THE PERIOPERATIVE PERIOD AND INTENSIVE CARE MEDICINE

  • Maria Lobo Antunes Intensive Care Medicine Service, Hospital Beatriz Ângelo, E.P.E, Loures, Portugal
  • Francisco D'Orey Intensive Care Medicine Service, Hospital Garcia de Orta, E.P.E, Almada- Portugal
  • Maria Inês Ribeiro Intensive Care Medicine Service, Hospital Garcia de Orta, E.P.E, Almada- Portugal
  • Paula Mendes Polyvalent Intensive Care Unit, Hospital de Santo Espírito da Ilha Terceira, E.P.R, Autonomous Region of the Azores – Portugal
  • Sara Lança Intensive Care Medicine Service, Hospital Garcia de Orta, E.P.E, Almada- Portugal
  • Antero Fernandes Intensive Care Medicine Service, Hospital Garcia de Orta, E.P.E, Almada, Portugal; Faculty of Health Sciences, Universidade da Beira Interior; Faculty of Medicine, Universidade de Lisboa; Faculty of Health Sciences, Universidade Fernando Pessoa, Portugal http://orcid.org/0000-0002-6986-083X

Abstract


High-risk surgery is related to the extent, invasiveness and complexity of the procedure, factors that result in an increased stress response due to surgical trauma, increased oxygen demand and increased rate of postoperative complications, which may lead to patient death.
Classically, the perioperative period comprises three interrelated sequential phases: preoperative, intraoperative and postoperative.
Regardless of the improvements in surgical treatment observed in terms of anaesthesia, surgical techniques and perioperative care, in patients considered high risk perioperative morbidity and mortality remains high, leading to an eminent need for early recognition of these patients, to allow optimizing the preoperative period by prehabilitating the most severe patients, defining the best anaesthetic-surgical strategy in the intraoperative period, and better managing the postoperative period, which if it happens improves the outcome.
Various predictive risk scores and classifications are used in the different phases of the perioperative period to identify and classify patients at higher risk, enabling early identification of patients. All patients should ideally have their risk re-stratified at the end of surgery using some “criteria protocol” to determine immediate postoperative care.
The evidence shows that patients considered high risk or patients with a risk of death ≥ 10% should be admitted to intensive care medicine, enabling quality immediate postoperative care.
Even though they are not ideal tools, several Intensive Care Units use various indices (Charlson Comorbidity Index, Coexisting Diseases Index, the National Early Warning Score (NEWS2)), among others) as preoperative indicators for postoperative admissions.
Perioperative assessment is very important and is justified by the possibility of postoperative complications, which despite having a variable incidence are still an important cause of morbidity and mortality, especially in high-risk patients.
As the systemic and differentiated area of Medical Sciences that specifically addresses the prevention, diagnosis and treatment of potentially reversible acute illness situations in patients presenting with imminent or established failure of one or more vital functions, Intensive Care Medicine through the effective monitoring of the evolutionary course of high-risk patients can play a relevant role in the perioperative period, stratifying not only patients with a real risk of death or morbidity, but above all identifying and treating early postoperative complications.
This article aims to revisit the main predictors of perioperative risk, but also the essential aspects of perioperative assessment, especially in patients at high risk of developing postoperative complications.
It reinforces the role of intensive care medicine as an active part of the perioperative management of these patients, emphasizing the importance of admitting high-risk patients to intensive care medicine, where effective monitoring of their course and the early identification and appropriate therapeutic approach to postoperative complications that generate high morbidity and mortality clearly have a positive impact.

Downloads

Download data is not yet available.

