1
|
Li G, Freundlich RE, Rice MJ, Dunworth BA, Sandberg WS, Higgins MS, Wanderer JP. The impact of a medically directed student registered nurse anesthesia staffing model on Postprocedural patient outcomes. J Clin Anesth 2024; 94:111413. [PMID: 38359686 DOI: 10.1016/j.jclinane.2024.111413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 02/17/2024]
Abstract
STUDY OBJECTIVE In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) "are not yet fully qualified anesthesia personnel." It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as in-room anesthesia providers impact surgical outcomes. DESIGN Retrospective, matched-cohort analysis. SETTING Adult patients (≥18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. PATIENTS 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. INTERVENTIONS None. MEASUREMENTS The primary composite outcome was postoperative occurrence of in-hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In-hospital mortality was analyzed as the secondary outcome. MAIN RESULTS In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94-1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in-hospital mortality (relative risk, 0.75; 95% CI, 0.59-0.96). CONCLUSIONS Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in-room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review. Clinical Trial and Registry URL: Not applicable.
Collapse
Affiliation(s)
- Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Robert E Freundlich
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Mark J Rice
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Brent A Dunworth
- Department of Anesthesiology, Vanderbilt University Medical Center, United States
| | - Warren S Sandberg
- Department of Anesthesiology, Department of Biomedical Informatics, Department of Surgery, Vanderbilt University Medical Center, United States
| | - Michael S Higgins
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States
| | - Jonathan P Wanderer
- Department of Anesthesiology, Department of Biomedical Informatics, Vanderbilt University Medical Center, United States.
| |
Collapse
|
2
|
Sowerbutts AM, Burden S, Sremanakova J, French C, Knight SR, Harrison EM. Preoperative nutrition therapy in people undergoing gastrointestinal surgery. Cochrane Database Syst Rev 2024; 4:CD008879. [PMID: 38588454 PMCID: PMC11001290 DOI: 10.1002/14651858.cd008879.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
BACKGROUND Poor preoperative nutritional status has been consistently linked to an increase in postoperative complications and worse surgical outcomes. We updated a review first published in 2012. OBJECTIVES To assess the effects of preoperative nutritional therapy compared to usual care in people undergoing gastrointestinal surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases and two trial registries on 28 March 2023. We searched reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) of people undergoing gastrointestinal surgery and receiving preoperative nutritional therapy, including parenteral nutrition, enteral nutrition or oral nutrition supplements, compared to usual care. We only included nutritional therapy that contained macronutrients (protein, carbohydrate and fat) and micronutrients, and excluded studies that evaluated single nutrients. We included studies regardless of the nutritional status of participants, that is, well-nourished participants, participants at risk of malnutrition, or mixed populations. We excluded studies in people undergoing pancreatic and liver surgery. Our primary outcomes were non-infectious complications, infectious complications and length of hospital stay. Our secondary outcomes were nutritional aspects, quality of life, change in macronutrient intake, biochemical parameters, 30-day perioperative mortality and adverse effects. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. We assessed risk of bias using the RoB 1 tool and applied the GRADE criteria to assess the certainty of evidence. MAIN RESULTS We included 16 RCTs reporting 19 comparisons (2164 participants). Seven studies were new for this update. Participants' ages ranged from 21 to 79 years, and 62% were men. Three RCTs used parenteral nutrition, two used enteral nutrition, eight used immune-enhancing nutrition and six used standard oral nutrition supplements. All studies included mixed groups of well-nourished and malnourished participants; they used different methods to identify malnutrition and reported this in different ways. Not all the included studies were conducted within an Enhanced Recovery After Surgery (ERAS) programme, which is now current clinical practice in most hospitals undertaking GI surgery. We were concerned about risk of bias in all the studies and 14 studies were at high risk of bias due to lack of blinding. We are uncertain if parenteral nutrition has any effect on the number of participants who had a non-infectious complication (risk ratio (RR) 0.61, 95% confidence interval (CI) 0.36 to 1.02; 3 RCTs, 260 participants; very low-certainty evidence); infectious complication (RR 0.98, 95% CI 0.53 to 1.80; 3 RCTs, 260 participants; very low-certainty evidence) or length of hospital