perioperative interventions that affect outcomes: what do ... · predictive value of in-hospital...

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