Do I need more monitoring to improve outcome

Acta Anaesth. Belg., 2007, 58, 235-241

R. M. GROUNDS

The treatment objective for any anaesthetist and intensivist is to provide the best and most safe treatment for any patient in his or her care. However, sometime this may be a little difficult or confusing if there are different alternatives for the recommended treatment. The patients clearly hope that they will have trouble-free safe anaesthesia and post-operative recovery. The single most important element of monitoring during anaesthesia must be the continuous presence of an expert anaesthetist for the duration of the operation, and so long as that doctor is awake, observant and competent then the patient is likely to have the best possible chance of survival. Over the last 25-50 years there is good evidence that the incidence of death directly attributable to anaesthesia has fallen but despite this the overall incidence of death following surgery has remained almost unchanged. In the mid -1950’s a number of studies suggested that the postoperative mortality solely associated with anaesthesia was approximately 1 in 2500 (1, 2, 3). However over the following 30 years this death rate was greatly reduced, due partly to improvements in anaesthesia but more probably due to the training and quality of anaesthetists and so by 1987 Buck et al. (4) showed that the death rate following surgery attributable solely to anaesthesia was now approximately 1 in 185000. Much more significantly their study showed that the post operative death rate due solely to the quality of surgery had not changed in the same 30 years. Furthermore the United Kingdom confidential enquiries in to peri-operative deaths (NCEPOD) 1989-2003 showed that surgical post operative mortality hardly changed in the 20 years following the publication of the first report (5, 6). In a recent study by PEARSE and colleagues (7) the outcome following surgery in 94 National Health Service hospital in the United Kingdom over a five year period. They studied over 4 million operations. 2.8 million of these were elective surgery and 1.2 million were emergency operations. The death rate following elective surgery was 0.44% and the death rate following emergency surgery was 5.4%. However, this information was more shocking as it was possible from the data they studied to identify a group of patients who were at high risk of post operative death (within 28 days of surgery) and post operative complications and in this group the post operative death rate was 12.3%. Furthermore, this accounted for 83.8% of all postoperative deaths even though they only account for 12.5% of hospital surgical admissions. This same population, of high risk patients, had a prolonged hospital stay (median 16 days inter-quartile range 9-29 days). Worse they also found that less than 15% of these patients at high risk from death and serious complications post-operatively were admitted to an intensive care unit or high dependency unit or other critical care area after their operation. Given that there are 3.3 million surgical operations per year in the United Kingdom and approximately 25,000 deaths then from this and the data from PEARSE et al. (7) it would suggest that there are approximately 166,000 patients per year undergoing major surgery who are a high risk of post operative death or serious complication. With 250 hospitals in the UK then this would mean that the average general hospital undertakes major surgery on 12-13 patients per week who are at high risk of post operative death or serious complications. [...]

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