Preoperative Evaluation of the Frail Patient

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery" provides recommendations to guide clinicians in the perioperative cardiovascular evaluation and management of adult patients undergoing noncardiac surgery.

METHODS

A comprehensive literature search was conducted from August 2022 to March 2023 to identify clinical studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Recommendations from the "2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery" have been updated with new evidence consolidated to guide clinicians; clinicians should be advised this guideline supersedes the previously published 2014 guideline. In addition, evidence-based management strategies, including pharmacological therapies, perioperative monitoring, and devices, for cardiovascular disease and associated medical conditions, have been developed.

Frailty; Time for Global Action : Commentary on "Frailty and its Association with Long-Term Mortality among Community-Dwelling older adults aged 75 years and Over"

This commentary examines the study "Frailty and Its Association with Long-Term Mortality Among Community-Dwelling Older Adults Aged 75 Years and Over" by Lewis et al. The retrospective cohort study utilized data from a primary healthcare provider in Israel to investigate frailty using the Frailty Index (FI) and its correlation with long-term mortality. Nearly half of the older adult cohort was identified as frail, with a strong association between higher frailty levels and increased mortality risk. The commentary emphasizes the importance of routine frailty screening in clinical practice and health policy. Integrating FI calculations into electronic health records can facilitate timely care for high-risk individuals. However, presenting frailty data must be managed carefully and in conjunction with patients' preferences to avoid stigmatizing and negatively influencing clinical decisions. While the FI is a valuable tool, it should complement, not replace, other assessments that provide a more holistic view of the patient's health. Furthermore, the commentary strongly advocates for a more comprehensive approach to patient care, emphasizing that non-geriatricians must also be proficient in recognizing and managing frailty. Effectively addressing frailty can lead to significant cost savings for healthcare systems, reduced burden on healthcare facilities, and decreased need for long-term care.

Incidence of post-operative delirium increases as severity of frailty increases

OBJECTIVE

The surgical population is ageing and often frail. Frailty increases the risk for poor post-operative outcomes such as delirium, which carries significant morbidity, mortality and cost. Frailty is often measured in a binary manner, limiting pre-operative counselling. The goal of this study was to determine the relationship between categorical frailty severity level and post-operative delirium.

METHODS

We performed an analysis of a retrospective cohort of older adults from 12 January 2018 to 3 January 2020 admitted to a tertiary medical center for elective surgery. All participants underwent frailty screening prior to inpatient elective surgery with at least two post-operative delirium assessments. Planned ICU admissions were excluded. Procedures were risk-stratified by the Operative Stress Score (OSS). Categorical frailty severity level (Not Frail, Mild, Moderate, and Severe Frailty) was measured using the Edmonton Frail Scale. Delirium was determined using the 4 A's Test and Confusion Assessment Method-Intensive Care Unit.

RESULTS

In sum, 324 patients were included. The overall post-operative delirium incidence was 4.6% (15 individuals), which increased significantly as the categorical frailty severity level increased (2% not frail, 6% mild frailty, 23% moderate frailty; P < 0.001) corresponding to increasing odds of delirium (OR 2.57 [0.62, 10.66] mild vs. not frail; OR 12.10 [3.57, 40.99] moderate vs. not frail).

CONCLUSIONS

Incidence of post-operative delirium increases as categorical frailty severity level increases. This suggests that frailty severity should be considered when counselling older adults about their risk for post-operative delirium prior to surgery.

The relationship between prognosis and temporal muscle thickness in 102 patients with glioblastoma

Temporal muscle thickness measured on 3D MRI has recently been linked to prognosis in glioblastoma patients and may serve as an independent prognostic indicator. This single-center study looked at temporal muscle thickness and prognosis in patients with primary glioblastoma. Overall survival was the major study outcome. For a retrospective analysis from 2010 to 2020, clinical data from 102 patients with glioblastoma at the Department of Oncology Radiotherapy of the First Affiliated Hospital of Dalian Medical University were gathered. Fifty-five cases from 2016 to 2020 contained glioblastoma molecular typing data, of which 45 were IDH wild-type glioblastomas and were analysed separately. TMT was measured on enhanced T1-weighted magnetic resonance images in patients with newly diagnosed glioblastoma.Overall patient survival (OS) was calculated by the Kaplan-Meier method and survival curves were plotted using the log-rank-sum test to determine differences between groups, and multifactorial analyses were performed using a Cox proportional-risk model.The median TMT for 102 patients was 6.775 mm (range: 4.95-10.45 mm). Patients were grouped according to median TMT, and the median overall survival (23.0 months) was significantly longer in the TMT > median group than in the TMT median group (P 0.001; Log-rank test). Analysing 45 patients with IDH wild type alone, the median overall survival (12 months) of patients in the TMT > median group was significantly longer than that of patients in the TMT ≤ median group (8 months) (P < 0.001; Log-rank test).TMT can serve as an independent prognostic factor for glioblastoma.

Genetic and phenotypic associations of frailty with cardiovascular indicators and behavioral characteristics

INTRODUCTION

Frailty Index (FI) is a common measure of frailty, which has been advocated as a routine clinical test by many guidelines. The genetic and phenotypic relationships of FI with cardiovascular indicators (CIs) and behavioral characteristics (BCs) are unclear, which has hampered ability to monitor FI using easily collected data.

OBJECTIVES

This study is designed to investigate the genetic and phenotypic associations of frailty with CIs and BCs, and further to construct a model to predict FI.

METHOD

Genetic relationships of FI with 288 CIs and 90 BCs were assessed by the cross-trait LD score regression (LDSC) and Mendelian randomization (MR). The phenotypic data of these CIs and BCs were integrated with a machine-learning model to predict FI of individuals in UK-biobank. The relationships of the predicted FI with risks of type 2 diabetes (T2D) and neurodegenerative diseases were tested by the Kaplan-Meier estimator and Cox proportional hazards model.

RESULTS

MR revealed putative causal effects of seven CIs and eight BCs on FI. These CIs and BCs were integrated to establish a model for predicting FI. The predicted FI is significantly correlated with the observed FI (Pearson correlation coefficient = 0.660, P-value = 4.96 × 10-62). The prediction model indicated "usual walking pace" contributes the most to prediction. Patients who were predicted with high FI are in significantly higher risk of T2D (HR = 2.635, P < 2 × 10-16) and neurodegenerative diseases (HR = 2.307, P = 1.62 × 10-3) than other patients.

