Bewertung des Anästhesierisikos beim Hund mithilfe eines multifaktoriellen Risikoindex: der LeiV-Risk-Index

Zusammenfassung

Gegenstand und Ziel Der Leipziger Veterinärmedizinische Risiko-Index kurz „LeiV-Risk-Index“ ist ein multifaktorieller Index, der zur objektiven und präzisen Bewertung des Anästhesierisikos beim Hund entwickelt wurde. Er basiert auf 10 Risikokriterien, welche die perioperative Mortalität beeinflussen. Ziel dieser Studie war eine Evaluierung der Anwendung des LeiV-Risk-Index und seiner Risikokriterien und ein direkter Vergleich mit der ASA-Klassifikation.

Material und Methoden Im Rahmen einer deutschlandweiten Online-Umfrage unter in der Kleintiermedizin tätigen Tierärzten wurde die Anwendung des LeiV-Risk-Index untersucht. Die Teilnehmer erhielten allgemeine Fragen zu ihrem beruflichen Hintergrund und der praktischen Anwendung des LeiV-Risk-Index. Zudem sollten sie 15 hypothetische Patienten mithilfe des LeiV-Risk-Index und der ASA-Klassifikation bewerten. Als Maß für die Übereinstimmung der Bewertung wurde ein Fleiss‘-Kappa bestimmt. Zudem wurde der Zusammenhang des LeiV-Risk-Index zur ASA-Klassifikation mittels eines Korrelationskoeffizienten untersucht.

Ergebnisse Die Übereinstimmung aller vergebenen LeiV-Risikoklassen zwischen den Teilnehmern war deutlich (κ = 0,55) und weitaus höher als bei Klassifizierung mittels ASA-Klassifikation (κ = 0,33). Es wurden im Schnitt für einen Patienten 3 verschiedene LeiV-Risikoklassen und 4 verschiedene ASA-Klassen vergeben. Zudem ließ sich eine positive Korrelation zwischen LeiV-Risikoklasse und steigender ASA-Klasse nachweisen. Es konnte kein signifikanter Einfluss vom Geschlecht des Anwenders, Sicherheit in der Anwendung des LeiV-Risk-Index oder klinischer Erfahrung auf die Höhe der vergebenen LeiV-Risikoklassen nachgewiesen werden.

Schlussfolgerung und klinische Relevanz Mit dem LeiV-Risk-Index steht in der Tiermedizin erstmals ein Index zur Bewertung des Anästhesierisikos zur Verfügung, der auf objektiven Risikokriterien basiert und dessen Objektivität die der ASA-Klassifizierung übertrifft. Anästhesiepatienten können somit auch in der Veterinärmedizin übereinstimmender bewertet werden. Auch Anwendung und Praktikabilität des LeiV-Risk-Index wurden von 95 % der Teilnehmer positiv aufgenommen. Eine weitere Überarbeitung einzelner Risikokriterien muss überdacht werden.

Abstract

Objective The Leipzig Veterinary Risk-Index – “LeiV-Risk-Index” is a multifactorial risk index developed to enable an improved objective assessment of the anesthetic risk in dogs. The scoring system is based on 10 risk factors affecting perioperative mortality. The aim of this study was to evaluate the applicability of the LeiV-Risk-Index and its risk factors as well as to perform a direct comparison with the ASA-classification.

Material and methods An online survey was conducted among veterinarians working in small animal medicine throughout Germany. Participants received a questionnaire containing information on 15 selected patients. They were asked to classify the patients according to the LeiV-Risk-Index and ASA-classification and to answer several questions concerning their professional background. The results were statistically analyzed considering the consistency among veterinarians of rating the different patients by using Fleiss’-Kappa. The correlation of LeiV-Risk-Index and ASA-classification was calculated.

