Revisiones_bibliográficas TyO_Web: El anciano quirúrgico / Suigical elderly patients

Marzo 21, 2017. No. 2635

Los pacientes geriátricos tienen más posibilidades de complicaciones perioperatorias, incluyendo la muerte. La fragilidad y las fallas orgánicas son factores de riesgo que se deben de conocer y cuantificar detenidamente durante la evaluación preanestésica. Esta semana le enviaremos información sobre este tema.

Geriatric patients are more likely to have perioperative complications, including death. Fragility and organic failure are risk factors that must be known and quantified carefully during the preanesthetic evaluation. This week we will send you information on this subject.

Pacientes geriátricos são mais propensos a complicações perioperatórias, incluindo a morte. Fragilidade e falência de órgãos são factores de risco que devem ser cumpridas e cuidadosamente quantificados durante a avaliação pré-anestésica. Nesta semana, vamos enviar-lhe informações sobre este tópico.

Evaluación preoperatoria del paciente quirúrgico de mayor edad: Sobre los síndromes geriátricos.

Preoperative assessment of the older surgical patient: honing in on geriatric syndromes.

Kim S1, Brooks AK2, Groban L2.

Clin Interv Aging. 2014 Dec 16;10:13-27. doi: 10.2147/CIA.S75285. eCollection 2015Abstract

Nearly 50% of Americans will have an operation after the age of 65 years. Traditional preoperative anesthesia consultations capture only some of the information needed to identify older patients (defined as ≥65 years of age) undergoing elective surgery who are at increased risk for postoperative complications, prolonged hospital stays, and delayed or hampered functional recovery. As a catalyst to this review, we compared traditional risk scores (eg, cardiac-focused) to geriatric-specific risk measures from two older female patients seen in our preoperative clinic who were scheduled for elective, robotic-assisted hysterectomies. Despite having a lower cardiac risk index and Charlson comorbidity score, the younger of the two patients presented with more subtle negative geriatric-specific risk predictors - including intermediate or pre-frail status, borderline malnutrition, and reduced functional/mobility - which may have contributed to her 1-day-longer length of stay and need for readmission. Adequate screening of physiologic and cognitive reserves in older patients scheduled for surgery could identify at-risk, vulnerable elders and enable proactive perioperative management strategies (eg, strength, balance, and mobility prehabilitation) to reduce adverse postoperative outcomes and readmissions. Here, we describe our initial two cases and review the stress response to surgery and the impact of advanced age on this response as well as preoperative geriatric assessments, including frailty, nutrition, physical function, cognition, and mood state tests that may better predict postoperative outcomes in older adults. A brief overview of the literature on anesthetic techniques that may influence geriatric-related syndromes is also presented.

KEYWORDS: frailty; mobility-disability; postoperative delirium; preoperative evaluation; stress response

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Mortalidad prevenible después de cirugía urológica común. ¿Fallar en el rescate?

Preventable mortality after common urological surgery: failing to rescue?

Sammon JD1, Pucheril D, Abdollah F, Varda B, Sood A, Bhojani N, Chang SL, Kim SP, Ruhotina N, Schmid M, Sun M, Kibel AS, Menon M, Semel ME, Trinh QD.

BJU Int. 2015 Apr;115(4):666-74. doi: 10.1111/bju.12833. Epub 2014 Aug 19.

Abstract

OBJECTIVE: To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in 'failure to rescue' (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable. PATIENTS AND METHODS: Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates. RESULTS: Between 1998 and 2010, an estimated 7,725,736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001). CONCLUSION: A shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.

KEYWORDS: failure to rescue; preventable mortality; urological surgery

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