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Herrmann EJ, Raghavan B, Tekeste M, Mantzsch K, Meybohm P, Assmus B. Randomized Pilot Trial of Pre- and Postoperative Heart Failure Nurse-Supported Care in Heart Failure Patients Requiring Noncardiac Surgery-Feasibility and Results. Clin Cardiol 2024; 47:e24304. [PMID: 38924180 PMCID: PMC11194970 DOI: 10.1002/clc.24304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION The perioperative cardiovascular management of patients undergoing noncardiac surgery is particularly challenging in those with pre-existing heart failure (HF). This study was designed to evaluate the effectiveness of nurse-based pre- and postoperative specialized HF management in reducing postoperative HF-associated complications in patients with known HF undergoing noncardiac surgery. METHODS This prospective, randomized pilot study included patients with established HF requiring intermediate- to high-risk noncardiac surgery. Patients received postoperatively either standard care (control group, CG) or nurse-supported HF management (intervention group, IG). The primary endpoint was a composite of HF-related postoperative complications at 30 days. Secondary endpoints included length on intensive care unit, length of hospital stay, death, hospitalization for HF, and quality of life assessment using the SF-12 questionnaire. RESULTS The trial was halted prematurely for futility. A total of 34 patients (median age 70.5 [IQR 67-75] years; with 15 HfpEF, 9 HfmrEF,10 HfrEF), with an average NT-proBNP of 1.413 [463-2.832] pg/mL were included. The IG had a lower rate of postoperative primary events (25%; n = 4) compared with the CG (33%; n = 6). There were no differences in secondary endpoints between the groups. Quality-of-life scores improved slightly in both groups (δ 5.6 ± 0.9 [CG] and 3.1 ± 1.2 [IG]). CONCLUSION Nurse-based pre- and postoperative HF care appears to be feasible and may reduce HF-associated complications in patients undergoing noncardiac surgery. Larger clinical trials are needed to further evaluate the effectiveness of this approach in reducing postoperative complications in this high-risk patient population.
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Affiliation(s)
- Ester J. Herrmann
- Department of Cardiology and AngiologyUniversity Hospital Giessen and MarburgGiessenGermany
| | | | - Meaza Tekeste
- Department of CardiologyUniversity Hospital Frankfurt/MainGiessenGermany
| | - Kathleen Mantzsch
- Department of CardiologyUniversity Hospital Frankfurt/MainGiessenGermany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care and Emergency and Pain MedicineUniversity Hospital WürzburgWürzburgGermany
| | - Birgit Assmus
- Department of Cardiology and AngiologyUniversity Hospital Giessen and MarburgGiessenGermany
- Department of CardiologyUniversity Hospital Frankfurt/MainGiessenGermany
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Katipoglu B, Kurtbeyoglu S, Demir ZA, Mavioglu HL. The effect of the anticholinergic burden on mortality following elective cardiac surgery. Curr Med Res Opin 2024; 40:27-34. [PMID: 37999982 DOI: 10.1080/03007995.2023.2288278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 11/22/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients. METHODS This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records. RESULTS A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10-1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27-3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively). CONCLUSION The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period. TRIAL REGISTRATION The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.
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Affiliation(s)
- Bilal Katipoglu
- Balikesir Atatürk City Hospital, Division of Geriatrics, Balikesir, Turkiye
| | - Seda Kurtbeyoglu
- Anesthesiology and Reanimation Department, Ankara City Hospital, Ankara, Turkiye
| | - Zeliha Asli Demir
- Anesthesiology and Reanimation Department, Ankara City Hospital, University of Health Sciences, Ankara, Turkiye
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Al Harbi MK, Alshaghroud SM, Aljahdali MM, Ghorab FA, Baba F, Al Dosary R, Bahadeq M. Regional anesthesia for geriatric population. Saudi J Anaesth 2023; 17:523-532. [PMID: 37779559 PMCID: PMC10540989 DOI: 10.4103/sja.sja_424_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 10/03/2023] Open
Abstract
Advancements in modern health care over 20 years have substantially increased the average lifespan in developed countries, and the fastest growing population is the elderly population. The proportion of people in Saudi Arabia aged 60 or more is predicted to be 25 percent of the total population of 40 million by the end of 2050. Moreover, the number of people aged 80 or more is expected to reach 1.6 million or 4 percent of the total population in the same period. Improvements in surgical techniques, anesthesia, and intensive care units make surgical interventions in older and sicker patients possible. It is estimated that over half of the population older than 65 years will require surgical intervention at least once during the remainder of their lives. Therefore, elderly patients are becoming an even larger part of anesthetic practice. Regional anesthesia (RA) is frequently used in elderly patients, especially during orthopedic surgery, genitourologic and gynecologic procedures, and hernia repair. Although age can no longer be considered a contraindication to anesthesia and surgery, anesthesia-related morbidity and mortality remain higher among elderly than among young adult surgical patients. Undoubtedly, peripheral nerve (PN) blocks improve analgesia and reduce opioid consumption and their associated side effects. This is beneficial in the perioperative care of elderly patients who may have less physiologic reserve to withstand the side effects of general anesthesia (GA).
