An invasive therapeutic surgical procedure involves incision, excision, manipulation, or suturing of tissue that penetrates or breaks the skin; typically requires use of an operating room; and requires regional anesthesia, general anesthesia, or sedation to control pain.
Surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function.
Surgical stress response can lead to organ dysfunction with increased morbidity and delayed surgical recovery.
High-risk surgery involves operations in which postoperative complications are common or the risk of perioperative death is approximately 1% or greater.
Cardiovascular complications most common cause of death among patients undergoing noncardiac surgery.
Approximately 300,000,000 people worldwide undergo surgery each year (Abbott T).
Approximately 17.2 million surgeries are performed annually in the US.
More than 30% of patients undergoing surgery lasting at least two hours with general anesthesia and mechanical ventilation may experience postoperative pulmonary complications.
Surgical volumes are increasing as the age and medical complexity of patients undergoing surgery, and this results in increased risk for perioperative complications.
The number of patients with chronic diseases and multimorbidity will increase the number of surgical procedures.
More than 60 million surgical procedures are performed annually in the United States.
Estimated nearly 1,000,000 adverse cardiac events occur each year following noncardiac operations.
20-30% of surgical procedures are performed on patients 65 years and older, and this percentage is increasing.
Cardiovascular complications are the leading cause of death within 30 days of noncardiac surgery.
40% of elderly patients experience minor or major medical, surgical, or anesthesia related complication during hospitalization for non-cardiac surgery.
21,937 operations per hundred thousand persons were performed in the US in 2004 (Weiser TG et al).
There are more than 4 million major operations performed annually in United States on individuals age 65 years and older.
Approximately 100,000,000 non-cardiac surgeries are undertaken worldwide annually, with 500, 000-900,000 of these patients experiencing operative cardiac death, nonfatal cardiac arrest, and nonfatal myocardial infarction.
Factors unique to the postoperative environment include sympathetic stimulation, hypercoagulable state, inflammation, hypotension, hypothermia, and tachycardia that contribute to the occurrence of adverse cardiac postoperative events.
Surgery causes transient elevation of acute inflammatory markers such as interleukin 6, and C-reactive protein.
Approximately half of patients who experience a perioperative myocardial infarction have evidence of plaque rupture, type 1MI, with the remainder related to ischemia from supply/demand mismatch, type 2 MI..
Orthopedic surgery accounts for almost 1 quarter operating room procedures in the US
with more than one and a half million hip, knee and spine surgeries each year.
Up to 1/3 of patients undergoing orthopedic surgery have preoperatively anemia, a risk factor for short-term mortality and cardiovascular complications in patients undergoing noncardiac surgery.
Approximately one third of orthopedic surgical patient receive a blood transfusion in the perioperative period.
More than 90% of non-cardiac surgeries are elective.
National expenditures for surgical procedures in the United States is estimated to be $400 billion annually.
Preoperative medical consultation before major elective non-cardiac surgery is associated with increased mortality and hospital stay, increased pharmacologic intervention, and testing (Wijeysundera DN).
10% of patients can be expected to have a complication with 30 days of major surgery.
In an international prospective cohort study of 15,133 adult patients undergoing noncardiac surgery a 30 day mortality of 1.9% was noted (VISION study).
Black men in the US, have a higher mortality rate after surgery than Black women, as well as White women and White men, based on the outcomes of more than 1.8 million black and white patients age 65 years old covered by Medicare: after undergoing elective surgery, 1.3% of black men died within 30 days compared with 0.85% of white men.
The rate of inpatient surgical complications is estimated to range from 3-17.4%, depending on the type of procedure, the type of complications noted, and the length of follow-up.
Approximately one in every 150 patients admitted to a hospital dies as a consequence of an adverse event and that almost 2/3 of in-hospital offense are associated with surgery loop (de Vries EN et al).
Approximately 40% of hospital complications occur in surgical patients, and half of surgical complications are preventable.
