"Just in time" decision making for ICU care after carotid endarterectomy

BACKGROUND: Many patients undergoing carotid endarterectomy (CE) do not require active intensive care unit (ICU) care (AIC). Until recently, all patients spent 24 hours postoperatively in an ICU, but many of these patients were simply monitored and did not need unique ICU services. METHODS: To aid in developing a selective policy for ICU admission following CE, we reviewed preoperative risk factors, recovery room course, and total hospital stay of 126 patients for 2 years when postoperative ICU admission was routine. Preoperative assessment included presence or absence of cardiac disease, hypertension, severe respiratory disease, diabetes, arrhythmia, renal failure, and a Goldman cardiac risk score. The operative, recovery room, and ward records were reviewed for conditions requiring AIC. Requirement for AIC was defined as need for infusion of vasoactive, bronchodilator, or antiarrhythmic medication beyond the recovery room period. In addition, treatment for coronary ischemia or MI, need for active diuresis, perioperative neurological event, or requirement for mechanical ventilation were indications for AIC. RESULTS: There were 132 CEs in 126 patients; 37% required AIC as defined above. When patients who required AIC were compared with patients not requiring AIC, the only significant difference was the number of risk factors per patient. Goldman cardiac risk class I patients were at less risk for cardiac morbidity than the combined Class II and III patients. CONCLUSIONS: In an individual patient, preoperative risk assessment does not aid in predicting the need for AIC following CE. Selection of patients for ICU admission following CE can be accurately determined by a short period of recovery room observation.