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Management of High-risk Patients

The Royal College of Surgeons of England/Department of Health. RCSENG. 2011.

Bottom line: This 2011 document by the Royal College of Surgeons of England and the Department of Health highlights the need for improved perioperative management of high-risk surgical patients who although account for only 15% of surgical procedures, they make up 80% of perioperative deaths. The authors identify numerous practical  recommendations on how to implement improved perioperative care in these patients. 

Major points:

1. Current pathways for emergent/urgent general surgical patients are typically ad-hoc and unstructured. There needs to be a structured pathway for these patients with a focus on early recognition and treatment of emergencies and complications. 

2. These pathways need to ensure that the patient's level of risk need to be appropriately matched with the: (a) urgency in appropriating diagnostic tests, (b) the level of seniority involved in decision making, (c) immanency of surgery and (d) the appropriate level of post-operative care. 

3. Risk calculators such as P-POSSUM should be used (and documented) pre-operatively, and then again post-operatively to provide an accurate estimate of risk. High-risk patients, those with estimated risk of death >5%, should have staff (as opposed to resident/fellow) input on all aspects of their perioperative care. While those at >10% risk should have a staff surgeon and anesthetist present during the entirety of their surgical procedure. 

4. A formalized reassessment of risk should occur at the end of surgery (called an "end of surgery bundle"). All patients >5% should at least receive consideration for critical care, while patients >10% should be admitted to critical care. 

    Whiteman AR, Dhesi JK, Walker D. The high-risk surgical patient: a role for a multi-disciplinary team approach?. Br J Anaesth. 2016;116(3):311-314. doi:10.1093/bja/aev355

    Bottom line: The growing cohort of high-risk, (multi-morbid and often frail and elderly) patients undergoing surgery are the ones that suffer the majority of perioperative complications. Similar to their use most notably in oncology and geriatrics, multi-disciplinary team meetings (MDTMs) should be used to improve perioperative outcomes in these patients.

    Major points:

    1. From a cost-effectiveness perspective, MDTMs should be focused on the small-subset of complex patients in which their is the greatest uncertainty on intervention due to a lack of high quality evidence. In essence, replacing high-quality evidence with the next available option: expert, consensus opinion. 

    2. Pros to MDTMs are: (a) they have been suggested to encourage an evidence-based decision making approach , (b) they streamline care to provide more timely management, and (c) although there is a lack evidence on improvement of clinical outcomes, it is suggested that expert consensus is useful in complex patients whose specific circumstances lack high-quality evidence on intervention. 

    3. Cons to MDTMs include: (a) cost, (b) the role of personalities wherein meeting outcomes favor people who are more forceful with their opinions and (c) high-level of coordination required to arrange a meeting time with specialists who have competing time constraints. 

    4. In the most complex patients, MDTMs should answer the following questions: whether to operate, how to best optimize the patient pre-operatively and which multi-disciplinary team members need to be involved pre and post-operatively. Wherein success would be defined as a reduction in perioperative morbidity and mortality as well as reduction in auxiliary scores such as length of stay.

    Puelacher C, Gualandro DM, Glarner N, Lurati Buse G, Lampart A, Bolliger D, Steiner LA, Grossenbacher M, Burri-Winkler K, Gerhard H, Kappos EA, Clerc O, Biner L, Zivzivadze Z, Kindler C, Hammerer-Lercher A, Filipovic M, Clauss M, Gürke L, Wolff T, Mujagic E, Bilici M, Cardozo FA, Osswald S, Caramelli B, Mueller C; BASEL-PMI Investigators. Long-term outcomes of perioperative myocardial infarction/injury after non-cardiac surgery. Eur Heart J. 2023 May 14;44(19):1690-1701. doi: 10.1093/eurheartj/ehac798. PMID: 36705050; PMCID: PMC10263270.

    Bottom line: 


    This prospective, multi-site, international observational study assessed the incidence of perioperative myocardial injury (PMI) and subsequently documented post-operative major adverse cardiac events (MACE) and all-cause mortality within one year. The etiology of PMI was also assessed, as adjudicated by two independent physicians based on all information obtained during the in-hospital evaluation of each patient. Among 7754 patients PMI occurred in 1016 (13.1%), and the incidence of post-operative MACE or death within one year differed significantly with the etiology of PMI; Type 1 MI was associated with 37% incidence of MACE and 27% incidence of death, while extra-cardiac PMI (30% MACE, 39% death), tachyarrhythmia (49%, 40%), acute heart failure (56%, 49%), and Type 2 MI (17%, 17%), were all greater than compared to patients without PMI (7%, 9%).


    Major points:


    1. Screening was performed on at-risk patients as defined by ≥65 years of age, OR ≥45 years with history of coronary artery disease, peripheral arterial disease, or stroke, undergoing inpatient non-cardiac surgery with a planned post-operative stay of ≥24 hours. PMI was prospectively defined as an absolute increase of ≥14 ng/L for hs-cTnT (high sensitivity cardiac troponin) or ≥45 ng/L for (troponin I). PMI was defined solely by the troponin biochemical criterion, independent of symptoms or ECG changes.


    2. PMI occurred in 1016/7754 patients (13.1%), of which 750/1016 (74%) were adjudicated as Type 2 MI, 71/1016 (7%) as Type 1 MI, 109/1016 (10.7%) as primarily extra-cardiac, 47/1016 (4.6%) as tachyarrhythmia, and 39/ 1016 (3.8%) as acute heart failure. PMI etiology was centrally adjudicated by two independent experts based on all clinical information obtained during index hospitalization. The sequence and extent of cardiac imaging performed in the individual patient was defined by the clinical cardiologist in charge of the PMI work-up, and not by a uniform study protocol.


    3. All causes of PMI were associated with an increased risk of MACE and death within 1 year compared to patients without PMI, a relationship that persisted after multivariable analysis. Adjusted hazard ratio for incidence of MACE were 3.2 for Type 1 MI, 1.8 for Type 2 MI, 3.0 for extra-cardiac PMI, 5.4 for tachyarrhythmia, and 5.5 for acute heart failure.


    4. The time from surgery to MACE within 120 days also differed substantially among the etiologies, from a median of 3 days following PMI from acute heart failure to 13 days following Type 2 MI, and 26 days in patients without PMI. The association of each etiology with incidence of MACE was stronger at 120 days than at one year, though underpowered.


    5. The authors generated a prognostic model for the occurrence of MACE and all-cause mortality following Type 2 MI, which identified chest pain or dyspnea (odds ratio 2.2), an absolute increase in troponin greater than two times the 99th percentile compared to baseline (OR 2.2), high-risk surgery according to the ESC/ESA surgical risk score (OR 2.8), and non-elective surgery (OR 2.6) as associated with increased MACE. After categorization by the prognostic model, ‘very high-risk’ Type 2 MI-PMI showed a rate of MACE or death of 31% (comparable to PMI of Type 1 MI), while the ‘low-risk’ group showed rates of 7% (comparable to patients without PMI).

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