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Why Is Surgery Bad For You? A Premeditated and Calculated Trauma Mishaps, bleeding Systemic Inflammatory Response –Increased VO 2 (Fitness) –Hypercoagulability (Stents, DVT, stroke) –Metabolic Response (Diabetes, Renal) Psychological (“Sickness”)
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Gary Minto
Consultant Anaesthetist
www.bowelcancerwest.org.uk
HOW DO WE ASSESS PATIENTS FOR HOW DO WE ASSESS PATIENTS FOR MAJOR SURGERY?MAJOR SURGERY?
www.bowelcancerwest.org.uk
Surgical mortality, UK Surgical mortality, UK
Why Is Surgery Bad For You?Why Is Surgery Bad For You? A Premeditated and Calculated A Premeditated and Calculated
TraumaTrauma Mishaps, bleedingMishaps, bleeding Systemic Inflammatory ResponseSystemic Inflammatory Response
– Increased VOIncreased VO22 (Fitness) (Fitness)– Hypercoagulability (Stents, DVT, stroke)Hypercoagulability (Stents, DVT, stroke)– Metabolic Response (Diabetes, Renal)Metabolic Response (Diabetes, Renal)
Psychological (“Sickness”)Psychological (“Sickness”)
Risk Stratification Risk Stratification
Scoring SystemsScoring Systems ASAASA Lee Revised Cardiac IndexLee Revised Cardiac Index APACHE ScoreAPACHE Score POSSUM ScorePOSSUM Score
Anaesthetic Hunch?
A conceptual model for outcome A conceptual model for outcome following surgeryfollowing surgery
Patient Factors + Effectiveness of Care + Random Variation = OutcomePatient Factors + Effectiveness of Care + Random Variation = Outcome
Iezzoni, L. I. An introduction to risk adjustment. Am J Med Qual 11, S8-11 (1996).
A conceptual model for outcome A conceptual model for outcome following surgeryfollowing surgery
Patient FactorsPatient Factors + + Effectiveness of Care + Random Variation = OutcomeEffectiveness of Care + Random Variation = Outcome
Comorbidity Comorbidity ““aerobic fitness/ functional capacity” aerobic fitness/ functional capacity” Genetics Genetics
Hammill 2008Hammill 2008ProcedureProcedure 30d 30d
Mortality Mortality (%)(%)
With CADWith CAD With CCFWith CCF
AAAAAA 4.84.8 5.85.8 10.310.3
Ca ColonCa Colon 5.45.4 6.36.3 11.911.9
Ca LungCa Lung 5.15.1 6.06.0 10.210.2
THRTHR 2.92.9 3.83.8 8.48.4
Cardio-Pulmonary Exercise Testing Cardio-Pulmonary Exercise Testing (CPET)(CPET)
ClinicClinic No clinicNo clinic
30 day 30 day mortalitymortality
2%2% 6%6%
Critical Critical CareCare
24%24% 12%12%
A conceptual model for outcome A conceptual model for outcome following surgeryfollowing surgery
Patient Factors +Patient Factors + Effectiveness of CareEffectiveness of Care + Random Variation + Random Variation
severity of surgeryseverity of surgery , urgency , urgencywhat happens during surgery what happens during surgery stress response (genetics) stress response (genetics)
A conceptual model for outcome A conceptual model for outcome following surgeryfollowing surgery
Patient Factors +Patient Factors + Effectiveness of CareEffectiveness of Care + Random Variation+ Random Variation = =
intra-op and post op complicationsintra-op and post op complications
response to complications / level of care response to complications / level of care
decision-making process decision-making process
www.bowelcancerwest.org.uk
10008006004002000
100
80
60
40
20
0
Time From Surgery (Days)
Perc
ent
FitUnfitUnableNo AT
Variable
Survival Plot for Fit, Unfit, Unable, No AtKaplan-Meier Method
www.bowelcancerwest.org.uk
www.bowelcancerwest.org.uk
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