Perioperative Interventions That Affect Outcomes: What Do the Data Tell Us?
David L. Reich, M.D.Professor of Anesthesiology
Preoperative Revascularization
Preop Revascularization
McFall EO et al: New Engl J Med 351:2795-3804
Stent Neointimal Hyperplasia
JACC 2003; 42:234-40
ACC/AHA Guidelines
Anesth Analg March 2008Circulation. 2007;116:1971-1996.
8
US National ImperativesUS National Imperatives
Cost of Complications: SCIP View
Attributable costs� Infectious complications - $1398� Cardiovascular complications - $7789� Respiratory complications - $52466� Thromboembolic complications - $18310
Dimick JB, et al. J Am Coll Surg. 2004;199:531-7
SCIP Adherence Infection Effect
Nonadherent Adherent OR (95% CI)
NInfection
Rate NInfection
Rate
S-INF-Core: all 3 original 44417 1.15% 154963 0.53% 0.86 (0.74-1.01)
S-INF: Full Set 59356 1.42% 158304 0.68% 0.85 (0.76-0.95)
Stulberg et al: JAMA 2010;303:2479-85
SCIP Adherence Infection Effect
Stulberg et al: JAMA 2010;303:2479-85
Perioperative Pharmacological Protection
Beta BlockadeRisk Factor Interaction
Lindenauer et al:
N Engl J Med
2005;353:349-61.
OutcomeMetoprolol
(n=4174), n (%)Placebo
(n=4177), n (%)Hazard
ratio pPrimary composite
243 (5.8) 290 (6.9) 0.83 0.04
Nonfatal MI 151 (3.6) 215 (5.1) 0.7 0.0007
Total mortality
129 (3.1) 97 (2.3) 1.33 0.03
Stroke 41 (1.0) 19 (0.5) 2.17 0.005
Primary Outcome and Major Secondary Outcomes
POISENovember 7, 2007
Temperature
Thermal Treatment and Morbid Cardiac Events
� Randomized, controlled trial of supplemental warming in abdominal/thoracic/vascular surgery
� 300 patients with CAD/high risk for CAD� 35.4±0.1 deg C. versus 36.7±0.1 deg C.� What is the relative risk of morbid cardiac
events:� unstable angina/ischemia, cardiac arrest, MI
Frank SM et al: JAMA 1997;277:1127-34
Postop Cardiac Outcomes (%)
Outcome Hypoth Normoth PIsch/V.Tach 16 7 0.02Morbid Event 6 1 0.02 Unstable Ang 4 1 Cardiac Arrest 1 1 MI 1 0ECG or Event 21 8 0.001
Frank SM et al: JAMA 1997;277:1127-34
Intraoperative Hypothermia
� 200 patients undergoing colorectal surgery� Standard Rx or additional warming� Normothermic pts had lower incidence of
wound infection (6% vs. 19%, p=0.009) and mean 2.6 days shorter hospital stay (p=0.01)
� Well-designed prospective randomized protocol
� No elucidation of mechanism involved
Kurz A et al: N Engl J Med 1996;334:1209-15
Slow Rewarming
Grigore A et al: Anesth Analg 2002: 94:4-10
Postop Hyperthermia
Grocott HP et al: Stroke. 2002;33:537-541
Transfusion
Hematocrit and Outcome
� Hematocrit groups:� High (>= 34%)� Medium (25% to 33%)� Low (<= 24%)
� MI: 8.3% vs 5.5% vs 3.6%; p < 0.03� LV Dysfunction: 11.7% vs 7.4% and 5.7%; p=0.006� Mortality rate: 8.6% vs 4.5% vs 3.2%; p < 0.001� Multivariate analysis: High Hct remained the most
significant predictor of adverse outcomes (RR 2.22 [1.04-4.76])
Spiess BD et al: J Thorac Cardiovasc Surg 1998;116:460-7
CPB Hct and Outcomes
Habib RH et al: J Thorac Cardiovasc Surg 2003;125:1438-50
Transfused Blood Storage
Koch CG et al: N Engl J Med 2008;358:1229-39
Antibiotics
Antibiotic Compliance
Antibiotic Compliance
29
Timeliness of Antibiotic
