Perioperative mortality

Short description: Any death occurring within 30 days after surgery

Perioperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital.[1] Globally, 4.2 million people are estimated to die within 30 days of surgery each year.[2] An important consideration in the decision to perform any surgical procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ various methods in assessing whether a patient is in optimal condition from a medical standpoint prior to undertaking surgery, and various statistical tools are available. ASA score is the most well known of these.

## Contents

* 1 Intraoperative causes
* 2 Complications following surgery
* 2.1 Infection
* 2.2 Blood clots
* 2.3 Lungs
* 2.4 Neurologic
* 2.5 Livers and kidneys
* 2.6 Postoperative fever
* 3 Epidemiology
* 4 See also
* 5 References
* 6 Further reading
* 7 External links

## Intraoperative causes

## Complications following surgery

### Infection

Main article: Medicine:Hospital-acquired infection

Countries with a low human development index (HDI) carry a disproportionately greater burden of surgical site infections (SSI) than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of the World Health Organization (WHO) recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication.[3][4][5][6]

Local infection of the operative field is prevented by using sterile technique, and prophylactic antibiotics are often given in abdominal surgery or patients known to have a heart defect or mechanical heart valves that are at risk of developing endocarditis.[7][8]

Methods to decrease surgical site infections in spine surgery include the application of antiseptic skin preparation (a.g. Chlorhexidine gluconate in alcohol which is twice as effective as any other antiseptic for reducing the risk of infection[9]), judicious use of surgical drains, prophylactic antibiotics, and vancomycin.[10] Preventative antibiotics may also be effective.[11]

Whether any specific dressing has an effect on the risk of surgical site infection of a wound that has been sutured closed is unclear.[12]

A 2009 Cochrane systematic review aimed to assess the effects of strict blood glucose control around the time of operation to prevent SSIs. The authors concluded that there was insufficient evidence to support the routine adoption of this practice and that more randomized controlled trials were needed to address this research question.[13]

### Blood clots

### Lungs

Many factors can influence the risk of postoperative pulmonary complications (PPC). (A major PPC can be defined as a postoperative pneumonia, respiratory failure, or the need for reintubation after extubation at the end of an anesthetic. Minor post-operative pulmonary complications include events such as atelectasis, bronchospasm, laryngospasm, and unanticipated need for supplemental oxygen therapy after the initial postoperative period.) [14] Of all patient-related risk factors, good evidence supports patients with advanced age, ASA class II or greater, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure, as those with increased risk for PPC.[15] Of operative risk factors, surgical site is the most important predictor of risk for PPCs (aortic, thoracic, and upper abdominal surgeries being the highest-risk procedures, even in healthy patients.[16] The value of preoperative testing, such as spirometry, to estimate pulmonary risk is of controversial value and is debated in medical literature. Among laboratory tests, a serum albumin level less than 35 g/L is the most powerful predictor and predicts PPC risk to a similar degree as the most important patient-related risk factors.[15]

Respiratory therapy has a place in preventing pneumonia related to atelectasis, which occurs especially in patients recovering from thoracic and abdominal surgery. .

### Neurologic

### Livers and kidneys

In people with cirrhosis, the perioperative mortality is predicted by the Child-Pugh score.[17]

### Postoperative fever

## Epidemiology

Most perioperative mortality is attributable to complications from the operation (such as bleeding, sepsis, and failure of vital organs) or pre-existing medical conditions. . Although in some high-resource health care systems, statistics are kept by mandatory reporting of perioperative mortality, this is not done in most countries. For this reason a figure for total global perioperative mortality can only be estimated. A study based on extrapolation from existing data sources estimated that 4.2 million people die within 30 days of surgery every year, with half of these deaths occurring in low- and middle-income countries.[2]

Perioperative mortality figures can be published 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, or other patient-related factors. 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.

Globally, there are few studies comparing perioperative mortality across different health systems. One prospective study of 10,745 adult patients undergoing emergency abdominal surgery from 357 centres across 58 countries found that mortality is three times higher in low- compared with high-human development index (HDI) countries even when adjusted for prognostic factors.[18] In this study the overall global mortality rate was 1·6 per cent at 24 hours (high HDI 1·1 per cent, middle HDI 1·9 per cent, low HDI 3·4 per cent), increasing to 5·4 per cent by 30 days (high HDI 4·5 per cent, middle HDI 6·0 per cent, low HDI 8·6 per cent; P < 0·001). A sub-study of 1,409 children undergoing emergency abdominal surgery from 253 centres across 43 countries found that adjusted mortality in children following surgery may be as high as 7 times greater in low-HDI and middle-HDI countries compared with high-HDI countries. This translate to 40 excess deaths per 1000 procedures performed in these settings.[19] Patient safety factors were suggested to play an important role, with use of the WHO Surgical Safety Checklist associated with reduced mortality at 30 days.

