Intended for healthcare professionals

Clinical Review

Managing perioperative risk in patients undergoing elective non-cardiac surgery

BMJ 2011; 343 doi: (Published 05 October 2011) Cite this as: BMJ 2011;343:d5759
  1. Rupert M Pearse, reader1,
  2. Peter J E Holt, clinical lecturer2,
  3. Michael P W Grocott, professor34
  1. 1Barts and The London School of Medicine and Dentistry, Queen Mary’s University of London EC1M 6BQ, UK
  2. 2Department of Outcomes Research, Vascular Institute, St George’s Hospital, London, UK
  3. 3University of Southampton, Southampton SO17 1BJ, UK
  4. 4Surgical Outcomes Research Centre, UCLH/UCL Comprehensive Biomedical Research Centre, London
  1. Correspondence to: R Pearse, Intensive Care Unit, Royal London Hospital, London E1 1BB r.pearse{at}

Summary points

  • Non-cardiac surgery has a low overall mortality but is associated with a large number of deaths because so many procedures are performed

  • Most deaths occur in a group of patients who are at high risk because of advanced age, comorbid disease, or major surgery (hospital mortality rate 12%)

  • More effective systems can improve quality of perioperative care and may improve survival while reducing healthcare costs

  • Further research is needed to identify the most effective approaches to perioperative medicine for high risk patients

  • Routine audit of outcomes after all non-cardiac surgery is urgently needed

The perioperative care of patients undergoing major surgery is increasingly recognised as an area that substantially affects public health and for which needs are poorly met. Around 15% of people who undergo inpatient surgery are at high risk of complications, such as pneumonia or myocardial infarction, because of age, comorbid disease, or the complexity of the surgical procedure.1 2 High risk surgical patients account for 80% of all perioperative deaths. Non-cardiac surgery is an important cause of death and disability, owing to the high volume of procedures and related adverse outcomes.1 2 3 4 5 6 Around 250 million major surgical procedures are performed worldwide each year.3 This number is increasing as gross domestic product rises in poorer countries.3 Assuming a hospital mortality rate of 1%, non-cardiac surgery will be associated with 2.5 million deaths worldwide each year and complication rates at least five times this figure.1 2 3 4 5 6 Patients who survive postoperative complications commonly experience functional limitations and reduced long term survival.4 5 6

Varying mortality rates between hospitals indicate the potential and the need to improve survival after surgery.7 However, the reasons for the variation in mortality are not fully understood, making effective planning more …

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