ICU protocol may affect the outcome of non-elective abdominal aortic aneurysm repair.

OBJECTIVES: To compare the outcome of patients undergoing non-elective abdominal aortic aneurysm repair at two hospitals under the care of a single vascular surgeon. DESIGN: Prospective and retrospective audit of 6 years of emergency and urgent infrarenal abdominal aortic aneurysm surgery. SETTING: Lewisham and North Southwark Health Authority. SUBJECTS: One hundred and forty-five patients who underwent emergency (46) or urgent (99) repair of an abdominal aortic aneurysm. PRIMARY OUTCOME MEASURE: Hospital mortality. SECONDARY OUTCOME MEASURES: Acute renal failure, intensive care and hospital length of stay distal ischaemia and return to theatre. RESULTS: Mortality was higher at hospital 2 than hospital 1 (28% vs. 9%, p = 0.0068). There was no significant difference in age, sex, cardiac history, hypertension, diabetes, smoking, renal impairment (all p > 0.05). There was no difference in operation time, blood loss and base excess at the end of surgery between the two groups (all p > 0.05). APACHE II scores on admission to ICU were similar in hospital 1 and hospital 2 (median 16 vs. 14, p > 0.03). Pulmonary artery catheters were placed in 18% of patients at hospital 1 compared with 96% at hospital 2. Patients at hospital 2 received more crystalloid (median 2990 vs. 2300 ml+, more colloid (median 4775 vs. 1500 ml), and more inotropes (median 1 vs. 0) than those at hospital 1 in their first 24 h on ICU (all p < 0.001). The volume of urine passed in the first 24 h was similar (median 2410 vs. 2000 ml, p = 0.12) yet the incidence of acute renal failure was higher at hospital 2 compared with hospital 1 (30% vs. 6%, p = 0.001). ICU length of stay of survivors was longer at hospital 2 (median 3 vs. 2 days, p = 0.0018) as was hospital length of stay (median 17.5 vs. 12 days, p = 0.0002). CONCLUSIONS: The outcome at both hospitals is at least as good as other reported series, but it is interesting to note that the hospital which used less pulmonary artery catheters and less intervention (in the form of colloid and inotropes) showed a reduced mortality. These data may be important in assessing the different therapeutic strategies employed postoperatively in the ICU.

A 4-year prospective audit of the cause of death after infrarenal aortic aneurysm surgery.

This study was a 4-year prospective audit of abdominal aortic aneurysm surgery including 222 aneurysm repairs: 106 elective, 76 urgent and 40 emergency. Twenty-five patients died: four who underwent elective surgery, seven urgent and 14 emergency. The two major causes of death, multiple organ failure and colonic ischaemia, were responsible for 11 of the 25 deaths. The three deaths from myocardial infarction all occurred in patients with a leaking aneurysm. Blood loss was significantly higher in patients with multiple organ failure and in those with colonic ischaemia. Methods to identify patients at high risk of massive blood loss and colonic ischaemia may be a way to reduce mortality.