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Krishnan S, Brovman EY, Urman RD. Preoperative Cognitive Impairment as a Perioperative Risk Factor in Patients Undergoing Total Knee Arthroplasty. Geriatr Orthop Surg Rehabil 2021; 12:21514593211004533. [PMID: 35186420 PMCID: PMC8848037 DOI: 10.1177/21514593211004533] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 03/02/2021] [Indexed: 12/21/2022] Open
Abstract
Background: The study assessed whether pre-existing cognitive impairment (CI) prior to elective total knee arthroplasty (TKA) is associated with worse postoperative outcomes such as delirium, in-hospital medical complications, 30-day mortality, hospital length of stay and non-home discharge. Methods: A retrospective database analysis from the NSQIP Geriatric Surgery Pilot Project was used. There was an initial cohort of 6350 patients undergoing elective TKA, 104 patients with CI were propensity score matched to 104 patients without CI. Results: Analysis demonstrated a significantly increased incidence of post-operative delirium (POD) in the cohort with pre-op CI (p = < .001), a worsened functional status (p = < .001) and increased nonhome discharge postoperatively compared to the group without CI (p = 0.029). Other post-operative outcomes included 30-day mortality of 0% in both groups, and low rate of complications such as infection (2.88% vs 0.96%), pneumonia (1.92% vs 0%), failure to wean (0.96% vs 0%), and reintubation (0.96% vs 0%). Some other differences between the CI group and non-CI group, although not statistically significant, included increased rate of transfusion (10.58% vs 6.73%), and sepsis (1.92% vs 0%). The length of stay was increased in the non-CI group (4.28% vs 2.32%, p = 0.122). Conclusion: CI in patients undergoing TKA is associated with an increased risk of POD, worsened postoperative functional status, and discharge to non-home facility.
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Affiliation(s)
- Sindhu Krishnan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ethan Y. Brovman
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Anesthesiology and Perioperative Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Center for Perioperative Research, Brigham and Women’s Hospital, Boston, MA, USA
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152
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Ramírez-Martín R, Menéndez Colino R, Déniz González V, Gazo Martínez JA, Marijuán Martín JL, González-Montalvo JI. [The efficiency of «Cross-speciality Geriatrics» in the co-management of patients older than 80 years admitted to the General Surgery Service. Economic results]. Rev Esp Geriatr Gerontol 2021; 56:87-90. [PMID: 33518381 DOI: 10.1016/j.regg.2020.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine the efficiency of «Cross-speciality Geriatrics» program in patients older than 80 years admitted to the Colorectal Pathology Unit of a General Surgery Department. MATERIAL AND METHODS A «before-after» study was conducted. The initial period (usual treatment for General Surgery) included patients admitted from 1st January to 31st August 2018, and the subsequent period (with support from geriatrics) from 1st January to 31st December 2019. Two types of patients were studied: Type 1, who were admitted to the Emergency Department, and Type 2, programmed admissions for colorectal cancer intervention. The Geriatrics intervention consisted of daily monitoring in the ward, collaboration in clinical management, and discharge planning. Furthermore, in Type 2 patients, a previous visit was made in the clinic, which included the detection and approach of frailty and pre-habilitation for surgery. RESULTS A total of 175 patients were included, of whom 53 were treated by General Surgery and 122 with the co-management of geriatrics. The mean age was 84.9 years (SD 4.8). In the period with the Cross-speciality Geriatrics program, the mean stay was reduced by 10.6 days (39%), and 8.5 days (44%) in types 1 and 2, respectively (P < .01). This led to a decrease in bed occupancy (3.3 beds/day) and a cost reduction (1,215,970 € / year). CONCLUSIONS The support of Cross-speciality Geriatrics in patients older than 80 years admitted to General Surgery is an efficient care model. These data support its implementation in hospitals where this care line has not yet been developed.
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Affiliation(s)
| | - Rocío Menéndez Colino
- Servicio de Geriatría. Hospital Universitario La Paz, Madrid, España; Facultad de Medicina. Universidad Autónoma de Madrid, Madrid, España
| | | | | | | | - Juan Ignacio González-Montalvo
- Servicio de Geriatría. Hospital Universitario La Paz, Madrid, España; Facultad de Medicina. Universidad Autónoma de Madrid, Madrid, España
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153
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The Impact of the Aging Population on Surgical Diseases. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-020-00352-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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154
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Hallman MJ, Dorinsky N, Wang Y, Li Q, Isaak R, Kolarczyk L, Kim HJ, Lobonc AJ. Objective postoperative pain assessment using incentive spirometry values: a prospective observational study. Pain Manag 2021; 11:315-324. [PMID: 33533288 DOI: 10.2217/pmt-2020-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Determine if incentive spirometry (IS) values correlate with postoperative pain control. Design: Prospective observational study. Setting & participants: A total of 100 patients undergoing major abdominal procedures at the University of North Carolina Medical Center. Interventions: Patients studied as a single cohort. All patients received thoracic epidural analgesia preoperatively. Outcome: Preoperative and daily postoperative numeric pain scores, subjective pain description and IS values were collected for all patients. Results: There was a strong correlation with IS values relative to baseline for both the numeric pain scores (p < 0.0001), postoperative day (p < 0.0001) and the subjective pain score (p < 0.0007). Conclusion: IS values are an objective surrogate data point for pain control after surgery, particularly when followed over time and compared with a preoperative baseline value.
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Affiliation(s)
- Matthew J Hallman
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Nancy Dorinsky
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Yueting Wang
- Department of Biostatistics, University of North Carolina Gillings School of Public Health, Chapel Hill, NC 27599-7400, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina Gillings School of Public Health, Chapel Hill, NC 27599-7400, USA
| | - Robert Isaak
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
| | - Hong J Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27599-7050, USA
| | - Andrew J Lobonc
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC 27599-7010, USA
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155
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Humeidan ML, Reyes JPC, Mavarez-Martinez A, Roeth C, Nguyen CM, Sheridan E, Zuleta-Alarcon A, Otey A, Abdel-Rasoul M, Bergese SD. Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery: The Neurobics Randomized Clinical Trial. JAMA Surg 2021; 156:148-156. [PMID: 33175114 DOI: 10.1001/jamasurg.2020.4371] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Postoperative delirium in older adults is a common and costly complication after surgery. Cognitive reserve affects the risk of postoperative delirium, and thus preoperative augmentation of reserve as a preventive technique is of vital interest. Objective To determine whether cognitive prehabilitation reduces the incidence of postoperative delirium among older adults. Design, Setting, and Participants This was a prospective, single-blinded randomized clinical trial conducted from March 2015 to August 2019 at the Ohio State University Wexner Medical Center in Columbus. Patients 60 years and older undergoing major, noncardiac, nonneurological surgery under general anesthesia, with an expected hospital stay of at least 72 hours, were eligible for trial inclusion. Patients were excluded for preoperative cognitive dysfunction and active depression. Interventions Participation in electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions. Main Outcomes and Measures The primary outcome was incidence of delirium between postoperative day 0 to day 7 or discharge, as measured by a brief Confusion Assessment Method, Memorial Delirium Assessment Scale, or a structured medical record review. Secondary outcomes compared delirium characteristics between patients in the intervention and control groups. Results Of the 699 patients approached for trial participation, 322 completed consent and 268 were randomized. Subsequently, 17 patients were excluded, leaving 251 patients in the primary outcome analysis. A total of 125 patients in the intervention group and 126 control patients were included in the final analysis (median [interquartile range] age, 67 [63-71] years; 163 women [64.9%]). Ninety-seven percent of the patients in the intervention group completed some brain exercise (median, 4.6 [interquartile range, 1.31-7.4] hours). The delirium rate among control participants was 23.0% (29 of 126). With intention-to-treat analysis, the delirium rate in the intervention group was 14.4% (18 of 125; P = .08). Post hoc analysis removed 4 patients who did not attempt any cognitive exercise from the intervention group, yielding a delirium rate of 13.2% (16 of 121; P = .04). Secondary analyses among patients with delirium showed no differences in postoperative delirium onset day or duration or total delirium-positive days across study groups. Conclusions and Relevance The intervention lowered delirium risk in patients who were at least minimally compliant. The ideal activities, timing, and effective dosage for cognitive exercise-based interventions to decrease postoperative delirium risk and burden need further study. Trial Registration ClinicalTrials.gov Identifier: NCT02230605.
