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Staying Alive After Surgery: The Second POMRC Report
Prof Kate Leslie Royal Melbourne Hospital and ANZCA
Scope of this Talk
Death and health in New Zealand
The Second POMRC report
International mortality data
International outcome studies
Conclusions and future directions
Life Expectancy in New Zealand
http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy
Human Development Index
Composite statistic of life expectancy, education, and income indices
UN Development Programme
Long and Healthy Lives
Peri
nata
l care
Imm
un
isati
on
Fo
od
/wate
r
Gu
n l
aw
s
Wo
rkp
lace law
s
Un
ivers
al h
ealt
hcare
Co
mm
un
ity c
are
To
bacco
law
s
Ro
ad
law
s
Ed
ucati
on
0
5000
10000
15000
0-
1-
2-
3-
4-
5-
10-
15-
20-
25-
30-
35-
40-
45-
50-
55-
60-
65-
70-
75-
80-
85+
Deat
hs
in N
Z
2009
Age (years) www.stats.govt.nz
Maori and Non-Maori Health
1202.5
1045.81016.6
1047.7
972.0
897.8
974.2 983.9
911.3
857.4897.2 899.6
792.6827.9
864.2
763.3
705.1732.4
708.0 691.7 706.8679.7 671.6
646.5 659.5630.9
649.4624.9
685.3645.7
599.7 612.6577.5 579.2
558.0532.9 523.7
482.6 483.9 475.7 474.9455.3440.9
406.2384.5 401.3
365.3 375.3 372.6 361.2 363.7332.9 338.4 329.8 330.7 321.2
0
200
400
600
800
1000
1200
1400
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
Māori males
Māori females
Non-Māori males
Non-Māori females
Rate
Rates per 100,000 population, age-standardised to WHO World Standard Population
Life Expectancy Gap
0
5
10
15
20
25
Mexico Panama New Zealand Guatemala Canada Nepal Australia
Lif
e E
xp
ecta
ncy G
ap
(years
)
www.un.org
World Healthcare Systems
http://www.kaiserhealthnews.org/Graphics/2010/020410Spending-By-Public-And-Private-Sectors.aspx
Scope of this Talk
Death and health in New Zealand
The Second POMRC report
International mortality data
International outcome studies
Conclusions and future directions
Data Collection in New Zealand
National Minimum Dataset (NMDS)
Public and private hospital discharge information
for inpatients and day patients
Limitations
Incomplete for privately-funded patients
No unifying code for ‘operation’
Surrogate marker of ‘GA/neuraxial block’ excludes
significant procedures under regional/local block
and/or sedation (e.g. cataract surgery)
Data Collection in New Zealand
Mortality Collection (MORT)
Classifies underlying cause of death for all deaths
and all stillbirths registered in New Zealand
ICD-10-AM 6th Edition and the WHO Rules and
Guidelines for Mortality Coding
Proximate cause of death not recorded
Underlying cause of death masks proximate causes
of death associated with surgery/anaesthesia
Cholecystectomies
0
1000
2000
3000
4000
5000
6000
0-44 45-64 65-79 80+
Deat
hs
per
100,0
00 a
dm
issi
ons Acute Elective
Age (years)
Cholecystectomies
Cause Acute Electives
Malignancy 23.5 40.0
Gallbladder calculi 22.2 14.3
GB, biliary & pancreas 14.8 -
MI/IHD 9.9 25.7
Other 29.6 20.0
Main underlying cause of death
% of deaths in category
• What is the mechanism of death from “GB calculi”? • How was myocardial infarction diagnosed?
ASA 1-2 Electives
0
100
200
300
400
500
600
700
800
0-24 25-44 45-64 65-79 80+
Deat
hs
per
100,0
00 a
dm
issi
ons
Age (years)
ASA 1-2 Electives
Cause 45-64 years 80+ years
Malignancy 53.4 41.3
MI/IHD/CVS 20.7 30.6
Respiratory 5.2 6.7
Other 20.7 21.3
Main underlying cause of death
% of deaths in category
• Was anaesthetic/surgical mishap a factor?