CONCLUSION

This study supports associations of FI with CIs and BCs from genetic and phenotypic perspectives. The model that is developed by integrating easily collected CIs and BCs data in predicting FI has the potential to monitor disease risk.

Validation of the Self-Reported Edmonton Frail Scale - Acute Care in Patients ≥ 65 Years Undergoing Surgery

BACKGROUND

Frailty is common in geriatric emergency surgery and associated with increased risk for poor postoperative outcomes. Frailty screening is challenging in emergency settings. The Edmonton Frail Scale (EFS) is a valid tool to screen for patients at high risk for poor postoperative outcomes. Recently, the EFS was modified to decrease dependence on staff to perform physical measures. This modification, the EFS-Acute Care (EFS-AC), has not been validated. We wish to assess the agreement between the EFS and the EFS-AC.

STUDY DESIGN

We performed a prospective cohort study from 10/2021 - 10/2022 screening 688 patients ≥ 65 years with both the EFS and EFS-AC preoperatively. We assessed the ability of the EFS-AC to discriminate frailty identified by the EFS and compared the association of both scales with loss of independence (LOI), hospital length of stay (LOS), ICU admissions, and ICU LOS. Receiver Operator Curves were used to estimate the discriminatory thresholds for LOI.

RESULTS

688 patients with a median age 73 (IQR 68, 77) were enrolled. The EFS-AC was able to discriminate individuals' frailty status by the EFS with excellent agreement (AUC 0.971 [0.958, 0.983]). An EFS-AC threshold score of ≥ 6 points lead to 93.60% of individuals being correctly identified (77.87% sensitivity and 97.00% specificity). Both EFS and EFS-AC ≥ 6 were similarly associated with a higher risk for all clinical outcomes assessed and demonstrated similar ability to predict LOI.

CONCLUSIONS

The EFS-AC is a valid preoperative frailty screen, and due to its self-reported nature, can be administered in the acute care setting, during virtual visits, or through digital health apps. Real-time screening can assist with better understanding patient needs and lead to interventions to prevent poor hospital outcomes.

Managing Delirium in the Emergency Department: An Updated Narrative Review

Purpose of Review

Emergency departments (EDs) are facing an epidemic of overcrowding and ED boarding, particularly of older adults who often present with, or develop, delirium in the ED. Delirium is associated with increased complications, longer hospital length of stay, mortality, and costs to the healthcare system. However, we only have limited knowledge of how to successfully prevent and treat delirium in the ED in a pragmatic, sustainable, and cost-effective way. We present a narrative review of recent literature of delirium prevention and treatment programs in the ED. We aim to describe the components of successful delirium management strategies to be used by EDs in building delirium management programs.

Recent Findings

We reviewed 10 studies (2005-2023) that report delirium interventions in the ED, and describe the different components of these interventions that have been studied. These interventions included: optimizing hemodynamics and oxygenation, treating pain, hydration and nutrition support, avoiding sedative hypnotics, antipsychotics and anticholinergics, promoting sleep, sensory stimulation, limiting the time spent in the ED, educating providers and staff, and developing multidisciplinary delirium protocols integrated into the electronic health record.

Summary

Through our narrative review of the recent literature on delirium prevention and treatment programs in the ED, we have identified nine components of successful delirium prevention strategies in the ED. We also discuss three high priority areas for further research including identification of most effective components of delirium prevention strategies, conduct of additional high-quality trials in non-hip.

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.

Use and Clinical Relevancy of Pericapsular Nerve Block (PENG) in Total Hip Arthroplasty: A Systematic Review and Meta-analysis

BACKGROUND

Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve.

OBJECTIVE

Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs.

METHODS

A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes.

RESULTS

We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75 mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block.

CONCLUSIONS

Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.

Modified frailty index predicts postoperative morbidity in adhesive small bowel obstruction: analyzing the National Inpatient Sample 2015-2019

BACKGROUND

There are limited data identifying predictors of postoperative outcomes in adhesive small bowel obstruction (ASBO). This study used the National Inpatient Sample (NIS) to assess the efficacy of the modified frailty index (mFI) to predict postoperative morbidity among patients undergoing an operation for ASBO.

METHODS

A retrospective analysis of the NIS between September 1, 2015, and December 31, 2019, was performed to identify adult patients who underwent nonelective operative intervention for ASBO. The mFI was used to stratify patients as either frail (mFI value ≥ 0.27) or robust (mFI value < 0.27). The primary outcomes were overall in-hospital postoperative morbidity and mortality. The secondary outcomes were system-specific morbidity, length of stay (LOS), total in-hospital healthcare cost, and discharge disposition. Univariable and multivariable regressions were used.

RESULTS

Overall, 23251 robust patients and 6122 frail patients were included. Adjusted analyses demonstrated that frail patients had increased in-hospital mortality (adjusted odds ratio [aOR], 2.16; 95% CI, 1.80-2.60), postoperative morbidity (aOR, 1.63; 95% CI, 1.52-1.74), postoperative LOS (adjusted mean difference [aMD], 0.97 days; 95% CI, 0.73-1.21), and total in-hospital healthcare costs (aMD, $18,921; 95% CI, $14,608-$23,235) and were less likely to be discharged home (aOR, 0.59; 95% CI, 0.55-0.63). The findings were unchanged on subgroup analysis of patients undergoing open operation and those older than 65 years of age.

CONCLUSION

The mFI may predict postoperative outcomes for ASBO. Stratifying patients based on frailty may assist clinicians and patients in making informed decisions, setting realistic expectations, and proactively planning postoperative disposition.

Social Determinants of Health and Preoperative Care

Preoperative care exists as part of perioperative continuum during which anesthesiologists and surgeons optimize patients for surgery. These multispecialty efforts are important, particularly for patients with complex medical histories and those requiring major surgery. Preoperative care improves planning and determines the clinical pathway and discharge disposition. The role of nonmedical social factors in the preoperative planning is not well described in anesthesiology. Research to improve outcomes based on social factors is not well described for anesthesiologists but could be instrumental in decreasing disparities and advancing health equity in surgical patients.