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Affiliation(s)
- Mohammed K. Al Harbi
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud Bin Abdulaziz University for Health Science, Riyadh, KSA
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Salah M. Alshaghroud
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud Bin Abdulaziz University for Health Science, Riyadh, KSA
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Mohammed M. Aljahdali
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud Bin Abdulaziz University for Health Science, Riyadh, KSA
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Fadi A. Ghorab
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud Bin Abdulaziz University for Health Science, Riyadh, KSA
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Fayaz Baba
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud Bin Abdulaziz University for Health Science, Riyadh, KSA
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Rayan Al Dosary
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
| | - Mohammed Bahadeq
- Department of Anesthesia, Ministry of National Guard Health Affair, Riyadh, KSA
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Oh AR, Park J, Lee JH, Cha D, Choi DC, Yang K, Ahn J, Sung JD, Park IH, Lee SH. Risk of age older than 65 years for 30-day cardiac complication may be comparable to low-to-moderate risk according to revised cardiac risk index in non-cardiac surgery. Sci Rep 2023; 13:15625. [PMID: 37730864 PMCID: PMC10511497 DOI: 10.1038/s41598-023-42460-z] [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: 07/18/2022] [Accepted: 09/11/2023] [Indexed: 09/22/2023] Open
Abstract
Revised cardiac risk index (RCRI) is widely used for surgical patients without containing age as a risk factor. We investigated age older than 65 years with respect to low-to-moderate risk of RCRI. From January 2011 to June 2019, a total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution. After excluding high-risk patients defined as RCRI score > 2, we stratified the patients into four groups according to RCRI and age (A: age < 65 with RCRI < 2, [n = 148,288], B: age ≥ 65 with RCRI < 2, [n = 42,841], C: age < 65 with RCRI = 2, [n = 5,271], and D: age ≥ 65 with RCRI = 2, [n = 5,698]). Incidence of major cardiac complication defined as a composite of cardiac death, cardiac arrest and myocardial infarction was compared. After excluding 1,689 patients with high risk (defined as RCRI score > 2), 202,098 patients were enrolled. The incidence with 95% confidence interval of major cardiac complication for A, B, C, and D groups was 0.3% (0.2-0.3), 1.1% (1.0-1.2), 1.8% (1.6-1.8), and 3.1% (2.6-3.6), respectively. In a direct comparison between B and C groups, old patients with RCRI < 2 showed a significantly lower risk compared to younger patients with RCRI = 2 (odd ratio, 0.62; 95% confidence interval, 0.50-0.78; p < 0.001). In non-cardiac surgery, the risk of age older than 65 years was shown to be comparable with low-to-moderate risk according to RCRI.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dahye Cha
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dan-Cheong Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwangmo Yang
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Ji Dong Sung
- Rehabilitation and Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I Hyun Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hwa Lee
- Wiltse Memorial Hospital, 437, Gyeongsu-daero, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea.
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Preoperative advanced cardiology evaluation in adult non-cardiac surgery: A retrospective cohort study. JOURNAL OF SURGERY AND MEDICINE 2023. [DOI: 10.28982/josam.7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Background/Aim: Advanced cardiology evaluation (ACE) is the most frequently requested consultation during preoperative medical evaluations (PMEs) performed in anesthesia outpatient clinics. However, the efficacy and results of this ACE request are unclear. We aimed to show the frequency of ACE requested during PME of patients undergoing non-cardiac surgery (NCS) and its effect on diagnosis, treatment process, and surgical time planning.
Methods: This is a single-center, retrospective cohort study of 300 patients aged 18 years and older who need ACE. Medical charts were reviewed for patient characteristics and diagnosis, planned surgery type, surgical intervention risk, revised cardiac risk index (RCRI), other consultation records, cardiology consultation indication, risk group determined by the cardiologist, metabolic equivalent (METs), and anticoagulant use were recorded.
Results: We analyzed the data of 300 patients for whom ACE was requested from 9825 patients who underwent PME. The mean age was 66 (12) years, and the most common age range was 60–79 years (62.7%). The proportion of patients with METs ≤4 was 11% (n=33). The most common additional consultation was chest disease (10%), and the most common co-morbidity was hypertension (61.6%). The most common reason for consultation was a history of ischemic heart disease (50%). According to the revised cardiac risk index, most patients were in class 2, while according to the cardiology consultation outcome grade, most patients were in the intermediate risk group. It was observed that the cardiology consultation process was mostly completed on the same day (255 patients, 85%), and the use of anticoagulant drugs was mostly left to the individual evaluation of the surgeon (143 patients, 47.7%).
Conclusion: PME should be given due care to prevent perioperative cardiac complications in patients undergoing NCS. More careful patient assessments are needed during ACEs. This would allow for more accurate risk stratifications and, if necessary, the ordering of additional testing.
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Gencer B, Gale CP, Aktaa S, Halvorsen S, Beska B, Abdelhamid M, Mueller C, Tutarel O, McGreavy P, Schirmer H, Geissler T, Sillesen H, Niessner A, Zacharowski K, Mehilli J, Potpara T. European Society of Cardiology Quality Indicators for the Cardiovascular Preoperative Assessment and Management of patients considered for non-cardiac surgery. Developed in collaboration with the European Society of Anaesthesiology & Intensive Care. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022:qcac057. [PMID: 36069905 DOI: 10.1093/ehjqcco/qcac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS To establish a set of quality indicators (QIs) for the cardiovascular (CV) assessment and management of patients undergoing non-cardiac surgery. METHODS AND RESULTS The Quality Indicator Committee of the European Society of Cardiology (ESC) and European Society of Anaesthesiology & Intensive Care (ESAIC) in collaboration with Task Force members of the 2022 ESC Guidelines on CV assessment and management of patients undergoing non-cardiac surgery followed the ESC methodology for QI development. This included 1) identification, by constructing a conceptual framework of care, of domains of the CV assessment and management of patients with risk factors or established cardiovascular disease (CVD) who are considered for or undergoing non-cardiac surgery, 2) development of candidate QIs following a systematic literature review, 3) selection of the final set of QIs using a modified Delphi method, 4) evaluation of the feasibility of the developed QIs. In total, eight main and nine secondary QIs were selected across six domains: 1) Structural framework (written policy), 2) Patient education and quality of life (CV risk discussion), 3) Peri-operative risk assessment (indication for diagnostic tests), 4) Peri-operative risk mitigation (use of hospital therapies), 5) Follow-up (post-discharge assessment) and 6) Outcomes (major CV events). CONCLUSION We present the 2022 ESC/ESAIC QIs for the CV assessment and management of patients with risk factors or established CVD who are considered for or are undergoing non-cardiac surgery. These indicators are supported by evidence from the literature, underpinned by expert consensus and align with 2022 ESC Guidelines on CV assessment and management of patients undergoing non-cardiac surgery.