Patients aged 80+ years
0
10000
20000
30000
40000
50000
60000
1-2 3 4 5 Not stated
Acute Elective
Deat
hs
per
100,0
00 a
dm
issi
ons
ASA Physical Status
Patients aged 80+ years
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Acute Elective
Deat
hs
per
100,0
00 a
dm
issi
ons
Data from 1st (2005-9) and 2nd (2006-10) POMRC reports
Patients aged 80+ years
Cause Acute Elective
Falls 19.8 -
Malignancy 15.2 30.5
MI/IHD/CVS 35.9 41.9
Respiratory 5.2 7.8
Other 23.9 19.8
Main underlying cause of death
% of deaths in category
• How was myocardial infarction diagnosed? • Were all falls preoperative?
Pulmonary Embolism
0
20
40
60
80
100
120
140
0-24 25-44 45-64 65-79 80+
Associated Attributed
Deat
hs
per
100,0
00 a
dm
issi
ons
Age (years)
• How was pulmonary embolism diagnosed? • Was thromboprophylaxis adequate?
Coronial Data
Majority of relevant information to mortality
review is obtainable from hospital records
Coronial files add important information when
Cause of death uncertain
Expert opinion is available
When death occurred out of hospital
In either case more contextual information
and/or case studies would add richness and
readability to POMRC reports
Scope of this Talk
Death and health in New Zealand
The Second POMRC report
International mortality data
International outcome studies
Conclusions and future directions
Mortality Events Weighted events per
million (95% CI)
Anaesthetic sole 151/8,610,720 25 (21-30)
Anaesthetic contributory 275/5,641,048 85 (75-96)
Total perioperative 1,723/934,781 1,982 (1,891-2,078)
Mortality audits with sample size over 3,000
87 studies included with >21,000,000 patients under GA
Most reported immediate (24-48 h) mortality
That’s 0.2%
Baseline risk INCREASED over the period 1937-2007 as per ASA scores
Australian Mortality Reporting
Anaesthesia- and surgery-related
mortality reported separately
National reports by College
mortality committees
State/territory sub-committees
undertake detailed review
Data collection methods vary
between reports
Incomplete data an issue for both
Public/private
States/territories
Anaesthesia Mortality 2003-5
1994-6 1997-9 2000-2 2003-5
Population (million) 12.57 13.40 13.75 13.68
Anaesthesia-related death (n) 116 99 122 112
Anaesthesia-related death ratio (pa) 3.08 2.46 2.96 2.73
Anaesthesia Mortality 2003-5
0
5
10
15
20
25
30
35
40
<11 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 >90
Num
ber
of deat
hs
Age (years)
Anaesthesia Mortality 2003-5
Factor N (%) (n = 112)
Preoperative management 31 (27)
Anaesthetic technique 41 (37)
Anaesthetic drug 36 (32)
Anaesthetic management 25 (22)
Postoperative management 17 (15)
Organisational factors 27 (13)
No correctable factor 37 (33)
Condition of patient significant factor 65 (58)
Death frequently multi-factorial with patient factors contributing
Surgical Mortality 2011
Surgical Mortality 2011
Surgical M
ortality 2
011
Scope of this Talk
Death and health in New Zealand
The Second POMRC report
International mortality data
International outcome studies
Conclusions and future directions
Collaboration
J McNeil A Forbes
P Myles
D Story
T Short M Chan
S Poustie
K Leslie M Paech
PJ Devereaux
The ANZCA Trials Group
Established in 2005 by ANZCA Council
Full-time ANZCA-supported co-ordinator
Additional co-ordinators supported by
peer-reviewed funding
Located at DEPM, Monash University
Annual workshop and education sessions
Survey research support
Pilot grant scheme
Trial initiation and update meetings
A/Prof Tim Short Trials Group Chair
2012-
Support by ANZCA
• Project grant funding >$800,000 per annum
• Novice investigator, senior investigator and pilot grants
Council
Foundation Committee
Investment Committee
Research Committee
Trials Group Executive