Association between frailty and clinical outcomes in patients undergoing craniotomy-systematic review and meta-analysis of observational studies

BACKGROUND

Frailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery.

METHODS

Our eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien-Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis.

RESULTS

In this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien-Dindo grade 1-4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90-2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients.

CONCLUSION

Increased frailty was associated with increased odds of any Clavien-Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery.

ETHICS AND DISSEMINATION

Formal ethical approval is not needed, as primary data were not collected.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240.

How to Determine Unresectability in Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is considered a biologically aggressive disease for which surgical resection remains the only curative treatment. Preoperative evaluation for resectability is challenging given tumor proximity to the porta hepatis, but minimal benefit and increased morbidity precludes recommendation for margin positive resection. This article reviews the determination of unresectability in hilar cholangiocarcinoma through discussion of the preoperative assessment, the intraoperative assessment, and key steps of surgical resection, as well as treatment options for unresectable tumors. Overall, evaluating patients preoperatively for resectability requires a multidisciplinary, holistic, and individualized approach to accurately determine resectability and optimize clinical outcomes for patients with hilar cholangiocarcinoma.

Impact of frailty on outcomes of elderly patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Frailty is a common condition in elderly patients who receive percutaneous coronary intervention (PCI). However, how frailty affects clinical outcomes in this group is unclear.

AIM

To assess the link between frailty and the outcomes, such as in-hospital complications, post-procedural complications, and mortality, in elderly patients post-PCI.

METHODS

The PubMed/MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were screened for publications up to August 2023. The primary outcomes assessed were in-hospital and all-cause mortality, major adverse cardiovascular events (MACEs), and major bleeding. The Newcastle-Ottawa Scale was used for quality assessment.

RESULTS

Twenty-one studies with 739693 elderly patients undergoing PCI were included. Frailty was consistently associated with adverse outcomes. Frail patients had significantly higher risks of in-hospital mortality [risk ratio: 3.45, 95% confidence interval (95%CI): 1.90-6.25], all-cause mortality [hazard ratio (HR): 2.08, 95%CI: 1.78-2.43], MACEs (HR: 2.92, 95%CI: 1.85-4.60), and major bleeding (HR: 4.60, 95%CI: 2.89-7.32) compared to non-frail patients.

CONCLUSION

Frailty is a pivotal determinant in the prediction of risk of mortality, development of MACEs, and major bleeding in elderly individuals undergoing percutaneous coronary intervention.

Frailty is a Predictor of Increased Readmissions and Increased Postoperative Complications After Elective Treatment of Unruptured Aneurysms

INTRODUCTION

Frailty is a state of decreased physiologic reserve associated with adverse treatment outcomes across surgical specialties. We sought to determine whether frailty affected patient outcomes after elective treatment (open microsurgical clipping or endovascular therapy [EVT]) of unruptured cerebral aneurysms (UCAs).

METHODS

The National Readmissions Database was queried from 2010 to 2014 to identify patients who had a known UCA and underwent elective clipping or EVT. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression analyses were conducted to assess the associations between frailty and the primary outcome variables of 30- and 90-day readmissions, complications, length of stay (LOS), and patient disposition.

RESULTS

Of 18,483 patients who underwent elective treatment for UCAs, 358 (1.9%) met the criteria for frailty. After adjusting for patient- and hospital-based factors, frailty (30-day: odds ratio [OR], 1.55; 95% confidence interval [CI], 1.11-2.17; P = 0.01; 90-day: OR, 1.47; 95% CI, 1.05-2.06; P = 0.02) and clipping versus EVT (30-day: OR, 2.12; 95% CI, 1.85-2.43; P < 0.000; 90-day: OR, 1.80; 95% CI, 1.59-2.03; P < 0.0001) were associated with increased readmission rates. Furthermore, frailty was associated with an increased rate of complications (surgical: OR, 2.91; 95% CI, 2.27-3.72; P < 0.0001; neurological: OR, 3.04; 95% CI, 2.43-3.81; P < 0.0001; major: OR, 2.75; 95% CI, 1.96-3.84; P < 0.0001), increased LOSs (incidence rate ratio, 3.08; 95% CI, 2.59-3.66; P < 0.0001), and an increased rate of nonroutine disposition (OR, 3.94; 95% CI, 2.91-5.34; P < 0.0001).

CONCLUSIONS

Frailty was associated with an increased likelihood of 30- and 90-day readmissions after elective treatment of UCAs. Frailty was notably associated with several postoperative complications, longer LOSs, and nonroutine disposition in the treatment of UCAs.

A Retrospective Cohort Study to Evaluate Adding Biomarkers to the Risk Analysis Index of Frailty

INTRODUCTION

The Risk Analysis Index (RAI) is a frailty assessment tool associated with adverse postoperative outcomes including 180 and 365-d mortality. However, the RAI has been criticized for only containing subjective inputs rather than including more objective components such as biomarkers.

METHODS

We conducted a retrospective cohort study to assess the benefit of adding common biomarkers to the RAI using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. RAI plus body mass index (BMI), creatinine, hematocrit, and albumin were evaluated as individual and composite variables on 180-d postoperative mortality.

RESULTS

Among 480,731 noncardiac cases in VASQIP from 2010 to 2014, 324,320 (67%) met our inclusion criteria. Frail patients (RAI ≥30) made up to 13.0% of the sample. RAI demonstrated strong discrimination for 180-d mortality (c = 0.839 [0.836-0.843]). Discrimination significantly improved with the addition of Hematocrit (c = 0.862 [0.859-0.865]) and albumin (c = 0.870 [0.866-0.873]), but not for body mass index (BMI) or creatinine. However, calibration plots demonstrate that the improvement was primarily at high RAI values where the model overpredicts observed mortality.

CONCLUSIONS

While RAI's ability to predict the risk of 180-d postoperative mortality improves with the addition of certain biomarkers, this only observed in patients classified as very frail (RAI >49). Because very frail patients have significantly elevated observed and predicted mortality, the improved discrimination is likely of limited clinical utility for a frailty screening tool.

