Challenges of high-risk surgery

A small group of "high-risk" patients account for a disproportionately high number of surgery-related deaths, complications, and costs. The April issue of Anesthesia & Analgesia, official journal of the International Anesthesia Research Society (IARS), commences a special series on high-risk surgery—focusing on new and emerging strategies for identifying and managing patients at high risk.

The 3-month series will present a "broad picture of the epidemiology, pathophysiology, and interventions in high-risk surgery," according to an introductory editorial by Dr. Jukka Takala of University of Bern, Switzerland. Dr. Takala adds, "We must focus on a systems approach to high-risk surgery, rather than clinging to the fragmented traditional disease-oriented approach."

High-Risk Surgery—New Approaches to Evaluation Needed
In a special invited review, Dr. Suneetha Ramani Moonesinghe of University College London and colleagues present an update on the epidemiology and outcomes of high-risk surgery. Their review draws on nearly two decades of work at UCL's Surgical Outcomes Research Centre (SOURCe).

A recent study of more than 4 million surgical procedures in the United Kingdom found that about 12 percent of patients accounted for more than 80 percent of postoperative deaths, with high use of health care resources. Wide variations in health care delivery may lead to significant differences in mortality and complication rates, according to Dr. Moonesinghe and coauthors.

They review current approaches to assessing patient risk surgery based on the patient's medical condition—for example, the widely used American Society of Anesthesiologists physical status score. While these and other approaches to risk stratification are useful, they also have important limitations. Particularly in patients undergoing emergency surgery—a group at consistently increased risk of poor outcomes—there's a "pressing requirement" to develop more precise risk stratification approaches with higher predictive value.

Dr. Moonesinghe and coauthors discuss the various measures used to assess the quality of surgical care, each of which has its strengths and weaknesses. Establishing a widely used surgical outcomes recording system "may improve the quality of surgical care and assist clinical research…and evaluation of treatment strategies targeted toward improving outcomes in the high-risk surgical patient," they write.

Study Highlights Role of Multiple Organ Failure
The series also includes a new research study by Dr. Suzana M. Lobo and colleagues of Hospital de Base (São José do Rio Preto, Brazil), who evaluated nearly 600 patients admitted to Brazilian intensive care units after noncardiac surgery. About 20 percent of the patients died in the hospital. More than half of the deaths were due to multiple organ failure (MOF)—a condition in which two or more organ systems fail concurrently.

The study identifies major risk factors for death due to MOF, including abdominal infection (peritonitis), diabetes, unplanned surgery, older age, high blood pressure, and fast heart rate. Being aware of these risk factors may help in assessing the patient's risk before surgery—and in developing potentially effective treatments.

The special series on high-risk surgery will continue in the May and June issues of Anesthesia & Analgesia, including additional reviews, studies, and editorials. Dr. Takala hopes the ideas presented—if at times controversial—will generate discussion of more systematic ways of identify and managing high-risk surgical patients. He writes, "The modern hospital should be able to identify patients with a substantially increased risk of peri- and postoperative morbidity, and design care paths that include specific interventions to reduce these complications."