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Affiliation(s)
- Baris Gencer
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
- Institute of Primary Health Care (BIHAM), Bern University, Bern, Switzerland
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ben Beska
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Magdy Abdelhamid
- Cardiology Department, Faculty of Medicine, Kase Al Ainy, Cairo University, Cairo, Egypt
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Heart Center, University Hospital Basel, Basel, Switzerland, University of Basel, Basel, Switzerland
| | - Oktay Tutarel
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Paul McGreavy
- Patient representatives, European Society of Cardiology (ESC)
| | - Henrik Schirmer
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway
| | - Tobias Geissler
- Department of Cardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
| | - Henrik Sillesen
- Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kai Zacharowski
- Department Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Julinda Mehilli
- Department of Cardiology, LMU University Hospital and German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Tatjana Potpara
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Serbia
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Global research trends in perioperative care for the elderly: a bibliometric and visualized study. J Anesth 2022; 36:210-220. [PMID: 34994826 DOI: 10.1007/s00540-021-03033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Aged surgical patients are at a relatively higher risk of morbidity and mortality than younger surgical patients. The present study aimed to investigate the trends and research status of perioperative care for the elderly in the anesthesiology field. METHODS We screened manuscripts published between May 31, 1991, and May 31, 2020, from the Web of Science Core Collection (WoSCC). A clustered network was derived from all references cited in all of the included manuscripts. The top authors, journals, institutions, countries, keywords, co-cited articles, and trends were identified through bibliometric analysis and visualization using CiteSpace 5.8.R3 and VOSviewer 1.6.15. RESULTS We included a total of 1860 manuscripts published between 1991 and 2020. The number of publications on perioperative care for the elderly sharply increased from 2014 onwards. The United States of America and the University of California, San Francisco were the leading publication country (24.8%, 461/1860) and institution (2.6%, 48/1860), respectively. High-frequency keywords in cluster analysis included the type of anesthesia, postoperative pain management, postoperative cognitive dysfunction, and postoperative delirium, indicating postoperative cognitive dysfunction and postoperative delirium remain the focus areas for research in perioperative care for the elderly. Organ function protection was the new research focus according to the burst detection analysis of top keywords. CONCLUSIONS The number of studies on perioperative care for the elderly has increased apparently worldwide. Postoperative cognitive dysfunction and postoperative delirium remain primary research focus areas. Organ function protection appears to be the second most highly researched topic in the perioperative care for the elderly.
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Patel R, Torke A, Nation B, Cottingham A, Hur J, Gruber R, Sinha S. Crucial Conversations for High-Risk Populations before Surgery: Advance Care Planning in a Preoperative Setting. Palliat Med Rep 2021; 2:260-264. [PMID: 34927151 PMCID: PMC8675221 DOI: 10.1089/pmr.2021.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 01/18/2023] Open
Abstract
Background: High-risk patients undergoing elective surgery are at risk for perioperative complications, including readmissions and death. Advance care planning (ACP) may allow for preparation for such events. Objectives: (1) To assess the completion rate of advance directives (ADs) and their association with one year readmissions and mortality (2) to examine clinical events for decedents. Design: This is an observational cohort study conducted through chart review. Setting/Subjects: Subjects were 400 patients undergoing preoperative evaluation for elective surgery at two hospitals in the United States. Measurements: The prevalence of ADs at the time of surgery and at one year, readmissions, and mortality at one year were determined. Results: Three-hundred ninety patients were included. In total, 102 (26.4%) patients were readmitted, yet did not complete an AD. Seventeen (4.4%) patients filed an AD during follow-up. Nineteen patients died and mortality rate was 4.9%. There was a significant association between completing an AD before death. Of the decedents, seven (37%) underwent resuscitation, but only four had ADs. Conclusions: Many high-risk surgical patients would benefit from ADs before clinical decline. Preoperative clinics present a missed opportunity to ensure ACP occurs before complications arise.
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Affiliation(s)
- Roma Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexia Torke
- IU Health Physicians, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Division of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, Indiana, USA.,Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana, USA.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA
| | - Barb Nation
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,IU Health Physicians, Indianapolis, Indiana, USA
| | - Ann Cottingham
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana, USA.,Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jennifer Hur
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Gruber
- Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Health Services and Outcomes Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Shilpee Sinha
- Indiana University School of Medicine, Indianapolis, Indiana, USA.,IU Health Physicians, Indianapolis, Indiana, USA.,Advanced Scholars Program for Internists in Research and Education (ASPIRE) Indiana University (IU) School of Medicine, Indianapolis, Indiana, USA
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Chu SY, Li PW, Fan FF, Han XN, Liu L, Wang J, Zhao J, Ye XJ, Ding WH. Combining CHA 2DS 2-VASc score into RCRI for prediction perioperative cardiovascular outcomes in patients undergoing non-cardiac surgery: a retrospective pilot study. BMC Anesthesiol 2021; 21:276. [PMID: 34753422 PMCID: PMC8576929 DOI: 10.1186/s12871-021-01496-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/29/2021] [Indexed: 12/31/2022] Open
Abstract
Background Treatment decisions in patients undergoing non-cardiac surgery are based on clinical assessment. The Revised Cardiac Risk Index (RCRI) is pragmatic and widely used but has only moderate discrimination. We aimed to test the efficacy of the CHA2DS2-VASc score and the combination of CHA2DS2-VASc and RCRI to predict perioperative risks for non-cardiac surgery. Methods This pre-specified analysis was performed in a retrospective cohort undergoing intra-abdominal surgery in our center from July 1st, 2007 to June 30th, 2008. The possible association between the baseline characteristics (as defined by CHA2DS2-VASc and RCRI) and the primary outcome of composite perioperative cardiac complications (myocardial infarction, cardiac ischemia, heart failure, arrhythmia, stroke, and/or death) and secondary outcomes of individual endpoints were explored using multivariate Logistic regression. The area under the receiver operating characteristic curve (C-statistic) was used for RCRI, CHA2DS2-VASc, and the combined models, and the net reclassification improvement (NRI) was calculated to assess the additional discriminative ability. Results Of the 1079 patients (age 57.5 ± 17.0 years), 460 (42.6%) were women. A total of 83 patients (7.7%) reached the primary endpoint. Secondary outcomes included 52 cardiac ischemic events, 40 myocardial infarction, 20 atrial fibrillation, 18 heart failure, four strokes, and 30 deaths. The endpoint events increased with the RCRI and CHA2DS2-VASc grade elevated (P < 0.05 for trend). The RCRI showed a moderate predictive ability with a C-statistics of 0.668 (95%CI 0.610–0.725) for the composite cardiac outcome. The C-statistics for the CHA2DS2-VASc was 0.765 (95% CI 0.709–0.820), indicating better performance than the RCRI (p = 0.011). Adding the CHA2DS2-VASc to the RCRI further increased the C-statistic to 0.774(95%CI 0.719–0.829), improved sensitivity, negative predictive value, and enhanced reclassification in reference to RCRI. Similar performance of the combined scores was demonstrated in the analysis of individual secondary endpoints. The best cut-off of a total of 4 scores was suggested for the combined CHA2DS2-VASc and RCRI in the prediction of the perioperative cardiac outcomes. Conclusions The CHA2DS2-VASc score significantly enhanced risk assessment for the composite perioperative cardiovascular outcome in comparison to traditional RCRI risk stratification. Incorporation of CHA2DS2-VASc scores into clinical-decision making to improve perioperative management in patients undergoing non-cardiac surgery warrants consideration. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01496-2.
