Preoperative Assessment in the Elderly Patients Undergoing Cardiac Surgery

This book provides a timely and authoritative synopsis of the current state of anaesthesia and the elderly patient at a time when the challenge of caring for the growing numbers of elderly patients is probably the greatest faced by healthcare across the globe. The book reviews important developments in the understanding of clinical practice serving the elderly. It describes the need for anaesthesia to deliver ‘best care’ to the elderly, with the aim to maintain their independent living. It then details the key features of ageing and the effect these have on physiology and pharmacology. Specific aspects of practice, including preoperative assessment; day surgery; emergency surgery; anaesthesia for orthopaedic, urological, and gynaecological surgery, as well as major abdominal surgery; neurosurgery; and critical care. Emphasis is placed on managing postoperative care and cognitive dysfunction (POCD), with additional discussion of ethical issues and the law pertaining to the elderly patient. A new chapter reviews the challenges of treating elderly patients in non-theatre environments.

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Elevated Procalcitonin as a Risk Factor for Postoperative Delirium in the Elderly after Cardiac Surgery—A Prospective Observational Study

Journal of Clinical Medicine ◽

10.3390/jcm9123837 ◽

2020 ◽

Vol 9 (12) ◽

pp. 3837

Author(s):

Anna Kupiec ◽

Barbara Adamik ◽

Natalia Kozera ◽

Waldemar Gozdzik

Keyword(s):

Cardiac Surgery ◽

Depressive Symptoms ◽

Elderly Patients ◽

Odds Ratio ◽

Postoperative Delirium ◽

Prospective Observational Study ◽

Reference Range ◽

The Elderly ◽

Daily Functioning ◽

Multivariable Logistic Regression Model

One of the most common complications after cardiac surgery with cardiopulmonary bypass (CBP) is delirium. The purpose of this study was to prospectively investigate the risk of developing postoperative delirium in a group of elderly patients using a multivariate assessment of preoperative and intraoperative risk factors. A total of 149 elderly patients were included. Thirty patients (20%) developed post-operative delirium. Preoperative procalcitonin (PCT) above the reference range (>0.05 ng/mL) was recorded more often in patients who postoperatively developed delirium than in the non-delirium group (50% vs. 27%, p = 0.019). After surgery, PCT was significantly higher in the delirium than the non-delirium group: ICU admission after surgery: 0.08 ng/mL vs. 0.05 ng/mL p = 0.011), and for consecutive days (day 1: 0.59 ng/mL vs. 0.25 ng/mL, p = 0.003; day 2: 1.21 ng/mL vs. 0.36 ng/mL, p = 0.006; day 3: 0.76 ng/mL vs. 0.34 ng/mL, p = 0.001). Patients with delirium were older (74 vs. 69 years, p = 0.038), more often had impaired daily functioning (47% vs. 28%, p = 0.041), depressive symptoms (40% vs. 17%, p = 0.005), and anemia (43% vs. 19%, p = 0.006). In a multivariable logistic regression model, preoperative procalcitonin (odds ratio (OR) = 3.05), depressive symptoms (OR = 5.02), age (OR = 1.14), impaired daily functioning (OR = 0.76) along with CPB time (OR = 1.04) were significant predictors of postoperative delirium.

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Use of clonidine following the weaning phase of the elderly patients underwent elective on-pump cardiac surgery: a prospective randomized study

BMC Geriatrics ◽

10.1186/1471-2318-10-s1-a97 ◽

2010 ◽

Vol 10 (S1) ◽

Author(s):

S Caroleo ◽

F Onorati ◽

O Bruno ◽

D Vuoto ◽

F Infelise ◽

...

Keyword(s):

Cardiac Surgery ◽

Elderly Patients ◽

Randomized Study ◽

The Elderly ◽

Prospective Randomized Study

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315 Cardiac surgery in the elderly: the underestimate role of frailty in the decision making

European Heart Journal Supplements ◽

10.1093/eurheartj/suab147.004 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Pasquale Campana ◽

Maddalena Conte ◽

Maria Emiliana Palaia ◽

Laura Petraglia ◽

Adele Ferro ◽

...

