Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study

Association between preoperative sarcopenia and postoperative delirium in older patients undergoing gastrointestinal cancer surgery

Background

Postoperative delirium (POD) is a usual neurological complication, often leading to poor prognoses. Early identification of high-risk patients is crucial for preventing POD. Sarcopenia is an age-related geriatric syndrome characterized by the loss of skeletal muscle mass and function, and previous studies indicated that preoperative low muscle mass might be a predictor for POD. However, the association between preoperative sarcopenia and POD remains to be fully elucidated. This study was to explore the correlation between preoperative sarcopenia and POD following gastrointestinal cancer surgery in older patients.

Methods

Older patients (≥60 years) undergoing gastrointestinal cancer surgery were enrolled. Sarcopenia was defined based on the Special Interest Group on sarcopenia of the International Society of Physical and Rehabilitation Medicine (ISarcoPRM), which combined the loss of muscle mass (evaluated by ultrasound) and function (assessed by chair stand test and handgrip strength) before surgery. POD assessment was performed using the Confusion Assessment Method (CAM) or CAM for the intensive care unit (CAM-ICU) during the first 7 days after surgery or before discharge. Multivariate logistic regression analysis examined the correlation between preoperative sarcopenia and POD. Moreover, the receiver operator characteristic (ROC) curve was applied to analyze the predictive effect of the preoperative sarcopenia in POD.

Results

One hundred and thirty patients were finally included, of which 43 patients presented with sarcopenia before surgery. Twenty-four patients ultimately developed POD, and the incidence was 18.5%. The results of the multivariate analyses demonstrated that preoperative sarcopenia was still independently associated with POD after adjusting for age ≥70 years, preoperative Mini-Mental State Examination score, and intraoperative blood transfusion. The area under the ROC curve of preoperative sarcopenia in predicting POD was 0.680 (95% confidence interval 0.557-0.804).

Conclusion

Preoperative sarcopenia defined by ISarcoPRM criteria was independently associated with POD in geriatric patients after gastrointestinal cancer surgery.

Predictive Value of Ultrasound-Measured Quadriceps Depth and Frailty Status for Hypotension in Older Patients Undergoing Reverse Total Shoulder Arthroplasty in the Beach Chair Position under General Anesthesia

The beach chair position (BCP) is widely used in shoulder surgery; however, it frequently leads to hypotension. Hypotension in BCP is prevalent among older patients who are at risk of secondary complications such as ischemic injuries. Therefore, this prospective study aimed to investigate the association and predictive value of frailty, as assessed by ultrasound-measured quadriceps depth and questionnaire, in patients aged ≥65 years undergoing elective shoulder surgery under general anesthesia. A multivariable logistic regression analysis was performed to identify independent risk factors for hypotension in BCP under general anesthesia. Receiver operating characteristic curves were constructed to assess the predictive values of various parameters. The results indicated that a quadriceps depth < 2.3 cm and BCP for an extended period significantly increased the risk of hypotension. The combined consideration of quadriceps depth < 2.3 cm and frailty demonstrated markedly superior predictive power compared with each factor individually. In conclusion, the study findings facilitate the screening and identification of risk factors for older patients undergoing surgery in BCP, thereby enhancing perioperative management.

Preoperative rectus femoris muscle ultrasound, its relationship with frailty scores, and the ability to predict recovery after cardiac surgery: a prospective cohort study

BACKGROUND

Frailty is common in patients undergoing cardiac surgery and is associated with poorer postoperative outcomes. Ultrasound examination of skeletal muscle morphology may serve as an objective assessment tool as lean muscle mass reduction is a key feature of frailty.

METHODS

This study investigated the association of ultrasound-derived muscle thickness, cross-sectional area, and echogenicity of the rectus femoris muscle (RFM) with preoperative frailty and predicted subsequent poor recovery after surgery. Eighty-five patients received preoperative RFM ultrasound examination and frailty-related assessments: Clinical Frailty Scale (CFS) and 5-m gait speed test (GST5m). Association of each ultrasound measurement with frailty assessments was examined. Area under receiver-operating characteristic curve (AUROC) was used to assess the discriminative ability of each ultrasound measurement to predict days at home within 30 days of surgery (DAH30).

RESULTS

By CFS and GST5m criteria, 13% and 34% respectively of participants were frail. RFM cross-sectional area alone demonstrated moderate predictive association for frailty by CFS criterion (AUROC: 0.76, 95% CI: 0.66-0.85). Specificity improved to 98.7% (95% CI: 93.6%-100.0%) by utilising RFM cross-sectional area as an 'add-on' test to a positive gait speed test, and thus a combined muscle size and function test demonstrated higher predictive performance (positive likelihood ratio: 40.4, 95% CI: 5.3-304.3) for frailty by CFS criterion than either test alone (p < 0.001). The combined 'add-on' test predictive performance for DAH30 (AUROC: 0.90, 95% CI: 0.81-0.95) may also be superior to either CFS or gait speed test alone.

