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Development of a predictive model for unplanned intensive care unit admission after pancreatic resection within an enhanced recovery pathway

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Abstract

Background

It is unclear whether routine postoperative admission to the intensive care unit (ICU) can improve outcomes for patients undergoing elective pancreatic surgery. Aim of the study was to determine preoperative and intraoperative predictors of unplanned ICU access in patients undergoing pancreatectomy treated within an established enhanced recovery pathway (ERP) and compare outcomes between direct and late ICU admission.

Methods

A retrospective observational study was conducted on adult patients who underwent pancreatic resection (2015–2019) within an ERP. Patients with preoperatively planned ICU admission were excluded from the study. Multiple multivariate logistic regression models were constructed to verify the association of preoperative and intraoperative variables with study outcomes.

Results

The study included 1486 consecutive patients (cancer diagnosis 60%, pancreaticoduodenectomy 60%; laparoscopic approach 20%; vascular resection 9%). Sixty-six (4.4%) patients had an unplanned ICU admission. Direct admission occurred in 22 (33%) patients and late ICU admission in 44 (67%) patients. Mortality was significantly lower in direct admission group (n = 3, 14%) compared to late admission (n = 25, 57%; p > 0.001). A comprehensive model including preoperative and intraoperative variables identified ASA score ≥ 3 (OR 5.59, p value < 0.001), history of hypertension (OR 2.29, p = 0.029), chronic obstructive pulmonary disease (OR 3.05, p = 0.026), proximal pancreatic resection (OR 2.79, p value 0.046), multivisceral resection (OR 8.86, p value < 0.001), high intraoperative blood loss (OR 1.01 per ml, p < 0.001), and increased serum lactate at the end of surgery (OR 1.25, p = 0.017) as independent factors associated with ICU admission. Area under the ROC curve was 0.891.

Conclusion

Patient comorbidities, surgical complexity, and lactic acidosis at the end of surgery were associated with unplanned postoperative ICU admission. Late ICU admission had very high mortality rates compared to direct admission. Our findings suggest that patients with a combination of preoperative and intraoperative risk factors could benefit from upfront postoperative ICU admission to potentially improve postoperative outcomes.

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Acknowledgements

The authors are grateful to Fondazione Umberto Veronesi for supporting Dr. Guarneri’s research fellowship.

Funding

Giovanni Guarneri’s research fellowship, unrelated to this study, was funded by Fondazione Umberto Veronesi.

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Authors and Affiliations

  1. Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy

    Nicolò Pecorelli, Giovanni Guarneri, Domenico Tamburrino, Stefano Crippa, Stefano Partelli & Massimo Falconi

  2. Vita-Salute San Raffaele University, Milan, Italy

    Nicolò Pecorelli, Maria Teresa Salvioni, Alessia Vallorani, Stefano Crippa, Stefano Partelli, Luigi Beretta & Massimo Falconi

  3. Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy

    Stefano Turi & Luigi Beretta

  4. Health Directorate, San Raffaele Scientific Institute, Milan, Italy

    Pietro Barbieri

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  1. Nicolò Pecorelli
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  2. Stefano Turi
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  3. Maria Teresa Salvioni
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  4. Giovanni Guarneri
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  11. Massimo Falconi
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Correspondence to Nicolò Pecorelli.

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Disclosures

Nicolò Pecorelli, Stefano Turi, Maria Teresa Salvioni, Giovanni Guarneri, Pietro Barbieri, Alessia Vallorani, Domenico Tamburrino, Stefano Crippa, Stefano Partelli, Luigi Beretta, and Massimo Falconi have no conflicts of interest or financial ties to disclose.

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Accepted as Oral presentation at SAGES 2022 Annual Meeting in Denver (CO).

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Pecorelli, N., Turi, S., Salvioni, M.T. et al. Development of a predictive model for unplanned intensive care unit admission after pancreatic resection within an enhanced recovery pathway. Surg Endosc 37, 2932–2942 (2023). https://doi.org/10.1007/s00464-022-09787-6

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  • DOI: https://doi.org/10.1007/s00464-022-09787-6

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