www.hospitalcompare.hhs.gov
Oxygenation
Supplemental Oxygen
Greif R et al: New Engl J Med 2000;342:161-7
Supplemental Oxygen
Greif R et al: New Engl J Med 2000;342:161-7
Brain Monitoring
Cerebral Oximetry Monitoring
Murkin et al: Anesth Analg 2007;104:51–8
Perioperative Glucose Control
Intraoperative Glucose Control
Ghandi et al: Ann Intern Med. 2007;146:233-243
GIK CPB Surgery
Lazar et al: Circulation. 2004;109:1497-1502
NICE SUGAR Trial
N Engl J Med 2009;360:1283-97
NICE SUGAR Trial
N Engl J Med 2009;360:1283-97
Hemodynamic Managementand
Depth of Anesthesia
Multivariate Predictors of Death
Variable Probability OR (95% CI)MPAP >20Pre-CPB
0.029 2.1 (1.1-4.2)
MAP <50During CPB
0.025 1.3 (1.0-1.8)
HR >120Post-CPB
0.001 3.1 (1.5-6.1)
DPAP >20Post-CPB
0.004 1.2 (1.1-1.4)
Reich et al: Anesth Analg 1999;88:814-22
0
5
10
15
20
25
30
35
40
30 45 60 75 90 105 120 135 150
Mean Arterial Pressure
Su
rvey
Par
tici
pan
ts
Very LowLowNormalHighVery High
Categorization of MAP by Anesthesiologists
Prevalence of Hypotension Following Induction of General Anesthesia
Baseline prior to Induction
0-5 min after Induction
5-10 min after Induction
0-10 min after Induction
ASA 1-2 46/2962 (1.5%)
81/2882 (2.8%) 163/2904 (5.6%) 216/2824 (7.7%)
ASA 3-5 19/1134 (1.7%)
48/1104 (4.4%) 110/1110 (9.9%) 136/1080 (12.6%)
Note : The denominators vary within groups based upon completeness of data.
Anesth Analg 2005;10:622-8
Independent Predictors of Hypotension 0-10 Minutes Following Anesthetic Induction
Variable OR [95% C.I.] P-Value
Baseline MAP <70 5.00 [2.78–9.02] <0.0001
Age ≥50 yrs 2.25 [1.75–2.89] <0.0001
Propofol induction 3.94 [2.42–6.43] <0.0001
Fentanyl dosage* 1.32 [1.13–1.56] 0.0008
ASA 3-5 (vs. ASA 1-2) 1.55 [1.22-1.99] 0.0004
* Fentanyl dosing categories: 1= 0-1.50 µg/kg; 2= 1.51-5.00 µg/kg; 3= >5 µg/kg
Anesth Analg 2005;10:622-8
Independent Predictors of Hospital Mortality
Variable Odds Ratio P-value
ASA 3-5 47.4 [6.4-349] 0.002
Propofol Induction 0.24 [0.12-0.48] <0.0001
Fentanyl Dosage -- 0.83
Post-Induct Hypotension 2.3 [0.95-5.5] 0.066
Anesth Analg 2005;10:622-8
BP Excursions and Mortality
Anesth Analg 2011;113:19–30
Onset of CPB Hypotension
pre-bypass MMAP mmHg
on CPB
AAC start
80% pre-bypass MMAP
AAC end
80% pre-bypass MMAP or
50mmHg
t60s
MAP min
t MAP minprocedure start
Levin MA et al: Circulation 2009;120:1664-71
Preoperative Hypertension and Lability
Risk of Death and BP Lability
Anesthetic Depth and Mortality
Monk et al: Anesth Analg 2005;100:4–10
Anesthetic Depth and Mortality
Monk et al: Anesth Analg 2005;100:4–10
Anesthetic Depth and Mortality
Monk et al: Anesth Analg 2005;100:4–10
Triple Low: BIS, BP, MAC
Group Vasopressor Triple Low N (%) RR Mortality 1 yr
1 No No 9700 (54.0%) 1.0
2 No Yes 2881 (16.0%) 1.31*
3 Yes No 4688 (26.1%) 0.83
4 Early (<5 min) Yes 104 (0.6%) 1.07
5 Late (>5 min) Yes 594 (3.3%) 1.20
Saager L et al: Anesthesiology 2010; A354
Hemodynamics, Anesthetic Depth and Mortality
� Association does not prove causation� Why should a brief period of hypotension or
deep anesthesia be associated with hospital mortality?� Acute organ injury?
