Journal of Vascular Surgery
Volume 34, Issue 1 , Pages 13-16, July 2001

Timing of postcarotid complications: A guide to safe discharge planning☆☆☆★

Presented at the Twenty-fourth Annual Meeting of the Midwest Vascular Surgical Society, Scottsdale, Ariz, Nov 6-8, 2000.

Division of Peripheral Vascular Surgery, Department of Surgery, Loyola University Medical Center. Maywood, Ill

Received 13 November 2000; accepted 21 February 2001.

Article Outline

Abstract 

Objectives: Currently, our standard of practice is that patients undergoing carotid endarterectomy (CEA) may be safely discharged on the first postoperative day. Because many patients do not appear to require overnight observation, we wanted to determine the safety and feasibility of same-evening discharge by establishing the timing of postoperative complications, which may potentially require operative intervention. Methods: A total of 835 consecutive patients undergoing CEA were retrospectively reviewed. Sixty-two patients had a postoperative wound hematoma or neurologic deficit (ND) (transient ischemic attack or stroke) within 24 hours of their operation, complications potentially requiring a second operation. Excluded were 64 patients not eligible for same-day discharge because of other reasons (eg, heparinization, CEA with coronary artery bypass grafting). Results: Sixty-two patients (8.0%) had ND (26 [3.4%]) or neck hematoma (NH) (36 [4.7%]) within 24 hours of their CEA. Nineteen (73%) of the NDs were diagnosed in the operating room or recovery room, 5 (19%) within 8 hours of the operation, and 2 (7.7%) after 8 hours but in less than 24 hours. Of the NHs, 23 (66%) were diagnosed in the recovery room, 11 (31%) within 8 hours, and 1 (2.7%) after 8 hours. Of the outliers, one patient experienced a blowout of the vein graft occurring on postoperative day 1, one patient had a delayed ipsilateral stroke, and one had a vertebrobasilar stroke. Overall, only three of 773 (0.4%) patients undergoing CEA had a complication occurring more than 8 hours after operation. Conclusion: NDs and NHs in post-CEA patients occurred within 8 hours of operation in 95% of those patients experiencing these complications or 99.6% of all CEA patients. These data indicate that same-evening discharge may be safely performed without increasing the adverse effects of stroke or hematoma. This plan has cautiously been initiated at this institution. (J Vasc Surg 2001;34:13-6.)

 

The treatment algorithm for patients undergoing routine carotid endarterectomy (CEA) has evolved over the past decade. Before the 1990s patients were admitted to the hospital preoperatively and evaluated with invasive angiography. After undergoing CEA they would be observed in the intensive care unit (ICU) before being transferred to the floor with subsequent discharge home. This algorithm has been truncated considerably within the last decade. Several studies have demonstrated the accuracy of duplex ultrasonography in the evaluation of carotid disease, and thus, angiography is infrequently used in the evaluation of carotid disease.1, 2, 3, 4 Other studies have proved the safety of routine postoperative floor admission5, 6, 7 and discharge home the morning after surgery.8, 9, 10 Currently, we follow this algorithm at our institution. However, we noted that after CEA many patients were ambulatory, were eating, and were free of complaints the night before discharge, and thus, we questioned whether overnight stay for all patients undergoing CEA was necessary.

As a first step toward establishing the feasibility of early discharge, we sought to identify when certain complications occur. Cardiovascular complications (eg, labile hypotension or hypertension, arrhythmias, acute myocardial infarction) have been documented to occur early after CEA.5, 6 The timing of postoperative stroke and bleeding, complications that may require reoperation, however, has not been as well established. If stroke and postoperative bleeding become evident shortly after operation, then discharge later the same day may be feasible in otherwise uncomplicated patients.

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Patients and methods 

We retrospectively reviewed the medical records of 835 consecutive CEA patients over a 10-year period (1988-1998) of whom 62 had either a neurologic deficit (ND) or neck hematoma (NH) within 24 hours after CEA. ND is defined as either a permanent or transient ischemic event. Excluded were 64 patients who required a hospital stay of more than 24 hours for other reasons (eg, heparinization of cardiac lesions [n = 21], concomitant coronary artery bypass grafting [n = 28], or other operations [n = 15]). Patients admitted to the ICU for monitoring were not excluded because most were discharged within 24 hours. Complications occurring or recognized more than 24 hours after CEA were not included. These patients would have already been discharged according to our current patient care plan, and thus, the treatment of these complications would not have been altered.

All CEAs were performed by one of five fellowship-trained, board-certified, attending vascular surgeons. Use of carotid shunting was not routine, but rather, the use was based on stump pressures and the surgeon's discretion.11, 12 Intraoperative duplex and general anesthesia were used almost universally. No drains were placed in the cervical incision in any patient. Charts and institutional databases were reviewed for information about postoperative development of ND or NH, timing of the complication in relation to the end of surgery, necessity for reoperation, and outcome.