Prospective cohort study at three Melbourne hospitals
Austin, Alfred and Royal Melbourne
1,102 non-cardiac surgery patients aged ≥70 years
70% had pre-existing co-morbidities
At day 30 postoperatively
6% had died (>1 in 20)
20% at least one night in ICU
19% had suffered a major complication
Predictor Mortality OR (95% CI) P value
Age per year >70 1.1 (1.0-1.1) <0.001
Albumin <30 g/dl 17% 4.0 (2.2-7.3) <0.001
Emergency surgery 10% 2.8 (1.7-4.7) <0.001
ASA 1-2 1% -
ASA 3 5% 4.6 (1.4-15.1) 0.01
ASA 4 14% 14.6 (4.3-49.4) <0.001
ASA 5 23% 26.4 (4.8-147.5) <0.001
Preoperative variables
Predictor Mortality OR (95% CI) P value
Myocardial infarction 30% 8.0 (3.1-20.9) <0.001
Acute kidney injury 16% 4.0 (2.1-7.7) <0.001
Sepsis 20% 5.1 (2.6-10.1) <0.001
Unplanned ICU 21% 5.4 (2.6-10.9) <0.001
Postoperative variables
Funded by ANZCA
Prospective cohort study at 23 hospitals
4,158 non-cardiac surgery patients aged ≥70 years
68% had pre-existing co-morbidities
At day 30 postoperatively
5% had died (1 in 20)
9% had an unscheduled ICU admission
20% had suffered a major complication
Lessons from REASON
Elderly patients are at high risk of perioperative
morbidity and mortality
Patient factors more important than surgical factors
Albumin should be used in preoperative risk assessment
Improved postoperative surveillance and care required
ASA status and ICU admission should be collected
routinely in surgical and anaesthetic audits
This information should be used to guide preoperative
discussions with patients
Survival in our large studies
Trial ASA 3-5
(%)
30-day
Mortality (%)
Master (Epidural) 100* 4.7
B-Aware (BIS monitoring) 75 4.3
ENIGMA-1 (Nitrous oxide) 25 0.9
POISE-1 (Metoprolol) 100* 5.0
REASON (≥70 years) 66 5.0
* Imputed from inclusion criteria and/or baseline characteristics
Surgical Patient Safety
More than 200 million patients
have surgery annually worldwide
proportion are elderly and at
risk of perioperative morbidity
No proven primary or secondary
prevention measures
Resources for monitoring and
treating complications inadequate
More action is required
THE MASTER TRIAL
25 centres in Australia, East Asia and Middle East
988 high-risk patients having non-cardiac surgery
Randomization Intra- and postoperative epidural analgesia
Intra- and postoperative intravenous analgesia
Primary endpoint Death or major morbidity at 30 days
Funding ANZCA, Health Department of WA and NHMRC
% Control (n = 441)
Epidural (n = 447)
P value
Death 4.3 5.2 0.67
Respiratory failure 30.2 23.3 0.02
Cardiovascular event 24.0 25.7 0.61
Renal failure 8.2 7.4 0.75
Inflammation/sepsis 46.7 42.7 0.26
Death or morbidity 60.7 57.1 0.29
A multi-centre, randomized, double-blind controlled trial of BIS
monitoring to prevent awareness during general anaesthesia
The B-Aware Trial
Funded by ANZCA, Alfred Hospital Research Trust, Royal Hobart
Hospital Research Foundation and the Centre for Encouragement of
Philanthropy in Australia and supported by Aspect Medical Systems
Lancet 2004; 363; 1757-63
Group n Aware
All cases 2,463 13 (0.53%)
All BIS monitored 1,225 2 (0.16%)
All Routine care 1,238 11 (0.89%)
Risk ratio = 0.18 (95% CI: 0.02-0.83); P = 0.022
Anesth Analg 2010; 110:816-22
Total
2,463 patients
BIS
1,225 patients (50%)
Optimal BIS
354 patients (14%)
No BIS
1,238 patients (50%)
Low BIS
871 patients (36%)
Long-term* mortality (n = 548; 22%)
Predictor HR (95% CI) P value
Age >70 years 3.10 (2.37-4.07) <0.0001
ASA 4 2.59 (1.87-3.60) <0.0001
Severe hypotension 1.27 (1.03-1.55) 0.02
Low BIS vs. No BIS 0.93 (0.78-1.12) 0.46
Optimal BIS vs. No BIS 0.66 (0.50-0.87) 0.003
Low BIS vs. Optimal BIS** 1.41 (1.02-1.95) 0.04
Anesth Analg 2010; 110:816-22
*median follow-up 4.1 (0-6.5 years) **propensity adjusted
N2O – A Historical Relic?
