CC BY-NC-ND 4.0 · Journal of Cardiac Critical Care TSS 2022; 06(03): 201-205
DOI: 10.1055/s-0042-1759816
Review Article

ICU Readmission in Cardiac Surgical Subset: A Problem Worth Pondering

Jaffrey Kalaiselvan
1   Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
Ramesh Chand Kashav
1   Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
Jasvinder Kaur Kohli
1   Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
1   Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
Iti Shri
1   Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
Vijay Grover
2   Department of Cardiothoracic and Vascular Surgery, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
,
Narender Singh Jhajharia
2   Department of Cardiothoracic and Vascular Surgery, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, Baba Kharak Singh Marg, New Delhi, India
› Author Affiliations
 

Abstract

Over the past decades, there have been noteworthy advancements in the cardiac surgical practice that have assisted fast-tracking and enhanced recovery after cardiac surgery (ERACS). With that said, intensive care unit (ICU) readmission in this high-risk patient cohort entails a significant morbidity–mortality burden. As an extension of the same, there has been a heightened emphasis on a comprehensive evaluation of the predisposition to readmission following a primary ICU discharge. However, the variability of the institutional perioperative practices and the research complexities compound our understanding of this heterogeneous outcome of readmission, which is intricately linked to both patient and organizational factors. Moreover, a discussion on ICU readmission in the recent times can only be rendered comprehensive when staged in close conjunction to the fast-tracking practices in cardiac surgery. From a more positive probing of the matter, a preventative outlook can likely mitigate a part of the larger problem of ICU readmission. Herein, focused cardiac prehabilitation programs can play a potential role given the emerging literature on the positive impact of the former on the most relevant readmission causes. Therefore, the index review article aims to address the subject of cardiac surgical ICU readmission, highlighting the magnitude and burden, the causes and risk-factors, and the research complexities alongside deliberating the topic in the present-day context of ERACS and cardiac prehabilitation.


#

Introduction

Needless to say, we have come a long way and continue to march ahead in our endeavors to refine the anesthesia-perfusion-surgical conduct aimed at ameliorating the perioperative morbidity and mortality in the cardiac surgical practice. Withstanding the same, fast-tracking and enhanced recovery after cardiac surgery (ERACS) are becoming increasingly conceivable in the present times.[1] [2] [3] As we embrace the ever-growing opportunities to fast-track following cardiac surgery, there is a concurrent need to holistically assess the research landscape of a closely related and equally (if, not more) important phenomenon of intensive care unit (ICU) readmission in cardiac surgical subset following a primary discharge.[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]


#

Readmission as an Event is “Far from Benign”

The incidence of ICU readmission in cardiac surgical patients within the course of the index hospitalization ranges from 2 to 8% based on the existing relevant literature.[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] ICU readmission entails a protracted length of stay in the hospital and consequent unfavorable clinical outcomes. The in-hospital mortality rates are to the remarkable tune of 11 to 24% for the readmitted patient cohort.[4] There are studies to suggest as much as six times escalation in mortality rates and, three to seven times the increase in the length of hospital stay and the length of ICU stay, respectively, in the readmitted patients, in contrast to the nonreadmitted patients.[7] [8] The former negatively impacts the morale of the entire perioperative team and more importantly, the resolute of the primary patient caregivers. Moreover, the resultant strain imposed on the health care system can also not be ignored, particularly in the context of an increased cost and resource burden on the already constrained ecosystem of the low- and middle-income countries.[4] [5] [7] [8] [9] [10] [11] [12] [13] [14] [15] Bettex and Rudiger adequately elaborate the negative impact of readmission not only on the health system but the family of the patient as well.[7]


#

ICU Readmission: Causes and Risk Factors

The causes for ICU readmission in cardiac surgical subset outlined by the various independent research groups have been summarized in [Table 1].[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] The majority of the ICU readmissions result owing to the underlying respiratory and cardiac reasons. Postoperative pneumonia (hospital-acquired/aspiration), pleural–effusion, poor ventilatory reserve, etc., leading to hypoxemia and respiratory failure necessitating reintubation and mechanical ventilation, account for the major cause of readmission. Cardiovascular decompensation, precipitated by arrhythmias and heart failure, classifies as the second leading cause.[13] The need for reoperative interventions, sepsis, and other morbid organ outcomes also contributes to the overall ICU readmission burden ([Table 1]).[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

