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Welsh SA, Pearson RC, Hussey K, Brittenden J, Orr DJ, Quinn T. A systematic review of frailty assessment tools used in vascular surgery research. J Vasc Surg 2023; 78:1567-1579.e14. [PMID: 37343731 DOI: 10.1016/j.jvs.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice. METHODS Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed. RESULTS Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population. CONCLUSIONS Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.
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Affiliation(s)
- Silje A Welsh
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland.
| | - Rebecca C Pearson
- Department of Medicine for the Elderly, Glasgow Royal Infirmary, Glasgow, Scotland
| | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Julie Brittenden
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Douglas J Orr
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland; Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Terry Quinn
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
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Schmidt AP, Del Maschi MM, Andrade CF. Anesthetic management for lower extremity vascular bypass procedures: The impact of general or regional anesthesia on clinical outcomes. Vascular 2023:17085381231193492. [PMID: 37540895 DOI: 10.1177/17085381231193492] [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: 08/06/2023]
Abstract
PURPOSE Postoperative complications after major surgery, especially vascular procedures, are associated with a significant increase in costs and mortality. Previous studies evaluating general anesthesia versus regional or neuraxial anesthesia for infrainguinal bypass have produced conflicting results. The main aim of the present study is to review current evidence on the application of regional or general anesthesia in patients undergoing infrainguinal bypass surgery and its potential favorable effects on postoperative outcomes. CONTENTS Patients undergoing vascular surgery often have multiple comorbidities, and it is important to outline both benefits and risks of regional anesthesia techniques. Neuraxial anesthesia in vascular surgery allows overall avoidance of general anesthesia and does provide short-term benefits beyond analgesia. Previous observational studies suggest that neuraxial anesthesia for lower limb revascularization may reduce morbidity and length of stay. However, evidence of long-term benefits is lacking in most procedures and further work is still warranted. CONCLUSIONS Neuraxial anesthesia is usually an effective anesthesia technique for infrainguinal bypass surgery. Elderly patients and those with underlying respiratory problems may display some benefit from neuraxial anesthesia. Further evaluation within institutions should be performed to identify which patients would most benefit from regional techniques. Notably, systemic antithrombotic and anticoagulation therapy is common among this population and may affect anesthetic choices.
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Affiliation(s)
- André P Schmidt
- Serviço de Anestesia e Medicina Perioperatória, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Serviço de Anestesia, Santa Casa de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Brazil
- Serviço de Anestesia, Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
- Programa de Pós-graduação em Ciências Pneumológicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Programa de Pós-Graduação em Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Marine M Del Maschi
- Serviço de Anestesia e Medicina Perioperatória, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Cristiano F Andrade
- Programa de Pós-graduação em Ciências Pneumológicas, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Li A, Dreksler H, Nagpal SK, Brandys T, Jetty P, Dubois L, Parsons Leigh J, Stelfox HT, McIsaac DI, Roberts DJ. Outcomes After Neuraxial or Regional Anaesthesia Instead of General Anaesthesia for Lower Limb Revascularisation Surgery: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Studies. Eur J Vasc Endovasc Surg 2023; 65:379-390. [PMID: 36336286 DOI: 10.1016/j.ejvs.2022.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 10/19/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine whether receipt of neuraxial or regional anaesthesia instead of general anaesthesia for lower limb revascularisation surgery affects patient outcomes. DATA SOURCES MEDLINE, EMBASE, Evidence Based Medicine Reviews, and Google Scholar. REVIEW METHODS After protocol registration, the data sources were searched for randomised and non-randomised studies comparing neuraxial or regional anaesthesia with general anaesthesia for lower limb revascularisation surgery in adults. Two investigators independently selected articles, extracted data, and assessed risks of bias. Data were pooled using random effects models. GRADE was used to assess certainty in cumulative evidence. RESULTS From 10 755 citations identified, five randomised (n = 970) and 13 non-randomised (n = 96 800) studies were included. Use of neuraxial instead of general anaesthesia for lower limb revascularisation surgery was associated with no statistically