Mortality directly related to anesthetic management is less common, and may include such causes as pulmonary aspiration of gastric contents,[20] asphyxiation[21] and anaphylaxis.[22] These in turn may result from malfunction of anesthesia-related equipment or more commonly, human error. A 1978 study found that 82% of preventable anesthesia mishaps were the result of human error.[23]

In a 1954 review of 599,548 surgical procedures at 10 hospitals in the United States between 1948 - 1952, 384 deaths were attributed to anesthesia, for an overall mortality rate of 0.064%.[24] In 1984, after a television program highlighting anesthesia mishaps aired in the United States, American anesthesiologist Ellison C. Pierce appointed a committee called the Anesthesia Patient Safety and Risk Management Committee of the American Society of Anesthesiologists.[25] This committee was tasked with determining and reducing the causes of peri-anesthetic morbidity and mortality.[25] An outgrowth of this committee, the Anesthesia Patient Safety Foundation was created in 1985 as an independent, nonprofit corporation with the vision that "no patient shall be harmed by anesthesia".[26]

The current mortality attributable to the management of general anesthesia is controversial.[27] Most current estimates of perioperative mortality range from 1 death in 53 anesthetics to 1 in 5,417 anesthetics.[28][29] The incidence of perioperative mortality that is directly attributable to anesthesia ranges from 1 in 6,795 to 1 in 200,200 anesthetics.[28] There are some studies however that report a much lower mortality rate. For example, a 1997 Canadian retrospective review of 2,830,000 oral surgical procedures in Ontario between 1973 - 1995 reported only four deaths in cases in which either an oral and maxillofacial surgeon or a dentist with specialized training in anesthesia administered the general anesthetic or deep sedation. The authors calculated an overall mortality rate of 1.4 per 1,000,000.[30] It is suggested that these wide ranges may be caused by differences in operational definitions and reporting sources.[28]

The largest study of postoperative mortality was published in 2010. In this review of 3.7 million surgical procedures at 102 hospitals in the Netherlands during 1991 - 2005, postoperative mortality from all causes was observed in 67,879 patients, for an overall rate of 1.85%.[31]

Anaesthesiologists are committed to continuously reducing perioperative mortality and morbidity. In 2010, the principal European anaesthesiology organisations launched The Helsinki Declaration for Patient Safety in Anaesthesiology, a practically based manifesto for improving anaesthesia care in Europe.

