Perioperative mortality

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Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital. [1] Globally, 4.2 million people are estimated to die within 30 days of surgery each year [2] . An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ various methods in assessing whether a patient is in optimal condition from a medical standpoint prior to undertaking surgery, and various statistical tools are available. ASA score is the most well known of these.

Contents

Intraoperative causes

Immediate complications during the surgical procedure, e.g. bleeding or perforation of organs may have lethal sequelae.[ citation needed ]

Complications following surgery

Infection

Countries with a low human development index (HDI) carry a disproportionately greater burden of surgical site infections (SSI) than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of the World Health Organization (WHO) recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication. [3]

Local infection of the operative field is prevented by using sterile technique, and prophylactic antibiotics are often given in abdominal surgery or patients known to have a heart defect or mechanical heart valves that are at risk of developing endocarditis.[ citation needed ]

Methods to decrease surgical site infections in spine surgery include the application of antiseptic skin preparation (a.g. Chlorhexidine gluconate in alcohol which is twice as effective as any other antiseptic for reducing the risk of infection [4] ), use of surgical drains, prophylactic antibiotics, and vancomycin. [5] Preventative antibiotics may also be effective. [6]

Whether any specific dressing has an effect on the risk of surgical site infection of a wound that has been sutured closed is unclear. [7]

A 2009 Cochrane systematic review aimed to assess the effects of strict blood glucose control around the time of operation to prevent SSIs. The authors concluded that there was insufficient evidence to support the routine adoption of this practice and that more randomized controlled trials were needed to address this research question [8] .

Blood clots

Examples are deep vein thrombosis and pulmonary embolism, the risk of which can be mitigated by certain interventions, such as the administration of anticoagulants (e.g., warfarin or low molecular weight heparins), antiplatelet drugs (e.g., aspirin), compression stockings, and cyclical pneumatic calf compression in high risk patients.[ citation needed ]

Lungs

Many factors can influence the risk of postoperative pulmonary complications (PPC). (A major PPC can be defined as a postoperative pneumonia, respiratory failure, or the need for reintubation after extubation at the end of an anesthetic. Minor post-operative pulmonary complications include events such as atelectasis, bronchospasm, laryngospasm, and unanticipated need for supplemental oxygen therapy after the initial postoperative period.) [9] Of all patient-related risk factors, good evidence supports patients with advanced age, ASA class II or greater, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure, as those with increased risk for PPC. [10] Of operative risk factors, surgical site is the most important predictor of risk for PPCs (aortic, thoracic, and upper abdominal surgeries being the highest-risk procedures, even in healthy patients. [11] The value of preoperative testing, such as spirometry, to estimate pulmonary risk is of controversial value and is debated in medical literature. Among laboratory tests, a serum albumin level less than 35 g/L is the most powerful predictor and predicts PPC risk to a similar degree as the most important patient-related risk factors. [10]

Respiratory therapy has a place in preventing pneumonia related to atelectasis, which occurs especially in patients recovering from thoracic and abdominal surgery.[ citation needed ].

Neurologic

Strokes occur at a higher rate during the postoperative period.[ citation needed ]

Livers and kidneys

In people with cirrhosis, the perioperative mortality is predicted by the Child-Pugh score.[ citation needed ]

Postoperative fever

Postoperative fevers are a common complication after surgery and can be a hallmark of a serious underlying sepsis, such as pneumonia, urinary tract infection, deep vein thrombosis, wound infection, etc. However, in the early post-operative period a low-level fever may also result from anaesthetic-related atelectasis, which will usually resolve normally.

Epidemiology

Most perioperative mortality is attributable to complications from the operation (such as bleeding, sepsis, and failure of vital organs) or pre-existing medical conditions.[ citation needed ]. Although in some high-resource health care systems, statistics are kept by mandatory reporting of perioperative mortality, this is not done in most countries. For this reason a figure for total global perioperative mortality can only be estimated. A study based on extrapolation from existing data sources estimated that 4.2 million people die within 30 days of surgery every year, with half of these deaths occurring in low- and middle-income countries [12] .

