Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (77 page)
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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.
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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.
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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.
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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.
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