Central Line
Episode Number: 127
Episode Title: Inside the Monitor – 30-Day Mortality after Anesthesia
and Surgery
Recorded: April 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ZACH DEUTCH:
Welcome to Central Line. I'm Dr. Zach Deutch, your host for today's
episode. Today I'm joined by Dr. Dan Sessler, who's contributed an article to the
May ASA Monitor, which explores the issue of 30-day mortality after anesthesia
and surgery. This is a hugely important topic for clinical and regulatory
purposes, and I'm looking forward to hearing more about this. So welcome
everyone and thank you for tuning in. Before we get into the substance of this
issue, Dan, can you tell our listeners a we do about yourself and give a brief
biographical sketch?
DR. DAN SESSLER:
With pleasure. I have the honor of the Outcomes Research Consortium, which
at 230 members is the world's largest anesthesia research group. Our goal is
simply to do as much clinical research as we can. And in that respect, we're
fairly successful. The consortium has published more than 2000 full papers, and
we knock out a new one every other day. Um, I'm board certified in pediatrics
and in anesthesia. Initially, I did pediatric anesthesia and I switched to an
adult anesthesia. But ultimately, I've been a clinical researcher my whole
life. That’s my focus and it continues to be where post focus my efforts.
DR. DEUTCH:
So you’re well poised obviously to talk about this issue. Let's get into
the substance of that. How common is death within 30 days after surgery?
DR. SESSLER:
Death after surgery is remarkably common, and I need to contrast it with
intraoperative death. Intraoperative mortality is now so rare that it's hard to
quantify. It's something on the order of one in 100,000 cases. That's less than
one preventable anesthetic death per career. It's really, really low. In marked
contrast, between 1 and 2% of surgical inpatients die within 30 days after
surgery. Put this in perspective, it's the third leading cause of death, period,
in the entire world. Many people die 30 days after surgery. And let me give you
an anecdote about this. Grandma comes to the hospital. She has major surgery
and arrives stable in the recovery room. Almost everyone assumes that grandma
has survived the most dangerous part of her perioperative experience, and
that's just absolutely untrue. Grandma's chances of dying in the next 30 days
are 140 times higher than they were in the operating room. It’s postoperative
mortality that we need to lower them because that's how people die. There’s just
no margin at this point in just intraoperative mortality, literal, um, so low
we can hardly quantify it. Post-operatively, lots of patients die. And we have
an opportunity to prevent those deaths.
DR. DEUTCH:
So basically what you're saying is what people have been indicating
before, we've kind of made this thing too easy intraoperatively, which is why
people tend to take us for granted, but they're really missing the real focus
of where there's some gains to be made in terms of public health, which would
be the postoperative mortality arena. Correct?
DR. SESSLER:
That is exactly right. Once you recognize that the 30-days after surgery
is the world's third leading cause of death, it's obvious that that's where we
need to focus. And we as anesthesiologists have much to contribute. We can
reduce that mortality.
DR. DEUTCH:
Okay. So let's talk then about some specifics. What are the major causes
of that and what factors can you think of, or have you identified in your
research, that contribute to preventable, uh, aspects of post-operative
mortality?
DR. SESSLER:
Okay. Let's let's start with causes of postoperative mortality. The two
major causes are bleeding and cardiovascular complications. Sepsis is a distant
third and respiratory deaths are even less common than that. But they deserve
special attention because they're nearly all preventable.
DR. DEUTCH:
Okay. Could you describe either generally or via actual vignettes, what
way would those be preventable, what type of clinical scenarios are you
referring to?
DR. SESSLER:
Myocardial injury after noncardiac surgery is is a major cause of
cardiovascular complications. Myocardial injury is defined as a troponin
elevation, apparently due to myocardial ischemia. It does not require symptoms
or signs, so patients don't have to have shortness of breath or chest pain. And
in fact, more than 90% of them do not have these symptoms. And you might say,
oh, it's asymptomatic. It's just atroponitis. It doesn't really matter. And
even cardiologists take that perspective. But that's really the wrong approach,
because the mortality for myocardial injury that's asymptomatic is nearly as
high as it is for a full myocardial infarction. Just because these events are
silent doesn't mean that they're unimportant. In fact, they kill people just
about at the same rate as a full myocardial infarction.
