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When not to operate!�Is it possible to provide a firm �Yes or No?�How much should the anaesthetist be involved in the decision making?

Jan G. Jakobsson

Departmen of Anaesthesia & Intensive Care, Danderyds Hospital, Stockholm

Jan.jakobsson@ki.se

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When not to operate

The Patient

Relatives

The Anaesthetist

Evidences

The

Surgeon

When not to operate!�Is it possible to provide

a firm Yes or No?

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When not to operate

Life expectancy

Quality of life

When not to operate!�Is it possible to provide a firm Yes or No?

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When not to operate

Life expectancy

Quality of life

When not to operate!�Is it possible to provide a firm Yes or No?

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When not to operate

Life expectancy

Quality of life

When not to operate!�Is it possible to provide a firm Yes or No?

Reduce pain

Reduce distress

…give it a chance

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Health Related Quality of Life

…limited information available

https://toolbox.eupati.eu/resources/measuring-health-related-quality-of-life-hrqol/

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When not to operate

Elective…

Age

Acute ….

Trauma …

Comorbidities

Physiology/

vital signs

Resources

Fragility

ASA class

​

​

When not to operate!�Is it possible to provide a firm Yes or No?

………….

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When not to operate

  • How much should the anaesthetist be involved/interact in the decision around whether operate or not?
    • Is there patients that we cannot anaesthetise?

​

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Anaesthesia peroperative care

Anaesthetic agents

  • Anaesthetics are safe
  • Modern anaesthesia techniques are associated to very low direct mortality
  • Patients rarely die directly related to anaesthesia

​

Anaesthetic techniques

  • General Anaesthesia
    • Inhaled vs total intravenous (TIVA)
  • Neuroaxial Anaesthesia
    • Spinal/Epidural
  • Combined techniques
    • Peripheral blocks

Enhanced Recover after Surgery, multi-modal opioid-sparing analgesia

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Analgesia and Anaesthesia peroperative care

  • Oral seadtion/anxiolysis
  • Iv. Sedation/anxiolysis
  • Iv. Sedation & analgesia
  • ”light anaesthesia”
  • Deep anaesthesia
    • Inhaled maintenance
    • Intravenous maintenance
  • Local anaesthesia
  • Regional anaesthesia
  • Neuroaxial anaesthesia
    • Spinal
    • Epdural
    • Combined, ”SPEDA”

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Anaesthesia peroperative care

  • Intraoperative ”goal directed anaesthesia and fluid therapy”
  • Increased monitoring
    • Cardiac out put
    • Swan Ganz catheter
    • ECO-cardiography
    • Brain monitoring
    • ….
  • Preoperative asessment
  • Preoperative optimazation
  • Prehabilitation

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When not to operate

  • How much should the anaesthetist be involved/interact in the decision around whether operate or not?
    • Is there patients that we cannot anaesthetise?

​

      • There are patients that will not be alive at day 7, 30 and 90

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Smilowitz NR, Berger JS. Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. JAMA. 2020 Jul 21;324(3):279-290. doi: 10.1001/jama.2020.7840. PMID: 32692391.

Cardiac risks

”MACE”

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George EL, Hall DE, Youk A, Chen R, Kashikar A, Trickey AW, Varley PR, Shireman PK, Shinall MC Jr, Massarweh NN, Johanning J, Arya S. Association Between Patient Frailty and Postoperative Mortality Across Multiple Noncardiac Surgical Specialties. JAMA Surg. 2021 Jan 1;156(1):e205152. doi: 10.1001/jamasurg.2020.5152. Epub 2021 Jan 13. PMID: 33206156; PMCID: PMC7675216.

Fragility

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..predict risk

RISK SCORES

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..September issue of BJA

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….goal directed haemodynamic therapy

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….goal directed haemodynamic therapy

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Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. Bispectral index for improving intraoperative awareness and early postoperative recovery in adults. Cochrane Database Syst Rev. 2019 Sep 26;9(9):CD003843. doi: 10.1002/14651858.CD003843.pub4. PMID: 31557307; PMCID: PMC6763215.

…but limited long term benefits

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  • The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis
    • Joel E Lambert 1 2, Lawrence D Hayes 3, Thomas J Keegan 1, Daren A Subar 2, Christopher J Gaffney 1
    • Meta-Analysis Ann Surg. 2021 Jul 1;274(1):70-77
    • Objective: To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer.
    • Background: "Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined.
    • Methods: Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model.
    • Results: Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114).
  • Conclusions: Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates.
    • Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

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Anaesthesia Society and Quality register �SFAI & SPOR

SPOR.SE

​

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Anaesthesia Society and Quality register �SFAI & SPOR

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SPOR

Patienter 18 år

2010 – 2022 Juni

3 313 960 proceudres

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SPOR

SPOR

Patienter 18 år

2010 – 2022 Juni

0.2 %

0.6 %

1.8 %

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ASA physical status and 30-day mortality

0.06

0.38

3.72

10.1

53.9

SPOR

Patienter 18 år

2010 – 2022 Juni

Deceased day 30

Deceased day 30

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Age and ASA-PS impact on all cause 30-day mortality

SPOR

Patienter 18 år

2010 – 2022 Juni

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Urgency impact on all-cause 30-day mortality

SPOR

Patienter 18 år

2010 – 2022 Juni

Deceased day 30

Deceased day 30

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Binary Logistic regression �Odds ratio diseased with 30 days

SPOR

Patienter 18 år

2010 – 2022 Juni

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Acute mesenteric ischaemia

Reintam Blaser, Annikaa,b; Forbes, Alastaira; Björck, Martinc

  • Abstract
  • Purpose of review 
  • To summarize the recent evidence on acute mesenteric ischaemia (AMI).
  • Recent findings 
  • The overall incidence of AMI is below 10/100 000 person years but increases exponentially with age.
  • The overall mortality of AMI remains high, exceeding 50%, despite continuing progress and increasing availability of imaging and endovascular interventions.
  • However, patients with (early) revascularization have significantly better outcomes.
  • The majority of patients surviving the acute event are still alive at 1 year, but evidence on quality of life is scarce.
  • Clinical suspicion of AMI is the key to timely diagnosis, with biphasic computed tomography-angiography the diagnostic method of choice. Currently, no biomarker has sufficient specificity to diagnose AMI.
  • Summary 
  • Improved awareness and knowledge of AMI are needed to raise the suspicion of AMI in relevant patients and thereby to achieve better outcomes.

