How can Anesthesia Improve Surgical Patient Outcomes?

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How can Anesthesia Improve Surgical Patient
Outcomes?

• Surgeons are great at putting things back
  together
• Reducing fractures
• Anastamosing bowel
• Approximating skin edges
• But then we need to work together to create the
  right conditions for healing to occur

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Anesthesia - a Leader in Safety
Anesthesia death rate for ASA 1 patients is now 4
per million. The Six Sigma target for factories
is 3.4 errors per million events.
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CMPA Dues
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Better equipment
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Better drugs

• HALOTHANE
• CURARE
• PENTOTHAL
• DEMEROL
• And soon ..
• NEOSTIGMINE

• SEVO DES
• ROCURONIUM
• PROPOFOL
• HYDROMORPHONE
• ALFENTANIL
• SUGAMMADEX

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Better education
MEETINGS WORKSHOPS
CAS and ASA Annual Meetings
Ontario Anesthesia Meeting
McGill Course
and many others
WEB SITES
GASNet
Virtual Anesthesia Textbook
NYSORA www.neuraxiom.com
www.thoracic- anesthesia.com
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Preoperative Medications
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ßeta Blockers 1990-2000

• Numerous studies showed
• ? incidence of postop ischemia
• ? incidence of perioperative MI
• ? cardiac mortality
• ß-Blockers became the craze
• 3 supporting editorials in NEJM
• One even suggested that ß-blockers might be
  better than preop revascularization in high risk
  patients!!!

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ßeta Blockers 2000-2006

• 2 large RCTs showed no reduction in 30 d and 6 mo
  cardiac event rates
• Similar study in patients with DM
• No beneficial effects of ß-blocker therapy
• Why?
• Inadequate ß-blockade?
• Low risk patients?
• Better overall preoperative care than 1990?

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ß-Blockers 2007Where do we stand now?

• Withdrawal of ß-blockers preop is BAD
• 2007 study showed 2.6X increased 1 year mortality
  when ß-blocker was stopped preop.
• High risk patients probably benefit more than low
  risk patients (prev. MI, poor LVF)
• Appropriate dose
• Target HR should be lt70 preop
• Lower risk of cardiac events with low HR.

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Statins 2004-2006

• Now thought to have properties beyond lipid
  lowering effect.
• Plaque stabilizing effect?
• Decrease vascular inflammation?

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Statins 2004-2006

• Several recent studies suggest statins are
  cardioprotective
• Lower incidence of cardiac events
• Decrease length of stay
• Decrease incidence of perioperative strokes
• Metanalysis BMJ 2006 (2 RCTs 15 cohort studies)
• Statin users had lower incidence of death and
  acute coronary syndromes

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Statins 2007

• Where do we stand in 2007?
• Theres probably something there
• Not enough data to recommend routine use
• We dont know which patient population will
  benefit most.
• Await results of DECREASE IV trial
• 6000 moderate and high risk patients randomized
  to b-blockers, statins or both.

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Stop Smoking forSafer Surgery

• We know smoking is a
• risk factor, but we are complacent about it.
• NOTE
• Smoking decreases tissue oxygenation, interferes
  with wound healing and impairs surgical outcome.
• Even brief interventions work sometimes.
• Patients can be referred for help to stop.
• Safer Healthcare Now makes advice to stop
  smoking a required part of the treatment of Acute
  MI.
• All smokers should be advised to stop smoking
  preoperatively.

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Template

• 6 8 hours of non-smoking reduces CO levels
• NPO after MN
• No smoking after Midnight

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Safer Healthcare Now

• SHN is the Canadian version of a US campaign to
  reduce medical errors, improve and standardize
  care, prevent hospital-acquired infection, and
  save lives.
• Looked for low hanging fruit the relatively
  quick and easy fixes.
• Data-driven, solidly researched.
• Six major areas chosen, including two related to
  anesthesia

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Central Line Infection

• In USA, 48,600 central line infections, possibly
  17,000 deaths.
• 2/3 are preventable with simple precautions.
• Extrapolating to Canada, this could save over
  1,000 lives per year.

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Central Line Infection

• Central Line Insertion
• Prep with 2 chlorhexidine in alcohol
• Scrub hands
• Mask, hat, gown and gloves
• Wide sterile field
• Consider subclavian route

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Reducing Surgical Site Infection

• Antibiotics start 1 hr preop, finish before
  incision. Usually only one dose.
• Perioperative blood sugar level lt11.1mmol/l in
  cardiac cases.
• Core temp. gt36 degrees in major cases.

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Mild Hypothermia

• Core 34 36 degrees
• Very common
• Early
• Redistribution of heat from core to periphery.
• Late
• Heat loss, convection, evaporation, cold fluid.

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Effects of Mild Hypothermia

• Cardiac - Incr Norepinephrine Incr BP
• Angina, MI, Arrest 2 v 10 if cold
• ECG Abn (Isch, VT) 7 v 16 if cold
• Coagulation
• Decr platelet functn, Incr PTT PT _at_ pt temp
• Double blood loss, 500 ml more
• Infection
• Vasocon, Decr Tissue O2
• Decr antibody production
• Decr neutrophil function

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Studies of Temp and Infection
KURZ Colorectal Surgery
NORMOTHERMIA HYPOTHERMIA
TEMP 36.6 34.7
INFECTIONS 6 19
Sutures in one day longer, LOS 2.6 days longer in hypothermia group Sutures in one day longer, LOS 2.6 days longer in hypothermia group Sutures in one day longer, LOS 2.6 days longer in hypothermia group
MELLING Clean minor surgery
NORMOTHERMIA HYPOTHERMIA
INFECTIONS 5 14
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What to do?

• Preheat patients
• Avoid heat loss
• Cover up (doesnt matter with what)
• Warm IV solutions
• Forced air warming over maximum surface area

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Regional Anesthesia and Patient Outcome

• Regional anesthesia is the standard for
• CSection (spinal/epidural)
• Epidural for AAA
• Thoracic Epidural for Lung Surgery

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The Benefits of Regional Anesthesia

• Avoid the major physiologic trespass associated
  with GA
• Rapid recovery
• ? Cardiac depression
• ? Respiratory depression
• ? PONV
• ? Ileus
• ? Blood loss
• ? Thromboembolism
• ? Post-operative pain control

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Proven Results of Regional

• Quicker wake up
• Shorter PACU Stay
• Earlier Ambulation
• Quicker Rehab
• Improved patient satisfaction
• Shorter Hospital Stay
• Less M M

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Is Regional for Everybody?

• It depends..
• For low risk patients probably no benefits,
  except for improved patient satisfaction
• For intermediate and high risk patients, proven
  less morbidity and mortality for all major organ
  systems except CARDIAC

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CONCLUSION

• Advances in anesthesia have already made surgery
  much safer.
• We can do more to perfect preoperative
  preparation, prevent infection, provide optimum
  conditions for healing.