Keyword(s):

Decision Making ◽

Cardiac Surgery ◽

Nutritional Status ◽

Elderly Patients ◽

Frailty Index ◽

The Elderly ◽

Risk Scores ◽

Surgical Risk ◽

The Impact

Abstract Aims Elders represent the most common population with indication to cardiac surgery, also presenting the highest mortality/disability after interventions. Both for valve and coronary artery surgery the estimation of the surgical risk, including the frailty assessment, is recommended to guide the decision making. However, frailty results not exhaustively assessed by the commonly used surgical risk scores such as EuroSCORE I-II and score of the Society of Thoracic Surgeons and is mostly used the Kat’s Index (included in the latest European guidelines). This study aims at establishing the feasibility and the value of a Comprehensive Geriatric Assessment (CGA) in elderly undergoing cardiac surgery. Methods From June 2021we consecutively enrolled 50 elderly patients undergoing cardiac surgery (age > 65 years old). All patients underwent CGA with an expert geriatrician and the demographic, biometrics, clinical and echocardiographic data were collected. We evaluated frailty and disability (Kats index, Barthel Index and Frailty Index FI), cognitive status (Montreal Cognitive Assessment MOCA, Mini Mental State Examination MMSE and Geriatric Depression Scale), physical status (Tinetti test, Short Performance Physical Battery SPPB, Physical Activity Scale for the Elderly PASE and 6-min Walking test), delirium condition, sarcopenia and nutritional status (Mini-Nutritional Assessment MNA). A clinical, echocardiographic, and geriatric 3-month follow-up is planned. In particular, we are evaluating the impact of frailty, assessed by CGA, on peri-surgical outcome and the potential additive value of a CGA on the commonly used surgical risk-scores and Kat’s Index. Furthermore, we are assessing the impact of cardiac surgery of frail elderly at GCA. Results The CGA was feasible in all patients and lasted 1 h/patient. In our baseline data, only 23% of the enrolled patients resulted ‘frail’ according to Kat’s Index. However, in the remaining 77% of the study population, the CGA have identified 30% of patients with increased frailty index and 30% with disability, assessed by Barthel Index and physical function indexes (PASE and SPPB). In these patient, frailty and disability were associated to impaired nutritional status, assessed at MNA. Furthermore, 40% of the patients of this group resulted sarcopenic at the hand grip test. The cognitive valuation has shown a cognitive impairment in the 20% of patients at the MMSE and the 70 % at the MOCA. Of note, the 40% of the patients resulted to suffer of depression, not diagnosed before the GCA. At mid-November 2021 the follow-up will be completed. Conclusions The preliminary results of the presents study suggest that in patients undergoing cardiac surgery frailty is currently underdiagnosed. The follow-up analysis will establish if a CGA has an additive value on common surgical risk estimators. This study has a potential impact on the risk stratification of elderly patients undergoing invasive procedures and defines the need of a geriatrician in the heart team.

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Elevated Procalcitonin and Depression As Risk Factors For Postoperative Delirium In The Elderly After Cardiac Surgery – A Prospective Observational Study.

10.21203/rs.3.rs-94378/v1 ◽

2020 ◽

Author(s):

Anna Kupiec ◽

Barbara Adamik ◽

Natalia Kozera ◽

Waldemar Gozdzik

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Elderly Patients ◽

Postoperative Delirium ◽

Inflammatory Marker ◽

Functional Decline ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Multivariable Logistic Regression Model