stay (mean difference (MD) 5.49 days, 95% CI 0.02 to 10.96; 2 RCTs, 135 participants; very low-certainty evidence). None of the enteral nutrition studies reported non-infectious complications as an outcome. The evidence is very uncertain about the effect of enteral nutrition on the number of participants with infectious complications after surgery (RR 0.90, 95% CI 0.59 to 1.38; 2 RCTs, 126 participants; very low-certainty evidence) or length of hospital stay (MD 5.10 days, 95% CI -1.03 to 11.23; 2 RCTs, 126 participants; very low-certainty evidence). Immune-enhancing nutrition compared to controls may result in little to no effect on the number of participants experiencing a non-infectious complication (RR 0.79, 95% CI 0.62 to 1.00; 8 RCTs, 1020 participants; low-certainty evidence), infectious complications (RR 0.74, 95% CI 0.53 to 1.04; 7 RCTs, 925 participants; low-certainty evidence) or length of hospital stay (MD -1.22 days, 95% CI -2.80 to 0.35; 6 RCTs, 688 participants; low-certainty evidence). Standard oral nutrition supplements may result in little to no effect on number of participants with a non-infectious complication (RR 0.90, 95% CI 0.67 to 1.20; 5 RCTs, 473 participants; low-certainty evidence) or the length of hospital stay (MD -0.65 days, 95% CI -2.33 to 1.03; 3 RCTs, 299 participants; low-certainty evidence). The evidence is very uncertain about the effect of oral nutrition supplements on the number of participants with an infectious complication (RR 0.88, 95% CI 0.60 to 1.27; 5 RCTs, 473 participants; very low-certainty evidence). Sensitivity analysis based on malnourished and weight-losing participants found oral nutrition supplements may result in a slight reduction in infections (RR 0.58, 95% CI 0.40 to 0.85; 2 RCTs, 184 participants). Studies reported some secondary outcomes, but not consistently. Complications associated with central venous catheters occurred in RCTs involving parenteral nutrition. Adverse events in the enteral nutrition, immune-enhancing nutrition and standard oral nutrition supplements RCTs included nausea, vomiting, diarrhoea and abdominal pain. AUTHORS' CONCLUSIONS We were unable to determine if parenteral nutrition, enteral nutrition, immune-enhancing nutrition or standard oral nutrition supplements have any effect on the clinical outcomes due to very low-certainty evidence. There is some evidence that standard oral nutrition supplements may have no effect on complications. Sensitivity analysis showed standard oral nutrition supplements probably reduced infections in weight-losing or malnourished participants. Further high-quality multicentre research considering the ERAS programme is required and further research in low- and middle-income countries is needed.
Collapse
Affiliation(s)
- Anne Marie Sowerbutts
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Sorrel Burden
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Jana Sremanakova
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Chloe French
- School of Health Sciences, The University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen R Knight
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
3
|
Power S, Maarof A, Power A, Feehan S, Whelan M. Nutritional risk predicts postoperative complications and length of stay, whereas sarcopenia risk predicts need for step-down care in a mixed elective surgery population. J Hum Nutr Diet 2024; 37:308-315. [PMID: 37908178 DOI: 10.1111/jhn.13256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Malnutrition and poor functional reserves place patients at risk for negative surgical outcomes. In this prospective study we aimed to measure preoperative nutritional and sarcopenia risk and evaluate their impact on postoperative outcomes. METHODS Adults scheduled to undergo elective general and gastrointestinal surgery were screened for nutrition risk using the Malnutrition Universal Screening Tool screening tool. Sarcopenia risk was measured using the SARC-F tool and hand-grip strength. Patients were followed postoperatively. Incidence of complications, length of stay (LOS), readmission rates, and need for step-down care were recorded. RESULTS One hundred and twenty-two patients were included. Mean age was 53.8 years (standard deviation [SD] 16.44). Sixty-six (54%) were scheduled for day-case procedures, and 56 (46%) for nonday-case procedures. About 18.9% (n = 23) were at nutritional risk preoperatively. Ten patients (8.2%) had probable sarcopenia based on SARC-F, whereas seven (5.7%) had measurably reduced HG. Incidence of postoperative complications was 23.8% (n = 29). Nutrition risk was associated with the development of complications (p = 0.018). In the nonday-case group, nutritional risk was associated with greater LOS (p = 0.013). Older age was associated with need for step-down care (p = 0.002) as was SARC-F (p = 0.003). CONCLUSIONS Preoperative nutritional screening can predict postoperative complications and LOS, whereas sarcopenia screening is predictive of the need for step-down care after discharge. Screening tools are quick and inexpensive and could provide valuable information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes.
