Gary Minto Consultant Anaesthetist HOW DO WE ASSESS PATIENTS FOR MAJOR SURGERY?

Surgical mortality, UK

Why Is Surgery Bad For You?  A Premeditated and Calculated Trauma  Mishaps, bleeding  Systemic Inflammatory Response –Increased VO 2 (Fitness) –Hypercoagulability (Stents, DVT, stroke) –Metabolic Response (Diabetes, Renal)  Psychological (“Sickness”)

Complications after Colorectal Surgery

Risk Stratification Scoring Systems  ASA  Lee Revised Cardiac Index  APACHE Score  POSSUM Score Anaesthetic Hunch?

A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = Outcome Iezzoni, L. I. An introduction to risk adjustment. Am J Med Qual 11, S8-11 (1996).

A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = Outcome Comorbidity “aerobic fitness/ functional capacity” Genetics

Hammill 2008 Procedure 30d Mortality (%) With CAD With CCF AAA Ca Colon Ca Lung THR

Cardio-Pulmonary Exercise Testing (CPET)

Clinic No clinic 30 day mortality 2%6% Critical Care 24%12%

A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation severity of surgery, urgency what happens during surgery stress response (genetics)

A conceptual model for outcome following surgery Patient Factors + Effectiveness of Care + Random Variation = intra-op and post op complications response to complications / level of care decision-making process

ANY QUESTIONS?