Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery

Background:

Preoperative anemia may affect postoperative mortality and morbidity following elective cranial operations.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify elective cranial neurosurgical cases (2006-2012). Morbidity was defined as wound infection, systemic infection, cardiac, respiratory, renal, neurologic, and thromboembolic events, and unplanned returns to the operating room. For 30-day postoperative mortality and morbidity, adjusted odds ratios (ORs) were estimated with multivariable logistic regression.

Results:

Of 8015 patients who underwent elective cranial neurosurgery, 1710 patients (21.4%) were anemic. Anemic patients had an increased 30-day mortality of 4.1% versus 1.3% in non-anemic patients (P < 0.001) and an increased 30-day morbidity rate of 25.9% versus 14.14% in non-anemic patients (P < 0.001). The 30-day morbidity rates for all patients undergoing cranial procedures were stratified by diagnosis: 26.5% aneurysm, 24.7% sellar tumor, 19.7% extra-axial tumor, 14.8% intra-axial tumor, 14.4% arteriovenous malformation, and 5.6% pain. Following multivariable regression, the 30-day mortality in anemic patients was threefold higher than in non-anemic patients (4.1% vs 1.3%; OR = 2.77; 95% CI: 1.65-4.66). The odds of postoperative morbidity in anemic patients were significantly higher than in non-anemic patients (OR = 1.29; 95% CI: 1.03-1.61). There was a significant difference in postoperative morbidity event odds with a hematocrit level above (OR = 1.07; 95% CI: 0.78-1.48) and below (OR = 2.30; 95% CI: 1.55-3.42) 33% [hemoglobin (Hgb) 11 g/dl].

Conclusions:

Preoperative anemia in elective cranial neurosurgery was independently associated with an increased risk of 30-day postoperative mortality and morbidity when compared to non-anemic patients. A hematocrit level below 33% (Hgb 11 g/dl) was associated with a significant increase in postoperative morbidity.

Prevalence of frailty and its association with mortality in general surgery

BACKGROUND

We assessed the prevalence of frailty in an older acute general surgical population and its correlation with length of hospital stay, readmission to hospital, and 30- and 90-day mortality.

METHODS

In 3 acute surgical admission units, we assessed consecutive participants aged over 65 years with general surgical conditions. We measured the prevalence of frailty using a 7-point frailty score. We measured length of hospital stay, readmission to hospital, and mortality at both 30 and 90 days.

RESULTS

We studied 325 participants with an average age of 77.3 years 8.2 (standard deviation), 185 (57%) women. There were 88 (28%) participants who were classified as being mildly, moderately, or severely frail. The frail group spent longer in hospital (7.6 days, 95% confidence interval [CI] 6.1 to 9.2 vs 11.1, 95% CI 7.2 to 15.0; P = .03). They also were more likely to die at both 30 and 90 days (adjusted odds ratio [OR] 4.0, 95% CI 1.1 to 15.2, P = .04; OR 3.0, 95% CI 1.3 to 7.4, P = .02). Readmission to hospital did not differ (OR 1.1, 95% CI .5 to 2.3).

CONCLUSIONS

Over 1 in 4 people were frail. These individuals spent longer in hospital and were more likely to die.

Peri-operative management of older people undergoing surgery

Increasing numbers of older people are undergoing both emergency and elective surgery. However, they remain at increased risk of adverse outcome in comparison with younger patients. This may relate to the association of ageing with physiological deterioration, multi-morbidity and geriatric syndromes such as frailty, all of which are independent predictors of adverse post-operative outcome. Although there is an emerging evidence base for the identification and management of these predictors, this has not yet translated into routine clinical practice. Older patients undergoing surgery often receive sub-optimal care and surgical pathways are not well suited to complex older patients with multi-pathology. Evidence is emerging for alternative models of care that incorporate the evolving evidence base for optimal peri-operative management of the older surgical patient, including risk assessment and optimization. This article aims to provide a practical overview of the literature to all disciplines working in this field.