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Oliver CM, Wagstaff D, Bedford J, Moonesinghe SR. Systematic development and validation of a predictive model for major postoperative complications in the Peri-operative Quality Improvement Project (PQIP) dataset. Anaesthesia 2024; 79:389-398. [PMID: 38369686 DOI: 10.1111/anae.16248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/20/2024]
Abstract
Complications are common following major surgery and are associated with increased use of healthcare resources, disability and mortality. Continued reliance on mortality estimates risks harming patients and health systems, but existing tools for predicting complications are unwieldy and inaccurate. We aimed to systematically construct an accurate pre-operative model for predicting major postoperative complications; compare its performance against existing tools; and identify sources of inaccuracy in predictive models more generally. Complete patient records from the UK Peri-operative Quality Improvement Programme dataset were analysed. Major complications were defined as Clavien-Dindo grade ≥ 2 for novel models. In a 75% train:25% test split cohort, we developed a pipeline of increasingly complex models, prioritising pre-operative predictors using Least Absolute Shrinkage and Selection Operators (LASSO). We defined the best model in the training cohort by the lowest Akaike's information criterion, balancing accuracy and simplicity. Of the 24,983 included cases, 6389 (25.6%) patients developed major complications. Potentially modifiable risk factors (pain, reduced mobility and smoking) were retained. The best-performing model was highly complex, specifying individual hospital complication rates and 11 patient covariates. This novel model showed substantially superior performance over generic and specific prediction models and scores. We have developed a novel complications model with good internal accuracy, re-prioritised predictor variables and identified hospital-level variation as an important, but overlooked, source of inaccuracy in existing tools. The complexity of the best-performing model does, however, highlight the need for a step-change in clinical risk prediction to automate the delivery of informative risk estimates in clinical systems.
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Affiliation(s)
- C M Oliver
- Centre for Peri-operative Medicine, University College London, UK
- Department of Anaesthesia and Peri-operative Medicine, UCL Hospitals, London, UK
| | - D Wagstaff
- Department of Anaesthesia and Peri-operative Medicine, UCL Hospitals, London, UK
- Centre for Peri-operative Medicine, University College London, UK
| | - J Bedford
- Department of Anaesthesia and Peri-operative Medicine, UCL Hospitals, London, UK
- Centre for Peri-operative Medicine, University College London, UK
| | - S R Moonesinghe
- Department of Anaesthesia and Peri-operative Medicine, UCL Hospitals, London, UK
- Centre for Peri-operative Medicine, University College London, UK
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2
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Eugene N, Kuryba A, Martin P, Oliver CM, Berry M, Moppett IK, Johnston C, Hare S, Lockwood S, Murray D, Walker K, Cromwell DA. Development and validation of a prognostic model for death 30 days after adult emergency laparotomy. Anaesthesia 2023; 78:1262-1271. [PMID: 37450350 DOI: 10.1111/anae.16096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.
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Affiliation(s)
- N Eugene
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - P Martin
- Department of Applied Health Research, University College London, London, UK
| | - C M Oliver
- UCL Division of Surgery and Interventional Science, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Berry
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - I K Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Repair, University of Nottingham, Nottingham, UK
| | - C Johnston
- Department of Anaesthesia, St George's Hospital, London, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - D Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - K Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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3
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Armstrong RA, Fayaz A, Manning GLP, Moonesinghe SR, Oliver CM. Predicting severe pain after major surgery: a secondary analysis of the Peri-operative Quality Improvement Programme (PQIP) dataset. Anaesthesia 2023; 78:840-852. [PMID: 36862937 DOI: 10.1111/anae.15984] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
Acute postoperative pain is common, distressing and associated with increased morbidity. Targeted interventions can prevent its development. We aimed to develop and internally validate a predictive tool to pre-emptively identify patients at risk of severe pain following major surgery. We analysed data from the UK Peri-operative Quality Improvement Programme to develop and validate a logistic regression model to predict severe pain on the first postoperative day using pre-operative variables. Secondary analyses included the use of peri-operative variables. Data from 17,079 patients undergoing major surgery were included. Severe pain was reported by 3140 (18.4%) patients; this was more prevalent in females, patients with cancer or insulin-dependent diabetes, current smokers and in those taking baseline opioids. Our final model included 25 pre-operative predictors with an optimism-corrected c-statistic of 0.66 and good calibration (mean absolute error 0.005, p = 0.35). Decision-curve analysis suggested an optimal cut-off value of 20-30% predicted risk to identify high-risk individuals. Potentially modifiable risk factors included smoking status and patient-reported measures of psychological well-being. Non-modifiable factors included demographic and surgical factors. Discrimination was improved by the addition of intra-operative variables (likelihood ratio χ2 496.5, p < 0.001) but not by the addition of baseline opioid data. On internal validation, our pre-operative prediction model was well calibrated but discrimination was moderate. Performance was improved with the inclusion of peri-operative covariates suggesting pre-operative variables alone are not sufficient to adequately predict postoperative pain.