Estimate that physicians operating on bilateral structures have a 25% lifetime risk of performing the wrong site surgery and that one in 8000 inpatient operations have a retained surgical item.
Surgical skill is essential to prevent intraoperative problems such as bleeding or tissue devascularization and may be associated with more precise reconstruction in cardiovascular or gastrointestinal surgery, possibly reducing the risk of complications.
Studies have found no association between surgeon sleep deprivation as assessed by operating the night prior to an operation, or when surgeons report few hours of sleep and patient outcomes.
No significant association between operating the night before and not operating the previous night for conversion to open cholecystectomy, risk of iatrogenic complications, or death for elective daytime cholecystectomy: there’s no support for safety concerns related to surgeons operating night before performing elective surgery (Vinden C et al).
A higher level of operator skill maybe associated with shorter operations, which is important relating to prolonged operating times to increase risks of infection venous thromboembolism.
Major complications add substantial costs previously estimated at $11,500 per patient (Dimick JB et al).
Myocardio injury defined as an elevated troponin level above the 90th percentile occurs and up to 20% of patients after noncardiac surgery.
Myocardial ischemia within 48 hours of surgery, confers a 9-fold increase in risk of unstable angina, nonfatal myocardial infarction, and cardiac death.
Population based studies demonstrate higher mortality rates with cardiovascular operations, major cancer resections, and other procedures at hospitals with low volumes of those procedures.
Currently in the U.S. 30 million surgical procedures are performed each year.
Of patients undergoing general surgery procedures an unplanned return to the operating room occurs in about 3.5% of cases.
The most common procedure for re-operation is colectomy.
Upper respiratory infections in children prior to cardiac surgery is associated with increased postoperative infections and multiple complications, but does not affect overall length of hospitalization nor the development of long-term sequelae.
Maintaining patients on their preoperative glucocorticoids dose effectively prevents hypotensive crisis and may avoid the potential complications of higher-dose steroids.
Patients with 2 or more coronary risk factors or with known coronary artery disease receiving atenolol prior to noncardiac major surgery have a significant survival advantage within several months compared to placebo treated patients.
A randomized controlled trial reported significant harm when beta blockers were initiated preoperatively in patients undergoing noncardiac surgery (Devereaux PJ et al).
Peri operative hypotension and bradycardia are associated with adverse outcomes, including stroke in patients undergoing noncardiac surgery.
Preoperative anemia is associated with increased morbidity and mortality in patients undergoing cardiac surgery.
Preoperative anemia, even to a mild degree, is associated with increased 30 day morbidity and mortality in patients undergoing non-cardiac surgery (Mussalam KM et al).
Early perioperative beta blocker exposure is associated with a reduction in 30 day all cause mortality and cardiac morbidity in patients undergoing noncardiac surgery (London MJ et al).
Perioperative beta blocker therapy should be administered to patients have been taking beta blockers chronically and should not be initiated on the day of surgical procedures.
Beta blocker use in patients with heart failure or a recent MI lowers the risk of major adverse cardiovascular events and all-cause mortality within 30 days after non cardiac surgery (Andersson C et al).
In the above study no benefit was seen in patients treated with beta blockers with stable heart disease.
It is proposed the beta blockers may prevent untoward events in the perioperative setting in high risk patients by protecting against catecholamine surges.
Randomized controlled clinical trials of perioperative beta blockers have yielded conflicting results.
In a review a 53 trials revealed no association between beta blocker use and all cause mortality, or with the incidence of acute myocardial infarction, cerebrovascular events, hypotension, bradycardia or congestive heart failure (Blessberger HK et al).
In the above study there was a decreased incidence of supraventricular tachycardias and ventricular arrhythmias with the use of beta blockers in cardiac surgery.
Among patients having elective non-cardiac surgery, heart failure with or without symptoms is significantly associated with 90 day postoperative mortality (Lerman BJ).