Table 1

The major causes for ICU readmission in cardiac surgical patients[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

• Respiratory failure (a substantial contributing percentage of 34.13–54.9%)

• Cardiac decompensation or cardiovascular instability (principal cause almost in every 4th readmitted patient, with some being post-CPR)

• Reoperative interventions for cardiac tamponade/bleeding (the causative percentage hovers around 6–9.58%)[a]

• Postoperative renal failure (3–6.6%)

• Sepsis (1.5–3.59%)

• Gastrointestinal complications (2–6%)

• Neurological reasons or an altered mental status (0.5–4.79%)

• Miscellaneous (peripheral ischemia, allergic reactions, embolic occlusion of peripheral vasculature, sternal dehiscence or DSWI, etc.)

Abbreviations: CPR, cardiopulmonary resuscitation; DSWI, deep sternal wound infections; ICU, intensive care unit.


a Some studies attribute cardiac tamponade as an isolated readmission cause in a considerable 14.37%.[2]


Simultaneously, there has been an ever-increasing emphasis on evaluating the risk factors responsible for predisposing the discharged patients to the likelihood of being readmitted to the ICU.[5] [Table 2] enlists the various preoperative patient-related, operative, and the primary ICU stay postoperative factors identified as the ICU readmission risk predictors across the existing cardiac surgical literature.[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

Table 2

Risk factors for readmission to the cardiac surgical ICU[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15]

Preoperative:

 • Pre-existing renal failure (a powerful independent readmission predictor in the literature)

 • COPD or chronic lung disease (COPD, in particular entails an elevated risk)

 • Previous myocardial infarction

 • High EuroSCORE II[a]

 • Advanced age (mixed literature with age in excess of 70–80 years being implicated)

 • Other potential factors adding to the risk (reduced LVEF, ≥NYHA III status, female sex, preoperative arrhythmias, diabetes mellitus, neurological disease, triple vessel disease, morbid obesity, PAD, Parsonett score)

Operative and primary ICU stay postoperative factors:

 • Emergency surgery

 • Combined CABG + valve surgery (a consistent operative risk-factor with additional risk contributed by redo-surgery, aortic procedure and prolonged ACC and CPB times)

 • Post-cardiotomy low cardiac output syndrome (requiring IABP/VAD assistance)

 • Prolonged mechanical ventilation > 24 hours (studies also implicate a primary ICU stay > 72 hours as a risk-factor)

 • Postoperative arrythmias

 • Need of hemofiltration/dialysis

 • Pulmonary complications

 • Cardiopulmonary resuscitation

 • Re-exploration for bleeding

 • Postoperative anemia and neurological dysfunction

 • Contributing factors, such as ICNARC score, inotropic requirement, fraction of inspired oxygen requirement, respiratory rate, gastrointestinal bleed and graft-infection.

Abbreviations: ACC, aortic cross-clamp; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; COPD, chronic obstructive pulmonary disease; EuroSCORE, European System for Cardiac Operative Risk Evaluation; IABP, intra-aortic balloon pump; ICNARC score, Intensive Care National Audit & Research Centre Score; ICU, intensive care unit; LVEF, left ventricle ejection fraction; NYHA, New York Heart Association; PAD, peripheral arterial disease; VAD, ventricular assist device.


a A EuroSCORE II > 8 in the Holaubek et al study.[4]