Results The consistency of all assigned LeiV-risk classes between participants was moderate (κ = 0.55) and higher than classification by ASA (κ = 0.33). On average, 3 different LeiV-risk classes and 4 different ASA-classes were assigned for one patient. There was a positive correlation between LeiV-risk class and increasing ASA-class. No effect of gender or clinical experience of the veterinarian could be demonstrated on ranking patients. There was also no effect of how confident veterinarians felt in applying the LeiV-Risk-Index.

Conclusion und clinical relevance The LeiV-Risk-Index is the first index available in veterinary medicine for assessing anesthetic risk that is based on objective risk criteria and whose objectivity exceeds that of the ASA classification. Anesthetic patients can thus be evaluated more consistently in veterinary medicine as well. Utility and practicability were positively received by 95 % of the participants. Further revision of individual risk criteria needs to be reconsidered.

Schlüsselwörter

Anästhesie - perioperative Mortalität - Subjektivität - Checkliste - ASA-Klassifikation

Key words

Anesthesia - perioperative mortality - subjectivity - checklist - ASA-classification

• Literatur

• 1 Brodbelt DC. The Confidential Enquiry into Perioperative Small Animal Fatalities. Royal Veterinaty College; 2006
• 2 Gil L, Redondo JI. Canine anaesthetic death in Spain: a multicentre prospective cohort study of 2012 cases. Vet Anaesth Analg 2013; 40: e57-e67
• 3 Itami T, Aida H, Asakawa M. et al. Association between preoperative characteristics and risk of anaesthesia-related death in dogs in small-animal referral hospitals in Japan. Vet Anaesth Analg 2017; 44: 461-472
• 4 Gong C-L, Hu J-P, Qiu Z-L. et al. A study of anaesthesia-related cardiac arrest from a Chinese tertiary hospital. Bmc Anesthesiol 2018; 18: 127
• 5 Stefani LC, Gamermann PW, Backof A. et al. Perioperative mortality related to anesthesia within 48 h and up to 30 days following surgery: A retrospective cohort study of 11,562 anesthetic procedures. J Clin Anesth 2018; 49: 79-86
• 6 Tikkanen J, Hovi-Viander M. Death associated with anaesthesia and surgery in Finland in 1986 compared to 1975. Acta Anaesth Scand 1995;
• 7 Junger A, Engel J, Quinzio L. et al. Risikoindizes, Scoring-Systeme und prognostische Modelle in der Anästhesie und Intensivmedizin. Teil I: Anästhesie 2002; 520-527
• 8 Saklad. Grading of patients for surgical procedures. Anesthesiology 1941; 31: 305-309
• 9 Wolters U, Wolf T, Stützer H. et al. ASA classification and perioperative variables as predictors of postoperative outcome. Bja Br J Anaesth 1996; 77: 217-222
• 10 Hackett NJ, Oliveira GSD, Jain UK. et al. ASA class is a reliable independent predictor of medical complications and mortality following surgery. Int J Surg 2015; 18: 184-190
• 11 Clarke KW, Hall LW. A survey of anaesthesia in small animal practice: AVA/BSAVA report. J Assoc Vet Anaesth Gt Br Irel 1990;
• 12 Owens W. ASA Physical Status Classification – A Study of Consistency of Ratings. Anesthesiology 1978; 49: 239-243
• 13 Haynes SR, Lawler PGP. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia 1995; 50: 195-199
• 14 Riley RH, Holman CDJ, Fletcher DR. Inter-rater reliability of the ASA physical status classification in a sample of anaesthetists in Western Australia. Anaesth Intens Care 2014; 42: 614-618
