Cecconi, M

Rhodes, A

English

PubMed

Andrew Rhodes

Maurizio Cecconi

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Critical Care

Can surgical outcomes be prevented by postoperative admission to critical care?

St George's Online Research Archive

Postoperative complications are hugely important for both the patient involved and also the health-care system that they develop within. Potentially disastrous for the patient, they cause prolonged lengths of stay and can be an expensive problem to resolve. Indeed, recent data suggest that these costs may not just be relevant to the short-term hospital stay but may result in signiﬁ cant increased costs for the longer term following repeated hospital admissions and chronic ill health [1-4]. Th e prevention of these complications is thus of the utmost importance for anyone caring for this group of patients. Th is involves developing systems that can avoid the complications occurring in the ﬁ rst place and then to identify and rapidly treat the complications when they arise [5].It has been estimated that up to 230  million surgical procedures are performed each year in the world [6]. If we consider patients undergoing non-cardiac surgery, up to 4% may die [7], and a signiﬁ cant portion more will develop postoperative complications [8] with a prolonged duration of hospital stay and a reduced longer-term sur-vival [3]. Although for the majority of surgical patients, the risks of complications are low, for a signiﬁ cant number this is not the case [9,10]. In major surgery, even in groups with a low mortality rate, the incidence of post-operative complications is disproportionately high. Th e identiﬁ cation of risk for these patients is not straight-forward. Important factors can be grouped into one of a number of main categories: ﬁ rst, those that are present prior to surgery that include the co-morbid status and age of the patient and the type and urgency of the surgery performed and, second, the physiological derange ment of the patient at the end of the surgical procedure [10]. Many other strategies and markers of physiological status are currently being examined in order to identify the risks involved and to better prioritize available resources to individual patients [11].It has been estimated that in the UK 12% of all patients undergoing surgery account for almost 80% of all complications and deaths [12]. Th ese ﬁ gures from 2006 were recently conﬁ rmed within the UK together with the suggestion that this pattern is also prominent in many other European countries [7]. Clearly, better identiﬁ -cation of this group of patients would enable evidence-based, resource-rich strategies to be directed toward this needy group who would be most likely to beneﬁ t. Patients are not receiving homogenous standards of care to identify and minimize the perioperative risk; even more, when complications occur, data suggest that diﬀ erent health-care systems react in diﬀ erent ways, leading to very diﬀ erent outcomes [5].One strategy would be to admit all postoperative patients to an intensive care environment following surgery to enable them to have any of a number of evidence-based interventions in order to improve their outcome [8,13,14]. Th e problem with this approach is that these beds are often unavailable and that this course mandates an expensive strategy that may not be aﬀ ordable in all health-care environments. Th e most appropriate use of this limited bed stock is thus very important. Clearly, it is neither possible nor desirable for every surgical patient to be admitted to critical care following surgery. Even if this were thought to be necessary, the capacity to deliver on this process is often not present. In 2006, it was estimated that 75% of surgical patients developing postoperative complications were neither cared for in a critical care environment nor referred back into the service [12]. Th ese numbers do not seem to have improved signiﬁ cantly since then [7]. If these patients are now expected to be admitted to intensive care as a routine measure postoperatively, then the numbers of patients would quickly overwhelm most hospitals’ critical care services.Across Europe, there is a marked heterogeneity in the numbers of critical care beds within each country, even when the numbers are corrected for population size [15,16]. Estimates suggest that Germany has almost ﬁ ve times the number of critical care beds as the UK [15,16]. Even if these numbers are exaggerated, there is still a marked discrepancy in the numbers of beds present © 2010 BioMed Central LtdCan surgical outcomes be prevented by postoperative admission to critical care?Andrew Rhodes* and Maurizio CecconiEDITORIAL*Correspondence: andyr@sgul.ac.ukDepartment of Intensive Care Medicine, St George’s Healthcare NHS Trust and St George’s University of London, London SW19 0QT, UKRhodes and Cecconi Critical Care 2013, 17:110 http://ccforum.com/content/17/1/110© 2013 BioMed Central Ltdbetween the two countries and this must reﬂ ect diﬀ er en-ces in practice patterns and seems also to reﬂ ect diﬀ er-ences in outcomes [7]. Although these inferences are anecdotal and most likely reﬂ ect an association rather than causation, they should make us ask the questions of how, where, and why health care should be delivered in a particular way. Wunsch [17] recently gave an