Baseline Frailty and Discharge to Advanced Care Facilities in Patients Undergoing Lumbar Interbody Fusion for Lumbar Degenerative Disease: A Multicenter Registry Analysis of 7153 Patient Cases Comparing the Risk Analysis Index to the 5-Factor Modified Frailty Index

OBJECTIVE

To evaluate the impact of frailty, as measured by the 5-factor modified Frailty Index (mFI-5) and the Risk Analysis Index (RAI), on advanced care facility discharge (FD) in patients who underwent lumbar fusion for lumbar degenerative spine disease.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (2012-2020) was queried for adults (≥18 years) undergoing lumbar fusion for lumbar degenerative disease. Descriptive statistics and univariate crosstabulation were used to assess baseline demographics, preoperative comorbidities, and postoperative outcomes. Receiver operating characteristic curve analysis was used to assess the discriminative threshold of the mFI-5 and RAI on FD within this population.

RESULTS

The median patient age in this study cohort (N = 7153) was 56 years and FD occurred in 7.3% of cases. Receiver operating characteristic curve analysis demonstrated that both the mFI-5 and the RAI accurately predicted FD (C-statistics: mFI-5: 0.627; RAI: 0.746). DeLong's test found that the RAI had superior discrimination when compared to the mFI-5 (P < 0.0001).

CONCLUSIONS

RAI is a reliable predictor of FD in lumbar degenerative disease patients who underwent lumbar interbody fusion and demonstrated superior discrimination compared to the mFI-5. Identification of patients at risk for FD may facilitate more precise risk stratification to enable better preoperative decision-making and help set more realistic expectations of care.

Impact of frailty on the outcomes of patients undergoing degenerative spine surgery: a systematic review and meta-analysis

BACKGROUND

Degenerative spinal diseases are common in older adults with concurrent frailty. Preoperative frailty is a strong predictor of adverse clinical outcomes after surgery. This study aimed to investigate the association between health-related outcomes and frailty in patients undergoing spine surgery for degenerative spine diseases.

METHODS

A systematic review and meta-analysis were performed by electronically searching Ovid-MEDLINE, Ovid-Embase, Cochrane Library, and CINAHL for eligible studies until July 16, 2022. We reviewed all studies, excluding spinal tumours, non-surgical procedures, and experimental studies that examined the association between preoperative frailty and related outcomes after spine surgery. A total of 1,075 articles were identified in the initial search and were reviewed by two reviewers, independently. Data were subjected to qualitative and quantitative syntheses by meta-analytic methods.

RESULTS

Thirty-eight articles on 474,651 patients who underwent degenerative spine surgeries were included and 17 papers were quantitatively synthesized. The health-related outcomes were divided into clinical outcomes and patient-reported outcomes; clinical outcomes were further divided into postoperative complications and supportive management procedures. Compared to the non-frail group, the frail group was significantly associated with a greater risk of high mortality, major complications, acute renal failure, myocardial infarction, non-home discharge, reintubation, and longer length of hospital stay. Regarding patient-reported outcomes, changes in scores between the preoperative and postoperative Oswestry Disability Index scores were not associated with preoperative frailty.

CONCLUSIONS

In degenerative spinal diseases, frailty is a strong predictor of adverse clinical outcomes after spine surgery. The relationship between preoperative frailty and patient-reported outcomes is still inconclusive. Further research is needed to consolidate the evidence from patient-reported outcomes.

Pituitary surgery outcome in patients 75 years and older: a retrospective study

BACKGROUND

As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results.

METHODS

A retrospective cohort study of patients with pituitary adenomas and Rathke's cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period.

RESULTS

Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3-96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing's disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different.

CONCLUSIONS

Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients

OBJECTIVE

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care.

BACKGROUND

Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications.

METHODS

Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics.

RESULTS

The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients.

CONCLUSIONS

This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Advances in the relationship between temporal muscle thickness and prognosis of patients with glioblastoma: a narrative review

The most dangerous variety of glioma, glioblastoma, has a high incidence and fatality rate. The prognosis for patients is still bleak despite numerous improvements in treatment approaches. We urgently need to develop clinical parameters that can evaluate patients' conditions and predict their prognosis. Various parameters are available to assess the patient's preoperative performance status and degree of frailty, but most of these parameters are subjective and therefore subject to interobserver variability. Sarcopenia can be used as an objective metric to measure a patient's physical status because studies have shown that it is linked to a bad prognosis in those with cancers. For the purpose of identifying sarcopenia, temporal muscle thickness has demonstrated to be a reliable alternative for a marker of skeletal muscle content. As a result, patients with glioblastoma may use temporal muscle thickness as a potential marker to correlate with the course and fate of their disease. This narrative review highlights and defines the viability of using temporal muscle thickness as an independent predictor of survival in glioblastoma patients, and it evaluates recent research findings on the association between temporal muscle thickness and prognosis of glioblastoma patients.

Holmium laser enucleation of prostate in nonagenarians and octogenarians Impact of age and frailty on surgical outcomes

INTRODUCTION

Holmium laser enucleation of the prostate (HoLEP) is a well-established technique for management of benign prostatic hyperplasia (BPH). With the growing aging population, a considerable percentage of octogenarians (80-90 years old) and nonagenarians (>90 years old) require surgical management for BPH. We aimed to assess the outcomes of HoLEP in those age groups.

METHODS

We reviewed a maintained database for HoLEP patients in a tertiary center. Patients were assigned to two groups: above (group A) and below (group B) 80 years old. Perioperative outcome and postoperative followup data were compared between both groups.

RESULTS

The study included 1090 patients, 201 and 889 in groups A and B, respectively. Median age was 83 and 70 years in groups A and B, respectively. Group A showed longer operative time, longer catheterization time, and higher 30-day emergency room visits and readmission rates. Hemoglobin drop was comparable, although associated with higher rate of blood transfusion in group A. Overall, 30-day postoperative complications were higher in group A (20.8% vs. 9.3%, p=0.008), although the majority of complications in both groups were grade I and II. The rate of complications over Clavien-Dindo grade II were statistically comparable (3.4% vs. 1.79%, p=0.133). Followup at six weeks, three months, and one year showed comparable functional outcomes in both groups.

CONCLUSIONS

HoLEP is a safe and effective option in the geriatric population of octogenarians and even nonagenarians. HoLEP is associated with higher overall complication rate in older age groups; however, most complications were minor.