Collapse
Affiliation(s)
- Siobhán Power
- Department of Nutrition and Dietetics, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Asryaf Maarof
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Aoibheann Power
- UCD School of Agriculture and Food Science, University College Dublin, Belfield, Dublin, Ireland
| | - Sinéad Feehan
- Department of Nutrition and Dietetics, Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland
| |
Collapse
|
4
|
Reed WT, Jiang R, Ohnuma T, Kahmke RR, Pyati S, Krishnamoorthy V, Raghunathan K, Osazuwa-Peters N. Malnutrition and Adverse Outcomes After Surgery for Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024; 150:14-21. [PMID: 37883116 PMCID: PMC10603580 DOI: 10.1001/jamaoto.2023.3486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/10/2023] [Indexed: 10/27/2023]
Abstract
Importance Patients with head and neck cancer (HNC) have an increased risk of malnutrition, partly due to disease location and treatment sequelae. Although malnutrition is associated with adverse outcomes, there is little data on the extent of outcomes and the sociodemographic factors associated with malnutrition in patients with HNC. Objectives To investigate the association of race, ethnicity, and payer type with perioperative malnutrition in patients undergoing HNC surgery and how malnutrition affects clinical outcomes. Design, Setting, and Participants This retrospective cohort study used data from the Premier Healthcare Database to assess adult patients who had undergone HNC surgery from January 2008 to June 2020 at 482 hospitals across the US. Diagnosis and procedure codes were used to identify a subset of patients with perioperative malnutrition. Patient characteristics, payer types, and hospital outcomes were then compared to find associations among race, ethnicity, payer type, malnutrition, and clinical outcomes using multivariable logistic regression models. Analyses were performed from August 2022 to January 2023. Exposures Race, ethnicity, and payer type for primary outcome, and perioperative malnutrition status, race, ethnicity, and payer type for secondary outcomes. Main Outcomes and Measures Perioperative malnutrition status. Secondary outcomes were discharge to home after surgery, hospital length of stay (LOS), total cost, and postoperative pulmonary complications (PPCs). Results The study population comprised 13 895 adult patients who had undergone HNC surgery during the study period; they had a mean (SD) age of 63.4 (12.1) years; 9425 male (67.8%) patients; 968 Black (7.0%), 10 698 White (77.0%), and 2229 (16.0%) individuals of other races; and 887 Hispanic (6.4%) and 13 008 non-Hispanic (93.6%) individuals. Among the total sample, there were 3136 patients (22.6%) diagnosed with perioperative malnutrition. Compared with White patients and patients with private health insurance, the odds of malnutrition were higher for non-Hispanic Black patients (adjusted odds ratio [aOR], 1.31; 95% CI, 1.11-1.56), Medicaid-insured patients (aOR, 1.68; 95% CI, 1.46-1.95), and Medicare-insured patients (aOR, 1.24; 95% CI, 1.10-1.73). Black patients and patients insured by Medicaid had increased LOS, costs, and PPCs, and lower rates of discharge to home. Malnutrition was independently associated with increased LOS (β, 5.20 additional days; 95% CI, 4.83-5.64), higher costs (β, $15 722 more cost; 95% CI, $14 301-$17 143), increased odds of PPCs (aOR, 2.04; 95% CI, 1.83-2.23), and lower odds of discharge to home (aOR, 0.34; 95% CI, 0.31-0.38). No independent association between malnutrition and mortality was observed. Conclusions and Relevance This retrospective cohort study found that 1 in 5 patients undergoing HNC surgery were malnourished. Malnourishment disproportionately affected Black patients and patients with Medicaid, and contributed to longer hospital stays, higher costs, and more postoperative complications.
