Abdominal Surgery In Elderly Patients Research Articles

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

BackgroundTo determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.MethodsPatients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.ResultsThe incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572–6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307–5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577–0.730] and GFI (OR 2.627, 95% CI 1.307–5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.ConclusionsElderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.Trial registrationThis study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/.

Metabolic change in monocytes and postoperative morbidity after major abdominal surgery in elderly patients: A prospective cohort study

BackgroundPostoperative complications in aging patients remain a significant cause of increased costs, hospital length of stay, and patient distress. Although alterations in energy metabolism have been closely linked to aging process and surgery, it is still unclear whether metabolic changes during surgery is associated with postoperative complications in elderly patients. This study was conducted to investigate whether metabolic changes during surgery predicts postoperative complications in elderly patients. MethodsWe conducted a prospective single-center observational cohort study. 244 adults (aged ≥65 years) who were scheduled for elective major non-cardiac surgery were recruited. Blood samples for each patient were taken before and after surgery. All patients were randomly divided into two groups (122 in each group), then oxygen consumption rate (OCR) or extracellular acidification rate (ECAR) was measured on isolated monocytes in each group. Results14 of 110 (12.7%) patients went through OCR measurement and 15 of 122 patients (12.3%) went through ECAR measurement experienced moderate to severe complications. Overall, there was an intensification of glycolysis in monocytes after surgery. Among all variables, only the change (preoperative -postoperative) of glycolytic reserve (GR)/glycolysis (G) and GR/non-glycolytic acidification (NG) were predictors of moderate to severe complications (AUC = 0.70; 95% CI, 0.56–0.81; P = 0.019 and AUC = 0.67; 95% CI, 0.55–0.80; P = 0.031). Decreased postoperative GR/G were associated with worse postoperative complications (RR = 9.08; 95% CI, 1.23–66.81; P = 0.024). ConclusionsCompared with mitochondria function, the change of glycolytic function in monocyte was more valuable in predicting postoperative complications after major abdominal surgery. Our study gave us a new insight into identifying patients at high risk in aging patients.

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study.

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

Predictors of mortality in elderly patients in emergency abdominal surgery: A retrospective single-center study

Background/Aim: Advancements in medical technologies and prolonged life expectancy have increased the number of surgical interventions for elderly patients. Despite this however, emergency surgical interventions remain associated with a high mortality rate. Managing an emergency abdominal surgery in elderly patients poses great challenges for both the surgeon and the anesthesiologist. However, knowing the risk factors that increase mortality may offer advantages to the clinician managing the treatment process. There are studies in the literature examining the mortality of emergency surgeries in elderly patients. However, there are very few studies that work with a specific patient group such as abdominal surgery and then analyze laboratory test results. Here, we aimed to identify the risk factors that can be used to predict mortality in elderly patients undergoing emergency abdominal surgery. Methods: The study was designed retrospectively in a single center; 100 patients over the age of 80 who underwent emergency abdominal surgery were included in the study. The patients were divided into two groups as survivor and non-survivor. Demographic, surgical, and anesthetic characteristics, laboratory tests, American Society of Anesthesiologists (ASA) physical status scores, postoperative intensive care needs, and treatments of the groups were compared using the chi-squared and Mann Whitney U-test. Determining factors were investigated with logistic regression analysis. Results: In multivariate analysis, ASA 3 and major surgery significantly increased mortality (P=0.041, P=0.011). Receiver operating characteristic (ROC) curve analysis showed that C-reactive protein with a cut-off value of >84 mg/L had a sensitivity of 58.8% and a specificity of 71.2% (AUC=0.636, P=0.004), while lactate with a cut-off value of >3.6 mmol/L had a sensitivity of 50% and a specificity of 95.5% in predicting mortality (AUC=0.776, P<0.001). Conclusion: The magnitude of surgery and the ASA score were the best predictors of mortality in elderly patients undergoing emergency abdominal surgery.

Psoas attenuation and cross-sectional area improve performance of traditional sarcopenia measurements in predicting one-year mortality among elderly patients undergoing emergency abdominal surgery: a pilot study of five computed tomography techniques.

