Predictor Of Adverse Postoperative Outcomes Research Articles

EARLY OUTCOME OF LEFT VENTRICULAR FUNCTION AFTER CORONARY ARTERY BYPASS SURGERY: A SINGLE-CENTER EXPERIENCE

Patients with ischemic heart disease and low ejection fraction often exhibit improved outcomes following coronary artery bypass grafting (CABG). Our study aimed to assess the impact of CABG on left ventricular (LV) systolic function and identify predictors of adverse postoperative outcomes. We conducted a prospective cross-sectional study involving 110 CABG patients with a mean age of 56.1 ± 12.2 years and preoperative left ventricular ejection fraction (LVEF) below 50%. Patients were categorized into two groups: group I (n=76, LVEF > 35%) and group II (n=34, LVEF < 35%). In group II, there was a significantly higher prevalence of diabetes mellitus (DM) (p = 0.05) and Euro SCORE II compared to group I (p < 0.001). However, other clinical predictors showed no significant difference between the two groups. Both groups exhibited a significant improvement in LVEF post-surgery (p = 0.05), with comparable in-hospital mortality rates recorded. The study identified DM, significant diastolic dysfunction, and intra-aortic balloon pump (IABP) insertion as predictors of in-hospital mortality (p = 0.001, 0.03, and < 0.001, respectively). These findings suggest a noticeable enhancement in LV systolic function post-CABG, contributing to improved survival rates. However, patients with DM, significant diastolic dysfunction, and those requiring IABP insertion during the perioperative period are at higher risk of mortality. Therefore, targeted attention and specialized care are essential for optimizing outcomes in these high-risk patients.

The effects of an IV fluid bolus on mitral annular velocity and the assessment of diastolic function: a prospective non-randomized study

BackgroundAbnormal diastolic function is an independent predictor of adverse postoperative outcomes. Mitral annular tissue Doppler velocity (e’) is a key parameter for assessing diastolic function. The purpose of this study was to confirm that an acute increase in preload did not significantly impact the intraoperative measurement of e’ and secondarily evaluate the impact of this acute intravascular volume increase on the clinical assessment of diastolic function using a previously described simplified algorithm.MethodsThis was a prospective, non-randomized study in adult patients undergoing elective cardiac surgeries requiring transesophageal echocardiographic monitoring, arterial pressure and Swan-Ganz catheter placements as part of the surgical procedure. Following baseline echocardiographic and hemodynamic measurements, 500 ml of crystalloid solution was infused over 10 min. Hemodynamic and echocardiographic measurements were repeated 5 min after fluid administration.ResultsComplete data sets were available from 84 of the 100 patients who were enrolled in this study. There was no significant change in the values of e’. The average baseline was 7.8 ± 2.0 cm/s (95%CI: 7.4, 8.2) and 8.1 ± 2.4 (95%CI: 7.6, 8.6) following the fluid bolus (p = 0.10). All hemodynamic variables associated with increased intravascular volume (central venous pressure, pulmonary arterial pressures and stroke volume variation) changed significantly. The overall distribution of diastolic function grades did not change following fluid administration (p = 0.69). However, there were many individual patient differences. When using this simplified algorithm, functional grading changed in 35 patients. Thirty of these 35 changes were only a single grade shift. 22 patients had worse functional grading after fluid administration while 13 had improved grading. Nine patients with normal diastolic function at baseline demonstrated diastolic dysfunction after fluid administration while 6 patients with baseline dysfunction normalized following the fluid bolus.ConclusionWe confirmed that e’ is a robust measurement that is reproducible in the intraoperative setting despite variable vascular volume loading conditions, however, the clinical assessment of diastolic function was still altered in 42% of the patients following an intravenous fluid bolus.

Sarcopenia as a Preoperative Risk Stratification Tool among Older Adults with Inflammatory Bowel Disease.

