David Story1,2,3

1. Austin Health,Melbourne,Australia
2. University of Melbourne,Melbourne,Australia
3. Trials Group,Australian and New Zealand College of Anaesthetists

In Perioperative Medicine research, relatively little work has been done on postoperative care beyond the important areas of pain and nausea management.To examine the extent of the problem we conducted a three-centre study in Melbourne to examine postoperative complications and mortality in older patients having non-cardiac surgery (1). The overall 30-day mortality was 6%.Nineteen percent of patients had at least one complication at a rate of 31 complications per 100 patients.The independent preoperative risk factors for mortality were increasing ASA status, increasing age and decreased plasma albumin.The independent postoperative factors were unplanned ICU admission, sepsis, and renal impairment.Only thoracic surgery was an independent predictor of mortality.These findings of significant mortality and morbidity are consistent with data from the United States and Europe. It is likely that data from hospitals across Australia and New Zealand would be similar. Using data from this Melbourne study1 we have developed a Perioperative Mortality Score that combines the three preoperative independent risk factors with the three postoperative factors.This score may assist in perioperative risk assessment and underline the combined risk of preoperative morbidity and postoperative complications.This score is yet to be validated.

In a survey of Fellows, the ANZCA Perioperative Medicine Taskforce found that there was enthusiasm for increasing the role of anaesthetists in postoperative particularly in the first 24 postoperative hours.A smaller group of anaesthetists was interested in an active role in postoperative care beyond the first 24 hours.One model of perioperative medicine is the UK concept of critical care outreach by groups such as the acute pain service2. We conducted a pilot study of critical care outreach to the general surgical wards3. Using before-and-after methodology, with high-risk patients, we found that combining critical care outreach with the acute pain service decreased postoperative complications from 21 per 100 patients to 16 per 100 patients.

The future of Perioperative Medicine research is collaborative multicentre studies.This model of critical care outreach coupled with the acute pain service (a more formal version of what many do anyway) could be tested in a multicentre study in Australia and New Zealand.The ANZCA Trials Group4 provides a mechanism to undertake these studies by co-ordinating centres and managing data.

1. McNicol L, Story DA, Leslie K,Myles PS, Fink M, Shelton AC, Clavisi O, et al. Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals.Med J Aust 2007;186:447-452.
2. Counsell DJ.The acute pain service: a model for outreach critical care. Anaesthesia 2001;56:925-926.
3. Story DA, Shelton AC, Poustie SJ, Colin-Thome NJ,McIntyre RE, McNicol PL. Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events. Anaesthesia 2006;61:24-28.
4. Story DA,Myles PS. Large multicentre trials in anaesthesia: the ANZCA Clinical Trials Group.Anaesth Intensive Care 2005;33:301-302.