Collapse
Affiliation(s)
- William T. Reed
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
| | - Rong Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Russel R. Kahmke
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
| | - Shreyas Pyati
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Karthik Raghunathan
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University Health System, Durham, North Carolina
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
| |
Collapse
|
5
|
Nasrollahi TS, Shahrestani S, Borrelli M, Hopp ML, Wu AW, Tang DM, Yu JS. The Influence of Modifiable Risk Factors on Postoperative Outcomes in Patients Receiving Surgery for Resection for Acoustic Neuroma. EAR, NOSE & THROAT JOURNAL 2023:1455613231191020. [PMID: 37605484 DOI: 10.1177/01455613231191020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
Acoustic neuromas are the most common tumor of the cerebellopontine angle that are associated with a number of symptoms that negatively impact a patient's quality of life. While the mainstay of treatment for these benign tumors remains microsurgical resection, there is limited research exploring how certain modifiable risk factors (MRFs) may affect the perioperative course. The purpose of this study was to investigate how MRFs including malnutrition, obesity, dyslipidemia, uncontrolled hypertension, and smoking may affect postoperative rates of readmission and nonroutine discharges. We utilized the 2016 and 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database. MRFs were queried using appropriate International Classification of Diseases, Tenth Revision (ICD-10) coding for categories including malnutrition, obesity, dyslipidemia, smoking, alcohol, and hypertension. The statistical analysis was done using RStudio (Version 1.3.959). Chi-squared tests were done to evaluate differences between categorical variables. The Mann-Whitney U-testing was utilized to evaluate for statistically significant differences in continuous data. The "Epitools" package was used to develop logistic regression models for postoperative complications and post hoc receiver operating characteristic curves were developed. Pertaining to nonroutine discharge, predictive models using malnutrition outperformed all other MRFs as well as those with no MRFs (P < .05). In the case of readmission, models using malnutrition outperformed those of obesity and smoking (P < .05). Again, an increase in predictive power is seen in models using dyslipidemia when compared to obesity, smoking, or uncontrolled hypertension. Lastly, models using no MRFs outperformed those of obesity, smoking, and uncontrolled hypertension (P < .05). This is the first study of its kind to evaluate the role of MRFs in those undergoing surgical resection of their acoustic neuroma. We concluded that certain MRFs may play a role in complicating a patient's perioperative surgical course.
Collapse
Affiliation(s)
- Tasha S Nasrollahi
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shane Shahrestani
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michela Borrelli
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Martin L Hopp
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Arthur W Wu
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dennis M Tang
- Division of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Sinus Center of Excellence, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - John S Yu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
6
|
Pettit MS, Crowder SL, Ackerman RS, Hafez O, Poch MA, Patel SY. Preoperative Nutritional Status and Enhanced Recovery after Surgery (ERAS) Prior to Radical Cystectomy: A Review of the Literature. Nutr Cancer 2023; 75:1743-1751. [PMID: 37553951 DOI: 10.1080/01635581.2023.2244172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
Preoperative nutritional status is an important and modifiable risk factor of a patient's recovery and outcome after radical cystectomy. There are multiple malnutrition screening tools and treatment options. In this review, we discuss the best indicators of this condition and how to optimize nutrition status prior to radical cystectomy.