Risk stratification is challenging in the growing population of geriatric patients requiring emergency surgery. Sarcopenia, which assesses muscle bulk, is a surrogate for frailty and predicts 1-year mortality, but does not incorporate potentially valuable additional information about muscle quality. To describe five different CT methods of measuring sarcopenia and muscle quality and to determine which method has the greatest sensitivity for predicting 1-year mortality following emergency abdominal surgery in elderly patients. This retrospective study includes 297 patients 70years and older who underwent "urgent" or "emergent" laparotomy or laparoscopy for acute abdominal disease between 2006 and 2011 at a single quaternary academic medical center. All patients received a CT abdomen and pelvis with intravenous contrast within 1month of surgery. Five different methods were applied to the psoas muscles on CT: method 1 (total psoas index TPI, which is total psoas area TPA normalized by height), method 2 ("pseudoarea" = anterior-posterior × transverse dimensions), method 3 (average HU), method 4 (TPA × HU), and method 5 ("pseudoarea" × HU). For all five CT measures, mortality was greatest for the lowest quartile by univariate and adjusted Cox proportional hazard analyses at all time points up to 1-year. The C-statistic was highest for Method 4, using a composite index of TPA and Hounsfield Units, indicating the greatest predictive ability to estimate mortality at all time points. Muscle quality and muscle size can be used in tandem to refine risk assessment of older patients undergoing emergency abdominal surgery. Routine calculation of the composite score of psoas cross-sectional area and HU in the emergency room setting may provide surgeons and patients valuable insight on the risk of 1-year mortality to guide preoperative decision-making and counseling. Muscle quality and size, both strong independent predictors of surgical outcomes in older patients undergoing emergency abdominal surgery, may be used in tandem to refine risk assessment. A composite score of psoas muscle cross-sectional area and Hounsfield units on CT may provide insight on 1-year mortality in this patient population.

Efficacy of Bioenergetic Health Index to Predict Delirium After Major Abdominal Surgery in Elderly Patients: A Protocol for a Prospective Observational Cohort Study.

IntroductionPostoperative delirium (POD) is a common disorder following surgery, which seriously threatens the quality of patients’ life, especially the older people. The multifactorial manner of this syndrome has made it hard to define an ideal method to predict individual risk. Mitochondria play a key role in the process of POD, which include inflammatory on the brain caused by surgeries and aging related neurodegeneration. As BHI (Bioenergetic Health Index) could be calculated in cells isolated from an individual’s blood to represent the patient’s composite mitochondrial statue, we hypotheses that HBI of monocytes isolated from individual’s peripheral blood can predict POD after major non-cardiac surgery in elderly patients.Methods and AnalysisThis is a prospective, observational single-blinded study in a single center. 124 patients aged ≥ 65 years and scheduled for major abdominal surgery (>3 h) under general anesthesia will be enrolled. Preoperative and postoperative delirium will be assessed by trained members using Confusion Assessment Method (CAM). For patients unable to speak in the ICU after the surgery, Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) will be used. All patients will undergo venous blood sampling twice to measure BHI (1–2 tubes, 5 ml/tube): before the surgery and 1 day after surgery in wards. After discharge, patients will be contacted by telephone 30 days after surgery to confirm the incidence of post-discharge complications. The severity of complications will be categorized as mild, moderate, severe or fatal using a modified Clavien-Dindo Classification (CDC) scheme.Ethics and DisseminationThe study has been approved by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University, Sichuan, China (Chairperson Prof Shaolin Deng, No. 2021-502). Study data will be disseminated in manuscripts submitted to peer-reviewed medical journals as well as in abstracts submitted to congresses.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [ChiCTR2100047554].

Effect of Entropy Index-Targeted Dextromeetomidine on Postoperative Neurocognitive Function in Elderly Patients with Gastrointestinal Tumors

