Perioperative and Anaesthetic-Related Mortality in Developed and Developing Countries: A Systematic Review and Meta-Analysis

Study Questions:

Has the risk of perioperative and anesthetic-related mortality related to surgery decreased over the past 5 decades, and if so, has this decline been comparable in developed and developing countries?


The authors performed a systematic review of papers published prior to February 2011, which reported perioperative mortality across a mixed surgical population, including patients who had undergone general anesthesia, and with a sample size greater than 3,000. Studies in any language were included. Two authors systematically, independently identified studies for inclusion and extracted data using standard data collection forms, including rates of anesthetic-related mortality, perioperative mortality, cardiac arrest, American Society of Anesthesiologists (ASA) physical status, geographic location, human development index (HDI), and year. The primary outcome of interest was anesthetic sole mortality, defined as death deemed attributable only to anesthesia. Secondary outcomes of interest were anesthetic contributory mortality, total perioperative mortality, and cardiac arrest. Meta-regression was done using the fixed-effect model and the random-effects model to calculate weighted event rates across all studies.


The authors identified 87 studies that met inclusion criteria, including more than 21.4 million anesthetic administrations for general anesthesia during surgery. Perioperative mortality rates decreased dramatically over time, from 10,603 per million (95% confidence interval [CI], 10,423-10,784) prior to the 1970s, down to 4,533 per million (95% CI, 4,405-4,664) during the 1970s and 1980s, and down to 1,176 per million (95% CI, 1,148-1,205) during the 1990s and 2000s (p < 0.00001). They also observed a significant decline in mortality solely attributable to anesthesia, from 357 per million (95% CI, 324-394) prior to the 1970s, down to 52 per million (95% CI, 42-64) during the 1970s and 1980s, and down to 34 per million (95% CI, 29-39) during the 1990s and 2000s (p < 0.00001). There was a significant association between mortality risk of all kinds and HDI (p < 0.00001). These improvements came despite a significant increase over these decades in the ASA score of patients who presented for surgery (p < 0.0001).


The authors concluded that despite increasing patient baseline risk, perioperative mortality has declined significantly over the past 50 years, with the greatest decline in developed countries.The authors also opined that global priority should be given to reducing total perioperative and anesthetic-related mortality by evidence-based best practices in developing countries.


The authors of this study are to be commended for the complexity of the study and the rigor with which they have approached a better understanding of perioperative risk. Incremental improvement over time can go unappreciated. This study demonstrates the magnitude of improvement—despite a trend toward the sicker patients—in the general safety of the surgical experience in developed countries. These data suggest that a more careful and rigorous application of current knowledge and technology, especially in less developed countries, could have an enormous impact. Given that the advances in medical knowledge and technology responsible for these improvements have already been made, these data suggest that the saving of many lives would be quite ‘simple’: Apply more broadly what we already know works.

Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Outcome Assessment (Health Care), Global Health, Developed Countries, Cardiovascular Diseases, Technology, Heart Arrest, Developing Countries, United States

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