The future of ambulatory surgery for geriatric patients

The elderly segment of the population is growing rapidly worldwide. Older patients comprise a disproportionate percentage of the surgical caseload. Physiological changes are inevitable with aging; some may impact a patient's response to anesthesia and surgery. Careful evaluation of an elderly patient preoperatively is vital to proper patient selection for ambulatory surgeries, particularly for complex and lengthy procedures. Cognitive issues, frailty, and geriatric syndromes make a patient vulnerable and sometimes unsuitable for certain ambulatory procedures. Preoperative planning and interventions may improve outcomes for the elderly patient undergoing ambulatory surgery.

Delayed mobilization following admission for hip fracture is associated with increased morbidity and length of hospital stay

BACKGROUND

Current national guidelines on caring for hip fractures recommend early mobilization. However, this recommendation does not account for time spent immobilized waiting for surgery. We sought to determine timing of mobilization following hip fracture, beginning at hospital admission, and evaluate its association with medical complications and length of hospital stay (LOS).

METHODS

We performed a retrospective review of prospectively collected data for 470 consecutive patients who underwent surgery for a hip fracture between September 2019 and August 2020 at an academic, tertiary-referral hospital. Outcomes of interest included time from hospital admission to mobilization, complication rate and LOS. We used a binary regression analysis to determine the effect of different surgical and patient factors on the risk of a postoperative medical complication.

RESULTS

The mean time from admission to mobilization was 2.8 ± 2.3 days (range 3 h-14 d). There were 125 (26.6%) patients who experienced at least 1 complication. The odds of developing a complication began to increase steadily once a patient waited more than 3 days from admission to mobilization (odds ratio 2.15, 95% confidence interval 1.42-3.25). Multivariate regression analysis showed that prefracture frailty (β = 0.276, p = 0.05), and timing from hospital admission to mobilization (β = 0.156, p < 0.001) and from surgery to mobilization (β = 1.195, p < 0.001) were associated with complications. The mean LOS was 12.2 ± 10.7 days (range 1-90 d). Prolonged wait to mobilization was associated with longer LOS (p = 0.01).

CONCLUSION

Comprehensive guidelines on timing of mobilization following hip fracture should account for cumulative time spent immobilized.

Early Outcomes Following Implementation of a Multispecialty Geriatric Surgery Pathway

OBJECTIVE

To examine geriatric-specific outcomes following implementation of a multispecialty geriatric surgical pathway (GSP).

BACKGROUND

In 2018, we implemented a GSP in accordance with the proposed 32 standards of American College of Surgeons' Geriatric Surgery Verification Program.

METHODS

This observational study combined data from the electronic health record system (EHR) and ACS-National Surgery Quality Improvement Program (NSQIP) to identify patients ≥65 years undergoing inpatient procedures from 2016 to 2020. GSP patients (2018-2020) were identified by preoperative high-risk screening. Frailty was measured with the modified frailty index. Surgical procedures were ranked according to the operative stress score (1-5). Loss of independence (LOI), length of stay, major complications (CD II-IV), and 30-day all-cause unplanned readmissions were measured in the pre/postpatient populations and by propensity score matching of patients by operative procedure and frailty.

RESULTS

A total of 533 (300 pre-GSP, 233 GSP) patients similar by demographics (age and race) and clinical profile (frailty) were included. On multivariable analysis, GSP patients showed decreased risk for LOI [odds ratio (OR) 0.26 (0.23, 0.29) P <0.001] and major complications [OR: 0.63 (0.50, 0.78) P <0.001]. Propensity matching demonstrated similar findings. Examining frail patients alone, GSP showed decreased risk for LOI [OR: 0.30 (0.25, 0.37) P <0.001], major complications [OR: 0.31 (0.24, 0.40) P <0.001], and was independently associated with a reduction in length of stay [incidence rate ratios: 0.97 (0.96, 0.98), P <0.001].

CONCLUSIONS

In our diverse patient population, implementation of a GSP led to improved geriatric-specific surgical outcomes. Future studies to examine pathway compliance would promote the identification of further interventions.

A Remote Diet and Exercise Intervention for Surgical Patients With Prefrailty and Frailty During the COVID-19 Pandemic

Objectives: To facilitate the success of surgical patients with prefrailty and frailty in meeting diet and exercise goals in the context of the COVID-19 pandemic, and to encourage patient satisfaction with remote care. Methods: In the setting of the COVID-19 pandemic, surgical patients with prefrailty and frailty were offered remote visits with a geriatrician and a remote diet and exercise coaching program. Results: The coaching participants set a mean of 37 (±15) individualized dietary goals and 17 (±11) individualized exercise goals. 75% of the coaching participants met at least 65% of their dietary goals and 75% met at least 50% of their exercise goals. All patients met at least one diet goal and at least one exercise goal. Patients endorsed high levels of satisfaction with the program. Discussion: Diet and exercise interventions for surgical patients with prefrailty and frailty have potential for adaptation to remote formats. Such interventions may facilitate patients' meeting of individualized diet and exercise goals and may also encourage patient satisfaction.

Validation of the self-reported domains of the Edmonton Frail Scale in patients 65 years of age and older

INTRODUCTION

In the era of virtual care, self-reported tools are beneficial for preoperative assessments and facilitating postoperative planning. We have previously reported the use of the Edmonton Frailty Scale (EFS) as a valid preoperative assessment tool.

OBJECTIVE

We wished to validate the self-reported domains of the EFS (srEFS) by examining its association with loss of independence (LOI) and mortality.

METHODS

This is a post-hoc analysis of a single-institution observational study of patients 65 years of age or older undergoing multi-specialty surgical procedures and assessed with the EFS in the preoperative setting. Exploratory data analysis was used to determine the threshold for identifying frailty using the srEFS. Procedures were classified using the Operative Stress Score (OSS) scored 1 to 5 (lowest to highest). Hierarchical Condition Category (HCC) was utilized to risk-adjust. LOI was described as requiring more support at discharge and mortality was defined as death occurring up to 30 days following surgery. Receiver operating characteristic (ROC) curves were used to determine the ability of the srEFS to predict the outcomes of interest in relation to the EFS.