Objective: To investigate the effect of entropy index targeted monitoring combined with dexmedetomidine infusion on cognitive function after thoracic and abdominal surgery in elderly patients. Methods: 60 elderly patients undergoing abdominal surgery in our hospital on October ~2017 and October 2019 were selected, ASAⅡ~ grade III, and the random digital table method was divided into 3 groups ,20 cases in each group. entropy index monitoring combined with dexmedetomidine group (D1 group), entropy index monitoring combined with dexmedetomidine group (D2 group) and dexmedetomidine monitoring combined with saline group (D0 group). All patients were subjected to sequential rapid induction of endotracheal intubation general anesthesia. D1, D2, the group was injected with 0.5μg/kg dexmedetomidine hydrochloride intravenously in the first 15 min of induction, followed by a 0.3μg•kg-1•h-1, 0.6μg•kg-1•h-1 maintenance pump until 30 minutes before the end of operation, respectively. The D0 group was injected with the same amount of saline intravenously before induction, and then maintained with the same amount of saline. D1 and D2 groups were calibrated at 40~60. preoperative (T1), tracheal intubation immediate (T2),30 min after operation (T3) and extubation immediate (T4) M after operation were compared in 3 groups AP (mmhg), hr (sub/ min), blood oxygen saturation (SpO2) and intraoperative anesthetic dosage, vasoactive drug use, and postoperative recovery status; simple intelligent mental state examination scale (MMSE) test was completed 1 day before ,1 day after ,3 days after and 7 days after operation to record the incidence of perioperative neurocognitive disorders (PND). To detect the necrosis factor-α(TNF-α) and C-reactive protein (CRP) of the above-mentioned concurrent serum tumors; Results Compared with D0 group, the MAP of D1 group and D2 group decreased significantly and the HR slowed down significantly (P<0.05), The MAP, HR of T3, T4 in D2 group was significantly decreased compared with that in the D1 group (P<0.05), but the difference was not significant at all time points (0.05);The respiratory recovery time (min), dialling time (min) and restoring directional force time (min) were significantly shortened compared with the D0 group and the D2 group, and the consumption of propofol and sufentanil during the operation was significantly decreased. Compared with the D2 group, the use of vasoactive drugs in the D1 group was significantly decreased (P<0.05). The TNF-α, CRP of patients in the first day and the third day were higher than those in the first day of operation, but the TNF-α, CRP of D1 group and D2 group were lower than those in the D0 group (0.05). The MMSE scores of l days and 3 days after operation in D1 and D2 groups were higher than those in D0 groups. Significantly decreased (P<0.05), and there was no significant difference between the groups 7 days after operation (P>0.05): Conclusion entropy index targeted monitoring combined with dexmedetomidine infusion (0.3μg/kg/h) in the elderly patients during surgery can improve the intraoperative and postoperative hemodynamic stability, can improve the perioperative neurocognitive disorders of patients, worthy of clinical promotion.

Risk factors for postoperative delirium after elective major abdominal surgery in elderly patients: A cohort study.

Prehabilitation programs have recently been suggested as potentially able to lower the incidence of delirium in elderly patients undergoing major abdominal surgery. For these prehabilitation programs to become successful, it is essential to identify those patients who are most likely to develop a delirium. A single-centre cohort study was conducted. Inclusion criteria were: age ≥70 years and scheduled for abdominal surgery for colorectal cancer or an abdominal aortic aneurysm between January 2013 and June 2018. Baseline patient, surgical, anaesthesiologic and haematological characteristics were collected. A risk factor analysis was conducted, with postoperative delirium as primary outcome, by performing a multivariable logistic regression analysis. In this study, 627 patients were included, of whom 64 (10%) developed a delirium. Variables that differed significantly between delirious and non-delirious patients were age, burden of comorbidity, renal impairment, hypertension, cognitive impairment, history of delirium, physical and nutritional impairment, open surgery, preoperative anaemia and erythrocyte transfusion. After multivariable logistic regression analysis, risk factors for postoperative delirium after major abdominal surgery were renal impairment (OR 2.2; 95%CI 1.2-4.3), cognitive impairment (OR 4.1; 95%CI 1.8-9.2), an ASA score ≥ 3 (OR 2.0; 95% CI 1.0-3.9), being an active smoker (OR 2.7; 95%CI 1.3-5.8), ICU admission (OR 7.1; 95%CI 3.5-14.3), erythrocyte transfusion (OR 2.4; 95%CI 1.2-4.9) and a diagnosis of colorectal cancer (CRC); (OR 4.0; 95% CI 1.7-9.6). Prehabilitation had a protective effect (OR 0.5; 95% CI 0.3-0.9). Postoperative delirium is a frequent complication after major abdominal surgery in the elderly, especially in octogenarians and after open procedures. Renal impairment, cognitive impairment, being an active smoker, ICU admission, erythrocyte transfusion and a diagnosis of CRC are important risk factors for the development of delirium. Prehabilitation lowers the risk of developing a delirium.

Myocardial injury in elderly patients after abdominal surgery.

