A SOBA response to NAP 7 Perioperative cardiac arrest “At the Heart of the Matter”

E. Warwick, A McKechnie, for and on behalf of SOBA UK

 

Introduction:

 

We read the article by Kane(1) et al published earlier this year and have now read the NAP 7 report(2) with interest. We would firstly like to thank and congratulate the authors and NAP 7 team on providing an up-to-date view on the current picture of anaesthesia in the UK, especially in the context of the COVID-19 pandemic and changing perioperative population and dynamics. At SOBA we have read the chapters examining the trends and outcomes in patients living with obesity with the greatest interest.
 

Key findings from the report
 

The authors found that since NAP 5 in 2013, the estimated median BMI (IQR) has increased from 24.9 to 26.7 kg.m-2. The percentage of patients now classified as at least overweight has increased by 10% in the non-obstetric population. Those living with obesity now represent 1 in 3 patients presenting to anaesthetists, with 59% of being overweight or obese. The increases in BMI are most prevalent in the higher classes of obesity (>35 kg m-2). These trends in increased BMI in those presenting for anaesthesia are above that of population trends. The NAP 7 report highlights that airway, breathing, circulatory and metabolic complications increased as BMI increased and particularly as BMI becomes greater than 50 kg.m-2. Concerningly, those patients living with obesity had poor preoperative assessment, an increase in postoperative events at extubation and postoperatively after recovery discharge. Hypoxaemia was particularly prevalent. Those patients with a BMI > 40 kg.m-2 who did have a perioperative cardiac arrest had worse outcomes. The quality of care in those with a high BMI was also deemed less good or poor. The report highlights how the increase in obesity is a national problem with medical, logistical and operational consequences and national initiatives are needed to address these.
 

Our positions at SOBA:
 

At SOBA UK, we agree with the authors that these trends are very concerning and require all anaesthetists to evaluate how they deliver care to those living with obesity. Regardless of speciality, anaesthetists will be caring for high BMI patients in all areas of the hospital, and we need to ensure that we are prepared to deliver care of the highest standard. It is time to stop purely documenting a high BMI preoperatively and to start thinking holistically about how these patients can be treated effectively in an evidence-based way throughout their whole perioperative journey.
 

The need for robust perioperative care:
 

When patients living with obesity present for emergency or elective anaesthesia, their BMI must be carefully considered in perioperative care planning. SOBA UK has a wealth of resources(3) which can support anaesthetists and patients in the perioperative period and help guide optimum preoperative, intraoperative and postoperative planning. For those living with obesity, there is not a “one size fits all” approach and all patients should be considered individually, thoroughly assessed preoperatively, experience shared decision making and have a plan for post operative destination made on the basis of the patients need and the surgery itself. Those living with obesity may be eligible for day surgery or they may need intensive care support, this is a decision that needs to be made on an individual basis with all factors considered. The 2015 SOBA and Association of Anaesthetists guidelines about the care of those living with obesity are also being updated and will provide a helpful resource for all anaesthetists.
 

We advocate for every patient to be treated as an individual. Anaesthetic pathways should be flexible enough to allow this. By assessing, planning, and optimising patients who live with obesity appropriately, SOBA’s belief is that complications can be avoided, patient satisfaction can be promoted, and resources can be deployed most appropriately.
 

SOBA and The National Perioperative Care agenda:
 

Our agenda aligns with NHS England and Getting it Right First Time who have collaborated to form the National Perioperative Care Programme(4). This guidance recommends that for elective surgery perioperative time be used to prepare patients optimally. With greater than 7.7 million waiting for surgery, waiting times can be used to improve the health of those waiting for surgery. For those living with obesity, this is not necessarily about weight loss - although advocating a healthy lifestyle and exercise, if possible, preoperatively is important - but includes optimising comorbidities(5) in line with up-to-date guidance e.g., diabetes(6), hypertension(7) (guideline currently being updated), screening and treating obstructive sleep apnoea etc. It also involves undertaking appropriate risk stratification to enable honest conversations with patients living with obesity about anaesthetic options, and risks, so they can make informed decisions about their care. Carrying out preoperative care optimisation and combining it with best practice modifications to anaesthetic technique, as advised by SOBA, will ensure the smoothest perioperative journeys for patients. It is also imperative that patients are involved in decisions about their care and are educated about risks and benefits. The RCoA/SOBA patient information is soon to be re-released after an update and is an invaluable resource for patients.
 

Collaboration is key:
 

SOBA continues to be at the forefront of anaesthesia for patients living with obesity in the UK and worldwide. We feel strongly that there is still more to be done to advance the care of patients living with obesity who undergo anaesthesia and we will continue to advocate for this. We believe that further cross speciality, multidisciplinary work is the key to improving this care and think that this must include specific training for anaesthesia and critical care. We welcome any future collaborations.

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1. Kane A.D, Soar J, Armstrong R.A, Kursumovic E et al. Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia 2023; Early View, online version

2. NAP 7 Perioperative cardiac arrest “At the heart of the matter” (website last accessed 20/11/2023) rcoa.ac.uk/sites/default/files/documents/2023-11/24832 RCoA_NAP7_Book %283%29.pdf

3.  https://www.sobauk.co.uk/guidelines-1 (last accessed 15th April 2023)

4. Getting It Right First Time. National Perioperative Care Programme Earlier screening, risk assessment and health optimisation in perioperative pathways: Guide for providers and integrated care. 2023

National Perioperative Care Programme - Getting It Right First Timhttps://gettingitrightfirsttime.co.uk/associated_projects/npcp/#:~:text=This%20national%20programme%20is%20working%20to%20improve%20and,opportunity%20to%20improve%20health%20and%20reduce%20health%20inequalities.e - GIRFT  (accessed 15th April 2023)

5. Warwick, E, Moonesinghe, S.R. Chronic Disease Management and Optimization of Functional Status Before Surgery: Does This Improve Long-Term Postoperative Outcomes?. Curr Anesthesiol Rep (2023). https://doi.org/10.1007/s40140-023-00587-9

6. Centre for Perioperative Care. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery. December 2022. https://cpoc.org.uk/sites/cpoc/files/documents/2022-12/CPOC-Diabetes-Guideline-Updated2022.pdf (accessed 15th April)

7. Hartle A, McCormack T, Carlisle J, Anderson S, Pichel A, Beckett N, Woodcock T, Heagerty A. The measurement of adult blood pressure and management of hypertension before elective surgery. Anaesthesia 2016; 71: 326-337