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Aakre EK, Ulvik A, Hufthammer KO, Jammer I. Mortality and complications after emergency laparotomy in patients above 80 years. Acta Anaesthesiol Scand 2020; 64:913-919. [PMID: 32270490 DOI: 10.1111/aas.13594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 12/22/2022]
Abstract
Emergency laparotomy (EL) is a high-risk procedure. However, available evidence regarding outcome after emergency surgery in very old patients is limited. The aim of this observational study was to investigate outcome following EL in patients ≥80 years of age. METHODS This single-center retrospective study was undertaken at Haukeland University Hospital, Norway. Demographic data, pre-operative risk assessment, surgical procedures, intrahospital logistics, complications, mortality, and discharge data were collected from the medical records. Primary outcome was 30-day mortality. Secondary outcomes were 90-day mortality, 1-year mortality, post-operative complications, and level of care at discharge. RESULTS One hundred and six patients aged 80-96 years underwent EL between 2015 and 2016. Of these, 58% had cardiopulmonary disease, and 16% lived in a nursing home before surgery. Resection of colon was performed in 26 cases, adhesiolysis was performed in 24, and resection of small intestine in 18. Within 30 days, 28 patients died (26%), 15 during the first post-operative week. For 82% of the patients, at least one complication occurred, and medical complications were far more frequent than surgical. Post-operatively, pulmonary morbidity was found in 51 patients (48%) and delirium in 42 (40%). The number of intrahospital deaths was 25 (24%). Among the 81survivors, 53 were discharged to a nursing home (65%). One-year mortality was 47% (50/106). CONCLUSIONS Mortality after EL in octo- and nonagenarians is very high. Medical complications are more common than surgical, and functional decline is frequent. Future studies should focus on the effect of a care bundle including geriatric intervention in these patients.
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Affiliation(s)
- Elin K. Aakre
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
| | - Atle Ulvik
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
| | - Karl O. Hufthammer
- Centre for Clinical Research Haukeland University Hospital Bergen Norway
| | - Ib Jammer
- Department of Anaesthesia and Surgical Services Haukeland University Hospital Bergen Norway
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Emergency Surgery and Male Gender Are Risk Factors of Postoperative Delirium After General or Gastrointestinal Surgery in Elderly Patients: A Multicenter Cohort Study. Int Surg 2020. [DOI: 10.9738/intsurg-d-16-00112.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
The aim of this study was to investigate the incidence and risk factors of postoperative delirium (PD) in elderly patients after general or gastrointestinal surgery.
Summary of background data
Societies worldwide are rapidly aging, and the number of surgeries in elderly patients has been increasing. PD, which adversely influences postoperative course, has thus become more common.
Methods
The Surgery and Anesthesia Network Group of the National Hospital Organization in Japan conducted this retrospective cohort study of patients older than 70 years of age who underwent general or gastrointestinal surgery.
Results
A total of 219 patients from 9 participating institutes underwent surgery between July 2013 and August 2014. We excluded 2 patients who died within 2 weeks after surgery. Of the remaining 217 cases, 31 (14.3%) developed PD. These patients were older (80 versus 76 years, P = 0.013), more likely to be male (74.2 versus 54.8%, P = 0.039), and had higher American Society of Anesthesia Physical Status scores than those without PD. Emergency surgery was more common than elective surgery in the PD group (41.9 versus 10.2%, P < 0.0001). Multivariate analysis showed that male gender (odds ratio, 3.31; 95% confidence interval, 1.32 to 9.39; P = 0.0098) and emergency surgery (odds ratio, 7.47; 95% confidence interval, 2.79 to 20.83; P < 0.0001) were independent risk factors of PD.
Conclusions
The incidence of PD was high in male patients and those undergoing emergency surgery. Effective interventions in these groups will be necessary to improve treatment outcomes in elderly patients.
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Saravana-Bawan B, Warkentin LM, Rucker D, Carr F, Churchill TA, Khadaroo RG. Incidence and predictors of postoperative delirium in the older acute care surgery population: a prospective study. Can J Surg 2019; 62:33-38. [PMID: 30693744 DOI: 10.1503/cjs.016817] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Among older inpatients, the highest incidence of delirium is within the surgical population. Limited data are available regarding postoperative delirium risk in the acute care surgical population. The purpose of our study was to establish the incidence of and risk factors for delirium in an older acute care surgery population. Methods Patients aged 65 years or more who had undergone acute care surgery between April 2014 and September 2015 at 2 university-affiliated hospitals in Alberta were followed prospectively and screened for delirium by means of a validated chart review method. Delirium duration was recorded. We used separate multivariable logistic regression models to identify independent predictors for overall delirium and longer episodes of delirium (duration ≥ 48 h). Results Of the 322 patients included, 73 (22.7%) were identified as having experienced delirium, with 49 (15.2%) experiencing longer episodes of delirium. Postoperative delirium risk factors included Foley catheter use, intestinal surgery, gallbladder surgery, appendix surgery, intensive care unit (ICU) admission and mild to moderate frailty. Risk factors for prolonged postoperative delirium included Foley catheter use and mild to moderate frailty. Surgical approach (open v. laparoscopic) and overall operative time were not found to be significant. Conclusion In keeping with the literature, our study identified Foley catheter use, frailty and ICU admission as risk factors for delirium in older acute care surgical patients. We also identified an association between delirium risk and the specific surgical procedure performed. Understanding these risk factors can assist in prevention and directed interventions for this high-risk population.