eloquent description of the ‘Starling curve for intensive care’, in which the beneﬁ ts and harms of simply creating more beds are delineated. Clearly, we are faced with some interesting dilemmas. Which patients following surgery should be admitted to a higher level of care and what should we then do for them? In addition, if the answer is that more patients need treating in this fashion, how are we to deliver the increased capacity that this would necessitate? Th e solution to these problems involves a series of evidence-based, ethical, resource, and economic arguments. By openly discussing and debating these issues, we should begin to understand who should be treating these patients – and why and how  – following their surgical insult.Competing interestsThe authors received lecture and consulting fees from LiDCO (London, UK) and Edwards (Irvine, CA, USA).Published: 28 January 2013References1. Nathan DP, Brinster CJ, Jackson BM, Wang GJ, Carpenter JP, Fairman RM, Woo EY: Predictors of decreased short- and long-term survival following open abdominal aortic aneurysm repair in a large contemporary series. J Vasc Surg 2011, 54:1237-1243.2. Kamphues C, Bova R, Schricke D, Hippler-Benscheidt M, Klauschen F, Stenzinger A, Seehofer D, Glanemann M, Neuhaus P, Bahra M: Postoperative complications deteriorate long-term outcome in pancreatic cancer patients. Ann Surg Oncol 2011, 19:856-863.3. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ, Participants in the VA National Surgical Quality Improvement Program: Determinants of long-term survival after major surgery and the adverse eff ect of postoperative complications. Ann Surg 2005, 242:326-341.4. Rhodes A, Cecconi M, Hamilton M, Poloniecki J, Woods J, Boyd O, Bennett D, Grounds RM: Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 2010, 36:1327-1332.5. Ghaferi AA, Birkmeyer JD, Dimick JB: Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009, 361:1368-1375.6. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA: An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008, 372:139-144.7. Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes A; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology: Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012, 380:1059-1065.8. Lees N, Hamilton M, Rhodes A: Clinical review: goal-directed therapy in high risk surgical patients. Crit Care 2009, 13:231.9. Findlay G, Goodwin A, Protopappa K, Smith N, Mason M: Knowing the Risk: A Review of the Peri-operative Care of Surgical Patients. London: National Confi dential Enquiry into Patient Outcome and Death (NCEPOD); 2011.10 . Rhodes A, Moreno RP, Metnitz B, Hochrieser H, Bauer P, Metnitz P: Epidemiology and outcome following post-surgical admission to critical care. Intensive Care Med 2011, 37:1466-1472.11 . Pearse RM, Holt PJ, Grocott MP: Managing perioperative risk in patients undergoing elective non-cardiac surgery. BMJ 2011, 343:d5759.12 . Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, Grounds RM, Bennett ED: Identifi cation and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006, 10:R81.13 . Hamilton MA, Cecconi M, Rhodes A: A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2010, 112:1392-1402.14 . Squadrone V, Coha M, Cerutti E, Schellino MM, Biolino P, Occella P, Belloni G, Vilianis G, Fiore G, Cavallo F, Ranieri VM; Piedmont Intensive Care Units Network (PICUN): Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 2005, 293:589-595.15 . Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EA, de Keizer NF, Kersten A, Linde-Zwirble WT, Sandiumenge A, Rowan KM: Variation in critical care services across North America and Western Europe. Crit Care Med 2008, 36:2787-2793.16 . Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP: The variability of critical care bed numbers in Europe. Intensive Care Med 2012, 38:1647-1653.17 . Wunsch H: Is there a Starling curve for intensive care? Chest 2012, 141:1393-1399.doi:10.1186/cc11687Cite this article as: Rhodes A, Cecconi M: Can surgical outcomes be prevented by postoperative admission to critical care? Critical Care 2013, 17:110.Rhodes and Cecconi Critical Care 2013, 17:110 http://ccforum.com/content/17/1/110Page 2 of 2

A: A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg

A: Clinical review: goal-directed therapy in high risk surgical patients. Crit Care

Epidemiology and outcome following post-surgical admission to critical care. Intensive Care Med

Identifi cation and characterisation of the high-risk surgical population in the United Kingdom. Crit Care

KM: Variation in critical care services across North America and Western Europe. Crit Care Med

Knowing the Risk: A Review of the Peri-operative Care of Surgical Patients. London: National Confi dential Enquiry into Patient Outcome and Death (NCEPOD);

Metnitz PG, Moreno RP: The variability of critical care bed numbers in Europe. Intensive Care Med

MP: Managing perioperative risk in patients undergoing elective non-cardiac surgery. BMJ

Rhodes A; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology: Mortality after surgery in Europe: a 7 day cohort study. Lancet

VM; Piedmont Intensive Care Units Network (PICUN): Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial.

Can surgical outcomes be prevented by postoperative admission to critical care?

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