significant reduction in short term (in hospital or 30 day) mortality in randomised studies (pooled odds ratio [OR] 0.77; 95% confidence interval [CI] 0.33 - 1.81; low certainty) and a statistically significant reduction in adjusted short term mortality in non-randomised studies (pooled OR 0.67; 95% CI 0.56 - 0.81; low certainty). Adults allocated to neuraxial anaesthesia in randomised studies had fewer pulmonary complications (pooled OR 0.35; 95% CI 0.16 - 0.76; low certainty). In non-randomised studies, neuraxial instead of general anaesthesia was associated with a lower adjusted odds of any morbidity (pooled OR 0.66; 95% CI 0.52 - 0.84), cardiac complications (pooled OR 0.68; 95% CI 0.58 - 0.79), pneumonia (pooled OR 0.81; 95% CI 0.64 - 1.02), prolonged mechanical ventilation (OR 0.09; 95% CI 0.002 - 0.55), and bypass graft thrombosis (OR 0.70; 95% CI 0.59 - 0.85), as well as a shorter operative duration (low certainty for all). Use of a nerve block instead of general anaesthesia was associated with a lower adjusted odds of delirium (OR 0.16; 95% CI 0.06 - 0.42) and a shorter operative duration (low certainty for both). CONCLUSION Randomised and non-randomised data suggest that neuraxial anaesthesia for lower limb revascularisation surgery reduces morbidity and possibly mortality. Until randomised trials with a low risk of bias become available, this study supports use of neuraxial anaesthesia for these procedures where appropriate.
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Affiliation(s)
- Allen Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Hannah Dreksler
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada; ICES, Ontario, Canada
| | - Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Department of Anaesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; O'Brien Institute for Public Health, University of Calgary, Alberta, Canada; School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Lim JA, Seo Y, Choi EJ, Kwak SG, Ryu T, Lee JH, Park KH, Roh WS. Impact of regional anesthesia on outcomes of geriatric patients undergoing lower extremity revascularization: A propensity score-matched cohort study. Medicine (Baltimore) 2022; 101:e32597. [PMID: 36596067 PMCID: PMC9803409 DOI: 10.1097/md.0000000000032597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Lower extremity revascularization (LER) for peripheral artery disease in elderly patients is associated with a high risk of perioperative morbidity and mortality. This study aimed to a conduct retrospective review and propensity score matching analysis to determine whether the use of regional anesthesia (RA) instead of general anesthesia (GA) in geriatric patients undergoing LER for peripheral artery disease results in improved short-term mortality and health outcomes. We reviewed medical records of 1271 patients aged >65 years who underwent LER at our center between May 1998 and February 2016. According to the anesthesia method, patients were grouped in the GA and RA groups. The primary outcome was short-term mortality (7-day and 30-day). The secondary outcomes were 5-year survival rate, intraoperative events, postoperative morbidity, and postoperative length of stay. A propensity score-matched cohort design was used to control for potentially confounding factors including patient demographics, comorbidities, American Society of Anesthesiologists physical status, and preoperative medications. After propensity score matching, 722 patients that received LER under GA (n = 269) or RA (n = 453) were identified. Patients from the GA group showed significantly higher 7-day mortality than those from the RA group (5.6% vs 2.7% P = .048); however, there was no significant difference in 30-day mortality between the groups (GA vs RA: 6.3% vs 3.6%, P = .083). The 5-year survival rate and incidence of arterial and central venous catheter placement or intraoperative dopamine and epinephrine use were significantly higher in the GA group than in the RA group (P < .05). In addition, the frequency of immediate postoperative oxygen therapy or mechanical ventilation support was higher in the GA group (P < .05). However, there was no difference in the postoperative cardiopulmonary and cerebral complications between the 2 groups. These results suggest that RA can reduce intraoperative hemodynamic support and provide immediate postoperative respiratory intensive care. In addition, the use of RA may be associated with better short-term and 5-year survival rates in geriatric patients undergoing LER.
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Affiliation(s)
- Jung A Lim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Yohan Seo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Eun-Joo Choi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Sang Gyu Kwak
- Department of Medical Statistics, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Taeha Ryu
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Jae Hoon Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Ki Hyuk Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
| | - Woon Seok Roh
- Department of Anesthesiology and Pain Medicine, School of Medicine, Daegu Catholic University, Daegu, Republic of Korea
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