• 15 Mak PHK, Campell Irwin. The ASA Physical Status Classification: Inter-observer Consistency. Anesthesiology 2002; 30: 633-640
• 16 Cuvillon P, Nouvellon E, Marret E. et al. American Society of Anesthesiologists’ Physical Status system. Eur J Anaesth 2011; 28: 742-747
• 17 Cassai AD, Boscolo A, Tonetti T. et al. Assignment of ASA-physical status relates to anesthesiologists’ experience: a survey-based national-study. Korean J Anesthesiol 2019; 72: 53-59
• 18 Hauber E, Alef M. Deutschlandweite Studie zur präanästhetischen Risikoeinschätzung mithilfe der ASA-Klassifikation beim Hund. Tierärztliche Praxis Ausgabe K Kleintiere Heimtiere 2020; 48: 157-162
• 19 Lutz H. Präoperative Risikoeinschätzung nach objektiven Kriterien. Ains – Anästhesiologie Intensivmedizin Notfallmedizin Schmerztherapie 1980; 15: 287-292
• 20 Copeland GP, Jones D, Walters M. POSSUM: A scoring system for surgical audit. Brit J Surg 1991; 78: 355-360
• 21 Brodbelt DC, Hammond R, Tuminaro D. et al. Risk factors for anaesthetic-related death in referred dogs. Vet Rec 2006; 158: 563-564
• 22 Hosgood G, Scholl DT. Evalution of age as a risk factor for perianesthetic morbidity and mortality in the dog. J Vet Emerg Crit Car 1998; 8: 222-236
• 23 Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesth Scand 1990;
• 24 Tiret L, Hatton F, Desmonts JM. et al. Prediction of outcome of anaesthesia in patients over 40 years: A multifactorial risk index. Stat Med 1988;
• 25 Farrow SC, Fowkes FGR, Lunn JN. et al. Epidemiology in Anaesthesia II: Factors affecting mortality in hospital. Bja Br J Anaesth 1982; 54: 811-817
• 26 Grimm KA, Lamont LA, Tranquilli WJ. et al. Veterinary Anesthesia and Analgesiea, Lumb and Jones.
• 27 Tiret L, Desmonts JM, Hatton F. et al. Complications associated with anaesthesiaa — prospective survey in France. Can Anaesth Soc J 1986; 33: 336-344
• 28 Mullen MG, Michaels AD, Mehaffey JH. et al. Risk Associated With Complications and Mortality After Urgent Surgery vs Elective and Emergency Surgery: Implications for Defining “Quality” and Reporting Outcomes for Urgent Surgery. Jama Surg 2017; 152: 768
• 29 Cohen MM, Duncan PG, Tate RB. Does Anesthesia Contribute to Operative Mortality?. Jama J Am Medical Assoc 1988; 260: 2859
• 30 Matthews NS, Mohn TJ, Yang M. et al. Factors associated with anesthetic-related death in dogs and cats in primary care veterinary hospitals. J Am Vet Med Assoc 2017; 250: 655-665
• 31 Arbous MS, Meursing AEE, Kleef JW van. et al. Impact of Anesthesia Management Characteristics on Severe Morbidity and Mortality. Anesthesiology 2005; 102: 257-268
• 32 Biboulet P, Aubas P, Dubourdieu J. et al. Fatal and non fatal cardiac arrests related to anesthesia. Can J Anesthesia J Can D’anesthésie 2001; 48: 326-332
• 33 Newland MC, Ellis SJ, Lydiatt CA. et al. Anesthestic-related Cardiac Arrest and Its Mortality. Anesthesiology 2002; 97: 108-115
• 34 Gruenheid M, Aarnes TK, McLoughlin MA. et al. Risk of anesthesia-related complications in brachycephalic dogs. J Am Vet Med Assoc 2018; 253: 301-306
• 35 Donati A, Ruzzi M, Adrario E. et al. A new and feasible model for predicting operative risk. Bja Br J Anaesth 2004; 93: 393-399
• 36 Brodbelt DC, Blissitt KJ, Hammond RA. et al. The risk of death: the Confidential Enquiry into Perioperative Small Animal Fatalities. Vet Anaesth Analg 2008; 35: 365-373
• 37 Rigotti CF, Brearley JC. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 2016; 418-427
