Department of Surgical Sciences and Integrated Diagnostics (DISC) University of Genoa – IRCCS AOU San Martino IST – Genoa, Italy The Role of Intensive Care to Improve Perioperative Mortality Pelosi Paolo Dubai Anaesthesia 2013

Annual figures for the European high-risk surgical population 21 million in-patient general procedures 2.6 million high-risk procedures 1.3 million patients develop complications 315,000 deaths in hospital Ghaferi A. N Engl J Med 2009; 361: Weiser T Lancet 2008; 372: ; Pearse R Crit Care 2006; 10: R81

Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis Bainbridge et al Lancet 2012; 380: 1075–81 Perioperative mortality per year

Country Patients (n) and Mortality (%) UK (Findlay G. 2011) Netherlands (Noordzij PG. 2010) Brasil (Yu PC. 2010) USA (Glance LG. 2012) Spain (Canet J. 2010) Post-op mortality at 30 days in different countries

80% of surgical deaths are from the high-risk population Pearse et al. Crit Care 2006; 10: R81. Surgical deaths: Size, Risk and Mortality

Surgical complications decrease long-term survival Khuri et al. Ann Surg 2005; 242: 326–343 Pts w/o complications Pts with 1/more complications

Variation in hospital mortality associated with in patient surgery Ghaferi AA et al N Engl J Med 2009;361: Complications Pneumonia % MV>48hr % Mortality Pneumonia % MV>48hr %

Euroanaesthesia 2010, Sunday, 13 June 2010 Eur J Anaesthesiol 2010;27:592–597

ESA Clinical Trials Network (ESA CTN) Research Committee Did you know that the most important and challenging clinical questions are more likely to be solved if several centres join forces ?

Poor quality of surgical outcome data Inaccurate healthcare systems data Specialty society data on limited subsets Mostly retrospective analyses Too much focus on elective surgery No comparative data across Europe

International seven day cohort study of standards of care and clinical outcomes for non-cardiac surgery European Surgical Outcomes Study EuSOS

European Surgical Outcomes Study EuSOS Lancet 2012; 380:

EuSOS: Inclusion criteria All adult patients undergoing in-patient non-cardiac surgery during the seven day study period Start: 09:00 4 th April 2011 Finish: 08:59 11 th April 2011 EuSOS European Surgical Outcomes Study Lancet 2012; 380:

EuSOS: Exclusion criteria No planned overnight hospital stay Neurosurgery Obstetrics Cardiac surgery (thoracic surgery is included) EuSOS European Surgical Outcomes Study Lancet 2012; 380:

Investigators !

EuSOS Cohort Patients admitted in ICU 3612 (8%) Patients admitted in ward (92%) Died in ICU 287 (8%) Died in ward 1358 (3%) Died in ward after ICU discharge 217 (6,5%) Total Mortality 1682 (4%)

EuSOS Cohort patients 1864 (4%) deaths Elective surgery (75%) 1132 (3%) Urgent surgery 8919 (19%) 483 (5%) Emergency surgery 2557 (5%) 249 (10%) Planned admission to ICU 1864 (5%) 32 (2%) Discharged to ward alive 2088 (97,5%) 104 (5%) Unplanned admission to ICU 278 (1%) 22 (8%) Unplanned admission to ICU 391 (4%) 63 (16%) Unplanned admission to ICU 356 (14%) 79 (22%) Planned admission to ICU 490 (5%) 54 (11%) Planned admission to ICU 201 (8%) 37 (18%) Discharged to ward alive 764 (87%) 63 (8%) Discharged to ward alive 441 (79%) 49 (11%)

Mortality Risk Factors VariableOdds Ratio Age (per year)1 ASA IV-V Metastatic Cancer1.39 Cirrhosis2.13 Urgent-Emergency surgery Upper gastro-intestinal surgery1.57 EuSOS European Surgical Outcomes Study Lancet 2012; 380:

EuSOS European Surgical Outcomes Study Lancet 2012; 380: Which are the “safer” types of surgery ? Laparoscopic surgery 0.75 – 0.25 Plastic/Cutaneous 0.71 – 0.66 Kidney/Urology 0.23 – 0.82 Head and Neck Odds Ratio

European Surgical Outcomes Study EuSOS Large numbers of patients die following in-patient non-cardiac surgery Large variations in mortality between countries suggest the need for national and international strategies to improve care for this patient group Patterns of critical care admission suggest process failure in the allocation of these resources Lancet 2012; 380: EuSOS: Conclusions

European Surgical Outcomes Study

Message to be delivered: Dear Colleagues funding medical care, …… care. “We suggest that even use of expensive resources, such as additional ICU beds, could rapidly become cost effective by reducing complications”. Vonlanthen R and Clavien PA. Lancet Sep 22;380(9847): What factors affect mortality after surgery?

