Background

Every year more than 310 million surgical procedures are performed worldwide, [1] and the number is increasing. Although the perioperative course is generally regarded as safe, patients are subjected to numerous procedures and treatments with inherent risk of harm. During anaesthesia patients undergo several high-risk procedures and are exposed to potent agents influencing e.g., respiration and circulation, aside from the direct consequences of surgery and inflammation.


The postoperative 30-day mortality in noncardiac surgery is approximately 2% as estimated in a population of 40,000 patients in North and South America, Africa, Asia, Australia, and Europe. [2] Several other serious complications, as e.g. infections, respiratory complications, allergic reactions, hypoperfusion, thrombosis, bleeding, kidney failure, pain, and delirium, are also associated with the perioperative patient course. [3-6]
 
It is imperative that the perioperative course is safe, and complications may prolong rehabilitation or leading to chronical pain or impairment, causing tragic personal consequences for the individual. Due to the sheer volume of surgical procedures, these complications also have massive socio-economic implications. Approximately 50 % of the in-hospital health care expenses in the US relates to surgical services, and the costliest 30-days postoperative complications are all related to, or heavily impacted by, anaesthesia. [7]

Modern and optimal perioperative care for surgical patients includes focus on prehabiliation [8] and rehabilitation, i.e., optimizing each aspect of the patient course and minimizing adverse effects of anaesthesia and the surgical stress response. Anaesthesia practice is specialized in securing safe and optimal treatment and care of patients undergoing surgery, and the quality of anaesthesia practice has a significant impact on perioperative morbidity and mortality as well as long term outcomes. [9-11] Anaesthesia practice includes amongst other preoperative optimization, safe handling of patients’ airways, and respiratory functions, per- and postoperative pain management, and supporting and preserving hemodynamic functionality and organ perfusion. Safe and evidence-based anaesthesia practice is the cornerstone for an optimal and safe course for surgical patients. [12,13]

 

Several of the most used interventions within anaesthesia practice are based on poor evidence relying on tradition; expert opinions; studies of basic physiology; or data from non-randomised studies or small, low-quality trials. [14-18] This poses a dilemma since these interventions may have no beneficial effect or may even harm patients. [19-22]

 

Recently we have established a unique network of clinicians, trialists, and researchers enabling us to effectively perform large multicentre trials in postoperative pain, [23,24] answering vital questions related to basic perioperative pain practice. Based on this experience we have developed and founded a larger network collaboration aiming to establish evidence-based answers to some of the major clinical questions in anaesthesia practice.

  • 1. Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet 2015; 385 Suppl 2: S11.

    2. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study I, Devereaux PJ, Chan MT, et al. JAMA 2012; 307(21): 2295-304.

    3. Hansen MS, Petersen EE, Dahl JB, Wetterslev J. Post-operative serious adverse events in a mixed surgical population - a retrospective register study. Acta Anaesthesiol Scand 2016; 60(9): 1209-21.

    4. Asehnoune K, Le Moal C, Lebuffe G, et al. Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial. BMJ 2021; 373: n1162.

    5. Kirmeier E, Eriksson LI, Lewald H, et al. Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med 2019; 7(2): 129-40.

    6. Szakmany T, Ditai J, Kirov M, et al. In-hospital clinical outcomes after upper gastrointestinal surgery: Data from an international observational study. Eur J Surg Oncol 2017; 43(12): 2324-32.

    7. Merkow RP, Shan Y, Gupta AR, et al. A Comprehensive Estimation of the Costs of 30-Day Postoperative Complications Using Actual Costs from Multiple, Diverse Hospitals. Jt Comm J Qual Patient Saf 2020; 46(10): 558-64.

    8. Waterland JL, McCourt O, Edbrooke L, et al. Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis. Front Surg 2021; 8: 628848.

    9. Scott MJ, Baldini G, Fearon KC, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59(10): 1212-31.

    10. Feldheiser A, Aziz O, Baldini G, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60(3): 289-334.

    11. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362(9399): 1921-8.

    12. Scott MJ, Miller TE. Pathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes. Anesthesiol Clin 2015; 33(1): 79-91.

    13. Mahajan A, Esper SA, Cole DJ, Fleisher LA. Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation. Anesthesiology 2021; 134(4): 526-40.

    14. Doleman B, Mathiesen O, Jakobsen JC, et al. Methodologies for systematic reviews with meta-analysis of randomised clinical trials in pain, anaesthesia, and perioperative medicine. Br J Anaesth 2021; 126(4): 903-11.

    15. Fabritius ML, Geisler A, Petersen PL, et al. Gabapentin for post-operative pain management - a systematic review with meta-analyses and trial sequential analyses. Acta Anaesthesiol Scand 2016; 60(9): 1188-208.

    16. Fabritius ML, Strom C, Koyuncu S, et al. Benefit and harm of pregabalin in acute pain treatment: a systematic review with meta-analyses and trial sequential analyses. Br J Anaesth 2017; 119(4): 775-91.

    17. Hojer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty: a systematic review. Pain 2015; 156(1): 8-30.

    18. Koyuncu S, Friis CP, Laigaard J, Anhoj J, Mathiesen O, Karlsen APH. A systematic review of pain outcomes reported by randomised trials of hip and knee arthroplasty. Anaesthesia 2021; 76(2): 261-9.

    19. Futier E, Garot M, Godet T, et al. Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial. JAMA 2020; 323(3): 225-36.

    20. Zampieri FG, Cavalcanti AB. Hydroxyethyl Starch for Fluid Replacement Therapy in High-Risk Surgical Patients: Context and Caution. JAMA 2020; 323(3): 217-8.

    21. Sessler DI, Bloomstone JA, Aronson S, et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 2019; 122(5): 563-74.

    22. Sessler DI, Meyhoff CS, Zimmerman NM, et al. Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial. Anesthesiology 2018; 128(2): 317-27.

    23. Thybo KH, Hagi-Pedersen D, Dahl JB, et al. Effect of Combination of Paracetamol (Acetaminophen) and Ibuprofen vs Either Alone on Patient-Controlled Morphine Consumption in the First 24 Hours After Total Hip Arthroplasty: The PANSAID Randomized Clinical Trial. JAMA 2019; 321(6): 562-71.

    24. Gasbjerg KS, Hagi-Pedersen D, Lunn TH, et al. DEX-2-TKA-DEXamethasone twice for pain treatment after Total Knee Arthroplasty: A protocol for a randomized, blinded, three-group multicentre clinical trial. Acta Anaesthesiol Scand 2020; 64(2): 267-75.