References

1. Boyd O, Jakson N. How is risk defined in high-risk surgical patient management? Crit Care. 2005;9(4):390-6;
2. Goldhill DR. Preventing surgical deaths: critical care and intensive care outreach services in the postoperative period. Br J Anaesth. 2005;95(1):88-94;
3. Nanthakumaran S, et al. Morbidity and mortality rates following gastric cancer surgery and contiguous organ removal, a population-based study. Eur J Surg Oncol, 2005. 31(10):1141-4;
4. Mentula PJ and Leppäniemi AK. Applicability of the Clavien-Dindo classification to emergency surgical procedures: a retrospective cohort study on 444 consecutive patients. Patient safety in surgery, 2014. 8: 31-31;
5. Weiser TG et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet, 2008. 372(9633):139-44;
6. Khan NA, et al. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med, 2006. 21(2):177- 80;
7. Jacobs JP, et al. What is Operative Morbidity? Defining Complications in a Surgical Registry Database. The Annals of Thoracic Surgery, 2007. 84(4):1416-1421;
8. Meynaar IA, van der Spoel JI, Rommes JH, van Spreuwel-Verheijen M, Bosman RJ, Spronk PE. Off hour admission to an intensivist-led ICU is not associated with increased mortality. Crit Care. 2009;13(3): R84;
9. Goldhill DR. Preventing surgical deaths: critical care and intensive care outreach services in the postoperative period. Br J Anaesth. 2005;95(1):88-94;
10. Cusack B and Buggy DJ. Anaesthesia, analgesia, and the surgical stress response. BJA Education, 20(9): 321e328 (2020);
11. Watt DG, Horgan PG, McMillan DC. Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery 2015; 157: 362e80;
12. Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85: 109e1;
13. Manou-Stathopoulou V, Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. Br J Anaesth 2019; 123: 570e83;
14. Paola A, Carlo L, Cinzia DR et al. Stress response to surgery, anaesthetics role and impact on cognition. J Anesth Clin Res 2015; 6: 1e5;
15. Iwasaki M, Edmondson M, Sakamoto A, Ma D. Anaesthesia, surgical stress, and “long-term” outcomes. Acta Anaesthesiol Taiwan 2015; 53: 99e104;
16. Marana E, Colicci S, Meo F, Marana R, Proietti R. Neuroendocrine stress response in gynaecological laparoscopy: TIVA with propofol versus sevoflurane anaesthesia. J Clin Anesth 2010; 22: 250e5;
17. Davisa G, Fayfmana M, et al. Stress hyperglycemia in general surgery: Why should we care? J Diabetes Complications. 2018 March; 32(3): 305–309;
18. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003; 78(12):1471–8;
19. Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011; 17(6):853–61;
20. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009; 32(6):1119–31;
21. McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin. 2001; 17(1):107–24;
22. Cerejeira J , Batista P , et.al. The stress response to surgery and postoperative delirium: evidence of hypothalamic-pituitary-adrenal axis hyperresponsiveness and decreased suppression of the GH/IGF-1 Axis. J Geriatr Psychiatry Neurol, 2013 Sep;26(3):185-94;
23. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000;
24. Cerejeira J, Mukaetova-Ladinska EB. A clinical update on delirium: from early recognition to effective management. Nurs Res Pract. 2011; 2011:875196;
25. Engel GL, Romano J. Delirium, a syndrome of cerebral insufficiency. 1959. J Neuropsychiatry Clin Neurosci. 2004;16(4):526- 538;
26. Knight JB, Lebovitz EE , et.al. Preoperative risk factors for unexpected postoperative intensive care unit admission: A retrospective case analysis. Anaesth Crit Care Pain Med,. 2018 Dec;37(6):571-575;
27. Dhesi JK, Nicholas PL, B and Partridge JSL. Frailty in the perioperative setting. Clinical Medicine 2019 Vol 19, No 6: 485–9;
28. Clegg A, Young J, Iliffe S, et al. Frailty in elderly people. Lancet 2013; 381: 752 – 62;
