Elderly Surgical Patients Research Articles

Effects of Different Hemoglobin Levels on Near-Infrared Spectroscopy-Derived Cerebral Oxygen Saturation in Elderly Patients Undergoing Noncardiac Surgery

Background: Near-infrared spectroscopy (NIRS) is a commonly used technique to evaluate tissue oxygenation and prevent harmful cerebral desaturation in the perioperative setting. The aims of the present study were to assess whether surgery-related anemia can be detected via NIRS of cerebral oxygen saturation and to investigate the effects of different perioperative transfusion strategies on cerebral oxygenation, potentially affecting transfusion decision-making. Study Design and Methods: Data from the ongoing multicenter LIBERAL-Trial (liberal transfusion strategy to prevent mortality and anemia-associated ischemic events in elderly noncardiac surgical patients, LIBERAL) were used. In this single-center sub-study, regional cerebral oxygenation saturation (rSO₂) was evaluated by NIRS at baseline, pre-, and post-RBC transfusion. The obtained values were correlated with blood gas analysis-measured Hb concentrations. Results: rSO₂ correlated with Hb decline during surgery (r = 0.35, p < 0.0001). Different RBC transfusion strategies impacted rSO₂ such that higher Hb values resulted in higher rSO₂. Cerebral desaturation occurred at lower Hb values more often. Discussion: Cerebral oxygenation monitoring using NIRS provides noninvasive rapid and continuous information regarding perioperative alterations in Hb concentration without the utilization of patients’ blood for blood sampling. Further investigations are required to demonstrate if cerebral rSO₂ may be included in future individualized transfusion decision strategies.

Accuracy of sternomental displacement test and thyromental height test as a predictive measure for difficult airway in elderly surgical patients: a prospective cohort study

ABSTRACT Background Airway assessment before anaesthesia in the elderly is crucial. The delay in endotracheal intubation in this age group can lead to fatal consequences. This study aimed to evaluate the validity of sternomental displacement (SMDD) as a predictor of difficult airway in the elderly and to compare it with the thyromental height test (TMHT). Methods This study included 150 patients aged > 65 years old, ASA i–iii, who were scheduled for elective surgeries under general anaesthesia with endotracheal intubation using conventional laryngoscopy. Cormack–lehane grades iii and iv were assigned as difficult laryngoscopy (DL). Difficult intubation (DI) was defined as insertion of endotracheal tube required more than two attempts or 10 minutes. The primary outcome was the AUROC curve for the SMDD as a predictor of difficult laryngoscopy. Results 14% of our patients showed DL, while 4.7% had DI. SMDD was a good predictor for DL with 0.692 AUC (95% ci: 0.611 − 0.765) at a cut-off value of ≤35 mm, with 71.43% sensitivity, 59.69% specificity, 22.4% PPV and 92.8% NPV. TMHT showed good prediction for DL with 0.794 AUC (95% ci: 0.721–0.856) at a cut-off value of ≤ 49.5 mm. For predicting DI, SMDD showed AUROC (95% ci): 0.814 (0.743–0.873) at a cut-off value ≤35 mm and TMHT had AUROC (95% ci): 0.719 (0.640–0.790) at a cut-off value ≤ 49.5 mm. Conclusion SMDD and TMHT are good objective predictors for DL and di in elderly surgical patients.

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014.

Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Vitamin D3 Supplementation Attenuates Surgery-Induced Neuroinflammation and Cognitive Impairment by Regulating NLRP3 Inflammasome in Mice.

