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The R ole of Intensive Care to I mprove Perioperative Mortality

The R ole of Intensive Care to I mprove Perioperative Mortality. Pelosi Paolo. Department of Surgical Sciences and Integrated Diagnostics (DISC) University of Genoa – IRCCS AOU San Martino IST – Genoa , Italy. ppelosi@hotmail.com. Dubai Anaesthesia 2013.

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The R ole of Intensive Care to I mprove Perioperative Mortality

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  1. The Role of Intensive Care to ImprovePerioperativeMortality Pelosi Paolo Department of Surgical Sciences and Integrated Diagnostics (DISC) University of Genoa – IRCCS AOU San Martino IST – Genoa , Italy ppelosi@hotmail.com Dubai Anaesthesia 2013

  2. Annual figures for the Europeanhigh-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

  3. Perioperative and anaesthetic-relatedmortality indeveloped and developingcountries: a systematicreviewand meta-analysis Bainbridge et al Lancet 2012; 380: 1075–81 Perioperativemortality per year

  4. Post-op mortalityat 30 days in differentcountries

  5. Surgical deaths: Size, Risk and Mortality Pearse et al. Crit Care 2006; 10: R81. 80% of surgical deaths are from the high-risk population

  6. Surgical complications decrease long-term survival Khuri et al. Ann Surg 2005; 242: 326–343 Ptsw/o complications Ptsw/o complications Pts with 1/more complications Pts with 1/more complications

  7. 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%

  8. Eur J Anaesthesiol 2010;27:592–597 Euroanaesthesia2010, Sunday, 13 June 2010

  9. ESA Clinical Trials Network (ESA CTN) ResearchCommittee research@euroanaesthesia.com Did you know that the most important and challenging clinical questions are more likely to be solved if several centres join forces ?

  10. 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

  11. EuSOS EuropeanSurgicalOutcomesStudy International seven day cohort study of standards of care and clinical outcomes for non-cardiac surgery

  12. EuSOS EuropeanSurgicalOutcomesStudy Lancet 2012; 380:1059-1065 Lancet 2012; 380:1059-1065

  13. EuSOS 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 EuropeanSurgicalOutcomesStudy Lancet 2012; 380:1059-1065

  14. EuSOS EuSOS:Exclusion criteria No planned overnight hospital stay Neurosurgery Obstetrics Cardiac surgery (thoracic surgery is included) EuropeanSurgicalOutcomesStudy Lancet 2012; 380:1059-1065

  15. 3 12 1923 Investigators ! 8 6 4 3 13 2 16 97 14 5 35 13 8 2 4 7 21 17 4 16 3 29 17 56 28 1

  16. EuSOS Cohort 46539 Patients admitted in ICU 3612 (8%) Patients admitted in ward 42927 (92%) Died in ward 1358 (3%) Died in ICU 287 (8%) Died in ward after ICU discharge 217 (6,5%) Total Mortality 1682 (4%)

  17. EuSOS Cohort 46539 patients 1864 (4%) deaths Urgent surgery 8919 (19%) 483 (5%) Emergency surgery 2557 (5%) 249 (10%) Elective surgery 35040 (75%) 1132 (3%) Planned admission to ICU 490 (5%) 54 (11%) Unplanned admission to ICU 391 (4%) 63 (16%) Unplanned admission to ICU 356 (14%) 79 (22%) Unplanned admission to ICU 278 (1%) 22 (8%) Planned admission to ICU 1864 (5%) 32 (2%) Planned admission to ICU 201 (8%) 37 (18%) Discharged to ward alive 441 (79%) 49 (11%) Discharged to ward alive 764 (87%) 63 (8%) Discharged to ward alive 2088 (97,5%) 104 (5%)

  18. EuSOS EuropeanSurgicalOutcomesStudy Lancet 2012; 380:1059-1065

  19. EuSOS EuropeanSurgicalOutcomesStudy Lancet 2012; 380:1059-1065 Which are the “safer” types of surgery ? Odds Ratio Laparoscopicsurgery 0.75 – 0.25 Plastic/Cutaneous 0.71 – 0.66 Kidney/Urology 0.23 – 0.82 Head and Neck 0.66 - 0.81