DR. DEUTCH:
And possibly we could see how that would progress in that it would tend
to be treated more cavalierly and dismissed. It's not the standard profusely
sweating, patient with crushing chest pain. Correct?
DR. SESSLER:
It is not yet the standard of care for post-operative patients to have
troponin screening, but it should be. Four different national societies,
including the American Heart Association, all now recommend troponin screening
in moderate to high risk patients. And the reason they recommended is that
these events are asymptomatic. If you don't measure troponin, you'll miss 90%
of them, and the 90% that you miss are not less serious than the ones you
identify. They have just about the same mortality. And you need to know about
these events, because there are lots of things you can and should do about
them. Somebody has myocardial injury. Well, somebody should have a conversation
with the patient and explain that they've had a myocardial infarction, which is
what it is. It's called myocardial injury after noncardiac surgery. It's a type
of infarction. It's a type two myocardial infarction. And by the way, type two
myocardial infarctions are more deadly than type one infarctions. So somebody
needs to tell the patient that they've had an infarction and that their chances
of having a reinfarction in the coming years is high, and that there are things
they can do to prevent that, or at least to reduce the risk, such as smoking
cessation, healthful eating and exercise. Most of these patients should be put
on aspirin. They should be considered for statins and ace inhibitors. And if
their blood pressure and heart rate isn't under control, this would be a really
good time to get it under control.
DR. DEUTCH:
So clearly this is an emerging change in the way we think about things
in the perioperative period and how we think about heart health as it relates
to risk modification and outcomes. So very interesting point there. But I would
like also to touch on the pulmonary system, because you did mention that though
the respiratory events, though not as common, are almost universally
preventable. Can you give a little bit more detail on that?
DR. SESSLER:
Yes. So respiratory deaths are not terribly common in hospitals, but
they nearly all are preventable. So they're really tragic when they happen.
What causes these events is not exactly nailed down. But my impression is that
opioids are a huge player here. Way more than obstructive sleep apnea. Worries
about patients with obstructive sleep apnea are perfectly appropriate, but I
don't think that's actually what causes most respiratory arrest. As far as I
can tell, it's opioids. And that means that this is preventable. It's
preventable because we can give less opioid. It's preventable because we can
monitor patients. And it’s preventable because we can treat opioid induced
respiratory depression.
DR. DEUTCH:
So having kind of dived into those specifics a little bit, let's step
back for a second, talk a little bit more in the epidemiologic sense or the
more global sense. So the 30 day mortality measure. Why is that important
really? And why is it really important to us as anesthesiologists? And assuming
that it is important, what role might we have using our particular expertise to
help mitigate or even solve this problem?
DR. SESSLER:
Thirty days is somewhat arbitrary number that people pulled out of the
air, but it's commonly used for outcome measures. But let me point out that one
third of the deaths within 30 days after surgery occurre during the initial
hospitalization. That is under our care in our highest level health care
facilities. These are not people who go home and get hit by a bus. And many of
the others are patients who were readmitted for some reason. So this is very
much a consequence of surgery. The chances of dying in the month after surgery
are way higher than dying in an otherwise comparable month, even after careful
risk adjustment. So there's something about surgery that promotes mortality.
And some of it's obviously a consequence of surgery, such as bleeding
complications. But much of this results from aggravation of poorly controlled
medical conditions that people come to us with. And then it gets aggravated by
surgery. Because surgery, of course, is an enormous stress and it produces an
enormous amount of inflammation, which sort of makes everything worse.
DR. DEUTCH:
Okay, that makes sense. And this concept of the inflammatory response
being a negative modulator of outcome isn't really a new thing. But the
specifics that you're adding in here are all kind of new and concerning. So
it'd be nice to pivot from this into kind of some potential solutions and
things that we could do as a specialty to make this better. First, we need to
take a quick patient safety break. Stay with us. We'll be right back.
(SOUNDBITE OF MUSIC)
DR: JONATHAN COHEN:
Hi, this is Dr. Jonathan Cohen with the ASA patient safety editorial
board. Amy Edmondson's best selling book, The Fearless Organization,
revealed something surprising about psychological safety in health care
settings. Better teams report more errors. Higher functioning teams don't
actually make more errors, but they have a climate of openness that allows them
to be reported more easily. Different from a safe space, free of differing
opinions, a culture of psychological safety encourages members to ask questions,
speak up when things seem amiss, and admit mistakes. As leaders on the
perioperative care team, anesthesiologists can help foster this climate by
doing things like admitting their own fallibility, asking for team members
opinions, and responding productively when they voice a concern, ask a question,
or admit an error. People will make errors when team members feel comfortable
speaking up. We can prevent those errors from harming our patients.
