Postoperative Complications: Occupational Hazard or Avoidable?

By Andy Mears, CEO Deltex Medical Ltd.

Postoperative complications; a term that encompasses a variety of undesirable events that can and do occur after surgery. These ‘events’ are often considered random, unavoidable things “that just happen” as a by-product of the operation. In this article, we observe that postoperative complications are expensive, inefficient, and detrimental for patients. Furthermore, far from being occupational hazards, we’ll make the case that employing a clinically validated technology can make them largely avoidable.

Patient Expectations: Everything Will Be Fine, Right?

Most people heading into hospital for major surgery will naturally feel a degree of trepidation. Yet the vast majority will happily sign their consent forms, presuming everything will be fine. Indeed, all but those patients considered at higher risk and undergoing riskier surgery will be expecting to follow a predetermined pathway of events. From start to finish, their care is timetabled, planned and set in stone. Once they wake up from surgery they anticipate their recovery, care, discharge, and recuperation will be standardised, normal, predictable, and ultimately successful.

Surprisingly however, the clinical evidence does not support these expectations.

Let’s put some numbers on it. There are roughly 300 million anaesthesia procedures performed annually worldwide¹. Of these, approximately 10% are high-risk patients. For the purposes of this piece, let’s set them aside (even though complications are arguably even more consequential in these cases).

Turning to medium-risk surgery, which constitutes about 40% of total surgical procedures, here’s the first striking fact: Nearly 30% of medium-risk surgical patients experience a postoperative complication². That’s about 36 million incidences!

Common Postoperative Complications³

• Nausea and vomiting
• Acute Kidney Injury (AKI)
• Acute Respiratory Distress Syndrome (ARDS)
• Surgical Site Infection (SSI)
• Anastomotic Breakdown
• Pneumonia.

Postoperative Complications: Expensive, Inefficient, and Harmful for Patients

To call any complication “minor” is often to underplay things. Some conditions listed as minor can be extremely unpleasant for the patient and may even have a long-term impact on life expectancy⁴. Furthermore, they are highly likely to require additional treatment and prolonged hospital stays. With the ever-present and indeed growing need for cost reduction and efficient bed occupancy, this is another undesirable consequence of a postoperative complication. In fact, decreasing the ability of hospitals to optimise capacity and increasing costs are the polar opposites of what healthcare providers around the world require.

Are Healthcare Providers Really Confronting the “Elephant in the Room?“

Attributing the root causes of these complications can be difficult, as they don’t necessarily relate to something going wrong during the procedure. Indeed, even acknowledging that a patient is suffering a postoperative complication is highly subjective. Separating a “complication” from the array of outcomes that result from the stress of surgery on the human body is an inexact science.

Serious or not, postoperative complications usually require additional therapy and extended hospital stays. On this basis, one might think they’d attract rather more attention. So why does this important subject remain in the shadows? We can offer three potential explanations:

1. The inherent variability and unpredictability of postoperative complications: It’s hard to prepare for an unintended consequence (although we’ll dismantle this argument later).

2. “Ownership” of the specific complication is often unclear: Whose fault is it, if anyone’s? The surgeon’s, the anaesthetist’s, the recovery protocol’s, or the patient’s?

3. Time: Many of these unwanted events take place hours or even days after the procedure, meaning a cause-and-effect relationship may not be obvious. Additionally, joining the dots between a kidney injury or deep wound infection and what was done in the operating theatre is likely to be neither popular nor easy.

Can We Avoid Postoperative Complications?

The starting point is recognising that outcomes can be improved if the patient’s condition is “optimised” throughout the perioperative period. Enhanced Recovery After Surgery (ERAS) protocols have become standardised pathways to optimal organ function, tissue healing, and reduced stress response. ERAS is an acknowledgement that patient condition during the perioperative period is a good predictor of postoperative outcome.

Optimising Perfusion Helps Optimise Outcomes

A deeper look into the data reveals that roughly three-quarters of low to moderate-risk surgical patients have haemodynamic instability during the perioperative period. This is a potentially complex subject, but simple in principle. Organs require oxygen, and blood delivers oxygen to organs and tissues—this is known as perfusion. Reduced blood volume (hypovolaemia) adversely affects perfusion. This in turn means that optimising blood volume optimises perfusion. Optimising perfusion wipes out a large slice of those complications of haemodynamic origin.

