ABSTRACT
Figure 86.1 Decreasing mortality primarily attributable to anesthetic management before the advent of patient-monitoring standards and the clinical application of pulse oximetry in the mid-1980s, by publication date of the study, 1952 through 1987.26'49~62 (Modified after Figure 79.9 in Orkin.46)
Comments Recognized association between environment and health Quantified and published London's mortality rates Compiled causes of death in England and Wales Published On the Mode of Communication of Cholera Attempted to resolve relative risks of ether and chloroform, without reaching reliable conclusions Characterized pulmonary acid aspiration syndrome, having reviewed large numbers of pregnancy records; leading to improved anesthesia practice Instituted systematic anesthesia record keeping; analyzed local anesthesia practice to improve quality of care Studied anesthesia-attributable deaths in 600000 anesthetics; showed relative safety of thiopental (thiopentone); highlighted threefold variation in perioperative mortality rates between hospitals; included some unreliable conclusions (e.g. "inherent toxicity" of curare) Urged all doctors to demand more scientific underpinning of medical practice Investigated association with hepatic necrosis; highlighted threefold variation in perioperative mortality rates between hospitals, after adjusting for patient risk factors Established major program in critical appraisal skills; pioneered applying literature-based knowledge to physicians' immediate clinical decision making Noted that clinicians are deluged with unmanageable amounts of information, and that most clinical procedures had never been properly evaluated; advocated more randomized controlled trials across the spectrum of medicine and more reliable, updated systematic reviews of available evidence Showed that differences between hospitals in perioperative mortality are partly explained by nonclinical, social, and organizational factors Derived predictive rules for perioperative risk of cardiac complications and respiratory failure, based upon multivariate modeling; ushered in efforts to predict adverse events and provide therapeutic guidance Developed predictive scoring for critical care mortality; attributed variation in outcome to a mix of clinical and organizational factors Quantified multivariate risk for perioperative mortality and complications, using patient, anesthesia, surgery, and hospital data Established headquarters in Copenhagen, linked to regional Cochrane Review Groups throughout the world, conducting and updating systematic reviews and creating a register of methodologically sound controlled trials
Table 86.2 Historic milestones: epidemiology from an anesthesia perspective
Authors (publication date) LunnandMushln(1982)58
Mortality rate 1 in 10000
1 in 18182
level of experience of anesthesiologists was often not well matched to the complexity of the cases. NCEPOD recommends better local policies to achieve this matching task, and more multidisciplinary working on quality improvement initiatives.