Sarcopenia, defined as a loss of muscle mass and function, is a physiologic factor that has been implicated as a predictor of adverse postoperative outcomes in many older adult populations. However, data related to sarcopenia in older adults with inflammatory bowel disease (IBD) remain limited. Older adults with IBD are particularly vulnerable to adverse postoperative outcomes, in part, due to muscle depletion from systemic inflammation, malnutrition, and reduced physical activity. However, few patients undergo routine muscle evaluation as a part of preoperative assessment. Moreover, cut-off values for measures of sarcopenia in the literature are modeled after non-IBD populations. The lack of standardized measures and values for sarcopenia in the IBD patient population has led to heterogenous findings and a paucity of preoperative risk stratification tools. Therefore, we aim to explore the scope of sarcopenia as a preoperative risk stratification tool among older adults with IBD.

Preoperative Laboratory Values Are Predictive of Adverse Postoperative Outcomes in Patients Older Than 65 Years Undergoing Brain Tumor Resection: A National Surgical Quality Improvement Program Study

In this study, we used a large national database to assess the effect of preoperative laboratory value (PLV) derangements on postoperative outcomes in patients older than 65 years undergoing brain tumor resection. Data was collected for patients >65 years old undergoing brain tumor resection from 2015 to 2019 (N= 10,525). Univariate and multivariate analysis were performed for 11 PLVs and 6 postoperative outcomes. Hypernatremia (odds ratio [OR], 4.707; 95% confidence interval [CI], 1.695-13.071; P < 0.01) and increased creatinine level (OR, 2.556; 95% CI, 1.291-5.060; P < 0.01) were the most significant predictors of 30-day mortality. The most significant predictor of Clavien-Dindo grade IV complications was increased creatinine level (OR, 1.667; 95% CI, 1.064-2.613; P < 0.05), whereas, significant predictors of major complications were hypoalbuminemia (OR, 1.426; 95% CI, 1.132-1.796; P < 0.05) and leukocytosis (OR, 1.347; 95% CI, 1.075-1.688; P < 0.05). Predictors of readmission were anemia (OR, 1.326; 95% CI, 1.047-1.680; P < 0.05) and thrombocytopenia (OR, 1.387; 95% CI, 1.037-1.856; P < 0.05), whereas, hypoalbuminemia (OR, 1.787; 95% CI, 1.280-2.495; P < 0.001) was predictive of reoperation. Increased partial thromboplastin time and hypoalbuminemia were predictors of extended length of stay (OR, 2.283, 95% CI, 1.360-3.834, P < 0.01 and OR, 1.553, 95% CI, 1.553-1.966, P < 0.001, respectively). Hypernatremia (OR, 2.115; 95% CI, 1.181-3.788; P < 0.05) and hypoalbuminemia (OR, 1.472; 95% CI, 1.239-1.748; P < 0.001) were the most significant predictors of NHD. Seven of 11 PLVs were associated with adverse postoperative outcomes. PLV derangements were significantly associated with adverse postoperative outcomes in patients older than 65 years undergoing brain tumor resection. The most significant predictors of adverse postoperative outcomes were hypoalbuminemia and leukocytosis.

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

The Frail Elderly Patient and the Need for a Video Store on Regional Anaesthesia Blocks

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

IntroductionConflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). MethodsAll patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan–Meier survival analysis. ResultsOf the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. ConclusionsObesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

IntroductionFrailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this...

Comparison of frailty metrics and the Charlson Comorbidity Index for predicting adverse outcomes in patients undergoing surgery for spine metastases.