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Affiliation(s)
- R A Armstrong
- Department of Population Health Sciences, University of Bristol, Bristol, UK
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - A Fayaz
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospital NHS Foundation Trust, London, UK
- Central London School of Anaesthesia, London, UK
| | | | - S R Moonesinghe
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospital NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - C M Oliver
- Department of Anaesthesia and Peri-operative Medicine, University College London Hospital NHS Foundation Trust, London, UK
- Centre for Peri-operative Medicine, Research Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, UK
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4
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Bedford J, Martin P, Crowe S, Wagstaff D, Santos C, Singleton G, Baumber R, Vindrola‐Padros C, Vohra R, Swart M, Oliver CM, Dorey J, Leeman I, Moonesinghe SR. Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model. Anaesthesia 2022; 77:1356-1367. [PMID: 36130834 PMCID: PMC9826419 DOI: 10.1111/anae.15858] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 01/11/2023]
Abstract
Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.
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Affiliation(s)
- J. Bedford
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - P. Martin
- Department of Applied Health ResearchUniversity College LondonUK
| | - S. Crowe
- Clinical Operational Research UnitUniversity College LondonUK
| | - D. Wagstaff
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - C. Santos
- Health Services Research Centre, National Institute for Academic AnaesthesiaRoyal College of AnaesthetistsLondonUK
| | - G. Singleton
- Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Baumber
- Department of AnaesthesiaRoyal National Orthopaedic Hospital NHS TrustLondonUK
| | - C. Vindrola‐Padros
- Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Vohra
- Department of SurgeryNottingham University Hospitals NHS TrustNottinghamUK
| | - M. Swart
- Department of AnaesthesiaTorbay and South Devon NHS TrustDevonUK
| | - C. M. Oliver
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - J. Dorey
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - I. Leeman
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - S. R. Moonesinghe
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
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5
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Boyd-Carson H, Shah A, Sugavanam A, Reid J, Stanworth SJ, Oliver CM. The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia 2020; 75:904-912. [PMID: 32315080 DOI: 10.1111/anae.15021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 01/28/2023]
Abstract
Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as 'mild' 129-110 g.l-1; 'moderate' 109-80 g.l-1; or 'severe' ≤ 79 g.l-1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09-1.21); moderate, 1.44 (1.36-1.52); and severe, 1.42 (1.24-1.63), p < 0.001 for all; mild, 1.07 (1.00-1.12), p = 0.030; moderate, 1.30 (1.21-1.38), p < 0.001; and severe, 1.22 (1.05-1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01-1.62); moderate, 3.41 (3.04-3.77); severe, 2.80 (1.83-3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06-1.21), p < 0.001; and severe 1.23 (1.06-1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - A Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Department of Anaesthesia, Danube Hospital, Vienna, Austria
| | - J Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C M Oliver
- Royal College of Anaesthetists, London, UK.,UCL Division of Surgery and Interventional Science, London, UK
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6
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Brinkler R, Edwards Z, Abid S, Oliver CM, Lo Q, Stewart A, Abayalingam M, Abid S, Afzal S, Aly H, Kasi Anandan T, Ariyanayagam R, Armstrong S, Ashiru G, Barrett S, Baytug B, Black R, Bowman S, Brayshaw S, Brinkler R, Brocklesby S, Cain J, Casey P, Chambers K, Chan C, Chapman R, Cheah C, Cheesman K, Cohen J, Cole A, Combeer A, Cowie V, Dabrowicz A, Desai N, Donovan C, Doraiswami M, El Amin O, Edwards Z, Ellimah T, Evans M, Fawcett E, Fletcher L, Forman E, Fulton L, Gardener K, George R, Gorur P, Gowripalann T, Greenslade T, Hamlyn L, Hawkins R, Herrmann R, Hilton J, Hutchinson J, Kelliher L, Kelly J, King K, Lim S, Mahinthan V, Mahmood N, Major J, Masood N, Matthews L, McHugh B, Milne S, Miltsios K, Monks D, Moores R, Nicklin A, Panesar N, Papageorgiou C, Patel R, Pathmabaskaran S, Perinpanayagam J, Peake M, Pritchard N, Powell K, Qureshi J, Redington K, Richards N, Rintoul E, Robson M, Routley C, Salota V, Samuel M, Sapsford M, Schwartz N, Sellers C, Shareiff I, Sharifi L, Shonfeld A, Stewart A, Story H, Sudunagunta S, Suppiah P, Tamilselvan P, Thompson H, Turner W, Uzkalniene V, Veglio E, Webb A, Waiting J, Wedgewood T, Westcott L, Wickham A, Wilson L, Wimble K, Wong R, Wong S, Wray S, Zafar S. A survey of antenatal and peripartum provision of information on analgesia and anaesthesia. Anaesthesia 2019; 74:1101-1111. [DOI: 10.1111/anae.14745] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 11/30/2022]
