Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery

Aerobic fitness and muscle density play a vital role in postoperative complications in colorectal cancer surgery

Background and Objectives

To assess the association of preoperative aerobic fitness and body composition variables with a patient's resilience to the development and impact of postoperative complications after elective colorectal cancer (CRC) surgery.

Methods

Preoperative aerobic fitness was assessed by steep ramp test performance. Preoperative body composition was assessed by muscle mass and density determined from preoperative computed tomography scan analysis at the L3‐level. Complication development and severity was graded according to Clavien‐Dindo. Complication impact was assessed by the time to recovery of physical functioning after complications. Multivariable logistic regression analyses adjusted for age, sex, comorbidities and tumour location was performed.

Results

Of 238 included patients, 96 (40.3%) developed postoperative complications. Better preoperative aerobic fitness decreased the likelihood to develop complications, independent of muscle mass (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.35−0.85) or muscle density (OR: 0.57, 95% CI: 0.36−0.89). A prolonged time to recovery following complications was associated with lower preoperative muscle density (OR: 4.14, 95% CI: 1.28−13.41), independent of aerobic fitness.

Conclusions

Lower aerobic fitness increases the risk of complication development, while low muscle density seems associated with a prolonged recovery from complications. Aerobic fitness and muscle density could be valuable additives to preoperative risk assessment.

Self-perceived recovery and quality of life in elderly patients surviving ICU-admission for abdominal sepsis

Introduction

Concern for loss of physical performance and Health-Related Quality of Life (HRQoL) may raise doubts regarding the meaningfulness of an Intensive Care (ICU) admission in elderly patients. We evaluated self-perceived long-term recovery and satisfaction in elderly surviving an abdominal sepsis related ICU-admission and related this to objective measures of HRQoL.

Methods

A cross-sectional survey study was performed in all ICU-survivors with age ≥70 admitted with abdominal sepsis. HRQoL, frailty and self-perceived long-term recovery were measured using the EQ-5D-3L, Groningen Frailty Indicator, and a self-developed questionnaire, respectively.

Results

Of 144 patients admitted, 48 were alive at follow up (2.42 [0.92; 3.83] years), and 29 (60%) returned the survey. Eleven patients out of 29 (38%) recovered to baseline functioning, and reported higher HRQoL compared to unrecovered patients (0.861 [0.807; 1.000] and 0.753 [0.499; 0.779] respectively, p=0.005). Of the unrecovered patients, 53% were satisfied with their functioning, and 94% were willing to return to ICU.

Conclusions

Mortality in elderly patients with abdominal sepsis is high and ICU-admission should be weighed carefully. However, despite substantial functional decline in survivors, it does not necessarily cause self-perceived unsatisfactory functioning, poor HRQoL and unwillingness to receive life-sustaining therapy again. Caution is advised to use an anticipated loss of functioning as an argument to deny an ICU-admission.

The level of postoperative care influences mortality prediction by the POSPOM score: A retrospective cohort analysis

BACKGROUND

The Preoperative Score to Predict Postoperative Mortality (POSPOM) assesses the patients' individual risk for postsurgical intrahospital death based on preoperative parameters. We hypothesized that mortality predicted by the POSPOM varies depending on the level of postoperative care.

METHODS

All patients age over 18 years undergoing inpatient surgery or interventions involving anesthesia at a German university hospital between January 2006, and December 2017, were assessed for eligibility for this retrospective study. Endpoint was death in hospital following surgery. Adaptation of the POSPOM to the German coding system was performed as previously described. The whole cohort was divided according to the level of postoperative care (normal ward vs. intensive care unit (ICU) admission within 24 h vs. later than 24 h, respectively).

RESULTS

199,258 patients were finally included. Observed intrahospital mortality was 2.0% (4,053 deaths). 9.6% of patients were transferred to ICU following surgery, and mortality of those patients was increased already at low POSPOM values of 15. 17,165 patients were admitted to ICU within 24 h, and these patients were older, had more comorbidities, or underwent more invasive surgery, reflected by a higher median POSPOM score compared to the normal-ward group (29 vs. 17, p <0.001). Mortality in that cohort was significantly increased to 8.7% (p <0.001). 2,043 patients were admitted to ICU later than 24 h following surgery (therefore denoted unscheduled admission), and the median POSPOM value of that group was 23. Observed mortality in this cohort was highest (13.5%, p <0.001 vs. ICU admission <24 h cohort).

CONCLUSION

Increased mortality in patients transferred to high-care wards reflects the significance of, e.g., intra- or early postoperative events for the patients' outcome. Therefore, scoring systems considering only preoperative variables such as the POSPOM reveal limitations to predict the individual benefit of postoperative ICU admission.

Prediction of Mortality in Patients After Oncologic Gastrointestinal Surgery: Comparison of the ASA, APACHE II, and POSSUM Scoring Systems

Scoring systems have been developed to predict the expected mortality and morbidity in surgical procedures. In this study, our aim was to compare the ASA (American Society of Anesthesiologists), APACHE (Acute Physiology and Chronic Health Evaluation) II, POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) scoring systems as predictors of mortality in patients who underwent gastrointestinal oncologic surgery, followed, and were admitted to the intensive care unit during the postoperative period. We examined the files of 82 patients who underwent oncologic gastrointestinal surgery and followed up in the intensive care units (ICUs). The patients’ APACHE II scores and predicted mortality rates (PMR) according to the APACHE II, POSSUM, and ASA scores were ​​calculated. The receiver operator characteristic (ROC) curve analysis was used when evaluating the performances of the ASA, APACHE, and POSSUM scoring systems in terms of accurate assessment of mortality. Accordingly, the area under the curve (AUC) = 0.5 no distinction, 0.5 <AUC <0.7 discriminative power of the test is statistically not significant, 0.7 <AUC <0.8 acceptable, 0.8 <AUC <0.9 very good and 0.9 <AUC <1 perfect. The evaluations showed that APACHE II had the best performance with 0.81, followed by POSSUM, which had an acceptable level at 0.78. On the other hand, the ASA score was 0.63 and its discriminative power was identified as statistically insignificant. Our results show that the POSSUM and APACHE II scoring systems were better at predicting mortality than the ASA scoring system for the prediction of mortality in the postoperative period. Both the POSSUM and APACHE II scoring systems can be confidently used for the prediction of mortality in patients undergoing operations due to oncologic gastrointestinal diseases.