The development of sensitive myocardial-specific cardiac biomarkers allows for detection of very small amounts of myocardial injury or necrosis. Myocardial injury (MI) as a prelude of the serious perioperative complication myocardial infarction, should be paid more attention, especially in elderly susceptible patients. Myocardial injury after abdominal surgery in elderly patients has not been described yet. The objectives of this study were to identify the incidence, predictors, characteristics and the impact of MI on outcome in elderly patients underwent abdominal surgery. Patients aged ≥ 65 who underwent abdominal surgery longer than 2h between January 2016 and March 2017 were reviewed. Patients with peak troponin I level of 0.04ng/ml or greater (abnormal laboratory threshold) within once-administration-period and without non-ischemia troponin elevation proof (e.g., sepsis) were assessed for characteristics and prognosis. Risk factors of MI were determined by multivariable regression. Among 285 patients with whole information, 36 patients (12.6%) suffered MI, only 2 patients (0.7%) fulfilled definition of myocardial infarction. With most of them occurred within first 7days after surgery. Multivariable analysis showed that coronary artery disease (CAD) history [odds ratio (OR) 2.817, P = 0.015], non-laparoscopic surgery (OR 5.181, P = 0.030), blood loss ≥ 800ml (OR 3.430, P = 0.008), non-venous maintain (OR 2.105, P = 0.047), and infection (OR 4.887, P = 0.008) as risk factors for MI. MI was associated with longer hospital stay (P = 0.006), more cardiac consultation (P = 0.011), higher infection(P = 0.016) and reoperation(P = 0.026) rate. MI is common in elderly patients who underwent abdominal surgery, while myocardial infarction is infrequent. They are both associated with risk factors and worse prognosis. MI deserves more attention especially in elderly patients. Troponin I measurement is a useful test after massive surgery, which can help risk-stratifying patients, effective preventing, prompt managing and predicting outcomes. Routine monitoring of cardiac biomarkers especially within 7days after abdominal surgery in elderly patients is recommended.

Use of sarcopenia to predict risk of mortality after emergency abdominal surgery in elderly patients.

Use of sarcopenia to predict risk of mortality after emergency abdominal surgery in elderly patients.

Sarcopenia increases risk of long-term mortality in elderly patients undergoing emergency abdominal surgery.

Frailty is associated with poor surgical outcomes in elderly patients but is difficult to measure in the emergency setting. Sarcopenia, or the loss of lean muscle mass, is a surrogate for frailty and can be measured using cross-sectional imaging. We sought to determine the impact of sarcopenia on 1-year mortality after emergency abdominal surgery in elderly patients. Sarcopenia was assessed in patients 70 years or older who underwent emergency abdominal surgery at a single hospital from 2006 to 2011. Average bilateral psoas muscle cross-sectional area at L3, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography. Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was mortality at 1 year. Secondary outcomes were in-hospital mortality and mortality at 30, 90, and 180 days. The association of sarcopenia with mortality was assessed using Cox proportional hazards regression and model performance judged using Harrell's C-statistic. Two hundred ninety-seven of 390 emergency abdominal surgery patients had preoperative imaging and height. The median age was 79 years, and 1-year mortality was 32%. Sarcopenic and nonsarcopenic patients were comparable in age, sex, race, comorbidities, American Society of Anesthesiologists classification, procedure urgency and type, operative severity, and need for discharge to a nursing facility. Sarcopenic patients had lower body mass index, greater need for intensive care, and longer hospital length of stay (p < 0.05). Sarcopenia was independently associated with increased in-hospital mortality (risk ratio, 2.6; 95% confidence interval [CI], 1.6-3.7) and mortality at 30 days (hazard ratio [HR], 3.7; 95% CI, 1.9-7.4), 90 days (HR, 3.3; 95% CI, 1.8-6.0), 180 days (HR, 2.5; 95% CI, 1.4-4.4), and 1 year (HR, 2.4; 95% CI, 1.4-3.9). Sarcopenia is associated with increased risk of mortality over 1 year in elderly patients undergoing emergency abdominal surgery. Sarcopenia defined by TPI is a simple and objective measure of frailty that identifies vulnerable patients for improved preoperative counseling, setting realistic goals of care, and consideration of less invasive approaches. Prognostic study, level III.