There are multiple reasons why, during surgery, a patient may become hypovolaemic, which is why haemodynamic monitoring is vital. It’s not just about administering more fluid; it’s about getting it right – hitting that sweet spot. This optimal fluid state gives the patient the best chance of maintaining oxygen delivery to their organs and tissues, enabling quicker and better tissue repair. Wounds heal better and are less likely to become infected, anastomoses are less likely to break down, kidneys are less stressed, respiratory systems work better, and so on.

TrueVue with ODM: A Proven Solution

The good news is that clinicians have the wherewithal to optimise the patient’s haemodynamic status. Indeed, there’s a burgeoning industry in devices claiming to do just this. One such system has been quietly, but successfully helping anaesthetists for the best part of 30 years, uniquely supported by 24 randomised controlled studies.

Oesophageal Doppler Monitoring (ODM) goes right to the heart of the matter. The clinician inserts a probe into the anaesthetised patient’s oesophagus, a procedure that sounds burdensome but is surprisingly straightforward in experienced hands. By carefully orienting the probe tip, the clinician gains a Doppler ultrasound signal from the blood flowing out of the heart and down the descending aorta. This translates into real-time stroke volume and cardiac output data. As such it provides a unique window into the patient’s haemodynamic status. 

A combination of blood flow and blood pressure tells the anaesthetist whether the patient needs more fluid to remain in that “sweet spot” of optimal perfusion. It’s noteworthy that this is a small target and requires utmost accuracy to be meaningful.

Monitoring the Impact of Vasoactive Drugs

ODM provides immediate feedback on the impact of administering vasoactive drugs. Vasopressors and inotropes are commonly used to optimise perfusion by constricting blood vessels or increasing heart contractility. Being able to see the haemodynamic impact of these drugs in real-time offers clinicians another vital window into the patient’s status and a guide for safe intervention.

Following the Evidence – Postoperative complications

The clinical evidence supporting oesophageal Doppler monitoring is unequivocal. Study after study confirms that using the system significantly reduces the incidence of complications of haemodynamic origin. For instance, the FEDORA RCT⁵ of 450 patients demonstrated that the number of patients suffering at least one complication was halved, with other reductions as shown in the table below.

Moreover, there were statistically significant reductions of between 75% and 100% in specific major complications, including acute kidney injury (AKI), acute pulmonary oedema, respiratory distress syndrome, pneumonia, and surgical site infection. Furthermore, hospital length of stay was shorter by an average of two days when compared to the control group.

Remembering that three-quarters of 36 million people globally suffer complications of haemodynamic origin, any reduction is welcome. If we could reduce haemodynamic complications by even half, that’s a very big number and a significant impact on the provision of surgical solutions.

In Conclusion

In this article, we’ve:

• Quantified the incidence of postoperative complications in medium-risk surgical patients—36 million per year, of which 27 million are attributed to being of haemodynamic origin.
• Established that many of these complications are costly, inefficient, and negatively impactful for patients.
• Discussed why postoperative complications are not headline news.
• Provided evidence to demonstrate that many of the more serious complications are “avoidable.”
• Summarised the evidence that monitoring with Deltex Medical’s TrueVue ODM system is the only proven (uniquely 24 RCTs) way to reduce postoperative complications associated with haemodynamic instability.

Postoperative complications may still be the “elephant in the room.” For the reasons we’ve put forward, they’ve remained largely under the radar. Yet, while it may not look like an obvious “win,” investing time into their avoidance demonstrably reduces costs, improves the use of precious resources, and enhances outcomes for patients. The unequivocal point here is that if you can control the haemodynamics, you really should control the haemodynamics. In new TrueVue with ODM, Deltex has delivered a system that is accurate, real-time and easy to operate.

References

1. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development – 

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60160-X/fulltext

2. Dharap SB, Barbaniya P, Navgale S. Incidence and Risk Factors of Postoperative Complications in General Surgery Patients. Cureus. 2022 Nov 1;14(11):e30975

https://pubmed.ncbi.nlm.nih.gov/36465229/

3. Classification of Surgical Complications – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1360123/
4. Khuri, S.F., et al., Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg, 2005. 242(3): p. 326-41; discussion 341-https://pubmed.ncbi.nlm.nih.gov/16135919/
5. JM Calvo-Veccino et al: Effect of goal directed haemodynamic therapy on post-operative complications in low-moderate risk surgical patients: a multi-centre randomised clinical trial (FEDORA RCT)

https://www.bjanaesthesia.org/article/S0007-0912(17)54207-5/fulltext