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…

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.

CMPA Dues

Better equipment

Better drugs

• HALOTHANEHALOTHANE• CURARE CURARE • PENTOTHAL PENTOTHAL • DEMEROL DEMEROL

And soon …..And soon …..• NEOSTIGMINENEOSTIGMINE

• SEVO & DES• ROCURONIUM• PROPOFOL• HYDROMORPHONE & ALFENTANIL

SUGAMMADEX

Better education

MEETINGS& WORKSHOPS

CAS and ASA Annual Meetings

Ontario Anesthesia Meeting

McGill Course

… and many others

WEB SITES

GASNet

Virtual Anesthesia Textbook

NYSORAwww.neuraxiom.com

www.thoracic- anesthesia.com

Preoperative Medications

βeta Blockers 1990-2000

• Numerous studies showed– ↓ incidence of postop ischemia– ↓ incidence of perioperative MI– ↓ cardiac mortality

• β-Blockers became the craze

• 3 supporting editorials in NEJM – One even suggested that β-blockers might be

better than preop revascularization in high risk patients!!!

βeta 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 β-blocker therapy

• Why?– Inadequate β-blockade? – Low risk patients?– Better overall preoperative care than 1990?

β-Blockers 2007Where do we stand now?

• Withdrawal of β-blockers preop is BAD– 2007 study showed 2.6X increased 1 year

mortality when β-blocker was stopped preop.

• High risk patients probably benefit more than low risk patients (prev. MI, poor LVF)

• Appropriate dose– Target HR should be <70 preop– Lower risk of cardiac events with low HR.

Statins 2004-2006

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

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

Statins 2007

• Where do we stand in 2007?– There’s probably something there– Not enough data to recommend routine use– We don’t 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.

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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• 6 – 8 hours of non-smoking reduces CO levels

• “NPO after MN”• “No smoking after

Midnight”

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:

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.

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

Reducing Surgical Site Infection:

• Antibiotics start 1 hr preop, finish before incision. Usually only one dose.

• Perioperative blood sugar level <11.1mmol/l in cardiac cases.

• Core temp. >36 degrees in major cases.

“Mild Hypothermia”

• Core 34 – 36 degrees

• Very common

• Early– Redistribution of heat from core to periphery.

• Late– Heat loss, convection, evaporation, cold fluid.

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 funct’n, Incr PTT PT @ pt temp– Double blood loss, 500 ml more

• Infection– Vasocon, Decr Tissue O2– Decr antibody production– Decr neutrophil function

Studies of Temp and Infection

NORMOTHERMIA HYPOTHERMIA

TEMP 36.6 34.7

INFECTIONS 6% 19%

Sutures in one day longer, LOS 2.6 days longer in hypothermia group

KURZ Colorectal Surgery

MELLING Clean minor surgery

NORMOTHERMIA HYPOTHERMIA

INFECTIONS 5% 14%

What to do?

• Preheat patients

• Avoid heat loss

• Cover up (doesn’t matter with what)

• Warm IV solutions

• Forced air warming over maximum surface area

Regional Anesthesia and Patient Outcome

Regional anesthesia is the standard for:

• CSection (spinal/epidural)

• Epidural for AAA

• Thoracic Epidural for Lung Surgery

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

Proven Results of Regional

• Quicker wake –up

• Shorter PACU Stay

• Earlier Ambulation

• Quicker Rehab

• Improved patient satisfaction

• Shorter Hospital Stay

• Less M & M

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

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.