With the major causes and risk factors being outlined, there are additional factors that may contribute to the overall problem. For instance, the inclusion of an overnight prolonged fasting in the traditional surgical bundle accentuates the propensity to surgical stress and catabolism.[16] [17] [18] To make the matter worse, our cardiac patients with advanced age, pre-existing malnutrition, comorbidities, and frailty may be even more predilected owing to a limited cardiopulmonary reserve, leading to an all the more challenging postoperative respiratory rehabilitation.[19] [20] [21] [22] [23] [24] [25] [26] The above-mentioned factors usher these high-risk surgical subset into a downward spiral manifesting as impaired healing, decreased immune response, heightened risk of surgical complications, readmission rates, hospital stay, and mortality.[22] [24] [26] [27] [28]


#

Cardiac Surgical ICU Readmission: A Complex Research Affair

Independent research groups have developed and internally validated various ICU readmission risk predictive models, emanating from their respective cardiac surgical settings ([Table 3]).[8] [9] [10] [11] [12] However, to date, only the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease risk predictive model by van Diepen et al has been subjected to an external validation in a cohort of 805 patients with a 4.6% readmission rate.[9]

Table 3

The ICU readmission risk models described in cardiac surgery[8] [9] [10] [11] [12]

Risk model

 • APPROACH model, van Diepen et al, 2014, developed in a prospective dataset of 10,799 CABG/valvular surgical patients, with a 4.4% readmission rate. Following an internal validation with bootstrapping, the model demonstrated an AUC = 0.80[9]

  Components: age, chronic lung disease, LVEF, single-valve/non-CABG surgery, multivalvular surgery, postoperative cardiac-arrest, pneumonia, pleural-effusion, DSWI, leg-graft harvest site infection, GI-bleeding, and neurologic-complication

 • APPROACH model refined, Verma et al, 2019, developed in a prospective cohort of 805 CABG/valvular surgical patients, with a 4.6% readmission rate. A good discrimination with an AUC = 0.78[10]

  Improvised APPROACH model with additional components: reintubation, tracheostomy, inotrope and oxygen requirements at discharge, HR, and SBP

 • BATS model, Magruder et al, 2015, developed in a prospective cohort of 421 CABG/AVR patients, with a 6.6% readmission rate. A good discrimination with an AUC = 0.81[11]

  Components: female sex, NYHA III/V functional status, urgent or emergent operation, and postoperative renal failure during the index ICU admission

 • Li et al model, 2019, developed from retrospective data of 824 valve surgery patients, with a 13.4% readmission rate. A good discrimination with an AUC = 0.88[12]

  Components: age > 65 years, chronic lung disease, previous cardiac surgery, LVEF < 50%; < 40%, NYHA III/IV status, multiple valve surgery, CPB time > 180 minutes, cardiac-arrest, ARDS, pneumonia, DSWI, and postoperative renal failure

 • Thomson et al model, 2018, developed retrospectively from a mixed surgical cohort of 4,869 patients, with a 3.2% readmission rate. They reported a well-calibrated bootstrapped model with a good discrimination, missing details on the statistical performance[8]

Components: surgical urgency, diabetes-mellitus, stage 3–5 chronic kidney disease, aortic valve surgery, hypertension, EuroSCORE II, preoperative neurologic disease, ICNRC score, and postoperative anemia

Abbreviations: APPROACH, Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease; ARDS, acute respiratory distress syndrome; AUC, area under the curve; AVR, aortic valve replacement; BATS, Bounce Back After Transfer; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; DSWI, deep-sternal wound infections; EuroSCORE II, European System for Cardiac Operative Risk Evaluation; GI, gastrointestinal; HR, heart rate; ICNRC, Intensive Care National Audit & Research Centre Score; ICU, intensive care unit; LVEF, left ventricle ejection fraction; NYHA, New York Heart Association; SBP, systolic blood pressure.


Furthermore, the very recently published systematic review on the topic of cardiac surgical ICU readmission by Kimani et al included a total of 25 ICU readmission studies and 5 readmission risk models.[5] Worthwhile to mention, the research group could not inculcate a formal meta-analysis owing to the range of inconsistencies that likely precluded the outcome-pooling across the studies and hence, robust statistical inferences.[5] Therefore, it becomes imperative to meticulously consider the intricate nuances of the readmission research.[4] [5] [6] [7] [8] [9] [10] [11] [12] [27] [28] [29] [30] [31] [Fig. 1] illustrates the general and specific complexities of the ICU readmission research in perioperative cardiac care.