29. Parmar KL, Law J, Carter B, et al. Frailty in Older patients undergoing emergency laparotomy: results from the uk observational emergency laparotomy and frailty (ELF) study. Ann Surg 2019: [Epub ahead of print];
30. Muscedere J, Waters B, Varambally A, et al. The impact of frailty on intensive care unit outcomes: a systematic review and metanalysis. Intensive Care Med 2017; 43: 1105 – 22;
31. Lin HS, Watts JN, Peel NM, et al. Frailty and post-operative outcomes in older surgical patients: a systematic review. BMC Geriatr 2016; 16: 157;
32. Fowler A, Abbott T, Prowle J, et al. Age of patients undergoing surgery. Br J Surg 2019; 106: 1012 – 8;
33. Lees NP, Peden CJ, Dhesi JK, et al. The high-risk general surgery patient: Raising the standard. London: Royal College of Surgeons of England, 2018;
34. Kristensen et al. Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) 2014. European Heart Journal (2014) 35, 2383–2431;
35. Wijeysundera DN, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018 Jun 30;391(10140):2631-2640;
36. Gupta PK, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. 2013 Annals of Surgery 258(6):1096-1102, December 2013;
37. Hofmann A, et al. Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol, 2013 Mar;27(1):59-68;
38. Parekh NR and Steiger E. Percentage of Weight Loss as a Predictor of Surgical Risk: From the Time of Hiram Studley to Today. Nutr Clin Pratice, 2004 Oct;19(5):471-6;
39. Wax DB, et al. Association of preanesthesia hypertension with adverse outcomes. Cardiothorac Vasc Anesth. 2010 Dec;24(6):927-30;
40. Sebranek JJ, et al. Glycaemic control in the perioperative period. Br J Anaesth. 2013 Dec;111 Suppl 1: i18-34;
41. Brummel NE et al. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med 2017. Jul 1;196(1):64-72;
42. Long SL, Shapiro WA and Leung JM. A brief review of practical preoperative cognitive screening tools. Can J Anaesth. 2012 Aug; 59(8): 798–804;
43. De Nadal M, Pérez-Hoyos S, Montejo-González JC, Pearse R, Aldecoa C. European Surgical Outcomes Study (EuSOS) in Spain. Intensive care admission and hospital mortality in the elderly after non-cardiac surgery. Med Intensiva (Engl Ed). 2018 Nov;42(8):463-472;
44. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin. 2015;33(1):17-33;
45. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017 Mar 1;152(3):292-298;
46. Santos L, et al. Post-operative complications in risk surgical patients admitted to the intermediate care unit of Portuguese Institute of Oncology, Porto: Relevant information to plan a patient centered care. Revista Portuguesa de Cirurgia, [S.l.], n. 51:137-142, feb. 2022;
47. Becquemin JP, Majewski M, et.al. Colon ischemia following abdominal aortic aneurysm repair in the era of endovascular abdominal aortic repair. J Vasc Surg,. 2008 Feb;47(2):258-63;
48. Baker ML, Williams RN, Nightingale JMD. Causes and management of a high-output stoma. Colorectal Dis. 2011 Feb;13(2):191-7;
49. Pironi L, et al. Definitions of intestinal failure and the short bowel syndrome. Best Pract Res Clin Gastroenterol. 2016 Apr;30(2):173-85;
50. Bassi C, Dervenis C, et.al. International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005 Jul;138(1):8-13;
51. Fernandes A, Rodrigues J, Antunes L, et.al. Development of a preoperative risk score on admission in surgical intermediate care unit in gastrointestinal cancer surgery. Perioperative Medicine (2020) Aug 6,9:23;
52. Choy R, Pereira. K, et.al. Use of Apfel Simplified Risk Score to Guide Postoperative Nausea and Vomiting Prophylaxis in Adult Patients Undergoing Same-day Surgery. J Perianesth Nurs. 2022 Aug;37(4):445-451;
53. Zarnescu E, et al. Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery. Diagnostics (Basel). 2021 Dec; 11(12): 2382;
54. Reintam A, Parm P, et.al. Gastrointestinal failure in intensive care: a retrospective clinical study in three different intensive care units in Germany and Estonia. BMC Gastroenterol. 2006; 6: 19;