Collapse
Affiliation(s)
- Matthew S Pettit
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Sylvia L Crowder
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Robert S Ackerman
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Osama Hafez
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Sephalie Y Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| |
Collapse
|
7
|
Pigeon CA, Frigault J, Drolet S, Roy ÈM, Bujold-Pitre K, Courval V. Emergency Colon Resection in the Geriatric Population: the Modified Frailty Index as a Risk Factor of Early Mortality. J Gastrointest Surg 2023; 27:1677-1684. [PMID: 37407902 DOI: 10.1007/s11605-023-05720-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/20/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Surgical interventions in the elderly are becoming more frequent given the aging of the population. Due to their increased vulnerability in an emergent context, we aimed to evaluate various risk factors associated with an early mortality and an unfavorable postoperative trajectory. METHODS We performed a retrospective, single-center cohort study including patients over the age of 75 who underwent emergency colon resection between January 2016 and December 2020. RESULTS Among 299 patients included, the type of resection most frequently encountered was right hemicolectomy (34%). Large bowel obstruction was the surgical indication for 61% of patients (n = 182). The mortality rate within 30 days of primary surgery was 14% (n = 42). The main factors having a significant impact on early mortality were the modified Frailty Index (mFI) (26% vs 4%; p < 0.001), Charlson comorbidity index (CCI) (20 vs 0%; p = 0.03) and surgical indication (36% vs 11%; p = 0.03). No statistically significant difference was observed according to the age of the patients. Patients with a higher mFI ([Formula: see text] 3) had an increased risk of early mortality with an odds ratio (OR) of 11.94 (95%CI: 2.38-59.88; p < 0.001) in multivariate analysis. This association was also observed for the secondary outcomes, as patients with a higher mFI were less likely to return home (59% vs 32%; p = 0.009) and have their stoma closured at the end of the follow-up period (94% vs 33%; p < 0.001). CONCLUSION In the geriatric population, the use of mFI is a good predictor of early mortality following an emergency colon resection. This accessible tool could be used to guide the surgical decision-making.
Collapse
Affiliation(s)
| | - Jonathan Frigault
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | - Sébastien Drolet
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | - Ève-Marie Roy
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| | | | - Valérie Courval
- Surgery Department, CHU de Quebec - Laval University, Quebec, Canada
| |
Collapse
|
8
|
Sanchez Leon RM, Rajaraman A, Kubwimana MN. Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention. Methodist Debakey Cardiovasc J 2023; 19:85-96. [PMID: 37547903 PMCID: PMC10402792 DOI: 10.14797/mdcvj.1248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/16/2023] [Indexed: 08/08/2023] Open
Abstract
In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.
Collapse
|
9
|
Durán Poveda M, Suárez-de-la-Rica A, Cancer Minchot E, Ocón Bretón J, Sánchez Pernaute A, Rodríguez Caravaca G. The Prevalence and Impact of Nutritional Risk and Malnutrition in Gastrointestinal Surgical Oncology Patients: A Prospective, Observational, Multicenter, and Exploratory Study. Nutrients 2023; 15:3283. [PMID: 37513700 PMCID: PMC10385494 DOI: 10.3390/nu15143283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
A prospective, observational, multicenter, and exploratory study was conducted in 469 gastrointestinal cancer patients undergoing elective surgery. The Malnutrition Universal Screening Tool (MUST) and the Global Leadership Initiative on Malnutrition (GLIM) criteria were used to assess nutritional risk. On admission, 17.9% and 21.1% of patients were at moderate (MUST score 1) and severe (MUST score ≥ 2) nutritional risk, respectively. The GLIM criteria used in patients with a MUST score ≥ 2 showed moderate malnutrition in 35.3% of patients and severe in 64.6%. Forty-seven percent of patients with a MUST score ≥ 2 on admission had the same score at discharge, and 20.7% with a MUST score 0 had moderate/severe risk at discharge. Small bowel, esophageal, and gastric cancer and diabetes were predictors of malnutrition on admission. Complications were significantly higher among patients with a MUST score 1 or ≥2 either on admission (p = 0.001) or at discharge (p < 0.0001). In patients who received nutritional therapy (n = 231), 43% continued to have moderate/severe nutritional risk on discharge, and 54% of those with MUST ≥ 2 on admission maintained this score at discharge. In gastrointestinal cancer patients undergoing elective surgery, there is an urgent need for improving nutritional risk screening before and after surgery, as well as improving nutritional therapy during hospitalization.
