Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process.
OBJECTIVE
Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality.


METHODS
A web-based international consensus conference.


METHODS
The study comprised 500 clinicians from 61 countries.


METHODS
A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey.


RESULTS
The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective decontamination of the gastrointestinal tract, insulin for tight glycemic control, preoperative intra-aortic balloon pump, leuko-depleted red blood cells transfusion, levosimendan, volatile agents, and remote ischemic preconditioning) and 2 interventions showing increased mortality (beta-blocker therapy and aprotinin). Interventions then were voted on by participating clinicians. Percentages of agreement among clinicians in different countries differed significantly for 6 interventions, and a variable gap between evidence and clinical practice was noted.


CONCLUSIONS
The authors identified 13 nonsurgical interventions that may decrease or increase perioperative mortality, with variable agreement by clinicians. Such interventions may be optimal candidates for investigation in high-quality trials and discussion in international guidelines to reduce perioperative mortality.
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy. Electronic address: landoni.giovanni@hsr.it.
Giovanni
G
Landoni
Division of Cardiac Anaesthesia and Intensive Care, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy.
Antonio
A
Pisano
Department of Anaesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia.
Vladimir
V
Lomivorotov
Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Universitaria "Mater Domini," Catanzaro, Italy.
Gabriele
G
Alvaro
Disciplina de Anestesia, Incor-Hospital das Clinicas, Sao Paulo, Brazil.
Ludhmila
L
Hajjar
Department of Cardiovascular Anaesthesia and Intensive Care, Ospedale San Carlo, Potenza, Italy.
Gianluca
G
Paternoster
Dante Pazzanese Institute of Cardiology, Department of Anesthesia and Intensive Care, Sao Paulo, Brazil.
Caetano
C
Nigro Neto
Department of Anaesthesia and Intensive Care, Spedali Civili, Brescia, Italy.
Nicola
N
Latronico
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Anaesthesia and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia.
Evgeny
E
Fominskiy
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Laura
L
Pasin
Anesthesia and Intensive Care Unit, Policlinico "Duilio Casula" AOU Cagliari, Department of Medical Sciences "M. Aresu," Cagliari, Italy.
Gabriele
G
Finco
Department of Cardiac Anaesthesia and Intensive Care, San Giovanni Battista Hospital, University of Turin, Turin, Italy.
Rosetta
R
Lobreglio
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Maria Luisa
ML
Azzolini
Department of Cardiac Anaesthesia and Intensive Care, IRCCS University Hospital San Martino IST, Genova, Italy.
Giuseppe
G
Buscaglia
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Alberto
A
Castella
Cardiac and Vascular Department, Ospedale Mauriziano Umberto I, Torino, Italy.
Marco
M
Comis
Division of Cardiac Anaesthesia and Intensive Care, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy.
Adele
A
Conte
Department of Anesthesia and Intensive Care, Mater Dei Hospital, Bari, Italy.
Massimiliano
M
Conte
Department of Anaesthesia and Intensive Care, Ente Ospedaliero Ospedali Galliera, Genova, Italy.
Francesco
F
Corradi
Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Università degli Studi di Bologna-Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy.
Erika
E
Dal Checco
Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Universitaria "Mater Domini," Catanzaro, Italy.
Giovanni
G
De Vuono
Cardiac and Vascular Department, Ospedale Mauriziano Umberto I, Torino, Italy.
Marco
M
Ganzaroli
Department of Anaesthesia and Intensive Care, Azienda Ospedaliera Universitaria "Mater Domini," Catanzaro, Italy.
Eugenio
E
Garofalo
Department of Anaesthesia and Intensive Care, Institute of Cardiovascular Diseases Dedinje, Belgrade, Serbia.
Gordana
G
Gazivoda
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Rosalba
R
Lembo
Department of Thoracic and Cardiac Surgery, University of Siena, Siena, Italy.
Daniele
D
Marianello
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Martina
M
Baiardo Redaelli
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Fabrizio
F
Monaco
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Valentina
V
Tarzia
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Marta
M
Mucchetti
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Alessandro
A
Belletti
Anesthesia and Intensive Care Unit, Policlinico "Duilio Casula" AOU Cagliari, Department of Medical Sciences "M. Aresu," Cagliari, Italy.
Paolo
P
Mura
Department of Cardiac Anaesthesia and Intensive Care, San Giovanni Battista Hospital, University of Turin, Turin, Italy.
Mario
M
Musu
Department of Cardioanesthesia and Intensive Care, Ospedale Civile Santissima Annunziata, Sassari, Italy.
Giovanni
G
Pala
Department of Anaesthesia and Intensive Care, Spedali Civili, Brescia, Italy.
Massimiliano
M
Paltenghi
Cardiac Anaesthesia and Intensive Care, Federal Centre for Cardiac Surgery, Astrakhan, Russia.
Vadim
V
Pasyuga
Anesthesia and Intensive Care Unit, Policlinico "Duilio Casula" AOU Cagliari, Department of Medical Sciences "M. Aresu," Cagliari, Italy.
Desiderio
D
Piras
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Claudio
C
Riefolo
Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy.
Agostino
A
Roasio
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Laura
L
Ruggeri
Division of Cardiac Surgery, IRCCS University Hospital San Martino IST, Genova, Italy.
Francesco
F
Santini
Department of Anaesthesiology and Intensive Care, Semmelweis Egyetem, Budapest, Hungary.
Andrea
A
Székely
Division of Cardiac Anaesthesia and Intensive Care, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy.
Luigi
L
Verniero
Dipartimento Cardio-Nefro-Polmonare, Sezione Terapia Intensiva Cardiochirurgica, Azienda Ospedaliero Universitaria di Parma, Parma, Italy.
Antonella
A
Vezzani
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
Alberto
A
Zangrillo
Intensive Care, Austin Hospital, Melbourne, Australia.
Rinaldo
R
Bellomo
D003226:Congresses as Topic; D032921:Consensus; D006801:Humans; D019990:Perioperative Care / Q000379:methods* / Q000401:mortality*; D011183:Postoperative Complications / Q000401:mortality* / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic / Q000379:methods*
anesthesia; consensus; intensive care; mortality; perioperative care