Zoom Image
Fig. 1 The complexities of intensive care unit (ICU) readmission research in cardiac surgery.[4] [5] [6] [7] [8] [9] [10] [11] [12] [27] [28] [29] [30] [31]

At the same time, the moderate precision with which ICU readmission can be predicted in practice only goes on to interrogate its use as a quality indicator.[30] If at all so, the readmissions limited to the first 48 hours of a primary discharge might connote the ICU performance to some extent, as elucidated by Bettex and Rudiger.[6] [7]


#

ICU Readmission in the Era of Fast-Tracking

A discussion on ICU readmission would only be complete when staged in close conjunction to the recent multimodal transdisciplinary initiative of ERACS and fast-tracking (an early tracheal extubation within 6 to 10 postoperative hours, an important component of ERACS).[1] [2] [3]

It is encouraging that the existing literature does not suggest heightened rates of ICU readmission following fast-tracking in cardiac surgery.[27] [28] [32] In a series of evaluation of the risk of ICU readmissions while fast-tracking, Kogan et al depicted an overall 3.29% readmission over a 27-month long period of prospectively studying 1,613 cardiac surgical patients. The research group outlined a 47.2, 28.3, and 24.5% readmission rate in the first 24 hours, 24 to 48 hours, and after 48 hours of the primary ICU discharge, respectively.[27] Notably, the incidence and risk-pattern in the Kogan et al study were largely in congruence with the overall readmission literature.[27] Furthermore, Toraman et al specifically delineated the impact of the nature of operative intervention in their discovery of a much higher 5.5% readmission rate in coronary artery bypass grafting (CABG) + valve surgeries compared with the 1.9% readmission rate in the patients undergoing an isolated CABG being fast-tracked.[28]

Nonetheless, with the fast-track protocols emerging as the standard of care across cardiac surgical centers, it remains to be highlighted that the practicalities surrounding any intervention aimed at an early ICU discharge should simultaneously consider the possibility of a subsequent clinical deterioration necessitating an unplanned ICU readmission.[27] For instance, a systematic review and meta-analysis by Vollam et al that suggest heightened ICU readmission rates in background of an out-of-hours discharge policy in a generalized ICU population are noteworthy from a practical standpoint.[33]

With the 2016 Cochrane systematic review deciphering the safety of fast-track protocols in patients with low-moderate perioperative risk,[32] the detrimental impact of failure to fast-track mandates due consideration amidst ever-growing complexities of the cardiac surgical interventions and the comorbid patient profile.[27] [28] This doubtlessly calls for a prudent patient selection.[34] As far as the dynamic factors are concerned, Probst et al propose to delay the decision-making on fast-track suitability till the surgical completion, to reduce the eventual rates of fast-track failure.[35]


#

Future Directions: Prevention to Prehabilitation

Considering the fact that ICU readmission is a complicated outcome interlinked to both the patient and organizational factors,[5] tackling the modifiable risk-factors offers viable opportunities to ameliorate the overall problem. Bettex and Rudiger substantiate the former by elaborating that the readmissions after 48 hours of a primary discharge are associated with the comorbid profile of the patients.[6] [7] This brings forth attention to the concept of potentially preventable ICU readmission. However, identifying the same can be peculiarly challenging in the cardiac surgical arena particularly when readmission studies tend to overlook the crucial factor of the timing of readmission as cited in [Fig. 1]. Therefore, future readmission research should aim at delineating the “true” incidence of this potentially preventable ICU readmission in the perioperative practice.[6]