RESULTS

Five hundred thirty-five patients were included. Exploratory analysis confirmed best positive predictive value for srEFS was greater or equal to 5. Overall, 113 (21 percent) patients were considered high risk for frailty (HRF) and 179 (33 percent) patients had an OSS greater or equal to 5. LOI occurred in 7 percent (38 patients) and the mortality rate was 4 percent (21 patients). ROC analysis showed that the srEFS performed similar to the standard EFS with no difference in discriminatory thresholds for predicting LOI and mortality. Examination of the domains of the EFS not included in the srEFS demonstrated a lack of association between cognitive decline and the outcomes of interest. However, functional status assessed with either the Get up and Go (EFS only) or self-reported ADLs was independently associated with increased risk for LOI.

CONCLUSION

This study shows that self-reported EFS may be an optional preoperative tool that can be used in the virtual setting to identify patients at HRF. Early identification of patients at risk for LOI and mortality provides an opportunity to implement targeted strategies to improve patient care.

Frailty as a predictor of neurosurgical outcomes in brain tumor patients: A systematic review and meta-analysis

BACKGROUND

Patients with frailty are at a high risk of poor health outcomes, and frailty has been explored as a predictor of adverse events, such as perioperative complications, readmissions, falls, disability, and mortality in the neurosurgical literature. However, the precise relationship between frailty and neurosurgical outcomes in patients with brain tumor has not been established, and thus evidence-based advancements in neurosurgical management. The objectives of this study are to describe existing evidence and conduct the first systematic review and meta-analysis of the relationship between frailty and neurosurgical outcomes among brain tumor patients.

METHODS

Seven English databases and four Chinese databases were searched to identify neurosurgical outcomes and the prevalence of frailty among patients with a brain tumor, with no restrictions on the publication period. According to the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines, two independent reviewers employed the Newcastle-Ottawa scale in cohort studies and JBI Critical Appraisal Checklist for Cross-sectional Studies to evaluate the methodological quality of each study. Then random-effects or fixed-effects meta-analysis was used in combining odds ratio (OR) or hazard ratio (RR) for the categorical data and continuous data of neurosurgical outcomes. The primary outcomes are mortality and postoperative complications, and secondary outcomes include readmission, discharge disposition, length of stay (LOS), and hospitalization costs.

RESULTS

A total of 13 papers were included in the systematic review, and the prevalence of frailty ranged from 1.48 to 57%. Frailty was significantly associated with increased risk of mortality (OR = 1.63; CI = 1.33-1.98; p < 0.001), postoperative complications (OR = 1.48; CI = 1.40-1.55; p < 0.001; I ² = 33%), nonroutine discharge disposition to a facility other than home (OR = 1.72; CI = 1.41-2.11; p < 0.001), prolonged LOS (OR = 1.25; CI = 1.09-1.43; p = 0.001), and high hospitalization costs among brain tumor patients. However, frailty was not independently associated with readmission (OR = 0.99; CI = 0.96-1.03; p = 0.74).

CONCLUSION

Frailty is an independent predictor of mortality, postoperative complications, nonroutine discharge disposition, LOS, and hospitalization costs among brain tumor patients. In addition, frailty plays a significant potential role in risk stratification, preoperative shared decision making, and perioperative management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021248424.

Phenotypic Frailty Score Predicts Perioperative Outcomes for Geriatric Total Joint Arthroplasty

Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32-3.70]), postoperative delirium (6.40 [1.78-23.03]), and length of stay greater than 2 days (3.90 [1.00-15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66-4.72]) or discharge to a specialized facility (1.48 [0.80-2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [Orthopedics. 2022;45(6):e315-e320.].

Prehabilitation in Patients before Major Surgery: A Review Article

The overall outcome of the patient after any surgery is determined not only by the fineness of the surgical procedure but also by preoperative conditioning and postoperative care. Prehabilitation decreases the surgical stress response and increases the preparedness of the patient to undergo planned surgical insult. Preoperatively structured inspiratory muscle exercises, cardiopulmonary fitness program, and planned exercise program for muscles of limbs, back, abdomen, head, and neck allow an overall upliftment of the physiological capacity of the patient to better cope with the surgical stress. Optimization of dietary status by macronutrients, micronutrients, and the nutrients has an impact on augmenting postoperative recovery and shortening the overall hospital stay. Preparing patients for the scheduled surgery and initiating alcohol and smoking cessation programs overhaul the patient's mental health and boost the healing process. This concept of prehabilitation a few weeks before surgery is equally beneficial compared to enhancing operative procedures and postsurgical care.

Keywords

length of stay; mental health; nutrients; preoperative exercise; smoking cessation.

Factors predicting postoperative morbidity after cytoreductive surgery for ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

Advances in ovarian cancer cytoreductive surgery have enabled more extensive procedures to achieve maximal cytoreduction but with a consequent increase in postoperative morbidity and mortality. The aim of this study was to evaluate factors for postoperative morbidity after extensive cytoreductive surgery for primary epithelial ovarian cancer (EOC), particularly those which may be modifiable.

METHODS

Electronic databases were searched. Meta-analysis was conducted using random-effects models.

RESULTS

Fifteen relevant studies, involving 15,325 ovarian cancer patients, were included in this review. Severe 30-day postoperative complications occurred in 2,357 (15.4%) patients. The postoperative mortality rate was 1.92%. Meta-analysis demonstrated that patient with following risk factors; age (p<0.001), Eastern Cooperative Oncology Group score >0 (p=0.001), albumin level <3.5 g/dL (p<0.001), presence of ascites on CT scan (p=0.013), stage IV disease (p<0.001) and extensive surgical procedure (p<0.001) has a significantly increase risk of developing postoperative complications. Surgical procedures including peritonectomy (p=0.012), splenectomy (p<0.001) and colon surgery (p<0.001) were significant predictors for postoperative complications. Moreover, we found that patients who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) had a lower risk of developing severe complications compared to those who underwent primary debulking surgery (PDS) (p<0.001).

CONCLUSION

Our study demonstrated that patient performance status and hypoalbuminemia were the only significant adjustable preoperative risk factors associated with postoperative complications. Patients who underwent NACT-IDS had a lower risk of developing severe complications compared to PDS.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) Identifier: CRD42021282770.

