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Reduced length of stay following carotid endarterectomy under general anesthesia
Reduced Length of Stay Following Carotid EndarterectomyUnder General Anesthesia Steven G. Friedman, MD, Anthony J. Tortolani,
BACKGROUND: The widespread use of diagnosisrelated groups has led to a significant reduction in the length of hospital stay following many surgical procedures. In light of this, an examination of early discharge following carotid endarterectomy under general anesthesia was undertaken. PATIENTS AND METHODS: A prospective study of 72 patients was conducted, in which the workup was done on an outpatient basis, admission took place on the same day as surgery, and patients were discharged home on the day after carotid endarterectomy. RESULTS: There were no strokes or deaths following carotid endarterectomy, and only two transient ischemic attacks occurred. In 88% of the cases, discharge was possible on the first postoperative day. CONCLUSIONS: Early discharge following carotid endarterectomy under general anesthesia is safe and cost effective. Am J Surg. 1995;170:235-236.
MD, Manhasset New York
diagncjsis-related groups (DRGs) have played an increasing role in patient management, surgeons have come under pressure to utilize hospital resources more efficiently. This has led to a dramatic reduction in the length c>f stay (LOS) following many surgical procedures. Patients undergoing carotid endarterectomy (CEA) have traditionally heen admitted at least 1 day preoperatively for an angiogram. The postoperative LOS has ranged from 2 to 7 days. Reasoning that the only morbidity from an uncomplicated CEA is that of a neck incision, we began a prospectlve policy of hospital discharge on the first postoperative day. In this policy, preoperative outpatient magnetic resonance angiograms (MRA) and duplex scans replaced conventional cerebral angiograms whenever possible. The results of this prospective policy are reported herein.
to 75 CEAs. They were admitted to the hospital on the morning of surgery and discharged the following day when feasible. This protocol and the risks and alternatives to CEA were thoroughly discussed with every patient prior to scheduling surgery. There were 62 men and 10 women ranging in age from 50 to 82 years (mean 68). Preoperative symptotns included transient ischemic attacks (TIAs) in 50 (69%) cases and stroke in I 1 (159,) cases. Fourteen (19%) CEAs were performed for asymptomatic high-grade stenoses. Risk factors included: coronary artery disease in 35 (49%) patients, dlahetes in 9 (13%), hypertension in 30 (420/o), and a history of smoking in 29 (40%). Conventional cerebral angiograms were the main imaging technique in 34 (47%) patients. Most of t-hese were during the early part of the study. More recently, a combination of MRA and duplex imaging has been used. We have found that MRA alone tends to overestimate the degree of stenosis. These combined studies were used in 30 (42%) individuals. Six (8%) patients underwent only an MRA prior to CEA, and 2 (3%) patients had only a duplex scan. All CEAs were performed under general anesthesia. Blood pressure was monitored with a radial-artery catheter in all case:,. Pulmonary-artery catheters were’ LWJ selcctively and with decreasing frequency ds the study progressed. Routine shunting was employed in ,111except 2 cases, in which passage of a shunt was impossible. All patients were monitored overnight in an intensive care unit. If there were no nrurologic changes, no cardiac or other complications, and no pharmacologic requirements for maintenanL.e of acceptable blood pressure, the patient was transferred to the vascular unit and discharged home severa1 hours later. Several patients were discharged directly from the intensive care unit. Patients uere seen postoperatively within 5 days, then I month, and 3 months later, and every 6 months thereafter.
PATIENTS AND METHODS
RESULTS
From January 1992 until December 1994, 72 patients underwent outpatient imaging of their carotid arteries prior
There were no complications resulting tram cerebral angiography, blRA, or duplex scanning. There were no srrokes or deaths following CEA. Two patients reported unwitnessed TIAs on the morning after surgery. In both cases, right upper-extremity weakness resolved within several minutes. Approximately 10 (14%) patients required IV sodium nitroprussidc in the recovery room to maintain a systolic blood pressure below 180 mm Hg. Only 3 (4%) patients required this blood pressure control until the following day. A total of 66 (88%) patients were discharged on the first postoperative day, 8 (1 I %) on the second postoperative day, apd 1 (1%) on the third day after CEA ( 1 patient had 2 ad-
A
s
From the Division of Vascular Surgery, North Shore University Hospital, Manhasset, New York. Requests for reprints should be addressed to S. Friedman, MD, Division of Vascular Surgery, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030. Presented at the 23rd Annual Meeting of The Society for Clinical Vascular Surgery, Fort Lauderdale, Florida, March 22-26, 1995.