CONCLUSIONS

Preoperative RFM ultrasound examination, especially when integrated with the gait speed test, may be useful to identify patients at high risk of frailty and those with poor outcomes after cardiac surgery.

TRIAL REGISTRATION

The study was registered on the Chinese Clinical Trials Registry (ChiCTR2000031098) on 22 March 2020.

Uncovering sarcopenia and frailty in older adults by using muscle ultrasound-A narrative review

Muscle ultrasound is a valuable non-invasive and cost-effective method in assessing muscle mass and structure, both of which are significant indicators for the development of sarcopenia and frailty in elderly individuals. Sarcopenia refers to the loss of muscle mass and strength that occurs with age, whereas frailty is a complex geriatric syndrome characterized by reduced physical function and an increased susceptibility to negative health outcomes. Both conditions are prevalent in older adults and are associated with higher risks of falls, disability, and mortality. By measuring muscle size and structure and several other ultrasound parameters, including muscle thickness, cross-sectional area, echogenicity (brightness in the ultrasound image), pennation angle, and fascicle length ultrasound can assist in identifying sarcopenia and frailty in older adults. In addition, ultrasound can be used to evaluate muscle function such as muscle contraction and stiffness, which may also be affected in sarcopenia and frailty. Therefore, muscle ultrasound could lead to better identification and tracking of sarcopenia and frailty. Such advancements could result in the implementation of earlier interventions to prevent or treat these conditions, resulting in an overall improvement in the health and quality of life of the elderly population. This narrative review describes the benefits and challenges when using ultra-sound for the evaluation of frailty and sarcopenia.

Low Bone Mineral Density on Computed Tomography: Association with Poor Survival after Transcatheter Aortic Valve Replacement

Background: Transcatheter aortic valve replacement (TAVR) has evolved as first-line therapy for severe aortic valve stenosis (AS), with pre-procedural computed tomography (CT) providing critical anatomical information. While primarily used for anatomical planning, TAVR-CT also offers an opportunity to assess low bone mineral density (BMD), a known indicator of frailty. Despite this, the prognostic role of BMD in TAVR patients remains unknown. This study aimed to evaluate BMD on routine TAVR-CT and its impact on long-term survival. Methods: In this retrospective study, 770 consecutive TAVR patients (mean age 80.7 ± 6.7 years, 54.0% males) between November 2015 and March 2022 were included. BMD was measured from a single axial image at the thoracic vertebral level on unenhanced CT scans. Cox regression models assessed the impact of BMD on mortality, and Restricted Cubic Spline models identified potential mortality thresholds. Results: The mean BMD value, as measured on non-contrast CT, was 147.5 ± 5.4 Hounsfield units, demonstrating a noteworthy association with mortality (adjusted hazard ratio per 100 HU decrease: 1.27 [95%CI: 1.01-1.59], p = 0.041). Restricted cubic spline analysis indicated that BMD below 200 HU was linked to a substantial increase in mortality risk. Upon crude Cox regression analysis, every 100 HU decrease was associated with a 32% increase in risk for death (HR 1.32 [95%CI: 1.068-1.65)], p = 0.010). Conclusions: In conclusion, low BMD on TAVR-CT is independently associated with reduced survival, suggesting its potential as a tool for comprehensive frailty assessment and improved risk prediction in TAVR patients.

The impact of frailty as a critical mediator causing postoperative neurocognitive disorders in postoperative cardiac patients

Frailty is prevalent in elderly cardiac patients and may be a critical predictor of post-operative neurocognitive disorders (PND). The aim of this review was to demonstrate the correlation of frailty with PND in postsurgical elder patients. A review of published literature and bibliometric analysis was undertaken. Electronic databases from 2009 to 2022 were searched to identify articles that evaluated the relationship between frailty and PND in aging populations. Demographic data, type of surgery performed, frailty measurement, and impact of frailty on PND were extracted from the selected studies. The quality of the studies and risk of bias were assessed by the Newcastle-Ottawa Quality Assessment Scale, and the included articles were assessed as medium to high quality. Eighty-one studies were selected for the Bibliometric review in terms of research trends and hotpots. Additionally, 35 observational studies (prospective and retrospective cohorts) were selected for this review. The mean age ranged from 63 to 84 years and included patients undergoing cardiac, orthopedic, and other surgeries who had cardiac symptoms. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results, and study quality was for associations between frailty and PND. This analysis found a steadily growing focus on frailty and PND research in cardiac and other patients. The observational studies account for the majority of this area, and frailty occurred in the older cardiac patients over 60 years of age, and pre-screening of frailty can be predictive of PND and mortality.