P1033Echocardiographic predictive model of new-onset postoperative atrial fibrillation after abdominal surgery.

and purpose: Postoperative atrial fibrillation (POAF) is a frequent complication post high-risk abdominal surgery in elderly patients. This study aimed to develop a predictive model of POAF based on preoperative transthoracic echocardiography (TTE) findings in these patients. We conducted a prospective study of 300 consecutive patients, age ≥ 65 years (mean age 72±6 years, 61% men), who underwent high-risk abdominal surgery under general anesthesia. Preoperative TTE was performed in all patients, including tissue Doppler imaging (TDI). We measured the time interval between the onset of the P-wave on ECG and a point of the peak-A wave on TDI from the lateral mitral annulus (PA lateral) and septal mitral annulus (PA septal). Left atrial (LA) dyssynchrony was measured by subtracting the PA septal from PA lateral. Right ventricular systolic pressure was estimated by using the tricuspid regurgitation jet (TRJ) Doppler velocity method. The primary endpoint was the occurance of new-onset POAF. Thirty-seven (12%) patients developed POAF. Multiple echocardiographic parameters were measured and tested in different combinations. The final model included the following variables with cutoff points predictive of POAF: PA lateral > 139 ms (69% sensitivity, 92% specificity), LA dyssynchrony > 35 ms (78% sensitivity, 89% specificity), and TRJ Doppler velocity >2.6 m/s (89% sensitivity, 64% specificity). A value of 0 was assigned when the result was below the cutoff point and a value of 1 if above the cutoff point. Coding of these three variables in the following order: PA lateral- TRJ Doppler- left atrial dyssynchrony can predict the probability of POAF. The model showed a postive predictive value of 79% and a negative predictive value of 95%. A model using three echocardiographic variables: PA lateral, LA dyssynchrony and TRJ Doppler velocity, can predict the incidence of POAF after high-risk abdominal surgery. The model can be used preoperatively to identify high-risk patients that would need aggressive prophylactic treatment.

Postacute Care After Major Abdominal Surgery in Elderly Patients: Intersection of Age, Functional Status, and Postoperative Complications.

Advanced age is an important risk factor for discharge to postacute care (PAC) facilities including skilled nursing and rehabilitation. Factors modifying the age-related risk of discharge to PAC have not been adequately examined for surgical patients. To evaluate how preoperative functional status and postoperative complications affect age-related risk of discharge to PAC facilities following major abdominal surgery. Retrospective cohort study of 55 238 patients aged 18 years or older having colorectal, pancreas, or liver operations in 2011 and 2012 at hospitals participating in the National Surgical Quality Improvement Program. Age was classified as younger than 65 years, 65 to 74 years, 75 to 84 years, and 85 years or older. The study was conducted between July 1, 2014, and July 1, 2015. The primary outcome was discharge to a PAC facility following surgery. The secondary outcome was type of PAC facility (skilled nursing, rehabilitation, or other facility). Among 55 238 patients (mean [SD] age, 61 [15] years; 49% male) having colorectal, pancreas, or liver operations, 5325 (10%) were discharged to PAC facilities after major abdominal surgery. Skilled nursing facilities were the most common type of PAC (63%), followed by rehabilitation hospitals (30%) and other facilities (7%). Older age was an important predictor of discharge to PAC facilities, but there were significant interaction effects with age and postoperative complications. Among functionally independent patients who avoided postoperative complications, rates of discharge to PAC increased from 1% in the group younger than 65 years to 30% in the group aged 85 years or older. For functionally independent patients with multiple complications, 13% of patients younger than 65 years were discharged to PAC facilities compared with 66% of those aged 85 years or older. After risk adjustment, the oldest patients were 27 times more likely to be discharged to PAC than the youngest group when there were no postoperative complications (odds ratio = 26.6; 95% CI, 21.6-32.7) and 11 times more likely after multiple complications (odds ratio = 11.4; 95% CI, 8.3-15.6). Among functionally dependent patients, the overall risk of discharge to PAC facilities was increased, but age was not as important a predictor for discharge to PAC. Older patients are frequently discharged to PAC facilities even when they are functionally independent and without postoperative complications. Helping older patients to return home after surgery and avoid placement in PAC facilities will require innovative programs that go beyond reducing complication rates and enhance postoperative recovery.

The impact of postoperative complications on the recovery of elderly surgical patients.

