Complications and mortality in older surgical patients in Australia and New Zealand (the REASON study): a multicentre, prospective, observational study.

We conducted a prospective study of non-cardiac surgical patients aged 70 years or more in 23 hospitals in Australia and New Zealand. We studied 4158 consecutive patients of whom 2845 (68%) had pre-existing comorbidities. By day 30, 216 (5%) patients had died, and 835 (20%) suffered complications; 390 (9.4%) patients were admitted to the Intensive Care Unit. Pre-operative factors associated with mortality included: increasing age (80-89 years: OR 2.1 (95% CI 1.6-2.8), p < 0.001; 90+ years: OR 4.0 (95% CI 2.6-6.2), p < 0.001); worsening ASA physical status (ASA 3: OR 3.1 (95% CI 1.8-5.5), p < 0.001; ASA 4: OR 12.4 (95% CI 6.9-22.2), p < 0.001); a pre-operative plasma albumin < 30 g.l⁻¹ (OR: 2.5 (95% CI 1.8-3.5), p < 0.001); and non-scheduled surgery (OR 1.8 (95% CI 1.3-2.5), p < 0.001). Complications associated with mortality included: acute renal impairment (OR 3.3 (95% CI 2.1-5.0), p < 0.001); unplanned Intensive Care Unit admission (OR 3.1 (95% CI 1.9-4.9), p < 0.001); and systemic inflammation (OR 2.5 (95% CI 1.7-3.7), p < 0.001). Patient factors often had a stronger association with mortality than the type of surgery. Strategies are needed to reduce complications and mortality in older surgical patients.

The effect of critical care outreach on postoperative serious adverse events.

We proposed that critical care outreach would decrease the incidence of postoperative serious adverse events and so conducted a sequential cohort study with a surveillance-only phase (baseline) followed by an intervention phase. We studied high-risk patients in a large Australian hospital. A critical care qualified nurse reviewed patients for the first three days after return to the general wards. During the intervention phase the nurse intervened in patient care where appropriate. We examined the incidence of 11 categories of serious adverse events per 100 patients during the first three days on the general wards during the surveillance and intervention phases. The surveillance phase had 319 patients and the intervention phase 345 patients. In a subgroup analysis, there were four myocardial infarctions per 100 patients in the surveillance phase and seven per 100 patients during the intervention phase (95% confidence interval: 1-7 infarctions per 100 patients increase). For the other 10 serious adverse events there were 19 per 100 patients in the surveillance phase and 11 per 100 patients in the intervention phase (95% confidence interval: 4-11 serious adverse events per 100 patients decrease). Outreach may have led to greater detection of myocardial infarctions while reducing the incidence of other serious adverse events.