Perioperative risk and mortality after major surgery

Abstract

Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.

Failure to Rescue, Rescue Surgery and Centralization of Postoperative Complications: A Challenge for General and Acute Care Surgeons

“…There is a major potential for improvement. Boehm et al (10) analyzed German data and considered that with 14 million surgical procedures per year, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40%, there are an estimated 60,000 preventable deaths per year in Germany. It becomes mandatory to expand preoperative risk assessment, to strategically prevent the post-operative complications, to implement systems for the early detection of postoperative complications, and to improve the effective and prompt medical and surgical (the rescue surgery) treatment of postoperative complications.…”

Die Implementierung medizinischer Einsatzteams als Beitrag zur Verbesserung der perioperativen Patientensicherheit. Wer? Wann? Wie?

“…Die meisten Todesfälle wurden hierbei auf einer Normalstation und nicht, wie vielleicht zu erwarten, auf einer Intensivstation verzeichnet. Einen großen Anteil der Todesursachen nach nicht kardialer Chirurgie stellen Krankheitsbilder wie Sepsis, akutes Nierenversagen und pulmonale Komplikationen dar, die sich oft schleichend entwickeln [12]. Diese Komplikationen entwickeln sich u. a. auch deshalb, weil messbare Warnzeichen und Frühsymptome in ihrer Entwicklung auf der Normalstation häufig nicht erkannt werden [13].…”

“…Bei jedem Patienten muss man sich die Frage stellen: "Kann die Therapie weiter optimiert werden?" [12].…”

Real-life use of diagnostic biopsies before treatment of kidney cancer: results from a Norwegian population-based study

“…To improve outcomes, it is important to avoid the "failure to rescue". Therefore, a department must postoperatively prevent complications, and organize the postoperative surveillance so that complications are caught early and treated by a competent specialist as soon as possible [203,210,212,220].…”