Complications: an anaesthetist's rather than a surgeon's notes (with apologies to Atul Gwande).

Abstract

Eight years ago, we identified a gap in the anaesthetic literature, and edited a book on anaesthetic and peri-operative complications 1. The topics covered generated sufficient interest that we were invited to organise a seminar on peri-operative complications at the Association of Anaesthetists of Great Britain and Ireland (AAGBI); it has grown in popularity and attendance year on year. The seminar now takes place twice a year, and is expanding into other UK venues. We did not anticipate that there would be so much interest among anaesthetists regarding the complications of anaesthetic practice and how to manage them. We felt the reason for the popularity of the seminars was that we attracted great speakers every time – real jobbing doctors, facing complications and providing advice to other front-line doctors, just like us. This special supplement of Anaesthesia focusing on risk and complications provides a timely and much-needed update; quantifying risks and addressing complications to help our understanding, while adding to our cognitive framework and filling in the gaps. This information helps us put more accurate, current figures to patients in a meaningful way when making shared decisions regarding best treatment options. We are familiar with the panoply of risk stratification scores available to help doctors; we believe that these articles will provide us with additional up-to-date information to start helping patients. They offer us the starting point of facts and knowledge that we require when consulting with patients on material risks, so that we can tailor our information them in a personalised way. However, before the wider issues regarding complications can be discussed, there are two questions which need to be addressed; namely, ‘Why are anaesthetists so interested in complications?’ and ‘What is a complication?’. These questions are particularly pertinent when we hear the paradox that, although the number of serious mistakes reported to the national reporting and learning system (NRLS) is falling, the overall number of incidents is increasing 2. Alan Merry goes some way to answering the surprisingly difficult question of how to define exactly what constitutes a complication 3. The AAGBI and Royal College of Anaesthetists recognised many years ago the need to understand complications of anaesthesia from a more pragmatic, rather than definitional viewpoint, and have worked to set standards globally, with national audit projects in order to provide both numerator and denominator data for major anaesthetic complications, as well as offering recommendations and advice on best practice 4. As anaesthetists, the majority of complications we see take immediate effect and require immediate action to prevent life-altering or life-threatening outcomes. There are two ways in which we can arm ourselves to deal with these stressful events. An understandable first response is to read and share knowledge of core topics, such as obstetric anaesthesia 5 and the management of adverse drug reactions 6, to enable us to recognise and manage events promptly. Another approach is to consider the management of the complication more broadly, in order to consider the impact of human factors on our individual and team performance in dealing with the emergency; Jones et al. talk explicitly about this area in their systematic review 7. It is also important to highlight more insidious, slowly evolving, yet equally devastating complications, such as postoperative cognitive decline or cerebrovascular accident, which are considered by Hood et al. 8. This is an area of uncertainty, as the contribution of anaesthesia to these problems has yet to be determined. With the expansion of the role of the anaesthetist to now incorporate peri-operative patient management from referral to discharge, we need to consider how to prevent, or more worryingly to identify and subsequently manage these adverse events in the days or weeks following surgery. We know that both patients and colleagues have high expectations regarding the safety of anaesthesia. Very few patients remember their anaesthetist; many see anaesthesia as low risk and merely a means to an end to permit their surgery. However, when a problem, such as postoperative vomiting or nerve injury occurs, we quickly gain prominence and become the one most likely to have made them sick after their successful surgery. Blame for peripheral nerve injury may also easily be laid at the anaesthetist's door, yet, Hewson et al. discuss the more complicated aetiology and multifactorial nature of the development of such injuries which will offer additional advice and perhaps comfort to the attending anaesthetist 9. However, what lies at the forefront of our medical minds? Which complications are most important to us? It is likely to be those that relate to end-organ damage/dysfunction, as a consequence of a poorly applied anaesthetic technique, whether that is excessive or inadequate depth of anaesthesia, accidental intra-operative hypotension or a technical failure of an intervention. These are comprehensively addressed by our authors who consider the major organ systems at the centre of anaesthetic practice: the airway 10; respiratory 11; cardiovascular 12; and renal systems 13; and, of course, the brain 14. Understanding risk and complications, their management and an ability to discuss them openly with patients, are core skills for all doctors. As anaesthetists, we have less contact with individual patients than many other