Collapse
Affiliation(s)
- Manuel Durán Poveda
- Department of General and Digestive Surgery, Hospital Universitario Rey Juan Carlos, 28933 Madrid, Spain
- Department of Medical Specialties and Public Health, Faculty of Health Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
| | - Alejandro Suárez-de-la-Rica
- Department of Anesthesiology and Surgical Critical Care, Hospital Universitario La Princesa, 28006 Madrid, Spain
| | - Emilia Cancer Minchot
- Department of Endocrinology and Nutrition, Hospital Universitario de Fuenlabrada, 28942 Madrid, Spain
| | - Julia Ocón Bretón
- Department of Endocrinology and Nutrition, Hospital Universitario "Lozano Blesa", 50009 Zaragoza, Spain
| | - Andrés Sánchez Pernaute
- Department of General and Digestive Surgery, Hospital Clínico San Carlos, 28040 Madrid, Spain
| | - Gil Rodríguez Caravaca
- Department of Medical Specialties and Public Health, Faculty of Health Sciences, Rey Juan Carlos University, 28933 Madrid, Spain
- Department of Preventive Medicine, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain
| |
Collapse
|
10
|
Salas De Armas IA, Bergeron A, Akkanti B, Akay MH, Scovell A, Patel MK, Patel J, Bhardwaj A, Al Rameni D, Marcano J, Nascimbene A, Kar B, Gregoric ID. Use of Percutaneous Left Ventricular Assist Device Before Durable Device Implantation in Patients With Cardiac Cachexia: Case Series. ASAIO J 2023; 69:e354-e359. [PMID: 37039827 DOI: 10.1097/mat.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Frailty and malnutrition in patients with heart failure are barriers to durable left ventricular assist device (D-LVAD) support and heart transplantation. Moreover, cachexia in patients with advanced heart failure carries a high mortality risk. There are no guidelines for these patients other than increased caloric intake and rehabilitation. Patients suffering from cardiac cachexia and heart failure may benefit from temporary, percutaneous assist device support to improve the underlying heart disease and reverse the catabolic state. We retrospectively reviewed patients from January 2017 to January 2022. All patients who received Impella support (5.0 or 5.5, Abiomed) before D-LVAD implantation were screened. Those who met the criteria for cardiac cachexia were included. Patient demographics, nutritional and biochemical markers, and survival data were collected. A total of 14 patients were included. The majority of patients were male (85.7%) with ischemic cardiomyopathy (64.3%). Caloric intake, physical strength, and ambulation improved. Prealbumin levels improved from a median of 13.7-18.0 mg/dl ( p < 0.006) while on Impella 5.0 or 5.5 support. All patients survived to discharge and the 6 month follow-up. In conclusion, use of the Impella device improves cardiogenic shock symptoms and, consequently, may improve cachexia status prior to D-LVAD implantation.
Collapse
Affiliation(s)
- Ismael A Salas De Armas
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Amanda Bergeron
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| | - Bindu Akkanti
- Divisions of Pulmonary, Critical Care, and Sleep, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Mehmet H Akay
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Alison Scovell
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas
| | - Manish K Patel
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Jayeshkumar Patel
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Anju Bhardwaj
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Dina Al Rameni
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Juan Marcano
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Angelo Nascimbene
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Biswajit Kar
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Igor D Gregoric
- From the Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas
| |
Collapse
|
11
|
Azbell RCG, Lanzkron SM, Desai PC. Current Evidence and Rationale to Guide Perioperative Management, Including Transfusion Decisions, in Patients With Sickle Cell Disease. Anesth Analg 2023; 136:1107-1114. [PMID: 37205803 DOI: 10.1213/ane.0000000000006463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Sickle cell disease (SCD) is a collection of inherited hemoglobin disorders that results in chronic hemolytic anemia, vaso-occlusion, pain, and end organ damage. Surgery in the SCD population requires careful planning, as perioperative stressors can lead to increased sickling and risk of inducing or further exacerbating vaso-occlusive episodes (VOEs). Additionally, the underlying hypercoagulability and immunocompromised state due to SCD places patients at increased risk of both venous thromboembolism and infection. Judicious fluid administration, temperature regulation, thorough preoperative and postoperative analgesic planning, and preoperative transfusion are all crucial components of decreasing risks of surgery in patients with SCD.
