Should we worry about

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• Should we worry about
• surgical outcomes?
• Rupert Pearse
• Senior Lecturer in Intensive Care Medicine
• William Harvey Research Institute
• Barts and the London School of Medicine and
  Dentistry

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• 234 million major surgical procedures worldwide
• 4,000 procedures per 100,000 population overall
• 11,000 procedures per 100,000 in high income
  countries

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Number of deaths reported by the National
Confidential Enquiry into Peri-Operative Deaths
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The high-risk surgical patient

• Elderly
• Co-morbid disease
• Major surgery
• Emergency surgery

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Mortality in selected UK general surgical
populations Pearse et al. Crit Care 2006 10
R81.
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Standard and high-risk surgical populations in
the UKPearse et al. Crit Care 2006 10 R81.
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Mortality following non-cardiac surgery in an NHS
Trust Jhanji et al Anaesthesia 2008 63(7)
695-701
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Less than 1/3 of high-risk patients are admitted
to critical care
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Annual figures for the UKhigh-risk surgical
population

• 1.4 million in-patient general procedures
• 166,000 high-risk surgical procedures
• 100,000 patients develop complications
• 25,000 deaths

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Quality and process improvement. should be
directed toward prevention of postoperative
complications. Khuri et al. Ann Surg 2005 242
326343
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Risk prediction for common surgical procedures
performed in the UKAylin et al. BMJ
2007(online first)
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High-risk surgeryComparison with the cardiac
surgery model
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UK Cardiac Surgical Register 1977-2000Society
for Cardiothoracic Surgeons of Great Britain
Ireland
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Why are outcomes so much better for cardiac
surgical patients?

• Younger / Fitter / Elective
• Efficient care pathway for single disease group
• Strong evidence base guides practice
• Post-operative intensive care is standard
• Outcome data influences practice

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The high-risk surgical patientJust a UK
problem?
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Mortality for common surgical procedures in the
USAKhuri et al. Ann Surg 2005 242 326343.
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Placebo 72 deaths among 459 patients (16)
Metoprolol 74 deaths among 462 patients (16)
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Outcomes across the UKComparison of England and
Scotland
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Number of deaths following emergency surgery
reported by the Scottish Audit of Surgical
Mortality
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Critical care resources in Scotland and England
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Surgical admissions to Scottish ICUs in
2006Kerssens J SICSAG 2008 unpublished
dataPearse et al. Crit Care 2006 10 R81.
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High-risk surgery is an important healthcare
problem

• Acknowledge the problem
• Identifying the high-risk patient
• Effective intervention
• Adequate resources
• Quality research
• Reliable outcome data

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Summary

• High-risk surgery is an important healthcare
  problem
• We need to....
• Accept we have a problem
• Better identify those patients at increased risk
• Post-operative morbidity and mortality
  concentrated in an easily identifiable high-risk
  surgical population

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Peri-operative ß-blockadePOISE Trial
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High-risk surgery Not a typical critical illness

• 56 surgical ICU pts need single or no organ
  support
• Median ICU stay 1.6 days (all patients)
• Median hospital stay 16 days (all patients)
• Strong evidence of infection in 76 patients
• Pearse et al, Crit Care 2006 10 R81.

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Pre-operative assessment of cardiovascular risk
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B-type natriuretic peptide and surgical
outcome Cuthbertson et al. BJA and AJC 2007
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Anaerobic threshold in high-risk surgical
patientsOlder P et al. Chest 1999 116 355-362.
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Cardio-Pulmonary Exercise Testing in high-risk
surgical patients

• Most published data are audits
• Most studies evaluate VO2max
• Only one peer reviewed paper on ATT

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High-risk surgery Specific interventions

• Sub-maximal exercise testing
• Peri-operative ß-blockade
• Overnight Intensive Recovery (OIR) Units
• Goal Directed Haemodynamic Therapy
• Non-invasive ventilation
• Enhanced Recovery After Surgery (ERAS) philosophy
• Reliable national audit of surgical outcome

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Surgical populations in a single NHS
TrustJhanji et al. 2007 unpublished data
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Admission to Critical Care for non-cardiac surgery
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Headline findings

• 12 cases result in gt70 of deaths
• Only one third of high-risk patients ever reach
  critical care
• Half the high-risk patients who die never reach
  critical care

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Headline findings

• Critical Care provision for elective surgery is
  acceptable but could improve
• Critical Care provision for emergency surgery is
  unacceptable and must increase
• Duration of critical care stay remains short