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Results 

A total of 835 CEAs were performed during the 10-year period. The patients had the usual mix of comorbidities with 30% having significant hypertension, 24% diabetes mellitus, and 36% known coronary artery disease, with 21% of patients having had a previous acute myocardial infarction.

Sixty-two patients (8.0%) experienced either an ND (n = 26 [3.4%]) or an NH (n = 36 [4.7%]) within 24 hours of their CEA (Table I).

Table I. Total complications
NHsNDs
No. patients623626
%8.0%4.7%3.4%
Nineteen patients had a related stroke, three a related transient ischemic attack (TIA), and six had a stroke syndrome unrelated to the operated carotid artery. Nineteen (73%) of the NDs were diagnosed in the operating room (OR) or recovery room (RR) and five (19%) within 8 hours of the operation. Two patients (7.7%) experienced an ND after 8 hours but in less than 24 hours. One patient had a delayed (approximately 18 hours postoperative) ipsilateral hemispheric stroke, and one patient had a vertebrobasilar stroke. Of the NHs, 24 (66%) were diagnosed in the RR and 11 (31%) within 8 hours. Only one patient (2.7%) with a vein patch blowout had an NH develop later than 8 hours postoperatively (Table II).
Table II. Timing of complications
OR/RR< 8 h> 8 h
NH24 (66%)11 (31%)1 (2.7%)*
ND19 (73%)5 (19%)2 (7.7%)*
*See text for details.
Thirty-six patients returned to the OR, 10 for a possible occluded carotid artery and 26 for hematoma evacuation. Overall, less than 0.4% of 773 patients undergoing CEA had a complication occurring between 8 and 24 hours after operation.

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Discussion 

The methodology of changing a patient care algorithm is as follows: A cohort of patients is reviewed to establish that the previous care was either incorrect or unnecessary. A new patient care pathway is designed and then prospectively tested. If this new pathway is found to be safe and efficacious, the pathway can then become an established practice.9, 14, 15, 16 For example, before the last decade, preoperative angiography was the accepted standard for evaluation of carotid stenosis. However, during the 1990s numerous studies demonstrated that a duplex examination was not only accurate but could also suffice as the sole preoperative test for diagnosing carotid stenosis.1, 2, 3, 4 Historically as well, postoperative CEA patients were routinely monitored in an ICU and then hospitalized on a medical-surgical floor for several more days before eventual discharge home. However, again numerous studies undertaken during the 1990s demonstrated that most ICU stays were not necessary, whereas others demonstrated the safety of discharging patients on the first postoperative day. As a result of these studies, many physicians changed their patient care algorithm by transferring patients to the floor after postanesthesia monitoring in the RR5, 6, 7 and discharging patients from the hospital the next day.

The above changes instituted in the perioperative care of CEA patients over the past decade beg the question, how has the patient fared? By examining outcome measures such as mortality, readmission, and postoperative complication rates, Holloway et al13 have shown that the changes instituted have not compromised patient care despite the fact that the average patient age and the number of comorbidities increased as these changes were being instituted. These changes in patient care have led many surgeons, including those in this group, to establish a plan to discharge their patients on postoperative day 1.8, 9, 10, 14

We noted that many of our patients were alert, walking, and eating their usual diet the evening of operation and did not appear to require hospitalization. However, is it safe to discharge patients hours after a major vascular procedure in the neck? From this institution, Morasch et al5 previously established that cardiac arrhythmias, hypotension, and acute myocardial infarction manifest early after CEA. However, neither this institution nor others have previously established exactly when the complications of stroke, TIA, and NH occur. NHs may need to be surgically drained, and patients who have had a stroke with an acutely occluded carotid artery after operation are said to be best treated with prompt restoration of flow. If patients have either of these complications after being discharged home, they may be denied prompt reexploration and may be harmed because of early discharge. Conversely, if these complications occur almost exclusively within hours of the operation, then discharge of patients without ND or NH later the same day would not only be feasible, but safe. Thus, we initiated this review of our patients with NHs and NDs after CEA as a prelude to changing our patient care algorithm.

In this study we found that most (69%) postoperative NDs and NHs are diagnosed in either the OR or the RR with an additional 26% diagnosed after the patient had been discharged from the RR but before 8 hours elapsed. Only three of 62 complications occurred 8 hours or more after operation, and they are detailed in the next paragraphs.

The one delayed postoperative hematoma (> 8 hours) was the result of a rent in the vein patch angioplasty that occurred on the first postoperative morning. This patient had been hypertensive all evening in the ICU. No such adverse events happened with synthetic patch angioplasty, which is currently the technique used in this institution.

