Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (77 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
This overview of the literature relating to the high-risk surgical patient and current improvements associated with goal-directed therapy leads to some inevitable conclusions:
There is good evidence to suggest that patients with poor cardiorespiratory reserve have a higher mortality and complication rate when undergoing major surgery. Most of these patients can be identified by simple clinical methods before surgery.
It is likely that there are significant numbers of patients undergoing different types of surgery who may be at substantial risk of developing major complications or death.
A number of randomised controlled clinical studies have consistently demonstrated the improvement in outcome that can be achieved in these patients by the use of goal-directed therapy aimed at temporarily improving the cardiovascular performance of high-risk patients so that non-survivors have the same cardiorespiratory performance as survivors.
Studies have shown that benefit may be obtained in a wide range of surgery, including vascular surgery, colorectal surgery, trauma, orthopaedics, major cancer surgery and cardiac surgery.
From the work of Shoemaker and colleagues it would seem that about 8% of the surgical population would fulfil this definition of being at high risk of complications or death following major surgery. It would appear that these patients have a postoperative 30-day mortality of 20–30%, representing 90–95% of all surgical deaths. This number is likely to increase with an ageing population on whom increasingly complex surgery is being performed.
Although optimising the circulation produces significant reductions in mortality and postoperative complications in the higher-risk patient, it is now clear that important reductions in complications can be achieved in patients who have a lower mortality risk but for whom a significant complication risk exists.
It is also apparent that optimising the circulation can be carried out using several different techniques and at different times (i.e. preoperatively, intraoperatively and postoperatively).
The decision to operate on high-risk patients should be made at consultant level and should involve surgeons as well as those who will provide the intra- and postoperative care (anaesthetists and critical care consultants).
An assessment of mortality risk should be made explicit to the patient and recorded clearly on the consent form and in the medical notes.
Appropriate intraoperative physiological monitoring is required for all high-risk patients and NICE Medical Technology Guidance 3 relating to cardiac output monitoring should be applied.
All hospitals undertaking surgery for high-risk patients should have facilities to provide perioperative goal-directed monitoring and therapy and the hospital should analyse the volume of work they undertake to ensure they have sufficient capacity of facilities to be able to accommodate all the patients they treat. This should be assessed annually.
6
The Royal College of Surgeons of England have considered the high-risk surgical patient and have made a series of key suggestions for improvement in care and outcomes.
39
These include recommendations that all hospitals should formalise their pathways for unscheduled adult surgical care. That there should be prompt recognition and treatment of emergencies and complications to improve outcomes and reduce costs. Hospitals should match theatre access to patient needs. Every patient should have his/her expected risk of death estimated and documented. High-risk patients are those at greater risk of death than 5% and all should have active consultant input and be admitted to a critical care area postoperatively for at least 12 hours. Surgical procedures with a risk of death greater than 10% should only be conducted under the direct supervision of a consultant surgeon and consultant anaesthetist.
Key points
Patients with poor cardiorespiratory reserve undergoing major operations have a high postoperative complication and mortality rate. The mortality rate is much higher if these patients have emergency operations.
These patients can be identified preoperatively by simple clinical history and examination.
This high postoperative complication and mortality rate can be significantly reduced by goal-directed therapy aimed at enhancing the cardiorespiratory performance of these patients with poor physiological reserve during the perioperative period.
Goal-directed therapy aims to ensure that tissue oxygen delivery is enhanced to levels shown to confer survival without postoperative complications.
1.
Beecher, H.K., Todd, D.P. A study of the deaths associated with anaesthesia and surgery.
Ann Surg
. 1954;140:2–5.
2.
Edwards, G., Morton, H.J.V., Pask, E.A., et al, Deaths associated with anaesthesia.
Anaesthesia
1956;11:194–220.
13340197
3.
Dornette, W.H.L., Orth, O.S. Death in the operating room.
Anesth Analg
. 1956;3:545–569.
4.
Buck, N., Devlin, H.B., Lunn, J.N.
The report of a confidential enquiry into perioperative deaths
. London: Nuffield Provincial Hospitals Trust and the King Edward's Hospital Fund for London; 1987.
5.
Pearse, R.M., Harrison, D.A., James, P., et al, Identification and characterisation of the high-risk surgical population in the United Kingdom.
Crit Care
. 2006;10(3):R81.
16749940
6.
National Confidential Enquiry into Patient Outcome and Death, Knowing the risk. A review of the perioperative care of surgical patients. 2011.
This report studies the risk of dying and postoperative complications and reports on the deficiencies in the UK NHS hospital system and clearly shows that poor outcome is related to lack of provision of care facilities and the inability of clinicians to grasp the significance that preoperative comorbidities have on patient outcome after surgery.
7.
Department of Health.
Guidelines on admission to and discharge from intensive care and high dependency units
. London: NHS Executive; 1996.
8.
McQuillan, P., Pilkington, S., Allan, A., et al. Confidential enquiry into quality of care before admission to intensive care.
Br Med J
. 1998;316(7148):1853–1858.
9.
Garrard, C., Young, D. Suboptimal care of patients before admission to intensive care is caused by a failure to appreciate or apply the ABCs of life support.
Br Med J
. 1998;316(7148):1841–1842.
10.
Purdie, J.A., Ridley, S.A., Wallace, P.G. Effective use of regional intensive therapy units.
Br Med J
. 1990;300(6717):79–81.
11.
Henao, F.J., Daes, J.E., Dennis, R.J. Risk factors for multi-organ failure: a case control study.
J Trauma
. 1991;31:74–80.
12.
Bion, J. Rationing intensive care.
Br Med J
. 1995;310(6981):682–683.
13.
Desborough, J.P., The stress response to trauma and surgery.
Br J Anaesth
2000;85:109–117.
10927999
14.
