Contraindications to time critical surgery; when not to proceed from the perspective of: The Physician A/Prof Peter Morley

British Journal of Surgery 2013; 100: 1045 1049

The risk of 30 day mortality increased with a surgical delay of more than 12h (odds ratio, 1.45; p = 0.02), more than 24h (odds ratio, 1.34; p = 0.02), and more than 48h (odds ratio, 1.56; p = 0.02); the risk of 90 day mortality increased with a surgical delay of more than 24h (odds ratio, 1.23; p = 0.04). An education level of the surgeon below that of an attending surgeon increased the risk of thirty-day mortality (odds ratio, 1.28; p = 0.035) and ninety-day mortality (odds ratio, 1.26; p = 0.016).

Physician input can be crucial Please avoid hypoxia and hypotension

Sometimes time is critical

Does a physician have a role?

There s really not much there...

Some will be covered in more detail later

Some will need to be comanaged by the physician, anaesthetist and surgeon

Three main areas Can I improve the problem in the time available? Should we operate at all? Recognise when you should not delay

Can I improve the problem in the time available? Do I understand what the surgeon needs to do? Do I understand what the anaesthetist needs to do? Can I help them do their job better? All crucially dependent on what resources are available

Systematic approach Airway Breathing Circulation Disability Exposure

Airway management

Systematic approach Airway Breathing Circulation Disability Exposure

Ventilation tricks Improve mechanics and oxygenation APO CPAP, diuretics, venesection Bronchoconstriction Beta-agonists, steroids, magnesium, volatiles Collapsed lung CPAP, bronchoscopy, physiotherapy ARDS Recruitment, better ventilator?

Systematic approach Airway Breathing Circulation Disability Exposure

For patients of GI perforation with associated septic shock, time from admission to initiation of surgery for source control is a critical determinant, under the condition of being supported by hemodynamic stabilization. The target time for a favorable outcome may be within 6 hours from admission. We should not delay in initiating EGDT-assisted surgery if patients are complicated with septic shock.

Azuhata et al. Critical Care 2014, 18:R87

British Journal of Surgery 2013; 100: 1045 1049

An automated prediction tool identified at risk patients and prompted a bedside evaluation resulting in more timely sepsis care, improved documentation, and a suggestion of reduced mortality. Journal of Hospital Medicine 2015;10:26 31

Crit Care Med 2014; 42:1749 1755) The results of the analysis of this large population of patients with severe sepsis and septic shock demonstrate that delay in first antibiotic administration was associated with increased in-hospital mortality. In addition, there was a linear increase in the risk of mortality for each hour delay in antibiotic administration.

The administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock.

Targeting a mean arterial pressure of 80 to 85 mm Hg, as compared with 65 to 70 mm Hg, in patients with septic shock undergoing resuscitation did not result in significant differences in mortality at either 28 or 90 days.

In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay.

N Engl J Med 2014;371:1381-91.

NEJM 1994; 331: 1105-9

Aggressive volume resuscitation of patients with raaas before proximal aortic control predicted an increased perioperative risk of death, which was independent of systolic blood pressure. Therefore, volume resuscitation should be delayed until surgical control of bleeding is achieved. J Vasc Surg 2013;57:943-50.

Cardiogenic issues Reversible rhythms Brady/asystole, tachy-dysrhythmias Pacing, electrolytes, anti-arrhythmics Ischaemia Revascularise? Cardiomypathy Inotropes? Tamponade Drain?

We could do with some more information

Anaesthesia 2012, 67, 714 720 Prospective observational study investigated the effect of focused transthoracic echocardiography in 99 patients who had suspected cardiac disease or were 65 years old, and were scheduled for emergency noncardiac surgery. The treating anaesthetist completed a diagnosis and management plan before and after transthoracic echocardiography, which was performed by an independent operator. Clinical examination rated cardiac disease present in 75%; the remainder were asymptomatic. The cardiac diagnosis was changed in 67% and the management plan in 44% of patients after echocardiography. Cardiac disease was identified by echocardiography in 64% of patients, which led to a step-up of treatment in 36% (4% delay for cardiology referral, 2% altered surgery, 4% intensive care and 26% intra-operative haemodynamic management changes). Absence of cardiac disease in 36% resulted in a step-down of treatment in 8% (no referral 3%, intensive care 1% or haemodynamic treatment 4%).

Anaesthesia 2012, 67, 714 720

Obstructive shock Pulmonary embolus??? Tension pneumothorax Drain?

Systematic approach Airway Breathing Circulation Disability Exposure

Disability Reversible neurological state Seizure control? Drugs Antidotes? Don t Ever Forget Glucose Hypoglycemia, hyperglycemia?

Systematic approach Airway Breathing Circulation Disability Exposure

This meta-analysis supports ortho-geriatric collaboration to improve mortality after hip repair. Further study is needed to determine the best model of ortho-geriatric collaboration, and if these partnerships improve functional outcomes. J Orthop Trauma. 2014 March ; 28(3): e49 e55

Older age, male gender, higher chronic comorbidity and higher severity measured by the Risk Mortality Index were associated with higher mortality, but the time to surgery was not.

Have a really good look Have we missed something? Drug effect/allergic reaction, anaphylaxis Metabolic/electrolyte/endocrine disturbance K, Mg, PO4, HCO3, etc Have we mis-diagnosed something? Fixation error? Anchoring bias? Recallability trap? Biliary pain is due to pneumonia Abdominal pain is due to myocardial ischaemia Should we be doing this Die with or without surgery Not what patient would want

Three main areas Can I improve the problem in the time available? Should we operate at all? Recognise when you should not delay

Should we operate at all? Futile? Are you sure? AVR in the 90s Is it what the patient would want? Previous expressed/documented wishes Able to consent, encompassing goals of care

Three main areas Can I improve the problem in the time available? Should we operate at all? Recognise when you should not delay

You may see things differently...

We know getting patients to ICU faster is good

There is a significant association between time to admission and survival rates. Each hour of waiting was independently associated with a 1.5% increased risk of ICU death (hazard ratio (HR): 1.015; 95% CI 1.006 to 1.023; P = 0.001).

the summary 79

Summary Can I improve the problem in the time available? ABCDE Should we operate at all? Goals of Care, Advanced Care Planning Recognise when you should not delay