Abstract Background One of the most common complications after cardiac surgery is delirium. Determining the origin of this complication from possible pathomechanisms is difficult. The activation of an inflammatory response during surgery has been suggested as one possible mechanism of delirium. The usefulness of the inflammatory marker procalcitonin (PCT) as a predictor of delirium after cardiac surgery with cardiopulmonary bypass (CBP) has not yet been investigated. Methods The purpose of this study was to prospectively investigate the risk of developing postoperative delirium in a group of elderly patients using a multivariate assessment of preoperative (PCT, comorbidities, functional decline, depression) and intraoperative risk factors. 149 elderly patients were included. Delirium was assessed using the Confusion Assessment Method for the ICU. Results Thirty patients (20%) developed post-operative delirium: hypoactive in 50%, hyperactive in 33%, mixed in 17%. Preoperative PCT above the reference range (> 0.05 ng/mL) was recorded more often in patients who postoperatively developed delirium than in the non-delirium group (50% vs. 27%, p=0.019). After surgery, PCT was significantly higher in the delirium than the non-delirium group: ICU admission after surgery: 0.08 ng/mL, IQR 0.03-0.15 vs. 0.05 ng/mL, IQR 0.02-0.09, p=0.011), and for consecutive days (day 1: 0.59 ng/mL, IQR 0.25-1.55 vs. 0.25 ng/mL, IQR 0.14-0.54, p=0.003; day 2: 1.21 ng/mL, IQR 0.24-3.29 vs. 0.36 ng/mL, IQR 0.16-0.76, p=0.006; day 3: 0.76 ng/mL, IQR 0.48-2.34 vs. 0.34 ng/mL, IQR 0.14-0.66, p=0.001). Patients with delirium were older (74 years, IQR 70 – 76 vs. 69 years, IQR 67 – 74; p=0.038) and more often had functional decline (47% vs. 28%, p=0.041). There was no difference in comorbidities with the exception of anaemia (43% vs. 19%, p=0.006). Depression was detected in 40% of patients with delirium and in 17% without delirium (p=0.005). In a multivariable logistic regression model of preoperative procalcitonin (OR= 3.05; IQR 1.02-9.19), depression (OR=5.02, IQR 1.67-15.10), age (OR=1.14; IQR 1.02-1.26), functional decline (OR=0.76; IQR 0.63-0.91) along with CPB time (OR=1.04; IQR 1.02-1.06) were significant predictors of postoperative delirium. Conclusion A preoperative PCT test and assessment of functional decline and depression may help identify patients at risk for developing delirium after cardiac surgery.

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Early Treatment with Risperidone for Subsyndromal Delirium after On-pump Cardiac Surgery in the Elderly

Anesthesiology ◽

10.1097/aln.0b013e31825153cc ◽

2012 ◽

Vol 116 (5) ◽

pp. 987-997 ◽

Cited By ~ 113

Author(s):

Sameh M. Hakim ◽

Ahmed I. Othman ◽

Dina O. Naoum

Keyword(s):

Cardiac Surgery ◽

Placebo Group ◽

Elderly Patients ◽

Primary Outcome ◽

The Elderly ◽

Early Administration ◽

Subsyndromal Delirium ◽

Surgery In The Elderly ◽

To Receive ◽

Risperidone Group

Background The aim of this randomized, parallel-arm trial was to study the effect of treating subsyndromal delirium with risperidone on the incidence of clinical delirium in elderly patients who underwent on-pump cardiac surgery. Methods One hundred one patients aged 65 yr or older who experienced subsyndromal delirium after on-pump cardiac surgery were randomized using a computer-generated list to receive 0.5 mg risperidone (n = 51) or placebo (n = 50) every 12 h by mouth. Patients were assessed at 8 h by a blinded observer using the Intensive Care Delirium Screening Checklist, and those scoring more than 3 were evaluated by a blinded psychiatrist to confirm delirium. Patients in either group who experienced delirium were treated according to the same algorithm. Initially, risperidone was administered and if symptoms were not controlled, haloperidol was administered. The primary outcome was the proportion of patients who experienced delirium in either group. Results Seven (13.7%) patients in the risperidone group experienced delirium versus 17 (34%) in the placebo group (P = 0.031) Competing-risks regression analysis showed that failure to treat subsyndromal delirium with risperidone was an independent risk factor for delirium (subhazard ratio, 3.83; 95% CI, 1.63-8.98; P = 0.002). Two (3.9%) patients in the risperidone group experienced extrapyramidal manifestations versus one (2%) in the placebo group (P = 1.0). Conclusion Administration of risperidone to elderly patients who experienced subsyndromal delirium after on-pump cardiac surgery was associated with significantly lower incidence of delirium. Larger studies are required to determine whether early administration of risperidone during the subsyndromal phase of delirium would influence the clinical course of such patients.

