Clinical Review

Managing perioperative risk in patients undergoing elective non-cardiac surgery

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5759 (Published 05 October 2011) Cite this as: BMJ 2011;343:d5759

Improvements in the peri-operative care of high risk non-cardiac surgical patients

Regarding the recent review article on managing peri-operative risk
in patients undergoing non-cardiac surgery, we present audit from our
institution and the development of peri-operative pathways that are
consistent with its recommendations.

Broomfield Hospital, Chelmsford is a busy district general hospital
undertaking a significant number of elective and emergency high risk
surgical procedures each year, particularly colorectal, upper GI,
urological and vascular. We conducted two audits of our high risk elective
surgical population, from April to December 2009 and for the year 2010.
Our primary outcome measures were pre-assessment attendance, post-
operative placement, complication rates, mortality and length of stay
(LOS). In 2009 we identified 98 elective patients, of these 42% had been
pre-assessed in preparation for a variety of surgical procedures. They had
a mean age of 67 years (SD11years). The modal ASA was II with only 43% ASA
III/IV patients admitted to a critical care unit post-operatively. The
post-operative complication rate was 39%, ranging from confusion to re-
laparotomy . Mortality rate was 1%. Median hospital LOS was 10 days. This
data is consistent with that from previous studies.[1]

Cardiopulmonary Exercise Testing (CPET) was introduced to the
anaesthetic pre-assessment clinic as part of the routine pre-operative
assessment of this high risk group towards the end of 2009. Following
assessment by a consultant anaesthetist and CPET, patients were stratified
to the appropriate post-operative care area as a result of their anaerobic
threshold and other physiological parameters measured by CPET. [2,3] Not
all patients could be assessed in this manner due to limitations in the
availability of clinicians. The 2010 audit identified 121 elective
patients, 100% of which had been pre-assessed by a consultant
anaesthetist, for a variety of surgical procedures. They had a mean age 68
years (SD 11years). The modal ASA was III with 72% ASA III/IV patients
electively admitted to a critical care unit post operatively. The post-
operative complication rate was 20%, and mortality was 2% (all patients
had extended hospital or ITU stays). In this audit the median critical
care unit LOS was 4.5 days with an overall median hospital LOS of 10 days.

By promoting consultant led pre-assessment and CPET, we have managed
to reduce complication rates from 39% (2009) to 20% (2010). This has been
achieved through focused peri-operative care of the high-risk patient and
greater elective post-operative critical care unit admission of such
patients (from 42% in 2009 to 72% in 2010). We also appear to be operating
on patients with a greater burden of co-morbidities, since the modal ASA
has increased from II (2009) to III (2010). Median hospital LOS remained
unchanged despite an apparent increase in co-morbid disease.

As suggested by the review we are continuing to audit our patient
data as part of an ongoing quality improvement process. We are now
performing 30-40 CPET tests per month due to increased referral rates from
surgical colleagues, increased clinical capacity and the local evidence
suggesting improved outcome. Multi-disciplinary discussion between GPs,
cardiologists, chest and ICU physicians now facilitates pre-operative
optimisation and peri-operative planning.[4] Data from the first two
months of this year of 60 patients show that 100% of patients are being
admitted to the appropriate post-operative destination as per our pathway,
the post-operative complication rate has fallen to less than 15%, and thus
far there have been no re-admissions to the critical care unit or deaths.

Most complications and deaths that follow non-cardiac surgery occur
in high-risk patients. We agree that it is imperative for hospitals to
develop strategies to identify such patients and ensure their high-quality
peri-operative care. Our experience supports the view that this approach
improves patient outcomes and is associated with fewer complications.

References

1. Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, et
al. Identification and characterisation of the high-risk surgical
population in the United Kingdom. Crit Care 2006;10:R81.

2. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a
screening test for perioperative management of major surgery in the
elderly. Chest 1999;116;355-62.

3. Carlisle J, Swart M. Mid-term survival after abdominal aortic
aneurysm surgery predicted by cardiopulmonary exercise testing. Br J Surg
2007;94:966-69.

4. Improving Surgical Outcomes Group. Modernising care for patients
under-going major surgery. Improving outcomes and increasing clinical
efficiency. June 2005.http://www.ebpom.org/publications

Competing interests: No competing interests

19 October 2011
Dr Ben Maddison
Consultant Anaesthetist
Dr Alistair Hughes, Dr Sameer Hanna-Jumma, Dr Kevin Kiff
Broomfield Hospital, Chelmsford
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