Long Term Outcomes

Long Term Outcomes

NEW: View the Long Term Outcomes Workshop Report

On September 21-22 APSF convened a selective group of experts from multiple medical specialties-anesthesiology, surgery, cardiology and immunology - and others involved in government and health quality organizations whose activities and policies impact patient safety to discuss long-term outcomes (months to years) after anesthesia and surgery.

This collaborative conference provided the opportunity to examine a variety of issues.  One had to do with surprising - but very preliminary - data regarding post-surgical survival that might affect the lives of tens of thousands of patients each year.  These new data showed an unexpected correlation between the time a person spent at more profound levels of 'brain wave" changes during anesthesia and the likelihood of their dying within the first year after their surgery from causes totally unrelated to the surgery.  These data also prompted speculation that some combination of anesthesia and surgery may trigger a cascade of inflammation in the body that enhances cardiovascular, respiratory, or even cancerous conditions. If such a correlation is confirmed, it prompts the question of how the short-lived event of surgery could result in long-term effects.

The workshop was intended to "connect the dots". Our deliberations allowed for the sharing of often-compartmentalized bodies of knowledge to forge a comprehensive understanding of the myriad factors that might be involved in this puzzle.

As in all scientific matters, there turned out to be more questions than answers regarding these issue.

The group arrived at a number of threads of agreement and observation, which will now serve as the basis for future analysis and action. These include:

1. Historically, surgeons and anesthesiologists have largely felt their actions only have immediate or near-term consequences. Things not directly related to the surgical procedure that occurred "way down the line" (the "long term outcomes") had to do with the patient's underlying medical conditions and were just bad luck. But the group thought it was distinctly possible that there are things that happen during surgery that have lasting effects and may have a long-term impact on how long you live.
2. The group acknowledged that there may in fact be excess mortality over the long-term linked to the process of anesthesia and surgery. But the data are extremely sparse, complicated and have many limitations and pitfalls. The question should be pursued further to find a more solid answer.
3. There should be more studies of large numbers of patients to better identify risk factors for the occurrence of adverse long-term outcomes as well as for short-term complications.
4. Inflammation has been implicated in many disease processes and it is definitely possible that there exists a relationship between inflammation and the long-term outcomes associated with surgery and anesthesia. But much remains to be determined to see if this linkage is present, and if so its strength and what can be done about it.  Studies are needed both on the basic biology of inflammation, and on the specifics of this biology in the setting of anesthesia and surgery.
5. As better data come in about the nature of outcomes after anesthesia and surgery, studies are needed to evaluate the mechanisms, and define possible interventions.  This may happen first in small-scale trials, but ultimately large-scale studies with thousands of patients will be needed.  Even for treatments that have already been looked at to minimize cardiovascular complications after surgery for high-risk patients with known heart disease, we had a spirited debate about whether the studies done to date are just too small to be sure whether treating large numbers of patients is justified.

This convergence of so many specialties focusing intensely on critical questions surrounding surgery, may, we hope, produce eventual revelations about how we care for a patient, before, during and long-after surgery.  The new mass of insight we generated together could well affect how we practice and relate to each other in the future.

Participants

• Jeffrey B. Cooper, PhD
• David M. Gaba, MD
• Terri G. Monk, MD
• Shukri F. Khuri, MD
• Robert S. Lagasse, MD
• Lee A. Fleisher, MD
• Steffen E. Meiler, MD
• C. Alvin Head, MD
• Jerod M. Loeb, PhD
• David R. Hunt, MD
• Robert K. Stoelting, MD
• Elliott Bennett-Guerrero, MD
• Marcel E. Durieux, MD
• R. Scott Jones, MD
• Thomas R. Russell, MD
• Simon Gelman, MD
• Donald R. Stanski, MD
• John G. Wade
• Karl Hammermeister, MD
• John Steiner, MD
• William G. Henderson, PhD
• Daniel I. Sessler, MD
• Charles N. Serhan, MD
• Michael A. E. Ramsay, MD
• George A Schapiro
• Robert C. Morell, MD
• Michael J. Bishop, MD
• Andrew Lichtman, MD
• Arno Kari, MD
  

David M. Gaba, M.D.

Secretary, Anesthesia Patient Safety Foundation
Long Term Outcomes Workshop Principal Investigator