Meanwhile, looking at the patient-specific predisposition to ICU readmission in cardiac surgery,[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] cardiac prehabilitation with its beneficial attributes like aerobic-conditioning, respiratory muscle training, lifestyle-modifications, nutritional and mental-health upliftment can likely provide some potential solutions.[36] [37] [38] [39] [40] Such a possibility is best seen in the light of the cardiac prehabilitation (a domain aimed at maintaining an adequate physiological-physical-psychosocial status of the patients to effectively mitigate the period of surgical stress) literature demonstrating improved postcardiac surgical functional ability and respiratory mechanics and, a reduced incidence of pulmonary complications like pneumonia, particularly when the respiratory causes contribute significantly to ICU readmission.[36] [39] [40] [41]


#

Conclusion

The existing literature implies a substantial morbidity–mortality burden to ICU readmission in cardiac surgical patients. Nevertheless, it is time we comprehend the complexities of ICU readmission better and increasingly focus on the research area from a much-required predictive and a preventative perspective. We are equally hopeful that the adoption of well-designed cardiac prehabilitation programs would be conducive to the overall aim of curtailing the burden of ICU readmission in cardiac surgical practice.


#
#

Conflict of Interest

None declared.

Informed Consent

Not required.


Ethical Approval

Not required.


Authors' Contributions

JK and RM were involved in conceptualization, literature search, and writing of the draft. JKK, IS, RCK, VG, and NSJ reviewed and edited the draft.