Neuroinflammation plays a dominant role in the progression of postoperative cognitive dysfunction (POCD). Vitamin D has been known to have important regulatory functions in inflammation and immune response. The NOD-like receptor protein 3 (NLRP3) is an essential inflammasome in the inflammatory response and could be activated by anesthesia and surgery. In this study, male C57BL/6 mice aged 14-16 months were given VD3 for 14 days straight before having an open tibial fracture surgery. The animals were either sacrificed to obtain the hippocampus or tested in a Morris water maze test. Western blot was employed to estimate the levels of NLRP3, ASC, and caspase-1, immunohistochemistry was used to identify microglial activation, and an enzyme-linked immunosorbent assay was used to measure the expression of IL-18 and IL-1β, while using the corresponding assay kits to assess ROS and MDA levels to reflect the oxidative stress status. We showed that VD3 pretreatment significantly improved surgery-induced memory and cognitive dysfunctions in aged mice, which was linked to the inactivation of the NLRP3 inflammasome and the inhibition of neuroinflammation. This finding provided a novel preventative strategy for clinically reducing postoperative cognitive impairment in elderly surgical patients. This study has some limitations. Gender differences in the effects of VD3 were not considered, and only male mice were used. Additionally, VD3 was given as a preventative measure; however, it is unknown whether it has any therapeutic benefits for POCD mice. This trial is registered with ChiCTR-ROC-17010610.

Food consumption, factors affecting food intake and nurses’ interventions in elderly orthopedic surgical patients: An analytic observational cross-sectional study

Food consumption, factors affecting food intake and nurses’ interventions in elderly orthopedic surgical patients: An analytic observational cross-sectional study

Frailty assessment tools and associated postoperative outcomes in older patients undergoing elective surgery: A prospective pilot study.

There is a need for a feasible tool to assess the risk of frailty prior to surgery. We aimed to identify the ratio of abnormal results for three clinically applicable screening tools to assess the risk of frailty, and their association with adverse outcomes in a cohort of elderly surgical patients. In this prospective pilot study, patients ≥65 years undergoing preoperative evaluation for elective surgery were included and subjected to three frailty screening tests; Program of Research to Integrate Services for the Maintenance of Autonomy 7-item questionnaire (PRISMA7), Timed Up and Go (TUG), and Clock Drawing Test (CDT). The primary outcome was the incidence of abnormal testing, and secondary outcomes were the association between abnormal tests and mortality, readmission, delirium, surgical complications and non-home discharge. Out of 99 patients, 41%, 37%, and 43% had abnormal PRISMA7, TUG, and CDT screening, respectively. Postoperative delirium was more likely to occur in patients with abnormal TUG screening (19% vs. 3%, p= .011) and CDT (17% vs. 2%, p= .019). When analyzing screening tool combinations, patients with abnormal PRISMA7 and TUG had a higher rate of non-home discharge (38% vs. 17%, p= .029); and patients with abnormal TUG and CDT had a higher rate of postoperative delirium (25% vs. 3%, p= .006) and any surgical complication (58% vs. 38%, p= .037); and patients with abnormal results from all three tools had a higher rate of postoperative delirium (21% vs. 5%, p= .045) and non-home discharge (42% vs. 18%, p= .034). Approximately 40% of elderly surgical patients have abnormal PRISMA7, TUG, and CDT screening tests for frailty, and they are associated individually or in combination with increased risk of adverse postoperative outcomes. The results will aid in designing studies to further risk-stratify patients at risk of frailty and attempt to modify associated outcomes.