� Anesthetic “stress test” is a marker for patients with more severe underlying illness?� Cancer patients (debilitated) have exaggerated
responses to “standard” anesthetic doses
Clinician/DSS Feedback Loop
AIMS
Near-Realtime
OR Datastore
Anesthesia Machine & Monitors
q 30 second updates;
1-2 min latency
q 15 second sampling
Decision Support System
Notifies Clinician
Clinician Acknowledges
Pain Management
Predictive Value of In-Hospital Pain Scores
Pain Well Controlled Everything to Help Pain
Statistic
Chi-square
Value Prob
First Pain 27.6505 <.0001
Last Pain 23.1361 <.0001
Median 41.4481 <.0001
Worst Pain 66.2230 <0.001
Statistic
Chi-square
Value Prob
First Pain 12.5169 0.0004
Last Pain 11.7258 0.0006
Median 13.1509 0.0003
Worst Pain 30.2835 <.0001
2010 ASA Abstract A1157
Predicting Inpatient Pain SeverityOdds Ratio Lower 95% CI Upper 95% CI
Age (per 10yrs) for female 0.825 0.802 0.848
Age (per 10yrs) for male 0.769 0.746 0.793
LOS >7 days (vs. LOS=1) 7.259 6.495 8.113
LOS 3-7 days (vs. LOS=1) 4.336 3.934 4.779
LOS 1-3 days (vs. LOS=1) 2.476 2.254 2.721
African American vs. White 1.113 1.016 1.219
Latino vs. White 1.104 1.013 1.204
Asian vs. White 0.797 0.674 0.942
Other CNS drug vs. no CNS drug 1.247 1.142 1.363
Antidepressant vs. no CNS drug 1.226 1.110 1.354
Anxiolytic vs. no CNS drug 1.216 1.130 1.309
2010 ASA Abstract A1157
Predicting Inpatient Pain Severity
2010 ASA Abstract A1157
(Odds Ratio vs. Medicine) Odds Ratio Lower 95% CI Upper 95% CI
Orthopedics 7.676 6.345 9.285
Transplant Institute 5.705 2.914 11.168
Surgery 3.711 3.364 4.093
Dentistry 2.883 1.431 5.807
Neurosurgery 2.805 2.343 3.357
Rehabilitation 2.801 2.378 3.298
Urology 2.062 1.705 2.493
Radiology (Interventional) 1.932 1.272 2.936
Otolaryngology 1.440 1.147 1.809
Cardiothoracic Surgery 1.164 1.011 1.340
Gynecology 0.841 0.720 0.982
Neurology 0.727 0.584 0.905
Psychiatry 0.273 0.230 0.325
Conclusions� Risk stratify for CV disease:
� Beta-blockade, statins or sympatholysis� Preop revascularization, if indicated
� Normothermia� Normoglycemia� High FiO2
� Consider regional techniques� Prevent low BP, high HR, low BIS� Timely antibiotic therapy� Postop thromboembolic prevention� Postop pain control