55. Kirkpatrick W, Nickerson D, et al. Intra-abdominal hypertension and abdominal compartment syndrome after abdominal wall reconstruction: quaternary syndromes? Scandinavian Journal of Surgery Volume 106, Issue 2, June 2017:97-106;
56. Starkopf J, Tamme K, Reintam.A. Diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome. Annals of Intensive Care 2012, 2(Suppl 1): S9;
57. Jammer I, Wickboldt N, Sander M, et.al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol . 2015 Feb;32(2):88-105;
58. Abbott TEF, Fowler AJ, Pelosi P, et.al. A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications. British Journal of Anaesthesia, 120 (5): 1066e1079 (2018);
59. Canet J, Sabaté S, Mazo V, et.al. Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Eur J Anaesthesiol. 2015 Jul;32(7):458-70;
60. Miskovic A, Lumb AB. Postoperative pulmonary complications*Miskovic and Lumb. British Journal of Anaesthesia, 118 (3): 317–34 (2017);
61. Fernandes A, Rodrigues J, Lages P, et.al. Root causes and outcomes of postoperative pulmonary complications after abdominal surgery: a retrospective observational cohort study. Patient Safety in Surgery (2019) 13:40;
62. Devereaux.PJ, Szczeklik W. Myocardial injury after non-cardiac surgery: diagnosis and management. Eur Heart J. 2020 May 1;41(32):3083-3091;
63. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015: 373:2258–2269;
64. Puelacher C, Buse GL, Seeberger D, et.al. Perioperative myocardial injury after noncardiac surgery: incidence, mortality, and characterization. Circulation 2018;137: 1221–1232;
65. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; ESC Scientific Document Group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2019; 40:237–269;
66. Puelacher C et al. Long-term outcomes of perioperative myocardial infarction/injury after non-cardiac surgery. Eur Heart J 2023 May 14;44(19):1690-1701.
67. Strobel RM, Leonhardt M, Krochmann A, Neumann K, Speichinger F, Hartmann L, et al. Reduction of postoperative wound infections by Antiseptica (RECIPE)?: a randomized controlled trial. Ann Surg. 2020;272(1):55–64;
68. Bowater RJ, Stirling SA, Lilford RJ. Is antibiotic prophylaxis in surgery a generally effective intervention? Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009;249(4):551–6;
69. World Health Organization. Global guidelines for the prevention of surgical site infection. Geneva; 2018;
70. Ballus.J, Delgado. JCL, et al. Surgical site infection in critically ill patients with secondary and tertiary peritonitis: epidemiology, microbiology and influence in outcomes. BMC Infectious Diseases (2015) 15:304;
71. Giacomettia A, Cirioni O, et.al. Epidemiology and microbiology of surgical wound infections. J Clin Microbiol. 2000;38:918–22;
72. de Ruiter J, Weel J, Manusama E, Kingma WP, van der Voort PH. The epidemiology of intra-abdominal flora in critically ill patients with secondary and tertiary abdominal sepsis. Infection. 2009;37:522–7;
73. Leaper DJ. Risk factors for and epidemiology of surgical site infections. Surg Infect (Larchmt). 2010;11:283–7;
74. Hagel S, Scheuerlein H. Perioperative antibiotic prophylaxis and antimicrobial therapy of intra-abdominal infections. Viszeralmedizin. 2014;30(5):310–6;
75. Kirby A, Santoni N. Antibiotic resistance in Enterobacteriaceae: what impact on the efficacy of antibiotic prophylaxis in colorectal surgery? J Hosp Infect. 2015;89(4):259–63;
76. Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet . 2022;399(10325):629–55;
77. Dubinsky-Pertzov B, Temkin E, Harbarth S, Fankhauser-Rodriguez C, Carevic B, Radovanovic I, et al. Carriage of extended-spectrum beta-lactamase-producing Enterobacteriaceae and the risk of surgical site infection after colorectal surgery: a Prospective Cohort Study. Clin Infect Dis . 2019;68(10):1699–704;