THE AMERICAN
JOURNAL
OF SURGERY”
VOLUME
170
AUGUST 1995
235
missions). The average LOS was 1.13 days. No patient required emergency readmission for neurologic, cardiac, blood pressure, or wound complications. A review of the 9 patients undergoing later discharge revealed that 5 cases were justified: 3 patients required IV pharmacologic control of their hypertension beyond the first postoperative morning and were discharged on the second postoperative day, and the 2 men who experienced postoperative TIAs were observed for at least 1 additional day to ensure neurologic stability. At their request, 3 patients were discharged on the second postoperative day for fatigue, and a lack of familiarity with our protocol by a referring physician accounted for the fourth avoidable late discharge. Complete follow-up (range 1 to 35 months, mean 12) was obtained. There were no additional TIAs. A 78-year-old man suffered a stroke 9 months after his CEA. An angiogram revealed thrombosis at the endarterectomy, and the patient made a fair recovery without additional surgery. All other patients have done well postoperatively with a very favorable response to early discharge.
COMMENTS Paul Collier’ first reported “a safe, cost-efficient approach” to CEA in 1992. He described a prospective policy that included outpatient angiography, admission on the day of surgery, selective use of the intensive care unit, and early discharge. He followed 52 patients prospectively and reported an average LOS of 1.29 days. Only 10% of his patients required an intensive care unit postoperatively, and 88% were discharged on the first postoperative day. An im-
236
THE AMERICAN
JOURNAL OF SURGERY@
VOLUME 170
portant difference between Collier and this report is that 83% of the former’s patients underwent CEA under cervical block anesthesia, whereas all of our patients had general anesthesia. The fact that 88% of the patients in both groups were discharged on the first postoperative day indicates that type of anesthesia is irrelevant to early discharge. Collier also reported no emergency readmissions. The mortality among his patients was zero and the permanent stroke rate was 1.9%. Collier concluded that a short stay with selective use of the intensive care unit is safe and cost effective following CEA. The results of this study are quite similar to those of Collier.’ They indicate that approximately 90% of patients can be safely discharged on the first postoperative day after CEA. The administration of general anesthesia is not an impediment to this policy. The stroke and mortality rates were quite acceptable in this series, and no patient required emergency readmission. DRGs have reduced the LOS for most surgical procedures, including CEA. The average LOS in this series was 1.13 days. Using MRAs and duplex scanning for preoperative imaging has eliminated the need for preoperative hospitalization for angiography. Alternatively, outpatient angiography has been shown to be safe.’ The complete absence of postoperative complications requiring readmission demonstrates the safety and cost effectiveness of early discharge following CEA under general anesthesia.
REFERENCE
1. Collier PE. Carotid endarterectomy:a safe cost-efficient approach. J Vmc Surg. 1992;16:926--933.
AUGUST
1995
BACKGROUND: The widespread use of diagnosisrelated groups has led to a significant reduction in the length of hospital stay following many surgical procedures. In light of this, an examination of early discharge following carotid endarterectomy under general anesthesia was undertaken. PATIENTS AND METHODS: A prospective study of 72 patients was conducted, in which the workup was done on an outpatient basis, admission took place on the same day as surgery, and patients were discharged home on the day after carotid endarterectomy. RESULTS: There were no strokes or deaths following carotid endarterectomy, and only two transient ischemic attacks occurred. In 88% of the cases, discharge was possible on the first postoperative day. CONCLUSIONS: Early discharge following carotid endarterectomy under general anesthesia is safe and cost effective. Am J Surg. 1995;170:235-236.
MD, Manhasset New York
diagncjsis-related groups (DRGs) have played an increasing role in patient management, surgeons have come under pressure to utilize hospital resources more efficiently. This has led to a dramatic reduction in the length c>f stay (LOS) following many surgical procedures. Patients undergoing carotid endarterectomy (CEA) have traditionally heen admitted at least 1 day preoperatively for an angiogram. The postoperative LOS has ranged from 2 to 7 days. Reasoning that the only morbidity from an uncomplicated CEA is that of a neck incision, we began a prospectlve policy of hospital discharge on the first postoperative day. In this policy, preoperative outpatient magnetic resonance angiograms (MRA) and duplex scans replaced conventional cerebral angiograms whenever possible. The results of this prospective policy are reported herein.