While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients. Elderly patients (70years and older) undergoing elective abdominal surgery, with a planned length of stay >1day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1week, 1, 3, and 6months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index-CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach. Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7±4.9years, mean BMI was 27.2±5.5kg/m(2), and the median CCI was 3 (IQR 2-6). The mean preoperative SPPB score was 9.62±2.33. A total of 52 patients (34.9%) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7±23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94-0.98, p value=0.0004) and hence increase the time to recovery. Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.

Sedation in elderly patient undergoing surgery with spinal anesthesia: propofol vs. midazolam

Abstract It is widely known the need for a high quality sedation associated with local regional anesthesia in elderly patients’ surgery. The aim of this study was to compare two sedation regimes: propofol and midazolam, associated to spinal anesthesia with isobaric 0.5% bupivacaine in lower abdominal surgery in elderly patients. After obtaining the informed consent, 60 patients aged between 65 and 82 years old (ASA I-III), scheduled for unilateral hernioplasty , under spinal anesthesia with isobaric bupivacaine 1,5 ml (0.5%), were randomized into two groups of 30 patients each: P group - patients received propofol 3mg/kg/body/hour in the first 10 minutes and then continuous infusion by injection of 1,8 mg/kg/body/hour, and group M-patients who have received midazolam 0,2mg/kg/body/hour in the first 10 minutes and then continuous infusion by injection of 0,15 mg/kg/body/hour. In order to achieve a similar level of sedation we used 0,1% midazolam infusion and 1% propofol. Intraoperative, the following have been monitored: heart rate and breath, mean arterial pressure, hemoglobin oxygen saturation. We have also recorded the sedation score (modified Wilson sedation scale), awakening times, patient satisfaction at 24 hours (satisfaction score according to Iowa University). The average score of sedation for group P was of 3,24 ± 0,23, compared to 2,64 ±0,42 in group M (p = 0.001). Both drugs reduce blood pressure, but not more than 20% of the initial value. There are no significant differences in the satisfaction score of the patient (p = 0,18). There was just one case of respiratory depression in group M with the decrease of SpO2 at 86%.Sedation with propofol associated with local regional anesthesia techniques in elderly patients seems to provide better conditions in terms of sedation score and lack of respiratory depression compared with the administration of midazolam. Recovery was significantly faster after sedation with propofol. The satisfaction score of the patient was similar in the two groups

Importance of a comprehensive geriatric assessment in prediction of complications following major abdominal surgery in elderly patients

Importance of a comprehensive geriatric assessment in prediction of complications following major abdominal surgery in elderly patients

Postoperative pain management after major abdominal surgery in elderly patients

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Perioperative Care of the Elderly

Efficacy of patient controlled subcutaneous analgesia with sufentanil after abdominal surgery in elderly patients

Objective To observe the efficacy of patient controlled subcutaneous analgesia (PCSA) with sufentanil after abdominal surgery in elderly patients. Methods Eighty patients, aged 65 -80 yr, weigheding 43 kg-75 kg, classified as ASA Ⅰ-Ⅱ,undergoing elective abdominal surgery were included in this study. Using a random number table, patients were randomly divided into four 4 groups (n=20 each) , A1 (sufentanil 60 μg), A2(sufentanil 80 μg), A3 (sufentanil 100 μg) and group B (sufentanil 80 μg). In the four groups, the drug was diluted 100 ml with 0.9% normal saline. A patient controlled subcutaneous analgesia mode was used in groups A1, A2 and A3, while a patient controlled intravenous analgesia (PCIA) mode was used in group B. AAPON-ZZB pump was set up with loading dose of 3 ml, background infusion of 1 ml/h, a bolus dose of 1 ml, and lockout interval of 15 min. The pain Visual Analogue Scale (VAS) score, Ramsay sedation score, MAP,HR, RR and SpO2 were recorded at 2(T1),4(T2),8(T3), 16(T4),24(T5) and 48 h (T6) after surgery. The number of deliveries (D1) and effective deliveries (D2), and the adverse effects related to analgesia treatment during a 48 h postoperative period were noted. Results The VAS score in the state of rest of group A, was significantly higher than group B[(3.1±1.5)vs(1.7±0.9) at T1, (3.2±1.7)vs(1.5±0.8) at T2, (2.8±1.3) vs(1.6±0.9) at T3,respectively](P<0.05);the VAS score in the state of cough of group A1 was significantly higher than group B[(3.3± 1.7) vs (2.2±1.0) at T1, (3.7±1.5) vs (2.3±1.2) at T2, (3.2±1.6) vs (2.1±0.9) at T3, respectively] (P<0.05). The Ramsay sedation score of group A3 was significantly higher than group B [(3.0±0.7) vs (2.1±0.3) at T3, (3.0±0.3) vs (2.1±0.2) at T4, respectively] (P<0.05). The MAP of group A1 was significantly higher than group B at T1,2 (P<0.05), the D1 and D2 of group A1 was significantly higher than group B (P<0.05). The incidence of nausea and vomiting was higher in group A3 compared to group B (P<0.05). Conclusion In elderly patients undergoing abdominal surgery, PCSA with 0.8 mg/L sufentanil was effective and safe, with good analgesic effect and low incidence of adverse effects. Key words: Sufentanil; Subcutaneous administration; Patient-controlled analgesia; Elderly