Preoperative diagnosis of frailty

The aging world population obliges physicians to establish measures to optimize and estimate the outcomes of increasingly frail patients. Thus, in the last few years there has been an increase in the application of frailty indices. Multiple scales have emerged that can be applied in the perioperative setting. Each one has demonstrated some utility, either by way of establishing postoperative prognosis or as a method for the clinical optimization of patient care. Anaesthesiologists are offered a wide choice of scales, the characteristics and appropriate management of which they are often unaware. This narrative review aims to clarify the concept of frailty, describe its importance in the perioperative setting and evaluate the different scales that are most applicable to the perioperative setting. It will also establish paths for the future optimization of patient care.

A new possible marker: can pennation angle defined by ultrasound predict the frailty?

BACKGROUND

Frailty indicates older people who are vulnerable to stressors. The relation between ultrasonographic parameters of muscle and frailty among older people has yet to be investigated.

AIMS

The aim of the study is to investigate the relationship between frailty and the ultrasonographic measurements of the rectus femoris muscle (RFM).

METHODS

This cross-sectional study included 301 participants who were ≥65 years. The FRAIL questionnaire assessed frailty. The thickness, cross-sectional area (CSA), fascicle length, pennation angle (PA), stiffness, and echogenicity of RFM were assessed by ultrasound. The accuracy of parameters in predicting the frailty was evaluated by ROC analysis.

RESULTS

Of all 301 participants, 24.6% were frail. Pre-frail and frail participants had significantly lower thickness (p = 0.002), CSA (p = 0.009), and fascicle length (p = 0.043) of RFM compared to robust. PA was significantly lowest in frails (p < 0.001). The multivariate logistic regression analysis showed that PA values lower than 10.65 degrees were an independent predictor of frailty (OR = 0.83, 95% Cl: 0.70-0.97, p = 0.019). Results of ROC analysis demonstrated a satisfactory result between the PA and frailty (AUC = 0.692, p < 0.001).

DISCUSSION

Thickness, CSA, and PA of RFM were found to be lower in frail subjects, which may indicate the changes in muscle structure in frailty. Among all parameters, lower PA values were independent predictors of frailty. These findings may indicate a novel ultrasound-based method in frailty, that is more objective and unrelated to the cross-sectional evaluation.

CONCLUSIONS

Ultrasonographic measurements of RFM, especially the lower PA may predict frailty in older people. As an objective and quantitative method, PA may be used to define frailty with acceptable sensitivity.

Smaller rectus femoris size measured by ultrasound is associated with poorer outcomes after cardiac surgery

OBJECTIVE

We sought to evaluate the association of low rectus femoris cross-sectional area (RFCSA) with hospital length of stay and poorer outcomes in patients undergoing cardiac surgery.

METHODS

A single right-leg RFCSA was measured with ultrasound preoperatively and baseline characteristics, clinical data, and outcomes recorded. Patients were categorized as low rectus femoris muscle size (lowRF) or normal rectus femoris muscle size (normalRF), if they were in the lowest quartile or not, respectively. All analyses were performed on both body surface area (BSA)- and sex-adjusted RFCSA.

RESULTS

One hundred eight-four patients had a RFCSA measured with a mean of 5.01 cm2 (1.41 cm2), and range of 0.71 to 8.77 cm2. When analyzing the BSA-adjusted RFCSA, we found the lowRF group had a longer hospital stay, 11.0 days [7.0-16.3] versus 8.0 days [6.0-10.0] for the normalRF group (P < .001), and a greater proportion of extended hospital stay (≥18.5 days) of 19.6% compared with 6.2% (P = .010). When the RFCSA was adjusted for sex, the lowRF group had a greater length of hospital stay, 9.0 days [7.0-14.5] versus 8.0 days [6.0-11.0] (P = .049). In both the BSA- and sex-adjusted RFCSA, the lowRF group suffered greater morbidity and were more likely discharged to a destination other than home. In multivariate analyses adjusting for European System for Cardiac Operative Risk Evaluation II, BSA-adjusted lowRF but not sex-adjusted lowRF was independently associated with log-transformed hospital length of stay. LowRF was not independently associated with increased major morbidity and death for both BSA and sex-adjusted RFCSA.

CONCLUSIONS

Low RFCSA has a significant association with increased hospital length of stay, morbidity, and nonhome discharge in patients undergoing cardiac procedures.

TRIAL REGISTRY NUMBER

ACTRN12620000678998.