• Widespread use worldwide for >150 years
• Contemporaries and successors obsolete
• Proud record of safety relative to historical agents
• Does N2O still have role in anaesthesia today?
Joseph Priestley Humphrey Davy Horace Wells
NHMRC &
ANZCA
Funding
ENIGMA-I
1000 Patients O2 30% & N2O 70%
1000 Patients O2 80% & N2 20%
2000 Non-Cardiac Patients Surgery > 2 hours duration
Randomised, Controlled Double-blind Trial
Primary Outcome Variable = Length of Hospital Stay
N2O – based
n (%)
N2O – free
n (%)
P value
Severe PONV 229 (23%) 104 (10%) <0.001
Wound infection 106 (10%) 77 (7.7%) 0.03
Pulmonary complication 132 (13%) 78 (7.8%) <0.001
Risk of MI 13 (1.3%) 7 (0.7%) 0.19
Death 9 (0.9%) 3 (0.3%) 0.26
Long-term* mortality (n = 380; 19%)
Predictor HR (95% CI) P value
Age >65 years 1.45 (1.09-1.91) 0.01
ASA physical status 3-4 1.12 (0.87-1.45) 0.36
MAC <0.75 1.59 (1.22-2.08) 0.0007
Duration of anaesthesia >4 h 2.03 (1.44-2.87) 0.0001
Nitrous oxide 0.98 (0.80-1.20) 0.82
* follow-up 3.5 (0-5.7 years) Anesth Analg 2011;112:387–93
RCT of metoprolol versus placebo
Non-cardiac surgery
With or at risk of IHD
Planned sample size
10,000 patients
Primary outcome
30 day cumulative risk of cardiac death, nonfatal MI
and non-fatal cardiac arrest
Dr PJ Devereaux
PHRI Canada
Metoprolol
(n = 4174)
Placebo
(n = 4177)
HR
(95% CI)
P
value
Primary outcome 243
(5.8%)
290
(6.9%)
0.83
(0.70-0.99)
0.04
Non-fatal MI 151
(3.6%)
215
(5.1%)
0.70
(0.56-0.86)
0.0008
Death 129
(3.1%)
97
(2.3%)
1.33
(1.02-1.74)
0.03
Stroke 41
(1.0%)
19
(0.5%)
2.17
(1.26-3.73)
0.005
Perioperative MI is common
5% of POISE patients within 30 days of surgery
74% within 48 h of surgery
66% asymptomatic
NSTEMI more common than STEMI
Perioperative MI has a poor prognosis
11.6% with PMI died within 30 days
Median time to death 48 h
Asymptomatic (12.5%) and symptomatic (9.7%)
MO
RT
AL
ITY
Isolated biomarker elevation in 8% of patients
Associated with worse outcomes than ‘normal’ patients
Median time to death 8 days (c.f. 48 h in PMI patients)
The VISION Study
Prospective cohort study
40,000 patients aged ≥45 years
Non-cardiac surgery with ≥ 1 night admission
30-day and 1-year follow-up
Objectives
Incidence of major perioperative vascular events
Optimal clinical model to predict events
MIs detected without cTnT monitoring
Relationship between cTnT and 1-year survival
Clinicaltrials.gov NCT00512109
PJ Devereaux
1st 15,000 patients monitored with 4th generation cTnT
1%
4%
9.3%
16.9%
Lessons from VISION
Risk of increased mortality rises at cTNT levels in
‘normal range’
Elevated cTNT associated with poor outcome
independent of other diagnostic features of MI
50% of deaths deemed non-vascular
Myocardial injury may decrease likelihood of surviving