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Affiliation(s)
- Bianka Saravana-Bawan
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
| | - Lindsey M. Warkentin
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
| | - Diana Rucker
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
| | - Frances Carr
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
| | - Thomas A. Churchill
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
| | - Rachel G. Khadaroo
- From the Department of Surgery, University of Alberta, Edmonton, Alta. (Saravana-Bawan, Warkentin, Churchill, Khadaroo); the Division of Geriatrics, Department of Medicine, University of Alberta, Edmonton, Alta. (Rucker, Carr); and the Department of Critical Care Medicine, University of Alberta, Edmonton, Alta. (Khadaroo)
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Tomlinson JH, Partridge JSL. Preoperative discussion with patients about delirium risk: are we doing enough? Perioper Med (Lond) 2016; 5:22. [PMID: 27594990 PMCID: PMC5009628 DOI: 10.1186/s13741-016-0047-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/08/2016] [Indexed: 11/24/2022] Open
Abstract
Postoperative delirium is a common complication in the older surgical population, occurring in 10-50 % of cases. It is thought to be more common if an individual is identified as frail. Postoperative delirium is associated with poor outcome including higher mortality rates, prolonged length of hospital stay, increased care needs on discharge and longer term post-traumatic stress disorder. Guidelines from the American Geriatric Society and the National Institute for Health and Care Excellence highlight the importance of risk assessment at the time of the preoperative visit. This enables the perioperative team to plan a care pathway that minimises the risk of delirium occurring postoperatively. Risk assessment also informs a discussion with patient and family regarding their risk, as part of a process of informed patient consent. This is an essential step in conforming to current legal and General Medical Council guidance on the process of consent.
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Affiliation(s)
- Judith H. Tomlinson
- Department of Critical Care, University College Hospital, T03, 3RD floor, 235 Euston Road, London, NW1 2BU UK
| | - Judith S. L. Partridge
- Proactive care of Older People undergoing Surgery (POPS), Department of Ageing and Health, St Thomas’ Hospital, 9th Floor North Wing, Westminster Bridge Road, London, SE1 7EH UK
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Raats JW, van Eijsden WA, Crolla RMPH, Steyerberg EW, van der Laan L. Risk Factors and Outcomes for Postoperative Delirium after Major Surgery in Elderly Patients. PLoS One 2015; 10:e0136071. [PMID: 26291459 PMCID: PMC4546338 DOI: 10.1371/journal.pone.0136071] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
Background Early identification of patients at risk for delirium is important, since adequate well timed interventions could prevent occurrence of delirium and related detrimental outcomes. The aim of this study is to evaluate prognostic factors for delirium, including factors describing frailty, in elderly patients undergoing major surgery. Methods We included patients of 65 years and older, who underwent elective surgery from March 2013 to November 2014. Patients had surgery for Abdominal Aortic Aneurysm (AAA) or colorectal cancer. Delirium was scored prospectively using the Delirium Observation Screening Scale. Pre- and peri-operative predictors of delirium were analyzed using regression analysis. Outcomes after delirium included adverse events, length of hospital stay, discharge destination and mortality. Results We included 232 patients. 51 (22%) underwent surgery for AAA and 181 (78%) for colorectal cancer. Postoperative delirium occurred in 35 patients (15%). Predictors of postoperative delirium included: delirium in medical history (Odds Ratio 12 [95% Confidence Interval 2.7–50]), advancing age (Odds Ratio 2.0 [95% Confidence Interval 1.1–3.8]) per 10 years, and ASA-score ≥3 (Odds Ratio 2.6 [95% Confidence Interval 1.1–5.9]). Occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality. Conclusion Postoperative delirium is a frequent complication after major surgery in elderly patients and is related to an increase in adverse events, length of hospital stay, and mortality. A delirium in the medical history, advanced age, and ASA-score may assist in defining patients at increased risk for delirium. Further attention to prevention of delirium is essential in elderly patients undergoing major surgery.
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Affiliation(s)
- Jelle W. Raats
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
- * E-mail:
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