Total Muscle Area and Visceral Adipose Tissue Measurements for Frailty Assessment in TAVR Patients

Background: Transcatheter aortic valve replacement (TAVR) is a treatment option for severe aortic valve stenosis. Pre-TAVR assessments, extending beyond anatomy, include evaluating frailty. Potential frailty parameters in pre-TAVR computed tomography (CT) scans are not fully explored but could contribute to a comprehensive frailty assessment. The primary objective was to investigate the impact of total muscle area (TMA) and visceral adipose tissue (VAT) as frailty parameters on 5-year all-cause mortality in patients undergoing TAVR. Methods: Between 01/2017 and 12/2018, consecutive TAVR patients undergoing CT scans enabling TMA and VAT measurements were included. Results: A total of 500 patients qualified for combined TMA and VAT analysis. Age was not associated with a higher risk of 5-year mortality (HR 1.02, 95% CI: 0.998-1.049; p = 0.069). Body surface area normalized TMA (nTMA) was significantly associated with 5-year, all-cause mortality (HR 0.927, 95% CI: 0.927-0.997; p = 0.033), while VAT had no effect (HR 1.002, 95% CI: 0.99-1.015; p = 0.7). The effect of nTMA on 5-year, all-cause mortality was gender dependent: the protective effect of higher nTMA was found in male patients (pinteraction: sex × nTMA = 0.007). Conclusions: Normalized total muscle area derived from a routine CT scan before transcatheter aortic valve replacement complements frailty assessment in patients undergoing TAVR.

Correlation of ultrasound measurement of limb muscle thickness and echo intensity with frailty assessment in elderly patients undergoing malignancies surgery

Introduction

It remains controversial which frailty score correlates with adverse outcomes. Instead of these subjective and time consuming scores, we studied whether ultrasound guided lower extremity thickness measurements more closely are associated with adverse outcomes.

Method

Patients undergoing gastrointestinal malignancy surgery were included as study subjects. Frailty was identified using the FRAIL scale assessment. Ultrasound measured the muscle thickness and echo intensity of the patient's upper and lower limbs. ANOVA was used to analyze the relationship between muscle data and frailty assessment. Significant indicators from the one-way analysis were included in the multivariate logistic regression equation.

Results

A total of 160 study subjects were included, 52 in the normal group, 78 in the prefrailty group, and 30 in the frailty group. The ANOVA showed that there were significant differences in age, hemoglobin, albumin, history of hypertension, history of coronary artery disease, the history of cerebrovascular disease, rate of postoperative complications, rate of transferring to intensive care unit, time out of bed, length of hospitalization, thickness and echo intensity of quadriceps femoris the vastus lateralis and the tibialis anterior, echo intensity of the medial gastrocnemius among the three groups (P < 0.05). Pearson's correlation analysis showed FRAIL score was correlated with muscle thickness and echo intensity of the lower limbs. Multifactor logistic regression analysis showed that the prefrailty group was positively correlated with age（β = 0.146, P = 0.004）, echo intensity of the medial gastrocnemius (β = 0.055, P = 0.031), and rate of postoperative complications（β = 1.439, P = 0.021）, also negatively correlated with muscle thickness of the tibialis anterior（β = -2.124, P = 0.007）. The frailty group was positively correlated with age（β = 0.22, P = 0.005）, tibialis anterior echo intensity (β = 0.082, P = 0.015), medial gastrocnemius echo intensity (β = 0.089, P = 0.026), cerebrovascular disease history (β = 2.311, P = 0.04), and postoperative complication rate (β = 2.684, P = 0.003). It was negatively correlated with albumin (β = -0.26, P = 0.017), quadriceps muscle thickness (β = -2.257, P = 0.017), and tibialis anterior muscle thickness (β = -5.408, P = 0.001).

Conclusion

Ultrasound measurement of lower (not upper) extremity muscle thickness and echo intensity was significantly associated with discriminating severity of frailty and postoperative outcomes than frailty scores in elderly patients.

Preoperative frailty assessment with ultrasound in elderly patients scheduled for total knee arthroplasty

BACKGROUND

Frailty, a decline in physical and cognitive reserve capacity, renders patients susceptible to various stressors and has been linked to adverse outcomes and increased healthcare utilization. This study aimed to determine whether ultrasound measurements of the rectus abdominis (RA) and biceps brachii (BB) could predict frailty in patients scheduled for total knee arthroplasty.

METHODS

Frailty was assessed using the Clinical Frailty Scale in adults aged ≥60 years. Ultrasound measurements of the rectus abdominis, BB, and quadriceps femoris muscles, along with thigh circumference measurements, were obtained before surgery. The predictive ability of the unadjusted and BMI- and body surface area (BSA)-adjusted measurements were evaluated using receiver operating characteristic curve analysis and area under the curve (AUC) values. Postoperative outcomes, such as admission to the intensive care unit or skilled nursing facility, delirium, falls, re-hospitalization, and 30-day mortality were recorded.