Perioperative mortality figures can be published in league tables that compare the quality of hospitals. Critics of this system point out that perioperative mortality may not reflect poor performance but could be caused by other factors, e.g. a high proportion of acute/unplanned surgery, or other patient-related factors. Most hospitals have regular meetings to discuss surgical complications and perioperative mortality. Specific cases may be investigated more closely if a preventable cause has been identified.

Globally, there are few studies comparing perioperative mortality across different health systems. One prospective study of 10,745 adult patients undergoing emergency abdominal surgery from 357 centres across 58 countries found that mortality is three times higher in low- compared with high-human development index (HDI) countries even when adjusted for prognostic factors. [13] In this study the overall global mortality rate was 1·6 per cent at 24 hours (high HDI 1·1 per cent, middle HDI 1·9 per cent, low HDI 3·4 per cent), increasing to 5·4 per cent by 30 days (high HDI 4·5 per cent, middle HDI 6·0 per cent, low HDI 8·6 per cent; P < 0·001). A sub-study of 1,409 children undergoing emergency abdominal surgery from 253 centres across 43 countries found that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. This translate to 40 excess deaths per 1000 procedures performed in these settings. [14] Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days.

Mortality directly related to anesthetic management is less common, and may include such causes as pulmonary aspiration of gastric contents, [15] asphyxiation [16] and anaphylaxis. [17] These in turn may result from malfunction of anesthesia-related equipment or more commonly, human error. A 1978 study found that 82% of preventable anesthesia mishaps were the result of human error. [18]

In a 1954 review of 599,548 surgical procedures at 10 hospitals in the United States between 1948 1952, 384 deaths were attributed to anesthesia, for an overall mortality rate of 0.064%. [19] In 1984, after a television program highlighting anesthesia mishaps aired in the United States, American anesthesiologist Ellison C. Pierce appointed a committee called the Anesthesia Patient Safety and Risk Management Committee of the American Society of Anesthesiologists. [20] This committee was tasked with determining and reducing the causes of peri-anesthetic morbidity and mortality. [20] An outgrowth of this committee, the Anesthesia Patient Safety Foundation was created in 1985 as an independent, nonprofit corporation with the vision that "no patient shall be harmed by anesthesia". [21]

The current mortality attributable to the management of general anesthesia is controversial. [22] Most current estimates of perioperative mortality range from 1 death in 53 anesthetics to 1 in 5,417 anesthetics. [23] [24] The incidence of perioperative mortality that is directly attributable to anesthesia ranges from 1 in 6,795 to 1 in 200,200 anesthetics. [23] There are some studies however that report a much lower mortality rate. For example, a 1997 Canadian retrospective review of 2,830,000 oral surgical procedures in Ontario between 1973 1995 reported only four deaths in cases in which either an oral and maxillofacial surgeon or a dentist with specialized training in anesthesia administered the general anesthetic or deep sedation. The authors calculated an overall mortality rate of 1.4 per 1,000,000. [25] It is suggested that these wide ranges may be caused by differences in operational definitions and reporting sources. [23]

The largest study of postoperative mortality was published in 2010. In this review of 3.7 million surgical procedures at 102 hospitals in the Netherlands during 1991 2005, postoperative mortality from all causes was observed in 67,879 patients, for an overall rate of 1.85%. [26]

Anaesthesiologists are committed to continuously reducing perioperative mortality and morbidity. In 2010, the principal European anaesthesiology organisations launched The Helsinki Declaration for Patient Safety in Anaesthesiology, a practically-based manifesto for improving anaesthesia care in Europe.

See also

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names.

Surgery Use of incisive instruments on a person to investigate or treat a medical condition

Surgery is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pathological condition such as a disease or injury, to help improve bodily function or appearance or to repair unwanted ruptured areas.

Anesthesia or anaesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes. It may include some or all of analgesia, paralysis, amnesia, and unconsciousness. A patient under the effects of anesthetic drugs is referred to as being anesthetized.

A laparotomy is a surgical procedure involving small incisions through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

General anaesthesia medically induced coma with loss of protective reflexes

General anaesthesia or general anesthesia is a medically induced coma with loss of protective reflexes, resulting from the administration of one or more general anaesthetic agents. It is carried out to allow medical procedures that would otherwise be intolerably painful for the patient; or where the nature of the procedure itself precludes the patient being awake.