  • References

  • 1 Magoon R, Jose J. Multimodal analgesia in paving the way for enhanced recovery after cardiac surgery. [ahead of print, October 18] Rev Bras Cir Cardiovasc 2022; ••• DOI: 10.21470/1678-9741-2022-0058.
  • 2 Engelman DT, Ben Ali W, Williams JB. et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA Surg 2019; 154 (08) 755-766
  • 3 Magoon R, Choudhury A, Sarkar S, Joshi S. Enhanced recovery after cardiac surgery: is it just about putting the bundles together?. Ann Card Anaesth 2021; 24 (02) 276-278
  • 4 Holaubek C, Winter F, Lesjak A. et al. Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36 (8 Pt A): 2339-2343
  • 5 Kimani L, Howitt S, Tennyson C, Templeton R, McCollum C, Grant SW. Predicting readmission to intensive care after cardiac surgery within index hospitalization: a systematic review. J Cardiothorac Vasc Anesth 2021; 35 (07) 2166-2179
  • 6 Magoon R, Jose J. Readmission to the cardiac surgery intensive care unit. J Cardiothorac Vasc Anesth 2022; 36 (04) 1223
  • 7 Bettex D, Rudiger A. Length of ICU stay after cardiac surgery: too long or too short?. J Cardiothorac Vasc Anesth 2018; 32 (06) 2692-2693
  • 8 Thomson R, Fletcher N, Valencia O, Sharma V. Readmission to the intensive care unit following cardiac surgery: a derived and validated risk prediction model in 4,869 patients. J Cardiothorac Vasc Anesth 2018; 32 (06) 2685-2691
  • 9 van Diepen S, Graham MM, Nagendran J, Norris CM. Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases. Crit Care 2014; 18 (06) 651
  • 10 Verma S, Southern DA, Raslan IR. et al. Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score. J Crit Care 2019; 54: 117-121
  • 11 Magruder JT, Kashiouris M, Grimm JC. et al. A predictive model and risk score for unplanned cardiac surgery intensive care unit readmissions. J Card Surg 2015; 30 (09) 685-690
  • 12 Li S, Tang BY, Zhang B. et al. Analysis of risk factors and establishment of a risk prediction model for cardiothoracic surgical intensive care unit readmission after heart valve surgery in China: a single-center study. Heart Lung 2019; 48 (01) 61-68
  • 13 Vohra HA, Goldsmith IR, Rosin MD, Briffa NP, Patel RL. The predictors and outcome of recidivism in cardiac ICUs. Eur J Cardiothorac Surg 2005; 27 (03) 508-511
  • 14 Litmathe J, Kurt M, Feindt P, Gams E, Boeken U. Predictors and outcome of ICU readmission after cardiac surgery. Thorac Cardiovasc Surg 2009; 57 (07) 391-394
  • 15 Kolat P, Guttenberger P, Ried M. et al. ICU readmission after cardiac surgery-still a matter of concern?. Thorac Cardiovasc Surg 2020; 68 (05) 384-388
  • 16 Smith I, Kranke P, Murat I. et al; European Society of Anaesthesiology. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28 (08) 556-569
  • 17 Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017; 126 (03) 376-393
  • 18 Abola RE, Gan TJ. Preoperative fasting guidelines: why are we not following them? The time to act is NOW. Anesth Analg 2017; 124 (04) 1041-1043
  • 19 Arnett SW, Laity JH, Agrawal SK, Cress ME. Aerobic reserve and physical functional performance in older adults. Age Ageing 2008; 37 (04) 384-389
  • 20 Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16 (01) 157
  • 21 Sorensen J, Kondrup J, Prokopowicz J. et al; EuroOOPS study group. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 2008; 27 (03) 340-349
  • 22 Tangvik RJ, Tell GS, Eisman JA. et al. The nutritional strategy: four questions predict morbidity, mortality and health care costs. Clin Nutr 2014; 33 (04) 634-641
  • 23 Lee SI, Ko KP, Choi CH, Park CH, Park KY, Son KH. Does the prognostic nutritional index have a predictive role in the outcomes of adult cardiac surgery?. J Thorac Cardiovasc Surg 2020; 160 (01) 145-153.e3
  • 24 Fried LP, Tangen CM, Walston J. et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 (03) M146-M156
  • 25 Wijeysundera DN, Pearse RM, Shulman MA. et al; METS study investigators. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391 (10140): 2631-2640
  • 26 Jeejeebhoy KN, Keller H, Gramlich L. et al. Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission. Am J Clin Nutr 2015; 101 (05) 956-965
  • 27 Kogan A, Cohen J, Raanani E. et al. Readmission to the intensive care unit after “fast-track” cardiac surgery: risk factors and outcomes. Ann Thorac Surg 2003; 76 (02) 503-507
  • 28 Toraman F, Senay S, Gullu U, Karabulut H, Alhan C. Readmission to the intensive care unit after fast-track cardiac surgery: an analysis of risk factors and outcome according to the type of operation. Heart Surg Forum 2010; 13 (04) E212-E217
  • 29 Magoon R, Jose J. Safeguarding anaesthesia research from spin. Br J Anaesth 2020; 125 (06) e460-e462
  • 30 Maniar H. Hospital readmissions after cardiac surgery: is it a game worth playing?. J Thorac Cardiovasc Surg 2015; 149 (03) 858
  • 31 Magoon R. Implications of practice variability: comment. Comment Anesthesiology 2020; 133 (04) 943-944
  • 32 Wong WT, Lai VK, Chee YE, Lee A. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 2016; 9 (09) CD003587
  • 33 Vollam S, Dutton S, Lamb S, Petrinic T, Young JD, Watkinson P. Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis. Intensive Care Med 2018; 44 (07) 1115-1129
  • 34 Jose J, Magoon R. Early but prudent. J Cardiothorac Vasc Anesth 2022; 36 (05) 1505-1506
  • 35 Probst S, Cech C, Haentschel D, Scholz M, Ender J. A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. Crit Care 2014; 18 (04) 468
  • 36 McCann M, Stamp N, Ngui A, Litton E. Cardiac prehabilitation. J Cardiothorac Vasc Anesth 2019; 33 (08) 2255-2265
  • 37 Makhija N, Magoon R, Kiran U. Mind-body-soul intervention: a cardiac surgical prehabilitation program. J Anaesthesiol Clin Pharmacol 2022; 38 (02) 322-323
  • 38 Anderson L, Thompson DR, Oldridge N. et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016; 2016 (01) CD001800
  • 39 Hulzebos EH, van Meeteren NL, van den Buijs BJ, de Bie RA, Brutel de la Rivière A, Helders PJ. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study. Clin Rehabil 2006; 20 (11) 949-959
  • 40 Waite I, Deshpande R, Baghai M, Massey T, Wendler O, Greenwood S. Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery. J Cardiothorac Surg 2017; 12 (01) 91
  • 41 Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev 2012; 2012 (09) CD004466