Frailty-the state defined by decreased physiological reserve and increased vulnerability to physiological stress-is exceedingly common in oncology patients. Given the palliative nature of spine metastasis surgery, it is imperative that patients be healthy enough to tolerate the physical insult of surgery. In the present study, the authors compared the association of two frailty metrics and the widely used Charlson Comorbidity Index (CCI) with postoperative morbidity in spine metastasis patients. A retrospective cohort of patients who underwent operations for spinal metastases at a comprehensive cancer center were identified. Data on patient demographic characteristics, disease state, medical comorbidities, operative details, and postoperative outcomes were collected. Frailty was measured with the modified 5-item frailty index (mFI-5) and metastatic spinal tumor frailty index (MSTFI). Outcomes of interest were length of stay (LOS) greater than the 75th percentile of the cohort, nonroutine discharge, and the occurrence of ≥ 1 postoperative complication. In total, 322 patients were included (mean age 59.5 ± 12 years; 56.9% of patients were male). The mean ± SD LOS was 11.2 ± 9.9 days, 44.5% of patients had nonroutine discharge, and 24.0% experienced ≥ 1 postoperative complication. On multivariable analysis, increased frailty on mFI-5 and MSTFI was independently predictive of all three outcomes: prolonged LOS (OR 1.67 per point, 95% CI 1.06-2.63, p = 0.03; and OR 1.63 per point, 95% CI 1.29-2.05, p < 0.01, respectively), nonroutine discharge (OR 2.65 per point, 95% CI 1.74-4.04, p < 0.01; and OR 1.69 per point, 95% CI 1.36-2.11, p < 0.01), and ≥ 1 complication (OR 1.95 per point, 95% CI 1.23-3.09, p = 0.01; and OR 1.41 per point, 95% CI 1.12-1.77, p < 0.01). CCI was found to be independently predictive of only the occurrence of ≥ 1 postoperative complication (OR 1.45 per point, 95% CI 1.22-1.72, p < 0.01). Frailty measured with either mFI-5 or MSTFI scores was a more robust independent predictor of adverse postoperative outcomes than the more widely used CCI. Both mFI-5 and MSTFI were significantly associated with prolonged LOS, higher complication rates, and nonroutine discharge. Further investigation in a prospective multicenter cohort is merited.

Association of baseline frailty status and age with outcomes in patients undergoing intracranial meningioma surgery: Results of a nationwide analysis of 5818 patients from the National Surgical Quality Improvement Program (NSQIP) 2015–2019

PurposeThe objective of this study was to compare the effect of frailty, as measured by the 5-factor modified frailty index (mFI-5), with that of age on postoperative outcomes of patients undergoing surgery for intracranial meningiomas, using data from a large national registry. MethodsThe National Surgical Quality Improvement Program (NSQIP) database (2015–2019) was queried to analyze data from patients undergoing intracranial meningioma resection (N = 5,818). Univariate and multivariate analyses of age and mFI-5 score were performed for 30-day mortality, major complications, unplanned reoperation, unplanned readmission, extended hospital length of stay (eLOS), and discharge to a non-home destination. ResultsBoth univariate and multivariate analyses (adjusted for sex, body mass index, transfer status, smoking, and operative time) demonstrated that mFI-5 and age were significant predictors of adverse postoperative outcomes in patients with intracranial meningioma. However, based on odds ratios (OR) and effect sizes, increasing frailty tiers were better predictors than age of adverse outcomes. Severely frail patients showed highest effects sizes for all postoperative outcome variables [OR 11.17 (95% CI 3.45–36.19), p<0.001 for mortality; OR 4.15 (95% CI 2.46–6.99), p<0.001 for major complications; OR 4.37 (95% CI 2.68–7.12), p<0.001 for unplanned readmission; OR 2.31 (95% CI 1.17–4.55), p<0.001 for unplanned reoperation; OR 4.28 (95% CI 2.74–6.68), p<0.001 for eLOS; and OR 9.34 (95% CI 6.03–14.47, p<0.001) for discharge other than home. ConclusionIn this national database study, baseline frailty status was a better independent predictor for worse postoperative outcomes than age in patients with intracranial meningioma.

OUTCOMES OF TOTAL PROCTOCOLECTOMY (TPC) WITH ILEAL POUCH ANAL ANASTOMOSIS (IPAA)