Redefining Multimorbidity in Elderly Surgical Patients

INTRODUCTION: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, the conventional multimorbidity definition (two or more comorbidities) labels the vast majority of elderly patients as multimorbid, limiting its clinical benefit. We developed and validated a better surgical specialty-specific multimorbidity definition based on distinct comorbidity combinations called qualifying comorbidity sets (QCSs). METHODS: We used Medicare claims data for patients aged 66 to 90 years hospitalized for general (GS), orthopedic (OS), or vascular surgery (VS). Using 2016 to 2017 data, we identified all comorbidity combinations associated with a double-or-greater risk of 30-day mortality compared with the overall population undergoing the same procedure; these were defined as QCSs. We applied these QCSs to 2018 to 2019 data (GS = 462,904 patients, OS = 1,493,999, VS = 301,336) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbid patients treated at better-resourced (based on nursing resources, surgical volume, teaching status) vs other hospitals had differential outcomes using multivariate matching. RESULTS: Compared with the conventional multimorbidity definition, the QCS-based definition labeled fewer patients as multimorbid: GS = 85.0% vs 55.9% (p < 0.0001); OS = 66.6% vs 40.2% (p < 0.0001); VS = 96.2% vs 52.7% (p < 0.0001) (Table). Thirty-day mortality was higher by the QCS-based definition: GS = 3.96% (conventional) vs 5.64% (QCS-based) (p < 0.0001); OS = 1.13% vs 1.68% (p < 0.0001); VS = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered larger mortality benefit for multimorbid vs nonmultimorbid GS and OS patients (GS absolute risk reduction difference-in-difference = −0.94% [95% CI −1.24%, −0.63%], p < 0.0001; OS difference-in-difference = −0.20% [95% CI −0.29%, −0.10%], p < 0.0001). CONCLUSION: Our QCS-based multimorbidity definition identifies a more specific, higher risk pool of patients compared with the conventional definition, allowing for better clinical decision-making. Table. - Rate of Multimorbidity and 30-Day Mortality with Conventional vs New Qualifying Comorbidity Set-Based Definitions Variable General surgery General surgery Orthopedic surgery Orthopaedic surgery Categorizations Frequency (% (N)) Mortality rate Frequency (% (N)) Mortality rate All patients 100.00% (230,410) 3.42% 100.00% (778,131) 0.79% Conventional multimorbidity definition Nonmultimorbid (0-1 comorbidities) 14.98% (34,521) 0.37% 33.36% (259,570) 0.12% Multimorbid (≥2 comorbidities) 85.02% (195,889) 3.96% 66.64% (518,561) 1.13% New multimorbidity definition Nonmultimorbid (QCS = 0) 44.11% (101,624) 0.61% 59.85% (465,702) 0.20% Multimorbid (QCS ≥ 1) 55.89% (128,786) 5.64% 40.15% (312,429) 1.68%

The prevention of delirium in elderly surgical patients with obstructive sleep apnea (PODESA): a randomized controlled trial

BackgroundObstructive sleep apnea (OSA) is associated with neurocognitive impairment – a known risk factor for postoperative delirium. However, it is unclear whether OSA increases the risk of postoperative delirium and whether treatment is protective. The objectives of this study were to identify OSA with a home sleep apnea test (HSAT) and to determine whether auto-titrating positive airway pressure (APAP) reduces postoperative delirium in older adults with newly diagnosed OSA undergoing elective hip or knee arthroplasty.MethodsWe conducted a multi-centre, randomized controlled trial at three academic hospitals in Canada. Research ethics board approval was obtained from the participating sites and informed consent was obtained from participants. Inclusion criteria were patients who were ge 60 years and scheduled for elective hip or knee replacement. Patients with a STOP-Bang score of ≥ 3 had a HSAT. Patients were defined as having OSA if the apnea–hypopnea index was ≥ 10/h. These patients were randomized 1:1 to either: 1) APAP for 72 h postoperatively or until discharge, or 2) routine care after surgery. The primary outcome was postoperative delirium, assessed twice daily with the Confusion Assessment Method for 72 h or until discharge or by chart review. The secondary outcome measures included length of stay, and perioperative complications occurring within 30 days after surgery.ResultsOf 549 recruited patients, 474 completed a HSAT. A total of 234 patients with newly diagnosed OSA were randomized. The mean age was 68.2 (6.2) years and 58.6% were male. Analysis was performed on 220 patients. In total, 2.7% (6/220) patients developed delirium after surgery: 4.4% (5/114) patients in the routine care group, and 0.9% (1/106) patients in the treatment group (P = 0.21). The mean length of stay for the APAP vs. the routine care group was 2.9 (2.9) days vs. 3.5 (4.5) days (P = 0.24). On postoperative night 1, 53.5% of patients used APAP for 4 h/night or more, this decreased to 43.5% on night 2, and 24.6% on night 3. There was no difference in intraoperative and postoperative complications between the two groups.ConclusionsWe had an unexpectedly low rate of postoperative delirium thus we were unable to determine if postoperative delirium was reduced in older adults with newly diagnosed OSA receiving APAP vs. those who did not receive APAP after elective knee or hip arthroplasty.Trial registrationThis trial was retrospectively registered in clinicaltrials.gov NCT02954224 on 03/11/2016.

