Should we worry about surgical outcomes? Rupert Pearse Senior Lecturer in Intensive Care Medicine William Harvey Research Institute Barts and the London School of Medicine and Dentistry

234 million major surgical procedures worldwide 4,000 procedures per 100,000 population overall 11,000 procedures per 100,000 in high income countries

Number of deaths reported by the National Confidential Enquiry into Peri-Operative Deaths

The high-risk surgical patient Elderly Co-morbid disease Major surgery Emergency surgery

Mortality in selected UK general surgical populations Pearse et al. Crit Care; 2006; 10 R81.

Standard and high-risk surgical populations in the UK Pearse et al. Crit Care; 2006; 10 R81. Standard riskHigh riskp n3,603,803513,924- Age (years)54 (38-69)75 (63-83)< Emergency procedures (%) 769,371 (21.3%)454,924 (88.5%)< Duration of hospital stay (days) 3 (1-6)16 (9-29)< Mortality (%)15,038 (0.42%)63,340 (12.3%)<0.0001

Mortality following non-cardiac surgery in an NHS Trust Jhanji et al Anaesthesia 2008; 63(7):

Less than 1/3 of high-risk patients are admitted to critical care

Annual figures for the UK high-risk surgical population 1.4 million in-patient general procedures 166,000 high-risk surgical procedures 100,000 patients develop complications 25,000 deaths

‘Quality and process improvement…. should be directed toward prevention of postoperative complications.’ Khuri et al. Ann Surg 2005; 242: 326–343

Risk prediction for common surgical procedures performed in the UK Aylin et al. BMJ; 2007(online first) Colo-rectal Unruptured AAA Ruptured AAA CABG Database size 144,37031,70512,781152,523 Overall mortality 10,424 (7.2%) 3,246 (10.2%) 5,987 (46.8%) 3,247 (2.1%) Effect of Urgency (odds ratio)

High-risk surgery: Comparison with the cardiac surgery model

UK Cardiac Surgical Register Society for Cardiothoracic Surgeons of Great Britain & Ireland

Why are outcomes so much better for cardiac surgical patients? Younger / Fitter / Elective Efficient care pathway for single disease group Strong evidence base guides practice Post-operative intensive care is standard Outcome data influences practice

The high-risk surgical patient: Just a UK problem?

Predicted Mortality Mt Sinai Observed mortality Portsmouth Observed mortality 0-10%5 (0.6%)43 (3.8%) 11-20%6 (5.3%)25 (14.9%) >20%11 (9.7%)84 (35.9%)

Mortality for common surgical procedures in the USA Khuri et al. Ann Surg 2005; 242: 326–343. n 30 day mortality Long term Mortality Colectomy 19,8956.5%46% Unruptured AAA 5,3004.5%37% Infra-inguinal vascular 19,1173.0%43% Carotid endarterectomy 16,8801.2%34% Laparoscopic Cholecystectomy 14,2950.6%17% Total Hip Replacement 12,1841%21%

Placebo: 72 deaths among 459 patients (16%) Metoprolol: 74 deaths among 462 patients (16%)

Outcomes across the UK: Comparison of England and Scotland

Number of deaths following emergency surgery reported by the Scottish Audit of Surgical Mortality

Critical care resources in Scotland and England EnglandScotland Population (millions) ICU : Acute bed ratio 1.02/ /100 ICU beds / million population

Surgical admissions to Scottish ICUs in 2006 Kerssens J SICSAG 2008 unpublished data Pearse et al. Crit Care; 2006; 10 R81. ICNARCSICSAG ElectiveEmergencyElectiveEmergency Mortality10.4%30.4%7.3%25.3% APACHE II ICU stay (days) Hospital stay (days) Urgency56%44%38%59%

High-risk surgery is an important healthcare problem Acknowledge the problem Identifying the high-risk patient Effective intervention Adequate resources Quality research Reliable outcome data

Summary High-risk surgery is an important healthcare problem We need to.... –Accept we have a problem –Better identify those patients at increased risk Post-operative morbidity and mortality concentrated in an easily identifiable high-risk surgical population

Peri-operative β -blockade: POISE Trial

56% surgical ICU pts need single or no organ support Median ICU stay 1.6 days (all patients) Median hospital stay 16 days (all patients) Strong evidence of infection in 76% patients Pearse et al, Crit Care; 2006; 10 R81. High-risk surgery: Not a typical critical illness

Pre-operative assessment of cardiovascular risk

B-type natriuretic peptide and surgical outcome Cuthbertson et al. BJA and AJC 2007

Anaerobic threshold in high-risk surgical patients Older P et al. Chest 1999; 116:

Cardio-Pulmonary Exercise Testing in high-risk surgical patients Most published data are audits Most studies evaluate VO 2 max Only one peer reviewed paper on ATT

Sub-maximal exercise testing Peri-operative β-blockade Overnight Intensive Recovery (OIR) Units Goal Directed Haemodynamic Therapy Non-invasive ventilation Enhanced Recovery After Surgery (ERAS) philosophy Reliable national audit of surgical outcome High-risk surgery: Specific interventions

Surgical populations in a single NHS Trust Jhanji et al. 2007; unpublished data Standard riskHigh riskp n23,3682,360- Age (years)44 (31-60)67 (51-76)< Emergency procedures (%) 8,159 (34.9%)1,437 (60.8%)< Duration of hospital stay (days) 3 (2-6)16 (9-30)< Mortality (%)106 (0.45%)284 (12.0%)<0.0001

Admission to Critical Care for non-cardiac surgery Standard riskHigh riskp n23,6372,414- Admitted to critical care 733 (0.03%) 852 (35.3%) < Mortality for patients admitted to critical care 35 (4.8%) 144 (16.9%) < Mortality for patients not admitted to critical care 64 (0.3%) 150 (9.6%) <0.0001

Headline findings 12% cases result in >70% of deaths Only one third of high-risk patients ever reach critical care Half the high-risk patients who die never reach critical care

Headline findings Critical Care provision for elective surgery is acceptable but could improve Critical Care provision for emergency surgery is unacceptable and must increase Duration of critical care stay remains short