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Affiliation(s)
- Michelle L Humeidan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus
| | - Joshua-Paolo C Reyes
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus
| | - Ana Mavarez-Martinez
- Renaissance School of Medicine, Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Cory Roeth
- Boonshoft School of Medicine, Wright State University, Dayton, Ohio
| | - Christopher M Nguyen
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus
| | - Elizabeth Sheridan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus
| | - Alix Zuleta-Alarcon
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus
| | - Andrew Otey
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus
| | - Mahmoud Abdel-Rasoul
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus
| | - Sergio D Bergese
- Renaissance School of Medicine, Department of Anesthesiology, Stony Brook University, Stony Brook, New York
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156
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Udelsman BV, Govea N, Cooper Z, Chang DC, Bader A, Meyer MJ. Variation in Patient-Reported Advance Care Preferences in the Preoperative Setting. Anesth Analg 2021; 132:210-216. [PMID: 31923000 DOI: 10.1213/ane.0000000000004617] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND High-quality shared decision-making for patients undergoing elective surgical procedures includes eliciting patient goals and treatment preferences. This is particularly important, should complications occur and life-sustaining therapies be considered. Our objective was to determine the preoperative care preferences of older higher-risk patients undergoing elective procedures and to determine any factors associated with a preference for limitations to life-sustaining treatments. METHODS Cross-sectional survey conducted between May and December 2018. Patients ≥55 years of age presenting for a preprocedural evaluation in a high-risk anesthesia clinic were queried on their desire for life-sustaining treatments (cardiopulmonary resuscitation, mechanical ventilation, dialysis, and artificial nutrition) as well as tolerance for declines in health states (physical disability, cognitive disability, and daily severe pain). RESULTS One hundred patients completed the survey. The median patient age was 68. Most patients were Caucasian (87%) and had an American Society of Anesthesiologists (ASA) score of III (88%). The majority of patients (89%) desired cardiopulmonary resuscitation. However, most patients would not accept mechanical ventilation, dialysis, or artificial nutrition for an indefinite period of time. Similarly, most patients (67%-81%) indicated they would not desire treatments to sustain life in the event of permanent physical disability, cognitive disability, or daily severe pain. CONCLUSIONS Among older, higher-risk patients presenting for elective procedures, most patients chose limitations to life-sustaining treatments. This work highlights the need for an in-depth goals of care discussion and establishment of advance care preferences before a procedure or operative intervention.
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Affiliation(s)
- Brooks V Udelsman
- From the Department of Surgery, Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts
| | - Nicolas Govea
- Department of Anesthesiology, NewYork-Presbyterian-Weill Cornell Medical Center, New York, New York
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Surgery, Center for Surgery and Public Health, Boston, Massachusetts
| | - David C Chang
- From the Department of Surgery, Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts
| | - Angela Bader
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew J Meyer
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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157
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Thillainadesan J, Jansen J, Close J, Hilmer S, Naganathan V. Geriatrician perspectives on perioperative care: a qualitative study. BMC Geriatr 2021; 21:68. [PMID: 33468061 PMCID: PMC7816344 DOI: 10.1186/s12877-021-02019-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022] Open
Abstract
Background Perioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services. Methods A qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach. Results Geriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development. Conclusions Geriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02019-x.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia. .,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia. .,Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia.
| | - Jesse Jansen
- Centre Wiser Healthcare, and Sydney Health Literacy Lab, School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jacqui Close
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, and Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Sarah Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Sydney, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Centre for Education and Research on Ageing, and Ageing and Alzheimers Institute, Sydney, Australia
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158
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Kwak MJ, Avritscher E, Holmes HM, Jantea R, Flores R, Rianon N, Chung TH, Balan P, Dhoble A. Delirium Among Hospitalized Older Adults With Acute Heart Failure Exacerbation. J Card Fail 2021; 27:453-459. [PMID: 33347994 DOI: 10.1016/j.cardfail.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Delirium among older adults hospitalized with acute heart failure is associated with increased mortality. However, studies concomitantly assessing the association of delirium with both clinical and economic outcomes in this population, such as mortality, hospital cost, or length of stay, are lacking. METHODS AND RESULTS We conducted a retrospective observational study using National Inpatient Sample data from 2011 to 2014. Using multivariable logistic regression, we assessed the association of delirium with in-hospital mortality, then estimated the incremental hospital cost and excessive length of stay adjusting for demographic and clinical factors using multivariable generalized linear regression. The association of other medical complications on clinical and economic outcomes was also assessed. A total of 568,565 (weighted N = 2,826,131) hospitalizations of patients 65 years or older with acute heart failure from 2011 to 2014 were included in the final analysis. The reported prevalence of delirium was 4.53%. After multivariable adjustment, delirium was associated with a 2.35-fold increase in the odds of in-hospital mortality (95% confidence interval [CI] 2.23-2.47), which was lower than the odds ratio for sepsis/septicemia (5.36; 95% CI, 5.02-5.72) or respiratory failure (4.53; 95% CI, 4.38-4.69), but similar to that for acute kidney injury (2.39; 95% CI, 2.31-2.48) and higher than for non-ST elevation myocardial infarct (1.57; 95% CI, 1.46-1.68). Delirium increased the total hospital cost by $4,262 (95% CI, $4,002-4,521) and the length of stay by 1.73 days (95% CI, 1.68-1.78), which was slightly lower than, but similar to, acute kidney injury ($4,771; 95% CI, $4,644-4,897) and 1.82 days (95% CI, 1.79-1.84), and higher than non-ST elevation myocardial infarct ($1,907; 95% CI, $1,629-2,185) and 0.31 days (95% CI, 0.25-0.37). CONCLUSIONS Delirium was associated with increased in-hospital mortality, total hospital cost, and length of stay, and the magnitude of the effect was similar to that for acute kidney injury. Enhanced efforts to prevent delirium are needed to decrease its adverse impact on clinical and economic outcomes for hospitalized older adults with acute heart failure.
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Affiliation(s)
- Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Elenir Avritscher
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Holly M Holmes
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Rachel Jantea
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Renee Flores
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Nahid Rianon
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas; Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Tong Han Chung
- Healthcare Transformation Initiatives, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Prakash Balan
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Abhijeet Dhoble
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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159
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Guidance for Improving Surgical Care and Recovery in Urogynecologic Surgery. Female Pelvic Med Reconstr Surg 2021; 27:223-224. [PMID: 33770804 DOI: 10.1097/spv.0000000000001004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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160
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Zhang Y, Ma L, Wang T, Xiao W, Lu S, Kong C, Wang C, Li X, Li Y, Yin C, Yan S, Li Y, Yang K, Chan P. Protocol for evaluation of perioperative risk in patients aged over 75 years: Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT study). BMC Geriatr 2021; 21:14. [PMID: 33407187 PMCID: PMC7788705 DOI: 10.1186/s12877-020-01956-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/10/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND With the extended life expectancy of the Chinese population and improvements in surgery and anesthesia techniques, the number of aged patients undergoing surgery has been increasing annually. However, safety, effectiveness, and quality of life of aged patients undergoing surgery are facing major challenges. In order to standardize the perioperative assessment and procedures, we have developed a perioperative evaluation and auxiliary decision-making system named "Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT)". METHODS We will conduct a perioperative risk evaluation and targeted intervention, with follow-ups at 1, 3, and 6 months after surgery. The primary objective of the study is to evaluate the effectiveness of the "Aged Patient Perioperative Longitudinal Evaluation-Multiple Disciplinary Trial Path" (hereinafter referred to as the APPLE-MDT path) in surgical decision-making for aged patients (≥75 years) undergoing elective surgery under non-local anesthesia in the operating room. The secondary objectives of the study are to evaluate the postoperative outcome and health economics of the APPLE-MDT path applied to the surgical decision-making of aged patients (≥75 years) undergoing elective surgery under non-local anesthesia and to optimize intervention strategies for aged patients undergoing surgery to reduce the occurrence of postoperative complications and improve the quality of life after surgery. DISCUSSION It is necessary to formulate a reliable, effective, and concise evaluation tool, which can effectively predict the perioperative complications and mortality of aged patients, support targeted intervention strategies, and allow for a more comprehensive risk and benefit analysis, thereby forming an effective senile perioperative surgery management path. It is expected that the implementation of this protocol can reduce the occurrence of postoperative complications, improve the postoperative quality of life, shorten hospital stay, reduce hospitalization expenses, reduce social burden, and allow the elderly to have a good quality of life after surgery. TRIAL REGISTRATION ChiCTR, ChiCTR1800020363 , Registered 15 December 2018.
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Affiliation(s)
- Yanhong Zhang
- Medical Administration Division, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
- China National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Lina Ma
- Department of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Shibao Lu
- Department of Orthopaedics, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Chao Kong
- Department of Orthopaedics, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Chaodong Wang
- China National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Xiaoying Li
- Medical Administration Division, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Yun Li
- Department of Geriatrics, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Chunlin Yin
- Department of Cardiology, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Suying Yan
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Ying Li
- Department of Nutrition, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China
| | - Piu Chan
- China National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China.