Impaired Mobility, ASA Status and Administration of Tramadol are Risk Factors for Postoperative Delirium in Patients Aged 75 Years or More After Major Abdominal Surgery

The aim of this prospective study was to determine incidence, duration, and risk factors for postoperative delirium (PD) in elderly patients undergoing major abdominal surgery. The incidence and risk factors of PD after major abdominal surgery in elderly patients are not well documented. From May 2006 to May 2008, 118 patients aged 75 years or more without severe preoperative cognitive dysfunction (mini mental state examination score >10/30) and undergoing major elective abdominal surgery were included. The preoperative geriatric assessment battery consisted of 4 tests evaluating physical (instrumental activities of daily living and timed get up and go test score) and cognitive function (mini mental state examination score), and detecting the presence of an underlying depression (Short-GDS). After the operation, geriatric patients were assessed for PD by the Confusion Assessment Method. Univariate and multivariate analyses were used to determine risk factors for PD. Overall, PD occurred in 28 patients (24%). Multivariate analysis showed that an American Society of Anesthesiologists status of 3-4 (P = 0.02), impaired mobility (timed get up and go test score >20 seconds) (P = 0.009) and postoperative tramadol administration (P = 0.0009) were risk factors for PD. The mortality rate was 14% in 28 patients with PD and 3.3% in 90 patients without PD (P = 0.051). The morbidity rate was 35.5% in 28 patients with PD and 32% in 90 patients without PD (NS). The mean hospital stay was 19 +/- 11 days for patients with PD and 14 +/- 8 for patients without PD (P = 0.01). Fifteen of 24 (62.5%) surviving patients with PD and 28 of 87 (32%) surviving patients without PD were discharged to geriatric rehabilitation unit (P = 0.007). PD is a frequent and severe postoperative event in elderly patients after major abdominal surgery. A perioperative geriatric assessment should be recommended to patients with an American Society of Anesthesiologists status of 3-4 and preoperative impaired mobility to facilitate the management of PD. In these patients, the postoperative administration of tramadol should be avoided.

Feasibility and Safety of Extensive Upper Abdominal Surgery in Elderly Patients with Advanced Epithelial Ovarian Cancer

We performed a retrospective study to evaluate the feasibility and safety of extensive upper abdominal surgery (EUAS) in elderly (≥65 yr) patients with advanced ovarian cancer. Records of patients with advanced epithelial ovarian cancer who received surgery at our institution between January 2001 and June 2005 were reviewed. A total of 137 patients including 32 (20.9%) elderly patients were identified. Co-morbidities were present in 37.5% of the elderly patients. Optimal cytoreduction was feasible in 87.5% of the elderly while 95.2% of young patients were optimally debulked (P=0.237). Among 77 patients who received one or more EUAS procedures, 16 (20.8%) were elderly. Within the cohort, the complication profile was not significantly different between the young and the elderly, except for pleural effusion and pneumothorax (P=0.028). Elderly patients who received 2 or more EUAS procedures, when compared to those 1 or less EUAS procedure, had significantly longer operation times (P=0.009), greater blood loss (P=0.002) and more intraoperative transfusions (P=0.030). EUAS procedures are feasible in elderly patients with good general condition. However, cautious peri-operative care should be given to this group because of their vulnerability to pulmonary complications and multiple EUAS procedures.