Collapse
Affiliation(s)
- Roberta C G Azbell
- From the Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sophie M Lanzkron
- Department of Internal Medicine, Division of Hematology, Johns Hopkins School of Medicine
| | - Payal C Desai
- Department of Internal Medicine, Division of Hematology, The Ohio State Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
12
|
Halle-Smith JM, Powell-Brett SF, Hall LA, Duggan SN, Griffin O, Phillips ME, Roberts KJ. Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients. Cancers (Basel) 2023; 15:cancers15092466. [PMID: 37173931 PMCID: PMC10177139 DOI: 10.3390/cancers15092466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.
Collapse
Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sarah F Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Lewis A Hall
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| | - Sinead N Duggan
- Department of Surgery, Trinity College Dublin, University of Dublin, Tallaght University Hospital, D24 NR0A Dublin, Ireland
| | - Oonagh Griffin
- Department of Nutrition and Dietetics, St. Vincent's University Hospital, D04 T6F4 Dublin, Ireland
| | - Mary E Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital, Guildford GU2 7XX, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TH, UK
| |
Collapse
|
13
|
Williams DGA, Miller TE. Nutrition screening and therapy in the older surgical patient: an area that is ignored. Int Anesthesiol Clin 2023; 61:29-33. [PMID: 36815485 DOI: 10.1097/aia.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- David G A Williams
- Duke University School of Medicine, Duke University Health System, Durham, North Carolina
| | | |
Collapse
|
14
|
Oleru OO, Seyidova N, Taub PJ. A Nationally Validated Novel Risk Assessment Calculator for Prediction of Unplanned Reoperations and Readmissions in Hand Surgery. J Plast Reconstr Aesthet Surg 2023; 81:42-52. [PMID: 37084533 DOI: 10.1016/j.bjps.2023.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Risk predictors are an emerging tool as the need for individualized risk estimation in clinical decision-making persists. Existing risk indices have had limited success in accurately predicting hand surgery risks. This study provides a novel risk calculator for reliably predicting reoperations and readmissions in hand surgery. METHODS Hand surgeries from the National Surgical Quality Improvement Program (NSQIP) 2012-2019 database were identified. Independent predictors of 30-day unplanned reoperation and readmission were identified in the modeling sample (2012-2019) and subsequently weighted to generate a Novel Risk Score (NRS). The NRS was validated on a 2020 NSQIP hand surgery cohort and compared to the modified frailty index (mFI-5) and the modified Charlson Comorbidity Index (mCCI) with receiver operating characteristics (ROC) analysis. RESULTS Eighty-three thousand four hundred nine hand surgeries were identified for modeling. Reoperations and readmissions rates were 1.1% and 1.3%, respectively. Independent risk factors included male gender, inpatient status, smoking, dialysis dependence, transfusion within 72 h of surgery, wound classification, ASA class, diabetes mellitus, CHF, sepsis or septic shock, emergent case, and operative time longer than 75 min (all P < 0.05). ROC analysis of the 2020 cohort rendered an area under the curve (AUC) of 0.730, which demonstrates the accuracy of this prediction model. The mFI-5 and mCCI rendered AUCs of 0.580 and 0.585, respectively. CONCLUSION We present a validated risk prediction tool for unplanned reoperations and readmissions following hand surgery that outperforms the mFI-5 and mCCI that are available online. Future studies should evaluate clinical efficacy.
Collapse
|
15
|
Veith SB, Nickl R, Rössel T, Lachmann B, Koch T, Richter T. Hemodynamics and cutaneous microcirculation during induction of general anesthesia with and without esketamine. Clin Hemorheol Microcirc 2023; 84:385-398. [PMID: 37334583 DOI: 10.3233/ch-231711] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVE Currently, there are limited data on the effect of macrocirculatory hemodynamic changes on human microcirculation, especially during the induction of general anesthesia (GA). METHODS We performed a non-randomized observational trial on patients receiving GA for elective surgery. In the control group (CG), for GA induction sufentanil, propofol, and rocuronium was administered. Patients assigned to the esketamine group (EG) received additional esketamine for GA induction. Invasive blood pressure (IBP) and pulse contour cardiac output (CO) measurement were performed continuously. Microcirculation was assessed using cutaneous Laser Doppler Flowmetry (forehead and sternum LDF), peripheral and central Capillary Refill Time (pCRT, cCRT), as well as brachial temperature gradient (Tskin-diff) at baseline, 5, 10 and 15 minutes after induction of GA. RESULTS 42 patients were included in the analysis (CG n = 22, EG n = 20). pCRT, cCRT, Tskin-diff, forehead and sternum LDF decreased following GA induction in both groups. IBP and CO were significantly more stable in esketamine group. However, the changes in the microcirculatory parameters were not significantly different between the groups. CONCLUSIONS The addition of esketamine for GA induction warranted better hemodynamic stability for the first five minutes, but had no significant effect on any of the cutaneous microcirculatory parameters measured.