Two (7.7%) of 26 NDs occurred more than 8 hours after the operation. An ipsilateral hemispheric stroke was diagnosed the morning after surgery in the ICU when the patient experienced sudden onset of right-arm paresia and aphasia. He was promptly reexplored, an occluded carotid was opened, but he had minimal postoperative improvement. In retrospect, the patient had been experiencing TIAs since the RR, but the nature and importance of these symptoms went unrecognized by the housestaff and nursing personnel. A second patient with delayed ND experienced a vertebrobasilar stroke. Postoperatively, the patient had nausea and emesis, but the stroke was not diagnosed until the patient arose from bed and was noted to have an ataxic gait. Had the patient ambulated earlier in the day, the diagnosis would most likely have been made sooner.

Our current policy is to discharge patients the morning after operation. Thus, late complications are not detailed in this article. Suffice it to say, there were no late strokes, and delayed hematomas occurred only in those hospitalized patients receiving anticoagulants. Of the complications occurring within 24 hours of operation, we diagnosed 95% of them within the first 8 postoperative hours. Conversely, only three patients detailed above had a complication manifest more than 8 hours after CEA. The NH occurred after a technique that is no longer used, the care for the patient who had a vertebrobasilar stroke was not altered, and the one related hemispheric stroke was recognized late but should have been recognized earlier.

What is to be gained by same-evening discharge? The cost savings by discharging an individual patient home 12 to 18 hours earlier is not the subject of this review but should be relatively little. Our institution, as well as others,17 is frequently more than 95% occupied. Thus, a discharge at 6:00 PM means that there is an available bed so that a patient may be transferred from the RR, ICU, or emergency department and relieve congestion in these units. Finally, if one assumes that early discharge reduces cost, this reduction in cost makes CEA more fiscally attractive when the operation is compared with carotid angioplasty.

This review establishes that same-evening discharge may be done with safety, in regard to the complications of stroke and NH. This review specifically excludes patients requiring prolonged monitoring and care of comorbid problems (eg, postoperative coronary artery bypass grafting, other operations, or those patients hospitalized for anticoagulation). As a priori these patients are not candidates for same-evening discharge. The findings of this study do not mean that all patients may be or ought to be discharged early. Many CEA patients are older and have multiple medical problems. Some patients lack either a satisfactory home environment or a trusted caregiver. Other patients may live long distances from the hospital. Therefore, all post-CEA patients need to be individually assessed. For those healthier patients who are up and about, eating, and relatively free of complaints, same-evening discharge should be feasible and safe. In fact, this policy has been cautiously initiated at our institution.

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Discussion 

Dr Patrick J. O'Hara  (Cleveland, Ohio). Dr Sheehan, I noticed you had the one delayed hematoma from a rent in the vein patch. What was the location of the harvest site of the vein patch? In our experience when we have taken vein from the groin, we have not seen a patch rupture, but we have had some when the vein is taken from the ankle. I wonder if this happened to be from the ankle.

Dr Maureen Sheehan.  The vein graft was taken from the groin.

Dr Gregory Zenni  (Cincinnati, Ohio). Very nice presentation. It is good to see that my alma mater is still somewhat cutting edge here.

A couple questions for you. As far as your hematomas go, are you reversing your heparin? If you are not, do you think that would lower your incidence of hematomas?

My second question is, what is your current status for anesthesia? Does the use of your anesthetic affect your ability to discharge them?

Thanks.

Dr Sheehan.  We do not routinely reverse the heparinization in our patients, and whether or not that would decrease our incidence of hematoma is something to consider. However, I do not think the incidence is that great that we have considered it to this point.

As for anesthesia, the majority of our carotid endarterectomies are done under general anesthesia, and this has caused some problems with sending our patients home. Some patients are nauseous and cannot go home the same day, but they stay until their nausea resolves and they can eat.

Dr Gerald Zelenock  (Royal Oak, Mich). Excellent paper. Do you have a protocol for the patients who are discharged home—that they be followed by a nurse clinician or a telephone survey to assess their well being?

Dr Sheehan.  Since instituting this we have one of our nurses follow up the next morning, calling the patients to find out if they have had any problems. To this point, we have had no problems with the patients who have been discharged home.

Dr Bruce Gewertz  (Chicago, Ill). Maureen, that was beautifully presented, and I know the work by our colleagues at Loyola is outstanding in its outcome. I am conflicted about getting up and saying this, but I wonder what the patients think about this. Have we pushed the envelope so far that we will be doing the carotids in the mall like the eye surgery? Is it really in the patient's best interest to go home, and are the savings worth it? My concern is that many of our patients, and I know your patients, are elderly people who are being watched by other persons who may have medical problems themselves, and I wonder what the patients' acceptance of this perfectly rational discharge planning has been.