RESULTS

We analyzed data from 148 patients. BB thickness provided a fair prediction of frailty. Average measurements of both BB adjusted for BMI (0.708, 95% CI 0.602-0.814; P<0.001), and BSA (0.708, 95% CI 0.598-0.817; P<0.001) had the highest AUC values. RA muscle measurements could not discriminate frailty. The BMI-adjusted measurements for: right quadriceps femoris thickness (AUC 0.614, 95% CI 0.503-0.725; P=0.044), left thigh circumference (AUC 0.648, 95% CI 0.528-0.769; P=0.016), and average thigh circumference (AUC 0.630, 95% CI 0.511-0.750; P=0.033) had statistically significant but poor AUC values.

CONCLUSIONS

Preoperative ultrasound measurements of the bilateral BB can fairly predict frailty in patients scheduled for total knee arthroplasty.

Muscle ultrasound and its application to point-of-care ultrasonography: a narrative review

Technological advances of hand-held ultrasound devices and educational programmes for their use, such as point-of-care ultrasonography (POCUS) training, have contributed to the increasing application of these devices in clinical practice. With the greater impact of frailty and sarcopenia in aging societies, attention is being focused on the use of ultrasound for skeletal muscle assessment. In this narrative review, we discuss how ultrasound can be applied to skeletal muscle assessment, especially that of the quadriceps muscle, in clinical practice. Muscle thickness by ultrasound has been shown to have good reliability and validity for the evaluation of muscle size, and echo intensity has been used to evaluate muscle quality. Muscle ultrasound has not only been useful to diagnose sarcopenia in various settings, but has also been validated to predict health-related outcomes such as death and functional disability. Recommended methods for muscle ultrasound was published recently, and the results of future studies are expected to be comparable. Although several challenging issues with muscle ultrasound remain, if it could be incorporated into educational programmes such as POCUS training, more clinicians may be able to use ultrasound for skeletal muscle assessment in the future.KEY MESSAGESThe evolution of hand-held ultrasound devices enables physicians to perform ultrasound at the bedside as part of regular medical examinations.Muscle ultrasound is considered an effective tool for evaluating muscle size and quality, and has been studied in various settings.More clinicians may be able to evaluate skeletal muscle assessment with the development of educational programmes on muscle ultrasound in the future.

Loss of Muscle Mass and Strength After Hip Fracture: an Intervention Target for Nutrition Supplementation

PURPOSEOF REVIEW

To summarize what is known about the deleterious effect of hip fracture on muscle mass and strength as well as the scientific evidence for post-surgical nutrition supplementation to maintain muscle and improve function.

RECENT FINDINGS

This review provides a discussion of the relationship between muscle mass, strength, and physical function following hip fracture, briefly describes the approaches to measuring lean mass, discusses prevalence of sarcopenia and malnutrition among older men and women with hip fracture, and reviews the effects of essential amino acids on muscle. Loss of muscle mass and strength following hip fracture is substantial with consequences for recovery of functional independence. EAA-based nutrition supplementation, which directly effects muscle, has potential to improve outcomes.

Preoperative Frailty Assessment Predicts Postoperative Mortality, Delirium and Pneumonia in Elderly Lung Cancer Patients: A Retrospective Cohort Study

BACKGROUND

The purpose of this study was to investigate the predictive value of the 5-factor modified frailty index (mFI-5) for postoperative mortality, delirium and pneumonia in patients over 65 years of age undergoing elective lung cancer surgery.

METHODS

Data were collected from a single-center retrospective cohort study conducted in a general tertiary hospital from January 2017 to August 2019. In total, the study included 1372 elderly patients aged over 65 who underwent elective lung cancer surgery. They were divided into frail group (mFI-5, 2-5), prefrail group (mFI-5, 1) and robust group (mFI-5, 0) on the basis of mFI-5 classification. The primary outcome was postoperative 1-year all-cause mortality. Secondary outcomes were postoperative pneumonia and postoperative delirium.

RESULTS

Frailty group had the highest incidence of postoperative delirium (frailty 31.2% versus prefrailty 1.6% versus robust 1.5%, p < 0.001), postoperative pneumonia (frailty 23.5% versus prefrailty 7.2% versus robust 7.7%, p < 0.001), and postoperative 1-year mortality (frailty 7.0% versus prefrailty 2.2% versus robust 1.9%. p < 0.001). Frail patients have significantly longer length of hospitalization than those in the robust group and prefrail patients (p < 0.001). Multivariate analysis showed a clear link between frailty and increased risk of postoperative delirium (aOR 2.775, 95% CI 1.776-5.417, p < 0.001), postoperative pneumonia (aOR 3.291, 95% CI 2.169-4.993, p < 0.001) and postoperative 1-year mortality (aOR 3.364, 95% CI, 1.516-7.464, p = 0.003).