Older, P., Hall, A., Hader, R., Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly.
Chest
1999;116:355–362.
10453862
15.
Shoemaker, W.C., Appel, P.L., Kram, H.B., Role of oxygen debt in the development of organ failure, sepsis and death in high-risk surgical patients.
Chest
1992;102:208–215.
1623755
16.
Gibbons, R.J., Balady, G.J., Timothy Bricker, J., et al, ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines).
J Am Coll Cardiol
2002;40:1531–1540.
12392846
17.
Shoemaker, W.C., Cardiorespiratory patterns of surviving and non-surviving postoperative patients.
Surg Gynecol Obstet
1972;134:810–814.
5031495
18.
Shoemaker, W.C., Montgomery, E.S., Kaplan, E., et al, Physiologic patterns in surviving and nonsurviving shock patients. Use of sequential cardiorespiratory variables in defining criteria for therapeutic goals and early warning of death.
Arch Surg
1973;106:630–636.
4701410
19.
Ruokonen, E., Takala, J., Kari, A., Regional blood flow and oxygen transport in patients with the low cardiac output syndrome after cardiac surgery.
Crit Care Med
1993;21:1304–1311.
8370293
20.
Ruokonen, E., Takala, J., Kari, A., et al, Regional blood flow and oxygen transport in septic shock.
Crit Care Med
1993;21:1296–1303.
8370292
21.
Uusaro, A., Ruokonen, E., Takal, J. Splanchnic oxygen transport after cardiac surgery: evidence for inadequate tissue perfusion after stabilization of hemodynamics.
Intensive Care Med
. 1996;22:26–33.
22.
Gutierrez, G., Bismar, H., Dantzker, D.R., et al, Comparison of gastric intramucosal pH with measures of oxygen transport and consumption in critically ill patients.
Crit Care Med
1992;20:451–457.
1559356
23.
Adar, R., Franklin, A., Spark, R.F., et al, Effect of dehydration and cardiac tamponade on superior mesenteric artery flow: role of vasoactive substances.
Surgery
1976;79:534–543.
1265661
24.
Bailey, R.W., Bulkley, G.B., Hamilton, S.R., et al, Protection of the small intestine from nonocclusive mesenteric ischemic injury due to cardiogenic shock.
Am J Surg
1987;153:108–116.
3799886
25.
McNeill, J.R., Stark, R.D., Greenway, C.V. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multi-centre prospective cohort study.
Br Med J
. 2003;327:1192–1197.
26.
Ohri, S.K., Somasundaram, S., Koak, Y., et al, The effect of intestinal hypoperfusion on intestinal absorption and permeability during cardiopulmonary bypass.
Gastroenterology
1994;106:318–323.
8299899
27.
Brooks, S.G., May, J., Sedman, P., et al, Translocation of enteric bacteria in humans.
Br J Surg
1993;80:901–902.
8369931
28.
O'Boyle, C.J., MacFie, J., Mitchell, C.J., et al. Microbiology of bacterial translocation in humans.
Gut
. 1998;42:29–35.
29.
Deitch, E.A., Multiple organ failure. Pathophysiology and potential future therapy.
Ann Surg
1992;216:117–134.
1503516
30.
Shoemaker, W.C., Appel, P.C., Cram, H.B., et al, Prospective trial of supranormal values of survivors as therapeutic goals in high risk surgical patients.
Chest
1988;94:1176–1186.
3191758
This study is important because it is the study that introduced the concept of goal-directed therapy for high-risk surgical patients nearly a quarter of a century ago. This year the Royal College of Surgeons of England has finally published guidelines for this group of patients that essentially endorse the findings and recommendations of Shoemaker et al.
31.
Boyd, O., Grounds, R.M., Bennett, E.D., A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high risk surgical patients.
JAMA
1993;270:2699–2708.
7907668
This was the first full well-conducted, randomised controlled study of goal-directed therapy for perioperative enhancement of the cardiovascular systems of these high-risk surgical patients. It was stopped before it was completed by the local hospital research ethics committee because the surgeons felt that it was obvious which group their patients were in and felt it was unethical to continue when the benefits were so obvious.
32.
Wilson, J., Woods, I., Fawcett, J., et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimization of oxygen delivery.
Br Med J
. 1999;318:1099–1103.
This study is important because not only did it have a control group where clinicians not involved with the study were able to decide on the postoperative treatment and send patients back to the ward postoperatively (which is common practice in many hospitals in the UK due to lack of critical care facilities), but it also divided the group admitted to intensive care into two groups for therapeutic intervention and thus showed that there could be a difference in outcome if different drugs were used for goal-directed therapy.
33.
Lobo, S.M., Salgado, P.F., Castillo, V.G., et al, Effects of maximizing oxygen delivery on morbidity and mortality in high-risk surgical patients.
Crit Care Med
2000;28:3396–3404.
11057792
34.
Bishop, M.H., Shoemaker, W.C., Appel, P.L., et al, Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation end points in severe trauma.
J Trauma
1995;38:780–787.
7760409
35.
Polonen, P., Rukonen, E., Hippelainen, M., et al, A prospective, randomized study of goal-orientated hemodynamic therapy in cardiac surgical patients.
Anesth Analg
2000;90:1052–1059.
10781452
36.
Pearse, R., Dawson, D., Fawcett, J., et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomized controlled study.
Crit Care
. 2005;9:R687–R693.
37.
British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP).
http://www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf
38.
Kuper, M., Gold, S.J., Callow, C., et al, Intraoperative fluid management guided by oesophageal Doppler monitoring.
Br Med J
2011;342:d3016. doi:
10.1136/bmj. d3016
39.
The Royal College of Surgeons of England, Department of Health, The higher risk general surgical patient: Towards improved care for a forgotten group. 2011. [London].