Perioperative mortality

Perioperative mortality is death in relation to surgery, often defined as death within two weeks of a surgical procedure. 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.

Intraoperative causes

Complications during surgery, e.g. bleeding or perforation of organs may have lethal sequelae.

Complications following surgery

Infection

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.

Methods to decrease surgical site infections in spine surgery include skin preparation, use of surgical drains, prophylactic antibiotics, and vancomycin.[1] Preventative antibiotics may also be effective.[2]

Whether any specific dressing has an effect on the risk of surgical site infection of a wound that has been sutured closed is unclear.[3]

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.

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.) [4] 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.[5] 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.[6] 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.[5]

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

Neurologic

Strokes occur at a higher rate during the postoperative period.

Livers and kidneys

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

Postoperative fever

Postoperative fevers are a common complication after surgery and can be a hallmark of a serious underlying condition, such as pneumonia, urinary tract infection, deep vein thrombosis, wound infection, etc.

Epidemiology

In many countries, statistics are kept by mandatory reporting of perioperative mortality. These may then be used 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. 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.

Most perioperative mortality is attributable to complications from the operation (such as bleeding, sepsis, and failure of vital organs) or pre-existing medical conditions. Mortality directly related to anesthetic management is less common, and may include such causes as pulmonary aspiration of gastric contents,[7] asphyxiation[8] and anaphylaxis.[9] 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.[10]

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%.[11] 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.[12] This committee was tasked with determining and reducing the causes of peri-anesthetic morbidity and mortality.[12] 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".[13]

The current mortality attributable to the management of general anesthesia is controversial.[14] Most current estimates of perioperative mortality range from 1 death in 53 anesthetics to 1 in 5,417 anesthetics.[15][16] The incidence of perioperative mortality that is directly attributable to anesthesia ranges from 1 in 6,795 to 1 in 200,200 anesthetics.[15] 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.[17] It is suggested that these wide ranges may be caused by differences in operational definitions and reporting sources.[15]

The largest and most recent 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%.[18]

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

References

  1. ↑ Pahys, JM (March 20, 2013). "Methods to decrease postoperative infections following posterior cervical spine surgery". J Bone Joint Surg Am. 95 (6): 549–54. doi:10.2106/JBJS.K.00756. PMID 23515990.
  2. ↑ James, M; Martinez, EA (Sep 2008). "Antibiotics and perioperative infections.". Best practice & research. Clinical anaesthesiology. 22 (3): 571–84. doi:10.1016/j.bpa.2008.05.001. PMID 18831304.
  3. ↑ Dumville, JC; Gray, TA; Walter, CJ; Sharp, CA; Page, T (Sep 1, 2014). "Dressings for the prevention of surgical site infection.". The Cochrane database of systematic reviews. 9: CD003091. doi:10.1002/14651858.CD003091.pub3. PMID 25178020.
  4. ↑ Cook, M.W.; Lisco, S.J. (2009). "Prevention of postoperative pulmonary complications.". International Anesthesiology Clinics. 47 (4): 65–88. doi:10.1097/aia.0b013e3181ba1406.
  5. 1 2 Smetana, G.W.; Lawrence, V. A., Cornell, J. E., & American College of Physicians (2006). "Preoperative pulmonary risk stratification for noncardiothoracic surgery: Systematic review for the american college of physicians.". Annals of Internal Medicine. 144 (8): 581–595. doi:10.7326/0003-4819-144-8-200604180-00009. Cite uses deprecated parameter |coauthors= (help)
  6. ↑ Smetana, G.W. (2009). "Postoperative pulmonary complications: An update on risk assessment and reduction.". Cleveland Clinic Journal of Medicine. 76 (Suppl 4): S60–5. doi:10.3949/ccjm.76.s4.10.
  7. ↑ Engelhart T, Webster NR (1999). "Pulmonary aspiration of gastric contents in anaesthesia" (PDF). Br J Anaesth. 83 (3): 453–60. doi:10.1093/bja/83.3.453. PMID 10655918.
  8. ↑ Parker RB (1956). "Maternal Death from Aspiration Asphyxia". BMJ. 2 (4983): 16–9. doi:10.1136/bmj.2.4983.16. PMC 2034767Freely accessible. PMID 13329366.
  9. ↑ Dewachter P, Mouton-Faivre C, Emala CW (2009). "Anaphylaxis and Anesthesia: Controversies and New Insights". Anesthesiology. 111 (5): 1141–50. doi:10.1097/ALN.0b013e3181bbd443. PMID 19858877.
  10. ↑ Cooper JB, Newbower RS, Long CD, McPeek B (1978). "Preventable anesthesia mishaps: a study of human factors". Anesthesiology. 49 (6): 399–406. doi:10.1097/00000542-197812000-00004. PMID 727541.
  11. ↑ Beecher HK; Todd DP (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". Ann Surg. 140 (1): 2–34. PMC 1609600Freely accessible. PMID 13159140.
  12. 1 2 Guadagnino C (2000). "Improving anesthesia safety". Narberth, Pennsylvania: Physician's News Digest. Retrieved 09-08-2010. Check date values in: |access-date= (help)
  13. ↑ Stoelting RK (2010). "Foundation History". Indianapolis, IN: Anesthesia Patient Safety Foundation. Retrieved 09-08-2010. Check date values in: |access-date= (help)
  14. ↑ Cottrell JE (2003). "Uncle Sam, Anesthesia-Related Mortality and New Directions: Uncle Sam Wants You!". ASA Newsletter. 67 (1).
  15. 1 2 3 Lagasse RS (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.
  16. ↑ Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw P, Werner FM, Grobbee DM (2005). "Impact of anesthesia management characteristics on severe morbidity and mortality" (PDF). Anesthesiology. 102 (2): 257–68. doi:10.1097/00000542-200502000-00005. PMID 15681938.
  17. ↑ Nkansah PJ, Haas DA, Saso MA (1997). "Mortality incidence in outpatient anesthesia for dentistry in Ontario". Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 83 (6): 646–51. doi:10.1016/S1079-2104(97)90312-7. PMID 9195616.
  18. ↑ Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, Boersma E (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

External links

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