VOICE OVER:
For more patient safety content, visit asahq.org/patient safety.
DR. DEUTCH:
Okay. We're back. Let's talk about some things that might mitigate or
even solve problems. One of the things that people have talked about, and, you
know, it's been talked about by industry and also by scholars within our
profession, is intermittent vital sign monitoring. What role could better
monitoring play in this clinical picture?
DR. SESSLER:
There are two major factors that contribute to postoperative mortality.
One of them is insufficient monitoring and the second is insufficient medical
management.
So let me start with monitoring. We monitor postoperative surgical
patients on surgical wards about the way hospitalized patients were monitored a
half century ago. But a half century ago, patients were admitted two days
before surgery. They stayed for two weeks after surgery. We didn't operate on
anybody over 60. We didn't operate on patients who had major comorbidities, and
we didn't even do really big operations. It's a half century ago. The average
acuity in a hospital wasn't much different from the acuity at a church picnic.
But that sure isn't the way it is anymore. Now more than half of our patients
go home on the day of surgery. We operate on anybody, no matter what their
comorbidities are. Half of our patients are over 60, and we do really big
operations. And then we leave these patients sitting on surgical wards. A
couple of decades ago, many of these patients would have been in an ICU, but
now they're sitting on surgical wards and they get vital signs every 4 to 6
hours. We know that this is insufficient. We know that because when you do sort
of autopsies of critical events, either that result in death or near death, and
you go back and you look, the vital signs are abnormal for hours in advance. So
these things don't just come out of the blue. People don't go from being
relatively healthy and stable on a surgical ward to being dead in bed in five
minutes. They deteriorate over hours. And if we were monitoring vital signs
constantly, we would see that deterioration. And we know that with every four
our vital signs, many deteriorations are missed completely. So we know that
patients have for long periods of desaturation. It is not picked up by the
nurses. They have for long periods of hypertension that's not picked up by the
nurses. Both of these abnormalities are common, profound, and prolonged. And
the nurses miss between 50 and 90% of these events. And let me make it clear
that this is not because the nurses are failing. We've actually quantified when
these events happen and they happen between the nursing assessments. It's not
the nurses’ fault. This is a system problem. And until we change the system,
we're simply going to miss these vital sign abnormalities that tell us a
patient is getting into trouble and would give us the opportunity to intervene.
So vital signs is the first thing we need to fix. And this is completely
fixable. There are FDA cleared devices that are battery powered, don't tether
patients, wearable, well-tolerated by patients that continuously measure all
vital signs.
Now, a problem with this is that you have a continuous stream of very
messy data. And it's not really fair to take, say, ten streams of data,
continuous data from surgical patients and just feed it to the nurses. They're
not trained to deal with this. And besides, they have full time nursing
responsibilities. So we have to come up with some better system. And probably
that involves using artificial intelligence and smart systems to identify
patients who are getting into trouble. Perhaps very early and perhaps in a
subtle way, long before any one vital sign passes a threshold, an AI system
could look at the pattern and say, this patient is not recovering the way they
should. This patient's going downhill, not uphill, and alert somebody. And then
somebody, perhaps in a bunker looking at many screens--ideally, an
anesthesiologist--looks at the vital sign records, the AI interpretation, and
of course has full access to the record--knows when surgery happened, when the
patient got their last dose of opioids--can interpret everything, and then make
a call to the ward. Hey Joe, check bed four now. That's that's the way we can
save lives with monitoring.
Let me now talk about medical management. I mentioned previously that
one of the main things that kills people after surgery is not the anesthesia.