Preoperative detection of serum phosphorylated neurofilament heavy chain subunit predicts postoperative delirium: a prospective observational study

Background &amp; Aims. Elderly surgical patients are susceptible to development of postoperative delirium. Interventions for postoperative delirium have little effect on its progression, indicating the importance of early detection and prevention. This study investigated preoperative biomarkers to predict postoperative delirium.Methods. Delirium-related serum biomarkers were measured before the start of surgery in patients who underwent esophageal cancer surgery and were compared between patients who did and did not develop postoperative delirium.Results. Fifteen of 96 patients (15.6%) developed postoperative delirium. Brain-derived phosphorylated neurofilament heavy subunit was preoperatively detected in 80% of patients with postoperative delirium. The preoperative interleukin-6 (IL-6) concentration was significantly higher whereas the concentrations of plasminogen activator inhibitor-1 (PAI-1) was significantly lower in patients with postoperative delirium. Detection of phosphorylated neurofilament heavy subunit was associated with postoperative delirium independent of age (adjusted odds ratio, 5.86; 95% confidence interval, 1.60-29.03; p = 0.0064). The sensitivity and specificity of postoperative delirium detection was increased when age was combined with detection of phosphorylated neurofilament heavy subunit.Conclusions. Preoperative evaluation of phosphorylated neurofilament heavy subunit can predict postoperative delirium independent of age. Early detection of serum phosphorylated neurofilament heavy subunit before surgery may enable clinicians to identify patients at risk for postoperative delirium and start early intervention.

Severe Obesity and Prolonged Postoperative Mechanical Ventilation in Elderly Vascular Surgery Patients

BackgroundSevere obesity, defined as body mass index (BMI) ≥ 40 kg/m2 is increasingly prevalent in elderly surgical patients. Although older age is associated with prolonged postoperative mechanical ventilation (PPMV), the contribution of obesity to this complication in the elderly has not been explored. We investigated the association of severe obesity with the PPMV and the role of severe obesity on mortality risk in patients requiring PPMV.MethodsWe assembled a retrospective cohort of patients ≥ 65 years who underwent inpatient surgical procedures and were either severely obese or normal weight (BMI 18.6 - 24.9 kg/m2 (National Surgical Quality Improvement Program (NSQIP) 2015 - 2018). PPMV was defined as requirement of postoperative mechanical ventilation for longer than 48 h following surgery. We examined the association between severe obesity and PPMV, using univariable and multivariable logistic regression.ResultsWe studied 34,936 patients who were ≥ 65 years of age. The incidence of PPMV was 2.0% (624/31,700) in normal weight patients and 2.8% (92/3,236) in severely obese patients (odds ratio (OR): 1.46; 95% confidence interval (CI): 1.17 - 1.82, P = 0.001). Multivariable analysis, controlling for confounders, estimated a 56% relative increase in the risk of PPMV in severely obese patients, relative to their normal weight peers (OR: 1.56; 95% CI: 1.22 - 1.99, P = 0.001). In normal weight patients, the risk of mortality was multiplied by 23 times in patients who required PPMV (39.6% vs. 2.64%; OR: 23.10; 95% CI: 18.96 - 28.16; P < 0.001). In severely obese patients, PPMV multiplied the risk of mortality by 25 times (30.4% vs. 1.6%; OR: 25.26, 95% CI: 13.44 - 47.50; P < 0.001).ConclusionsSevere obesity increased the odds of PPMV. Although the incidence of PPMV was low, its requirement conferred up to 25 times greater risk of postoperative mortality, underscoring the need for perioperative mitigation strategies to minimize PPMV risk in elderly patients undergoing vascular surgery.

Machine learning prediction of postoperative unplanned 30-day hospital readmission in older adult.