non-vascular complication
Risk may be modifiable with cardiovascular Mx
ANZCA Trials Group Studies
l ENIGMA-2 POISE-2 Balanced RELIEF
N 6,457/7,000 7,610/10,000 50/6,5000 0/2,4000
Intervention Nitrous oxide
or nitrogen
Aspirin and/or
clonidine
Deep or light
volatile GA
Restricted or
liberal IV fluid
Age (years) ≥45 ≥45 ≥60 ≥18
Type of surgery Non-cardiac
≥2 h
Non-cardiac
Cardiac & non-
cardiac ≥2 h
Major
abdominal
Inclusions With or at risk
of IHD
With or at risk
of IHD
With or at risk
of M&M
With or at risk
of M&M
Exclusions Bowels, brains High risk of
thrombosis or
bleeding
Brains, TIVA Liver, thoracic,
renal failure
Primary
outcome
30-day CVS
M&M
30-day CVS
M&M
1-year
survival
1-year disability
free survival
The Balanced Study
Endorsed by the ANZCA Trials Group
Supported by ANZCA, NZ HRC ($1.1M) and Australian NHMRC ($2.8M)
Due to commence in December 2012
Tim
Short
Kate
Leslie
Matthew
Chan
Paul
Myles
Michael
Paech
Chief Investigators
Tomas
Corcoran
The Balanced Study
6,600-patient randomized controlled trial
Patients: Aged >60 years, ASA 3, major surgery
Anaesthesia: Volatile-based general anaesthesia >2 h
Intervention: BIS 35 vs. BIS 50
Primary outcome: One-year mortality
Sample size based on 20% mortality reduction (from 10%)
125-patient pilot study has been completed
Seven centres in New Zealand, Australia and HK
Balanced Pilot Results
BIS 35 BIS 50
Number 61 64
Age (year) 74 (61-92) 72 (60-87)
Sex (male) 36 (59%) 44 (69%)
BIS 39 (5) 48 (6)
MAC 0.95 (0.23) 0.63 (0.19)
MAP (mmHg) 86 (11) 89 (10)
Mortality (1 year) 12% 9%
Composite complications (1 year) 28% 17%
Scope of this Talk
Death and health in New Zealand
The Second POMRC report
International mortality data
International outcome studies
Conclusions and future directions
Conclusions & Future Directions
Perioperative mortality in New Zealand is very low
and consistent with other high HDI countries
The New Zealand system for data collection is
national, consistent and increasingly complete
Data collection in New Zealand could be improved
Private as well as public hospitals
Unifying code for ‘operation’
Full documentation of ASA status
Recording of proximate cause of death
Conclusions & Future Directions
Analysis of data by POMRC could be improved
Annual reporting of total perioperative mortality
Attribution of death to anaesthetic and surgical causes
More lessons for anaesthetists and surgeons
More work is needed to ensure compliance with safe
surgery checklists (antibiotics & VTE prophylaxis)
More research is needed to improve outcomes for
ASA 1-2 patients having surgery
Patients with acute cholecystitis
Patients aged over 80 years of age
Thank You
RMH Hokkaido Trauma Conference – on again in 2014!