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Surgical Risk Dr Chris Snowden MD FRCA Consultant Anaesthetist Freeman Hospital Newcastle upon Tyne.

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Presentation on theme: "Surgical Risk Dr Chris Snowden MD FRCA Consultant Anaesthetist Freeman Hospital Newcastle upon Tyne."— Presentation transcript:

1 Surgical Risk Dr Chris Snowden MD FRCA Consultant Anaesthetist Freeman Hospital Newcastle upon Tyne

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3 Population Studies: Safety in Numbers Metanalyses –Multiple RCTs –Trial Omissions Large Cohort e.g. NSQUIP –clinically meaningful data –standardized outcome definition –validated risk-adjustment Decreased unadjusted –30-day mortality (3.2% to 2.3%) –30-day morbidity (17.4% to 9.9%)

4 Procedural Risk Netherlands Population study 3.5 M Operations Evaluated trends Elective, open, non-laparoscopic Results All cause 30 d mortality – 1.85% Hugely Variable High/Low stratification unacceptable Anesthesiology 2010; 112:1105

5 Mortality Ghaferi et al. Annals of Surgery 2009: 250;6, N= 110,000 pts

6 Across Procedures Ghaferi et al NEJM 2009: 361:1638

7 Khuri SF et al; Ann Surg 2005 Population 105,952 pts

8 Complications and Outcome Khuri et al. Ann Surg 2005

9 Defining Surgical Risk Outcome Abdominal Ortho Vascular Transplant “FTR” Mortality Complications Survival Surgical Intervention

10 Complication Types Prospective data 3970 pts Age >50 yrs Non-cardiac surgery Adjusted Data Fleischmann KE et al; Am J Med: 2003 Complications Length of Stay (Days) None 4 (3-4) Non-cardiac 11 (10-12) Cardiac and non- cardiac 15 (12-18)

11 Patterns of Complications No GI comps GI comps Median: 10 vs 17 days P=0.0001

12 Cardiorespiratory Complications Median: 8 vs 12 vs 23 days P< No Comps CVS/RS Non-CVS/RS

13 Defining Surgical Risk Abdominal Ortho Vascular Transplant FTR Delayed Recovery GI Inf Ren Complications No Complications Extended Recovery CVS RS Appropriate Recovery Survival Death Complications

14 Surgical Risk

15 Defining Surgical Risk Abdominal Ortho Vascular Transplant FTR Delayed Recovery GI Inf Ren Complications No Complications Extended Recovery CVS RS Appropriate Recovery Death Patient

16 Ischaemia or Heart Failure Elderly (> 65 yrs) Elderly (> 65 yrs) 159,327 procedures 18% HF; 34% CAD Mortality/Readmissions –Hazard Ratios HF 1.63 CAD 1.08 Hammill et al. Anesthesiology 2008;

17 Heart Failure Prevalence

18 “Asymptomatic” Heart failure Retrospective study Three groups; –EF > 40 (n=385) –EF < 40 (n=192) –Controls (n=10,000) “Optimised” heart failure Results: –No Difference in mortality (short term) –Difference ; Longer hospital stays - 2 days Hospital readmissions - 18% (EF >40% more likely than EF >40) Long term outcome Xu-Cai et al. Mayo clinic Proc 2008;

19 1000 patients 501 (50%) LV dysfunction (EF<50%) 52% diastolic dysfunction Anesthesiology 2010; 112:1316 –24

20 Defining Surgical Risk Abdominal Ortho Vascular Transplant FTR Delayed Recovery GI Inf Ren Complications No Complications Extended Recovery CVS RS Appropriate Recovery Death Patient Cardiorespiratory Dysfunction Exercise Ability

21 CPET: Risk Tool ? CPeT –Comorbidity summary measure –Quantitative and Qualitative endpoints –Multiple, simultaneous CVS/RS components Structured approach –Concept Proof –Incremental value –Clinical Utility –Predictive validity –Intervention

22 EvidencenPatientsOutcomeTrialConceptIncremental Clinical Utility Older ElderlyMortalityProspective Cohort (?Blinded) >11 ; 4% <11 ; 42% Older ElderlyMortalityProspective Cohort (No blinding) CP deaths confined to <11 or ischaemia Forshaw OesophagusMorbidityProspective Cohort (No blinding) 13.2 vs 14.4 CP complications Readmissions NA Carlisle Vascular Mid term mortality Retrospective Cohort (No blinding) CPeT related to survival AT VE/VCO2 RCRI Hazard Ratio Hightower Major Abdominal MorbidityProspective, Pilot (Blinded) PC related to outcome ASA vs AT,HR Wilson Major Surgery MortalityProspective Cohort (No Blinding) <11 Relative risk 7x death Greater than Clinical factors Snowden Major Abdominal MorbidityProspective (Blinded) CPeT variables related to outcome Improvement on subjective and established factors Risk increase

23 Hospital mortality by AT group - effect of cardiac risk factors: AT < 11AT >11RR (95% CI) Patients with 1 or more cardiac risk factors (n=271) 3.8%1.1%3.3 ( ) Patients with no cardiac risk factors (n=576) 3.2%0.3%10.0 ( ) BJA ; Pts Mortality 2.1%

24 Optimum AT 10.1 ml/min/kg AUC 0.85 ; Sens 88%; Spec 79% Snowden et al 2010 Ann Surg

25 Types of Complications

26 Modelling Outcome

27 Exercise Ability and Cardiorespiratory Complications P< *** *

28 “High Risk” CCU Groups ITU 3ITU 7nDay 3 Poms Day 7 Poms LOS No YesNo Yes NoYes34431 Proportion Remaining in Hospital

29 CCU and Exercise Prediction Low RiskHigh Risk High risk ITU ROC Analysis: Opt AT 10.6 (62%,80%) AUC ( ) P= (2.6) 9.6 (2.3)

30 CPX Clinic _________ No CPX Clinic _________ CPX ClinicNo clinic 30 day mortality 3/194 (2%)8/139 (6%) Critical Care 22%10% The CPeT “Package of Care” Swart et al. Personal communication

31 High Risk Surgery: Liver Transplantation Highest Surgical Risk (O.R. 15.8) Early Mortality - 18% Ensure appropriate organ allocation –Limited resource –Marginal Organs –High Comorbidity

32 Recipient Scores SurvivorsNon Survivors Signif N=496 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)

33 Transplantation and Exercise ROC analysis: Optimum AT 9.6 ml/min/kg AUC 0.97 ; (p=0.001) p< Snowden et al (In Prep)

34 CCU Stay and Liver Tx Median CCU LOS 9 days vs 27 days P=0.001 Proportion remaining in CCU AT< 9.6 AT>= 9.6 Days in CCU

35 Donor – Recipient Matching P=0.04 Snowden et al (In Prep)

36 Selective Training Effect

37 Summary Surgical risk - evolving concept Insights from large population studies New concepts for: –Operative risk variability –Mortality and “Failure to rescue” –Importance of complications (esp CVS) –Cardiac “Dysfunction”

38 Summary Exercise Ability (and assessment): –Defines important end point for comorbidity –Relates to mortality and morbidity –Varying surgical specialities –Pedigree in cardiorespiratory dysfunction Future –Prospective comparative trials –Interventional strategy tool


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