Optimising outcomes for the high-risk surgical patient: models for postoperative care

This narrative article explores the case of a 78-year-old man with a short history of nausea, vomiting and abdominal pain, as well as a background of type 2 diabetes mellitus and previous myocardial infarction. Investigations revealed small bowel ischaemia requiring emergency laparotomy. The use of a risk prediction tool confirmed the patient to be at high risk of postoperative morbidity and mortality. As there were no critical care beds available, the patient was transferred to a ward following an emergency laparotomy and small bowel resection. He later deteriorated and required critical care outreach input. The case is used to illustrate the need for robust pathways for high-risk surgical patients, as well as the value of risk scoring tools in planning the appropriate postoperative destination. The need for a proactive, preventative approach is discussed and the concept of failure to rescue is examined. The global perspective is also addressed. We explore how, in some settings in which postoperative processes are inconsistent, the healthcare system contributes to postoperative complications. This fictitious case study explores some of the practices utilised to optimise care during the postoperative period, including proleptic critical care admission, early assessment of the deteriorating patient by critical outreach teams and provision of dedicated higher acuity wards. It illustrates a situation in which a patient recovering from high-risk surgery is likely to have benefited from a period of enhanced observation and invasive haemodynamic monitoring. We use it to emphasise the value of enhanced care, a dedicated perioperative team and a proactive approach in the prevention of postoperative complications.