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Affiliation(s)
- Song-Yun Chu
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Pei-Wen Li
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Fang-Fang Fan
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Xiao-Ning Han
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Lin Liu
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Jie Wang
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Jing Zhao
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Xiao-Jin Ye
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China
| | - Wen-Hui Ding
- Department of Cardiology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034, People's Republic of China.
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Ho ST, Chen TJ, Yeh TC, Kao S, Lin TC, Wang JO. Anesthesia services in Taiwan: A nationwide population-based study. J Chin Med Assoc 2021; 84:713-717. [PMID: 34029215 DOI: 10.1097/jcma.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This study was conducted to provide an overview of anesthesia services in Taiwan from 2001 to 2010. METHODS A retrospective population-based analysis was performed using data from Taiwan's National Health Insurance Research Database for the period 2001 to 2010. The results were stratified by patient sex, patient age, anesthesia type, and hospital setting. Categorical data are presented as totals and percentages. Linear regression was performed to analyze the anesthesia trends. RESULTS The annual use of anesthesia increased continually from 964,440 instances in 2001 to 1,073,160 in 2010, totaling 10,076,600 cases with a total cost of 25.4 billion USD. The overwhelming majority (83.9%) of anesthesia cases was for anesthesia in an inpatient setting; general anesthesia accounted for 73.8% of anesthesia cases, and female patients outnumbered male patients (52.4% vs 47.6%). The average number of anesthesia cases was 44.2 per thousand of the population annually, but this percentage was much higher in elderly people (100.9 cases per thousand people annually). The annual number of anesthesia cases per thousand of the population increased from 104.4 in 2001 to 113.0 in 2010 in the oldest group (>80 years). By contrast, a considerable decline in use of anesthesia was discovered over the study period among those aged younger than 18 years. CONCLUSION The use of anesthesia services in Taiwan has increased over the years. The relationships of age with anesthesia volume and cost were found to follow an inverse U-shaped pattern. Elderly people used anesthesia services more frequently. The planning of geriatric anesthesia services deserves attention, especially in continually aging societies such as Taiwan.
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Affiliation(s)
- Shung-Tai Ho
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Te-Chun Yeh
- Development and Planning Center, Taipei City Hospital, Taipei, Taiwan, ROC
| | - Senyeong Kao
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Tso-Chou Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ju-O Wang
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
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Chu SY, Li PW, Han XN, Liu L, Ye XJ, Wang J, Zhao J, Ding WH. Differences in perioperative cardiovascular outcomes in elderly male and female patients undergoing intra-abdominal surgery: a retrospective cohort study. J Int Med Res 2021; 49:300060520985295. [PMID: 33472460 PMCID: PMC7829535 DOI: 10.1177/0300060520985295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Perioperative cardiovascular events constitute the majority of complications in noncardiac surgery. Older and female patients have been less investigated. We aimed to evaluate differences in perioperative cardiovascular outcomes by age and sex. METHODS We enrolled 1079 patients (57.5 ± 17.0 years, 42.6% women) undergoing intra-abdominal surgery from July 2007 to June 2008 and compared occurrence of perioperative cardiac events by age (≥65 vs. <65 years) and sex. Multivariable logistic regression was used to investigate associations between age, sex, and outcomes. RESULTS Age ≥65 years was associated with perioperative myocardial infarction (MI) (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.3-6.6) and total cardiovascular events (OR 2.4, 95% CI: 1.3-4.2). Age ≥65 years was associated with higher perioperative MI risks in men (OR 4.7, 95% CI: 1.3-17.6) than in women (OR 3.1, 95% CI: 1.2-8.3). Advanced age was associated with heart failure in women (OR 13.9, 95% CI: 1.7-110.5). Female sex was a risk factor for heart failure in elderly patients (OR 4.2, 95% CI: 1.1-15.7). CONCLUSIONS Advanced age appeared to be associated with increased perioperative cardiac risk but differed by sex. Tailored strategies should be considered with respect to the patient's sex.
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Affiliation(s)
- Song-Yun Chu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Pei-Wen Li
- Department of Cardiology, Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Xiao-Ning Han
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Lin Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xiao-Jin Ye
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jing Zhao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Wen-Hui Ding
- Department of Cardiology and Department of Internal Medicine, Peking University First Hospital, Beijing, China
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Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis. Cancers (Basel) 2021; 13:cancers13092104. [PMID: 33925512 PMCID: PMC8123886 DOI: 10.3390/cancers13092104] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient. Abstract Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.
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Wang Y, Li H, Ye H, Xie G, Wu S, Song S, Cheng B, Fang X. Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study. Psychogeriatrics 2021; 21:158-165. [PMID: 33415803 DOI: 10.1111/psyg.12648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/09/2020] [Accepted: 11/30/2020] [Indexed: 12/13/2022]
Abstract
AIM Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China. METHODS We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted. RESULTS Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications. CONCLUSIONS The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.
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Affiliation(s)
- Yan Wang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Li
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Ye
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guohao Xie
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuijing Wu
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shengwen Song
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Baoli Cheng
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangming Fang
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Perioperative myocardial damage and the incidence of type 2 myocardial infarction in patients with intermediate and high cardiovascular risk. Anatol J Cardiol 2020; 25:89-95. [PMID: 33583815 DOI: 10.14744/anatoljcardiol.2020.45752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Perioperative myocardial infarction is a major cause of morbidity and mortality in patients undergoing surgical operations. We aimed to determine the incidence of perioperative myocardial infarction in patients with intermediate- or high-risk Framingham scores. METHODS One hundred and one patients (62 males, 39 females) over 40 years of age (mean age 72±11 years) median 73 (65-81), min- max (46-96), with Framingham risk scores of 10% or higher, and scheduled for surgical interventions in the orthopedics and urology departments of our hospital were included in the study. Patient demographics, comorbidities, blood pressures, and biochemical data were recorded. Troponin values and electrocardiographic findings were obtained during the immediate preoperative period and on postoperative day 2 and then compared. Perioperative myocardial injury and infarction were diagnosed using the third universal definition of myocardial infarction. RESULTS In 44 (43%) patients, postoperative troponin values were compared with the preoperative values. In 26 (25%) patients, the changes were consistent with myocardial ischemia or damage. Alterations in troponin values with significant electrocardiogram (ECG) changes were found in 6 patients (6%). CONCLUSION The risk of postoperative myocardial damage was high in our patients with intermediate or high-risk Framingham scores. This im-plies that close follow-up of these patients with abnormal ECG and troponin values during the pre- and postoperative period is required.