Background: Although unplanned hospital readmission is an important indicator for monitoring the perioperative quality of hospital care, few published studies of hospital readmission have focused on surgical patient populations, especially in the elderly. We aimed to investigate if machine learning approaches can be used to predict postoperative unplanned 30-day hospital readmission in old surgical patients. Methods: We extracted demographic, comorbidity, laboratory, surgical, and medication data of elderly patients older than 65 who underwent surgeries under general anesthesia in West China Hospital, Sichuan University from July 2019 to February 2021. Different machine learning approaches were performed to evaluate whether unplanned 30-day hospital readmission can be predicted. Model performance was assessed using the following metrics: AUC, accuracy, precision, recall, and F1 score. Calibration of predictions was performed using Brier Score. A feature ablation analysis was performed, and the change in AUC with the removal of each feature was then assessed to determine feature importance. Results: A total of 10,535 unique surgeries and 10,358 unique surgical elderly patients were included. The overall 30-day unplanned readmission rate was 3.36%. The AUCs of the six machine learning algorithms predicting postoperative 30-day unplanned readmission ranged from 0.6865 to 0.8654. The RF + XGBoost algorithm overall performed the best with an AUC of 0.8654 (95% CI, 0.8484–0.8824), accuracy of 0.9868 (95% CI, 0.9834–0.9902), precision of 0.3960 (95% CI, 0.3854–0.4066), recall of 0.3184 (95% CI, 0.259–0.3778), and F1 score of 0.4909 (95% CI, 0.3907–0.5911). The Brier scores of the six machine learning algorithms predicting postoperative 30-day unplanned readmission ranged from 0.3721 to 0.0464, with RF + XGBoost showing the best calibration capability. The most five important features of RF + XGBoost were operation duration, white blood cell count, BMI, total bilirubin concentration, and blood glucose concentration. Conclusion: Machine learning algorithms can accurately predict postoperative unplanned 30-day readmission in elderly surgical patients.

Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study).

To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium. Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years. Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes. Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days]. One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.

Pre-operative evaluation in geriatric patients

The population of the United States, as well as developing countries like India, is rapidly ageing. Surgical operations are more common in the elderly than in younger age groups. A comprehensive pre-operative evaluation of these elderly patients is an important component of improving perioperative outcomes. It is very different from the pre-operative assessment in younger patients, which usually encompasses evaluating cardiac risk for non-cardiac surgery and single end-organ functional assessment. Functional and cognitive impairment are additional risk factors associated with poorer outcomes in older patients. Guidelines for pre-operative assessment of elderly surgical patients have been developed by the American College of Surgeons and the American Geriatrics Society.

Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients.

At present, we have entered an aging society. Many diseases suffered by the elderly, such as malignant tumors, cardiovascular diseases, fractures, surgical emergencies and so on, need surgical intervention. With the improvement of Geriatrics, surgical minimally invasive technology and anesthesia level, more and more elderly patients can safely undergo surgery. Elderly surgical patients are often complicated with a variety of chronic diseases, and the risk of postoperative myocardial injury/infarction (PMI) is high. PMI is considered to be the increase of cardiac troponin caused by perioperative ischemia, which mostly occurs during operation or within 30 days after operation, which can increase the risk of short-term and long-term death. Therefore, it is suggested to screen troponin in elderly patients during perioperative period, timely identify patients with postoperative myocardial injury and give appropriate treatment, so as to improve the prognosis. The pathophysiological mechanism of PMI is mainly due to the increase of myocardial oxygen consumption and / the decrease of myocardial oxygen supply. Preoperative and postoperative risk factors of myocardial injury can be induced by mismatch of preoperative and postoperative oxygen supply. The treatment strategy should first control the risk factors and use the drugs recommended in the guidelines for treatment. Application of cardiovascular drugs, such as antiplatelet β- Receptor blockers, statins and angiotensin converting enzyme inhibitors can effectively improve postoperative myocardial ischemia. However, the risk of perioperative bleeding should be fully considered before using antiplatelet and anticoagulant drugs. This review is intended to describe the epidemiology, diagnosis, pathophysiology, risk factors, prognosis and treatment of postoperative myocardial infarction /injury.