Impact of preoperative laboratory frailty index on mortality and clinical outcomes in older surgical patients with cancer

Frailty in older patients is associated with poor postoperative outcomes. The use of uncomplicated frailty measurement tools is preferred in busy clinical settings. Therefore, we validated the frailty index using routine laboratory data and the surgical outcomes of older patients with cancer who underwent cancer resection. We retrospectively analyzed 9015 patients aged 65 years and older who underwent cancer resection at a single tertiary hospital. Based on electronic-medical-record data regarding preoperative blood test results and vital signs, Laboratory Frailty Index (FI-Lab) scores were generated to measure preoperative frailty. The associations of FI-Lab with postoperative length of stay (LOS), readmission within 30 days, intensive care unit (ICU) admission within 30 days, and mortality were evaluated. The mean FI-Lab score of the 9015 patients was 0.20 ± 0.10. Increased FI-Lab scores (0.25–0.4; > 0.4) were associated with longer LOS, increased readmission within 30 days of surgery, ICU admission, and increased mortality, compared with FI-Lab scores < 0.25. The FI-Lab score, as a frailty indicator, was able to predict the risk of poor postoperative outcomes. Therefore, the FI-Lab is a potentially useful tool for assessing preoperative frailty in older patients with cancer in acute clinical setting.

Preoperative frailty based on laboratory data and postoperative health outcomes in patients undergoing coronary artery bypass graft surgery

BACKGROUND

Frailty is associated with adverse surgical outcomes. Patients with cardiovascular diseases have many risk factors of frailty; thus, preoperative frailty evaluation is necessary to predict adverse outcomes after coronary artery bypass graft (CABG) surgery. Laboratory data based-frailty assessments are objective and not time-consuming, addressing the need for an accurate but simple frailty screening for patients awaiting CABG surgery.

OBJECTIVES

This retrospective study aimed to determine the association between laboratory based-frailty and patient health outcomes after CABG surgery.

METHODS

We evaluated 896 patients who underwent on-pump or off-pump CABG surgery between August 1, 2015 and July 31, 2020 at a tertiary hospital. The frailty index-laboratory (FI-LAB), which comprises 32 laboratory parameters and vital signs, was used for frailty assessment.

RESULTS

The patients were divided into three groups according to their preoperative FI-LAB level as low (FI-LAB <0.25, 23.0%), moderate (FI-LAB ≥0.25 to ≤0.4, 54.9%), and high (FI-LAB>0.4, 22.1%) frailty groups. In the confounder-adjusted analysis, the lengths of hospital stay and intensive care unit stay were longer by 2.20 days (p=.023) and by 0.89 days (p=.009), respectively, in the high frailty group than those in the low frailty group. The odds ratio for 30-day readmission was also 2.58 times higher in the high frailty group than that in the low frailty group.

CONCLUSION

A high preoperative FI-LAB score indicates increasing risks of adverse postoperative outcomes among CABG surgery patients. FI-LAB has potential strengths to capture the need for a more thorough frailty assessment for cardiac surgery patients.

Implementation of a machine learning application in preoperative risk assessment for hip repair surgery

Background

This study aims to develop a machine learning-based application in a real-world medical domain to assist anesthesiologists in assessing the risk of complications in patients after a hip surgery.

Methods

Data from adult patients who underwent hip repair surgery at Chi-Mei Medical Center and its 2 branch hospitals from January 1, 2013, to March 31, 2020, were analyzed. Patients with incomplete data were excluded. A total of 22 features were included in the algorithms, including demographics, comorbidities, and major preoperative laboratory data from the database. The primary outcome was a composite of adverse events (in-hospital mortality, acute myocardial infarction, stroke, respiratory, hepatic and renal failure, and sepsis). Secondary outcomes were intensive care unit (ICU) admission and prolonged length of stay (PLOS). The data obtained were imported into 7 machine learning algorithms to predict the risk of adverse outcomes. Seventy percent of the data were randomly selected for training, leaving 30% for testing. The performances of the models were evaluated by the area under the receiver operating characteristic curve (AUROC). The optimal algorithm with the highest AUROC was used to build a web-based application, then integrated into the hospital information system (HIS) for clinical use.

Results

Data from 4,448 patients were analyzed; 102 (2.3%), 160 (3.6%), and 401 (9.0%) patients had primary composite adverse outcomes, ICU admission, and PLOS, respectively. Our optimal model had a superior performance (AUROC by DeLong test) than that of ASA-PS in predicting the primary composite outcomes (0.810 vs. 0.629, p < 0.01), ICU admission (0.835 vs. 0.692, p < 0.01), and PLOS (0.832 vs. 0.618, p < 0.01).

Conclusions

The hospital-specific machine learning model outperformed the ASA-PS in risk assessment. This web-based application gained high satisfaction from anesthesiologists after online use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01648-y.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE

Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic.

METHODS

We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments.

RESULTS

The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management.

CONCLUSIONS

In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.

Comparison of preoperative assessment tools in older patients undergoing cancer surgery: A prospective study

INTRODUCTION

Surgery in older adults with cancer is complex due to multiple age related confounding factors. There are many scoring systems available for preoperative risk stratifications of older patients. Currently very few prospective studies comparing the various commonly used scales are available. This is the first study which compares the established preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS).

MATERIAL AND METHODS

This is a prospective observational study of older patients with cancer who underwent oncosurgery in a tertiary cancer centre during the one-year study period. Patients were scored on the CFS, MFI, ASA and ECOG scales. All patients were followed up for 30 days immediately following surgery and their post operative complications were documented. Univariate and multivariate analyses were done and a p value of ≤0.05 was considered statistically significant.

RESULTS

Of the 820 patients studied, 15.6% had prolonged hospital stay, 9.1% had 30-day morbidity, 0.7% had readmission, and mortality was 1.1%. High-risk scores on the ASA and CFS were significantly associated with prolonged postoperative stay, readmission, morbidity, and mortality (p < 0.05). High-risk scores on the ECOG was significantly associated with prolonged hospital stay (p = 0.027), 30-day morbidity (p = 0.003), and mortality (p = 0.001), but not with readmission. There was no significant association between MFI score and the postoperative variables studied (p > 0.05). On multivariate analysis, morbidity was significantly associated only with male gender (p = 0.015), higher cancer stage (p = 0.005), higher ASA score (p = 0.029), and prolonged hospital stay (p = 0.001). Mortality was significantly associated only with emergency surgery (p = 0.012) and prolonged hospital stay (p = 0.004), and prolonged hospital stay was significantly associated with advanced cancer stage (p = 0.001) and emergency surgery (p = 0.02).