Dr Sheehan.  I think part of sending home a patient successfully the same day starts in the preoperative counseling. You need to tell them that if they are feeling well, etc, there is a chance they can go home that same day. If they are prepared for that, it is not as much of a shock on the day of surgery. The patients tend to accept going home the same day pretty well because they feel well enough and they want to go home. We are not pushing the patients out the door. If they say that they are not comfortable going home or we are uncomfortable sending them home either because they live too far away or because we do not feel that they have reliable help at home, then we are keeping them in the hospital overnight.

Dr William Turnipseed  (Verona, Wis). Maureen, I wonder if you might comment on this policy for the poor old country doctors who are taking care of farmers that live 150 miles away. If you send them home in 8 hours and if they have a problem out there at the farm, who looks after the patient? A couple of years ago when this whole process of early discharge was becoming more popular I had a conversation with Greg Sicard. He had looked over his data and found that about 98% of all of the postoperative problems occurred within the first 24 hours. You have said that about 93% of them occur within the first 8 hours. Do you think your policy would hold for a rural practice plan as opposed to a metropolitan area?

Dr Sheehan.  I think again that this must be used judiciously, and if your patients live that far away I do not think at this point in time it is wise to send them home. We do not send home any of our patients who live a significant distance away because we are concerned that should they develop a problem, they would not be able to get back to the hospital in time to be treated appropriately.

Dr Richard Pennell  (St Louis, Mo). Just a word of caution. I recently did a carotid subclavian bypass on a patient and sent him home as a 23-hour stay, not an inpatient, and Medicare, using the new APCs that were just begun in August, is refusing to pay our hospital for reimbursement for the case.

Dr Walter Whitehouse  (Ann Arbor, Mich). This is a very nice series, and it stimulates a few questions. There are reasons to streamline care and some have to do with better outcomes. Some have to do with cost savings. I think this paper relates as much to cost savings as anything. I wonder if you have looked at the actual cost of your old protocol versus your new protocol, that is, a 24-hour stay versus something that is somewhat less than 24 hours.

Dr Sheehan.  We attempted to look at cost savings in this study, but trying to get those numbers from our hospital and from the nationwide database was more difficult than we had hoped, so we do not have those numbers. The reason that we are discharging patients the same day is because greater than 50% of the time our hospital is at greater than 95% capacity. If we can open up a bed and get another patient in and treated, we feel that it might be beneficial to the patient care overall.

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References 

  1. Blakeley DD, Oddone EZ, Hasselblad V, Simel DL, Matchar DB. Noninvasive carotid artery testing: a meta-analytic review. Ann Intern Med. 1995;122:360–367
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  9. Collier PE. Are one-day admissions for carotid endarterectomy feasible?. Am J Surg. 1995;170:140–143
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  11. Baker WH, Littooy FN, Hayes A, Dorner D. Carotid endarterectomy without a shunt: the control series. J Vasc Surg. 1984;1:50–56
  12. Littooy FN, Halstuk K, Mamdani M, Calandra D, Hayes AC, Baker WH. Factors influencing morbidity of a carotid endarterectomy without a shunt. Am Surg. 1984;50:350–353
  13. Holloway RG, Witter DM, Mushlin AI, Lawton KB, McDermott MP, Samsa GP. Carotid endarterectomy trends in the patterns and outcomes of care at academic medical centers, 1990-1995. Arch Neurol. 1998;55:25–32
  14. Kraiss LW, Kilberg L, Critch S, Johansen KJ. Short-stay carotid endarterectomy is safe and cost effective. Am J Surg. 1995;169:512–515
  15. Syrek JR, Calligaro KD, Dougherty MJ, Doerr KJ, McAfee-Bennett S, Ravioloa CA, et al.  Five-step protocol for carotid endarterectomy in the managed helath care era. Surgery. 1999;125:96–101
  16. Hirko MK, Morasch MD, Burke K, Greisler HP, Littooy FN, Baker WH. The changing face of carotid endarterectomy. J Vasc Surg. 1996;23:622–627
  17. Goldberg C. Emergency crews worry as hospitals say no vacancy. The New York Times. 2000 Dec 17;27; Sect 1

☆ Competition of interest: nil.

☆☆ Reprint requests: William H. Baker, MD, Loyola University Medical Center, Department of Surgery, 2160 S First Avenue, Maywood, IL 60153.

★ Please see commentary by Dr John J. Ricotta on pages 178-9 .

PII: S0741-5214(01)57552-7

doi:10.1067/mva.2001.116106

Refers to article:

  • Regarding: “Timing of postcarotid complications: A guide to safe discharge planning”

    John J. Ricotta
    Journal of Vascular Surgery July 2001 (Vol. 34, Issue 1, Pages 178-179)

Journal of Vascular Surgery
Volume 34, Issue 1 , Pages 13-16, July 2001

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