The impact of intravenous iron supplementation in elderly patients undergoing major surgery

BackgroundAge and preoperative anaemia are risk factors for poor surgical outcome and blood transfusion. The aim of this study was to examine the effect of iron supplementation in iron-deficient (ID) elderly patients undergoing major surgery.MethodIn this single-centre observational study, patients ≥ 65 years undergoing major surgery were screened for anaemia and ID. Patients were assigned to the following groups: A− (no anaemia); A−,ID+,T+ (no anaemia, iron-deficient, intravenous iron supplementation); A+ (anaemia); and A+,ID+,T+ (anaemia, iron-deficient, intravenous iron supplementation).ResultsOf 4,381 patients screened at the anaemia walk-in clinic, 2,381 (54%) patients were ≥ 65 years old and 2,191 cases were included in analysis. The ID prevalence was 63% in patients with haemoglobin (Hb) < 8 g/dl, 47.2% in patients with Hb from 8.0 to 8.9 g/dl, and 44.3% in patients with Hb from 9 to 9.9 g/dl. In severely anaemic patients, an Hb increase of 0.6 (0.4; 1.2) and 1.2 (0.7; 1.6) g/dl was detected with iron supplementation 6–10 and > 10 days before surgery, respectively. Hb increased by 0 (-0.1; 0) g/dl with iron supplementation 1–5 days before surgery, 0.2 (-0.1; 0.5) g/dl with iron supplementation 6–10 days before surgery, and 0.2 (-0.2; 1.1) g/dl with supplementation > 10 days before surgery (p < 0.001 for 1–5 vs. 6–10 days). Overall, 58% of A+,ID+,T+ patients showed an Hb increase of > 0.5 g/dl. The number of transfused red blood cell units was significantly lower in patients supplemented with iron (0 (0; 3)) compared to non-treated anaemic patients (1 (0; 4)) (p = 0.03). Patients with iron supplementation > 6 days before surgery achieved mobility 2 days earlier than patients with iron supplementation < 6 days.ConclusionsIntravenous iron supplementation increases Hb level and thereby reduces blood transfusion rate in elderly surgical patients with ID anaemia.

The changing landscape of general surgery in the elderly - trends over a decade in a tertiary centre in Singapore.

We take stock of our local experience in a high volume tertiary centre in Singapore, Tan Tock Seng Hospital by reviewing the number of surgical procedures performed for elderly patients (65 years old and above) across a decade and reviewing their post-operative outcomes. This retrospective cohort study included elderly patients (>= aged 65) who underwent surgical procedures under general anaesthesia from January 2008 to December 2019. Demographic data, nature of operation, preoperative American Society of Anaesthesiologists (ASA) status of patients and surrogate markers of outcome including average length of stay (ALOS), 30 and 90-day mortality were retrospectively analysed. Across a 12-year period, we observed a nearly overall two-fold increase in the number of surgical procedures for elderly patients from 1,129 cases in 2008 to 2,118 cases in 2019. The ALOS for elderly surgical patients trended downwards from an average of 12.3 days in 2008 to 9.0 days in 2019. All cause 30-day mortality rate of elderly patients dropped from 5.8% in 2008 to 2.7% in 2019. The landscape for general surgery in the elderly is changing in the context of advances in health care and a paradigm shift in treatment beliefs and perspectives. Ultimately, informed decision making, patient engagement and empowerment by the surgeon are keys to better outcomes and improved patient experience.

The Impact of Age on Propofol Requirement for Inducing Loss of Consciousness in Elderly Surgical Patients.

It is generally accepted that geriatric patients are more sensitive to propofol than adults; thus, a dose-adjusted propofol is recommended for these patients during the induction of anesthesia. However, for patients aged 75 years and over, established guidelines for propofol induction doses do not provide dose references. To this end, we observed 80 surgical patients (female 39, male 41, American Society of Anesthesiologists physical status score I ∼ II) to access the appropriate dose of propofol for inducing loss of consciousness (LOC). Accordingly, patients were subdivided into group A (20 patients, 45–64 years), group B (20 patients, 65–74 years), group C (20 patients, 75–84 years), and group D (20 patients, ≥ 85 years). All patients received propofol (at a rate of 0.3 mg/kg/min) alone for inducing LOC, which was defined by loss of both eyelash reflex and verbal response. Compared with group A, the propofol requirement for LOC in Group B, C and D decreased by 14.8, 25.2 and 38.5%, respectively. Bivariate linear correlation analysis showed that propofol requirement was negatively correlated with age. After adjusting for potential confounders, age was still an independent factor affecting propofol requirement. In conclusion, the propofol requirement for inducing LOC decreased significantly in elderly patients. We demonstrated that age was an independent factor impacting propofol requirement for LOC during the induction of general anesthesia, implying that the propofol dose for anesthesia induction should be further reduced in elderly surgical patients, especially those aged 75 years and over.