Spinal anaesthesia Form of neuraxial regional anaesthesia

Spinal anaesthesia, also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the subarachnoid space, generally through a fine needle, usually 9 cm (3.5 in) long. It is a safe and effective form of anesthesia performed by anesthesiologists and nurse anesthetists which can be used as an alternative to general anesthesia commonly in surgeries involving the lower extremities and surgeries below the umbilicus. The local anesthetic or opioid injected into the cerebrospinal fluid provides anesthesia, analgesia, and motor and sensory blockade. The tip of the spinal needle has a point or small bevel. Recently, pencil point needles have been made available.

Awareness under anesthesia, also referred to as intraoperative awareness or accidental awareness during general anesthesia (AAGA), is a rare complication of general anesthesia when patients regain varying levels of consciousness during their surgical procedures. While it's possible to regain consciousness during surgery without any memory of it, the more clinically significant entity is awareness with explicit recall, where patients can remember the events related to their surgery. This article focuses on intraoperative awareness with explicit recall.

Postoperative nausea and vomiting (PONV) is the phenomenon of nausea, vomiting, or retching experienced by a patient in the postanesthesia care unit (PACU) or within 24 hours following a surgical procedure. It is an unpleasant complication that affects about 10% of the population undergoing general anaesthesia each year.

Epidural administration Medication injected into the epidural space of the spine

Epidural administration is a method of administration in which a drug is injected into the epidural space around the spinal cord. The epidural route is used by physicians and nurse anesthetists to administer local anesthetic agents, analgesics, diagnostic medicines such as radiocontrast agents, and other medicines such as glucocorticoids. Epidural administration is often accomplished through use of a catheter placed into the epidural space. The technique of epidural administration was first described in 1921 by Spanish military surgeon Fidel Pagés.

Pancreaticoduodenectomy major surgical procedure involving the pancreas, duodenum, and other organs

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours off the head of the pancreas. It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

Posterior ischemic optic neuropathy (PION) is a medical condition characterized by damage to the retrobulbar portion of the optic nerve due to inadequate blood flow (ischemia) to the optic nerve. Despite the term posterior, this form of damage to the eye's optic nerve due to poor blood flow also includes cases where the cause of inadequate blood flow to the nerve is anterior, as the condition describes a particular mechanism of visual loss as much as the location of damage in the optic nerve. In contrast, anterior ischemic optic neuropathy (AION) is distinguished from PION by the fact that AION occurs spontaneously and on one side in affected individuals with predisposing anatomic or cardiovascular risk factors.

Postoperative fever refers to an elevated body temperature occurring after a recent surgical procedure. Diagnosing the cause of postoperative fever can sometimes be challenging; while fever in this context may be benign, self-limited, or unrelated to the surgical procedure, it can also be indicative of a surgical complication, such as infection.

Postoperative cognitive dysfunction (POCD) is a decline in cognitive function that may last from 1–12 months after surgery, or longer. In some cases, this disorder may persist for several years after major surgery. POCD is distinct from emergence delirium. Its causes are under investigation and occurs commonly in older patients and those with pre-existing cognitive impairment.

The ASA physical status classification system is a system for assessing the fitness of patients before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added. These are:

  1. Healthy person.
  2. Mild systemic disease.
  3. Severe systemic disease.
  4. Severe systemic disease that is a constant threat to life.
  5. A moribund person who is not expected to survive without the operation.
  6. A declared brain-dead person whose organs are being removed for donor purposes.

The Outcomes Research Consortium is an international clinical research group that focuses on the perioperative period, along with critical care and pain management. The Consortium's aim is to improve the quality of care for surgical, critical care, and chronic pain patients and to “Provide the evidence for evidence-based practice.” Members of the Consortium are especially interested in testing simple, low-risk, and inexpensive treatments that have the potential to markedly improve patients’ surgical experiences.

Continuous wound infiltration (CWI) refers to the continuous infiltration of a local anesthetic into a surgical wound to aid in pain management during post-operative recovery.

The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. The checklist serves to remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained instruments. While the checklist has been widely adopted due to its efficacy in many studies as well as for its simplicity, some hospitals still struggle with implementation due to local customs and to a lack of "buy-in" from surgical staff.

