Speaker: Rupert Pearse Recorded at: SSAI2017 More from conference: https://scanfoam.org/ssai2017/

1. How can perioperative
medicine change outcomes?
Rupert Pearse
Professor of Intensive Care Medicine
Barts and the London School of Medicine and Dentistry

2. • 310 million surgical procedures worldwide
• True mortality rate is not known
• 3 million deaths each year

3. Variation in mortality after emergency surgery
Symons N et al. Brit J Surg 2013; 100: 1318-25.

4. Complications decrease long-term survival
Khuri et al. Ann Surg 2005; 242: 326–343

5. What is a post-operative complication?

6. Complication or Consequence..?
Complication
• Wound infection
• Pneumonia
• Myocardial injury
• Pulmonary embolism
• Stroke
• Acute kidney injury
Consequence
• Inflammation
• Respiratory impairment
• Pain
• Immobility
• Confusion
• Organ dysfunction

7. SURGERY
PATIENT
PERI-OPERATIVE CARE
Understanding post-operative complications

8. Redefining the inflammatory
response....
Xiao W et al. J Exp Med 2011; 208: 2581-90.

9. Acute harm is characterised by inflammation

11. Hobson C et al. Circulation 2009;119: 2444
Acute Kidney Injury and long-term mortality after
cardiac surgery

12. Acute Kidney Injury:
A key cause of Chronic Kidney Disease
CKD 1
CKD 4
CKD 2
CKD 3
CKD 5 = DIALYSIS
AKI
AKI
AKI
AKI

13. Acute organ injury as a cause of
long-term harm
• Acute kidney injury
• Acute lung injury
• Myocardial injury
• Polyneuropathy & myopathy
• Delirium

15. Use of surgical checklists across Europe

17. Minimally invasive measurement of
cardiac output

18. Carson JL et al. NEJM 2011; 365: 2453-62
Restrictive
transfusion in hip
fracture surgery

19. Lancet 2008; 372: 562-9.

20. Squadrone V et al. JAMA
2005; 293: 589-95.
Control
CPAP

21. Surgery as a sentinel event...
• First contact with doctor
• Co-morbid disease
• Secondary prevention

22. EPOCH Trial:
Enhanced Peri-Operative
Care for High-risk patients

24. Strategies to improve surgical outcome
• No surgery?!
• Smoking cessation
• Patient information
• Early CPAP & NIV
• Haemodynamic Rx
• Epidural analgesia
• Normothermia
• Mobilisation
• Early enteral nutrition
• Process & Audit

25. ‘Bleeding London’
Emma Williams 2006