## See also

* Patient safety
* ASA physical status classification system

## References

1. ↑ "Effect of definition of mortality on hospital profiles". Medical Care 40 (1): 7–16. January 2002. doi:10.1097/00005650-200201000-00003. PMID 11748422.
2. ↑ 2.0 2.1 "Global burden of postoperative death" (in en). Lancet 393 (10170): 401. February 2019. doi:10.1016/S0140-6736(18)33139-8. PMID 30722955.
3. ↑ Organization, World Health (2018) (in en). Global guidelines for the prevention of surgical site infection. World Health Organization. ISBN 978-92-4-155047-5. https://iris.who.int/handle/10665/277399.
4. ↑ "Overview | Surgical site infections: prevention and treatment | Guidance | NICE". 2019-04-11. https://www.nice.org.uk/guidance/ng125.
5. ↑ Gwilym, Brenig L.; Ambler, Graeme K.; Saratzis, Athanasios; Bosanquet, David C.; Stather, Philip; Singh, Aminder; Mancuso, Enrico; Arifi, Mohedin et al. (August 2021). "Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction Models: Development, Internal Validation, and Comparison with Existing Risk Prediction Models Identified in a Systematic Literature Review". European Journal of Vascular and Endovascular Surgery 62 (2): 258–266. doi:10.1016/j.ejvs.2021.05.009. ISSN 1078-5884. PMID 34246547.
6. ↑ "Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study". The Lancet. Infectious Diseases 18 (5): 516–525. May 2018. doi:10.1016/S1473-3099(18)30101-4. PMID 29452941.
7. ↑ Gwilym, Brenig L.; Dovell, George; Dattani, Nikesh; Ambler, Graeme K.; Shalhoub, Joseph; Forsythe, Rachael O.; Benson, Ruth A.; Nandhra, Sandip et al. (2021-04-01). "Editor's Choice – Systematic Review and Meta-Analysis of Wound Adjuncts for the Prevention of Groin Wound Surgical Site Infection in Arterial Surgery". European Journal of Vascular and Endovascular Surgery 61 (4): 636–646. doi:10.1016/j.ejvs.2020.11.053. ISSN 1078-5884. PMID 33423912.
8. ↑ Gwilym, Brenig L.; Ambler, Graeme K.; Saratzis, Athanasios; Bosanquet, David C.; Stather, Philip; Singh, Aminder; Mancuso, Enrico; Arifi, Mohedin et al. (2021-08-01). "Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction Models: Development, Internal Validation, and Comparison with Existing Risk Prediction Models Identified in a Systematic Literature Review". European Journal of Vascular and Endovascular Surgery 62 (2): 258–266. doi:10.1016/j.ejvs.2021.05.009. ISSN 1078-5884. PMID 34246547.
9. ↑ Wade, Ryckie G.; Burr, Nicholas E.; McCauley, Gordon; Bourke, Grainne; Efthimiou, Orestis (1 September 2020). "The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis". Annals of Surgery 274 (6): e481–e488. doi:10.1097/SLA.0000000000004076. PMID 32773627.
10. ↑ "Methods to decrease postoperative infections following posterior cervical spine surgery". The Journal of Bone and Joint Surgery. American Volume 95 (6): 549–54. March 2013. doi:10.2106/JBJS.K.00756. PMID 23515990.
11. ↑ "Antibiotics and perioperative infections". Best Practice & Research. Clinical Anaesthesiology 22 (3): 571–84. September 2008. doi:10.1016/j.bpa.2008.05.001. PMID 18831304.
12. ↑ "Dressings for the prevention of surgical site infection". The Cochrane Database of Systematic Reviews 2016 (12). December 2016. doi:10.1002/14651858.CD003091.pub4. PMID 27996083.
13. ↑ "Peri-operative glycaemic control regimens for preventing surgical site infections in adults". The Cochrane Database of Systematic Reviews (3). July 2009. doi:10.1002/14651858.cd006806.pub2. PMID 19588404.
14. ↑ "Prevention of postoperative pulmonary complications". International Anesthesiology Clinics 47 (4): 65–88. 2009. doi:10.1097/aia.0b013e3181ba1406. PMID 19820479.
15. ↑ 15.0 15.1 "Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians". Annals of Internal Medicine 144 (8): 581–95. April 2006. doi:10.7326/0003-4819-144-8-200604180-00009. PMID 16618956.
16. ↑ "Postoperative pulmonary complications: an update on risk assessment and reduction". Cleveland Clinic Journal of Medicine 76 (Suppl 4): S60-5. November 2009. doi:10.3949/ccjm.76.s4.10. PMID 19880838.
17. ↑ Tsoris, Andrea; Marlar, Clinton A. (2025), "Use Of The Child Pugh Score In Liver Disease", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 31194448, https://www.ncbi.nlm.nih.gov/books/NBK542308/, retrieved 2025-03-08
18. ↑ "Mortality of emergency abdominal surgery in high-, middle- and low-income countries". The British Journal of Surgery 103 (8): 971–988. July 2016. doi:10.1002/bjs.10151. PMID 27145169.
19. ↑ "Determinants of morbidity and mortality following emergency abdominal surgery in children in low-income and middle-income countries". BMJ Global Health 1 (4). 2016. doi:10.1136/bmjgh-2016-000091. PMID 28588977.
20. ↑ "Pulmonary aspiration of gastric contents in anaesthesia". British Journal of Anaesthesia 83 (3): 453–60. September 1999. doi:10.1093/bja/83.3.453. PMID 10655918.
21. ↑ "Maternal death from aspiration asphyxia". British Medical Journal 2 (4983): 16–9. July 1956. doi:10.1136/bmj.2.4983.16. PMID 13329366.
22. ↑ "Anaphylaxis and anesthesia: controversies and new insights". Anesthesiology 111 (5): 1141–50. November 2009. doi:10.1097/ALN.0b013e3181bbd443. PMID 19858877.
23. ↑ "Preventable anesthesia mishaps: a study of human factors". Anesthesiology 49 (6): 399–406. December 1978. doi:10.1097/00000542-197812000-00004. PMID 727541. http://journals.2lww.com/anesthesiology/Abstract/1978/12000/Preventable_Anesthesia_Mishaps__A_Study_of_Human.4.aspx.
24. ↑ "A study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive". Annals of Surgery 140 (1): 2–35. July 1954. doi:10.1097/00000658-195407000-00001. PMID 13159140.
25. ↑ 25.0 25.1 "Improving anesthesia safety". Narberth, Pennsylvania: Physician's News Digest. 2000. http://physiciansnews.com/spotlight/200wp.html.
26. ↑ "Foundation History". Indianapolis, IN: Anesthesia Patient Safety Foundation. 2010. http://www.apsf.org/about_history.php.
27. ↑ Cottrell JE (2003). "Uncle Sam, Anesthesia-Related Mortality and New Directions: Uncle Sam Wants You!". ASA Newsletter 67 (1). http://www.asahq.org/Newsletters/2003/01_03/cottrell.html.
28. ↑ 28.0 28.1 28.2 "Anesthesia safety: model or myth? A review of the published literature and analysis of current original data". Anesthesiology 97 (6): 1609–17. December 2002. doi:10.1097/00000542-200212000-00038. PMID 12459692.
29. ↑ "Impact of anesthesia management characteristics on severe morbidity and mortality". Anesthesiology 102 (2): 257–68; quiz 491–2. February 2005. doi:10.1097/00000542-200502000-00005. PMID 15681938. http://www.klinikum-memmingen.de/fileadmin/anaesthesie/literatur/Arbous_1.pdf.
30. ↑ "Mortality incidence in outpatient anesthesia for dentistry in Ontario". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 83 (6): 646–51. June 1997. doi:10.1016/S1079-2104(97)90312-7. PMID 9195616. http://www.ooooe.net/article/S1079-2104(97)90312-7/abstract.
31. ↑ "Postoperative mortality in The Netherlands: a population-based analysis of surgery-specific risk in adults". Anesthesiology 112 (5): 1105–15. May 2010. doi:10.1097/ALN.0b013e3181d5f95c. PMID 20418691.