- Department of Neurology and Neurobiology, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China.
- Department of Neurology, Xuanwu Hospital of Capital Medical University, Beijing, 100053, China.
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161
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Peden CJ, Miller TR, Deiner SG, Eckenhoff RG, Fleisher LA. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team. Br J Anaesth 2021; 126:423-432. [PMID: 33413977 DOI: 10.1016/j.bja.2020.10.037] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022] Open
Abstract
Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.
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Affiliation(s)
- Carol J Peden
- Department of Anesthesiology, Keck Medicine of the University of Southern California, Los Angeles, CA, USA.
| | | | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Centre, Lebanon, NH, USA
| | - Roderic G Eckenhoff
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lee A Fleisher
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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162
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Preoperative Assessment of Geriatric Surgical Patients: Update on Clinical Scales Used for Elective General and Digestive Surgery. Surg Laparosc Endosc Percutan Tech 2021; 31:368-375. [PMID: 33399357 DOI: 10.1097/sle.0000000000000896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 11/16/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Higher life expectancy in the general population entails a growing interest in the surgical management of diseases affecting elderly patients. Preoperative assessment when planning surgery needs to carefully evaluate physical and functional status of the patient. This review aims to describe the most commonly used scales in the evaluation of elderly patients scheduled for surgery and provides a useful tool to decide the scales that would be better to assess these specific patients. METHODS According to the PRISMA statement of publications published, we have carried out a systematic review focused on elderly patients who underwent surgical procedures in General and Surgery. Using Medline, Embase, and Cochrane library, a systematic search of the literature from 1992 to 2018 was performed. This enabled us to retrieve information from the selected articles on scales to evaluate medical fitness, functional status, or both, in the elderly or frail patients. RESULTS We reviewed 102 articles and selected the most frequently used assessment scales or indexes. After this extensive analysis, we selected 4 functional scales (Katz Index, Barthel Scale, Karnofsky Performance Score, and Vulnerable Elders Survey), 4 clinical scales (American Society of Anaesthesiologists Index, Charlson Comorbidity Index, Pfeiffer Test, and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity Scale) and finally, 2 mixed scales (American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator and Edmonton Frail Scale). CONCLUSIONS No consensus on the use of a unified assessment scale for elderly patients exists. However, with this review, we provide a brief guideline about the most useful and used scales to perform a comprehensive assessment of geriatric patients undergoing surgery.
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Shanker A, Upadhyay P, Rangasamy V, Muralidhar K, Subramaniam B. Impact of frailty in cardiac surgical patients-Assessment, burden, and recommendations. Ann Card Anaesth 2021; 24:133-139. [PMID: 33884967 PMCID: PMC8253036 DOI: 10.4103/aca.aca_90_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.
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Affiliation(s)
- Akshay Shanker
- Department of Anesthesia, Critical Care, and Pain Medicine, Lewis Katz School of Medicine at Temple University, 3500 North Broad St., Philadelphia, Pennsylvania; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Preeti Upadhyay
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Valluvan Rangasamy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Kanchi Muralidhar
- Department of Anesthesia, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya Health City, Bengaluru, Karnataka, India
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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164
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Aitken R, Harun NS, Maier AB. Which preoperative screening tool should be applied to older patients undergoing elective surgery to predict short-term postoperative outcomes? Lessons from systematic reviews, meta-analyses and guidelines. Intern Emerg Med 2021; 16:37-48. [PMID: 32613471 PMCID: PMC7843484 DOI: 10.1007/s11739-020-02415-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/20/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older surgical patients have a higher risk of postoperative mortality and morbidity compared to younger patients. Timely identification of high-risk patients facilitates comprehensive preoperative evaluation, optimization, and resource allocation to help reduce this risk. This review aims to identify a preoperative screening tool for older patients undergoing elective surgery predictive of poor short-term postoperative outcomes. METHODS A scoping review was conducted. An Ovid MEDLINE search was used to identify systematic reviews or meta-analyses comprising older elective patients in at least two different surgical settings. International guidelines were reviewed for recommendations regarding preoperative tools in this population. RESULTS Over 50 screening tools were identified. The majority showed a positive association with short-term postoperative mortality and morbidity in older patients. The most commonly described tools were the American Society of Anesthesiologists Physical Status (ASA-PS), frailty tools and domain-specific tools administered as part of comprehensive geriatric assessment (CGA). Due to heterogeneity in outcome measures and statistical methodology the predictive capacity between tools could not be compared. International guidelines described a comprehensive preoperative approach incorporating domain-specific tools rather than recommending a screening tool. CONCLUSION Multiple tools were associated with poor short-term postoperative outcomes in older elective surgical patients. No single superior tool could be identified. Frailty, cognitive and/or functional tools were most frequently utilized.
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Affiliation(s)
- Rachel Aitken
- Department of Medicine and Aged Care, The University of Melbourne, The Royal Melbourne Hospital, @AgeMelbourne, Parkville, VIC, Australia
| | - Nur-Shirin Harun
- Department of Medicine, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrea Britta Maier
- Department of Medicine and Aged Care, The University of Melbourne, The Royal Melbourne Hospital, @AgeMelbourne, Parkville, VIC, Australia.
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, @AgeAmsterdam, Amsterdam, The Netherlands.
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Schenning KJ, Holden S, Davis BA, Mulford A, Nevonen KA, Quinn JF, Raber J, Carbone L, Alkayed NJ. Gene-Specific DNA Methylation Linked to Postoperative Cognitive Dysfunction in Apolipoprotein E3 and E4 Mice. J Alzheimers Dis 2021; 83:1251-1268. [PMID: 34420963 PMCID: PMC8801332 DOI: 10.3233/jad-210499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Geriatric surgical patients are at higher risk of developing postoperative neurocognitive disorders (NCD) than younger patients. The specific mechanisms underlying postoperative NCD remain unknown, but they have been linked to genetic risk factors, such as the presence of APOE4, compared to APOE3, and epigenetic modifications caused by exposure to anesthesia and surgery. OBJECTIVE To test the hypothesis that compared to E3 mice, E4 mice exhibit a more pronounced postoperative cognitive impairment associated with differential DNA methylation in brain regions linked to learning and memory. METHODS 16-month-old humanized apolipoprotein-E targeted replacement mice bearing E3 or E4 were subjected to surgery (laparotomy) under general isoflurane anesthesia or sham. Postoperative behavioral testing and genome-wide DNA methylation were performed. RESULTS Exposure to surgery and anesthesia impaired cognition in aged E3, but not E4 mice, likely due to the already lower cognitive performance of E4 prior to surgery. Cognitive impairment in E3 mice was associated with hypermethylation of specific genes, including genes in the Ephrin pathway implicated in synaptic plasticity and learning in adults and has been linked to Alzheimer's disease. Other genes, such as the Scratch Family Transcriptional Repressor 2, were altered after surgery and anesthesia in both the E3 and E4 mice. CONCLUSION Our findings suggest that the neurocognitive and behavioral effects of surgery and anesthesia depend on baseline neurocognitive status and are associated with APOE isoform-dependent epigenetic modifications of specific genes and pathways involved in memory and learning.
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Affiliation(s)
- Katie J. Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Sarah Holden
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
| | - Brett A. Davis
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Amelia Mulford
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
| | - Kimberly A. Nevonen
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joseph F. Quinn
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Jacob Raber
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Department of Radiation Medicine, Division of Neuroscience, ONPRC, Portland, OR, USA
| | - Lucia Carbone
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
- Division of Genetics, Oregon National Primate Research Center, Portland, OR, USA
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Nabil J. Alkayed
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Donovan AL, Braehler MR, Robinowitz DL, Lazar AA, Finlayson E, Rogers S, Douglas VC, Whitlock EL. An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults. Anesth Analg 2020; 131:1911-1922. [PMID: 33105281 DOI: 10.1213/ane.0000000000005223] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution. METHODS This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night. RESULTS During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline. CONCLUSIONS A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.