CONCLUSIONS

mFI-5 has potential clinical utility in predicting postoperative death, delirium and pneumonia incidence in elderly patients undergoing radical lung cancer surgery. Frailty screening of patients (mFI-5) may provide benefits in risk stratification, targeted intervention efforts, and assist physicians in clinical decision-making.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

Expiratory abdominal muscle thickness, a new point of care ultrasound measure for respiratory muscle mass in the intensive care unit: a prospective observational cohort study

BACKGROUND

Even if expiratory muscles are key muscles in intensive care unit (ICU) patients, the association between their thickness and mortality has never been assessed. This study aimed to determine whether expiratory abdominal muscle thickness assessed by ultrasonography (US) was associated with 28-day mortality in ICU patients.

BASIC PROCEDURES

US expiratory abdominal muscle thickness was measured within the first 12 h after ICU admission. The primary endpoint was 28-day mortality.

MAIN FINDINGS

In 310 analyzed patients, a thinner total abdominal expiratory muscle thickness at admission was associated with 28-day mortality (median value with interquartile range: 10.8 [10; 14.6] versus 16.5 [13.4; 20.7] mm). Total abdominal expiratory muscle thickness had an area under the curve of 0.78 [0.71;0.86] to discriminate 28-day mortality.

CONCLUSIONS

US expiratory abdominal muscle thickness was associated with 28-day mortality, supporting its use in predicting ICU patient outcome.

Point-of-care ultrasound in geriatrics: a national survey of VA medical centers

BACKGROUND

Point-of-care ultrasound (POCUS) can aid geriatricians in caring for complex, older patients. Currently, there is limited literature on POCUS use by geriatricians. We conducted a national survey to assess current POCUS use, training desired, and barriers among Geriatrics and Extended Care ("geriatric") clinics at Veterans Affairs Medical Centers (VAMCs).

METHODS

We conducted a prospective observational study of all VAMCs between August 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of geriatric clinics.

RESULTS

All Chiefs of Staff (n=130) completed the survey (100% response rate). Chiefs of geriatric clinics ("chiefs") at 76 VAMCs were surveyed and 52 completed the survey (68% response rate). Geriatric clinics were located throughout the United States, mostly at high-complexity, urban VAMCs. Only 15% of chiefs responded that there was some POCUS usage in their geriatric clinic, but more than 60% of chiefs would support the implementation of POCUS use. The most common POCUS applications used in geriatric clinics were the evaluation of the bladder and urinary obstruction. Barriers to POCUS use included a lack of trained providers (56%), ultrasound equipment (50%), and funding for training (35%). Additionally, chiefs reported time utilization, clinical indications, and low patient census as barriers.

CONCLUSIONS

POCUS has several potential applications for clinicians caring for geriatric patients. Though only 15% of geriatric clinics at VAMCs currently use POCUS, most geriatric chiefs would support implementing POCUS use as a diagnostic tool. The greatest barriers to POCUS implementation in geriatric clinics were a lack of training and ultrasound equipment. Addressing these barriers systematically can facilitate implementation of POCUS use into practice and permit assessment of the impact of POCUS on geriatric care in the future.

Moderate exercise-induced dynamics on key sepsis-associated signaling pathways in the liver

BACKGROUND

There is a clear relationship between quantitative measures of fitness (e.g., VO₂ max) and outcomes after surgical procedures. Whether or not fitness is a modifiable risk factor and what underlying biological processes drive these changes are not known. The purpose of this study was to evaluate the moderate exercise training effect on sepsis outcomes (survival) as well as the hepatic biological response. We chose to study the liver because it plays a central role in the regulation of immune defense during systemic infection and receives blood flow directly from the origin of infection (gut) in the cecal ligation and puncture (CLP) model.

METHODS

We randomized 50 male (♂) and female (♀) Sprague-Dawley rats (10 weeks, 340 g) to 3 weeks of treadmill exercise training, performed CLP to induce polymicrobial "sepsis," and monitored survival for five days (Part I). In parallel (Part II), we randomized 60 rats to control/sedentary (G1), exercise (G2), exercise + sham surgery (G3), CLP/sepsis (G4), exercise + CLP [12 h (G5) and 24 h (G6)], euthanized at 12 or 24 h, and explored molecular pathways related to exercise and sepsis survival in hepatic tissue and serum.

RESULTS

Three weeks of exercise training significantly increased rat survival following CLP (polymicrobial sepsis). CLP increased inflammatory markers (e.g., TNF-a, IL-6), which were attenuated by exercise. Sepsis suppressed the SOD and Nrf2 expression, and exercise before sepsis restored SOD and Nrf2 levels near the baseline. CLP led to increased HIF1a expression and oxidative and nitrosative stress, the latter of which were attenuated by exercise. Haptoglobin expression levels were increased in CLP animals, which was significantly amplified in exercise + CLP (24 h) rats.

