Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Catheter Complications

In: Surgical Patients

15 Mar 2015

Prospective Trial of Supranormal Values of Survivors as Therapeutic Goals in High-Risk Surgical Patients: Catheter ComplicationsComplications were observed less frequently in patients treated by the protocol in both series (Table 8). Both the proportion of patients who had complications and the average number of complications per patient were lowest in the PA-protocol group (p<0.05). There was a higher incidence of patients with multiple complications in the control group of both series. There were 17 patients (57 percent) in the CVP group who in the opinion of the primary service developed indications for PA catheterization for management in the postoperative period; seven (29 percent) of these patients subsequently died.

Of the 55 patients in the second series who fulfilled the entrance criteria but were not randomized, ten were operated on immediately; four of these died. This group was too small for further statistical analysis. The remaining 45 patients (NR group) were not considered sufficiently ill in the opinions of their primary service resident and attending staff to warrant invasive monitoring and declined the study. Ironically, despite the initial reluctance, 27 (60 percent) of these patients subsequently had a PA catheter placed by their primary service, usually after they developed lethal postoperative complications. This nonrandomized, nonemergency group had the highest mortality and morbidity (Tables 7 and 8).
Table 6 compares mortality of patients whose monitoring was begun preoperatively with that of patients whose monitoring was started postoperatively in the first series. The data is stratified in those with normal, high, and low preoperative Cl values. Table 9 summarizes the mortality rates for both series and the intervening control periods over a 7y2-year study.
Catheter Complications
There were transient dysrhythmias (almost always premature ventricular complexes) on insertion of the PA catheter in 12 percent, local infection or inflammation at the catheter site in 5 percent, and positive blood cultures drawn from the PA catheters in 44 percent of the septic patients. There were no major or permanent complications that could be attributed to the PA catheters.
Cost Analysis
The hospital charges in the second series averaged $31,438 for patients in the nonrandomized group, $30,748 for the CVP group, $37,335 for the PA-control group and $27,665 for the PA-protocol group. The average patient expenditure distributed over the survivors was $50,525 for the nonrandomized group, $40,106 for the CVP group, $58,950 for the PA-control group and $28,690 in the PA-protocol group.
Table 8—Complications

Series 1 Series 2
Control (N = 151) Protocol (N = 101) Nonrandomized (N = 45) CVP-Control (N = 30) PA-Control (N = 30) PA-Protocol (N = 28)
Complications in the therapeutic groups
Respiratory failure 64 33 11 7 9 1
Renal failure 29 9 10 7 7
Sepsis and septic shock 44 23 11 6 9
Hepatic failure 6 3 2 2 2
Cardiac arrest 11 5 3 2
Pulmonary edema 8 4 2 3 2
Pleural effusion 2 2 2 2 3 3
Wound infection 5 4 2 2 2 1
DIC 13 5 2 2
Acute MI 5 1 3
Evisceration 6 1 1
Abdominal abscess 13 2 1 1
Postoperative hemorrhage 11 3 1 1 1
Pancreatitis 14 3 1 1
Gastric outlet obstruction 0 0 1
Urinary tract infection 0 0 1 1
Cerebral infarct 0 1 1
Pulmonary embolism 1 0
No. of complications 232 98* 52 31 39 11*
Complications per patient 1.54 0.97 1.16 1.03 1.3 0.39
Frequency of multiple complications
Patients with complications 99 (66%) 61 (61%) 28 (62%) 15 (50%) 15 (50%) 8 (28%)t
Patients with 0 complications 52 (34%) 40 (39%) 17 (38%) 15 (50%) 15 (50%) 20 (71%)
Patients with 1 complication 42 (28%) 38 (38%) 13 (29%) 7 (23%) 3 (10%) 5 (18%)
Patients with 2 complications 21 (14%) 14 (14%) 8 (18%) 3 (10%) 4 (13%) 3 (11%)
Patients with 3 complications 20 (13%) 6 (6%) 5 (11%) 2 (7%) 4 (13%) 0
Patients with 4 or more complications 15 (10%) 3 (3%) 2 (4%) 3 (10%) 4 (13%) 0

Table 9—Summary of Mortality of the Prospective Series

Series Control Protocol
Date Number Deaths Number Deaths,%
Series 1 1/78-6/80 168 57 (34%) 108 21 (19%)
Control period between trials 6/80-5/83 239 66 (28%)
Series 2 5/83-5/84 105 34 (32%) 28 1 (4%)
Control period after trials 5/84-5/85 160 40 (25%)
Total 672 197 (29%) 136 22 (16%)

About this blog

Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.