ppelosi@hotmail.com

Department of Surgical Sciences and Integrated Diagnostics (DISC)

University of Genoa – IRCCS AOU San Martino IST – Genoa , Italy

The Role of Intensive Care to Improve

Perioperative Mortality

Pelosi Paolo

Dubai Anaesthesia 2013

Annual figures for the European

high-risk surgical population

• 21 million in-patient general procedures

• 2.6 million high-risk procedures

• 1.3 million patients develop complications

• 315,000 deaths in hospital

Ghaferi A. N Engl J Med 2009; 361: 1368-75

Weiser T Lancet 2008; 372: 139-144; Pearse R Crit Care 2006; 10: R81

Perioperative and anaesthetic-related mortality indeveloped and developing countries:

a systematic review and meta-analysisBainbridge et al Lancet 2012; 380: 1075–81

Perioperative mortality per year

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

Post-op mortality at 30 days in different countries

80% of surgical deaths are from the high-risk population

Overall Standard High-risk0

1

2

3

4

5

0

5

10

15

Size Mortality

Po

pu

lati

on

siz

e (

mil

lio

ns

)P

os

t-op

era

tive

mo

rtality

(%)

Pearse et al. Crit Care 2006; 10: R81.

Surgical deaths: Size, Risk and Mortality

Surgical complications decrease long-term survival

Khuri et al. Ann Surg 2005; 242: 326–343

Pts w/o complications Pts w/o complications

Pts with 1/more complications Pts with 1/more complications

Variation in hospital mortality associatedwith in patient surgery

Ghaferi AA et al N Engl J Med 2009;361:1368-75.

ComplicationsPneumonia 1.8-2.4 %MV>48hr 6.3-8.1 %

Mortality Pneumonia 17-25.5%MV>48hr 20.6-30.1%

Euroanaesthesia 2010, Sunday, 13 June 2010

Eur J Anaesthesiol 2010;27:592–597

ESA Clinical Trials Network (ESA CTN)

Research Committee

Did you know that the most importantand challenging clinical questions

are more likely to be solved if severalcentres join forces ?

research@euroanaesthesia.com

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

International seven day cohort study of

standards of care and clinical outcomes

for non-cardiac surgery

European Surgical Outcomes Study

EuSOS

European Surgical Outcomes StudyEuSOS

Lancet 2012; 380:1059-1065

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

EuSOSEuropean Surgical Outcomes Study

Lancet 2012; 380:1059-1065

EuSOS: Exclusion criteria

• No planned overnight hospital stay

• Neurosurgery

• Obstetrics

• Cardiac surgery (thoracic surgery is included)

EuSOSEuropean Surgical Outcomes Study

Lancet 2012; 380:1059-1065

97

16

13

1

2

13

4

12

21

35

28

7

3

16

29

23

14

8

5

17 56

173

8

44

61923 Investigators !

EuSOS Cohort46539

Patients admitted in ICU

3612 (8%)

Patients admitted in ward

42927 (92%)

Died in ICU 287 (8%)

Died in ward1358 (3%)

Died in ward after ICU discharge

217 (6,5%)

Total Mortality 1682 (4%)

EuSOS Cohort46539 patients

1864 (4%) deaths

Elective surgery35040 (75%)

1132 (3%)

Urgent surgery8919 (19%)483 (5%)

Emergency surgery2557 (5%)249 (10%)

Planned admission

to ICU1864 (5%)

32 (2%)

Discharged to ward alive

2088 (97,5%)104 (5%)

Unplanned admission

to ICU278 (1%)22 (8%)

Unplanned admission

to ICU391 (4%)63 (16%)

Unplanned admission

to ICU356 (14%)79 (22%)

Planned admission

to ICU490 (5%)54 (11%)

Planned admission

to ICU201 (8%)37 (18%)

Discharged to ward alive764 (87%)

63 (8%)

Discharged to ward alive441 (79%)49 (11%)

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

EuSOSEuropean Surgical Outcomes Study

Lancet 2012; 380:1059-1065

EuSOSEuropean Surgical Outcomes Study

Lancet 2012; 380:1059-1065

Which are the “safer” types of surgery ?

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

Odds Ratio

European Surgical Outcomes StudyEuSOS

• 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

Lancet 2012; 380:1059-1065

EuSOS: Conclusions

European Surgical Outcomes Study

Message to be delivered:

Dear Colleagues funding medical care, ……care.

“We suggest that even use of expensiveresources, such as additional ICU beds, could rapidly become cost effective by reducing complications”.

Vonlanthen R and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6

What factors affect mortality after surgery?

Lancet 2012; 380:1059-1065; Intensive Care Med 2012; 38:1647-1653

Peri-op Mortality and GDP/inhabitant

R = 0.55P < 0.01

MORTALITY (%)

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

What factors affect mortality after surgery?

Vonlanthen R and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6

Need of Surgery

Comorbidity- Age (per year)- ASA IV-V- Metastatic cancer- Cirrhosis

High risk surgery- Urgent/emergency- Upper gastro-intestinal

No comorbidityNo high risk

surgery

High risk surgeryand

No comorbidity

Comorbidityand

No High risk surgery

High risk surgery

and comorbidity

Surgical ward Surgical ward/ monitoring

Surgical ward/monitoring

orPost-op ICU

Post-op ICUand

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

Anesthesiology 2011: 115: 10-11

Pelosi P and Gama de Abreu M

How to evaluate the risk of PPCs ?

11

13 % (score 26-44) – 54 % (score >45) risk to develop PPCs

Canet J et al for ARISCAT, Anesthesiology. 2010; 113(6):1338-50.

Steering Committee:

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)

 

Prospective Evaluation of a RISk Score for

postoperative pulmonary COmPlications

in Europe

research@euroanaesthesia.com

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

Primary outcome (composite) Respiratory insufficiency Bronchospasm Pleural effusion Respiratory infection Atelectasis Aspiration pneumonitis Pneumothorax

Methods 5/5

Unified definitions of variables

PPCs Incidence

ARISCAT development subsample

ARISCAT validation subsample

PERISCOPE sample0

1

2

3

4

5

6

7

8

9

PPC (%)

7.92%

4.37%

6.21%5384 patients

PPCs or CHF ?

PPCs & Surgical Speciality

Lenght of Hospital Stay

Periscope Ariscat

Patients without PPCs

Patients with PPCs

3(1-10.9)

3(1-11.0)

9(4-33)

12(4-36.8)

Median (10th -90th percentile)

Periscope Ariscat

Patients without PPCs

Patients with PPCs

0.2 8.3

8.0 23.6

Post-Op In-Hospital Mortality (%)

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

GeneralICU

In HospitalEmergencies

In HospitalPlanned

Critical Care

Step-Down ICU

Ward

SpecializedICUs

Out of HospitalEmergencies

Thanks