It's not the surgery per se. It's that surgery and the inflammatory response
and the stress to surgery aggravate underlying medical conditions. And most of
our patients now have lots of underlying medical conditions, and very often
they're poorly controlled. So we bring people who are just sort of barely
hanging on with their medical conditions into the hospital. We do a major
operation that aggravates their baseline medical condition, and they end up
with myocardial injury, acute kidney injury, liver injury, sepsis, all sorts of
nasty things that then goes on and kills some of them. Medical management is
lacking in hospitals. So surgical patients get perhaps ten minutes of surgical
management early in the morning before surgeons disappear into the operating
room. And some patients get a pain consult from an anesthesiologist. But most
patients don't get management of their underlying medical conditions, and their
underlying medical conditions is actually more serious than their surgery or
their anesthesia. And I think that's what's killing them. So the second thing
that's missing, in addition to continuous vital signs, is somebody to interpret
the vital signs in context with the patient's medical condition and to optimize
their medical condition. And I think if we do both of those, we have the potential
to save an enormous number of lives. Even if we could save 10% of the deaths,
we're talking about tens of thousands of patients per year just in the United
States. We can make a huge difference here.
The alternative to adopting continuous monitoring and taking an active
role in medical management of patients is for anesthesiologists to declare
their responsibility ending when patients leave the recovery room. That is
exactly the same as declaring anesthesia as irrelevant to the major
perioperative problem. That is not a wise thing for our specialty to do.
DR. DEUTCH:
Just to elaborate, you said quite a bit there, and I think a lot of it
was very illuminating. You made a very strong case, you know, for especially
for talking about the monitoring and ways of trying to interpret it that make
sense. My follow up question is really about the medical management. And you
kind of just touched on it in what your last statement there. But how do you
envision the proper medical management of patients going forward that isn't,
you know, the quick rounds with the surgeon and the every four hour checks with
the nursing staff? How would you see that happening? Whether it involved
hospitalists, anesthesiologists, critical care physicians, whatever mixture of
personnel, what construct do you see that would be most effective?
DR. SESSLER:
Somebody needs to take responsibility for this. And it doesn't have to
be anesthesiologist. Hospitalists are already moving into this space. Internal
medicine folks are already moving in. There are already fellowships in
post-operative care in internal medicine departments. We should own this field.
But we don't have to. If we don't take it, other fields will take it. But I
think we're perfectly positioned to take it because nobody is better suited
than we are for interpreting continuous physiologic data, including all the
artifact that comes with that, understanding what it means, recognizing subtle
deterioration, and intervening before patients have a catastrophe. That's our
core expertise.
Now, I fully recognize the challenge. There's a national shortage of
anesthesiologists, although I don't think this is going to last as long as
people imagine. But currently there is. And so nobody wants to divert
anesthesiologists from the operating room into ward management. But I still
think it's the right thing for the specialty to do. And what it will involve is
having anesthesia attendings spend time on wards, that is assigned there for
entire days, or days on end, getting to know the patients, seeing the patients
several times a day, essentially making rounds with them, treating it like a
step down ICU because so many of the post-operative patients are sick enough to
be in a step down ICU. They should be getting a higher level of care than we're
currently giving them. We are perfectly positioned to do that. It's a field we
should own. We should have residents do serious rotations in that we should do
the research that defines the value that comes with post-operative care to
actually demonstrate that it saves lives. And finally, we should have some
board certification so that we can own this field.
DR. DEUTCH:
So tying into that, a lot of what we do is risk modeling and risk
stratification in terms of determining whether, in the perioperative period,
the patients are appropriate for the surgery or planned procedure. And that's
obviously a huge part of any type of medical decision making. Can you tie that
in or talk about how risk models can be used to address the problem of
postoperative mortality?
DR. SESSLER:
Indeed. There are many models now for predicting risk in surgical
patients and in many other contexts in medicine. My favorite is one that I've
been involved in from inception now more than a decade, it's a model developed
by the Health Data Analytics Institute in Boston. It's highly, highly
predictive. To give you an example, if you use their models and you identify
just the 5% of patients with the highest risk, 20% of all major complications
will occur in those 5% of patients. And if you take the top 20% of patients,
sorted by risk, more than half of all serious complications and deaths will
occur in those patients. So you can use risk models to identify which patients
will most benefit from intense post-operative management. In the spirit of full
disclosure, I was a minor co-founder of the Health Data Analytics Institute.
I'm a shareholder in the company, and I'm a consultant for them.
DR. DEUTCH:
Okay, so this sounds like another application for artificial
intelligence and software that's specifically designed to get a certain type of
outcome. Is that correct?
DR. SESSLER:
Yes. It's both deterministic and guided by artificial intelligence. And
it also identifies the trajectory of a patient over time. And it updates in
real time. And that's where the artificial intelligence part of this comes in,
helping to update it in real time. So it's a combination of modeling methods.
