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Partridge JSL, Ryan J, Dhesi JK, Barker C, Bates L, Bell R, Bryden D, Carter S, Clegg A, Conroy S, Cowley A, Curtis A, Diedo B, Eardley W, Evley R, Hare S, Hopper A, Humphry N, Kanga K, Kilvington B, Lees NP, McDonald D, McGarrity L, McNally S, Meilak C, Mudford L, Nolan C, Pearce L, Price A, Proffitt A, Romano V, Rose S, Selwyn D, Shackles D, Syddall E, Taylor D, Tinsley S, Vardy E, Youde J. New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary. Age Ageing 2022; 51:6847803. [PMID: 36436009 DOI: 10.1093/ageing/afac237] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/02/2022] [Indexed: 11/28/2022] Open
Abstract
Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
| | - Jack Ryan
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
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Thomas G, West MA, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW, Levett DZH. Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing. Perioper Med (Lond) 2020; 9:18. [PMID: 32518637 PMCID: PMC7271469 DOI: 10.1186/s13741-020-00148-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET. Aim We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice. Methods We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET. Results Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male. Conclusion To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.
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Affiliation(s)
- G Thomas
- Department of Intensive Care, Spaarne Hospital, Haarlem, The Netherlands
| | - M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Maidstone, Kent, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, 9th Floor Terence Lewis Building, Plymouth, UK.,Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- STRAPH Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, East Ayrshire, Scotland, UK
| | - S Jack
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - M P W Grocott
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
| | - D Z H Levett
- Anaesthesia Perioperative and Critical Care Research Group, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust/University of Southampton, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Sir Henry Wellcome Laboratories, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Mailpoint 810, Tremona Road, Southampton, SO16 6YD UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Mailpoint 27, D Level, Centre Block, Tremona Road, Southampton, SO16 6YD UK
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016. [PMID: 26914526 DOI: 10.1002/bjs.10112)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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West MA, Asher R, Browning M, Minto G, Swart M, Richardson K, McGarrity L, Jack S, Grocott MPW. Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery. Br J Surg 2016; 103:744-752. [PMID: 26914526 DOI: 10.1002/bjs.10112] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/28/2015] [Accepted: 12/16/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery. METHODS Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity. RESULTS Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o2 at θ^L ) and at peak exercise (V˙o2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o2 at θ^L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙E /V˙co2 at θ^L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m2 : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres. CONCLUSION These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.
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Affiliation(s)
- M A West
- Academic Unit of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Liverpool, UK
| | - M Browning
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - G Minto
- Directorate of Anaesthesia, Derriford Hospital, Plymouth, UK.,Plymouth University, Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - M Swart
- Department of Anaesthesia and Critical Care Medicine, Torbay Hospital, Torquay, UK
| | - K Richardson
- Sports Therapy, Physical Activity and Health Research Group, School of Sport and Exercise Sciences, University of Kent, Canterbury, UK.,Anaesthesia and Intensive Care Medicine, Medway Maritime Hospital, Gillingham, UK
| | - L McGarrity
- Department of Anaesthesia, University Hospital Crosshouse, Kilmarnock, UK
| | - S Jack
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Critical Care Research Area, National Institute for Health Research Respiratory Biomedical Research Unit, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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