## Further reading

* "Auditing perioperative mortality". Annals of the Royal College of Surgeons of England 69 (4): 185–7. July 1987. PMID 3631878.
* "Long-term survival is superior after resection for cancer in high-volume centers". Annals of Surgery 242 (4): 540–4; discussion 544–7. October 2005. doi:10.1097/01.sla.0000184190.20289.4b. PMID 16192814.
* "Effect of definition of mortality on hospital profiles". Medical Care 40 (1): 7–16. January 2002. doi:10.1097/00005650-200201000-00003. PMID 11748422.
* "Refining the definition of perioperative mortality following hepatectomy using death within 90 days as the standard criterion". HPB 13 (7): 473–82. July 2011. doi:10.1111/j.1477-2574.2011.00326.x. PMID 21689231.
* "NCEPOD: revisiting perioperative mortality". BMJ 304 (6835): 1128–9. May 1992. doi:10.1136/bmj.304.6835.1128. PMID 1392785.
* "Survival, surgical management and perioperative mortality of colorectal cancer in the 21-year experience of a specialised registry". International Journal of Colorectal Disease 24 (7): 777–88. July 2009. doi:10.1007/s00384-009-0687-1. PMID 19280201.
* "Perioperative and perinatal death as measures for quality assurance". Quality Assurance in Health Care 2 (3–4): 235–41. 1990. doi:10.1093/intqhc/2.3-4.235. PMID 1983243.
* "Surgery for hip fractures: Does surgical delay affect outcomes?". Indian Journal of Orthopaedics 45 (1): 27–32. January 2011. doi:10.4103/0019-5413.73660. PMID 21221220.
* "Acp. Best practice no 155. Pathological investigation of deaths following surgery, anaesthesia, and medical procedures". Journal of Clinical Pathology 52 (9): 640–52. September 1999. doi:10.1136/jcp.52.9.640. PMID 10655984.
* "Defining perioperative mortality after open and endovascular aortic aneurysm repair in the US Medicare population". Journal of the American College of Surgeons 212 (3): 349–55. March 2011. doi:10.1016/j.jamcollsurg.2010.12.003. PMID 21296011.

## External links

* Perioperative Mortality Review Committee, Department of Health, New Zealand (2009). "Terms of Reference for the Perioperative Mortality Review Committee". http://www.pomrc.health.govt.nz/moh.nsf/pagescm/7722/$File/pomrc-tor-sept09.pdf. * "National Confidential Enquiry into Patient Outcome and Death". http://www.ncepod.org.uk/.

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