Bleeding and myocardial damage are the leading cause of death after noncardiac surgery

Major bleeding, myocardial injury and sepsis are the three leading causes of death after noncardiac surgery, accounting for approximately 45% of these deaths, according to the VISION study of vascular events in patients with noncardiac surgery. But deaths are rare and the vast majority occur in the postoperative period, say the investigators.

"Most people tend to believe that it is venous events that kill patients at the time of surgery," said Chief Investigator PJ Devereaux, MD, Ph.D. (Institute for Research on Cancer). population health, Hamilton, Canada). "If you have a pulmonary embolism, it can kill you. But what the research shows dramatically is that, unlike 30 years ago, venous events are very low. Arterial events, bleeding and episodes of sepsis are the cause of many deaths. If we want to reduce surgical mortality over the next decade, that's where we need to focus. "

For the TCTMD, Devereaux said that in recent decades, perioperative care has progressed, including less invasive surgery, improved anesthesia, strengthened interoperative surveillance and greater mobilization after the procedure, but that no major international study has been conducted on the incidence. mortality after modern day surgery. In addition, the patients operated on today are older and have more comorbidities than in the past. For this reason, researchers sought to evaluate the incidence of death after noncardiac surgery, as well as the timing and causes of death.

We have failed patients in postoperative care. P.J. Devereaux

The study, published on July 29, 2019, in CMAJ, includes 40,004 patients aged 45 and over who underwent noncardiac surgery in 28 hospitals in 14 countries between 2007 and 2013. Overall, 19.9% ​​of patients underwent major general surgery, 17.5 % major orthopedic surgery and 12.1% major surgery in urology and gynecology. . Just over one-third underwent a low-risk operation, while 6.6%, 5.9% and 2.9% underwent major vascular surgery, major neurosurgery and major thoracic surgery. General anesthesia was used in 51.9% of the procedures.

While 715 patients (1.8%) died within 30 days of the operation, only five deaths occurred in the operating room. Of the remaining events, 500 patients (69.9%) died after surgery during hospital admission and 210 patients (29.4%) died after their discharge from the hospital but within 30 days.

"People are still waiting impatiently for the surgeon to come to the recovery room to tell the families if their loved one has been able to get surgery," Devereaux said, noting that such concern is even being addressed in patients' homes. movies and on television. "The reality is that surgery is currently the safest period. Of the patients who will die, 99.3% will die after the operating room, which is to the credit of anesthesiologists and surgeons: they made the intraoperative setting extremely safe. We have failed patients in postoperative care. "

Better monitoring and management after surgery

A total of eight complications were independently badociated with death at 30 days, including major bleeding, myocardial injury after noncardiac surgery, sepsis, acute renal injury with dialysis, stroke, venous thromboembolism, congestive heart failure and a new clinically important atrial fibrillation. The three main mortality factors were major bleeding, myocardial injury and sepsis, with the highest risk fractions that can be attributed.

Myocardial injury is largely the result of a mismatch between supply and demand during a surgical procedure, said Devereaux, noting that major operations may trigger procoagulant and other pathways. pro-inflammatory at the origin of thrombotic events. In 2017, VISION investigators reported that elifted in troponin T of high peak sensitivity Rates of (hs-cTnT) were strongly correlated with 30-day mortality and could account for approximately one-quarter of deaths from noncardiac surgery. As myocardial lesions are predominantly asymptomatic, the study suggested that measuring hs-cTnT might be a way to identify patients at risk. In 2018, the same investigators reported data suggesting that use of dabigatran (Pradaxa, Boehringer Ingelheim) in patients with myocardial injury after noncardiac surgery reduced the risk of major arterial and venous complications.

Researchers, led by Devereaux, are currently leading the Study POISE-3, a randomized controlled trial of 10,000 patients whose primary goal is to test tranexamic acid for the prevention of serious organ bleeding, a major and critical risk within 30 days of non-cardiac surgery.

With respect to patient care, Devereaux noted that patients return home sooner after surgery and that, although this is an advantage over an extended stay in the hospital, it is necessary to put in place better surveillance and management strategies as patients move from hospital to hospital. House. For example, after surgery, many patients are treated with badgesics that can mask the symptoms of complications, such as chest pain, but do not receive follow-up 3 or 4 weeks later in the doctor's office.

"Our goal should be that no matter what age or type of comorbidity you have, we can operate safely," Devereaux said. "We should never lose sight of the fact that people undergo surgery for very important reasons. Our goal should be to know how to secure this so that you can get the benefits of surgery and we will do our job to make sure that there are no complications or that there is complications, they are recognized and treated well so that does not become a big problem. That's what I hope.