To Operate or Not - Pre-operative Assessment
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1 To Operate or Not - Pre-operative Assessment DR IVAN WARD CONSULTANT ANAESTHETIST FLINDERS MEDICAL CENTRE PULSE ANAESTHETICS
2 About me
3 Disclosure I am married to a Palliative Physician
4 Risk of Death Historical perspective s Chloroform anaesthetics 1 death for every 3000 cases Ether anaesthesia 1 death for every 12,000 cases Edmond I Eger II, Lawrence Saidman, Rod Westhorpe 2013, The Wondrous Story of Anesthesia, Springer Science & Business Media, 944 pages
5 Australian Anaesthetic Mortality Australian and New Zealand College of Anaesthetists Longitudinal data 1960 s 1 deaths per 10,000 cases End of 1980 s 1 death per 25,000 cases death per 58,039 cases A review of anaesthesia-related mortality reporting in Australia and New Zealand
6 Australian Anaesthetic Mortality Estimated anaesthesia related mortality in Australia 17 Deaths per million A review of anaesthesia-related mortality reporting in Australia and New Zealand Australian and New Zealand Audit of Surgical Mortality National Report 2013
7 Risk of Death Summary Overall risk of intraoperative death 1 in 58,000 Risk of death in ASA 1 Approximately 1 in 200,000 Risk of death solely due to anaesthetic related factors 1 in 411,000
8 Risk of Death Summary Overall risk of intraoperative death 1 in 58,000 Risk of death in ASA 1 Approximately 1 in 200,000 Risk of death solely due to anaesthetic related factors 1 in 411,000
9 The Reason Study STORY D, ET AL. COMPLICATIONS AND MORTALITY IN OLDER SURGICAL PATIENTS IN AUSTRALIA AND NEW ZEALAND (THE REASON STUDY): A MULTICENTRE, PROSPECTIVE, OBSERVATIONAL STUDY. ANAESTHESIA, 2010; 65:
10 REASON Study Inclusion Criteria Non-cardiac surgical patients aged > 70 years Expected to stay at least one night in hospital Admitted to one of 23 hospitals in Australia and New Zealand Story D, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON Study): a multicentre, prospective, observational study. Anaesthesia, 2010; 65:
11 REASON Study Results Studied 4158 consecutive patients By day (5%) of patients had died 835 (20%) suffered complications Story D, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON Study): a multicentre, prospective, observational study. Anaesthesia, 2010; 65:
12 REASON Study Independent pre-operative patient factors associated with an increased 30-day mortality included Increasing Age years: OR 2.1 [95% CI ] 90+ years: OR 4.0 [95% CI ]) Worsening ASA Status ASA 3: OR 3.1 [95% CI ] ASA 4: OR 12.4 [95% CI ] ASA 5: OR 40.8 [95% CI ]
13 REASON Study
14 REASON Study Applicable to our patient group Local hospitals Open inclusion criteria Inclusive of both elective and emergency surgery Difficult to apply to specific patients
15 Population based risk assessment
16 Australian Bureau of Statistics Life expectancy tables and likelihood of dying Most recent tables are from Based on age-specific death rates
17 Australian Bureau of Statistics
18 Australian Bureau of Statistics Gives a population based prediction of yearly mortality Independent of surgical intervention Not individualised to the patient Can be considered baseline
19 Individualised risk assessment
20 Individualised risk assessment Numerous risk stratification tools Specific for surgical procedures Euroscore II for cardiac surgery Specific post operative complications Lees Revised Cardiac Risk Index Specific patient populations APACHE II risk index for ICU patients General preoperative risk assessment POSSUM / P-POSSUM ACS NSQIP
21 ACS - NSQIP AMERICAN COLLEGE OF SURGEONS: NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM
22 ACS - NSQIP American College of Surgeon National Surgical Quality Improvement Program Collects high-quality, standardised clinical data from more than 500 hospitals in the US Preoperative risk factors Post operative complications Originally used Risk-adjusted 30 day outcome comparisons. Generate procedure specific risk prediction tools for a limited number of postoperative outcomes g/
23 ACS - NSQIP Universal ACS - NSQIP surgical risk calculator Developed using data from 393 ACS NSQIP hospitals 1,414,006 patients Subspecialties included
24 ACS - NSQIP Universal ACS - NSQIP surgical risk calculator Data Source Collects reliable and validated data on patient demographics, laboratories, comorbidities and 30-day postoperative outcomes Standardised data definitions Thirty-day outcomes are assessed from the medical record, or patients are contacted after discharge Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
