Excellent anaesthesia needs patient preparation and postoperative support to influence outcome

Incidents in anaesthesia: past occurrence and future avoidance

This article is a revised version of an analysis of reported incidents related to anaesthesia, originally published in the journal Anaesthesia (Catchpole et al 2008a) and undertaken on behalf of the National Patient Safety Agency. The purpose was to examine the range, types, frequencies and causes of reported patient safety incidents associated with anaesthesia. First we examined anaesthetic incidents as a sub-set of the total number of reported incidents; then we examined pre-surgery assessment, epidural anaesthesia, and anaesthetic awareness incidents, as they were identified as being frequent and of potential concern. To our knowledge it was the first paper to analyse and present results of the NPSA's database in a clinical academic journal. Here, we take the opportunity to re-present and review the findings in light of subsequent progress in understanding and improving patient safety and quality of care.

Postoperative complications in elderly patients and their significance for long-term prognosis

PURPOSE OF REVIEW

To outline perioperative risk factors for postoperative mortality in older patients, the relationship of these factors with long-term mortality, and to examine possible strategies to reduce mortality.

RECENT FINDINGS

For patients aged 70 years and over 30-day mortality is about 6%, whereas 20% are likely to have at least one complication during their hospital stay. The mortality risk increases by 10% for every year after age 70. Mortality is also strongly associated with preoperative status and postoperative complications, particularly systemic inflammation and renal impairment. Unplanned postoperative intensive care unit admission is an important predictor for mortality. Requirement for postoperative vasopressors or inotropes is associated with 50% mortality in patients aged 80 years or more. Early postoperative complications are likely to be associated with an increased long-term (a year or more later) mortality. Strategies such as critical care outreach may decrease both 30-day and long-term mortality.

SUMMARY

Strategies are needed to prevent, or at least adequately manage, complications in elderly patients. Agreed international definitions for risks and complications can help in assessing risks and benefits.

Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals

OBJECTIVE

To determine the incidence of postoperative complications, including 30-day mortality rate, and need for intensive care unit (ICU) admission in older patients after non-cardiac surgery.

DESIGN AND SETTING

Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004.

MAIN OUTCOME MEASURES

Postoperative complications and 30-day mortality rate.

RESULTS

1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04-1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65-3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09-4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63-9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17-6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06-5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44-9.10; P = 0.008) in the multivariate analysis.

CONCLUSION

Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.