​

Current Opinion in Critical Care: August 11, 2022 - Volume - Issue - 10.1097/MCC.0000000000000972

doi: 10.1097/MCC.0000000000000972

​

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K55 acute bowel ischemia

SPOR

Patienter 18 år

2010 – 2022 Juni

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C18.1 – C18.9 Colon Cancers

SPOR

Patienter 18 år

2010 – 2020 Juni

Deceased day 30

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..no impact of anaesthetic technique

SPOR

Patienter 18 år

2016 – 2017 Juni

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Anaesthetic technique used for abdominal surgery in Sweden

SPOR

n = 29 069

KVÅ-surgical code starting with the letter J

and a KVÅ- code for anaesthesia

n = 27 497

Inhalation based anaesthesia

n = 22 231

TIVA

n = 4 637

Anaesthesia codes that does not fulfill requirements

n = 629

Missing anaesthesia code:

n = 1 572

SPOR

Patienter 18 år

2015 – 2020 Juni

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Abdominal cancer surgery all cause 30-day mortality

SPOR

Patienter 18 år

2015 – 2020 Juni

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Crude OR 95%CI

Crude

p-value*

Adjusted OR 95% CI

Adjusted

p-value*

Anaesthetic technique

Inhalational anaesthesia

Intravenous anaesthesia

 

1.320 [0.879-1.982]

0.758 [0.504-1.138]

 

0.181

0.181

 

1.232 [0.817-1.856]

0.812 [0.539-1.224]

 

0.320

0.320

Age group

Adult

Elderly

Geriatric

 

0.177 [0.096-0.327]

0.770 [0.571-1.038]

3.702 [2.743-4.997]

 

<0.001

0.086

<0.001

 

0.229 [0.123-0.425]

0.718 [0.532-0.970]

3.119 [2.275-4.274]

 

<0.001

0.031

<0.001

Sex

Female

Male

 

0.712 [0.525-0.966]

1.404 [1.035-1.905]

 

0.029

0.029

 

0.671 [0.490-0.918]

1.491 [1.089-2.041]

 

0.013

0.013

ASA-classification

High

Low

 

3.202 [2.358-4.349]

0.293 [0.215-0.401]

 

<0.001

<0.001

 

2.265 [1.653-3.104]

0.412 [0.299-0.567]

 

<0.001

<0.001

BMI

0.976 [0.935-1.019]

0.270

1.003 [0.595-1.049]

0.883

Type of surgery

Acute

Elective

 

4.094 [2.918-5.744]

0.244 [0.174-0.343]

 

<0.001

<0.001

 

3.441 [2.423-4.888]

0.291 [0.205-0.413]

 

<0.001

<0.001

Duration of anaesthesia

Minor

Major

 

1.105 [0.802-1.522]

0.905 [0.657-1.246]

 

0.541

0.541

 

1.090 [0.791-1.502]

0.917 [0.666-1.246]

 

0.597

0.597

Duration of surgery

Minor

Major

 

1.102 [0.817-1.486]

0.908 [0.673-1.225]

 

0.526

0.526

 

0.918 [0.671-1.254]

1.090 [0.798-1.489]

 

0.589

0.589

Time in PACU

Short

Long

 

0.703 [0.503-0.983]

1.413 [1.011-1.975]

 

0.039

0.043

 

0.696 [0.498-0.972]

1.428 [1.022-1.995]

 

0.034

0.037

No impact of anaesthetic technique

SPOR

Patienter 18 år

2015 – 2020 Juni

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When not to operate

The Patient

Relatives

The Anaesthetist

Evidences

The Surgeon

When not to operate!�Is it possible to provide a firm Yes or No?

Can % risk derived from register based study be translated into a decision of the individual patient

At what % should we say no?

37 of 40

When not to operate

The Patient

Relatives

The Anaesthetist

Evidences

The Surgeon

When not to operate!�Is it possible to provide a firm Yes or No?

Can % risk derived from register based study be translated into a decision of the individual patient

If elective procedure is denied and patient comes back with acute symptoms – worsened risk?

38 of 40

When not to operate

The Patient

Relatives

The Anaesthetist

Evidences

The Surgeon

When not to operate!�Is it possible to provide a firm Yes or No?

Can % risk derived from register based study be translated into a decision of the individual patient

At what % should we say no?

All involved should feel comfortable with the decision

39 of 40

When not to operate

The Patient

Relatives

The Anaesthetist

Evidences

The Surgeon

When not to operate!�Is it possible to provide a firm Yes or No?

Can % risk derived from register based study be translated into a decision of the individual patient

At what % should we say no?

All involved should feel comfortable with the decision

…we can put any patient a sleep but we can’t promise that all survive …

40 of 40

When not to operate!�

  • Is it possible to provide a firm Yes or No?
    • We can provide data from experience and big data sets but not explicit for an individual patient

​

​

  • And how much should the anaesthetist be involved in the decision making?
    • The anaesthetist should be part of the process,
      • Help assess and optimize
      • Discuss with surgeon
      • Inform patient