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Report
The Role of Intensive Care
to Improve
Perioperative Mortality
Pelosi Paolo
Department of Surgical Sciences and
Integrated Diagnostics (DISC)
University of Genoa – IRCCS AOU San Martino
IST – Genoa , Italy
[email protected]
Dubai Anaesthesia 2013
Annual figures for the European
high-risk surgical population
Ghaferi A. N Engl J Med 2009; 361: 1368-75
Weiser T Lancet 2008; 372: 139-144; Pearse R Crit Care 2006; 10: R81
• 21 million in-patient general procedures
• 2.6 million high-risk procedures
• 1.3 million patients develop complications
• 315,000 deaths in hospital
Perioperative and anaesthetic-related mortality in
developed and developing countries:
a systematic review and meta-analysis
Bainbridge et al Lancet 2012; 380: 1075–81
Perioperative mortality per year
Post-op mortality at 30 days
in different countries
Country
Patients (n) and Mortality (%)
UK
(Findlay G. 2011)
13.513 - 1.60
Netherlands
(Noordzij PG. 2010)
3.667.875 - 1.84
Brasil
(Yu PC. 2010)
32.659.515 - 1.77
USA
(Glance LG. 2012)
322.398 - 1.34
Spain
(Canet J. 2010)
2.464 - 1.44
Surgical deaths: Size, Risk and Mortality
Pearse et al. Crit Care 2006; 10: R81.
80% of surgical deaths are from the high-risk population
15
4
10
3
2
5
1
0
0
Overall
Standard
S iz e
High-risk
M o r t a lit y
P os t-ope ra tiv e m orta lity (% )
P opula tion s iz e (m illions )
5
Surgical complications decrease long-term survival
Khuri et al. Ann Surg 2005; 242: 326–343
Pts w/o complications
Pts with 1/more complications
Pts w/o complications
Pts with 1/more complications
Variation in hospital mortality associated
with in patient surgery
Ghaferi AA et al N Engl J Med 2009;361:1368-75.
Complications
Pneumonia 1.8-2.4 %
MV>48hr 6.3-8.1 %
Mortality
Pneumonia 17-25.5%
MV>48hr 20.6-30.1%
Eur J Anaesthesiol 2010;27:592–597
Euroanaesthesia 2010, Sunday, 13 June 2010
ESA Clinical Trials Network (ESA CTN)
Research Committee
[email protected]
Did you know that the most important
and challenging clinical questions
are more likely to be solved if several
centres join forces ?
Poor quality of surgical outcome data
• Inaccurate healthcare systems data
• Specialty society data on limited subsets
• Mostly retrospective analyses
• Too much focus on elective surgery
• No comparative data across Europe
EuSOS
European Surgical Outcomes Study
International seven day cohort study of
standards of care and clinical outcomes
for non-cardiac surgery
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
Lancet 2012; 380:1059-1065
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
EuSOS: Inclusion criteria
All adult patients undergoing
in-patient non-cardiac surgery during the
seven day study period
Start: 09:00 4th April 2011
Finish: 08:59 11th April 2011
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
EuSOS: Exclusion criteria
• No planned overnight hospital stay
• Neurosurgery
• Obstetrics
• Cardiac surgery (thoracic surgery is included)
3
12
1923 Investigators !
8
6
4
3
13
16
97
2
14
35
13
21
5
4
8
4
16
2
7
17
3
29
17
56
28
1
EuSOS Cohort
46539
Patients admitted
in ICU
3612 (8%)
Died in ICU
287 (8%)
Patients admitted
in ward
42927 (92%)
Died in ward
after ICU discharge
217 (6,5%)
Total Mortality 1682 (4%)
Died in ward
1358 (3%)
EuSOS Cohort
46539 patients
1864 (4%) deaths
Elective surgery
35040 (75%)
1132 (3%)
Planned
admission
to ICU
1864 (5%)
32 (2%)
Unplanned
admission
to ICU
278 (1%)
22 (8%)
Discharged to
ward alive
2088 (97,5%)
104 (5%)
Urgent surgery
8919 (19%)
483 (5%)
Planned
admission
to ICU
490 (5%)
54 (11%)
Unplanned
admission
to ICU
391 (4%)
63 (16%)
Discharged to
ward alive
764 (87%)
63 (8%)
Emergency surgery
2557 (5%)
249 (10%)
Planned
admission
to ICU
201 (8%)
37 (18%)
Unplanned
admission
to ICU
356 (14%)
79 (22%)
Discharged to
ward alive
441 (79%)
49 (11%)
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
Mortality Risk Factors
Variable
Odds Ratio
Age (per year)
1
ASA IV-V
4.75-18.03
Metastatic Cancer
1.39
Cirrhosis
2.13
Urgent-Emergency surgery
1.78-3.23
Upper gastro-intestinal surgery
1.57
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
Which are the “safer” types of surgery ?
Odds Ratio
Laparoscopic surgery
0.75 – 0.25
Plastic/Cutaneous
0.71 – 0.66
Kidney/Urology
0.23 – 0.82
Head and Neck
0.66 - 0.81
EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
EuSOS: Conclusions
• Large numbers of patients die following in-patient
non-cardiac surgery
• Large variations in mortality between countries
suggest the need for national and international
strategies to improve care for this patient group
• Patterns of critical care admission suggest process
failure in the allocation of these resources
European Surgical Outcomes Study
What factors affect mortality after surgery?
Vonlanthen R and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6
Message to be delivered:
Dear Colleagues funding medical care, ……
care.
“We suggest that even use of expensive
resources, such as additional ICU beds, could
rapidly become cost effective by reducing
complications”.
Peri-op Mortality and GDP/inhabitant
Lancet 2012; 380:1059-1065; Intensive Care Med 2012; 38:1647-1653
R = 0.55
P < 0.01
MORTALITY (%)
What factors affect mortality after surgery?
Vonlanthen R and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6
 The definition of ICU beds (recovery room vs post-op
ICU vs General ICU) and resources might differ
between countries