  20. EuSOS EuropeanSurgicalOutcomesStudy 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

  21. EuropeanSurgicalOutcomesStudy

  22. Whatfactorsaffectmortalityaftersurgery? VonlanthenR and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6 Message to be delivered: DearColleaguesfundingmedical care, …… care. “Wesuggestthateven use of expensive resources, suchasadditional ICU beds, couldrapidlybecomecosteffectiveby reducingcomplications”.

  23. 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 (%)

  24. Whatfactorsaffectmortalityaftersurgery? VonlanthenR and Clavien PA. Lancet. 2012 Sep 22;380(9847):1034-6 • The definitionof ICU beds(recovery room vs post-op ICU vs General ICU) and resourcesmightdifferbetweencountries • Otherfactors are important: • - Use of surgicalsafetychecklists • Clinicalpathways • Enhancedrecoverystrategy (fast tracksurgery) • Volume of cases • Presenceof general versus specialisedsurgeons • Abilityto recognise and managecomplications • Quality of care and Economicresources

  25. Need of Surgery • Comorbidity • Age (per year) • ASA IV-V • Metastatic cancer • Cirrhosis • High risk surgery • Urgent/emergency • Upper gastro-intestinal High risk surgery and comorbidity No comorbidity No high risk surgery High risk surgery and No comorbidity Comorbidity and No High risk surgery Post-op ICU and monitoring in ward after discharge Surgical ward/monitoring Surgical ward/monitoring or Post-op ICU Surgical ward

  26. 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

  27. Post-operativepulmonarycomplications: EFFECTS ON SURVIVAL Fernandez-Perez et al Thorax 2009;64;121-127

  28. PPCs

  29. Pelosi P and Gama de Abreu M Anesthesiology 2011: 115: 10-11

  30. How to evaluate the risk of PPCs ? CanetJ et al for ARISCAT, Anesthesiology. 2010; 113(6):1338-50. 13 % (score 26-44) – 54 % (score >45) risk to develop PPCs 11

  31. Prospective Evaluation of aRISkScore for postoperative pulmonary COmPlications in Europe Steering Committee: Jaume Canet (S) Sergi Sabaté (S) Valentín Mazo (S) LluisGallart (S) Marcelo Gama de Abreu (G) Javier Belda (S) Olivier Langeron (F) Andreas Hoeft (G) Paolo Pelosi (I) Brigitte Leva (ESA Secretariat) (B) research@euroanaesthesia.com

  32. Methods 1/5 • Design • Prospective, multicenter, observational, cohort study • Geographic scope • ARISCAT: 51 Anesthesiology Departments (Catalonia, Spain) • PERISCOPE: 63 Anesthesiology Departments (21 European countries)

  33. 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)

  34. Methods 3/5 • Inclusioncriteria • Undergoing a surgical procedure under regional or general anesthesia (epidural, spinal or saddle block) ... • ... on the selected days at a participating center • Informed consent

  35. 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

  36. Methods 5/5 • Primary outcome (composite) • Respiratory insufficiency • Bronchospasm • Pleural effusion • Respiratory infection • Atelectasis • Aspiration pneumonitis • Pneumothorax • Unified definitions of variables

  37. PPCsIncidence 5384 patients 7.92% 6.21% 4.37%

  38. PPCs or CHF ?

  39. PPCs & SurgicalSpeciality

  40. Lenght of Hospital Stay Median (10th -90th percentile) Periscope Ariscat 3 (1-10.9) Patients withoutPPCs 3 (1-11.0) 9 (4-33) Patients with PPCs 12 (4-36.8)

  41. Post-Op In-Hospital Mortality (%) Ariscat Periscope Patients withoutPPCs 0.2 8.3 Patients with PPCs 8.0 23.6

  42. PLOS and In–Hospital Mortality& PPCs

  43. 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.

  44. 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.

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