Patient Care

Dr. Bartz shaking hands with patient.

Despite modern advances in patient care, postoperative complications remain a significant clinical challenge, and organ failure is a leading cause of death after surgery and during critical care. Duke Anesthesiology’s Center for Perioperative Organ Protection is pioneering new clinical standards for patient care and innovative translational research in perioperative and critical care settings.

On average, Americans undergo 9.2 surgical procedures during their lifetime. Perioperative mortality is defined as any death, regardless of cause, that occurs within 30 days after surgery in or out of the hospital. Despite modern advances in critical care, perioperative mortality for overall inpatient surgical procedures accounts for nearly 200,000 deaths each year in the United States alone. This represents the third leading cause of death only after heart disease and cancer. This challenge is even more dramatic after major surgical procedures; 15 - 17 percent of these patients suffer major postoperative complications. Nearly one in seven patients hospitalized for a major surgical procedure is readmitted to the hospital within 30 days after discharge, and if patients develop postoperative critical illness, mortality rates reach up to 20 percent. Development of a significant postoperative complication in the first 30 days after surgery is associated with up to a 20 percent increase in mortality over the subsequent 10 postoperative years.

Organ dysfunction is central to the complications seen in perioperative medicine, and multiple organ dysfunction occurs in up to 50 percent of patients who experience postoperative critical illness. During surgery, both non-infectious (aseptic, trauma) and infectious (sepsis) stimuli trigger immunologic responses that are critical for healing and controlling infections. However, these immunologic responses can become more dangerous than the original infection and cause systemic inflammatory response syndrome (SIRS), cardiovascular disorders and organ dysfunction, including acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and acute gut injury (AGI). Future approaches to reduce perioperative morbidity and mortality will require ongoing efforts to 1) better understand mechanisms of immune responses in healing vs organ injury, 2) discover ways to prevent organ injury, and 3) fine-tune the healing response to promote early return of organ function after surgery.

Duke Anesthesiology’s CPOP strives to prevent organ injury and improve recovery through individualized optimization of preoperative, intraoperative and postoperative care by:

  • Strengthening relationships among researchers and providers through local and international collaborations (such as the Morpheus Consortium)
  • Identifying gaps in clinical management therapies and services
  • Developing an interdisciplinary, evidence-based approach to integrative perioperative medicine
  • Evaluating the efficacy of new drugs/medical devices
  • Exploring factors that contribute to organ injury
  • Studying cellular and genetic modifiers of postoperative organ dysfunction
  • Identifying individual characteristics that enable or disable progression to organ dysfunction
  • Using big-data and machine learning to study organ dysfunction in perioperative and critical care settings
  • Duke Perioperative Enhancement Team (POET) clinics for optimization prior to surgery
    • Anemia clinic
    • Diabetes clinic
    • Nutrition optimization clinic
    • Pain clinic
    • Senior health clinic
    • Several other clinics that are planned
  • Metabolic phenotyping
    • Muscle assessment: muscle cross-sectional area, intramuscular adipose tissue (IMAT), and intramuscular glycogen content (IMGC) derived from comprehensive analyses of echo intensity and texture of ultrasound images and CT of different muscle groups
    • Assessment of resting energy expenditure (REE) and substrate utilization (carbohydrates, fats and protein) with use of indirect calorimetry (V02 and VC02) during ICU stay to tailor caloric need on a day-by-day basis
  • Prehabilitation: a strong relationship between the development of postoperative complications and aerobic fitness is well established. At the Duke Human Pharmacology and Physiology Laboratory (HPPL), we study how aerobic fitness improves postoperative recovery. These studies allow us to develop new interventions for our patients. At HPPL, we use a translational approach to metabolic and physiologic phenotyping in the preoperative period, and are exploring approaches to maximize the efficacy of preoperative exercise training.
    • Prehabilitation: nutrition and/or cardiopulmonary exercise testing (CPET)-guided exercise intervention
      • Impaired preoperative exercise capacity is associated with increased morbidity and mortality in the postoperative period across a wide range of pathologies and surgeries. Exercise-based prehabilitation strategies using CPET-guided structured responsive exercise training programs (SRETP) have shown to improve indices of aerobic fitness.
  • Enhanced recovery after surgery (ERAS) care pathways to promote early return of organ function following surgery
  • Duke hyperbaric facility for wound healing, carbon monoxide poisoning, decompression sickness, and oxygen toxicity

The Critical Care and Perioperative Epidemiologic Research (CAPER) Unit applies population health approaches using epidemiologic, health services research, implementation science, and large, multicenter clinical and administrative databases to improve perioperative and critical care outcomes.

CAPER provides:

  • Access to large, multicenter administrative databases to measure risk factors, treatments and outcomes in diverse populations of perioperative and critical care patients
  • Core support for cutting-edge techniques in epidemiology, causal inference, prediction, and data science
  • Subject matter experts leading a diverse portfolio of research expertise in major pillars of perioperative and critical care medicine, including:
    • Methods in epidemiology, causal inference and data science
    • Injury epidemiology
    • Nutrition, metabolism and resuscitation
    • Opioids and multimodal analgesia
    • Multi-organ dysfunction and outcomes
    • Implementation science
  • Weekly work-in-progress sessions, quarterly methods seminars, and education of students, residents, fellows, and faculty in population health methods