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 ppelosi@hotmail.com
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
UK
(Findlay G. 2011)
Netherlands
(Noordzij PG. 2010)
Brasil
(Yu PC. 2010)
USA
(Glance LG. 2012)
Spain
(Canet J. 2010)
Patients (n) and Mortality (%)
13.513 1.60
3.667.875 1.84
32.659.515 1.77
322.398 1.34
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
5
4
3
2
1
0
15
10
5
Overall
Size
Standard High-risk
M ortality
0

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 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

Research Committee 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 ?

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

Eu
S
O
S
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 4 th April 2011
Finish: 08:59 11 th 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
1923 Investigators !
17
16
56
97
21 4
8
13
13
14
35
12
6
5
4
8
16
29
2
7
3
4
2
3
28
17
1

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

EuSOS Cohort
46539 patients
1864 (4%) deaths
Urgent surgery
8919 (19%)
483 (5% )
Elective surgery
35040 (75%)
1132 (3%)
Emergency surgery
2557 (5%)
249 (10%)
Planned admission to ICU
1864 (5%)
32 (2%)
Unplanned admission to ICU
278 (1%)
22 (8%)
Planned admission to ICU
490 (5%)
54 (11%)
Discharged to ward alive
2088 (97,5%)
104 (5% )
Unplanned admission to ICU
391 (4%)
63 (16%)
Discharged to ward alive
764 (87%)
63 (8%)
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
Variable
Mortality Risk Factors
Odds Ratio
Age (per year)
ASA IV-V
Metastatic Cancer
Cirrhosis
Urgent-Emergency surgery
Upper gastro-intestinal surgery
1
4.75-18.03
1.39
2.13
1.78-3.23
1.57

EuSOS
European Surgical Outcomes Study
Lancet 2012; 380:1059-1065
Which are the “safer” types of surgery ?
Laparoscopic surgery
Odds Ratio
0.75 – 0.25
Plastic/Cutaneous
Kidney/Urology
0.71 – 0.66
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

Eu
S
O
S

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

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

• 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

P rospective E valuation of a RIS k Score for postoperative pulmonary CO m P lications in E urope research@euroanaesthesia.com
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)

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
7
6
5
4
3
2
1
0
9
8
PPC (%)
4.37%
ARISCAT development subsample
6.21%
ARISCAT validation subsample
7.92%
PERISCOPE sample

PPCs or CHF ?

Lenght of Hospital Stay
Median (10th -90th percentile)
Patients without PPCs
Periscope
3
(1-10.9)
Patients with PPCs
9
(4-33)
Ariscat
3
(1-11.0)
12
(4-36.8)

Patients with PPCs
Post-Op In-Hospital
Mortality (%)
Periscope
Patients without PPCs
0.2
8.0
Ariscat
8.3
23.6

PLOS and In–Hospital
Mortality & PPCs

• 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.

• Strongest risk factors for PPCs are age, preoperative SpO
2
, 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.

Out of Hospital
Emergencies
In Hospital
Emergencies
In Hospital
Planned
Critical Care
General
ICU
Ward
Specialized
ICUs
Step-
Down ICU