Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Chapter 5 - Intraoperative neurophysiological monitoring during brainstem surgery

Brainstem surgery is challenging due to the high concentration of essential neural structures such as cranial nerve nuclei, sensorimotor and auditory pathways, as well as the reticular formation. Therefore, even a small injury to the brainstem can hinder the functional integrity of one or more of these neural pathways and result in neurological deficits. Intraoperative neurophysiology aims not merely to predict but also to prevent neurological injury, thanks to the tailored intraoperative use of standard clinical neurophysiological techniques such as electromyography, and somatosensory, brainstem auditory and motor evoked potentials. Monitoring these potentials allows to prevent an injury to the long pathways within the brainstem. In addition, mapping techniques provide functional identification of critical anatomical landmarks, whenever their visual identification is ambiguous, to select the safest entry route to the brainstem. In this chapter we critically review the various intyraoperative mapping and monitoring techniques that can be used during surgery for lesions in the midbrain, pons, and medulla oblongata