Address for correspondence

Rohan Magoon, DM, MD
Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital
Baba Kharak Singh Marg, New Delhi-110001
India   

Publication History

Article published online:
03 December 2022

© 2022. Official Publication of The Simulation Society (TSS), accredited by International Society of Cardiovascular Ultrasound (ISCU). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Magoon R, Jose J. Multimodal analgesia in paving the way for enhanced recovery after cardiac surgery. [ahead of print, October 18] Rev Bras Cir Cardiovasc 2022; ••• DOI: 10.21470/1678-9741-2022-0058.
  • 2 Engelman DT, Ben Ali W, Williams JB. et al. Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations. JAMA Surg 2019; 154 (08) 755-766
  • 3 Magoon R, Choudhury A, Sarkar S, Joshi S. Enhanced recovery after cardiac surgery: is it just about putting the bundles together?. Ann Card Anaesth 2021; 24 (02) 276-278
  • 4 Holaubek C, Winter F, Lesjak A. et al. Perioperative risk factors for intensive care unit readmissions and mortality after cardiac surgery. J Cardiothorac Vasc Anesth 2022; 36 (8 Pt A): 2339-2343
  • 5 Kimani L, Howitt S, Tennyson C, Templeton R, McCollum C, Grant SW. Predicting readmission to intensive care after cardiac surgery within index hospitalization: a systematic review. J Cardiothorac Vasc Anesth 2021; 35 (07) 2166-2179
  • 6 Magoon R, Jose J. Readmission to the cardiac surgery intensive care unit. J Cardiothorac Vasc Anesth 2022; 36 (04) 1223
  • 7 Bettex D, Rudiger A. Length of ICU stay after cardiac surgery: too long or too short?. J Cardiothorac Vasc Anesth 2018; 32 (06) 2692-2693
  • 8 Thomson R, Fletcher N, Valencia O, Sharma V. Readmission to the intensive care unit following cardiac surgery: a derived and validated risk prediction model in 4,869 patients. J Cardiothorac Vasc Anesth 2018; 32 (06) 2685-2691
  • 9 van Diepen S, Graham MM, Nagendran J, Norris CM. Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10,799 surgical cases. Crit Care 2014; 18 (06) 651
  • 10 Verma S, Southern DA, Raslan IR. et al. Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score. J Crit Care 2019; 54: 117-121
  • 11 Magruder JT, Kashiouris M, Grimm JC. et al. A predictive model and risk score for unplanned cardiac surgery intensive care unit readmissions. J Card Surg 2015; 30 (09) 685-690
  • 12 Li S, Tang BY, Zhang B. et al. Analysis of risk factors and establishment of a risk prediction model for cardiothoracic surgical intensive care unit readmission after heart valve surgery in China: a single-center study. Heart Lung 2019; 48 (01) 61-68
  • 13 Vohra HA, Goldsmith IR, Rosin MD, Briffa NP, Patel RL. The predictors and outcome of recidivism in cardiac ICUs. Eur J Cardiothorac Surg 2005; 27 (03) 508-511
  • 14 Litmathe J, Kurt M, Feindt P, Gams E, Boeken U. Predictors and outcome of ICU readmission after cardiac surgery. Thorac Cardiovasc Surg 2009; 57 (07) 391-394
  • 15 Kolat P, Guttenberger P, Ried M. et al. ICU readmission after cardiac surgery-still a matter of concern?. Thorac Cardiovasc Surg 2020; 68 (05) 384-388
  • 16 Smith I, Kranke P, Murat I. et al; European Society of Anaesthesiology. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28 (08) 556-569
  • 17 Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 2017; 126 (03) 376-393
  • 18 Abola RE, Gan TJ. Preoperative fasting guidelines: why are we not following them? The time to act is NOW. Anesth Analg 2017; 124 (04) 1041-1043
  • 19 Arnett SW, Laity JH, Agrawal SK, Cress ME. Aerobic reserve and physical functional performance in older adults. Age Ageing 2008; 37 (04) 384-389