CONCLUSIONS

Moderate exercise training (3 weeks) increased the survival in rats exposed to CLP, which was associated with less inflammation, less oxidative and nitrosative stress, and activation of antioxidant defense pathways.

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

Predictability of Radiologically Measured Psoas Muscle Area for Intraoperative Hypotension in Older Adult Patients Undergoing Femur Fracture Surgery

This retrospective study aimed to determine the predictive value of radiologically measured psoas muscle area (PMA) for intraoperative hypotension (IOH) using receiver operating characteristic (ROC) curves in older adult patients with hip fractures. The cross-sectional axial area of the psoas muscle was measured by CT at the level of the 4th lumbar vertebrae and normalized by body surface area (BSA). The modified frailty index (mFI) was used to assess frailty. IOH was defined as an absolute threshold of mean arterial blood pressure (MAP) < 65 mmHg or a relative decrease in MAP > 30% from baseline MAP. Among the 403 patients, 286 (71.7%) had developed IOH. PMA normalized by BSA in male patients was 6.90 ± 0.73 in the no-IOH group and 4.95 ± 1.20 in the IOH group (p < 0.001). PMA normalized by BSA in female patients was 5.18 ± 0.81 in the no-IOH group and 3.78 ± 0.75 in the IOH group (p < 0.001). The ROC curves showed that the area under the curve for PMA normalized by BSA and modified frailty index (mFI) were 0.94 for male patients, 0.91 for female patients, and 0.81 for mFI (p < 0.001). In multivariate logistic regression, low PMA normalized by BSA, high baseline systolic blood pressure, and old age were significant independent predictors of IOH (adjusted odds ratio: 3.86, 1.03, and 1.06, respectively). PMA measured by computed tomography showed an excellent predictive value for IOH. Low PMA was associated with developing IOH in older adult patients with hip fractures.

Cross-disciplinary training of nursing informatics and nursing engineering at the postgraduate level: A feasibility analysis based on the qualitative method

BACKGROUND

The trend of interdisciplinary education is becoming increasingly prominent. Nursing informatics and nursing engineering have received much attention and development at different levels of nursing education in many Western countries. Meanwhile, in China, the cultivation of interdisciplinary nursing talents has either not been initiated or has only entered an initial stage.

OBJECTIVES

This study aims to explore experts' opinions from nursing, informatics and engineering on the feasibility of interdisciplinary education at graduate master's level in nursing through interview.

DESIGN

This was a descriptive qualitative study.

SETTING

Interviews were conducted online or face to face.

PARTICIPANTS

Experts in the fields of nursing, informatics, and engineering who met the study qualifications were enrolled.

METHODS

This study used a purposive sampling method and collected data via semi-structured interviews. A total of 14 experts were involved based on data saturation, which eight were interviewed face-to-face and six were interviewed online. A content analysis method was used to summarize and analyze the attitudes, opinions, and suggestions of experts.

RESULTS

A total of 579 min of interviews with 66,387 words were transcribed and analyzed after 30-50 min time range of each interview, and 4 themes were established. A consensus was obtained on the necessity and importance of interdisciplinary education. Policy guidance, financial support, and mutual recognition were the prerequisites for the cultivation. Moreover, feasibility of interdisciplinary education depends on multi-cooperation, including society, university, and hospital. Finally, a linkage mechanism among relevant stakeholders was required.

CONCLUSION

The necessity and feasibility of such integrated training was concluded. Learning from the experience of relevant countries, China should launch an interdisciplinary training model suitable for its national condition.

Frailty and emergency surgery: identification and evidence-based care for vulnerable older adults

Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.

The Utility of Grip Strength as a Simplified Measure of Frailty in the Older Adult in the Preoperative Clinic

Objective

 The aim of this study was to compare the measure of grip strength against other validated methods of measuring frailty.

Materials and methods

This was a single-center, cross-sectional study that took place at the Westchester Medical Center Pre-Procedural Testing Clinic. The patient population included n = 73 patients ≥65 years of age evaluated for elective surgery. During the study, patients’ grip strength, CFS-I (Clinical Frailty Score of Investigator), CFS-P (Clinical Frailty Score of Participant), and FRAIL (Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight) scores were measured.

Results

Grip strength correlated negatively with the CFS-I, CFS-P, and FRAIL scores for females. Reduced grip strength in females correlated with higher frailty scores and vice versa. Male grip strength showed no significant relationship with the frailty scales. In addition, multivariate linear regression analysis revealed that the independent measure that demonstrated a significant inverse association with grip strength was age (β= -0.43, p = <0.001).