But the result is a model that's highly, highly predictive. And it's predictive
for not only death but about 200 other things. So you can say, I'm interested
in acute kidney injury. And there's a model specific for acute kidney injury.
DR. DEUTCH:
Okay, so we've touched on quite a bit here, and you've definitely
introduced some food for thought in terms of how we approach things like
myocardial injury, how we staff our hospital itself, and how we, you know,
prepare patients or assess patients prior to their, episode of care. So there's
a lot of overtly suggested and implied changes that that kind of came out of
what you've presented. What are the barriers that you see to making these type
of changes in our system?
DR. SESSLER:
The most obvious barrier is personnel. As I said, there's a national
shortage of anesthesiologists. Nobody wants to take anesthesiologists out of
the operating room or non operating room anesthesia and divert them into the
ward. We are better qualified than anybody else to do post-operative management
and to reduce post-operative mortality. If we don't take it though somebody
else will. But I really hope that we do, because it's important for the future
of our specialty. We don't want to be just operating room technicians, and I'm
sorry to put it that way, but that's what is at risk of happening here if we
don't take a broader view. And if we're not willing to recognize that it's not
the intraoperative period that's killing patients. And therefore we have
responsibilities post-operatively and we have opportunities post-operatively to
reduce mortality. This is something that we, as a specialty, need to recognize
and need to take on.
DR. DEUTCH:
Okay, so that being said, do you yourself feel optimistic about solving
this problem? What is your overall view of it in terms of where the next few
years lie, in terms of our specialty and really perioperative medicine in
general?
DR. SESSLER:
I have mixed feelings about it. I am worried that we as a specialty will
miss this opportunity. I'm optimistic that people will recognize that this is
essentially a fourth branch of anesthesia. So in addition to pain medicine,
critical care, operating room anesthesia, post-operative care should be a
specialty of anesthesia, should be subboards specialized. We should have people
who focus in this area. And if we could do we can save an enormous number of
lives. And it's an opportunity for us to have a glorious legacy like previous
generations. Previous generations of anesthesiologists have a well-deserved,
glorious reputation for solving intraoperative mortality. No other specialty
has remotely reduced mortality the way anesthesia has. And we all should be
proud of this. It's a wonderful accomplishment for our specialty. But that was
20 years ago. What have we done since? The major problem in perioperative
medicine is postoperative mortality. If we define anesthesia responsibility as
ending at the PACU, that's exactly the same as defining us as being irrelevant
to the major perioperative problem. I hope we don't do that.
DR. DEUTCH:
Your answer made me think of something else. You’re really talking
about, you know, fundamental paradigm shift not only in the way we view our
role clinically, but in how what duties we have and how we approach our jobs.
So a lot of this has to do with training future generations. I'm just curious
if you or anyone of your same mindset have had these discussions with
educational leaders, you know, among our specialty, ACGME level or lower, I
really don't know. I'm just curious if those discussions have been had about
the curriculum should be changed in this way, or we should be looking at these
type of things to, you know, for the future of our specialty. If you could
comment on that, that'd be great.
DR. SESSLER:
I've been talking to anyone who would listen for the last decade, but I
haven't made specific overtures to educational folks.
DR. DEUTCH:
Understood. So maybe that's an area of future endeavor, especially if
you're very active with the research part of this. It really ties into people's
scholarly and academic aims, which are usually developed within training
programs.
DR. SESSLER:
Yes.
DR. DEUTCH:
So we're coming to the end here. And I want to give you just a, you
know, a last minute to to speak to our listeners and to readers of the Monitor.
Any final words you want to leave them with, or most important points that they
should come away from this podcast and any articles that they might read that
are relevant?
DR. SESSLER:
Yes. Folks, we have an opportunity here to develop a fourth branch of
anesthesia. A branch of anesthesia that can save tens of thousands of lives per
year. A branch of anesthesia that can give our generation the legacy that
previous generations of anesthesiologists have. We have an opportunity. Carpe
diem. Seize the day, today.
DR. DEUTCH:
And with that, I want to thank you so much, Dr. Dan Sessler, for joining
us. It's been a very interesting conversation. Listeners thank you for tuning
in as well. We hope to see you on the next episode of the Central Line podcast.
And for more on the topic of morbidity, mortality and risk modification, refer
to asamonitor.org. Take care.
(SOUNDBITE OF MUSIC)
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