• 38 Bellows J, Colitz C, Daristotle L. et al. Common physical and functional changes associated with aging in dogs. J Am Vet Med Assoc 2015; 246: 67-75
• 39 Johnston GM, Taylor PM, Holmes MA. et al. Confidential enquiry of perioperative equine fatalities (CEPEF-1): preliminary results. Equine Vet J 1995; 27: 193-200
• 40 Hughes JML. Anaesthesia for the geriatric dog and cat. Irish Vet J 2008; 61: 380
• 41 Kramer S. Pediatric and geriatric small animal patients as risk groups in anesthesia management. Tierärztliche Praxis Ausgabe K Kleintiere Heimtiere 1997; 25: 637-642
• 42 Love L, Cline MG. Perioperative physiology and pharmacology in the obese small animal patient. Vet Anaesth Analg 2015; 42: 119-132
• 43 Schwilk B, Muche R, Bothner U. et al. Zwischenfälle, Ereignisse und Komplikationen in der perioperativen Phase bei normal- und fehlernährten Patienten – Ergebnisse von 23 056 Anästhesien. 1995; 30: 99-107
• 44 Kretz F-J, Schäffer J, Terboven T. Springer-Lehrbuch. 2016; 3-64
• 45 Mosing M. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 2016; 13-23
• 46 Oechtering G. Das Brachyzephalensyndrom – Neue Informationen zu einer alten Erbkrankheit. Vet Focus 2010; 17: 02-09
• 47 Radford HM. Sepsis, severe sepsis and septic shock in adults and anaesthesia. Southern African Journal of Anaesthesia and Analgesia. 2002
• 48 Trzeciak S, Dellinger RP, Parrillo JE. et al. Microcirculatory Alterations in Resuscitation and Shock Investigators. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med 2007; 49 (01) 88-98 98.e1–2
• 49 Lienhart A, Auroy Y, Péquignot F. et al. Survey of Anesthesia-related Mortality in France. Anesthesiology 2006; 105: 1087-1097
• 50 Mörner MEM, Edgren G, Martling A. et al. Preoperative anaemia and perioperative red blood cell transfusion as prognostic factors for recurrence and mortality in colorectal cancer – a Swedish cohort study. Int J Colorectal Dis 2017; 32: 223-232
• 51 Wendelburg KM, Toole TEO, McCobb E. et al. Risk factors for perioperative death in dogs undergoing splenectomy for splenic masses: 539 cases (2001–2012). J Am Vet Med Assoc 2014; 245: 1382-1390
• 52 Weil AB. Anesthesia for Patients with Renal/Hepatic Disease. Top Companion Anim M 2010; 25: 87-91
• 53 Lysak N, Bihorac A, Hobson C. Mortality and cost of acute and chronic kidney disease after cardiac surgery. Curr Opin Anaesthesiol 2017; 30: 113-117
• 54 Lawrence J, Chang Y-MR, Szladovits B. et al. Breed-Specific Hematological Phenotypes in the Dog: A Natural Resource for the Genetic Dissection of Hematological Parameters in a Mammalian Species. Plos One 2013; 8: null
• 55 Lübbeke A, Hovaguimian F, Wickboldt N. et al. Effectiveness of the Surgical Safety Checklist in a High Standard Care Environment. Med Care 2013; 51: 425-429
• 56 Bock M, Fanolla A, Segur-Cabanac I. et al. A Comparative Effectiveness Analysis of the Implementation of Surgical Safety Checklists in a Tertiary Care Hospital. Jama Surg 2016; 151: 639
• 57 Haynes AB, Weiser TG, Berry WR. et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. New Engl J Medicine 2009; 360: 491-499
• 58 Bergström A, Dimopoulou M, Eldh M. Reduction of Surgical Complications in Dogs and Cats by the Use of a Surgical Safety Checklist. Vet Surg 2016; 45: 571-576
• 59 Cray MT, Selmic LE, McConnell BM. et al. Effect of implementation of a surgical safety checklist on perioperative and postoperative complications at an academic institution in North America. Vet Surg 2018; 47: 1052-1065