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Role of Frailty on Risk Stratification in Cardiac Surgery and Procedures. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1216:99-113. [PMID: 31894551 DOI: 10.1007/978-3-030-33330-0_11] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The number of older people candidates for interventional cardiology, such as PCI but especially for transcatheter aortic valve implantation (TAVI) , would increase in the future. Generically, the surgical risk, the amount of complications in the perioperative period, mortality and severe disability remain significantly higher in the elderly than in younger. For this reason it's important to determine the indication for surgical intervention, using tools able to predict not only the classics outcome (length of stay, mortality), but also those more specifically geriatrics, correlate to frailty: delirium, cognitive deterioration, risk of institutionalization and decline in functional status. The majority of the most used surgical risks scores are often specialist-oriented and many variables are not considered. The need of a multidimensional diagnostic process, focused on detect frailty, in order to program a coordinated and integrated plan for treatment and long term follow up, led to the development of a specific geriatric tool: the Comprehensive Geriatric Assessment (CGA). The CGA has the aim to improve the prognostic ability of the current risk scores to capture short long term mortality and disability, and helping to resolve a crucial issue providing solid clinical indications to help physician in the definition of on interventional approach as futile. This tool will likely optimize the selection of TAVI older candidates could have the maximal benefit from the procedure.
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Reis P, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Abelha F. Incidence, predictors and validation of risk scores to predict postoperative mortality after noncardiac vascular surgery, a prospective cohort study. Int J Surg 2020; 73:89-93. [DOI: 10.1016/j.ijsu.2019.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 12/18/2022]
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Dhir S, Dhir A. The Global Perspective of Cardiovascular Assessment for Noncardiac Surgery: Comparisons from Around the World. J Cardiothorac Vasc Anesth 2019; 33:2287-2295. [DOI: 10.1053/j.jvca.2019.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 01/09/2023]
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Free Flap Transfer for Head and Neck Reconstruction Using Local Anesthesia in Elderly Patients. Ann Plast Surg 2019; 80:S30-S35. [PMID: 29369912 DOI: 10.1097/sap.0000000000001303] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of skin cancer appearing on the head and neck areas is higher in elderly patients. Although free flap reconstruction is the mainstay after tumor excision, it is challenging to complete in elderly patients, owing to the high risk of complications and/or mortality rates associated with the use of general anesthesia. In this study, we used only local anesthesia in free tissue reconstruction of the head and neck in five elderly patients. MATERIALS AND METHODS From 2013 to 2016, 5 elderly patients with high risk of general anesthesia underwent reconstruction with either anterolateral thigh free flaps or groin free flap under local anesthesia, after wide excision of malignant tumors at head and neck. For each patient, the following information was collected: age, gender, body weight, anesthesia agents, intravenous fluid, blood loss, site of lesion, flap size, operation time, complications, and follow-up time. RESULTS All flaps survived completely. The mean age of 5 patients (3 male patients and 2 female patients) was 84 years (range, 68-100 years), and mean flap size was 199.6 cm (range, 120-330 cm). The mean follow-up period was 26.6 months (range, 5-38 months). No complications were found. CONCLUSIONS With proper local anesthesia, successful head and neck reconstruction with free flap was possible, and patient prognosis was positive. There are numerous advantages, including: (1) a safer and inexpensive operation; (2) no complications from general anesthesia; (3) the fact that free flap transfer can be performed in elderly patients, even if they cannot tolerate general anesthesia; and (4) allowance of the performance of free tissue transferring in countries without adequate medical resources.
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Abstract
Surgery represents one of the main therapeutic references in the world, affording greater survival and life expectancy for many patients. In general, the estimated postoperative mortality is low (around 1-4%). Thirteen percent of the surgical procedures have a high risk of complications, accounting for 80% of all postoperative deaths. Recently, there have been significant advances related to organizational aspects, new anesthetic and surgical techniques, prognostic scales, perioperative management and greater participation and involvement of the patient. This new series of Medicina Intensiva will address fundamental aspects of how Departments of Intensive Care Medicine can add value to the surgical process, in a coordinated manner with other services. Institutional policies are required to ensure the detection of patients at risk in hospitalization wards, with early admission to the ICU of those patients in whom admission is indicated, adapting the treatment in the ICU and optimizing the criteria for discharge. The detection and prevention of post-ICU syndrome in patients and relatives, and the follow-up of ICU discharge and hospitalization in a multidisciplinary manner can reduce the sequelae among critical surgical patients, improving the outcomes and quality of life, and restoring the patient to society. In future publications of this series directed to the surgical patient, updates will be provided on the perioperative management of some of the most complex surgeries.
