1. 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

2. 234 million major surgical procedures worldwide 4,000 procedures per 100,000 population overall 11,000 procedures per 100,000 in high income countries

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

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

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

7. 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)<0.0001 Emergency procedures (%) 769,371 (21.3%)454,924 (88.5%)<0.0001 Duration of hospital stay (days) 3 (1-6)16 (9-29)<0.0001 Mortality (%)15,038 (0.42%)63,340 (12.3%)<0.0001

8. Mortality following non-cardiac surgery in an NHS Trust Jhanji et al Anaesthesia 2008; 63(7): 695-701

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

10. 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

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

12. 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) 3.462.761.381.54

13. High-risk surgery: Comparison with the cardiac surgery model

14. UK Cardiac Surgical Register 1977-2000 Society for Cardiothoracic Surgeons of Great Britain & Ireland

15. 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

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

17. 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%)

19. 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%

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

21. Outcomes across the UK: Comparison of England and Scotland

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

24. Critical care resources in Scotland and England EnglandScotland Population (millions) 50.85.1 ICU : Acute bed ratio 1.02/1000.92/100 ICU beds / million population 24.531.3

25. 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 II13.916.614.517.5 ICU stay (days)1.02.01.21.9 Hospital stay (days)15211419 Urgency56%44%38%59%

26. 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

27. 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

28. Peri-operative β -blockade: POISE Trial

29. 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

30. Pre-operative assessment of cardiovascular risk

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

32. Anaerobic threshold in high-risk surgical patients Older P et al. Chest 1999; 116: 355-362.

33. 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

34. 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

35. 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)<0.0001 Emergency procedures (%) 8,159 (34.9%)1,437 (60.8%)<0.0001 Duration of hospital stay (days) 3 (2-6)16 (9-30)<0.0001 Mortality (%)106 (0.45%)284 (12.0%)<0.0001

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

37. 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

38. 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