THE PERIOPERATIVE PERIOD AND INTENSIVE CARE MEDICINE
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.
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References
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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;
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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 apr. 2024.
doi: https://doi.org/10.34635/rpc.1008.
Issue
Section
Review Article