  • 20 Lin HS, Watts JN, Peel NM, Hubbard RE. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16 (01) 157
  • 21 Sorensen J, Kondrup J, Prokopowicz J. et al; EuroOOPS study group. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 2008; 27 (03) 340-349
  • 22 Tangvik RJ, Tell GS, Eisman JA. et al. The nutritional strategy: four questions predict morbidity, mortality and health care costs. Clin Nutr 2014; 33 (04) 634-641
  • 23 Lee SI, Ko KP, Choi CH, Park CH, Park KY, Son KH. Does the prognostic nutritional index have a predictive role in the outcomes of adult cardiac surgery?. J Thorac Cardiovasc Surg 2020; 160 (01) 145-153.e3
  • 24 Fried LP, Tangen CM, Walston J. et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 (03) M146-M156
  • 25 Wijeysundera DN, Pearse RM, Shulman MA. et al; METS study investigators. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391 (10140): 2631-2640
  • 26 Jeejeebhoy KN, Keller H, Gramlich L. et al. Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission. Am J Clin Nutr 2015; 101 (05) 956-965
  • 27 Kogan A, Cohen J, Raanani E. et al. Readmission to the intensive care unit after “fast-track” cardiac surgery: risk factors and outcomes. Ann Thorac Surg 2003; 76 (02) 503-507
  • 28 Toraman F, Senay S, Gullu U, Karabulut H, Alhan C. Readmission to the intensive care unit after fast-track cardiac surgery: an analysis of risk factors and outcome according to the type of operation. Heart Surg Forum 2010; 13 (04) E212-E217
  • 29 Magoon R, Jose J. Safeguarding anaesthesia research from spin. Br J Anaesth 2020; 125 (06) e460-e462
  • 30 Maniar H. Hospital readmissions after cardiac surgery: is it a game worth playing?. J Thorac Cardiovasc Surg 2015; 149 (03) 858
  • 31 Magoon R. Implications of practice variability: comment. Comment Anesthesiology 2020; 133 (04) 943-944
  • 32 Wong WT, Lai VK, Chee YE, Lee A. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev 2016; 9 (09) CD003587
  • 33 Vollam S, Dutton S, Lamb S, Petrinic T, Young JD, Watkinson P. Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis. Intensive Care Med 2018; 44 (07) 1115-1129
  • 34 Jose J, Magoon R. Early but prudent. J Cardiothorac Vasc Anesth 2022; 36 (05) 1505-1506
  • 35 Probst S, Cech C, Haentschel D, Scholz M, Ender J. A specialized post anaesthetic care unit improves fast-track management in cardiac surgery: a prospective randomized trial. Crit Care 2014; 18 (04) 468
  • 36 McCann M, Stamp N, Ngui A, Litton E. Cardiac prehabilitation. J Cardiothorac Vasc Anesth 2019; 33 (08) 2255-2265
  • 37 Makhija N, Magoon R, Kiran U. Mind-body-soul intervention: a cardiac surgical prehabilitation program. J Anaesthesiol Clin Pharmacol 2022; 38 (02) 322-323
  • 38 Anderson L, Thompson DR, Oldridge N. et al. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2016; 2016 (01) CD001800
  • 39 Hulzebos EH, van Meeteren NL, van den Buijs BJ, de Bie RA, Brutel de la Rivière A, Helders PJ. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study. Clin Rehabil 2006; 20 (11) 949-959
  • 40 Waite I, Deshpande R, Baghai M, Massey T, Wendler O, Greenwood S. Home-based preoperative rehabilitation (prehab) to improve physical function and reduce hospital length of stay for frail patients undergoing coronary artery bypass graft and valve surgery. J Cardiothorac Surg 2017; 12 (01) 91
  • 41 Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev 2012; 2012 (09) CD004466

Zoom Image
Fig. 1 The complexities of intensive care unit (ICU) readmission research in cardiac surgery.[4] [5] [6] [7] [8] [9] [10] [11] [12] [27] [28] [29] [30] [31]