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Reis P, Lopes AI, Leite D, Moreira J, Mendes L, Ferraz S, Amaral T, Abelha F. Predicting mortality in patients admitted to the intensive care unit after open vascular surgery. Surg Today 2019; 49:836-842. [DOI: 10.1007/s00595-019-01805-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 03/23/2019] [Indexed: 01/22/2023]
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. Severity of disease scoring systems and mortality after non-cardiac surgery. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 29628154 PMCID: PMC9391813 DOI: 10.1016/j.bjane.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. Methods Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann–Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). Results 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR = 1.24); emergent surgery (OR = 4.10), serum sodium (OR = 1.06) and FiO2 at admission (OR = 14.31). Serum bicarbonate at admission (OR = 0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR = 1.02), APACHE II (OR = 1.09), emergency surgery (OR = 1.82), high-risk surgery (OR = 1.61), FiO2 at admission (OR = 1.02), postoperative acute renal failure (OR = 1.96), heart rate (OR = 1.01) and serum sodium (OR = 1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. Conclusion Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Reis PV, Sousa G, Lopes AM, Costa AV, Santos A, Abelha FJ. [Severity of disease scoring systems and mortality after non-cardiac surgery]. Rev Bras Anestesiol 2018; 68:244-253. [PMID: 29628154 DOI: 10.1016/j.bjan.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/22/2017] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Mortality after surgery is frequent and severity of disease scoring systems are used for prediction. Our aim was to evaluate predictors for mortality after non-cardiac surgery. METHODS Adult patients admitted at our surgical intensive care unit between January 2006 and July 2013 was included. Univariate analysis was carried using Mann-Whitney, Chi-square or Fisher's exact test. Logistic regression was performed to assess independent factors with calculation of odds ratio and 95% confidence interval (95% CI). RESULTS 4398 patients were included. Mortality was 1.4% in surgical intensive care unit and 7.4% during hospital stay. Independent predictors of mortality in surgical intensive care unit were APACHE II (OR=1.24); emergent surgery (OR=4.10), serum sodium (OR=1.06) and FiO2 at admission (OR=14.31). Serum bicarbonate at admission (OR=0.89) was considered a protective factor. Independent predictors of hospital mortality were age (OR=1.02), APACHE II (OR=1.09), emergency surgery (OR=1.82), high-risk surgery (OR=1.61), FiO2 at admission (OR=1.02), postoperative acute renal failure (OR=1.96), heart rate (OR=1.01) and serum sodium (OR=1.04). Dying patients had higher scores in severity of disease scoring systems and longer surgical intensive care unit stay. CONCLUSION Some factors influenced both surgical intensive care unit and hospital mortality.
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Affiliation(s)
- Pedro Videira Reis
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Gabriela Sousa
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | | | - Ana Vera Costa
- Universidade do Porto, Faculdade de Medicina, Porto, Portugal
| | - Alice Santos
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal
| | - Fernando José Abelha
- Hospital de São João, Serviço de Anestesiologia, Porto, Portugal; Universidade do Porto, Faculdade de Medicina, Porto, Portugal.
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Intensive medicine services. How to add value to the surgical process? Med Intensiva 2018; 42:461-462. [PMID: 29615273 DOI: 10.1016/j.medin.2018.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 12/20/2022]
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Balance risks and benefits when selecting anaesthetic and perioperative care options in elderly surgical outpatients. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Planas A, Ramasco F. Search for biomarkers to identify surgical patients at high cardiovascular and perioperative mortality risk. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:547-549. [PMID: 29102403 DOI: 10.1016/j.redar.2017.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- A Planas
- Servicio de Anestesia y Reanimación, Hospital Universitario de la Princesa, Madrid, España.
| | - F Ramasco
- Servicio de Anestesia y Reanimación, Hospital Universitario de la Princesa, Madrid, España
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Abstract
The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.
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Ondrakova M, Motovska Z, Waldauf P, Knot J, Havluj L, Bittner L, Bartoska R, Gűrlich R, Krbec M, Dzupa V, Grill R, Widimsky P. Antithrombotic therapy of patients with atrial fibrillation discharged after major non-cardiac surgery. 1-year follow-up. Sub-analysis of PRAGUE 14 study. PLoS One 2017; 12:e0177519. [PMID: 28542316 PMCID: PMC5443499 DOI: 10.1371/journal.pone.0177519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/29/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The study investigated the discharge antithrombotic medication in patients with atrial fibrillation (AF) after major non-cardiac surgery and the impact on one-year outcomes. METHODS A subgroup of 366 patients (mean age 75.9±10.5 years, women 42.3%, acute surgery 42.9%) undergoing major non-cardiac surgery and having any form of AF (30.6% of the total population enrolled in the PRAGUE-14 study) was followed for 1 year. RESULTS Antithrombotics (interrupted due to surgery) were resumed until discharge in 51.8% of patients; less frequently in men (OR 0.6 (95% CI 0.95 to 0.35); p = 0.029), and in patients undergoing elective surgery (OR 0.6 (95% CI 0.91 to 0.33); p = 0.021). Dual antiplatelet therapy was resumed more often (91.7%) in comparison to aspirin monotherapy (57.3%; p = 0.047), and vitamin K antagonist (56.3%; p = 0.042). Patients with AF had significantly higher one-year mortality (22.1%) than patients without AF (14.1%, p = 0.001). The causes of death were: ischaemic events (32.6% of deaths), bleeding events (8.1%), others (N = 51; 59.3%, 20 of them died due to cancer). Non-reinstitution of aspirin until discharge was associated with higher one-year mortality (17.6% vs. 34.8%; p = 0.018). CONCLUSION Preoperatively interrupted antithrombotics were re-administrated at discharge only in half of patients with AF, less likely in male patients and those undergoing elective surgery. The presence of AF was recognized as a predictor of one-year mortality, especially if aspirin therapy was not resumed until discharge. TRIAL REGISTRATION ClinicalTrials.gov NCT01897220.
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Affiliation(s)
- Martina Ondrakova
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Zuzana Motovska
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
- * E-mail:
| | - Petr Waldauf
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Jiri Knot
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Lukas Havluj
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Lukas Bittner
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Radek Bartoska
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Robert Gűrlich
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Martin Krbec
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Valer Dzupa
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Robert Grill
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Petr Widimsky
- University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University Prague, Prague, Czech Republic
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Chasing myocardial outcomes: perioperative myocardial infarction and cardiac troponin. Can J Anaesth 2015; 63:227-32. [PMID: 26634279 DOI: 10.1007/s12630-015-0539-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 10/30/2015] [Accepted: 11/12/2015] [Indexed: 02/06/2023] Open
Abstract
Perioperative myocardial infarction represents the most common cardiovascular complication following non-cardiac surgery, but frequently presents without the usual clinical signs and symptoms consistent with acute coronary syndrome. Given the silent nature of this event, a clinician's reliance on risk stratification tools and cardiac specific biomarkers to assist in the identification of at-risk individuals is heightened in the perioperative setting. Although cardiac troponin elevations following non-cardiac surgery have been consistently linked to increased mortality, uncertainty remains over how to clinically intervene to prevent harm. This decision is further complicated by the increasing sensitivity of the newest generation of cardiac biomarker immunoassays. In this narrative review, the growing body of evidence surrounding cardiac troponin elevations in the perioperative setting, how the evidence has been integrated into recent clinical practice guidelines, and its implications for the detection of perioperative myocardial infarction are discussed.