78. Nutman A, Temkin E, Harbarth S, et al. Personalized ertapenem prophylaxis for carriers of extended-spectrum β-lactamase – producing Enterobacteriaceae undergoing colorectal surgery. Clin Infect Dis. 2020;70(9):1891–7;
79. European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2022. Stockholm; 2022;
80. Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2:CD003543;
81. European Centre for Disease Prevention and Control. Proposals for EU guidelines on the prudent use of antimicrobials in humans 2017;
82. National Institute for Health and Care Excellence. NICE guideline: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use .2015;
83. Doernberg SB, Abbo LM, Burdette SD, Fishman NO, Goodman EL, Kravitz GR, et al. Essential resources and strategies for antibiotic Stewardship Programs in the acute care setting. Clin Infect Dis. 2018;67(8):1168–74;
84. Karanika S, Paudel S, Grigoras C, Kalbasi A, Mylonakis E. Systematic review and meta-analysis of clinical and economic outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs. Antimicrob Agents Chemother. 2016;60(8):4840–52;
85. Baur D, Gladstone BP, Burkert F, Carrara E, Foschi F, Dobele S, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17(9):990–1001;
86. Stocker H, Mehlhorn C, Jordan K, Eckholt L, Jefferys L, Arasteh K. Clinical and economic effects of an antimicrobial stewardship intervention in a surgical intensive care unit. Infection. 2020;48(4):509–19;
87. Gruber MM, Weber A, Jung J, Werner J, Draenert R. Impact and Sustainability of Antibiotic Stewardship on Antibiotic Prescribing in Visceral Surgery. Antibiotics. 2021;10(12):1518;
88. Dyar O, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793–8;
89. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4;
90. Schuts EC, Hulscher ME, Mouton JW, Verduin CM, Stuart JWC, Overdiek HW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847–56.
91. Saklad, M., Grading of patients for surgical procedures. Anesthesiology, 1941. 2(3): p. 281-284. 182
92. Dripps, R.D., New classification of physical status. Anesthesiology, 1963. 24: p. 111.
93. Goldman, L., et al., Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med, 1977. 297(16): p. 845-50.
94. Copeland, G.P., D. Jones, and M. Walters, POSSUM: a scoring system for surgical audit. Br J Surg, 1991. 78(3): p. 355-60.
95. Klein, N. and C. Weissman, Evaluating intraoperative therapeutic and diagnostic interventions. Anesth Analg, 2002. 95(5): p. 1373-80.
96. Keene, A.R. and D.J. Cullen, Therapeutic Intervention Scoring System: update 1983. Crit Care Med, 1983. 11(1): p. 1-3. 187. Herrmann, J., et al., Evaluation and management of patients with heart disease and cancer: cardio-oncology. Mayo Clin Proc, 2014. 89(9): p. 1287-306.
97. Smilowitz, N.R. and J.S. Berger, Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. JAMA, 2020. 324(3): p. 279- 290.
98. Arozullah, A.M., et al., Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med, 2001. 135(10): p. 847-57.
99. Arozullah, A.M., et al., Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg, 2000. 232(2): p. 242-53.
100. Canet, J., et al., PERISCOPE study: predicting post-operative pulmonary complications in Europe. European Journal of Anaesthesiology | EJA, 2011. 28(6): p. 459-461.
101. Menezes. AS , Fernandes. A et al. Optimizing classical risk scores to predict complications in Head and Neck surgery: a new approach. Eur Arch Otorhinolaryngol. 2021; 278(1): 191–202
Published
2024-01-11
How to Cite
LOBO ANTUNES, Maria et al. THE PERIOPERATIVE PERIOD AND INTENSIVE CARE MEDICINE. Revista Portuguesa de Cirurgia, [S.l.], n. 56, p. 7-21, jan. 2024. ISSN 2183-1165. Available at: <https://revista.spcir.com/index.php/spcir/article/view/1008>. Date accessed: 29 feb. 2024. doi: https://doi.org/10.34635/rpc.1008.
Section
Review Article