Brachial plexus block regional anesthesia technique

Brachial plexus block is a regional anesthesia technique that is sometimes employed as an alternative or as an adjunct to general anesthesia for surgery of the upper extremity. This technique involves the injection of local anesthetic agents in close proximity to the brachial plexus, temporarily blocking the sensation and ability to move the upper extremity. The subject can remain awake during the ensuing surgical procedure, or s/he can be sedated or even fully anesthetized if necessary.

Local anesthetic nerve block short-term nerve block involving the injection of local anesthetic

Local anesthetic nerve block is a short-term nerve block involving the injection of local anesthetic as close to the nerve as possible for pain relief. The local anesthetic bathes the nerve and numbs the area of the body that is innervated by that nerve. The goal of the nerve block is to prevent pain by blocking the transmission of pain signals from the surgical site. The block provides pain relief during and after the surgery. The advantages of nerve blocks over general anesthesia include faster recovery, monitored anesthesia care vs. intubation with an airway tube, and much less postoperative pain.

Postoperative wounds are those wounds acquired during surgical procedures. Postoperative wound healing occurs after surgery and normally follows distinct bodily reactions: the inflammatory response, the proliferation of cellular and tissues that initiate healing, and the final remodeling. Postoperative wounds are different from other wounds in that they are anticipated and treatment is usually standardized depending on the type of surgery performed. Since the wounds are 'predicted' actions can be taken beforehand and after surgery that can reduce complications and promote healing.

