ICU stay is associated with poor patient outcome and increased costs it is of utmost importance to identify patients at a high risk for prolonged ICU stay. More frequent off-pump CABG may optimize patient outcome.

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Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, Heart Center, University of Leipzig, Strümpellstrasse 39, 04289, Leipzig, Germany

    Jan Bucerius, Jan F. Gummert, Thomas Walther, Nicolas Doll, Volkmar Falk, Dierk V. Schmitt & Friedrich W. Mohr

Authors
  1. Jan Bucerius
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  2. Jan F. Gummert
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  3. Thomas Walther
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  4. Nicolas Doll
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  7. Friedrich W. Mohr
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Corresponding author

Correspondence to Jan Bucerius.

Appendix

Appendix

The following table shows peroperative variables analyzed by univariate analysis (factors that had a statistically significant association with prolonged ICU-stay are printed in bold)

 

Patients with ICU−stay ≥3 days (n =3,988)

Patients with ICU−stay <3 days (n =6,771)

 

Preoperative variables

Prevalence % (n)

P−value

 Age

  Age <60 years

18.3% (730)

29.1% (1,973)

<0.0001

  Age ≥70 and <80 years

37.2% (1,483)

28.4% (1,926)

<0.0001

 Age ≥80 years

4.3% (171)

2.4% (161)

<0.0001

 History of syncope

8.4% (336)

7.3% (494)

0.033

 History of embolism

3.5% (138)

2.2% (148)

<0.0001

 History of cardiogenic shock

11.1% (442)

5.2% (353)

<0.0001

 Diabetes mellitus (glucose intolerance treated with diet, oral hypoglycemics or insulin)

41.2% (1,645)

33.1% (2,238)

<0.0001

 Arterial hypertension (patient taking antihypertensive medication preoperatively)

75.8% (3,021)

72.3% (4,898)

<0.0001

 History of renal disease (history of renal failure or pathological elevated serum creatinine treated medically without hemofiltration and/or dialysis)

6.4% (256)

2.3% (159)

<0.0001

 Dialysis dependent renal insufficiency

1.1% (42)

0.3% (19)

<0.0001

 Preoperative infection (infectious disease including endocarditis)

1.5% (59)

0.6% (42)

<0.0001

 History of cerebrovascular disease (including stroke, TIA, and PRIND)

4.7% (186)

2.6% (178)

<0.0001

 NYHA ≥3

81.8% (3,263)

76.4% (5,175)

<0.0001

 LVEF ≤30% (assessed by angiography or 2D echocardiography)

11.1% (441)

6.1% (413)

<0.0001

 History of peripheral vascular disease

26.2% (1,046)

17.2% (1,164)

<0.0001

 Atrial fibrillation (history of preoperative atrial fibrillation)

5.9% (235)

3.0% (202)

<0.0001

 Urgent operation

27.5% (1,097)

16.4% (1,100)

<0.0001

 Emergency surgery (emergent surgery due to complications during coronary angiography and/or PTCA)

1.1% (42)

0.6% (39)

0.008

 History of pulmonary disease (chronic pathologic pulmonary function test)

8.0% (320)

4.8% (325)

<0.0001

 Prior myocardial infarction

58.5% (2,331)

51.4% (3,479)

<0.0001

 CCS ≥3

37.8% (1,509)

35.9% (2,435)

0.05

 Sex (male)

76.2% (3,039)

77.5% (5,250)

0.117

 Hyperlipidemia

52.7% (2,100)

54.3% (3,679)

0.155

 Prior cardiac surgery

4.4% (174)

3.7% (252)

0.102

 Prior CABG

3.8% (150)

3.1% (213)

0.097

 Prior aortic valve surgery

0.2% (9)

0.4% (26)

0.219

 Prior mitral valve surgery

0.1% (6)

0.2% (16)

0.386

Intraoperative variables

 Duration of surgery ≥3 h

24.1% (961)

16.4% (1,113)

<0.0001

 Total CPB time ≥2 h

10.9% (435)

4.3% (293)

<0.0001

 Ischemic time ≥1 h

11.6% (462)

8.9% (607)

<0.0001

 Intraoperative hemofiltration

9.2% (367)

4.7% (321)

<0.0001

 Intraoperative hypothermia ≤32 °C

29.2% (1,166)

21.3% (1,439)

<0.0001

 Intraoperative RBC transfusion ≥1,000 ml

2.9% (115)

1.0% (67)

<0.0001

 Intraoperative low cardiac output

3.9% (154)

1.1% (75)

<0.0001

 Intraoperative IABP−support

4.2% (168)

1.2% (78)

<0.0001

 Intraoperative assist device (ECMO, Berlin heart)

1.4% (54)

0.4% (24)

<0.0001

 Intraoperative need for pacemaker stimulation

19.5% (776)

11.3% (766)

<0.0001

 Use of cardioplegia

76.3% (3,043)

69.6% (4,711)

<0.0001

 Beating heart surgery

10.4% (415)

21.1% (1,427)

<0.0001

  OPCAB

4.9% (194)

8.0% (544)

<0.0001

  MIDCAB

5.3% (210)

12.8% (867)

<0.0001

 Coronary bypass grafts ≥2

82.5% (3,290)

75.7% (5,127)

<0.0001

 Intraoperative blood loss ≥500 ml

0.7% (26)

0.4% (26)

0.061

CABG coronary artery bypass grafting, OPCAB off-pump coronary artery bypass grafting, MIDCAB minimally invasive direct coronary artery bypass grafting, RBC red blood cells, LVEF left ventricular ejection fraction, PTCA percutaneous transluminal coronary angioplasty, CPB cardiopulmonary bypass, IABP intra-aortic ballon pump, ECMO extracorporal membrane oxygenation

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Bucerius, J., Gummert, J.F., Walther, T. et al. Predictors of prolonged ICU stay after on-pump versus off-pump coronary artery bypass grafting. Intensive Care Med 30, 88–95 (2004). https://doi.org/10.1007/s00134-003-1950-5

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