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Affiliation(s)
- Anne L Donovan
- From the Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care
| | | | | | - Ann A Lazar
- Department of Preventive and Dental Sciences.,Department of Epidemiology and Biostatistics
| | - Emily Finlayson
- Department of Surgery and Philip R. Lee Institute for Health Policy Studies.,Division of Geriatrics, Department of Medicine
| | | | - Vanja C Douglas
- Department of Neurology, University of California, San Francisco, California
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Braghiroli KS, Einav S, Heesen MA, Villas Boas PJF, Braz JRC, Corrente JE, Porto DDSM, Morais AC, Neves GC, Braz MG, Braz LG. Perioperative mortality in older patients: a systematic review with a meta-regression analysis and meta-analysis of observational studies. J Clin Anesth 2020; 69:110160. [PMID: 33338975 DOI: 10.1016/j.jclinane.2020.110160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE Older patients have a higher probability of developing major complications during the perioperative period than other adult patients. Perioperative mortality depends on not only on a patient condition but also on the quality of perioperative care provided. We tested the hypothesis that the perioperative mortality rate among older patients has decreased over time and is related to a country's Human Development Index (HDI) status. DESIGN A systematic review with a meta-regression and meta-analysis of observational studies that reported perioperative mortality rates in patients aged ≥60 years was performed. We searched the PubMed, EMBASE, LILACS and SciELO databases from inception to December 30, 2019. SETTING Mortality rates up to the seventh postoperative day were evaluated. MEASUREMENTS We evaluated the quality of the included studies. Perioperative mortality rates were analysed by time, country HDI status and baseline American Society of Anesthesiologists (ASA) physical status using meta-regression. Perioperative mortality and ASA status were analysed in low- and high-HDI countries during two time periods using proportion meta-analysis. MAIN RESULTS We included 25 studies, which reported 4,412,100 anaesthesia procedures and 3568 perioperative deaths from 12 countries. Perioperative mortality rates in high-HDI countries decreased over time (P = 0.042). When comparing pre-1990 to 1990-2019, in high-HDI countries, the perioperative mortality rates per 10,000 anaesthesia procedures decreased 7.8-fold from 100.85 (95% CI 43.36 to 181.72) in pre-1990 to 12.98 (95% CI 6.47 to 21.70) in 1990-2019 (P < 0.0001). There were no studies from low-HDI countries pre-1990. In the period from 1990 to 2019, perioperative mortality rates did not differ between low- and high-HDI countries (P = 0.395) but the limited number of patients in low-HDI countries impaired the result. Perioperative mortality rates increased with increasing ASA status (P < 0.0001). There were more ASA III-V patients in high-HDI countries than in low-HDI countries (P < 0.0001), and the perioperative mortality rate increased 24-fold in ASA III-V patients compared with ASA I-II patients (P < 0.0001). CONCLUSION The perioperative mortality rates in older patients have declined over the past 60 years in high-DHI countries, highlighting that perioperative safety in this population is increasing in these countries. Since data prior to 1990 were lacking in low-HDI countries, the evolution of their mortality rates could not be analysed. The perioperative mortality rate was similar in low- and high-HDI countries in the post-1990 period, but the low number of patients in the low-HDI countries does not allow a definitive conclusion.
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Affiliation(s)
- Karen S Braghiroli
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Sharon Einav
- Shaare Zedek Medical Centre, Jerusalem, Israel; Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Michael A Heesen
- Department of Anaesthesia, Kantonsspital Baden, Baden, Switzerland
| | - Paulo J F Villas Boas
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Jose R C Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Jose E Corrente
- Department of Biostatistics, Institute of Biosciences, Sao Paulo State University - UNESP, Brazil
| | - Daniela de S M Porto
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Arthur C Morais
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Gabriel C Neves
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Mariana G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil
| | - Leandro G Braz
- Anaesthesia Cardiac Arrest and Mortality Study Commission, Department of Surgical Specialties and Anaesthesiology, Botucatu Medical School, Sao Paulo State University - UNESP, Brazil.
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Dworsky JQ, Shellito AD, Childers CP, Copeland TP, Maggard-Gibbons M, Tan HJ, Saliba D, Russell MM. Association of Geriatric Events With Perioperative Outcomes After Elective Inpatient Surgery. J Surg Res 2020; 259:192-199. [PMID: 33302219 DOI: 10.1016/j.jss.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/14/2020] [Accepted: 11/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Older adults undergoing surgery are at risk for geriatric events (GEs: delirium, dehydration, falls or fractures, failure to thrive, and pressure ulcers). The prevalence and association of GEs with clinical outcomes after elective surgery is unclear. MATERIALS AND METHODS Using the 2013-2014 National Inpatient Sample, we analyzed hospital admissions for the five most common elective procedures (total knee arthroplasty, right hemicolectomy, carotid endarterectomy, aortic valve replacement, and radical prostatectomy) in older adults (age ≥ 65). Our primary variable of interest was presence of any GE. Logistic regression estimated the association of GEs with (1) age group and (2) perioperative outcomes (mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility). RESULTS Of 1,255,120 admissions, 66.5% were aged ≥65. The overall rate of any GE was 2.4% and increased with age (55-64 y: 1.5%; 65-74: 2.2%; ≥75: 4.1%; P < 0.001). After adjustment, the probability of any GE increased with age (P < 0.001). Rates of GEs varied by procedure (P < 0.001). In comparison with admissions with no GEs, one or more GE was associated with higher probability of worse outcomes including mortality, postoperative complications, prolonged length of stay, and discharge to skilled nursing facility (all P < 0.001). In addition, there was a dose-dependent relationship between GEs and these poor perioperative outcomes. CONCLUSIONS GEs are strongly associated with poor perioperative outcomes. Efforts should focus on mutable factors responsible for GEs to optimize surgical care for older adults.
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Affiliation(s)
- Jill Q Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California.
| | - Adam D Shellito
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance California.
| | | | - Timothy P Copeland
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Debra Saliba
- Los Angeles VA GRECC & UCLA Borun Center, Los Angeles, California
| | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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Klose P, Lorenzen U, Berndt R, Borzikowsky C, Hill M, Gruenewald M, Elke G, Renner J. Continuous noninvasive monitoring of arterial pressure using the vascular unloading technique in comparison to the invasive gold standard in elderly comorbid patients: A prospective observational study. Health Sci Rep 2020; 3:e204. [PMID: 33204849 PMCID: PMC7654630 DOI: 10.1002/hsr2.204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/09/2020] [Accepted: 10/13/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND AIMS Elderly patients aged ≥65 years represent a growing population in the perioperative field, particularly orthopedic and vascular surgery. The higher degree of age-related or comorbid-dependent vascular alterations renders these patients at risk for hemodynamic complications and likely denote a possible limitation for modern, non-invasive arterial pressure monitoring devices. The aim was to compare vascular unloading technique-derived to invasive measurements of systolic (SAP), diastolic (DAP), and mean arterial pressure (MAP) in elderly perioperative patients. METHODS This prospective observational study included patients aged ≥65 years scheduled for orthopedic and patients ≥50 years with peripheral artery disease Fontaine stage ≥ II scheduled for vascular surgery, respectively. Invasive radial artery and non-invasive finger-cuff (Nexfin system) arterial pressures were recorded before and after induction of general anesthesia and during surgery. Correlation, Bland-Altman, and concordance analyses were performed. Measurements of arterial pressure were also compared during intraoperative hypotension (MAP <70 mm Hg) and hypertension (MAP >105 mm Hg). RESULTS Sixty patients with orthopedic (N = 25, mean (SD) age 77 (5) years) and vascular surgery (N = 35, age 69 [10] years) were enrolled. Seven hundred data pairs of all patients were analysed and pooled bias and percentage error were: SAP: 14.43 mm Hg, 43.79%; DAP: -2.40 mm Hg, 53.78% and MAP: 1.73 mm Hg, 45.05%. Concordance rates were 84.01% for SAP, 77.87% for DAP, and 86.47% for MAP. Predefined criteria for interchangeability of absolute and trending values could neither be reached in the overall nor in the subgroup analyses orthopedic vs vascular surgery. During hypertension, percentage error was found to be lowest for all pressure values, still not reaching predefined criteria. CONCLUSION Arterial pressure monitoring with the vascular unloading technique did not reach criteria of interchangeability for absolute and trending values. Nevertheless, the putatively beneficial use of noninvasive arterial pressure measurements should be further evaluated in the elderly perioperative patient.
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Affiliation(s)
- Phil Klose
- Department of Anaesthesiology and Intensive Care MedicineUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Ulf Lorenzen
- Department of Anaesthesiology and Intensive Care MedicineUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Rouven Berndt
- Department of Cardiovascular SurgeryUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and StatisticsChristian‐Albrechts‐University Kiel, University Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Moritz Hill
- Department of Anaesthesiology and Intensive Care MedicineUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Matthias Gruenewald
- Department of Anaesthesiology and Intensive Care MedicineUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care MedicineUniversity Medical Center Schleswig‐Holstein, Campus KielKielGermany
| | - Jochen Renner
- Department of AnesthesiologyHelios Kliniken SchwerinSchwerinGermany
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Wright FC, Hsu AT, Hallet J. Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment. JAMA Surg 2020; 155:e203754. [PMID: 33026417 DOI: 10.1001/jamasurg.2020.3754] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Functional outcomes are central to cancer care decision-making by older adults. Objective To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure. Design, Setting, and Participants This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018. Main Outcomes and Measures The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used. Results A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time. Conclusions and Relevance This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Frances C Wright
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre-Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
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Butler DC. Dermatology's Management of Flagship Diseases in Older Adults: Lifting the Blindfold. JAMA Dermatol 2020; 156:1175-1176. [PMID: 32822493 DOI: 10.1001/jamadermatol.2020.2310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Daniel C Butler
- Department of Dermatology, University of California, San Francisco
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172
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Abstract
Curative-intent surgery is the treatment of choice for thoracic malignancies, including lung cancer. There is significant complexity and uncertainty associated with the diagnosis, prognosis, and surgical treatment decision-making in thoracic surgery. From a patient point of view, this complexity and uncertainty can be overwhelming. Therefore, for high-quality cancer care, an emphasis on patient-centered care-including the improvement in quality of life (QOL) through symptom and functional monitoring-is essential. Using the current literature and our previous research, the purpose of this paper is to: (I) review the current evidence on symptom and functional monitoring in surgery; (II) describe strategies to monitor symptoms and functional recovery in surgery; and (III) describe a model of patient-centered care in thoracic surgery.