References

  1. Johnson ML, Gordon HS, Petersen NJ, Wray NP, Shroyer AL, Grover FL, Geraci JM (January 2002). "Effect of definition of mortality on hospital profiles". Medical Care. 40 (1): 7–16. doi:10.1097/00005650-200201000-00003. PMID   11748422. S2CID   10839493.
  2. Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A (February 2019). "Global burden of postoperative death". Lancet. 393 (10170): 401. doi: 10.1016/S0140-6736(18)33139-8 . PMID   30722955.
  3. Bhangu A, Ademuyiwa AO, Aguilera ML, Alexander P, Al-Saqqa SW, Borda-Luque G, et al. (GlobalSurg Collaborative) (May 2018). "Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study". The Lancet. Infectious Diseases. 18 (5): 516–525. doi:10.1016/S1473-3099(18)30101-4. PMC   5910057 . PMID   29452941.
  4. Wade, Ryckie G.; Burr, Nicholas E.; McCauley, Gordon; Bourke, Grainne; Efthimiou, Orestis (1 September 2020). "The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis". Annals of Surgery. Publish Ahead of Print. doi: 10.1097/SLA.0000000000004076 .
  5. Pahys JM, Pahys JR, Cho SK, Kang MM, Zebala LP, Hawasli AH, et al. (March 2013). "Methods to decrease postoperative infections following posterior cervical spine surgery". The Journal of Bone and Joint Surgery. American Volume. 95 (6): 549–54. doi:10.2106/JBJS.K.00756. PMID   23515990.
  6. James M, Martinez EA (September 2008). "Antibiotics and perioperative infections". Best Practice & Research. Clinical Anaesthesiology. 22 (3): 571–84. doi:10.1016/j.bpa.2008.05.001. PMID   18831304.
  7. Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, et al. (December 2016). "Dressings for the prevention of surgical site infection". The Cochrane Database of Systematic Reviews. 12: CD003091. doi:10.1002/14651858.CD003091.pub4. PMC   6464019 . PMID   27996083.
  8. Kao LS, Meeks D, Moyer VA, Lally KP (July 2009). "Peri-operative glycaemic control regimens for preventing surgical site infections in adults". The Cochrane Database of Systematic Reviews (3): CD006806. doi:10.1002/14651858.cd006806.pub2. PMC   2893384 . PMID   19588404.
  9. Cook MW, Lisco SJ (2009). "Prevention of postoperative pulmonary complications". International Anesthesiology Clinics. 47 (4): 65–88. doi:10.1097/aia.0b013e3181ba1406. PMID   19820479.
  10. 1 2 Smetana GW, Lawrence VA, Cornell JE (April 2006). "Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians". Annals of Internal Medicine. 144 (8): 581–95. doi: 10.7326/0003-4819-144-8-200604180-00009 . PMID   16618956.
  11. Smetana GW (November 2009). "Postoperative pulmonary complications: an update on risk assessment and reduction". Cleveland Clinic Journal of Medicine. 76 Suppl 4 (Suppl 4): S60-5. doi:10.3949/ccjm.76.s4.10. PMID   19880838. S2CID   20581319.
  12. Nepogodiev D, Martin J, Biccard B, Makupe A, Bhangu A (February 2019). "Global burden of postoperative death". Lancet. 393 (10170): 401. doi: 10.1016/S0140-6736(18)33139-8 . PMID   30722955.
  13. Fitzgerald JE, Khatri C, Glasbey JC, Mohan M, Lilford R, Harrison EM, et al. (GlobalSurg Collaborative) (July 2016). "Mortality of emergency abdominal surgery in high-, middle- and low-income countries". The British Journal of Surgery. 103 (8): 971–988. doi:10.1002/bjs.10151. hdl: 20.500.11820/7c4589f5-7845-4405-a384-dfb5653e2163 . PMID   27145169.
  14. Ademuyiwa AO, Arnaud AP, Drake TM, Fitzgerald JE, Poenaru D, et al. (GlobalSurg Collaborative) (2016). "Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries". BMJ Global Health. 1 (4): e000091. doi:10.1136/bmjgh-2016-000091. PMC   5321375 . PMID   28588977.
  15. Engelhardt T, Webster NR (September 1999). "Pulmonary aspiration of gastric contents in anaesthesia" (PDF). British Journal of Anaesthesia. 83 (3): 453–60. doi:10.1093/bja/83.3.453. PMID   10655918.
  16. Parker RB (July 1956). "Maternal death from aspiration asphyxia". British Medical Journal. 2 (4983): 16–9. doi:10.1136/bmj.2.4983.16. PMC   2034767 . PMID   13329366.
  17. Dewachter P, Mouton-Faivre C, Emala CW (November 2009). "Anaphylaxis and anesthesia: controversies and new insights". Anesthesiology. 111 (5): 1141–50. doi: 10.1097/ALN.0b013e3181bbd443 . PMID   19858877.
  18. Cooper JB, Newbower RS, Long CD, McPeek B (December 1978). "Preventable anesthesia mishaps: a study of human factors". Anesthesiology. 49 (6): 399–406. doi:10.1097/00000542-197812000-00004. PMID   727541.[ permanent dead link ]
  19. Beecher HK, Todd DP (July 1954). "A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive". Annals of Surgery. 140 (1): 2–35. doi:10.1097/00000658-195407000-00001. PMC   1609600 . PMID   13159140.
  20. 1 2 Guadagnino C (2000). "Improving anesthesia safety". Narberth, Pennsylvania: Physician's News Digest. Archived from the original on 2010-08-15.
  21. Stoelting RK (2010). "Foundation History". Indianapolis, IN: Anesthesia Patient Safety Foundation.
  22. Cottrell JE (2003). "Uncle Sam, Anesthesia-Related Mortality and New Directions: Uncle Sam Wants You!". ASA Newsletter. 67 (1). Archived from the original on 2010-07-31.
  23. 1 2 3 Lagasse RS (December 2002). "Anesthesia safety: model or myth? A review of the published literature and analysis of current original data". Anesthesiology. 97 (6): 1609–17. doi:10.1097/00000542-200212000-00038. PMID   12459692. S2CID   32903609.
  24. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, et al. (February 2005). "Impact of anesthesia management characteristics on severe morbidity and mortality" (PDF). Anesthesiology. 102 (2): 257–68, quiz 491-2. doi:10.1097/00000542-200502000-00005. hdl:1874/12590. PMID   15681938.[ dead link ]
  25. Nkansah PJ, Haas DA, Saso MA (June 1997). "Mortality incidence in outpatient anesthesia for dentistry in Ontario". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 83 (6): 646–51. doi:10.1016/S1079-2104(97)90312-7. PMID   9195616.
  26. Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, Boersma E (May 2010). "Postoperative mortality in The Netherlands: a population-based analysis of surgery-specific risk in adults". Anesthesiology. 112 (5): 1105–15. doi: 10.1097/ALN.0b013e3181d5f95c . PMID   20418691.

Further reading