Perioperative mortality

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.^{[citation needed]}

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

Main article: Hospital-acquired 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][4][5][6]

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.^[7][8]

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^[9]), use of surgical drains, prophylactic antibiotics, and vancomycin.^[10] Preventative antibiotics may also be effective.^[11]

Whether any specific dressing has an effect on the risk of surgical site infection of a wound that has been sutured closed is unclear.^[12]

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.^[13]

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.) ^[14] 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.^[15] 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.^[16] 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.^[15]

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.^{[citation needed]}

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.^[2]

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.^[17] 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.^[18] 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,^[19] asphyxiation^[20] and anaphylaxis.^[21] 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.^[22]

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%.^[23] 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.^[24] This committee was tasked with determining and reducing the causes of peri-anesthetic morbidity and mortality.^[24] 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".^[25]

The current mortality attributable to the management of general anesthesia is controversial.^[26] Most current estimates of perioperative mortality range from 1 death in 53 anesthetics to 1 in 5,417 anesthetics.^[27][28] The incidence of perioperative mortality that is directly attributable to anesthesia ranges from 1 in 6,795 to 1 in 200,200 anesthetics.^[27] 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.^[29] It is suggested that these wide ranges may be caused by differences in operational definitions and reporting sources.^[27]

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%.^[30]

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

• Patient safety
• ASA physical status classification system

References

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8. Gwilym BL, Ambler GK, Saratzis A, Bosanquet DC, Stather P, Singh A, Mancuso E, Arifi M, Altabal M, Elhadi A, Althini A, Ahmed H, Davies H, Rangaraju M, Juszczak M (2021-08-01). "Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction Models: Development, Internal Validation, and Comparison with Existing Risk Prediction Models Identified in a Systematic Literature Review". European Journal of Vascular and Endovascular Surgery. 62 (2): 258–266. doi:10.1016/j.ejvs.2021.05.009. hdl:1983/8e17b0f2-2b9e-4c7f-947b-82f0535b1ffb. ISSN 1078-5884. PMID 34246547.
9. Wade RG, Burr NE, McCauley G, Bourke G, Efthimiou O (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. 274 (6): e481–e488. doi:10.1097/SLA.0000000000004076. PMID 32773627.
10. 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.
11. 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.
12. 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. 2016 (12): CD003091. doi:10.1002/14651858.CD003091.pub4. PMC 6464019. PMID 27996083.
13. 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.
14. Cook MW, Lisco SJ (2009). "Prevention of postoperative pulmonary complications". International Anesthesiology Clinics. 47 (4): 65–88. doi:10.1097/aia.0b013e3181ba1406. PMID 19820479. S2CID 9060298.
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18. 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.
19. Engelhardt T, Webster NR (September 1999). "Pulmonary aspiration of gastric contents in anaesthesia". British Journal of Anaesthesia. 83 (3): 453–60. doi:10.1093/bja/83.3.453. PMID 10655918.
20. 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.
21. 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.
22. 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]}
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24. Guadagnino C (2000). . Narberth, Pennsylvania: Physician's News Digest. Archived from the original on 2010-08-15.
25. Stoelting RK (2010). "Foundation History". Indianapolis, IN: Anesthesia Patient Safety Foundation.
26. Cottrell JE (2003). . ASA Newsletter. 67 (1). Archived from the original on 2010-07-31.
27. 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.
28. 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]}
29. 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.
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Further reading

• Deans GT, Odling-Smee W, McKelvey ST, Parks GT, Roy DA (July 1987). "Auditing perioperative mortality". Annals of the Royal College of Surgeons of England. 69 (4): 185–7. PMC 2498471. PMID 3631878.
• Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF (October 2005). "Long-term survival is superior after resection for cancer in high-volume centers". Annals of Surgery. 242 (4): 540–4, discussion 544–7. doi:10.1097/01.sla.0000184190.20289.4b. PMC 1402350. PMID 16192814.
• 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. JSTOR 3767954. PMID 11748422. S2CID 10839493.
• Mayo SC, Shore AD, Nathan H, Edil BH, Hirose K, Anders RA, et al. (July 2011). "Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion". HPB. 13 (7): 473–82. doi:10.1111/j.1477-2574.2011.00326.x. PMC 3133714. PMID 21689231.
• Nixon SJ (May 1992). "NCEPOD: revisiting perioperative mortality". BMJ. 304 (6835): 1128–9. doi:10.1136/bmj.304.6835.1128. PMC 1882135. PMID 1392785.
• de Leon MP, Pezzi A, Benatti P, Manenti A, Rossi G, di Gregorio C, Roncucci L (July 2009). "Survival, surgical management and perioperative mortality of colorectal cancer in the 21-year experience of a specialised registry". International Journal of Colorectal Disease. 24 (7): 777–88. doi:10.1007/s00384-009-0687-1. PMID 19280201. S2CID 24925839.
• Shaw CD (1990). "Perioperative and perinatal death as measures for quality assurance". Quality Assurance in Health Care. 2 (3–4): 235–41. doi:10.1093/intqhc/2.3-4.235. PMID 1983243.
• Simunovic N, Devereaux PJ, Bhandari M (January 2011). "Surgery for hip fractures: Does surgical delay affect outcomes?". Indian Journal of Orthopaedics. 45 (1): 27–32. doi:10.4103/0019-5413.73660. PMC 3004074. PMID 21221220.
• Start RD, Cross SS (September 1999). "Acp. Best practice no 155. Pathological investigation of deaths following surgery, anaesthesia, and medical procedures". Journal of Clinical Pathology. 52 (9): 640–52. doi:10.1136/jcp.52.9.640. PMC 501538. PMID 10655984.
• Schermerhorn ML, Giles KA, Sachs T, Bensley RP, O'Malley AJ, Cotterill P, Landon BE (March 2011). "Defining perioperative mortality after open and endovascular aortic aneurysm repair in the US Medicare population". Journal of the American College of Surgeons. 212 (3): 349–55. doi:10.1016/j.jamcollsurg.2010.12.003. PMC 3051838. PMID 21296011.

External links

• Perioperative Mortality Review Committee, Department of Health, New Zealand (2009). "Terms of Reference for the Perioperative Mortality Review Committee" (PDF).{{cite web}}: CS1 maint: multiple names: authors list (link)^{[permanent dead link]}
• "National Confidential Enquiry into Patient Outcome and Death".