Surgical Risk Dr Chris Snowden MD FRCA Consultant Anaesthetist Freeman Hospital Newcastle upon Tyne.
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Transcript of Surgical Risk Dr Chris Snowden MD FRCA Consultant Anaesthetist Freeman Hospital Newcastle upon Tyne.
Surgical Risk Surgical Risk
Dr Chris Snowden MD FRCADr Chris Snowden MD FRCAConsultant Anaesthetist Consultant Anaesthetist
Freeman HospitalFreeman HospitalNewcastle upon Tyne Newcastle upon Tyne
Population Studies: Population Studies: Safety in NumbersSafety in Numbers
MetanalysesMetanalyses– Multiple RCTsMultiple RCTs– Trial OmissionsTrial Omissions
Large Cohort Large Cohort e.g. NSQUIP e.g. NSQUIP – clinically meaningful data clinically meaningful data – standardized outcome definition standardized outcome definition – validated risk-adjustmentvalidated risk-adjustment
Decreased unadjusted Decreased unadjusted – 30-day mortality (3.2% to 2.3%)30-day mortality (3.2% to 2.3%)– 30-day morbidity (17.4% to 9.9%) 30-day morbidity (17.4% to 9.9%)
Procedural RiskProcedural Risk
Netherlands Population study3.5 M Operations1991-2005Evaluated trends Elective, open, non-laparoscopic
ResultsAll cause 30 d mortality – 1.85%Hugely Variable High/Low stratification unacceptable
Anesthesiology 2010; 112:1105
Mortality Mortality
Ghaferi et al. Annals of Surgery 2009: 250;6,
N= 110,000 pts
Across ProceduresAcross Procedures
Ghaferi et al NEJM 2009: 361:1638
Khuri SF et al; Ann Surg 2005
Population105,952 pts
Complications and Outcome Complications and Outcome
Khuri et al. Ann Surg 2005
Defining Surgical Risk
Outcome
Abdominal
Ortho
Vascular
Transplant
“FTR”
MortalityComplications
Survival
Surgical Intervention
Complication TypesComplication Types
Prospective data 3970 pts Age >50 yrsNon-cardiac surgeryAdjusted Data
Fleischmann KE et al; Am J Med: 2003
ComplicationComplicationss
Length of Length of Stay (Days)Stay (Days)
NoneNone 4 (3-4)4 (3-4)
Non-cardiacNon-cardiac 11 (10-12)11 (10-12)
Cardiac and Cardiac and non-cardiacnon-cardiac
15 (12-18)15 (12-18)
0
2
4
6
8
10
12
14
1 2 3 4 5 6 7
Postoperative day
Patie
nts
with
Com
plic
atio
ns
(%) Cardiac
Non-Cardiac
Patterns of Complications Patterns of Complications
No GI comps
GI comps
Median: 10 vs 17 daysP=0.0001
Cardiorespiratory Complications Cardiorespiratory Complications
Median: 8 vs 12 vs 23 daysP<0.0001
No Comps
CVS/RS
Non-CVS/RS
Defining Surgical Risk
Abdominal
Ortho
Vascular
Transplant
FTR
Delayed Recovery
GIInf
Ren
Complications
No Complications
ExtendedRecoveryCVS RS
Appropriate Recovery
Survival
Death
Complications
Surgical Risk Surgical Risk
Defining Surgical Risk
Abdominal
Ortho
Vascular
Transplant
FTR
Delayed Recovery
GIInf
Ren
Complications
No Complications
ExtendedRecoveryCVS RS
Appropriate Recovery
Death
Patient
Ischaemia or Heart FailureIschaemia or Heart Failure
Elderly (> 65 yrs)Elderly (> 65 yrs)159,327 procedures 159,327 procedures 18% HF; 34% CAD 18% HF; 34% CAD Mortality/Readmissions Mortality/Readmissions – Hazard RatiosHazard Ratios
HF 1.63HF 1.63CAD 1.08CAD 1.08
Hammill et al. Anesthesiology 2008; 108. 599
Heart Failure PrevalenceHeart Failure Prevalence
“Asymptomatic” Heart failure
Retrospective studyRetrospective studyThree groups; Three groups; – EF > 40 (n=385) EF > 40 (n=385) – EF < 40 (n=192) EF < 40 (n=192) – Controls (n=10,000)Controls (n=10,000)
““Optimised” heart failureOptimised” heart failure
Results: Results: – No Difference in mortality (short term) No Difference in mortality (short term) – Difference ;Difference ;
Longer hospital stays - 2 days Longer hospital stays - 2 days Hospital readmissions - 18% (EF >40% more likely than EF >40)Hospital readmissions - 18% (EF >40% more likely than EF >40)Long term outcomeLong term outcome
Xu-Cai et al. Mayo clinic Proc 2008; 83. 203
1000 patients1000 patients501 (50%) LV dysfunction (EF<50%)501 (50%) LV dysfunction (EF<50%)52% diastolic dysfunction52% diastolic dysfunction
Anesthesiology 2010; 112:1316 –24
Defining Surgical Risk
Abdominal
Ortho
Vascular
Transplant
FTR
Delayed Recovery
GIInf
Ren
Complications
No Complications
ExtendedRecoveryCVS RS
Appropriate Recovery
Death
Patient Cardiorespiratory Dysfunction
Exercise Ability
CPET: Risk Tool ?CPET: Risk Tool ?