Most patients who undergo diagnostic catheterizationn for non cardiac surgery are asymptomatic and the discovery of obstructive coronary artery disease is common although no clinical trials have demonstrated benefit in outcomes, revascularization is recommended in the early half of such patients (National Cardiovascular Data Registry Cath PCI Registry).
Estimates for wrong-site surgery and retained surgical items are one event per 100,000 and one event per 10,000 procedures, respectively.
Early ambulation following surgery helps decrease postoperative complications, expedites functional recovery, improves overall well-being, shortens hospital length of stay, and reduces morbidity and mortality.
Most Surgical Adverse Events Result From Human Error.
More than half of adverse events occurring during surgical procedures are a result of human error.
Over half of adverse surgical errors are cognitive in nature(JAMA).
Among 5365 patients, 3.4% experience an adverse event during a surgical operation.
51% of the errors were related to execution whereas 29.3% were related to planning or problem solving, 12.8% to communication, 4.8% to teamwork, and 3.2% to rules violation.
Most errors occur during the surgery itself (54.8%) whereas 8% occurred preoperatively and 26.6% postoperatively.
Cognitive errors in execution included lack of attention, memory lapses, or lack of recognition of a problem, which together comprised nearly one third (31.8%) of the cognitive errors.
Another 19.8% resulted from cognitive bias in care planning or problem solving.
Findings suggest the dominant role of cognitive error as a root cause of surgical adverse events, even those that would appear to be technical rather than cognitive in nature.
Lack of recognition is the most prevalent cognitive error.
The NT-proBNP test can predict cardiovascular complications of non-cardiac surgery.
The N-terminal prohormone of brain natriuretic peptide (NT-proBNP or BNPT) is a prohormone with a 76 amino acid N-terminal inactive protein that is cleaved from the molecule to release brain natriuretic peptide.
It measures both stretch in the heart and also cardiac ischemia that is commonly not recognized clinically.
Both BNP and NT-proBNP levels in the blood are used for screening, diagnosis of acute congestive heart failure (CHF) and may help establish prognosis in heart failure.
Both markers are typically higher in patients with worse outcome.
The plasma concentrations of both BNP and NT-proBNP are also typically increased in patients with asymptomatic or symptomatic left ventricular dysfunction.
The plasma concentrations of both BNP and NT-proBNP are also typically
associated with coronary artery disease and myocardial ischemia.
Upper limit of blood ranges
for NT-proBNP in healthy people:
Male < 45 yrs 90
45-59 yrs 140
55-64 yrs 180
65-74 yrs 230
> 75 yrs 850
Females < 45 yrs 180
45-54 yrs 190
55-64 yrs 230
65-74 yrs 350
> 75 yrs 620
Congestive heart failure likely <75 years > 125 pg/mL
>75 years >450pg/mL
There is no level of BNP that perfectly separates patients with and without heart failure.
Assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP) level prior to noncardiac surgery may predict whether the patient might experience adverse cardiac outcomes, such as myocardial injury or vascular death after noncardiac surgery.
Higher levels of preoperative NT-proBNP are associated with higher rates of cardiovascular events.
Patients whose levels were >1500 pg/mL had a fivefold increased risk for the primary outcome, a composite of vascular death and myocardial injury at 30 days, compared to patients with levels <100 pg/mL.
NT-proBNP currently used to predict perioperative cardiac risk.
This test can measure whether adults undergoing noncardiac surgery whether they are going to suffer a major cardiovascular event or even death.
Preoperative NT-proBNP values were found to be statistically significantly associated with 30-day all-cause mortality:
?100 pg/mL: 0.3%
100 to ?200 pg/mL: 0.7%
200 to ?1500 pg/mL: 1.4%
?1500 pg/mL: 4.0%
NT-proBNP can help identify patients who are at higher risk for postoperative cardiac events and may identify the patients who benefit from perioperative troponin monitoring.