Predictors of intensive care unit utilization in gynecologic oncology surgery.

OBJECTIVES: The objectives of the study were to examine factors predicting intensive care unit (ICU) admission after surgery for gynecologic cancer and to determine the impact of ICU admission on survival. METHODS: This was a retrospective study of women undergoing laparotomy for staging and debulking of gynecologic cancer at an academic hospital with tertiary ICU facilities from July 2000 through June 2003. Data on clinicopathologic factors, comorbidities, operative outcomes, and survival were obtained from medical records and institutional cancer registry. The χ analysis, Kaplan-Meier analysis, and Cox regression methods were used for analyses. RESULTS: Two hundred fifty-five patients met our inclusion criteria, 43 of whom had a postoperative admission to the ICU. Factors predicting ICU admission on univariate analysis included age 60 years or older, hematocrit of 30% or less, albumin of 3.5 g/dL or less, and Charlson Comorbidity Index (CCI) score greater than 8; after multivariate analysis, CCI score of greater than 8 (hazard ratio, 2.5; confidence interval, 1.11-5.69) and albumin of 3.5 or less (hazard ratio, 3.8; confidence interval, 1.66-8.85) were associated with an increased risk of ICU admission. After adjusting for albumin and CCI score, ICU admission did not have a significant effect on survival. CONCLUSIONS: The ability to predict ICU admission helps in appropriate counseling of patients and identification of institutional resource utilization.

Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery.

OBJECTIVES: Our aim was to compare perioperative patient controlled epidural analgesia (PCEA) versus patient controlled intravenous analgesia (PCA) after gynecologic oncology laparotomy. METHODS: This was a prospective cohort study where perioperative pain management was decided through patient-centered discussion by anesthesia and surgical teams. The study was designed to accrue 224 patients, to test for equivalence in pain control on postoperative day 1, defined as less than a 10% difference in the proportion of patients with a visual analog scale pain score of <2 (0-10 scale). RESULTS: Two hundred forty patients were enrolled, with 205 patients evaluable for outcomes: 98 received PCA, while 107 received a thoracic level PCEA. Utilization of PCEA was associated with longer anesthesia time pre-op (means: 60 vs. 44 min, p<0.0001), as well as more likely use of pressors during surgery (78% vs. 57%, p=0.002). Pain control was comparable between groups on postoperative day 1 (mean VAS: 2.4 vs. 2.5, p=0.56), but patients with PCEA tended to require more supplemental pain medications. Time to first ambulation was longer in the PCEA patients (means: 49 vs. 36 h post-op, p=0.03), with no difference in time to tolerating regular diet (means: 89 vs. 77 h post-op, 0.17) and no difference in readiness for discharge (means: 144 vs. 145 h post-op, p=0.95). CONCLUSIONS: In this nonrandomized prospective study, selection of a PCEA for perioperative pain management did not improve pain management for patients undergoing gynecologic oncology surgery.

Epidural blood patch for headache after lumboperitoneal shunt placement.

Headaches complicating lumboperitoneal (LP) shunt placement have been attributed to shunt failure with resultant high intracranial pressure or to overdrainage with resultant low intracranial pressure. In this case, a 17-yr-old girl had symptoms of a low-pressure headache after LP shunt placement alleviated by an epidural blood patch. The success of this therapy suggests postdural puncture as a possible cause for low-pressure headache after LP shunt placement. Epidural blood patch may be an alternative initial therapy for some low-pressure headaches after LP shunt placement.