Affiliation(s)
- R. Brinkler
- Department of Anaesthesia University College Hospital LondonUK
| | - Z. Edwards
- Department of Anaesthesia Queen Charlotte's and Chelsea Hospital London UK
| | - S. Abid
- Department of Anaesthesia Queen Charlotte's and Chelsea Hospital London UK
| | - C. M. Oliver
- Division of Surgery and Interventional Science University College London UK
| | - Q. Lo
- Department of Anaesthesia Queen Charlotte's and Chelsea Hospital London UK
| | - A. Stewart
- Department of Anaesthesia University College Hospital LondonUK
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7
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Boyd-Carson H, Doleman B, Herrod PJJ, Anderson ID, Williams JP, Lund JN, Tierney GM, Murray D, Hare S, Lockwood S, Oliver CM, Spurling LJ, Poulton T, Johnston C, Cromwell D, Kuryba A, Martin P, Lourtie J, Goodwin J, Mooesinghe R, Eugene N, Catrin-Cook S, Anderson I. Association between surgeon special interest and mortality after emergency laparotomy. Br J Surg 2019; 106:940-948. [DOI: 10.1002/bjs.11146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/07/2019] [Accepted: 01/31/2019] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy.
Methods
Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes.
Results
A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12).
Conclusion
Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - P J J Herrod
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - I D Anderson
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
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8
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Oliver CM. Risk tools for emergency laparotomy. Br J Anaesth 2019; 117:668. [PMID: 27799184 DOI: 10.1093/bja/aew346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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9
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Lacey J, Khan N, Oliver CM. Perioperative risk. Br J Hosp Med (Lond) 2017; 78:616-621. [PMID: 29111800 DOI: 10.12968/hmed.2017.78.11.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The high-risk surgical patient is a growing challenge to modern health care. This cohort, although comprising only 10-15% of surgical procedures, accounts for approximately 80% of postoperative deaths and suffers a high rate of postoperative morbidity. Developing robust systems to help identify and better manage this patient group should be a priority. Risk stratification has become a valuable clinical tool for shared decision-making and the development of individualized care plans. Methods for stratifying individual risk include assessment tools, measures of functional capacity and plasma biomarker assays. Routine evaluation of perioperative risk is central to the delivery of high quality, appropriate surgical care.
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Affiliation(s)
- Jrn Lacey
- Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - N Khan
- Post-CCT Fellow in Perioperative Medicine and Anaesthesia, University College London Hospitals NHS Trust, London
| | - C M Oliver
- NIHR Clinical Lecturer in Anaesthesia, Division of Surgery and Interventional Science, University College London, London WC1E 6AU
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10
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Oliver CM, Phillips S, Saibaba RJ. Anaesthetic management of a patient with critical respiratory compromise resulting from procedure-induced broncho-oesophageal fistulation (BOF). J Clin Anesth 2017; 42:10-11. [PMID: 28962939 DOI: 10.1016/j.jclinane.2017.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/08/2017] [Accepted: 07/15/2017] [Indexed: 11/15/2022]
Affiliation(s)
- C M Oliver
- Division of Surgery And Interventional Science, University College London, 74 Huntley Street, London WC1E 6AU, United Kingdom.
| | - S Phillips
- Queen Victoria Hospital, Holtye Road, East Grinstead RH19 3DZ, United Kingdom
| | - R J Saibaba
- Croydon University Hospital, 530 London Road, Croydon CR7 7YE, United Kingdom
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11
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Oliver CM, Walker E, Giannaris S, Grocott MPW, Moonesinghe SR. Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review. Br J Anaesth 2015; 115:849-60. [PMID: 26537629 DOI: 10.1093/bja/aev350] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.