Psychological distress among elderly surgical patients who had their surgery postponed during the COVID-19 pandemic

BackgroundMany institutions withheld elective lists and triaged surgeries during the peak of coronavirus disease 2019 (COVID-19) pandemic. As a result, older surgical patients have had to wait for rescheduled dates in a long waitlist. This study aimed to identify the psychological impact in these patients when they returned for surgery.MethodsThis was a cross-sectional study which included 153 patients aged ≥ 65 years undergoing elective surgery. Trained interviewers recruited and assessed psychological status pre-operatively with two validated questionnaires - Hospital Anxiety and Depression Scale (HADS) and 36-item Short Form Health Survey (SF-36). Specific questions were asked about their postponed surgeries, appetite and fear.ResultsA total of 36 out of 153 (23.5%) patients had their procedures deferred during the first wave of COVID-19 pandemic. Postponed cases were significantly based on the nature of surgery (p = 0.002), cancer diagnosis (p = 0.006) and surgical specialty (p = 0.023). Median HADS scores were higher for patients who were postponed (2.00 versus 4.00 for anxiety, p = 0.180 and 0.00 versus 1.00 for depression, p = 0.424) although no statistical significance was shown. In the whole study population, anxiety was a significant predictor for depression and vice versa (p < 0.001) with other predictive risk factors for anxiety that were age ≥ 85 years old (odds ratio [OR] 6.14, p = 0.018), female (OR 2.41, p = 0.024), cancer (OR 2.19, p = 0.039) and major surgery (OR 2.39, p = 0.023). Similarly, older patients ≥ 85 years old (OR 10.44, p = 0.003) and female (OR 6.07, p = 0.006) had higher risk for depression. Both anxiety and depression were significant risks for loss of appetite (p = 0.005 and 0.001). Lastly, the fear of disease progression due to rescheduling was more frequent in cancer patients (p = 0.035).ConclusionThe mental health and disease burden of older surgical patients should be taken into careful consideration when cases need to be postponed in our healthcare system.

787 THE PRUNE PROJECT: USING PRUNES AS A CONSTIPATION AID IN OLDER SURGICAL INPATIENTS

Abstract Introduction Constipation is a common and difficult issue in elderly surgical patients, often contributing to prolonged stay on inpatient wards (Sethi et al, Am J Gastroenterol. 2014;109:250–256). Increasing dietary fibre is a commonsense tactic to mitigate against constipation. However it is rarely formally employed on NHS wards. Prunes are beneficial in increasing fibre intake and are a natural source of sorbitol, which acts as an osmotic laxative (Stacewicz-Sapuntzakis et al, Crit Rev Food Sci Nutr. 2001;41:251–86.) Method We performed a closed-loop audit on the use of prunes in reducing constipation. We collected data from surgical inpatients over 60 years, including the number of days since bowels were last opened, and the number of laxatives that each patient was taking. Patients were then given a prune product (either 3 dried prunes, 125 mL prune juice or 70 g prune puree) three times a week. Following the intervention, the data was recollected to complete the audit cycle. Results In our cohort of 36 patients, the mean time since bowels were last opened reduced from 1.49 to 1.17 days (p = 0.1624) after introducing prunes three times a week, and the mean number of laxatives reduced from 1.81 to 1.50 (p = 0.1671). Conclusion Surgical patients are at increased risk of constipation (Davies et al, J Clin Pharm Ther. 2008; 31:561–566) due to multiple factors including immobility, poor oral intake and opiate use. Constipation is more common in the elderly (Talley et al, Am J Gastroenterol. 1996;91:19–25), who are also at increased risk of polypharmacy (Morin et al, Clin Epidemiol. 2018;10:289–298). These results show that using prunes to aid regular bowel motion can have a positive impact on reducing pharmacy and increasing frequency of bowels opening. We hope that, by introducing tactics to promote regular bowel motions in hospital, we can reduce polypharmacy and instill good health habits post-discharge.