Minutes of the Liverpool Society of Anaesthetists Meeting
Thursday 8th January 2015
‘Improving Outcome for High Risk Surgery’
Professor Rupert Pearse, Royal London Hospital
The meeting was opened by Professor Max McCormick, President of the Liverpool Medical Institution who welcomed everyone to the meeting. He then handed over to the LSA President, Dr Ewen Forrest, who introduced the speaker.
Professor Pearse opened his talk by declaring two conflicts of interest; firstly he believed that surgical outcomes can improve and secondly, despite having trained as an anaesthetist, he no longer gives anaesthetics. He quoted the paper by Weiser T.G. et al (Lancet 2008;372:139-44) which estimated that there were 234 million major surgical procedures worldwide each year. The mortality rate for all this surgery is not known. If 1% of patients could be prevented from dying as a result of surgery, this would result in 2.3 million avoidable deaths each year. He then showed a slide demonstrating the international variation in adjusted mortality risk in comparison with the UK. It appeared that northern European and in particular Scandinavian countries had the best results with eastern and southern European countries having the worst. He looked at the work of Ghaferi (NEJM 2009;361:1368-75). This showed that although surgical death rates vary widely across hospitals, the rate of complications seem to be similar.
To understand post-operative complications, Professor Pearse thought that you had to consider 3 things. Firstly the surgery, which technically had greatly improved, for example, with significantly lower rates of anastomotic leaks. Therefore these major surgical complications had reduced in incidence. However the medical conditions with which patients present had changed. Those with significantly greater comorbidities were now undergoing major surgery for which, in the past, they would be deemed unsuitable. Finally the perioperative care of these patients was becoming increasingly important with the recognition and early treatment of worsening medical conditions becoming vital. He looked at the consequences of anaesthesia and surgery where an inevitable consequence, such as wound inflammation, develops into a wound infection; a complication. This could also be respiratory impairment becoming a pneumonia, immobility resulting in pulmonary embolism and organ dysfunction becoming acute kidney injury. This was far more likely in the increasingly frail and comorbid population undergoing surgery.
Professor Pearse spoke about his vision of perioperative medicine, of which there are many definitions. He offered one which was the prevention and treatment of harm resulting from the tissue injury of surgery (and anaesthesia). He thought that the battle for safety in anaesthesia had now been largely won and thought that is was time to take this further outside the operating theatre. He discussed pre-operative assessment which tried to predict patients who may have poor surgical outcomes. He highlighted cardiopulmonary exercise testing, one area in which he was currently researching. He quoted a paper by Musallam K et al (Lancet 2011;378:1396-407) which highlighted the incremental risk of anaemia with other comorbidities such as cardiac disease, COPD, renal impairment, all being associated with a higher mortality. Therefore, as Shander A et al (BJA 2012;109:55-68) had highlighted, peri-operative patient blood management is vital for good outcome. This includes optimising haemopoiesis, minimising blood loss and bleeding and the improvement of tolerance of anaemia. He wondered how many of us have been presented with a patient on the day of surgery who had been inadequately optimised but we all felt the pressure to continue. Almost always we manage to get the patient through anaesthesia and surgery but the real problems seem to start a couple of days afterwards where inevitable consequences often become complications. Therefore individualised care must be the aim of pre-operative assessment.
Professor Pearse then looked at the surgical event and highlighted the importance of checklists and the variable use of the WHO checklist across Europe. He spoke about other factors that may help to improve outcomes such as minimally invasive cardiac output measurements and the use of epidural anaesthesia. He thought that these were very important and anaesthetists in general were not very good at highlighting the necessity of putting their case across strongly for pieces of equipment or better nursing care.
Professor Pearse discussed events occurring early after surgery and reminded the audience that acute organ injury can be a cause of long-term harm. This can include acute lung injury, sepsis-related myocardial injury and loss of muscle function. He quote a paper Squadrone V et al (JAMA 2005:293;589-95) which showed that the early use of CPAP for the treatment of post-operative hypoxaemia can significantly reduce post-operative respiratory complications. He also highlighted the association between post-operative troponin levels and mortality. Post-operative rises in troponin were associated with a much higher mortality than similarly raised levels found in patients admitted through A&E.
Professor Pearse went on to look at events later after surgery and showed a paper by Khuri et al (Ann Surg 2005:242;326-343) which demonstrated those with either pulmonary or wound complications had a significantly lower 5 and 10 year survival after surgery. This was again demonstrated for acute kidney injury after cardiac surgery (Hobson C et al, Circulation 2009:119;2444). Acute kidney injury was a key cause of chronic kidney disease as a result of loss of nephrons during each episode. He reminded the audience that the serum creatinine actually falls after surgery and therefore if it is raised, this is evidence of a much bigger injury than a rise associated with no surgery. Finally, he thought that anaesthetists should see some patients in post-operative clinics because they tend to be better at looking at the whole patient rather than just the outcome of surgery. They can then refer patients to relevant specialists if organ dysfunction has worsened as a result of these surgical episodes.
Professor Pearse thought that surgery could often be a sentinel event with this being the first contact that many patients will have with a doctor. This can lead to the unmasking of many co-morbidities which often need to be treated prior to surgery and anaesthesia. He highlighted a number of quality improvement initiatives, such as the publication of performance data for individual surgeons and the way that cardiological services have been reorganised over the last 10 years showing a major improvement in 30 day survival following STEMI. He spoke about the EPOCH trial (Enhanced Perioperative Care for High Risk Patients) which is a project to implement an integrated care pathway for patients scheduled for emergency laparotomy. He said that healthcare can learn lessons from other industries and highlighted the way that the building of Crossrail in central London had changed building culture to greatly improve the safety of workers on the project.
Finally he thought that the Royal College of Anaesthetists should be renamed that Royal College of Perioperative Medicine and reminded the audience that the College was soon to roll out its initiative in this area.
Professor Pearse took some questions from the audience. Dr Alison Hall gave the vote of thanks and the meeting concluded at 8.30.