anesthesia impact on perioperative outcomes · overselling anesthesia safety is a natural...

Anesthesia Impact on Perioperative

Outcomes

David L. Reich, M.D.

Hospital President and COO

Professor of Anesthesiology

Icahn School of Medicine at Mount Sinai

New York, NY

2000: Institute of Medicine “To

Err is Human” Report “Anesthesia is an area in which very impressive

improvements in safety have been made…. preventable

mishaps have declined… mortality rates are about one

death per 200,000–300,000 anesthetics administered,

compared with two deaths per 10,000 anesthetics in the

early 1980s.

“The gains in anesthesia are very impressive and were

accomplished through a variety of mechanisms, including

improved monitoring techniques, the development and

widespread adoption of practice guidelines, and other

systematic approaches to reducing errors.”

2000 IOM Report

Notably reduced error

Responding to rising malpractice premiums in the

mid-1980s:

Technological advances (most notably the pulse

oximeter)

Standardization of equipment, and changes in training

They were able to bring about major, sustained,

widespread reduction in morbidity and mortality

attributable to the administration of anesthesia.”

2002: Lagasse Review 2.17 deaths per 10,000 anesthetics

Lagasse RS. Anesthesiology. 2002;97:1609-17.

1990: Arthur Keats

“There are no agreed definitions of what

constitutes anesthesia mortality, no

agreement as to what to look for and

count, no agreement over how much of

the perioperative period to include or how

many years to cover before practices

change too dramatically.”

Anesth Analg 1990; 71:113-19

1990: Arthur Keats

“Instead of events, these (anesthesia

mortality) studies recorded judgments,

what someone thought was a cause of

death in the remote past, and that

judgment cannot be reviewed in the light

of any new knowledge.”

Anesth Analg 1990; 71:113-19

1990: Arthur Keats

“We are all brainwashed by the

error-blame mentality in reviewing

anesthetic records…. When brain

damage follows an incident, the reviewer

is much more likely to find inappropriate

care—that is, errors—than if the patient

recovers.” (JAMA 1991;265:1957-60)

Anesth Analg 1990; 71:113-19

$0

$20 000

$40 000

$60 000

$80 000

$100 000

$120 000

$140 000

$160 000

Co

nsta

nt

Do

llars

(2

011)

Malpractice Insurance Rates-NY County

Anesthesia

General Surgery

Obstetrics

Data courtesy FOJP Service Corporation

Surgical Mortality

Nationwide Inpatient Sample

30-day surgical mortality declined from

1.68% in 1996 to 1.32% in 2006

Surgical mortality is therefore a

significant public health problem,

responsible for nearly 190,000 deaths in

the US in 2006

Semel ME et al. Surgery 2012;151:171-82

Anesthesia Proportion of

Surgical Mortality

Lagasse estimate:

<2% of surgical mortalities

IOM estimate:

0.03% of surgical mortalities

Truth or Consequences

2nd lowest level of NIH funding

Existential threat to the specialty?

“Anesthesia has gotten remarkably safe in recent

decades, with roughly one death occurring in every

200,000 to 300,000 cases in which anesthetics are

administered during surgery, childbirth or other

procedures.”

“From a patient’s point of view, it would seem

preferable to have a broadly trained anesthesiologist

perform or supervise anesthesia services, but, in

truth, the risk is minuscule either way.”

“Who Should Provide Anesthesia Care?” September 6, 2010

SCIP Adherence Infection Effect

Nonadherent Adherent OR (95% CI)

N

Infection

Rate N

Infection

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

Perioperative Pharmacological

Protection

Beta BlockadeRisk Factor Interaction

Lindenauer et al:

N Engl J Med

2005;353:349-61.

Outcome

Metoprolol

(n=4174), n (%)

Placebo

(n=4177), n (%)

Hazard

ratio p

Primary

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

POISE Study Group, Devereaux PJ et al.

Lancet. 2008;371:1839-47

High-Dose Metoprolol

Temperature

Postop Cardiac Outcomes (%)

Outcome Hypoth Normoth P

Isch/V.Tach 16 7 0.02

Morbid Event 6 1 0.02

Unstable Ang 4 1

Cardiac Arrest 1 1

MI 1 0

ECG 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

Transfused Blood Storage

Koch CG et al: N Engl J Med 2008;358:1229-39

Antibiotics

Antibiotic Compliance

Oxygenation

High FiO2 Meta-Analysis

Thibon et al. Anesthesiology 2012;117:504 –11

Brain Monitoring

Cerebral Oximetry Monitoring

Murkin et al: Anesth Analg 2007;104:51–8

Perioperative Glucose Control

GIK CPB Surgery

Lazar et al: Circulation. 2004;109:1497-1502

NICE SUGAR Trial

N Engl J Med 2009;360:1283-97

Pain Management

Am J Med Qual. 2012 Sep 25 [Epub]

Am J Med Qual. 2012 Sep 25 [Epub]

Predicting Inpatient Pain Severity

Odds 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

Am J Med Qual. 2012 Sep 25 [Epub]

Predicting Inpatient Pain Severity(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

Am J Med Qual. 2012 Sep 25 [Epub]

Orthopedic Nursing Unit

0

2

4

6

8

10

12

14

16

18

Number of Patients

Pre-Neuraxial Morphine

Post-Neuraxial Morphine

Am J Med Qual. 2012 Sep 25 [Epub]

Hemodynamic Management

and

Depth of Anesthesia

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

Unpublished Data

Age and BP Instability

Death Non-fatal MI

≤ 40 0.68 (0.46 - 1.01) 0.54 (0.24 - 1.22)

40 - 50 1.19 (0.89 - 1.61) 2.06 (1.25 - 3.41)

50-60 (ref) - - - -

60 - 70 1.29 (0.95 - 1.74) 3.25 (1.99 - 5.3)

70 - 80 0.59 (0.39 - 0.9) 0.26 (0.09 - 0.77)

≥ 80 1.95 (1.41 - 2.69) 3.33 (1.93 - 5.73)

Anesthetic Depth and Mortality

Monk et al: Anesth Analg 2005;100:4–10

Sessler D et al: Anesthesiology 2012;116:1195-203

http://xkcd.com/552

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

PatientClinician

Anesthesia

Machine &

Monitors

q 30 second

updates;

1-2 min latency

q 15 second

sampling

Decision

Support

System

Notifies

Clinician

Clinician

Acknowledges

Anesthesiology 2012;

117:717–25

Anesthesiology 2012; 117:717–25

Pearse RM et al: JAMA 2014; 311:2181-90

Pearse RM et al: JAMA 2014; 311:2181-90

PSI Index PSI 4 is absolutely the largest of all PSI and as such makes the

largest effect on PSI index for the same relative change.

Data Source: Quality Dashboard – All Payers

PSI 4 PSI 6 PSI 9 PSI 11 PSI 14 PSI 15

Rate

(p

er

1,0

00

)

0

10

20

30

40

110

120

130

140

1502009-2011 (USNWR 2013)

2010-2012 (USNWR 2014)

2011-2013 (USNWR 2014)

USNWR PSI Index

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

(Contrarian?) Conclusions

Overselling anesthesia safety is a natural

consequence of the error-blame mentality (and

it feels good)

Maintaining (or reclaiming?) relevance

demands a strategic claim to a larger

proportion of adverse perioperative outcomes

Age is almost always a risk factor, but focusing

on patient selection and modifiable variables is

a more constructive strategy