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Affiliation(s)
- C M Oliver
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - E Walker
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
| | - S Giannaris
- Centre for Anaesthesia, University College London, London, UK
| | - M P W Grocott
- National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences Faculty of Medicine, University of Southampton, Southampton, UK University Hospital Southampton NHS Foundation Trust/University of Southampton, NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - S R Moonesinghe
- UCL/UCLH Surgical Outcome Research Centre (SOuRCe), 3rd Floor, Maples Link Corridor, University College Hospital, 235 Euston Road, London NW1 2BU, UK National Institute of Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK Centre for Anaesthesia, University College London, London, UK
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13
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Abstract
AIM This study was undertaken to examine whether a correlation exists between apical dye penetration and the clinical performance of root fillings. METHODOLOGY Apical dye penetration into 116 roots of human teeth that had been root-filled at least 6 months prior to extraction was tested in vitro using a vacuum technique and by measuring the length of dye penetration. Endodontic treatment was classified as clinically successful or unsuccessful and results for these groups were compared using analysis of variance and the Student's t-test. Positive and negative controls were used to test the experimental system. RESULTS All controls performed as expected. Dye penetrated significantly further in unsuccessful cases although the raw data suggested little difference. Overall, dye penetrated 99.5% of the specimens, indicating that the presence of dye in the canal is a poor indicator of whether the technique or material will succeed. However, the extent of dye penetration may be related to the clinical outcome. CONCLUSIONS Clinically placed root canal fillings do not provide an apical seal that prevents fluid penetration. The outcome of treatment cannot be predicted from the results of apical dye leakage studies.
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Affiliation(s)
- C M Oliver
- School of Dentistry, University of Western Australia, Perth Australia
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14
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Abstract
The purpose of this in vitro study was to compare both apical and coronal dye penetration when Ketac-Endo and AH-26 sealers were used with laterally condensed gutta percha. Crowns were removed from 28 teeth and the root canals were biomechanically prepared. The teeth were divided into two groups of 12-teeth each and a control group of 4 teeth. Root canals in the two experimental groups were filled with laterally condensed gutta percha and either Ketac-Endo or AH-26 sealer. The Ketac-Endo group had the coronal 3 mm of gutta percha and sealer removed and the resultant cavity was filled with Ketac-Endo alone. After the sealers had set, the root surfaces were coated with nail varnish except at the apex and at the coronal end. Positive controls had no root fillings and were coated with nail varnish in the same manner while the negative controls were sealed apically and coronally with Cavit prior to sealing the entire external root surface with nail varnish. Specimens were placed in 2% methylene blue dye in a vacuum of 660 mm of mercury for five minutes and then left immersed for a further two days. The roots were vertically sectioned to determine the following mean levels of dye penetration: Ketac-Endo, 1.08 mm apically and 6.29 mm coronally; AH-26, 0.75 mm apically and 6.67 mm coronally. Positive controls had total leakage and negative controls had no leakage. This study demonstrated that the apical and coronal seals obtained with Ketac-Endo and AH-26 were not significantly different although the apical seal obtained with each material was significantly better than the corresponding coronal seal.
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Affiliation(s)
- C M Oliver
- School of Dentistry, University of Western Australia
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15
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Oliver CM. Driving and dementia. N Z Med J 1991; 104:288-9. [PMID: 1852330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- C M Oliver
- Psychogeriatric Service, Sunnyside Hospital, Christchurch
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16
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Abstract
This study was conducted to determine the effect of entrapped air on the ability of methylene blue dye to penetrate known and measurable voids. Thirty six capillary tubes were sealed at one end and had standardized voids created within the lumen. Three equal groups of 12 test specimens and 4 controls were subjected to dye penetration by the methods of passive immersion for 7 days, centrifuging at 3,000 rpm for 5 minutes and immersion in a vacuum of 26 mm of mercury for 5 minutes. Measurement of linear dye penetration was made by removing shavings from the sealed end until dye could be observed. Negative controls showed no dye penetration and positive controls showed complete penetration. The vacuum method showed 100% penetration in all cases, while centrifuging had a mean of 91.7 /+ 8.7% penetration and passive immersion had a mean of 20.7 +/- 5.4% penetration. This study demonstrates that passive dye leakage studies are unreliable and very variable. The vacuum method whereby all entrapped air is removed is the most reliable method for dye penetration studies.
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Affiliation(s)
- C M Oliver
- Division of Restorative Dentistry, Dental School, University of Western Australia, Perth
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17
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Abstract
Leboyer describes a method of handling babies at birth designed to decrease initial stimulation and lessen trauma for the infant. Twenty clinic patients were delivered using a modification of this method. They were compared to 17 control patients delivered in the customary manner. Significant differences were noted between the two groups in five of 18 neonate behaviors observed in the delivery room. Among control subjects there was significantly more time spent with hand muscles tense during the first ten minutes after birth; more trembling, shuddering, and blinking during the first 15 minutes after deliver; and more trembling and shuddering overall. Experimental subjects spent significantly more time with hand muscles relaxed during the first ten minutes after birth and more time with open eyes overall. Results of this study indicate the Leboyer method is safe for mother and infant and promotes infant relaxation in the delivery room.
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