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Affiliation(s)
- Virginia Sun
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - Jae Kim
- Division of Thoracic Surgery, Department of Surgery, City of Hope, Duarte, CA, USA
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173
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Abstract
The number of older adults with cancer is growing in the United States, and there is a relative paucity of data relating the presence of frailty with its outcomes of interest. The authors present the surgical oncology, radiation oncology, and medical oncology literature with respect to the presence of frailty in older adults with cancer. More research is needed to understand how the presence of frailty should be used by surgical, radiation, and medical oncologists to guide patient counseling and treatment planning.
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Affiliation(s)
- Christina A Minami
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Cancer Institute, 450 Brookline Avenue, Yawkey 1274, Boston, MA 02215, USA
| | - Zara Cooper
- Division of Trauma, Burn, and Critical Care, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont Street, Suite 2-016, Boston, MA 02120, USA.
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174
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Sentí S, Gené C, Troya J, Pacho C, Nuñez R, Parrales M, Jimenez I, Fernandez-Llamazares J, Julian JF, Parés D. Comprehensive geriatric assessment: Influence on clinical results after colorectal surgery in advanced age patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 44:472-480. [PMID: 33199132 DOI: 10.1016/j.gastrohep.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/08/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The objective of this work was to analyse the postoperative clinical results of patients surgically treated for colorectal cancer in relation to the results of the preoperative comprehensive geriatric evaluation. METHODS Observational study in which postoperative morbidity and mortality at 30 and 90 days were analysed in a cohort of patients surgically treated for colorectal cancer according to age groups: group 1) between 75 and 79 years old; group 2) between 80 and 84 years old, and group 3) ≥85 years old. In addition to the anaesthetic risk assessment, patients were assessed with the Karnofsky, Barthel and Pfeiffer indexes. Mortality at 30 and 90 days after surgery was analysed in relation to the results of the comprehensive evaluation. RESULTS A total of 227 patients with colorectal cancer were included in the study period: 91 in group 1, 89 in group 2 and 47 in group 3. There were statistically significant differences in mortality at 30 days (p=0,029) but not at 90 days after surgery, according to age groups. Mortality at 90 days was significantly higher in patients with worse scores on the Karnofsky and Barthel scales. CONCLUSIONS Comprehensive geriatric assessment using different scales is a good tool to assess postoperative mortality in the mid-term postoperative period.
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Affiliation(s)
- Sara Sentí
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Clara Gené
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - José Troya
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Cristina Pacho
- Unidad de Geriatría de Agudos, Servicio Medicina Interna, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Raquel Nuñez
- Unidad de Geriatría de Agudos, Servicio Medicina Interna, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Mauricio Parrales
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Irene Jimenez
- Unidad de Atención al Ciudadano, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Jaume Fernandez-Llamazares
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - Joan-Francesc Julian
- Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España
| | - David Parés
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Germans Trias y Pujol, Universitat Autónoma de Barcelona, Badalona, Barcelona, España.
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175
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Hansen J, Rasmussen LS, Steinmetz J. Management of Ambulatory Anesthesia in Older Adults. Drugs Aging 2020; 37:863-874. [PMID: 33073330 DOI: 10.1007/s40266-020-00803-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.
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Affiliation(s)
- Joachim Hansen
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Lars Simon Rasmussen
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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176
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Dworsky JQ, Shenoy R, Childers CP, Russell MM. Older veterans undergoing inpatient surgery: What is the compliance with best practice guidelines? Surgery 2020; 169:356-361. [PMID: 33077200 DOI: 10.1016/j.surg.2020.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/01/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution. METHODS A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications. RESULTS The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care). CONCLUSION Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes.
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Affiliation(s)
- Jill Q Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rivfka Shenoy
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA; National Clinician Scholars Program, University of California, Los Angeles, CA
| | | | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA.
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177
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Wu S, Jackson N, Larson S, Ward KT. Teaching Geriatrics and Transitions of Care to Internal Medicine Resident Physicians. Geriatrics (Basel) 2020; 5:geriatrics5040072. [PMID: 33050060 PMCID: PMC7720122 DOI: 10.3390/geriatrics5040072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 11/21/2022] Open
Abstract
(1) Background: Internal medicine (IM) resident physicians need to be trained to care for older adults and transition them safely across care settings. Objective: The study purpose was to evaluate the efficacy of a curriculum in geriatrics assessment and communication skills for transitions of care (TOCs) to IM resident physicians. (2) Methods: IM residents rotated for 4 weeks on the geriatrics consult service at a large public teaching hospital, where they received didactic lectures and clinical experience in consultation and transitional care. The curriculum was designed to meet consensus guidelines for minimum geriatrics competencies expected of IM residents. Previously validated and published assessment tools were used for geriatrics knowledge and attitudes. Locally developed tools were used to directly observe and rate communication skills, and self-assess geriatrics assessment and health literacy skills. The curriculum was evaluated using a quasi-experimental, nonrandomized, single-group pre- and post-test observational design. Data on 31 subjects were collected over 18 months and analyzed using mixed-effects models. (3) Results: Average knowledge scores improved from 65% to 74% (Δ9%, 95% CI 4–13%, p < 0.001). Communication skills improved by an average of 1.15 points (95% CI 0.66–1.64, p < 0.001) on a 9-point scale. Attitudes did not change significantly. Self-rated confidence in geriatrics assessment and health literacy skills improved modestly. (4) Conclusions: The curriculum is effective in teaching basic geriatrics knowledge and communication skills, and increasing self-confidence in geriatrics assessment skills. In settings where an inpatient geriatrics consult service is feasible, the curriculum may be a model for combining geriatrics and TOC training.
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Affiliation(s)
- Shirley Wu
- Section of Geriatrics, Division of General Internal Medicine, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
- Lundquist Research Institute, Torrance, CA 90502, USA
- Correspondence:
| | - Nicholas Jackson
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Spencer Larson
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
| | - Katherine T. Ward
- Section of Geriatrics, Division of General Internal Medicine, Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
- Lundquist Research Institute, Torrance, CA 90502, USA
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178
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Guisado-Gil AB, Ramírez-Duque N, Barón-Franco B, Sánchez-Hidalgo M, De la Portilla F, Santos-Rubio MD. Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients. Res Social Adm Pharm 2020; 17:1306-1312. [PMID: 33023830 DOI: 10.1016/j.sapharm.2020.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/21/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. OBJECTIVE To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. METHODS We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. RESULTS Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p = 0.317). The mean LOS was 13 ± 12 vs. 11 ± 5 days in the pre-intervention and the intervention cohort, respectively (p = 0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p = 0.038) and those >75 years old (p = 0.043) was observed. No difference was detected in the mortality rate (p = 0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p = 0.004) and insulin reconciliation in patients with treated diabetes (p = 0.003) were statistically better in the intervention group. CONCLUSIONS No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.