CONCLUSIONS

In older patients undergoing cancer surgery, ASA and CFS are predictors of prolonged postoperative stay, morbidity, mortality, and readmission. A high-risk ECOG score is predictive of prolonged post operative stay, 30-day morbidity, and mortality, but not of readmission. Score on MFI is not a predictor of postoperative outcomes. Newer predictive tools which include cancer- specific factors are required for better management of these patients.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Role of handgrip strength testing in pre-anaesthetic check-up: A prospective cross-sectional study

Background and Aims

Frailty has been known to be associated with postoperative adverse events and longer hospital length of stay (LOS). Hand grip strength (HGS) is one of the parameters of measuring frailty. The aim of the study was to correlate preoperative handgrip strength and 30-day outcome of patients undergoing major abdominal surgery. It also aimed to evaluate the role of the standard preoperative variables like metabolic equivalents, revised cardiac risk index (RCRI), serum albumin, and serum creatinine along with their association with HGS testing in determining the postoperative outcome in surgical patients.

Material and Methods

This prospective observational study included 149 American Society of Anesthesiologists class III/IV patients presenting for major abdominal surgery. A mean of three measurements of dominant HGS using Camry hand dynamometer was measured. The patients were divided into groups: weak, normal, and strong depending on grip strength. Patients were followed for 30 days and postoperative outcome in terms of ventilatory support, admission to intensive care unit, cardiac complications, in-hospital mortality, and LOS were recorded. Observational data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann-Whitney Rank test. Associations between RCRI, serum albumin, and LOS with HGS were evaluated using logistic regression.

Results

The hospital LOS was significantly longer in patients with weak HGS (15.11 ± 11.03 days versus 10 ± 5.71 days, P = 0.001). Patients with weak HGS had significantly lower mean serum albumin levels compared to normal HGS (P = 0.0001) and a statistically significant RCRI score (P = 0.013).

Conclusion

HGS can be used as a preoperative test in predicting hospital LOS after major surgery.

Preoperative measures predicting outcome after pancreatic resection in aged patients

BACKGROUND AND OBJECTIVE

High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years.

PATIENTS AND METHODS

Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival.

RESULTS

A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010).

CONCLUSIONS

The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.

Long-term Outcomes After Emergency Laparotomy: a Retrospective Study

BACKGROUND

Emergency laparotomy (EL) is a common surgical operation with poor outcomes. Patients undergoing EL are often frail and have chronic comorbidities, but studies focused on the long-term outcomes after EL are lacking. The aim of the present study was to examine the long-term mortality after EL.

METHODS

We conducted a retrospective single-center cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The follow-up lasted until September 2020. The primary outcome was 2-year mortality after surgery. The secondary outcome was factors associated with mortality during follow-up.

RESULTS

A total of 554 (82%) patients survived > 90 days after EL and were included in the analysis. Of these patients, 120 (18%) died during the follow-up. The survivors were younger than the non-survivors (median [IQR] 64 [49-74] vs. 71 [63-80] years, p < 0.001). In a Cox regression model, death during follow-up was associated with longer duration of operation (OR 2.21 [95% CI 1.27-3.83]), higher ASA classification (OR 2.37 [1.15-4.88]), higher CCI score (OR 4.74 [3.15-7.14]), and postoperative medical complications (OR 1.61 [1.05-2.47]).

CONCLUSIONS

Patient-related factors, such as higher ASA classification and CCI score, were the most remarkable factors associated with poor long-term outcome and mortality after EL.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

International Continence Society white paper on ethical considerations in older adults with urinary incontinence

Urinary incontinence is a common problem among older adults that is often complicated by many nuanced ethical considerations. Unfortunately, there is a lack of guidance for healthcare professionals on how to navigate such concerns. This International Continence Society white paper aims to provide healthcare professionals with an ethical framework to promote best care practices in the care of older adults with urinary incontinence.

A novel radiographic marker of sarcopenia with prognostic value in glioblastoma

OBJECTIVE

Sarcopenia is an important prognostic consideration in surgical oncology that has received relatively little attention in brain tumor patients. Temporal muscle thickness (TMT) has recently been proposed as a novel radiographic marker of sarcopenia that can be efficiently obtained within existing workflows. We investigated the prognostic value of TMT in primary and progressive glioblastoma.

METHODS

TMT measurements were performed on magnetic resonance images of 384 patients undergoing 541 surgeries for glioblastoma. Relationships between TMT and clinical characteristics were examined on bivariate analysis. Optimal TMT cutpoints were established using maximally selected rank statistics. Predictive value of TMT upon postoperative survival (PS) was assessed using Cox proportional hazards regression adjusted for age, sex, Karnofsky performance status (KPS), Stupp protocol completion, extent of resection, and tumor molecular markers.

RESULTS

Average TMT for the primary and progressive glioblastoma cohorts was 9.55 mm and 9.40 mm, respectively. TMT was associated with age (r = -0.14, p = 0.0008), BMI (r = 0.29, p < 0.0001), albumin (r = 0.11, p = 0.0239), and KPS (r = 0.11, p = 0.0101). Optimal TMT cutpoints for the primary and progressive cohorts were ≤ 7.15 mm and ≤ 7.10 mm, respectively. High TMT was associated with increased Stupp protocol completion (p = 0.001). On Cox proportional hazards regression, high TMT predicted increased PS in progressive [HR 0.47 (95% confidence interval (CI)) 0.25-0.90), p = 0.023] but not primary [HR 0.99 (95% CI 0.64-1.51), p = 0.949] glioblastoma.

CONCLUSIONS

TMT correlates with important prognostic variables in glioblastoma and predicts PS in patients with progressive, but not primary, disease. TMT may represent a pragmatic neurosurgical biomarker in glioblastoma that could inform treatment planning and perioperative optimization.

The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis

BACKGROUND

Both frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD.

METHODS

We searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05.

RESULTS

Nine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias.

CONCLUSIONS

This meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.