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.
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Major points:
1. High-risk surgical patients account for only 12.5% of post-op hospital admissions but 84% of post-operative deaths.
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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).
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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%.
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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.
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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.
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Major points:
1. 73% of all patients who died were not admitted to critical care at any stage after surgery.
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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.
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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.
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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.
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Major points:
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1. 1 in 6 patients developed a complication before hospital discharge, and 1 in 35 (2.8%) who experienced a complication died before discharge.
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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.
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4. Interestingly, 28% of all patients who died were not admitted to critical care at any point during their admission.
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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.
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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.
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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.
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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.
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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.
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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.