Lancet 2012; 380: ; Intensive Care Med 2012; 38: Peri-op Mortality and GDP/inhabitant R = 0.55 P < 0.01 MORTALITY (%)

The definition of ICU beds (recovery room vs post-op ICU vs General ICU) and resources might differ between countries Other factors are important: - Use of surgical safety checklists -Clinical pathways -Enhanced recovery strategy (fast track surgery) -Volume of cases -Presence of general versus specialised surgeons -Ability to recognise and manage complications -Quality of care and Economic resources What factors affect mortality after surgery? Vonlanthen R and Clavien PA. Lancet Sep 22;380(9847):1034-6

Need of Surgery Comorbidity -Age (per year) -ASA IV-V -Metastatic cancer -Cirrhosis High risk surgery -Urgent/emergency -Upper gastro-intestinal No comorbidity No high risk surgery High risk surgery and No comorbidity Comorbidity and No High risk surgery High risk surgery and comorbidity Surgical ward Surgical ward/ monitoring or Post-op ICU and monitoring in ward after discharge

PPCs: are they a problem? Variable incidence (2%-40%), depending on definition, kind of surgery and patients Prevalence: as cardiac complications Leading cause of long hospital stay and mortality Etiology: anesthesia and surgery induce changes

Post-operative pulmonary complications: EFFECTS ON SURVIVAL Fernandez-Perez et al Thorax 2009;64;

PPCs

Anesthesiology 2011: 115: Pelosi P and Gama de Abreu M

How to evaluate the risk of PPCs ? % (score 26-44) – 54 % (score >45) risk to develop PPCs Canet J et al for ARISCAT, Anesthesiology. 2010; 113(6):

Steering Committee: Jaume Canet (S) Sergi Sabaté (S) Valentín Mazo (S) Lluis Gallart (S) Marcelo Gama de Abreu (G) Javier Belda (S) Olivier Langeron (F) Andreas Hoeft (G) Paolo Pelosi (I) Brigitte Leva (ESA Secretariat) (B)

Methods 1/5  Design – Prospective, multicenter, observational, cohort study  Geographic scope – ARISCAT: 51 Anesthesiology Departments (Catalonia, Spain) – PERISCOPE: 63 Anesthesiology Departments (21 European countries)

Methods 2/5  Data collection – 7 days ARISCAT: January 2006 – January 2007 – Randomized days (one for each day of the week) for each center. PERISCOPE: May 2011 – August 2011 – Continuous days (a full week)

Methods 3/5 Inclusion criteria –Undergoing a surgical procedure under regional or general anesthesia (epidural, spinal or saddle block)... –... on the selected days at a participating center –Informed consent

Methods 4/5 Exclusion criteria – Age < 18 years – Obstetric/childbirth procedures – Local or peripheral nerve anesthesia with or without sedation – Diagnostic and therapeutic procedures outside the operating room – Intubated on arrival at the operating room – Re-operation due to an in-hospital postoperative complication – Transplantss and brain-dead patients

 Primary outcome (composite)  Respiratory insufficiency  Bronchospasm  Pleural effusion  Respiratory infection  Atelectasis  Aspiration pneumonitis  Pneumothorax  Methods 5/5  Unified definitions of variables

PPCs Incidence 7.92% 4.37% 6.21% 5384 patients

PPCs or CHF ?

PPCs & Surgical Speciality

Lenght of Hospital Stay Periscope Ariscat Patients without PPCs Patients with PPCs 3 (1-10.9) 3 (1-11.0) 9 (4-33) 12 (4-36.8) Median (10th -90th percentile)

Periscope Ariscat Patients without PPCs Patients with PPCs Post-Op In-Hospital Mortality (%)

PLOS and In–Hospital Mortality & PPCs

Conclusions Postoperative pulmonary complications are frequent, expensive and associated with increased mortality There is increased national focus on the need for higher quality, safer and more appropriate care. Readmission of surgical patients with pneumonia is a significant source of increased healthcare costs.

Conclusions Strongest risk factors for PPCs are age, preoperative SpO 2, previous respiratory infection, anemia, kind of surgery and surgical aggressiveness More than 50% of the risk is related to patient factors A risk index based on 7 objective factors discriminates well across a wide range of patients, surgeries and geographic areas. Stratifying risk for PPCs can be calculated preoperatively and, in case, recalibrated.

The ICUs & Hospital activities General ICU In Hospital Emergencies In Hospital Planned Critical Care Step- Down ICU Ward Specialized ICUs Out of Hospital Emergencies

Thanks