25 ACS - NSQIP Universal ACS - NSQIP surgical risk calculator Preoperative risk factors Preoperative risk factors were selected a priori based on Predictive value Routine availability to the surgeon before the procedure Clinical face validity Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
26 ACS - NSQIP Universal ACS - NSQIP surgical risk calculator Used individual Current Procedural Terminology (CPT) codes for each surgical procedure CPTs with more than 25 cases were used in the calculator
27 ACS - NSQIP Risk Prediction Models Models for 8 surgical outcomes were evaluated Mortality Pneumonia Cardiac event (cardiac arrest or myocardial infarction) Surgical site infection Urinary tract infection Deep vein thrombosis Renal failure Other Morbidity
28 ACS - NSQIP Surgeon Risk Adjustment Allows modification based on comorbidities not accounted for Increase the risk of surgery within the confidence interval for each CPT Surgeon Adjustment Score (SAS) SAS 1 = default estimated risk from the model SAS 2 = adjusted to +1 standard deviation of predicted risks SAS 3 = adjusted to +2 standard deviations of predicted risks Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
29 ACS - NSQIP Performance of the risk calculator Three metrics C-statistic Is a measure of discrimination Ranges from 0.5 (chance) to 1.0 (perfect) Brier score The average squared difference between patients predicted probabilities and observed outcomes (1 or 0 depending on event or non-event) The Brier score will approach 0.0 with perfect prediction Hosmer-Lemeshow (HL) Statistic Measure of calibration that reflects bias in predicting risk across the range of risk Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
30
31 ACS NSQIP Benefits of universal risk calculator Uses 21 preoperative risk factors which are usually available in most patients preoperatively Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
32
33
34 ACS - NSQIP Limitations Questionable applicability of a US based risk prediction model Preoperative variables were selected based on what was available in the NSQIP data base Other preoperative factors such as albumin is not included despite high association with post operative morbidity Bilimoria KY, et al. Development and evaluation of the universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons. Journal of American College of Surgeons 2013; 217(5):
35 Applying this knowledge in practice
36 Practical use of tools Use of peri-operative risk tools High risk patients having procedures which are not necessary Stoma reversals Exceptionally high risk patients Potentially pre-terminal
37 Case Mid 70 s renal patient with a potential ischaemic gut Usual renal co-morbidities Critical aortic stenosis Severe pulmonary hypertension Actively septic Significant abdominal pain
38
39 Useful Questions
40 Useful Questions What is your understanding of the current situation, and what is likely to happen?
41 Useful Questions What is your understanding of the current situation, and what is likely to happen? What have the other doctors explained so far?
42 Useful Questions What is your understanding of the current situation, and what is likely to happen? What have the other doctors explained so far? What is your biggest concern at the moment?
43 Useful Questions What is your understanding of the current situation, and what is likely to happen? What have the other doctors explained so far? What is your biggest concern at the moment? What do you hope we could do? What do you hope to gain from having the procedure?
44 Useful Questions What is your understanding of the current situation, and what is likely to happen? What have the other doctors explained so far? What is your biggest concern at the moment? What do you hope we could do? What do you hope to gain from having the procedure?
45 Stress that they will continue to be looked after even if they don t proceed with surgery Discuss which teams will be responsible for their ongoing care
46 Importance of communication The anaesthetist is the last hurdle to overcome prior to surgery Communication is vital between surgeons and anaesthetist Also vital between anaesthetist and patients
47 Conclusions Perioperative mortality is higher than people realise
48 Conclusions Perioperative mortality is higher than people realise There are tools which are available to help quantify risks
49 Conclusions Perioperative mortality is higher than people realise There are tools which are available to help quantify risks There are alternatives to surgery
50 Conclusions Perioperative mortality is higher than people realise There are tools which are available to help quantify risks There are alternatives to surgery Need to ask important and difficult questions
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