|
Home | Issues | eMJA shop | Classifieds | Contact | More... | Topics | Search | Login | Buy full access |
Does the risk of complications warrant more than overnight stay?
MJA 1998; 168: 149-150
|
Each year an estimated 32 000 Australians suffer a first-ever stroke1 (about 80% of which are ischaemic2 ), and a similar number are affected by transient ischaemic attacks (TIAs).3 About 40% of patients with ischaemic stroke syndromes have extracranial arterial lesions accessible to surgery,4 most commonly carotid stenosis. Significant carotid stenosis is present in an estimated 80 000 Australians aged 50-74 years.2 For many with this condition, carotid endarterectomy is the treatment of choice.2 The operation of carotid endarterectomy is more or less standardised, although controversies persist over technical issues (eg, local versus general anaesthesia, need for monitoring of cerebral perfusion or brain function, indications for shunting to maintain carotid flow during carotid clamping, and closure of the arteriotomy directly versus with a patch).5 Nevertheless, for most patients, the operation is straightforward. In this issue of the Journal, Bourke and Crimmins report 59 patients who underwent carotid endarterectomy with short hospital stay.6 Patients were admitted on the morning of the operation (performed under local anaesthesia) and discharged the next day. Before admission, patients were counselled about possible complications and how to respond. Six were excluded from overnight hospital stay for good reasons. No strokes or major complications occurred among the 59, although one developed the reperfusion syndrome which threatened a haemorrhagic stroke, another developed headaches severe enough to prolong hospital stay, and a third was returned to the operating theatre because of complications in the groin wound. The major conclusion of the report is that patients can safely undergo carotid endarterectomy with only an overnight stay. Short-stay carotid endarterectomy is practised in some other Australian institutions, notably Victorian teaching hospitals, probably in response to management efficiencies driven by casemix funding. In the United States, overnight carotid endarterectomy has been usual for several years, with some groups even advocating same-day carotid endarterectomy (with discharge the afternoon or evening of the operation). What are the main disadvantages of overnight carotid endarterectomy? Apart from inconvenience, there is the possibility that longer hospital stay might allow the complications of the surgery to be prevented or better treated. Firstly, stroke may follow carotid endarterectomy. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) found perioperative stroke rates of 1%-5%,7 while rates are considerably higher in many institutions.8 The neurologic deficit may be evident on conclusion of the operation, but more often there is a latent period during which the patient is awake and neurologically intact. For example, unpublished data from the European Carotid Surgery Trial (ECST) show that, among 1807 patients who underwent carotid endarterectomy, 85 had a perioperative stroke or died within the first 24 hours after surgery, 14 on the second day, five on the third day, eight on the fourth day, and 13 from the fifth day onwards (Dr Graeme J Hankey, Neurologist, Royal Perth Hospital, Perth, WA, personal communication, 1997). Most delayed strokes are caused by thrombotic occlusion of the internal carotid artery or by embolism of thrombus formed at the site of the reconstruction. 9 Stroke progression will be halted, and about half the patients returned to normal, by urgent repeat disobliteration of the carotid reconstruction.9 Therefore, based on the ECST data, remaining in hospital a second night might mitigate or prevent perhaps 5% of perioperative strokes. Cerebral haemorrhage occurs in about one per 400 patients, typically from the fifth day onwards.10 Often there is preceding hypertension, headaches, and sometimes epileptiform convulsions. These are attributed to cerebral hyperperfusion, and treated by reduction of blood pressure to normal, bedrest, and pain relief. If a late stroke occurs, urgent cerebral computed tomography is needed to distinguish cerebral haemorrhage from infarction, as treatment otherwise usually includes heparin and perhaps redo carotid reconstruction. A second complication after carotid endarterectomy is temporary instability in control of blood pressure and heart rate, which occurs in a little over half of patients.11 In 60% of these, hypertension (presumably due to interference with carotid baroreceptors) persists and may lead to cerebral oedema and stroke. The other 40% develop hypotension and/or bradycardia and may require heparin to minimise the chance of carotid thrombosis, although fluid replacement and atropine are usually effective. The cardiovascular instability usually resolves within 24 hours of surgery, and patients may be discharged when their blood pressure has returned to the usual preoperative level. A third early hazard after carotid endarterectomy is bleeding into the neck wound. At St Vincent's Hospital, Sydney, haemorrhage from the carotid suture line or other vessels needs to be corrected urgently in the operating theatre after about one per 200 operations (unpublished data), while at the Cleveland Clinic, United States, cervical haematoma requiring drainage developed after 1.5% of operations.12 Although most developed within the first 24 hours after surgery, some were delayed to the second or third day. A neck haematoma can rapidly obstruct the airway, and, as laryngeal oedema makes endotracheal intubation difficult, an expert anaesthetist and facilities for urgent tracheotomy should be available. Sudden disruption of the arterial suture line with heavy bleeding can be fatal or lead to a stroke through impaired carotid flow. None of these complications affected the patients reported by Bourke and Crimmins, although one patient was urgently readmitted for the reperfusion syndrome. The authors also had the advantage of treating local patients, facilitating postdischarge supervision and care. However, complications do occur for other surgeons, and, in general, patients should remain in hospital while complications are a real risk. Same-day carotid endarterectomy is inappropriate for most Australian institutions, as most patients return home on discharge from hospital rather than transfer to a nearby hospital-affiliated domiciliary service, as in the United States. Bourke and Crimmins also reported using duplex ultrasonography routinely instead of cerebral angiography to assess carotid stenosis before surgery. Duplex ultrasonography of the cervical vessels is indicated when carotid stenosis is suspected or the significance of a neck bruit is uncertain. It accurately confirms the presence of carotid stenosis, and measures its degree, but caveats apply. It cannot directly assess the arteries within the chest or cranial cavity, its accuracy depends on operator experience, and it is less reliable when the carotid arteries are tortuous or rotated or when the internal carotid artery is completely, or apparently completely, occluded. Angiography is more comprehensive, allowing visualisation of the intrathoracic and intracranial vessels, as well as the neck vessels, and nowadays can be performed on outpatients using a fine catheter introduced into the brachial or femoral artery by percutaneous puncture. Further, intra-arterial digital subtraction angiography reduces the volume of contrast medium, but, even so, angiography is invasive and potentially dangerous, causing stroke in about one per 200 patients, even in good centres,11 and more in less-skilled hands.13 Magnetic resonance angiography is a safer alternative, but current Federal Government policies restrict its availability. The cost of a carotid endarterectomy in Australia has been variously estimated as $56002 and $7000.5 This can be reduced by eliminating unnecessary investigations and by shortening hospital stay. Nevertheless, safety demands that patients are properly advised and their suitability assessed before they enter an overnight program. Short hospital stay is not appropriate if patients cannot be accommodated close to the hospital after discharge. It is also inadvisable when patients have persisting cardiovascular instability, questionable neurologic status or will be returning to unsupervised solitary accommodation. Short-stay policies must be designed to provide ongoing supervision by the clinical team, including domiciliary nurses during convalescence. Further, short-stay policies from institutions with demonstrated excellent outcomes and well organised postdischarge supervision and care cannot be translated to others with inferior or uncertain standards. In the case of carotid endarterectomy, most of the postoperative hazards needing urgent intervention are unlikely after 48 hours. Therefore, hospital discharge two days after the operation is a reasonable compromise and, in my opinion, safer than discharge a day earlier. Reginald S A Lord
Reprints: Professor RSA Lord, Surgical Professorial Unit, Level 17, O'Brien Building, St Vincent's Hospital, Darlinghurst, NSW 2010.
|