Abstract BACKGROUND Total proctocolectomy (TPC) followed by ileal pouch anal anastomosis (IPAA) is the surgery of choice for eligible ulcerative colitis patients who are refractory to medical therapy or develop complications such as adenocarcinoma or dysplasia. Although associated with excellent quality of life, IPAA can lead to complications including chronic antibiotic-refractory pouchitis, anatomical complications, and development of Crohn’s disease. These outcomes remain a clinical challenge. The aim of this study was to evaluate the rate of complications and their treatment following TPC with IPAA to assess for predictors of adverse postoperative outcomes. METHODS This was a single center, retrospective study from January 1,2010 to December 31, 2020. We included patients who underwent TPC with IPAA and reported at least one episode of pouchitis, some of whom also had additional complications. Chronic pouchitis was defined as recurrent episodes of biopsy-proven inflammation or as reported in the patient record based on clinical presentation and responsiveness to treatment. Crohn’s disease of the pouch was defined as pre-pouch ileitis or development of a fistula more than 6 months post-operatively. Data is presented as number of cases and proportions. RESULTS A total of 44 subjects who underwent IPAA (52% female, mean age 46.4 ± 11.3 years) were included. The rate of acute pouchitis was 9%, the rate of chronic pouchitis was 75%. In the chronic pouchitis group, 45% were antibiotic-dependent and 7% were antibiotic-refractory. We found that 70% of subjects required the initiation of medical therapy to treat symptoms of pouchitis, with the majority requiring chronic antibiotics (73%) (Table). A total of 10 subjects (23%) required biologics and 10 subjects (23%) required chronic steroid therapy. Anatomic complications were noted in 23 subjects (52%), the most common being abscess/fistula formation (30%), followed by stricture formation (27%). Anatomic complications appeared more likely to occur when more time had elapsed since the original surgery. 10 subjects (23%) needed repeat surgery and 9 subjects (20%) developed Crohn’s disease of the pouch. CONCLUSIONS In our cohort, we found that nearly two thirds of subjects required medical therapy to treat pouchitis following IPAA including 25% requiring treatment biologic/immunosuppressant therapy. In addition, one quarter required repeat surgery for treatment of complications. Limitations of this study include a tertiary patient population and small sample size. We found a lack of standardized characterization of pouchitis with respect to symptoms and lab abnormalities. In future work, we plan to use this data to develop a prospective, multi-center study to establish a standardized database of patients who underwent IPAA. This will help better understand factors that influence outcomes and guide management.

OUTCOMES OF TOTAL PROCTOCOLECTOMY (TPC) WITH ILEAL POUCH ANAL ANASTOMOSIS (IPAA)

Total proctocolectomy (TPC) followed by ileal pouch anal anastomosis (IPAA) is the surgery of choice for eligible ulcerative colitis patients who are refractory to medical therapy or develop complications such as adenocarcinoma or dysplasia. Although associated with excellent quality of life, IPAA can lead to complications including chronic antibiotic-refractory pouchitis, anatomical complications, and development of Crohn’s disease. These outcomes remain a clinical challenge. The aim of this study was to evaluate the rate of complications and their treatment following TPC with IPAA to assess for predictors of adverse postoperative outcomes.

Management of Perioperative Anemia in Patients that Performed Abdominal Major Surgery.

Introduction: Anemia is a recognized predictor of adverse postoperative outcomes in patients during abdominal major surgery. The management of perioperative anemia involves many strategies. Pre-operative anemia has adverse outcomes in major surgery and is called the fourth factor. Anemia was then classified into mild, moderate, and severe depending on hemoglobin level. It is present almost in 40% of patients that performed elective major surgery. Patients with preoperative anemia are associated with an increased rate of blood transfusion together with a risk for high morbidity and mortality. The most usual cause of preoperative anemia is iron deficiency, which can be treated with oral/intravenous iron depending on the time scheduled for surgery. A review concluded that anemia recovery earlier with preoperative intravenous iron than with oral iron supplement. A perioperative erythropoietin injection is also a reasonable approach for patients with hemoglobin between 10 and 13 g/dL and if autologous blood donation is performed. The protocol requires a baseline complete blood count and iron studies and all patients should receive iron supplementation during erythropoietin therapy. The next strategy is stabilized macro/ microcirculation to optimize the patient´s tolerance to bleeding. Recent recommendation, in general, suggests no bridging therapy consider it only if high thrombotic risk. Finally, targeted surgery should be used to reduce intraoperative and postoperative bleeding. We recommend a restrictive transfusion strategy. Allogeneic blood transfusion is associated with an increased incidence of nosocomial infections. Postoperative anemia must be treated with the use of intravenous iron. We ought to know fresh frozen plasma used in deficit in factor V, XI, in dose 15-30ml/kg and be aware of its complications as immunomodulation, acute lung injury, and cardiac overload.&#x0D; Conclusion: Our goal is to improve patients´ clinical outcomes.

Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database

BackgroundFrailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. MethodsAll adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). Results4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. ConclusionsFrailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.

Should we routinely screen for frailty prior to gynecologic oncology surgery? Frailty as a potential predictor of adverse postoperative outcomes in elderly patients.

6517 Background: Frailty is increasingly recognized as an adverse prognostic factor of postoperative morbidity and survival in several surgical disciplines. There is no consensus on routine frailty screening in Gynecologic Oncology. Our goal was to evaluate the predictive role of the National Surgical Quality Improvement Program(NSQIP) comorbidity-based modified Frailty Index-5(mFI-5) in Gynecologic Oncology patients over the age of 70. Methods: Elective laparotomies between 01/2016-09/2020 at the Juravinski Hospital in Hamilton, ON were reviewed using prospectively-collected NSQIP data and chart review. Complication severity was assessed by Clavidien-Dindo classification. The primary outcome was rate of 30-day grade III-V complications. Secondary outcomes were: grade II-V complications, myocardial injury, length of stay(LOS), non-home discharge, and non-initiation/non-completion of adjuvant chemotherapy. Logistic regression analysis was performed. Survival analysis and receiver-operator characteristic curves are underway. Results: In this cohort of 259 patients, frail patients(mFI-5≥2) were at significantly greater risk of grade III-V complications (OR23.77, 95%CI 9.69-66.26, p &lt; 0.0001), grade II-V complications (OR3.8, 95%CI 1.96-7.85, p = 0.0002), myocardial injury (OR3.44, 95%CI 1.66-7.05, p = 0.0009), LOS≥5days (OR2.96, 95%CI 1.61-5.52, p = 0.0006), non-home discharge (OR7.37, 95%CI 2.81-20.46, p &lt; 0.0001), and non-initiation/non-completion of chemotherapy (OR7.34, 95%CI 2.43-23.06, p = 0.0006), than non-frail patients on univariate analysis(UVA). On multivariable analysis, frailty remained independently associated with grade II-V complications and grade III-V complications (OR4.64, 95%CI 2.31-9.94, p &lt; 0.0001, controlling for stage, operative duration and intraoperative complication, and OR24.49, 95%CI 9.72-70.67, p &lt; 0.0001, adjusting for BMI, stage and operative duration, respectively). On UVA, age, surgical complexity score, and smoking were not predictive of complications. Frailty also independently predicted non-home discharge (OR7.37, 95%CI 2.81-20.46, p &lt; 0.0001) when adjusting for age. Conclusions: Frailty as assessed with mFI-5, independent of age, strongly predicted morbidity and non-home discharge after Gynecologic Oncology surgery. Strategies for perioperative optimization could help address these disparities. mFI-5 is a concise tool that can be used for routine frailty screening and risk stratification.

Predicting High-Value Care Outcomes After Surgery for Skull Base Meningiomas

Although various predictors of adverse postoperative outcomes among patients with meningioma have been established, research has yet to develop a method for consolidating these findings to allow for predictions of adverse health care outcomes for patients diagnosed with skull base meningiomas. The objective of the present study was to develop 3 predictive algorithms that can be used to estimate an individual patient's probability of extended length of stay (LOS) in hospital, experiencing a nonroutine discharge disposition, or incurring high hospital charges after surgical resection of a skull base meningioma. The present study used data from patients who underwent surgical resection for skull base meningiomas at a single academic institution between 2017 and 2019. Multivariate logistic regression analysis was used to predict extended LOS, nonroutine discharge, and high hospital charges, and 2000 bootstrapped samples were used to calculate an optimism-corrected C-statistic. The Hosmer-Lemeshow test was used to assess model calibration, and P < 0.05 was considered statistically significant. A total of 245 patients were included in our analysis. Our cohort was mostly female (77.6%) and white (62.4%). Our models predicting extended LOS, nonroutine discharge, and high hospital charges had optimism-corrected C-statistics of 0.768, 0.784, and 0.783, respectively. All models showed adequate calibration (P>0.05), and were deployed via an open-access, online calculator: https://neurooncsurgery3.shinyapps.io/high_value_skull_base_calc/. After external validation, our predictive models have the potential to aid clinicians in providing patients with individualized risk estimation for health care outcomes after meningioma surgery.

