Perioperative Medicine
The Future of Anesthesiology
Surgical Outcomes
Pearse RM, Harrison DA, James P, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10(3):R81. doi:10.1186/cc4928
Bottom Line: There is the existence of a high-risk surgical population which accounts for only 13% of surgical admissions post-operatively but more than 80% of post-operative deaths. Furthermore, out of this population, only a small proportion are admitted directly to the ICU post-op, suggesting inadequate critical care bed allocation. There is a need to better identify these high-risk patients pre-op and take proactive measures to prevent post-operative complications and triage them to an appropriate level of care.
Major points:
1. High-risk surgical patients account for only 12.5% of post-op hospital admissions but 84% of post-operative deaths.
2. High-risk patients were generally: older ( 74 y/o vs. 54 y/o in standard risk group), had a higher mortality rate (12.5% vs. 0.42% in standard risk group), and had a longer hospital length of stay (16 days vs. 3 days in standard risk group).
3. Cardiac surgery patients in comparison, were also undergoing major surgery and had multiple co-morbid conditions, but their post-op mortality rate was only 3.5%.
4. Interestingly, the highest mortality rate was seen in patients who were initially admitted to the general ward post-operatively, then transferred to the ICU.
5. High-risk surgical patients need to be better identified pre-op, so that they can be proactively triaged to an appropriate level of care post-operatively before complication develop or their underlying condition worsens.
Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380(9847):1059-1065. doi:10.1016/S0140-6736(12)61148-9
Bottom line: The in-hospital mortality rate (prior to discharge) for patients undergoing non-cardiac surgery was higher than expected (4%). There was also considerable variation in mortality among countries. The results of this study raise public health concerns about the provision of critical care resources post-operatively. The study highlights the need as well as the potential for effective perioperative care to improve post-operative outcomes.
Major points:
1. 73% of all patients who died were not admitted to critical care at any stage after surgery.
2. Only 5% of patients were planned admissions to critical care post-op despite evidence that early critical care improves outcomes.
3. 14% of patients admitted to critical care died before hospital discharge -- of whom 43% died after their first admission to critical care was complete and they had been discharged to the general ward.
3. In contrast to high-risk cardiac surgery patients who have a 2% post-operative mortality rate, the study suggests that improvements can be made to the allocation of critical care resources post-operatively and general quality of post-operative care in patients undergoing surgery in Europe.
4. Higher mortality rates after surgery might be modified by changes in the organization post-operative care pathways.
International Surgical Outcomes Study group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries [published correction appears in Br J Anaesth. 2017 Sep 1;119(3):553]. Br J Anaesth. 2016;117(5):601-609. doi:10.1093/bja/aew316
Bottom Line: This international 7-day cohort study followed adult patients, undergoing planned admission after elective surgery and showed that a large number of patients develop complications (16.8%) after surgery. A large proportion of those patients (16.4%) required admission to critical care to treat the complications of which 2.8% died before being discharged.
As global access to surgical treatments increase, we need to take into account the resultant increase in demand for perioperative care services as well.
Major points:
1. 1 in 6 patients developed a complication before hospital discharge, and 1 in 35 (2.8%) who experienced a complication died before discharge.
2. A 2.8% failure to rescue rate, indicates a need for more effective treatment response for patients who develop post-operative complications.
3. 9.7% of patients were routinely admitted to critical care post-op. Of which 50% developed a complication and 2.4% died.
4. Interestingly, 28% of all patients who died were not admitted to critical care at any point during their admission.
5. Routine admission to critical care after cardiac surgery is common, while high-risk patients undergoing non-cardiac surgery are not routinely admitted to critical care despite having a much higher mortality rate.
McQueen, K., Gottumukkala, V., Davies, J.F. et al. Perioperative Implications of the Global Cancer Epidemic. Curr Anesthesiol Rep 5, 243–249 (2015). https://doi.org/10.1007/s40140-015-0123-8
Bottom line: As the global population rapidly expands and ages, the incidence of cancer is rising. Two-thirds of cancer cases requiring either curative or palliative surgery thus making surgery the mainstay treatment for cancer.
Anesthesiologists a part of the multidisciplinary perioperative cancer team aiming to pre-operatively optimize co-morbidities, provide safe anesthesia and reduce post-op complications while providing optimal pain control so that the patient can make a quick functional recovery and return to their cancer care journey.
Major points:
1. Perioperative strategy for cancer patients should target complication free recovery with enhanced functional recovery. This would allow patients to return to their cancer care journey and pursue adjuvant therapies.
2. The surgical state is characterized by intense emotional and physiological stress (i.e. pain, stress, inflammation etc.), which if left uncontrolled can have negative effects for long-term cancer outcomes. Conversely, effective perioperative medicine (attenuation of stress response, effective analgesia, avoid post-op complications etc.) can positively influence long-term cancer outcomes.
3. In the US, one-third of health-care expenditure is deemed wasted (treatments with low/no evidence, fragment/inefficient care, errors, preventable complications) with 52% of total healthcare expenditure on perioperative therapies. Perioperative physicians have a role to play to eliminate these wasteful processes.
4. Multidisciplinary perioperative cancer care requires a concerted effort to develop metrics for perioperative recovery. This will reduce post-op complications, improve pain control, decrease hospital LOS/readmissions and allow for timely access to adjuvant cancer therapies and ultimately improve long-term outcomes for cancer patients.