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Surgery… a risky business

Here, we explore the concept of risk and how we communicate this to our patients
NCEPOD Report: Knowing the risk. (Image credit: NCEPOD, source)

So, what do we know so far about perioperative risk?

We know that:

  • Approximately 1 in 5 patients will sustain a complication in the perioperative period. Even major complication rates must be as high as 15%
  • We know that if a patient sustains a major complication in the perioperative period, the chance of dying, or living with life-changing complications, is significantly increased.
  • The gold standard is, firstly, preventing complications before they happen, by anticipating which patients are high-risk for these events and acting upon it.
  • Secondly, when such events occur (which inevitably in some they do), it is important to identify and respond promptly to problems before they become life threatening. In this work of 2006 by Dr Rupert Pearse, it can be seen that postoperative ‘failure to rescue’ (which is failure or delay in recognising and responding to a complication) significantly increases patient’s morbidity and mortality rate.
  • The key is to PREVENT rather than to REACT.
Mortality rates for general surgical patients. (Image credit: 2006 Pearse et al., licensee BioMed Central Ltd, source and license)

In the UK, while only 12.5% of surgical cases are considered ‘high-risk’ (by definition, high-risk is a mortality >5%), they shockingly account for a disproportionally high post-operative death rate.

Listen to Dr Rob Stephens, a perioperative clinician from UCLH, – talk about this graph.

If you’d like to read more on postoperative morbidity and mortality (M&M), click to open the articles by Moonesinghe et al 2014 and by Pearse et al 2006.
By now you may be thinking, “let’s just rewind a minute…”. We talk a lot about patients being ‘high-risk’, but how is risk defined and assessed? And indeed, risk of what? Yes, let’s not get too far into this chapter without understanding this important point better.

Defining Risk

Risk is an incredibly difficult topic to squeeze into a small section, but let’s try to highlight some important points. In its simplest form, risk is the chance of something bad happening! (We don’t say what’s the risk of me winning £1,000, but we do say, what’s the risk of it raining today?) It has uncertainty attached “it may happen, it may not”.
And risk means different things to different people – “I’m not surprised he is planning to jump out of a plane without a parachute – he’s always been a bit of a risk taker, unlike his mum, she’s afraid of her own shadow” (sorry for the poor example) – but you get the idea, I’m sure – we all have a different perception of risk!
The amount of risk (of major complications or even death) a person is willing to accept most often depends on the individual and is likely to be influenced by the circumstances. This latter point is often forgotten in healthcare – individuals change their risk perception and, therefore, their behaviour based on the situation in which they find themselves. A person may not accept the risk of being given an anaesthetic for the removal of a small lump on their back which is painless and benign, but accept any risk if the lump is associated with a cancer. These are the real health issues we ask patients to grapple with each day.
Healthcare professionals’ understanding of risk. (Photo credit: Pikwizard, open access license)
We, as healthcare professionals, maybe – are at times poor at conveying the concept of risk to our patients, yet we expect our patients to be good at it! We often discuss the risk of patient’s treatment or surgery with them in clinic, when they have just received the shocking news that they have a cancer. We give them options for treatment with a bewildering set of percentage risks attached and they are unable to take on any meaningful information, never mind weigh up the risks involved.
For example:
“the risk of permanent nerve damage with an epidural is X, the chance of needing a blood transfusion is Y and the chance of being dead in 3 months if you don’t have surgery is Z…“
Indeed, it can be as blunt and bewildering as that!

Another example:

When a patient was told he had a 1 in 4 chance of impotence after cancer surgery on his prostate, he took a moment to reflect and said: “Doctor, I am willing to accept that one time in four, I will not be able to ejaculate during sexual intercourse”. Of course, what the surgeon meant here was, that this patient had a 1 in 4 chance of never regaining sexual function after surgery, but the patient had clearly misunderstood.
It always helps to ask your patient what they understand about what they have been told – you may be quite surprised!

So that is a lot to digest, let’s take it a little further. We should begin a discussion about risk by asking “risk of what”?

As healthcare workers, we must inform a patient of all common risks which may result in harm to the patient. A surgeon may say, “there is a chance I could damage your eyesight during this surgery and the risk of permanent blindness is around 10%”. That’s good practice, but it would better to talk in terms of proportions. Instead of saying “10%”, you could say, “there is a 1 in 10 chance”, or “1 time out of 10”, etc.
You could even use an image to demonstrate the risk – sometimes patients find this easier to visualise. For example, the image below shows 2 in 5 people, 2/5 patients which to us might mean 40%.” Your patient may find this easier to understand than you saying, “you have a 40% risk of developing a complication”.
Image to demonstrate risk. (Image credit: Dr Ellie Powell)
When we are in the POCU/Critical care/Anaesthesia environment and we talk about ‘risk’ or ‘high-risk’, it is usually associated with the risk of death or major complication in the perioperative period.
Below is a graphic about risk of death in the perioperative period, it is important to note the risk is termed low, moderate and high.
Ideally, we could plot where our patient appears on a risk curve – read on. (Image credit: C Britton)
Discussion question: What do you think of the risk thresholds of 1%, 1-5% and 5% or greater to describe low, moderate and high risk – should the threshold be set higher or lower in your opinion? Use the discussion forum box below to jot down your thoughts as see how these compare with your peers.
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Road to Recovery: Mastering Postoperative Care of the High-Risk Patient

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