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Ghaly RF, Anantamongkol U, Candido KD, Knezevic NN. A rare case of delayed subarachnoid anesthetic blockade effects in a 103-year-old female patient. Surg Neurol Int 2015; 6:88. [PMID: 26060597 PMCID: PMC4448518 DOI: 10.4103/2152-7806.157658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/17/2015] [Indexed: 11/29/2022] Open
Abstract
Background: The elderly represent a unique challenge for the effects of regional anesthesia, and very few cases of block onset delay have been described. Their delayed response is attributed to a number of factors that include: Physiologic deterioration, musculoskeletal contractures, degenerative joint disease, autonomic regulatory dysfunction, cognitive dysfunction, altered pharmacokinetics, and pharmacodynamics of local anesthetics and adjuvants. Case Description: In this report we present the rare case of 45-min delay between the administration and onset of action of a subarachnoid blockade in a 103-year-old female, who was scheduled for left hip pinning, for repair of a femoral neck fracture. Patient received an injection of hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl into the subarachnoidal space and underwent the surgical procedure without complications. Conclusions: Delayed responses to subarachnoid anesthesia can be expected in extremely elderly patients. Anesthetic procedures should be monitored and managed on a case-by-case basis.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 ; Department of Anesthesiology, JHS Hospital of Cook County, Chicago, IL 60612 ; Ghaly Neurosurgical Associates, Aurora, IL 60504 ; Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
| | | | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 ; Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 ; Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
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Bajwa SJS. Clinical conundrums and challenges during geriatric orthopedic emergency surgeries. Int J Crit Illn Inj Sci 2015; 5:38-45. [PMID: 25810963 PMCID: PMC4366827 DOI: 10.4103/2229-5151.152342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Despite so many advancements and innovations in anesthetic techniques, expectations and challenges have also grown in plenty. Cardiac, pediatric, obstetric and neuro-anesthesia have perfectly developed to fulfill the desired needs of respective patient population. However, geriatric anesthesia has been shown a lesser interest in teaching and clinical practices over the years as compared with other anesthetic sub-specialties. The large growing geriatric population globally is also associated with an increase number of elderly patients presenting for orthopedic emergency surgeries. Orthopedic emergency surgery in geriatric population is not only a daunting clinical challenge but also has numerous socio-behavioral and economic ramifications. Decision making in anesthesia is largely influenced by the presence of co-morbidities, neuro-cognitive functions and the current socio-behavioral status. Pre-anesthetic evaluation and optimization are extremely important for a better surgical outcome but is limited by time constraints during emergency surgery. The current review aims to highlight comprehensively the various clinical, social, behavioral and psychological aspects during pre-anesthetic evaluation associated with emergency orthopedic surgery in geriatric population.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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Grupo de Trabajo Conjunto sobre cirugía no cardiaca: Evaluación y manejo cardiovascular de la Sociedad Europea de Cardiología (ESC) y la European Society of Anesthesiology (ESA). Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Myocardial injury after surgery is a risk factor for weaning failure from mechanical ventilation in critical patients undergoing major abdominal surgery. PLoS One 2014; 9:e113410. [PMID: 25409182 PMCID: PMC4237423 DOI: 10.1371/journal.pone.0113410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 10/22/2014] [Indexed: 11/19/2022] Open
Abstract
Background Myocardial injury after noncardiac surgery (MINS) is a newly proposed concept that is common among adults undergoing noncardiac surgery and associated with substantial mortality. We analyzed whether MINS was a risk factor for weaning failure in critical patients who underwent major abdominal surgery. Methods This retrospective study was conducted in the Department of Critical Care Medicine of Peking University People's Hospital. The subjects were all critically ill patients who underwent major abdominal surgery between January 2011 and December 2013. Clinical and laboratory parameters during the perioperative period were investigated. Backward stepwise regression analysis was performed to evaluate MINS relative to the rate of weaning failure. Age, hypertension, chronic renal disease, left ventricular ejection fraction before surgery, Acute Physiologic and Chronic Health Evaluation II score, pleural effusion, pneumonia, acute kidney injury, duration of mechanical ventilation before weaning and the level of albumin after surgery were treated as independent variables. Results This study included 381 patients, of whom 274 were successfully weaned. MINS was observed in 42.0% of the patients. The MINS incidence was significantly higher in patients who failed to be weaned compared to patients who were successfully weaned (56.1% versus 36.5%; P<0.001). Independent predictive factors of weaning failure were MINS, age, lower left ventricular ejection fraction before surgery and lower serum albumin level after surgery. The MINS odds ratio was 4.098 (95% confidence interval, 1.07 to 15.6; P = 0.04). The patients who were successfully weaned had shorter hospital stay lengths and a higher survival rate than those who failed to be weaned. Conclusion MINS is a risk factor for weaning failure from mechanical ventilation in critical patients who have undergone major abdominal surgery, independent of age, lower left ventricular ejection fraction before surgery and lower serum albumin levels after surgery.
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Juanatey JRG, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery. Eur J Anaesthesiol 2014; 31:517-73. [DOI: 10.1097/eja.0000000000000150] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383-431. [PMID: 25086026 DOI: 10.1093/eurheartj/ehu282] [Citation(s) in RCA: 805] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Bhaskar SB, Bajwa SJS. From pre-operative comorbidities to post-operative cognitive dysfunction: The challenging face of geriatric anaesthesia. Indian J Anaesth 2014; 58:248-50. [PMID: 25024464 PMCID: PMC4090987 DOI: 10.4103/0019-5049.135024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- S Bala Bhaskar
- Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India. E-mail:
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Dewan SK, Zheng SB, Xia SJ. Preoperative geriatric assessment: comprehensive, multidisciplinary and proactive. Eur J Intern Med 2012; 23:487-94. [PMID: 22863423 DOI: 10.1016/j.ejim.2012.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 06/13/2012] [Accepted: 06/20/2012] [Indexed: 11/17/2022]
Abstract
With the changing global demographic pattern, our health care systems increasingly have to deal with a greater number of elderly patients, which consequently also takes its toll on our surgical services. The elderly are not simply older adults. They represent a heterogeneous branch of the population with specific physiological, psychological, functional and social issues that require individualised attention prior to surgery. Increased acknowledgement that chronological age alone is not an exclusion criterion, along with advances in surgical and anaesthetic techniques have today lead to decreased reluctance to deny the elderly surgical treatment. In order to ensure a safe perioperative period, we believe that a comprehensive, multidisciplinary and proactive preoperative assessment will be helpful to detect the multiple risk factors and comorbidities common in older patients, to assess functional status and simultaneously allow room for early preoperative interventions and planning of the intra- and postoperative period. In this review we outline the currently available preoperative geriatric risk assessment tools and provide an insight on how a comprehensive, multidisciplinary and proactive approach can help improve perioperative outcome.