to 75 CEAs. They were admitted to the hospital on the morning of surgery and discharged the following day when feasible. This protocol and the risks and alternatives to CEA were thoroughly discussed with every patient prior to scheduling surgery. There were 62 men and 10 women ranging in age from 50 to 82 years (mean 68). Preoperative symptotns included transient ischemic attacks (TIAs) in 50 (69%) cases and stroke in I 1 (159,) cases. Fourteen (19%) CEAs were performed for asymptomatic high-grade stenoses. Risk factors included: coronary artery disease in 35 (49%) patients, dlahetes in 9 (13%), hypertension in 30 (420/o), and a history of smoking in 29 (40%). Conventional cerebral angiograms were the main imaging technique in 34 (47%) patients. Most of t-hese were during the early part of the study. More recently, a combination of MRA and duplex imaging has been used. We have found that MRA alone tends to overestimate the degree of stenosis. These combined studies were used in 30 (42%) individuals. Six (8%) patients underwent only an MRA prior to CEA, and 2 (3%) patients had only a duplex scan. All CEAs were performed under general anesthesia. Blood pressure was monitored with a radial-artery catheter in all case:,. Pulmonary-artery catheters were’ LWJ selcctively and with decreasing frequency ds the study progressed. Routine shunting was employed in ,111except 2 cases, in which passage of a shunt was impossible. All patients were monitored overnight in an intensive care unit. If there were no nrurologic changes, no cardiac or other complications, and no pharmacologic requirements for maintenanL.e of acceptable blood pressure, the patient was transferred to the vascular unit and discharged home severa1 hours later. Several patients were discharged directly from the intensive care unit. Patients uere seen postoperatively within 5 days, then I month, and 3 months later, and every 6 months thereafter.
PATIENTS AND METHODS
RESULTS
From January 1992 until December 1994, 72 patients underwent outpatient imaging of their carotid arteries prior
There were no complications resulting tram cerebral angiography, blRA, or duplex scanning. There were no srrokes or deaths following CEA. Two patients reported unwitnessed TIAs on the morning after surgery. In both cases, right upper-extremity weakness resolved within several minutes. Approximately 10 (14%) patients required IV sodium nitroprussidc in the recovery room to maintain a systolic blood pressure below 180 mm Hg. Only 3 (4%) patients required this blood pressure control until the following day. A total of 66 (88%) patients were discharged on the first postoperative day, 8 (1 I %) on the second postoperative day, apd 1 (1%) on the third day after CEA ( 1 patient had 2 ad-
A
s
From the Division of Vascular Surgery, North Shore University Hospital, Manhasset, New York. Requests for reprints should be addressed to S. Friedman, MD, Division of Vascular Surgery, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030. Presented at the 23rd Annual Meeting of The Society for Clinical Vascular Surgery, Fort Lauderdale, Florida, March 22-26, 1995.
THE AMERICAN
JOURNAL
OF SURGERY”
VOLUME
170
AUGUST 1995
235
missions). The average LOS was 1.13 days. No patient required emergency readmission for neurologic, cardiac, blood pressure, or wound complications. A review of the 9 patients undergoing later discharge revealed that 5 cases were justified: 3 patients required IV pharmacologic control of their hypertension beyond the first postoperative morning and were discharged on the second postoperative day, and the 2 men who experienced postoperative TIAs were observed for at least 1 additional day to ensure neurologic stability. At their request, 3 patients were discharged on the second postoperative day for fatigue, and a lack of familiarity with our protocol by a referring physician accounted for the fourth avoidable late discharge. Complete follow-up (range 1 to 35 months, mean 12) was obtained. There were no additional TIAs. A 78-year-old man suffered a stroke 9 months after his CEA. An angiogram revealed thrombosis at the endarterectomy, and the patient made a fair recovery without additional surgery. All other patients have done well postoperatively with a very favorable response to early discharge.
COMMENTS Paul Collier’ first reported “a safe, cost-efficient approach” to CEA in 1992. He described a prospective policy that included outpatient angiography, admission on the day of surgery, selective use of the intensive care unit, and early discharge. He followed 52 patients prospectively and reported an average LOS of 1.29 days. Only 10% of his patients required an intensive care unit postoperatively, and 88% were discharged on the first postoperative day. An im-
236
THE AMERICAN
JOURNAL OF SURGERY@
VOLUME 170
portant difference between Collier and this report is that 83% of the former’s patients underwent CEA under cervical block anesthesia, whereas all of our patients had general anesthesia. The fact that 88% of the patients in both groups were discharged on the first postoperative day indicates that type of anesthesia is irrelevant to early discharge. Collier also reported no emergency readmissions. The mortality among his patients was zero and the permanent stroke rate was 1.9%. Collier concluded that a short stay with selective use of the intensive care unit is safe and cost effective following CEA. The results of this study are quite similar to those of Collier.’ They indicate that approximately 90% of patients can be safely discharged on the first postoperative day after CEA. The administration of general anesthesia is not an impediment to this policy. The stroke and mortality rates were quite acceptable in this series, and no patient required emergency readmission. DRGs have reduced the LOS for most surgical procedures, including CEA. The average LOS in this series was 1.13 days. Using MRAs and duplex scanning for preoperative imaging has eliminated the need for preoperative hospitalization for angiography. Alternatively, outpatient angiography has been shown to be safe.’ The complete absence of postoperative complications requiring readmission demonstrates the safety and cost effectiveness of early discharge following CEA under general anesthesia.
REFERENCE
1. Collier PE. Carotid endarterectomy:a safe cost-efficient approach. J Vmc Surg. 1992;16:926--933.
AUGUST
1995