Perioperative Mortality - Epidemiology

Epidemiology

In many countries, statistics are kept by mandatory reporting of perioperative mortality. These may then be used 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. 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.

Most perioperative mortality is attributable to complications from the operation (such as bleeding, sepsis, and failure of vital organs) or pre-existing medical conditions. Mortality directly related to anesthetic management is less common, and may include such causes as pulmonary aspiration of gastric contents, asphyxiation and anaphylaxis. 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.

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 0.64%. 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. This committee was tasked with determining and reducing the causes of peri-anesthetic morbidity and mortality. An outgrowth of this committee, the Anesthesia Patient Safety Foundation was created in 1985 as an independent, nonprofit corporation with the vision that "that no patient shall be harmed by anesthesia".

The current mortality attributable to the management of general anesthesia is controversial. Most current estimates of perioperative mortality range from 1 death in 53 anesthetics to 1 in 5,417 anesthetics. The incidence of perioperative mortality that is directly attributable to anesthesia ranges from 1 in 6,795 to 1 in 200,200 anesthetics. 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. It is suggested that these wide ranges may be caused by differences in operational definitions and reporting sources.

The largest and most recent 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%.

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.