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Affiliation(s)
- A B Guisado-Gil
- Unidad de Gestión Clínica Farmacia. Hospital Universitario Virgen del Rocío, Sevilla, Spain; Departamento de Farmacología. Facultad de Farmacia, Universidad de Sevilla, Sevilla, Spain.
| | - N Ramírez-Duque
- Unidad de Gestión Clínica Medicina Interna. Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - B Barón-Franco
- Unidad de Gestión Clínica Medicina Interna. Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - M Sánchez-Hidalgo
- Departamento de Farmacología. Facultad de Farmacia, Universidad de Sevilla, Sevilla, Spain
| | - F De la Portilla
- Unidad de Gestión Clínica Cirugía General y Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - M D Santos-Rubio
- Unidad de Gestión Clínica Farmacia. Hospital Juan Ramón Jiménez, Huelva, Spain
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179
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Do Not Resuscitate in the Operating Room: Suspend or Not to Suspend. CLIN NURSE SPEC 2020; 34:246-249. [PMID: 33009109 DOI: 10.1097/nur.0000000000000551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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180
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Vincenzi P, Starnari R, Faloia L, Grifoni R, Bucchianeri R, Chiodi L, Venezia A, Stronati M, Giampieri M, Montalti R, Gaudenzi D, De Pietri L, Boccoli G. Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery. Surg Open Sci 2020; 2:5-11. [PMID: 32885157 PMCID: PMC7453121 DOI: 10.1016/j.sopen.2020.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/21/2020] [Accepted: 07/13/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Limited studies have applied thoracic continuous spinal anesthesia in abdominal surgery, relying exclusively on opioids. This retrospective study analyzes 2 different schemes of thoracic continuous spinal anesthesia and postoperative analgesia in elderly patients undergoing major abdominal surgery. METHODS A total of 98 patients aged ≥ 75 years were divided into 2 groups. The control group (60 patients) received bupivacaine plus fentanyl, whereas the study group (38 patients) received bupivacaine plus ketamine and midazolam. Both received analogous postoperative continuous intrathecal analgesia. Several perioperative variables were evaluated. RESULTS Spinal anesthesia was performed without complications in all patients. Doses of noradrenaline administered, incidence of respiratory depression, need for intraoperative sedation, and time to first flatus were significantly reduced in the bupivacaine plus ketamine and midazolam group. CONCLUSION In a population of frail, elderly patients, thoracic continuous spinal anesthesia with local anesthetic plus midazolam and ketamine was superior to local anesthetic plus fentanyl. In the group receiving local anesthetic plus midazolam and ketamine, the incidence of respiratory depression was reduced, and doses of norepinephrine and intraoperative sedating medications were lower. Intraoperative anesthesia and postoperative analgesia were similar in both groups.
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Affiliation(s)
- Paolo Vincenzi
- Department of General Surgery, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Roberto Starnari
- Department of Anesthesiology, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Lucia Faloia
- Department of Anesthesiology, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Riccardo Grifoni
- Department of General Surgery, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Roberto Bucchianeri
- Department of General Surgery, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Leonardo Chiodi
- Department of General Surgery, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Alfredo Venezia
- Department of Anesthesiology, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Massimo Stronati
- Department of Anesthesiology, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Marina Giampieri
- Department of Anesthesiology, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University of Napoli, via Sergio Pansini n. 5, 80131, Napoli, Italy
| | - Diletta Gaudenzi
- Department of Perioperative Services, AOU “Ospedali Riuniti di Ancona”, via Conca n. 71, 60100, Ancona, Italy
| | - Lesley De Pietri
- Division of Anesthesiology and Intensive Care Unit, Sassuolo Hospital, Sassuolo, Italy
| | - Gianfranco Boccoli
- Department of General Surgery, IRCSS-INRCA, via della Montagnola n. 81, 60127, Ancona, Italy
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181
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Curtis MS, Forman NA, Donovan AL, Whitlock EL. Postoperative delirium: why, what, and how to confront it at your institution. Curr Opin Anaesthesiol 2020; 33:668-673. [PMID: 32796170 PMCID: PMC7489931 DOI: 10.1097/aco.0000000000000907] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE OF REVIEW The current article reviews the importance of postoperative delirium (POD), focusing on the older surgical population, and summarizes the best-practice guidelines about POD prevention and treatment which have been published within the last several years. We also describe our local experience with implementing a perioperative delirium risk stratification and prevention pathway, and review implementation science principles which others may find useful as they move toward risk stratification and prevention in their own institutions. RECENT FINDINGS There are few areas of consensus, backed by strong experimental data, in POD best-practice guidelines. Most guidelines recommend preoperative cognitive screening, nonpharmacologic delirium prevention measures, and avoidance of deliriogenic medications. The field of implementation science offers strategies for closing the evidence-practice gap, which we supplement with lessons learned from our own experience implementing a perioperative delirium risk stratification and prevention pathway. SUMMARY POD continues to be a serious perioperative complication commonly experienced by older adults. Growing appreciation of its prognostic implications and evidence behind multidisciplinary, collaborative, and focused prevention strategies rooted in implementation science have prompted several major groups to issue consensus guidelines. Adopting best practices POD risk stratification and prevention pathways will improve perioperative care for older adults.
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Affiliation(s)
- Michael S. Curtis
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Nell A. Forman
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Anne L. Donovan
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
| | - Elizabeth L. Whitlock
- Department of Anesthesia & Perioperative Care, University of California, San Francisco; 500 Parnassus Ave, San Francisco, CA 94143
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182
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Weyker PD, Webb CAJ, Flynn BC. Adverse Discharge Disposition (ADD): When Things Do Not ADD Up After Surgery. J Cardiothorac Vasc Anesth 2020; 35:490-491. [PMID: 33032858 DOI: 10.1053/j.jvca.2020.09.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Paul David Weyker
- Divisions of Critical Care and Interventional Pain Management, Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, South San Francisco, CA
| | - Christopher A J Webb
- Regional Anesthesia and Acute Pain Medicine, Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, South San Francisco, CA
| | - Brigid C Flynn
- University of Kansas Medical Center, Department of Anesthesiology, Kansas City, KS.
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183
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Logistic Regression Model in a Machine Learning Application to Predict Elderly Kidney Transplant Recipients with Worse Renal Function One Year after Kidney Transplant: Elderly KTbot. J Aging Res 2020; 2020:7413616. [PMID: 32922997 PMCID: PMC7453245 DOI: 10.1155/2020/7413616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022] Open
Abstract
Background Renal replacement therapy (RRT) is a public health problem worldwide. Kidney transplantation (KT) is the best treatment for elderly patients' longevity and quality of life. Objectives The primary endpoint was to compare elderly versus younger KT recipients by analyzing the risk covariables involved in worsening renal function, proteinuria, graft loss, and death one year after KT. The secondary endpoint was to create a robot based on logistic regression capable of predicting the likelihood that elderly recipients will develop worse renal function one year after KT. Method Unicentric retrospective analysis of a cohort was performed with individuals aged ≥60 and <60 years old. We analysed medical records of KT recipients from January to December 2017, with a follow-up time of one year after KT. We used multivariable logistic regression to estimate odds ratios for elderly vs younger recipients, controlled for demographic, clinical, laboratory, data pre- and post-KT, and death. Results 18 elderly and 100 younger KT recipients were included. Pretransplant immune variables were similar between two groups. No significant differences (P > 0.05) between groups were observed after KT on laboratory data means and for the prevalences of diabetes mellitus, hypertension, acute rejection, cytomegalovirus, polyomavirus, and urinary infections. One year after KT, the creatinine clearance was higher (P = 0.006) in youngers (70.9 ± 25.2 mL/min/1.73 m2) versus elderlies (53.3 ± 21.1 mL/min/1.73 m2). There was no difference in death outcome comparison. Multivariable analysis among covariables predisposing chronic kidney disease epidemiology collaboration (CKD-EPI) equation <60 mL/min/1.73 m2 presented a statistical significance for age ≥60 years (P = 0.01) and reduction in serum haemoglobin (P = 0.03). The model presented goodness-fit in the evaluation of artificial intelligence metrics (precision: 90%; sensitivity: 71%; and F 1 score: 0.79). Conclusion Renal function in elderly KT recipients was lower than in younger KT recipients. However, patients aged ≥60 years maintained enough renal function to remain off dialysis. Moreover, a learning machine application built a robot (Elderly KTbot) to predict in the elderly populations the likelihood of worse renal function one year after KT.
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184
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Boukovalas S, Goepfert RP, Smith JM, Mecham E, Liu J, Zafereo ME, Chang EI, Hessel AC, Hanasono MM, Gross ND, Yu P, Lewin JS, Lewis CM, Diaz EM, Weber RS, Myers JN, Offodile AC. Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center. Cancer 2020; 126:4905-4916. [PMID: 32931057 DOI: 10.1002/cncr.33185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer. METHODS We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS). RESULTS A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P = .002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS. CONCLUSION Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.
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Affiliation(s)
- Stefanos Boukovalas
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ryan P Goepfert
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - J Michael Smith
- Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, Texas
| | | | - Jun Liu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amy C Hessel
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew M Hanasono
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neil D Gross
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peirong Yu
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan S Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eduardo M Diaz
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey N Myers
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
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185
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Abstract
Geriatric patients are not just older adult patients. Aging brings about unique physiologic, psychological, and sociologic changes within individuals. Recognition of these unique characteristics and measuring for their impact; instituting mitigating strategies; using age-specific anesthetic measures; and performing a systematic, algorithmic care model in the postoperative period overseen by a multidisciplinary team brings about enhanced outcomes and improved quality of care for this expanding group of patients.
