Preoperative Screening at the Outpatient Clinic: Predicting cardiac risk in noncardiac surgery

The first chapter of this thesis analyzes perioperative cardiovascular mortality in noncardiac surgery at the Erasmus Medical Center, Rotterdam, The Netherlands. The performance of Lee et al’s index in predicting perioperative cardiovascular mortality is validated in a 10-year surgical cohort of patients undergoing noncardiac surgery. Based on the results of chapter one, the analysis of perioperative mortality risk factors is continued in chapter two. In this chapter, over one million Dutch patients undergoing noncardiac surgery between 1991-2002 were studied. The influence of well known perioperative risk factors in high risk patients was analyzed in the general noncardiac surgical population, and the impact of surgery related risk on perioperative mortality was further clarified. The total cohort was used to derive and validate a newly constructed perioperative risk index to accurately predict all-cause mortality in noncardiac surgery

Perioperative care of the older patient

Nearly 60% of the Dutch population undergoing surgery is aged 65 years and over. Older patients are at increased risk of developing perioperative complications (e.g., myocardial infarction, pneumonia, or delirium), which may lead to a prolonged hospital stay or death. Preoperative risk stratification calculates a patient's risk by evaluating the presence and extent of frailty, pathophysiological risk factors, type of surgery, and the results of (additional) testing. Type of anesthesia, fluid management, and pain management affect outcome of surgery. Recent developments focus on multimodal perioperative care of the older patient, using minimally invasive surgery, postoperative anesthesiology rounds, and early geriatric consultation

Postoperative mortality in the Netherlands: A population-based analysis of surgery-specific risk in sdults

BACKGROUND: Few data are available that systematically describe rates and trends of postoperative mortality for fairly large, unselected patient populations. METHODS: This population-based study uses a registry of 3.7 million surgical procedures in 102 hospitals in The Netherlands during 1991-2005. Patients older than 20 yr who underwent an elective, nonday case, open surgical procedure were enrolled. Patient data included main (discharge) diagnosis, secondary diagnoses, dates of admission and discharge, death during admission, operations, age, sex, and a limited number of comorbidities classified according to the International Classification of Diseases 9th revision Clinical Modification. The main outcome measure was postoperative all-cause mortality. Univariable and multivariable logistic regression analyses were applied to evaluate the relationship between type of surgery and the main outcome. RESULTS: Postoperative all-cause death was observed in 67,879 patients (1.85%). In a model based on a classification into 11 main surgical categories, breast surgery was associated with lowest mortality (adjusted incidence, 0.07%), and vascular surgery was associated with highest mortality (adjusted incidence, 5.97%). In a model based on 36 surgical subcategories, the adjusted mortality ranged from 0.07% for hernia nuclei pulposus surgery to 18.5% for liver transplant. The c-index of the 36-category model was 0.88, which was significantly (P < 0.001) higher than the c-index that was associated with the simple surgical classification (low vs. high risk) in the commonly used Revi