Re: Managing perioperative risk in patients undergoing elective non-cardiac surgery
I read with interest the excellent letter by Dr Ben Maddison on ‘Improvements in the perioperative care of high risk non-cardiac surgical patients’
I agree with his comments that most complications and deaths that follow non-cardiac surgery occur in high-risk patients and that cardio-pulmonary exercise testing (CPET) has an important role to play in assessing patients coming for elective surgery. However, we would like to add that those who come for emergency surgery are more likely to present with major complications and die perioperatively. Emergency cases are not offered CPET as it is impractical to conduct in such critically ill patients and their assessment by junior staff remains to be a problem.
In September 2011, the Royal College of Surgeons and the Department of Health, with the support of several professional bodies for anaesthesia and critical care medicine published a report on the perioperative care of the high risk general surgical patients.1
The report stated that published evidence shows successful outcomes are dependent on good perioperative care and this can be challenging and not always delivered in acute hospitals. It singled out emergency surgery in this group due to growing concern that these patients receive sub-optimal care, which has important implications for patients and the healthcare economy. Emergency cases alone are said to account for 14,000 admissions to intensive care in England and Wales annually. 2 The mortality of these cases is over 25% and the intensive care unit (ICU) cost alone is at least £88 million. Indeed patients who are over 80 are more likely to present for emergency surgery than elective surgery where the risks multiply. 3
The Association of Surgeons of Great Britain and Ireland state that for a successful outcome patients need rapid identification of the problem. However, to identify such mortality rate is not easy in medical practice especially by junior doctors. 4 Another complicating factor in assessing emergency patients is that the chance of a patient dying in a UK hospital is 10% higher if he or she is admitted at a weekend rather than during the week. 5
The authors of the Royal College of Surgeons (England) report recommend that objective assessment of perioperative risk must become routine, should be recorded for each patient, and should be the trigger for senior clinicians’ involvement at an early stage.
They recommend that patients with a predicted mortality of ≥5% should be managed as high risk. Most major emergency laparotomy procedures fall in this category, together with complex elective gastrointestinal and vascular procedures in patients with co-morbidity.
To determine the risk of death the report recommends to clinicians various risk scores each with its advantages and limitations. The HES online dataset include accessible national annual mortality rates (in percentages) for each surgical procedure. Junior doctors may find these mortality figures very useful. However, risk adjusted mortality is not accessible for general use and doctors need to consider the added risk to the average figures when dealing with patients having severe co-morbidity.
In addition to CPET, this dataset is useful to have for pre-operative assessment clinics giving information to clinicians and patients coming for elective surgery and to junior doctors during their shifts. One disadvantage is that it takes time to get to the relevant information required based on procedural codes. To help junior doctors make these timely assessments we should make it possible to have direct access through IT stations in hospitals and even through mobile phone applications that incorporate HES dataset.
POSSUM, P-POSSUM, and V-POSSUM are other risk scores recommended by the report for general surgery (first two) and vascular surgery (last score). These risk scores can be downloaded and used as tools to calculate the risk for each patient using their physiological data before emergency surgery and can be updated after surgery. The report highlights the fact that such risk scores may over estimate the risk, especially in those patients with less co-morbidity. However, the risk score given is specific for that patient and can be very helpful for emergency general surgical admissions. Again, these two risk scores should be downloaded and made available on mobile phone applications and various IT stations in A&E and theatres if its not available already.
Miss Miriam Hassani
1. The Higher Risk General Surgical Patient- Towards Improved care for the Forgotten Group. Royal College of Surgeons-England and Department of Health. 2011.
2. Intensive Care National Audit & Research Centre (ICNARC), London 2010. Data derived from Case Mix Programme Database based on 170,105 admissions to 185 adult, general critical care units in NHS hospitals across England, Wales and Northern Ireland.
3. Ford PNR, Thomas I, Cook TM, Whitley E, Peden CJ. Outcome in critically ill octogenarians after surgery: an observational study. British Journal of Anaesthesia 2007; 99: 824–829.
4. Emergency General Surgery: The future. A consensus statement. Association of Surgeons of Great Britain and Ireland. http://asgbi.org.uk/en/publications/consensus_statement.cfm
5. Aylin P, Yunus A, Bottle A, Majeed A, Bell D. Weekend mortality for emergency admissions. A large, multicentre study. Qual Saf Health Care 2010; 19: 213–217.
Competing interests: No competing interests