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Affiliation(s)
- Sheilesh Kumar Dewan
- Department of Geriatric Medicine, Huadong Hospital affiliated to Fudan University, 221 West Yan'An Road, Shanghai 200040, China.
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Chopra V, Froehlich JB. Assessing and Managing Cardiovascular Risk. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Kumar S, Bajwa SJS. Neuraxial opioids in geriatrics: A dose reduction study of local anesthetic with addition of sufentanil in lower limb surgery for elderly patients. Saudi J Anaesth 2011; 5:142-9. [PMID: 21804793 PMCID: PMC3139305 DOI: 10.4103/1658-354x.82781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background and Objectives: Neuraxial anesthesia in the elderly is associated with exaggerated responses to conventional doses of local anesthetics, thereby increasing the incidence of hemodynamic complications. A double-blind prospective study was carried out in our institute with an aim to compare the hemodynamic stability and quality of the conventional dose of hyperbaric bupivacaine (LA) with low dose of LA and sufentanil in elderly patients scheduled for lower limb surgery, randomized to receive combined spinal epidural anesthesia. Methods: A total of 50 elderly patients of ASA grade I and II, divided randomly into groups I and II, of either sex undergoing lower limb surgery under combined spinal epidural anesthesia at our institute attached to a Government Medical College were enrolled for study. Group I received 2.5 ml of intrathecal hyperbaric bupivacaine (LA), while group II received 1.5 ml of intrathecal LA+0.1 ml sufentanil (5 μg). Both initial and postoperative subarachnoid block characteristics, hemodynamic and respiratory parameters, duration of analgesia, and side effects were observed and recorded. Statistical analysis was carried out using Chi-square and paired t test. Results: Demographic profile was comparable in both groups. Group I had a greater incidence of hypotension and, consequently, higher use of vasopressors (P<0.05). Onset of sensory analgesia, time to achieve peak sensory level, and recovery from motor blockade were significantly earlier in group II (P<0.05). Postoperative consumption of LA through epidural route was significantly higher in group I (P<0.05). The side effect profile was similar, except for a significantly higher incidence of shivering in group I (P<0.05). Conclusions: The study established that the dose of a local anesthetic can be safely and significantly lowered by 40%, with addition of low-dose sufentanil, thereby avoiding the hemodynamic fluctuation and providing a stable perioperative and postoperative period in the geriatric population. In addition, duration of sensory analgesia is prolonged and postoperative requirement for the epidural top-up also decreases.
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Affiliation(s)
- Sumit Kumar
- Department of Anaesthesiology, Government Medical College, Patiala, India
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Anaesthesia for the elderly outpatient: preoperative assessment and evaluation, anaesthetic technique and postoperative pain management. Curr Opin Anaesthesiol 2010; 23:726-31. [DOI: 10.1097/aco.0b013e3283400b6c] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reppel M, Weil J. [Limitation of operability. What does the internist need to know?]. Internist (Berl) 2010; 51:442-50. [PMID: 20232031 DOI: 10.1007/s00108-009-2451-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The number of elderly people that are critically ill and are send for surgery is rising rapidly. As co-morbidities such as heart disease have huge impact on the perioperative risk, identification of specific risk factors should guide the pre- and perioperative management. Several risk scores and the guidelines published by the European Society of Cardiology recently are currently available and are reviewed in the current manuscript. Evaluation of the medical history of the individual patient and functional tests are the basis for further decisions. Patients that are suffering from co-morbidities or reduced physical fitness are identified as risk patients. Patients without risk factors can be sent for surgery without additional evaluation. In moderate risk patients medication should be optimized prior to surgery. Except emergency surgery cases critical illness should be identified and treated before surgery is initiated. Depending on the number of potential risk factors non-invasive cardiac stress tests are recommended. Depending on the results also coronary angiography/-angioplasty should be performed. Acute coronary syndromes or unstable angina should preferentially be treated prior to surgery.
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Affiliation(s)
- M Reppel
- Medizinische Klinik II, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck.
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Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur J Anaesthesiol 2010; 27:92-137. [DOI: 10.1097/eja.0b013e328334c017] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Guía de práctica clínica para la valoración del riesgo cardiaco preoperatorio y el manejo cardiaco perioperatorio en la cirugía no cardiaca. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73133-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, Gorenek B, Hennerici MG, Iung B, Kelm M, Kjeldsen KP, Kristensen SD, Lopez-Sendon J, Pelosi P, Philippe F, Pierard L, Ponikowski P, Schmid JP, Sellevold OFM, Sicari R, Van den Berghe G, Vermassen F, Vanhorebeek I, Vahanian A, Auricchio A, Bax JJ, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, McGregor K, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas P, Widimsky P, De Caterina R, Agewall S, Al Attar N, Andreotti F, Anker SD, Baron-Esquivias G, Berkenboom G, Chapoutot L, Cifkova R, Faggiano P, Gibbs S, Hansen HS, Iserin L, Israel CW, Kornowski R, Eizagaechevarria NM, Pepi M, Piepoli M, Priebe HJ, Scherer M, Stepinska J, Taggart D, Tubaro M. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J 2009; 30:2769-812. [PMID: 19713421 DOI: 10.1093/eurheartj/ehp337] [Citation(s) in RCA: 431] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raffaele De Caterina
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Stefan Agewall
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Nawwar Al Attar
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Felicita Andreotti
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Stefan D. Anker
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Gonzalo Baron-Esquivias
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Guy Berkenboom
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Laurent Chapoutot
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Renata Cifkova
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Pompilio Faggiano
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Simon Gibbs
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Henrik Steen Hansen
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Laurence Iserin
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Carsten W. Israel
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Ran Kornowski
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | | | - Mauro Pepi
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Massimo Piepoli
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Hans Joachim Priebe
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Martin Scherer
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Janina Stepinska
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - David Taggart
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
| | - Marco Tubaro
- The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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McIntyre HF. Lighting the vascular fuse--late surgical attrition in older patients. Int J Clin Pract 2007; 61:718-20. [PMID: 17493084 DOI: 10.1111/j.1742-1241.2007.01308.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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