A simplified preoperative risk assessment tool as a predictor of complications in the surgical management of forearm fractures

PurposeFrailty is a well-known predictor of adverse postoperative outcomes and is often considered in the preoperative planning stage of surgery. In recent years, the modified frailty index (mFI), a novel metric used to quantify frailty, has become increasingly used in the orthopedic literature as a risk assessment tool. In this study, we analyze the utility of the mFI in predicting unplanned repeat operations and morbidity in the surgical treatment forearm fractures. MethodsWe used the American College of Surgeons National Surgical Quality Improvement Program 2006–2014 dataset to identify patients undergoing open fixation of forearm fractures. The mFI was calculated based on 5 possible comorbid conditions. Demographic and predictor variables were analyzed for associations with each outcome. In order to assess frailty in both the general and elderly population, two analyses were completed: one for the entire population and one for a population of age 65 or older. The primary outcome of interest was unplanned repeat operation. Secondary outcomes included discharge destination and major post-operative complications. Chi square and logistic regression analyses were used to identify associations. ResultsA total of 4641 patients were included in our final analysis. There was a higher prevalence of females and patients between the ages of 61 and 80 compared to other age groups. An mFI score ≥2 was a positively associated with unplanned repeat operation in the general population. An mFI score ≥2 was also positively associated with a discharge destination other than home and major post-operative complications. In the elderly population, mFI ≥2 was similarly associated with a discharge destination other than the patient’s home. ConclusionsPatients undergoing open treatment of forearm fractures were at an increased likelihood of having an unplanned repeat operation and having major complications as frailty score increased, demonstrating that the mFI may be clinically applicable risk assessment tool for these patients.

Usefulness of Timed Up and Go (TUG) Test for Prediction of Adverse Outcomes in Patients Undergoing Thoracolumbar Spine Surgery.

Spine surgery rates have increased and the high postoperative morbidity in these patients result in increased costs. Consequently, it is essential to identify patients at risk of adverse outcomes. To assess whether preoperative Timed Up and Go (TUG) test performance can predict high-grade postoperative complications. A prospective cohort study of patients undergoing elective thoracolumbar spine surgery in a tertiary care hospital between 2017 and 2018. Patients were assessed preoperatively and assigned to the slow-TUG group if unable to perform or test performance time was ≥18.4 s. Primary outcome: high-grade postoperative complications. Secondary outcomes: overall complications, length of stay (LOS), discharge to healthcare facility, readmission and emergency department (ED) presentation. Patients were followed-up until 6 wk after surgery. One hundred three patients (mean age 62.95±10.97 yr) were enrolled. Slow-TUG group were more likely to be classified as American Society of Anaesthesiology (ASA) class 3 (74.1% vs 47.4%, P=.02), non-independent (25.9% vs 5.3%, P<.01), and frail (92.3% vs 42.1%, P<.01). TUG was an independent predictor of high-grade complications (adjusted odds ratio (OR): 4.97, 95% CI: 1.18-22.47), overall complications (OR: 3.77, 95% CI: 1.33-11.81), discharge to a skilled-nursing facility (OR: 3.2, 95% CI: 1.00-10.70), readmission within 6 wk of surgery (OR: 9.14, 95% CI: 2.39-41.26) and LOS (adjusted incident rate ratio (IRR): 1.45, 95% CI: 1.16-1.80). Compared to traditional risk factors, TUG is an important predictor of adverse postoperative outcomes and may be used preoperatively to identify high-risk thoracolumbar surgery patients.

Frailty in the older person undergoing elective surgery: a trigger for enhanced multidisciplinary management - a narrative review.

