Criteria for selective utilization of the intensive care unit following carotid endarterectomy

The common practice of admitting all patients to an intensive care unit (ICU) following carotid endarterectomy (CEA) is based upon concern for adverse events that may be properly cared for only in the ICU. We developed restrictive criteria for postoperative nursing unit admission based on analysis of adverse outcomes and risk factors. 365 CEAs over 15 years were reviewed. In the first 24 hours after CEA, 38 patients experienced 46 events that may have been best managed in an ICU. Preoperative factors associated with significant risk for complications were indications of cardiac disease within 6 months (n = 62, p < 0.05), emergent CEA (n = 2, p = 0.01), and need for postoperative anticoagulation (n = 2, p = 0.01). Only 56 (15%) of patients had indications for ICU admission, 57 (16%) would have been admitted to an EKG-monitored nursing unit, and 252 (69%) would have been admitted to a standard nursing unit. Immediate admission to the ICU after CEA is indicated for patients undergoing emergent CEA, those requiring anticoagulation postoperatively, those with intraoperative stroke or major cardiac complication, and possibly those with chronic renal failure. All other patients should be admitted to the RR. Patients experiencing stroke, major cardiac events, significant wound hemorrhage, or reintubation in the RR, and those requiring vasoactive medication more than 3 hours after surgery should be transferred to the ICU. Patients with indications of cardiac disease within 6 months prior to CEA but no indications for ICU admission may be discharged from the RR to an EKG monitored unit. All others may be discharged to a standard nursing unit.