11 Apr 11
Posted in Coronary artery disease, Pre-operatie evaluation at 11:48 by Laci
By D Wijeysundera, W Beattie, R Elliot, P Austin, J Hux, A Laupacis
BMJ 2010; 340:b5526
To determine the association of non-invasive cardiac stress testing before elective intermediate to high risk non-cardiac surgery with survival and hospital stay.
Design
Population based retrospective cohort study.
Setting
Acute care hospitals in Ontario, Canada, between 1 April 1994 and 31 March 2004.
Participants
Patients aged 40 years or older who underwent specific elective intermediate to high risk non-cardiac surgical procedures.
Interventions Non-invasive cardiac stress testing performed within six months before surgery.
Main outcome measures
Postoperative one year survival and length of stay in hospital.
Results
Of the 271 082 patients in the entire cohort, 23 991 (8.9%) underwent stress testing. After propensity score methods were used to reduce important differences between patients who did or did not undergo preoperative stress testing and assemble a matched cohort (n=46 120), testing was associated with improved one year survival (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.99; P=0.03) and reduced mean hospital stay (difference −0.24 days, 95% CI −0.07 to −0.43; P<0.001). In an analysis of subgroups defined by Revised Cardiac Risk Index (RCRI) class, testing was associated with harm in low risk patients (RCRI 0 points: HR 1.35, 95% CI 1.05 to 1.74), but with benefit in patients who were at intermediate risk (RCRI 1-2 points: 0.92, 95% CI 0.85 to 0.99) or high risk (RCRI 3-6 points: 0.80, 95% CI 0.67 to 0.97).
Conclusions
Preoperative non-invasive cardiac stress testing is associated with improved one year survival and length of hospital stay in patients undergoing elective intermediate to high risk non-cardiac surgery. These benefits principally apply to patients with risk factors for perioperative cardiac complications.
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04 Apr 11
Posted in Anesthesia, Pre-operatie evaluation at 1:01 by Laci
By A Klein, J Arrowsmith
Anaesthesia 2010;65:974–976
In January 2010, the Association of Anaesthetists of Great Britain and Ireland published its safety guideline Pre-operative Assessment and Patient Preparation – The Role of the Anaesthetist 2. The opening line of the section on tests and investigations states that ‘Routine pre-operative investigations are expensive, labour intensive and of questionable value, especially as they may contribute to morbidity or cause additional delays due to spurious results’. Citing Clinical Guidelines 3, published in 2004 by the National Institute for Clinical Excellence (NICE), the authors go on to recommend that routine tests should indeed be undertaken in a number of specific patient groups before most types of surgery, including many procedures that are typically performed on a day-case basis. In the prevailing economic climate, can continued expenditure on tests of questionable value be justified, and is there sufficient evidence to consider abandoning routine pre-operative testing altogether?
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03 Apr 11
Posted in Anesthesia at 13:10 by Laci
By S Kinsella
Anaesthesia 2011;66:243-246
‘There are lies, damned lies, and statistics’. The above comment derives from a statistic, but is it accurate? And if inaccurate, how did this 2010 headline from a respectable newspaper, quoting an original paper in The Lancet, come to be written?
National maternal mortality statistics have been collected in the UK for over 150 years, and the Maternal Death Enquiry (MDE) celebrated its 50th anniversary in 2002. There is a well-deserved pride in the accuracy of the figures, and major efforts are made to count all cases. Thus, for instance, there was a 22% increase in deaths from the 1991–93 to the 1994–96 reports, owing to the application of computerised searches of death certificate data to identify cases that had not initially been linked to pregnancy.
However, the internationally used measure of Maternal Mortality Ratio (MMR) is defined differently. The MMR numerator uses death certificate data, and includes direct and indirect deaths, but not coincidental or late deaths. In the latest report, 155 out of 261 maternal deaths were identified on death certificates, but an additional 106 cases came to the attention of the Centre for Maternal and Child Enquiries (CMACE) via professionals and CMACE regional managers. Furthermore, the denominator used for the MMR is all live births, whereas for the MDE, the denominator is all maternities in the UK. Thus, this report quotes two UK maternal death rates, the maternal mortality rate of 11.4 per 100 000 maternities and the MMR of 6.7 per 100 000 live births – a striking difference.
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Posted in Anesthesia at 13:04 by Laci
The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom
BJOG 2011:118 s1:1–203
In the triennium 2006–2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003–2005 to 4.67 per 100,000 maternities in 2006–2008 (p = 0.02). This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003–2005 to 1.13 deaths in 2006–2008, and sepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirect death; the Indirect maternal mortality rate has not changed significantly since 2003–2005. This Confidential Enquiry identified substandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remain the same as those identified in previous Enquiries. Recommendations for improving care have been developed and are highlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overall UK maternal mortality rate continues to decline.
Our aim is to improve the health of mothers, babies and children by carrying out confidential enquires and related work on a nationwide basis and by widely disseminating our findings and recommendations.
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