INTRODUCTION
As a center for malignant pleural mesothelioma (MPM), UCLA has one of the largest American cohorts of patients undergoing thoracotomy for complete visceral and parietal pleurectomy/decortication (P/D). In the anesthesiology literature, evidence supports the association of intraoperative hypotension with increased operative morbidity and mortality. Our aim is to determine the incidence and impact of significant perioperative hypotension in patients undergoing complete P/D, along with other factors contributing to ICU admission, 30-day readmission, and mortality.
METHODS:
We reviewed the electronic records of 71 patients with mesothelioma who underwent complete P/D between April 2013 and November 2016. We collected data regarding survival, complications, and factors leading to ICU admission and 30-day readmission.
RESULTS:
Overall surgical mortality, defined as death within 30 days or before discharge, occurred in two patients (2.8%). Follow-up information was not available for all patients because some obtained primary care outside the UCLA system. An additional 20 patients expired at intervals ranging from one month to 17 months after surgery, with 13 of these patients surviving less than six months.
ICU Admission:
17 patients (24%) were admitted to ICU:
* Six patients were extubated in the OR, transferred to PACU, and subsequently sent to the ICU because of hypotension.
* Five were transferred directly from OR to ICU for intraoperative hypotension, respiratory insufficiency, or aborted procedures.
* Six were transferred from ward care to ICU because of adverse events that necessitated emergency transfer, with length of stay from 14 to 58 days. Five experienced either cardiac arrest or near-arrest cardiorespiratory events following prolonged hypotension during the first few postoperative days.
30-day Readmission:
Only patients readmitted to UCLA had records available for review. Of the 15 patients who survived to hospital discharge after ICU admission, two (13%) were readmitted within 30 days of discharge. Of the 54 patients who did not receive ICU care, 21 (38.8%) presented again within 30 days. Four of these were Emergency Department visits only, while 17 patients required admission (31.5%). The most common symptom was shortness of breath; two readmitted patients expired.
DISCUSSION
The short-term mortality rate of 2.8% is comparable to that reported in other large series. The incidence of postoperative hypotension as a precursor to more severe adverse events is of concern. Though numbers are small, patients transferred to ICU from the ward experienced worse outcomes including prolonged length of stay and increased mortality.
We intend to continue this study to analyze duration and severity of hypotension, to look for other risk factors and associations that could predict a need for ICU care, and to identify possible modifications to our care pathway. As a quality improvement initiative, this work has the potential to lead to better outcomes and fewer complications for this high-risk patient cohort.