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Affiliation(s)
- Teresa S Jones
- Rocky Mountain Regional Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), VA Eastern Colorado Health Care System, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045.
| | - John T Moore
- Department of Surgery, Rocky Mountain Regional Medical Center Veterans Administration Healthcare, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045, USA
| | - Thomas N Robinson
- Rocky Mountain Regional Medical Center Veterans Affairs Medical Center, University of Colorado School of Medicine, 1700 North Wheeling Street, Aurora, CO 80045, USA
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186
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Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2020; 32:1647-1673. [PMID: 32651902 PMCID: PMC7508736 DOI: 10.1007/s40520-020-01624-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.
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187
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Elhage SA, Shao JM, Deerenberg EB, Prasad T, Colavita PD, Kercher KW, Augenstein VA, Todd Heniford B. Laparoscopic Ventral Hernia Repair in the Geriatric Population : An Assessment of Long-Term Outcomes and Quality of Life. Am Surg 2020; 86:1015-1021. [PMID: 32856944 DOI: 10.1177/0003134820942149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Laparoscopic ventral hernia repair (LVHR) has been shown to decrease wound complications and length of stay (LOS) but results in more postoperative discomfort. The benefits of LVHR for the growing geriatric population are unclear. The aim of our study is to evaluate long-term outcomes and quality of life (QOL) after LVHR in the geriatric population. METHODS A prospectively collected single-center database was queried for all patients who underwent LVHR (1999-2019). Age groups were defined as <40 (young), 40-64 (middle age), and ≥65 years (geriatric). QOL was assessed with the Carolinas Comfort Scale. RESULTS LVHR was performed in 1181 patients, of which 13.4% were young, 61.6% middle aged, and 25.0% geriatric. Hernia defect size (64.2 ± 94.4 vs 79.9 ± 102.4 vs 84.7 ± 110.0 cm2) and number of comorbidities (2.2 ± 2.1 vs 3.2 ± 2.2 vs 4.3 ± 2.2) increased with age (all P < .05). LOS increased with age (2.9 ± 2.5 vs 3.8 ± 2.9 vs 5.2 ± 5.3 days, P < .0001). Rates of postoperative cardiac events, pneumonia, respiratory failure, wound complication, reoperation, and death were similar (P > .05). Geriatric patients had increased rate of ileus and urinary retention (all P < .05). Overall recurrence rate was 5.7% with an average follow-up of 43.5 months, with no differences in recurrence between groups (P > .05). Geriatric patients had better overall QOL at 2 weeks (P = .0008) and similar QOL at 1, 6, and 12 months. DISCUSSION LVHR offers excellent results in the geriatric population. Despite having increased rates of comorbidities and larger hernia defects, which may relate to LOS, rates of complications and recurrence were similar compared with younger cohorts, with better short-term QOL.
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Affiliation(s)
- Sharbel A Elhage
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Jenny M Shao
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Eva B Deerenberg
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Tanushree Prasad
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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188
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Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Hsu AT, Hallet J. Immediate and Long-Term Health Care Support Needs of Older Adults Undergoing Cancer Surgery: A Population-Based Analysis of Postoperative Homecare Utilization. Ann Surg Oncol 2020; 28:1298-1310. [PMID: 32789531 DOI: 10.1245/s10434-020-08992-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA. METHODS This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used. RESULTS Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%). CONCLUSION Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.
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Affiliation(s)
- Tyler R Chesney
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Victoria Zuk
- Sunnybrook Research Institute, Toronto, ON, Canada
| | | | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Sunnybrook Health Sciences Centre - Odette Cancer Centre, Toronto, ON, Canada. .,Sunnybrook Research Institute, Toronto, ON, Canada. .,ICES, Toronto, ON, Canada.
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189
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Multi-disciplinary and pharmacological interventions to reduce post-operative delirium in elderly patients: A systematic review and meta-analysis. J Clin Anesth 2020; 67:110004. [PMID: 32768990 DOI: 10.1016/j.jclinane.2020.110004] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 06/19/2020] [Accepted: 07/17/2020] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE An estimated 80% of older people undergoing surgery develop postoperative delirium (POD) making them a high-risk group. Research in this area is growing fast but there is no established consensus on strategies for POD prevention or management. A systematic review and meta-analysis were conducted to synthesise data on clinical interventions used to reduce POD among older people undergoing elective and emergency surgery. METHODS A range of database searches generated 336 papers. A total of 25 studies met the inclusion criteria and were assessed using the Joanna Briggs Institute Critical Appraisal Checklist. The studies were undertaken across the world. RESULTS This review identified a range of intervention approaches: comparisons between anaesthetic and sedatives agents, medication-specific interventions and multidisciplinary models of care. Results found more consistencies across multidisciplinary interventions than the pharmacological interventions. In pooled analyses, haloperidol (OR 0.74; 95% CI (confidence interval) 0.44, 1.26) was not statistically significantly associated with reduced POD incidence any more than a placebo. CONCLUSION There is a need to implement multidisciplinary interventions, as well as collaboration between clinicians on pre- and postoperative care practices regarding pharmacological interventions to more effectively reduce and manage POD in older people.
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190
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Decker J, Kaloostian CL, Gurvich T, Nguyen P, Widjaja W, Cardona H, Pagan V, Motamed A, Peden CJ. Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative. J Am Geriatr Soc 2020; 68:2359-2364. [DOI: 10.1111/jgs.16720] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Justyne Decker
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Carolyn L. Kaloostian
- Department of Family Medicine Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Tatyana Gurvich
- Department of Pharmacy Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Phuong Nguyen
- Chan Division of Occupational Science and Occupational Therapy Herman Ostrow School of Dentistry, University of Southern California Los Angeles California USA
| | - William Widjaja
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Hugo Cardona
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Veronica Pagan
- Gehr Family Center for Health Systems Innovation University of Southern California Los Angeles California USA
| | - Arash Motamed
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California Los Angeles California USA
- Gehr Family Center for Health Systems Innovation University of Southern California Los Angeles California USA
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191
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Dezube AR, Cooper L, Jaklitsch MT. Prehabilitation of the Thoracic Surgery Patient. Thorac Surg Clin 2020; 30:249-258. [DOI: 10.1016/j.thorsurg.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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192
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Abstract
IMPORTANCE Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. OBSERVATIONS Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose β-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without β-blocker use; P = .005) and mortality (3.1% vs 2.3% without β-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. CONCLUSIONS AND RELEVANCE Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.
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Affiliation(s)
- Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
- Division of Cardiology, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, New York
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
- Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, New York
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193
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Yohe N, Weisberg MD, Ciminero M, Mannino A, Erez O, Saleh A. Complications and Readmissions After Total Hip Replacement in Octogenarians and Nonagenarians. Geriatr Orthop Surg Rehabil 2020; 11:2151459320940959. [PMID: 32742739 PMCID: PMC7375711 DOI: 10.1177/2151459320940959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction As the US population ages, the need for total hip arthroplasty (THA) is predicted to increase by 174% by 2030. The purpose of our study was to examine the rate and risks of 30-day complications and unplanned readmission in patients over the age of 80 years old. Materials and Methods The National Surgical Quality Improvement Project database for the years 2008 to 2014 was queried for patients over the age of 80 undergoing THA. The risks of major complications, minor complications, bleeding occurrences, unplanned readmissions, and deaths over a 30-day period were examined using univariate and multivariate analyses. Results A total of 7730 patients were included for analysis; 324 (4.2%) patients experienced a major complication, 1944 (25.1%) patients experienced a minor complication, 1776 (22.9%) patients had a bleeding occurrence requiring transfusion, and 376 (4.9%) patients experienced an unplanned readmission to the hospital within 30 days. A total of 33 (0.4%) patient deaths were recorded within 30 days postoperatively. Patients with congestive heart failure were at increased risk for developing a major complication, odds ratio (OR) 3.618 (1.052-12.437), and postoperative death, OR 11.920 (1.362-104.322). Patients with an American Society of Anesthesiologists >2, OR: 1.351 (1.131-1.613), and an operative time greater than 120 minutes, OR: 1.346 (1.084-1.670), had increased risks of minor complications. Patients with a body mass index greater than 30 had reduced rates of minor complications, OR: 0.609 (0.486-0.763). Increased risk of unplanned readmission was seen in patients with chronic obstructive pulmonary disease, OR: 2.403 (1.324-4.359). Discussion/Conclusion Elderly patients undergoing THA have high complication and readmission rates. Surgeons should convey these increased risk factors and rates of complications in elective THAs to their elderly patients and work with primary care physicians to mitigate these risks.
