anesthesia impact on perioperative outcomes · overselling anesthesia safety is a natural...
TRANSCRIPT
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
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$20 000
$40 000
$60 000
$80 000
$100 000
$120 000
$140 000
$160 000
Co
nsta
nt
Do
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(2
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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