Perioperative mortality

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Perioperative mortality can be caused by factors that affect the preoperative period, intraoperative period and postoperative period. High risk factors such as cardiovascular diseases and pulmonary diseases affect the outcome of the surgery. During the intraoperative period, hemorrhage and perforation can increase the perioperative mortality. The postoperative factors which increase the perioperative mortality are infections, DVT and cerebrovascular accidents. Antimicrobial therapy is the mainstay of therapy for infections that arise in the postoperative period.

Perioperative mortality

Perioperative mortality is mortality in relation to surgery, usually taken as death within two weeks of a surgical procedure. One of the vital steps in the decision to perform a surgical procedure is to weigh the benefits against the risks. Anaesthestists (and internists) employ various methods in assessing whether a patient is fit for surgery, and various statistical tools are available. Cardiovascular disease and pulmonary disease are both associated with poor outcome of surgery.

Intraoperative

Complications during surgery, e.g. hemorrhage or perforation of organs may have lethal sequelae.

Postoperative

Infection

Local infection of the operative field is prevented by asepsis (using sterile materials), and prophylactic antibiotics are often given in abdominal surgery or patients known to have a heart defect or mechanical heart valves (that would be more prone to endocarditis).

DVT/PE

Various specific perioperative complications are recognised, and preventive measures are taken. Examples are deep venous thrombosis and pulmonary embolism, which is prevented by the administration of low molecular weight heparins and compression stockings, and cyclical pneumatic calf compression in very high risk patients.

Hypostatic pneumonia

Physiotherapy has a place in preventing pneumonia due to shallow inspirations, which occurs especially in patients recovering from abdominal surgery. Early treatment with antibiotics may be necessary.

CVA

Cerebrovascular accidents do occur at a higher rate during the postoperative period. Few specific measures can be taken to prevent this.

Specific diseases

Liver disease

In patients with cirrhosis, the perioperative mortality is predicted by the Child-Pugh score.

Monitoring

Most hospitals have regular meetings to discuss surgical complications and perioperative mortality. Specific cases may be investigated more closely if a preventable cause has been identified.

In many countries, statistics are kept by mandatory reporting of perioperative mortality. These may then be used in league tables that compare the quality of hospitals. Critics of this system point out that perioperative mortality may not reflect poor performance but could be caused by other factors, e.g. a high proportion of acute/unplanned surgery.

Antimicrobial Regimen

Surgical site infection

• Surgical site infection treatment

• 1. Surgery of intestinal or genitourinary tract

• 1.1 Single-drug regimens

• Preferred regimen (1): Ticarcillin-clavulanate 3.1 g IV q6h
• Preferred regimen (2): Piperacillin-tazobactam 3.375 g IV q6h OR Piperacillin-tazobactam 4.5 g IV q8h
• Preferred regimen (3): Imipenem-cilastatin 500 mg IV q6h
• Preferred regimen (4): Meropenem 1 g IV q8h
• Preferred regimen (5): Ertapenem 1 g IV q24h

• 1.2 Combination regimens

• Preferred regimen (1): Ceftriaxone 1 g IV q24h AND metronidazole 500 mg IV q8h
• Preferred regimen (2): Ciprofloxacin 400 mg IV q12h (or Ciprofloxacin 750 mg IV PO q12h) AND metronidazole 500 mg IV q8h
• Preferred regimen (3): Levofloxacin 750 mg IV q24h AND metronidazole 500 mg IV q8h
• Preferred regimen (4): Ampicillin-sulbactam 3 g IV q6h AND gentamicin (OR tobramycin 5 mg/kg IV q24h)

• 2. Surgery of trunk or extremity away from axilla or perineum

• Preferred regimen (1): Oxacillin or nafcillin 2 g IV q6h
• Preferred regimen (2): Cefazolin 0.5–1 g IV q8h
• Preferred regimen (3): Cephalexin 500 mg PO q6h
• Preferred regimen (4): SMX-TMP 160–800 mg PO q6h
• Preferred regimen (5): Vancomycin 15 mg/kg IV q12h

• 3. Surgery of axilla or perineum

• Preferred regimen (1): Metronidazole 500 mg IV q8h AND Ciprofloxacin 400 mg IV q12h (OR Ciprofloxacin 750 mg PO q12h)
• Preferred regimen (2): Metronidazole 500 mg IV q8h AND Levofloxacin 750 mg IV/PO q24h
• Preferred regimen (3): Metronidazole 500 mg IV q8h AND Ceftriaxone 1 g

See also

• Patient safety