specialties, with some clinicians of the view that we exist solely to provide a service that permits the delivery of predominantly surgical treatment – our specialty is seen as a commodity. In addition to this view, many of our interventions are not therapeutic and, at times, it is challenging to balance the risk of anaesthesia with the benefit of the treatment or diagnostic test. Somewhere in the back of our minds, we know, perhaps with a healthy a degree of fear, that a major complication could happen to a patient when they are under our care. In this respect, we as individual practitioners are exposed to a number of risks. There is the potential for medicolegal action should things go wrong. In an increasingly time-pressured peri-operative setting, there is limited time to have a full and open discussion with patients. This may have a number of unwanted sequelae: the development of a sound doctor–patient relationship becomes more challenging; insufficient opportunity for discussion regarding the potential risks and benefits of particular anaesthetic or analgesia techniques; and greater difficulty in providing anaesthetic review should a patient be dissatisfied or suffer a delayed complication. An area that is often overlooked in the published literature is what to do after a complication has occurred, with articles tending to place greater focus on the emergency medical response. Cruikshanks and Bryden provide pause for thought and comprehensive practical advice in their article answering this very question 15. If we get this right then the outcome for our patients is improved, and our own risk is reduced. Maybe the evolution of anaesthetists into peri-operative physicians 16 will go some way to resolving some of these, as yet unaddressed, problems. Taking more responsibility for individualising and optimising medical care throughout the surgical journey, from referral to discharge, is one of many avenues where anaesthetists can reduce complications. The pro-active management of diabetes 17, hypertension 18 and anaemia 19, to name but a few examples, is where we can make real differences to patient care. Anaesthetists will often take the lead in the management of adverse drug reactions in the operating theatre, but our wider responsibility in avoidance of polypharmacy, antibiotic stewardship, responsible opiate prescribing and deprescribing 20 may be as important in terms of optimal patient outcome and needs to be considered. With the evolution of peri-operative medicine, shared decision making must surely become a reality, and identifying a point of contact after adverse outcomes made easier; there is, however, still some way to go. The legal framework under which we work and practice demands shared decision making, discussion of risks pertinent to individual patients (in light of the Montgomery ruling 21), and openness when things go wrong (duty of candour) 22; is this possible in a service-driven, target-laden, resource and time-pressured healthcare system? Whether it is possible is not open to question on the part of the Department of Health and front-line providers, as there is an increased focus and determination on their part to improve patient safety across the NHS. The draft Health Service Safety Investigations Bill was laid before parliament on 14 September 2017, in which proposals for a Health Service Safety Investigations Board (HSSIB) were introduced [23]. The HSSIB will replace the Healthcare Safety Investigation Board (HSIB), with the fundamentals of its work enshrined in law to include making recommendations across the NHS, developing national standards and promoting training into investigation of incidents. One could question whether this is just a case of semantics or whether there is real change proposed. The aims of the Board are to learn the lessons of accident investigation from aviation; to move from a blame culture to one where serious incidents are investigated independently, within a ‘safe space’ free from information disclosure, unless exceptional circumstances exist, thereby encouraging and supporting the reporting of adverse events. Perhaps the recent reduction in the incidence of serious adverse events has been due to a reluctance to report, or even to underestimate the severity of such events, rather than a genuine reduction in absolute numbers. This possibility might go some way to explaining the increase in total events reported. An opening up of ‘safe spaces’, a changing of culture, and a willingness to learn and share rather than punish could definitely help reduce all unwanted complications. Although this supplement deals predominantly with the immediate complications of anaesthesia, the 2019 supplement will focus on pre-operative optimisation of the surgical patient. This will highlight how anaesthetic involvement in peri-operative medicine can help improve patient outcome and further mitigate against complications. In the interim, the increasing demands placed upon us as anaesthetists, in conjunction with an ageing population with a greater number of comorbid conditions, underpin the pressing need for this special supplement of Anaesthesia, with the hope that it will help practicing clinicians in the prevention, management and aftermath of a complication. JS is part of the educational faculty for Medical Protection. She provides educational services as an independent contractor to members of Medical Protection. The article is her own opinion and has not been seen by, reviewed or added to by anyone at Medical Protection and does not reflect Medical Protection opinion. No other conflicts of interest.