Surviving Surgery – How GPs can make a difference

Monica Baird Paul Hersch

Andrew Souter

September 13th 2011

Very safe these days.....

• 1:180 000 anaesthesia alone • 1:50 000 anaesthesia related • 1:200 elective surgery • 1:20 emergency surgery

1.Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Peri-Operative Deaths. London: Nuffield Provincial Hospitals Trust and the King’s Fund, 1987. 2.Pearce RM et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10;R81.

A very risky business.....

• 1:180 000 anaesthesia alone • 1:50 000 anaesthesia related • 1:200 elective surgery • 1:20 emergency surgery

1.Buck N, Devlin HB, Lunn JN. The Report of a Confidential Enquiry into Peri-Operative Deaths. London: Nuffield Provincial Hospitals Trust and the King’s Fund, 1987. 2.Pearce RM et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care 2006;10;R81.

Preoperative optimisation, enhanced recovery &

fitness for referral

Paul Hersch Consultant Anaesthetist

Objectives

• Preoperative optimisation = best practice GP • Enhanced recovery pathway • Better understanding of risk will inform

• Patient discussion • Timing of referral • Lifestyle changes

This is NOT about…...

• Barrier to referral • Learning new skills • Taking on additional responsibilities

– Performing a formal risk/benefit analysis – Performing an anaesthetic assessment

Aims

• Improve quality of care

• Reduce length of stay

• Evidence based approach to preoperative, intraoperative and postoperative care

• Reduced length of stay – from 8-12 days to 2-5 days

• Reduced morbidity • Reduced mortality • Reduced convalescence • Reduced cost

• General principles can be transferred to any specialty

Enhanced Recovery Pathway

Optimising elective care pathways • The contribution from Primary Care

– Optimisation chronic medical conditions • Ideally prior to referral • If necessary with specialist involvement

– Surgery provides impetus for change • The changing process in hospital

– Centralised Preoperative Assessment Department • Integrated service

– One Stop Service • Decision to operate, preoperative assessment and date for admission

– Anaesthetic Assessment Clinic • Clinical risk profile • Plan management of risk over entire perioperative period

– Enhanced Recovery for colorectal surgery

Pre/referral from primary care

• Vital that assessment and preparation start in primary care

• The GP can play a major role in identifying causes of increased morbidity – anaemia, suboptimal diabetic control,

hypertension, obesity, smoking , low levels of physical fitness

• Either continue with referral or instigate management plans to optimise the patient’s condition

Optimisation is for life, not just for surgery.

• The overriding theme of this document is

that intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.

• Indications for angiography and CABG are independent of surgery.

• Intervention is not just to “get patients through” surgery.

http://images.google.co.uk/imgres?imgurl=http://med.kuleuven.be/cardim/CMR/European%20Society%20of%20Cardiology%20-%20official%20logo.jpg&imgrefurl=http://med.kuleuven.be/cardim/CMR/main.htm&usg=__BA0ALjXAD-HLW3JA5Y4wb6PpTQU=&h=945&w=945&sz=92&hl=en&start=1&itbs=1&tbnid=LmDkk72PLlRYKM:&tbnh=148&tbnw=148&prev=/images?q=european+society+of+cardiology&gbv=2&hl=en&sa=G

Revised Cardiac Risk Index

Risk factor Criteria Risk High-risk surgery Vascular, thoracic, abdominal 0.5% IHD MI, Q on ECG, angina, nitrates, ETT+ 1% CCF History, examination, CXR 5% Cerebrovascular disease Stroke, TIA 10% Diabetes Insulin treatment 15% Renal impairment Creatinine >177 µmol/L 30%

Lee et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation 1999;100:1043-1049

Risk Assessment Index

• Goldman – Larsen – Detsky

• www.vasgbi.com – Lee

• POSSUM • Physiological & Operative Severity Score for the enUmeration of Mortality

& Morbidity – P-POSSUM – CR / OG / Vascular – POSSUM

• www.riskprediction.org.uk

http://www.vasgbi.com/http://www.riskprediction.org.uk/

Estimated energy requirements

Hlatky MA et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651– 4. Fletcher GF et al. Exercise standards: a statement for healthcare professionals from the American Heart Association. Circulation. 1995;91:580–615.

Canadian Cardiovascular Society

Campeau L. Grading of angina pectoris (Letter to the Editor). Circulation. 1976; 54: 522-523.

http://www.ruh.nhs.uk/gps/services/specialties/anaesthesia

Conclusion

• Primary Care is best placed to optimise chronic medical conditions.

• Hospital specialists should become involved whenever necessary.

• Only the anaesthetist can decide if the patient is “fit for surgery”.

• Only the patient can choose to accept the risks and proceed with surgery.

Discussion

Summary

• Preoperative optimisation is essential for high quality care and enhanced recovery

• Optimisation is best carried out as part of high quality, routine general practice

• Guidelines to aid optimisation of comorbidities and not minimum standards for referral

Surviving Surgery – How GPs can make a differenceVery safe these days.....A very risky business.....Preoperative optimisation, enhanced recovery &�fitness for referralObjectivesThis is NOT about…... AimsSlide Number 8Enhanced Recovery PathwayOptimising elective care pathwaysPre/referral �from primary careOptimisation is for life, �not just for surgery.��Revised Cardiac Risk Index�Risk Assessment IndexEstimated energy requirementsCanadian Cardiovascular Societyhttp://www.ruh.nhs.uk/gps/services/specialties/anaesthesiaSlide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23ConclusionDiscussionSummary