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Affiliation(s)
- Nicholas Yohe
- Maimonides Medical Center Orthopedics, Brooklyn, NY, USA
| | | | | | - Angelo Mannino
- Maimonides Medical Center Orthopedics, Brooklyn, NY, USA
| | - Orry Erez
- Maimonides Medical Center Orthopedics, Brooklyn, NY, USA
| | - Ahmed Saleh
- Maimonides Medical Center Orthopedics, Brooklyn, NY, USA
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194
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McKenzie GAG, Bullock AF, Greenley SL, Lind MJ, Johnson MJ, Pearson M. Implementation of geriatric assessment in oncology settings: A systematic realist review. J Geriatr Oncol 2020; 12:22-33. [PMID: 32680826 DOI: 10.1016/j.jgo.2020.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/04/2020] [Accepted: 07/06/2020] [Indexed: 12/20/2022]
Abstract
Older adults with cancer are more likely to have worse clinical outcomes than their younger counterparts, and shared decision-making can be difficult, due to both complexity from adverse ageing and under-representation in clinical trials. Geriatric assessment (GA) has been increasingly recognised as a predictive and prehabilitative tool for older adults with cancer. However, GA has been notoriously difficult to implement in oncological settings due to workforce, economic, logistical, and practical barriers. We aimed to review the heterogenous literature on implementation of GA in oncology settings to understand the different implementation context configurations of GA and the mechanisms they trigger to enable successful implementation. A systematic realist review was undertaken in two stages: i) systematic searches with structured data extraction combined with iterative key stakeholder consultations to develop programme theories for implementing GA in oncology settings; ii) synthesis to refine programme theories. Medline, Embase, PsycInfo, Cochrane Library, CINAHL, Web of Science, Scopus, ASSIA, Epistemonikos, JBI Database of Systematic Reviews and Implementation Reports, DARE and Health Technology Assessment were searched. Four programme theories were developed from 53 included articles and 20 key stakeholder consultations addressing the major barriers of GA implementation in oncology practice: time (leveraging non-specialists), funding (creating favourable health economics), practicalities (establishing the use of GA in cancer care), and managing limited resources. We demonstrate that a whole system approach is required to improve the implementation of GA in cancer settings. This review will help inform policy decisions regarding implementation of GA and provide a basis for further implementation research.
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Affiliation(s)
- Gordon A G McKenzie
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom.
| | - Alex F Bullock
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Sarah L Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Michael J Lind
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, Allam Medical Building, University of Hull, Hull HU6 7RX, United Kingdom
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195
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The concept of peri-operative medicine to prevent major adverse events and improve outcome in surgical patients: A narrative review. Eur J Anaesthesiol 2020; 36:889-903. [PMID: 31453818 DOI: 10.1097/eja.0000000000001067] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Peri-operative Medicine is the patient-centred and value-based multidisciplinary peri-operative care of surgical patients. Peri-operative stress, that is the collective response to stimuli occurring before, during and after surgery, is, together with pre-existing comorbidities, the pathophysiological basis of major adverse events. The ultimate goal of Peri-operative Medicine is to promote high quality recovery after surgery. Clinical scores and/or biomarkers should be used to identify patients at high risk of developing major adverse events throughout the peri-operative period. Allocation of high-risk patients to specific care pathways with peri-operative organ protection, close surveillance and specific early interventions is likely to improve patient-relevant outcomes, such as disability, health-related quality of life and mortality.
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196
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Cooper L, Abbett SK, Feng A, Bernacki RE, Cooper Z, Urman RD, Frain LN, Edwards AF, Blitz JD, Javedan H, Bader AM. Launching a Geriatric Surgery Center: Recommendations from the Society for Perioperative Assessment and Quality Improvement. J Am Geriatr Soc 2020; 68:1941-1946. [DOI: 10.1111/jgs.16681] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Lisa Cooper
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Sarah K. Abbett
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Aiden Feng
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Rachelle E. Bernacki
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts USA
| | - Zara Cooper
- Department of Surgery Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Laura N. Frain
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Angela F. Edwards
- Department of Anesthesiology Wake Forest School of Medicine Winston‐Salem North Carolina USA
| | - Jeanna D. Blitz
- Department of Anesthesiology Duke University School of Medicine Durham North Carolina USA
| | - Houman Javedan
- Division of Aging, Department of Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
| | - Angela M. Bader
- Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Womenʼs Hospital Boston Massachusetts USA
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197
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Kata A, Cenzer I, Sudore RL, Covinsky KE, Tang VL. Advance Care Planning Prior to Death in Older Adults with Hip Fracture. J Gen Intern Med 2020; 35:1946-1953. [PMID: 32367390 PMCID: PMC7351969 DOI: 10.1007/s11606-020-05644-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/18/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although hip fractures in older adults are associated with a high degree of mortality and disability, the use of advance care planning (ACP) in this population is unknown. OBJECTIVE To determine the prevalence of ACP and need for surrogate decision-making prior to death in older adults with hip fracture and to identify factors associated with ACP. DESIGN Retrospective cohort study using Health and Retirement Study (HRS) interviews linked to Medicare fee-for-service claims data. PARTICIPANTS Six hundred six decedent participants aged 65 or older who sustained a hip fracture during HRS enrollment and had a proxy participate in the exit HRS survey. MAIN MEASURES Survey responses by proxies were used to determine ACP, defined by either advance directive completion or surrogate designation, and to assess decision-making at the end of life. Multivariate logistic regression was used to analyze correlates of ACP. KEY RESULTS Prior to death, 54.9% of all participants had an advance directive and 68.9% had designated a surrogate decision-maker; however, 24.5% had no ACP. Of the total cohort, 32.5% required decisions to be made about treatment at the end of life and lacked capacity to make these decisions themselves. In this subset, 19.9% had no ACP. In all participants, ACP was less likely in non-white individuals (adjusted odds ratio (aOR) 0.14, 95% CI 0.06-0.31), those with less than a high school education (aOR 0.58, 95% CI 0.35-0.97), and those with a net worth below the median of the cohort (aOR 0.49, 95% CI 0.26-0.72). No clinical factors were found to be associated with ACP completion prior to death. CONCLUSIONS A considerable number of older adults with hip fracture required surrogate decision-making at the end of life, of whom one fifth had no ACP prior to death. Clinicians providing care for these patients are uniquely poised to address ACP.
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Affiliation(s)
- Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA.
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA.,Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA.,Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California, 4150 Clement Street, 306B, San Francisco, CA, 94121, USA.,Division of Hospital Medicine, Department of Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA
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198
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Carli F, Baldini G. From preoperative assessment to preoperative optimization of frail older patiens. Eur J Surg Oncol 2020; 47:519-523. [PMID: 32753116 DOI: 10.1016/j.ejso.2020.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022] Open
Abstract
Physiological and mental reserve decreases with age and the ability to mount a response to a stress like surgery can represent a burden to the frail and sarcopenic patient. It is necessary to evaluate the cardiorespiratory capacity and muscle strength before surgery in the older persons and prepare adequately to the same extent the marathon runner prepares before a full marathon. Assessment and stratification of risk are necessary for decision-making, but also for planning interventions aimed at improving the functional and emotional status in anticipation of surgery. Prehabilitation can improve the physiological reserve by optimizing cardiorespiratory capacity, muscle strength, and mental resiliency. Patients with low reserve and chronic medical conditions at high risk can benefit.
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Affiliation(s)
- Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Room D10.165, 1650 Cedar Ave, Montreal, Quebec, H3G 1A4, Canada
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199
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Kim TI, Brahmandam A, Skrip L, Sarac T, Dardik A, Ochoa Chaar CI. Surgery for the Very Old: Are Nonagenarians Different? Am Surg 2020. [DOI: 10.1177/000313482008600129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Octogenarians and nonagenarians are considered the “very old” and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007–2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30–1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.
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Affiliation(s)
- Tanner I. Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anand Brahmandam
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Laura Skrip
- Yale School of Public Health, New Haven, Connecticut; and
| | - Timur Sarac
- Division of Vascular Diseases and Surgery, Department of Surgery, Ohio State University School of Medicine, Columbus, Ohio
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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200
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Dworsky JQ, Childers CP, Copeland T, Maggard-Gibbons M, Tan HJ, Saliba D, Russell MM. Geriatric Events among Older Adults Undergoing Nonelective Surgery are Associated with Poor Outcomes. Am Surg 2020. [DOI: 10.1177/000313481908501003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55–64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure ( P < 0.001). After adjustment, the probability of any GE increased with age category ( P < 0.001); having any GE was associated with higher probability of all outcomes ( P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose–response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.
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Affiliation(s)
- Jill Q. Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Christopher P. Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Timothy Copeland
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | | | - Hung-Jui Tan
- Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Debra Saliba
- Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
- UCLA/JH Borun Center for Gerontological Research, Los Angeles, California
- RAND Corporation, Santa Monica, California
| | - Marcia M. Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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