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Prognostic impact of frailty in elderly cardiac surgery patients

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2017.855 ◽

2017 ◽

Vol 87 (2) ◽

Cited By ~ 3

Author(s):

Francesco Vetta ◽

Gabriella Locorotondo ◽

Giampaolo Vetta ◽

Maria Mignano ◽

Sonia Bracchitta

Keyword(s):

Cardiac Surgery ◽

Elderly Patients ◽

Perioperative Management ◽

Cardiovascular Surgery ◽

Preoperative Assessment ◽

Scientific Data ◽

Perioperative Outcomes ◽

Prognostic Impact ◽

Frailty Syndrome ◽

Technical Requirements

<p>Over the past few decades, the progressive aging of the population combined with the resulting increase in cardiovascular disease and the marked improvement of technologies applied to surgery justify the marked increase of the elderly patients requiring cardiovascular surgery. This claims a highly skilled perioperative management, which should be aimed at treating cardiac disease without increasing risk of hospitalization-related harmful events. Current preoperative assessment for cardiac surgery, such as the European System for Cardiac Operative Risk Evaluation II (EUROSCORE II) and the Society of Thoracic Surgeons (STS) risk score, are limited in their ability to predict perioperative outcomes in older patients. This is because patients’ chronological age should not be considered as the only tool to identify the surgical risk. In recent years, indeed, several studies have highlighted the role of frailty syndrome in determining the prognosis of elderly patients undergoing cardiac surgery. Particularly, some functional aspects, such as gait speed seem to have a high sensitivity and specificity in this regard. Therefore, further research is needed in order not only to identify a unique, fast and easy to use tool aimed to recognize frailty syndrome, but chiefly resulting able to give us information about the effectiveness of focused preoperative interventions. Finally, we need to have scientific data on the role that surgical, percutaneous and transcatheter procedures have on outcome in elderly patients in terms of perioperative mortality, postoperative quality of life and regarding the possible reversibility of frailty. Cardiovascular surgery is to date a “moving target”, due to changing face of patients and changing face of technical requirements and perioperative management should reflect such changes. </p>

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Preoperative assessment and preparation of elderly patients undergoing major surgery

10.1093/med/9780198735571.003.0004 ◽

2017 ◽

Author(s):

Chris Dodds ◽

Chandra M. Kumar ◽

Frédérique Servin

Keyword(s):

Elderly Patients ◽

Elective Surgery ◽

Preoperative Assessment ◽

The Elderly ◽

Major Surgery ◽

Patient Factors ◽

Functional Reserve ◽

Behavioural Adaptation ◽

Disease States ◽

Better Than

The benefits to the elderly of current surgical advances are as good as or better than to younger patients. Preassessment serves to individualize operative decisions to optimize the patient’s condition and improve the outcome. These processes require experienced surgical and anaesthetic input. General patient factors are detailed, including communication skills, behavioural adaptation, functional reserve, cognitive function, and frailty. Systematic comorbidities, such as cardiovascular, neurological, respiratory, renal and nutritional status are discussed. The risk/benefit of the proposed procedure, which is often assessed using risk-stratification systems, is reviewed. Time to full recovery and the duration of convalescence are identified as lacking appropriate data at present. Finally, the emerging data on active, multidisciplinary ‘prehabilitation’ before surgery to improve and optimize the general fitness, chronic disease states, and medication of elderly patients in the weeks before elective surgery are examined.

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Oxford Handbook of Anaesthesia

10.1093/med/9780198719410.001.0001 ◽

2016 ◽

Cited By ~ 6

Keyword(s):

Interventional Radiology ◽

Cardiac Surgery ◽

Informed Consent ◽

Acute Pain ◽

Weight Reduction ◽

Ultrasound Guidance ◽

Preoperative Assessment ◽

The Elderly ◽

Drug Formulary ◽

Patient Journey

The Oxford Handbook of Anaesthesia is a comprehensive, authoritative, and practical guide to the whole field of anaesthetic practice. It encompasses all ages, from neonates to the elderly, and all surgical specialties, including cardiac surgery, interventional radiology, and weight-reduction surgery. Local, regional, and neuraxial techniques are described, including ultrasound guidance. The entire patient journey is covered, from preoperative assessment and investigation, through informed consent, to post-operative analgesia. There are substantial sections dealing with acute pain and the management of intra-operative emergencies. A comprehensive drug formulary is provided.

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