CPeTCPeT– Comorbidity summary measure Comorbidity summary measure – Quantitative and Qualitative endpointsQuantitative and Qualitative endpoints– Multiple, simultaneous CVS/RS componentsMultiple, simultaneous CVS/RS components
Structured approach Structured approach – Concept ProofConcept Proof– Incremental valueIncremental value– Clinical UtilityClinical Utility– Predictive validityPredictive validity– Intervention Intervention
EvidenceEvidencenn Patients Patients OutcomeOutcome TrialTrial ConceptConcept IncrementalIncremental Clinical Clinical
Utility Utility
Older Older
19931993
187187 Elderly Elderly MortalityMortality Prospective Cohort (?Blinded)
>11 ; 4%
<11 ; 42%
Older Older
19991999
548548 ElderlyElderly MortalityMortality Prospective Cohort
(No blinding)
CP deaths confined to <11 or ischaemia
Forshaw
2008
7878 OesophagusOesophagus MorbidityMorbidity Prospective Cohort
(No blinding)
13.2 vs 14.4
CP complications
Readmissions
NA
CarlisleCarlisle
20072007
130130 VascularVascular Mid term Mid term mortalitymortality
Retrospective Cohort
(No blinding)
CPeT related to survival
AT
VE/VCO2
RCRI
Hazard Ratio
Hightower Hightower
20102010
3232 Major Major Abdominal Abdominal
MorbidityMorbidity Prospective, Pilot
(Blinded)
PC related to outcome
ASA vs AT,HR
Wilson Wilson 20102010
847847 Major Major SurgerySurgery
MortalityMortality Prospective Cohort
(No Blinding)
<11 Relative risk 7x death
Greater than Clinical factors
Snowden Snowden
20102010
116116 Major Major Abdominal Abdominal
MorbidityMorbidity Prospective
(Blinded)
CPeT variables related to outcome
Improvement on subjective and established factors
Risk increase
Hospital mortality by AT group - effect of cardiac risk factors:
AT < 11 AT >11 RR (95% CI)
Patients with 1 or more cardiac risk factors (n=271)
3.8% 1.1% 3.3 (0.5-20.6)
Patients with no cardiac risk factors (n=576)
3.2% 0.3% 10.0 (1.7-61.0)
BJA . 2010 105; 297
847 PtsMortality 2.1%
Optimum AT 10.1 ml/min/kgAUC 0.85 ; Sens 88%; Spec 79%
Snowden et al 2010 Ann Surg
Types of ComplicationsTypes of Complications
Modelling Outcome Modelling Outcome
Exercise Ability and Cardiorespiratory Exercise Ability and Cardiorespiratory Complications Complications
P<0.0001
***
*
“High Risk” CCU Groups
ITU 3 ITU 7 n Day 3 Poms
Day 7 Poms
LOS
No No 45 2 0 9
Yes No 45 3 1 12
Yes Yes 20 5 4 19
No Yes 3 4 4 31
0 25 50 75 100
Length of Stay
0.0
0.2
0.4
0.6
0.8
1.0
Pro
port
ion R
em
ain
ing in H
osp
ital
CCU and Exercise Prediction
Low Risk High Risk
High risk ITU
8.0
9.0
10.0
11.0
12.0
ROC Analysis:
Opt AT 10.6 (62%,80%)
AUC 0.873 (0.80-0.95)
P=0.0001
11.4 (2.6)
9.6 (2.3)
CPX Clinic _________No CPX Clinic _________
CPX Clinic No clinic
30 day mortality
3/194 (2%) 8/139 (6%)
Critical Care
22% 10%
The CPeT “Package of Care” The CPeT “Package of Care”
Swart et al. Personal communication
High Risk Surgery:High Risk Surgery:Liver TransplantationLiver Transplantation
Highest Surgical Risk (O.R. 15.8)Highest Surgical Risk (O.R. 15.8)
Early Mortality - 18% Early Mortality - 18%
Ensure appropriate organ allocationEnsure appropriate organ allocation – Limited resourceLimited resource– Marginal OrgansMarginal Organs– High Comorbidity High Comorbidity
Recipient ScoresRecipient Scores
Survivors Non Survivors
Signif
N= 49 6
AGE (Mean;SD) 53.1 (10.6) 49.2 (12.4) NS
BMI (Mean;SD) 26.3 (5.3) 26.7 (6.9) NS
Waiting List (Mean;SD) 94 (82) 129 (112) NS
UKELD (Mean;SD) 53 (5.2) 53 (6.7) NS
MELD (Mean;SD) 17 (9) 18 (9) NS
Snowden et al (In Prep)
Transplantation and Exercise Transplantation and Exercise
ROC analysis:Optimum AT 9.6 ml/min/kgAUC 0.97 ; (p=0.001)
p<0.00001
Snowden et al (In Prep)
CCU Stay and Liver Tx CCU Stay and Liver Tx
0 10 20 30 40
0.0
0.2
0.4
0.6
0.8
1.0 Median CCU LOS9 days vs 27 days
P=0.001
Pro
po
rtio
n r
emai
nin
g i
n C
CU
AT< 9.6
AT>= 9.6
Days in CCU
Donor – Recipient MatchingDonor – Recipient Matching
P=0.04
Snowden et al (In Prep)
Selective Training Effect
Summary Summary
Surgical risk - evolving conceptSurgical risk - evolving concept
Insights from large population studiesInsights from large population studies
New concepts for: New concepts for: – Operative risk variability Operative risk variability – Mortality and “Failure to rescue”Mortality and “Failure to rescue”– Importance of complications (esp CVS)Importance of complications (esp CVS)– Cardiac “Dysfunction”Cardiac “Dysfunction”
Summary Summary
Exercise Ability (and assessment):Exercise Ability (and assessment):– Defines important end point for comorbidityDefines important end point for comorbidity– Relates to mortality and morbidityRelates to mortality and morbidity– Varying surgical specialitiesVarying surgical specialities– Pedigree in cardiorespiratory dysfunctionPedigree in cardiorespiratory dysfunction
FutureFuture– Prospective comparative trials Prospective comparative trials – Interventional strategy toolInterventional strategy tool