-
Other factors are important:
Use of surgical safety checklists
Clinical pathways
Enhanced recovery strategy (fast track surgery)
Volume of cases
Presence of general versus specialised surgeons
Ability to recognise and manage complications
Quality of care and Economic resources
Need of Surgery
-
Comorbidity
Age (per year)
ASA IV-V
Metastatic cancer
Cirrhosis
No comorbidity
No high risk
surgery
Surgical ward
High risk surgery
and
No comorbidity
Surgical ward/
monitoring
-
High risk surgery
Urgent/emergency
Upper gastro-intestinal
Comorbidity
and
No High risk
surgery
High risk
surgery
and
comorbidity
Surgical
ward/monitoring
or
Post-op ICU
Post-op ICU
and
monitoring in
ward after
discharge
PPCs: are they a problem?
• Variable incidence (2%-40%), depending
on definition, kind of surgery and
patients
• Prevalence: as cardiac complications
• Leading cause of long hospital stay and
mortality
• Etiology: anesthesia and surgery induce
changes
Post-operative pulmonary complications:
EFFECTS ON SURVIVAL
Fernandez-Perez et al Thorax 2009;64;121-127
PPCs
Pelosi P and Gama de Abreu M
Anesthesiology 2011: 115: 10-11
How to evaluate the risk of PPCs ?
Canet J et al for ARISCAT, Anesthesiology. 2010; 113(6):1338-50.
13 % (score 26-44) – 54 % (score >45) risk to develop PPCs
11
Prospective Evaluation of a RISk Score for
postoperative pulmonary COmPlications
in Europe
Steering Committee:
[email protected]
Jaume Canet (S)
Sergi Sabaté (S)
Valentín Mazo (S)
Lluis Gallart (S)
Marcelo Gama de Abreu (G)
Javier Belda (S)
Olivier Langeron (F)
Andreas Hoeft (G)
Paolo Pelosi (I)
Brigitte Leva (ESA Secretariat) (B)
Methods 1/5

Design
Prospective, multicenter, observational, cohort
study
–

Geographic scope
–
ARISCAT: 51 Anesthesiology Departments
(Catalonia, Spain)
–
PERISCOPE: 63 Anesthesiology Departments
(21 European countries)
Methods 2/5

Data collection
–
7 days
• ARISCAT: January 2006 – January 2007
– Randomized days (one for each day of the
week) for each center.
• PERISCOPE: May 2011 – August 2011
– Continuous days (a full week)
Methods 3/5
•
Inclusion criteria
– Undergoing a surgical procedure under regional
or general anesthesia (epidural, spinal or saddle
block) ...
– ... on the selected days at a participating center
– Informed consent
Methods 4/5
•
Exclusion criteria
– Age < 18 years
– Obstetric/childbirth procedures
– Local or peripheral nerve anesthesia with or without
sedation
– Diagnostic and therapeutic procedures outside the
operating room
– Intubated on arrival at the operating room
– Re-operation due to an in-hospital postoperative
complication
– Transplantss and brain-dead patients
Methods 5/5


Primary outcome (composite)
 Respiratory insufficiency
 Bronchospasm
 Pleural effusion
 Respiratory infection
 Atelectasis
 Aspiration pneumonitis
 Pneumothorax
Unified
definitions
of
variables

PPCs Incidence
PPC (%)
9
8
7.92%
5384 patients
6.21%
7
6
4.37%
5
4
3
2
1
0
ARISCAT development
subsample
ARISCAT validation
subsample
PERISCOPE sample
PPCs or CHF ?
PPCs &
Surgical Speciality
Lenght of Hospital Stay
Median (10th -90th percentile)
Periscope
Ariscat
Patients
without PPCs
3
(1-10.9)
3
(1-11.0)
Patients
with PPCs
9
(4-33)
12
(4-36.8)
Post-Op In-Hospital
Mortality (%)
Periscope
Ariscat
Patients
without PPCs
0.2
8.3
Patients
with PPCs
8.0
23.6
PLOS and In–Hospital
Mortality & PPCs
Conclusions
• Postoperative pulmonary complications are
frequent, expensive and associated with
increased mortality
• There is increased national focus on the need for
higher quality, safer and more appropriate care.
• Readmission of surgical patients with pneumonia
is a significant source of increased healthcare
costs.
Conclusions
• Strongest risk factors for PPCs are age,
preoperative SpO2, previous respiratory infection,
anemia, kind of surgery and surgical
aggressiveness
• More than 50% of the risk is related to patient
factors
• A risk index based on 7 objective factors
discriminates well across a wide range of patients,
surgeries and geographic areas.
• Stratifying risk for PPCs can be calculated
preoperatively and, in case, recalibrated.
The ICUs & Hospital activities
Out of Hospital
Emergencies
In Hospital
Emergencies
General
ICU
Ward
In Hospital
Planned
Critical Care
Specialized
ICUs
StepDown ICU
Thanks

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