The ageing of our society has led to increasing numbers of older people requiring elective surgical procedures. Preoperative frailty is a strong predictor of adverse post-operative outcomes. This review aims to summarize the evidence for interventions aimed at improving outcomes in frail older people who may undergo elective surgery. Articles published on perioperative management of frailty between 1 January 1970 and 31 May 2019 were searched using PubMed and EMBASE. We identified very few studies investigating such interventions, such as comprehensive geriatric assessment, prehabilitation (alone or as a multicomponent strategy) and other multicomponent interventions. Administration of a comprehensive geriatric assessment was shown to be associated with reduced mortality, fewer complications and shorter length of hospital stay, and may be best targeted towards those who are identified as frail for resource efficiency. Multicomponent interventions including prehabilitation may be associated with improved outcomes, but the evidence base for these needs to be strengthened. Establishing multidisciplinary collaborative services to provide person-centred models of care should be considered for older people presenting for elective surgery, particularly in those with greater preoperative frailty. Further large-scale studies should focus on implementing and evaluating such multicomponent models of care.

Derivation and Validation of a Generalizable Preoperative Frailty Index Using Population-based Health Administrative Data.

To develop and validate a preoperative frailty index (pFI) for use in population-based health administrative (HA) data. Frailty is a robust predictor of adverse postoperative outcomes. Population-level frailty measures used in surgical studies have significant methodological limitations. Frailty indices (FIs) are a well-defined approach to measuring frailty with well-described methods for development and evaluation. An appropriate preoperative FI in HA data has not been derived or evaluated. Retrospective cohort study using linked HA data in Canada. We identified people >65 years (2002-2015) who had major elective or emergency surgery. Standardized methods were used to construct a 30-variable pFI. Unadjusted and multilevel, multivariable adjusted models were used to measure the association of the pFI with 1-year mortality and institutional discharge. Elective patients were the derivation cohort, emergency patients were the validation cohort. Prespecified sensitivity analyses were performed. We identified 415,704 elective, and 95,581 emergency patients. The elective 1-year mortality rate was 4.7%. Thirty percent of population-level deaths occurred in people with frailty. Every 0.1-unit increase in the pFI was associated with a 2.20-fold increase in the adjusted odds of mortality (95% CI 2.15-2.26; c-statistic 0.81), and a 1.70-fold increase in institutional discharge (95% CI 1.59-1.80; c-statistic 0.71). pFI performance was similar in emergency patients, and was robust to changes in index composition. A preoperative FI derived from HA data is a robust method to measure frailty in elective and emergency patients. Generalizable FIs should be considered a standard approach to population-level study of surgical frailty.

About efficiency of the pharmacological scores as a predictors of outcomes after cardiac surgery

Pharmacological scores, such as inotropic score (IS) and vasoactive-inotropic score (VIS) were created to quantify doses of vasoactive and inotropic drugs. The number of studies where IS and VIS were used for evaluation of postoperative period of adult patients after cardiac surgery is small. Objective: to estimate IS and VIS as an approach for monitoring of the hemodynamic profile and clinical outcomes in the early postoperative period of cardiac surgery. Methods. The study involved 144 patients older than 18 years who underwent cardiac surgery under cardiopulmonary bypass (CPB). In perioperative period we measured cardiac output using a Swan-Ganz catheter with the calculation of central hemodynamic parameters, and also VIS and IS wcre calculated. We evaluated the prognostic value of these pharmacological scores in the development of complications of the early postoperative period, as well as their correlation with the duration of respiratory support, the length of stay in the ICU, and total hospital time. Results. IS ≥ 10 significantly associated with prolonged respiratory support, a long stay in the ICU and with a mortality rate of 28.6 %. Patients with IS ≥ 10 are characterized by a violation of tissue perfusion, main cause of which may be a low cardiac output syndrome. IS ≥ 10 can be used as criteria for the low cardiac output syndrome with impaired organ perfusion. The use of this pharmacological score as a predictor of adverse clinical outcomes and increased mortality is justified. The hemodynamic profile of patients with VIS ≥ 10 is characterized by the absence of signs of cardiac output decrease and normal organ perfusion. It has low prognostic significance for the adverse postoperative clinical outcomes and should not be used as perioperative criteria for low cardiac output. In addition, VIS ≥ 10 requires careful use as a predictor of adverse postoperative outcomes and mortality.