Conclusions

 There exists a difference in the utility of grip strength as a measure of frailty between males and females.

Effect of sarcopenia in predicting postoperative mortality in emergency laparotomy: a systematic review and meta-analysis

Background

While emergency laparotomy has been associated with high rates of postoperative mortality and adverse events, preoperative systematic evaluation of patients may improve perioperative outcomes. However, due to the critical condition of the patient and the limited operation time, it is challenging to conduct a comprehensive evaluation. In recent years, sarcopenia is considered a health problem associated with an increased incidence of poor prognosis. This study aimed to investigate the effect of sarcopenia on 30-day mortality and postoperative adverse events in patients undergoing emergency laparotomy.

Methods

We systematically searched databases including PubMed, Embase, and Cochrane for all studies comparing emergency laparotomy in patients with and without sarcopenia up to March 1, 2022. The primary outcome was of 30-day postoperative mortality. Secondary outcomes were the length of hospital stay, the incidence of adverse events, number of postoperative intensive care unit (ICU) admissions, and ICU length of stay. Study and outcome-specific risk of bias were assessed using the Quality in Prognosis Studies (QUIPS) tool. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Result

A total of 11 eligible studies were included in this study. The results showed that patients with sarcopenia had a higher risk of death 30 days after surgery (OR = 2.42, 95% CI = 1.93–3.05, P < 0.00001). More patients were admitted to ICU after surgery (OR = 1.58, 95% CI = 1.11–2.25, P = 0.01). Both the ICU length of stay (MD = 0.55, 95% CI = 0.05–1.06, P = 0.03) and hospital length of stay (MD = 2.33, 95% CI = 1.33–3.32, P < 0.00001) were longer in the sarcopenia group. The incidence of postoperative complications was also significantly higher in patients with sarcopenia (OR = 1.78, 95% CI = 1.41–2.26, P < 0.00001).

Conclusion

In emergency laparotomy, sarcopenia was associated with increased 30-day postoperative mortality. Both the lengths of stay in the ICU and the total length of hospital stay were significantly higher than those in non-sarcopenic patients. Therefore, we concluded that sarcopenia can be used as a tool to identify preoperative high-risk patients, which can be considered to develop new postoperative risk prediction models.

Registration number Registered on Prospero with the registration number of CRD42022300132.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00440-0.

Addressing comorbidities in the perioperative setting and optimizing perioperative medicine education

PURPOSE OF REVIEW

Preoperative clinics and patient optimization are examples of collaborative, multidisciplinary care pathways that create value. This article reviews current literature to demonstrate the importance of preoperative enhancement of patients' cognitive and functional status. This article underscores the importance of formal training in multidisciplinary topics, such as frailty, brain health, and shared decision-making for anesthesiology house staff.

RECENT FINDINGS

Preoperative cognitive screening of older patients is a valuable metric for risk stratification and detection of patients at risk of postoperative delirium. Frailty is another syndrome that can be identified and optimized preoperatively. Sarcopenia has been shown to correlate with frailty; this shows promise as a method to detect frailty preoperatively.

SUMMARY

Anesthesiologists as perioperative physicians are in a unique position to lead and coordinate interdisciplinary conversations that incorporate patient goal concordant care and realistic assessment of perioperative complications. Formal house staff training in early recognition and management of patients at risk of adverse outcomes in the short and long term postoperatively improves patient outcomes and decreases healthcare spending.

Perceived Social Support and Associated Factors Among Community-Dwelling Older Adults With Frailty and Pre-frailty in Hangzhou, China

OBJECTIVES

The present study aimed to explore the social support among community-dwelling older adults with frailty and pre-frailty and to ascertain associated factors.

METHODS

The frailty status of the participant was assessed via the Chinese FRAIL Scale. The dependent variable, level of social support, was evaluated using the Social Support Rating Scale (range: 12-66). This study explored the influencing factors from three aspects containing sociodemographic characteristics, family environment, and community environment. Independent-sample t-test, Analysis of Variance, and multiple linear regression analyses were conducted to examine determinants of social support.

RESULTS

There were significant differences in overall social support between non-frail, pre-frail, and frail participants [38.01 (SD = 6.48) vs. 33.62 (SD = 6.25) vs. 30.50 (SD = 6.68), F = 62.157, p < 0.001]. Older adults with frailty and pre-frailty who were single would have lower levels of overall social support. In the pre-frail group, living alone was associated with lower overall social support. In contrast, the relationship with children and the availability of recreational activities were associated factors for the frail group.

CONCLUSIONS

The level of social support among frail and pre-frail community-dwelling older adults was lower than the robust older adults and influenced by different factors according to the frailty category, which suggests taking targeted measures for social support improvement.