Collapse
Affiliation(s)
- Sarah Berger Veith
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Rosa Nickl
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Thomas Rössel
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Björn Lachmann
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Thea Koch
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| | - Torsten Richter
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
16
|
Ścisło L, Bodys-Cupak I, Walewska E, Kózka M. Nutritional Status Indicators as Predictors of Postoperative Complications in the Elderly with Gastrointestinal Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13453. [PMID: 36294035 PMCID: PMC9603671 DOI: 10.3390/ijerph192013453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
In patients scheduled for surgery, nutritional disorders worsen during the perioperative period, which is often a risk factor for postoperative complications. The aim of the study was to determine relationship between the preoperative nutritional status of elderly people with stomach, pancreatic and colon cancer and the incidence of postoperative complications and the length of hospital stay. The study included 143 patients with gastrointestinal cancer, aged 65-68, qualified for surgery. Mini Nutritional Assessment, body mass index questionnaires and medical records were used. Malnutrition was found in 9.8%, and a risk of malnutrition in 53.5% of the respondents. Body mass index showed overweight in 28% and obesity in 14% of the patients. Complications occurred in all types of nutritional status, the most common were those requiring intensive care unit treatment (36.8%), pancreatic and biliary fistulas (29.4%) and surgical site infections (58.2%). Gastric cancer patients at risk of malnutrition stayed longer in the hospital. Postoperative complications and longer hospital stays were observed more frequently in cases of overweight, obesity, malnutrition and its risk. Disturbances in the nutritional status, in the form of malnutrition and its risk, as well as overweight and obesity, determined more frequent occurrence of postoperative complications and longer hospital stay.
Collapse
Affiliation(s)
- Lucyna Ścisło
- Department of Clinical Nursing, Faculty of Health Sciences, Institute of Nursing and Midwifery, Jagiellonian University Medical College, 31-501 Krakow, Poland
| | - Iwona Bodys-Cupak
- Laboratory of Theory and Fundamentals of Nursing, Faculty of Health Sciences, Institute of Nursing and Midwifery, Jagiellonian University Medical College, 31-126 Krakow, Poland
| | - Elżbieta Walewska
- Department of Clinical Nursing, Faculty of Health Sciences, Institute of Nursing and Midwifery, Jagiellonian University Medical College, 31-501 Krakow, Poland
| | - Maria Kózka
- Department of Clinical Nursing, Faculty of Health Sciences, Institute of Nursing and Midwifery, Jagiellonian University Medical College, 31-501 Krakow, Poland
| |
Collapse
|
17
|
Burden ST, Bibby N, Donald K, Owen K, Rowlinson-Groves K, French C, Gillespie L, Murphy J, Hurst SJ, Mentha R, Baguley K, Rowlands A, McEwan K, Moore J, Merchant Z. Nutritional screening in a cancer prehabilitation programme: A cohort study. J Hum Nutr Diet 2022; 36:384-394. [PMID: 35775402 DOI: 10.1111/jhn.13057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/16/2022] [Accepted: 06/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cancer patients are often malnourished pre-operatively. Study aims were to establish if current screening was appropriate for use in prehabilitation and investigate any association between nutritional risk, functionality and quality of life (QoL). METHODS This cohort study used routinely collected data from September 2020 to August 2021 from patients in a Prehab4cancer programme. Included patients were aged >18 years, had colorectal, lung or oesophago-gastric cancer and were scheduled for surgery. Nutritional assessment included patient generated subjective global assessment (PG-SGA) short-form and QoL with a sit-to-stand test. Association between nutritional risk and outcomes were analysed using adjusted logistic regression. RESULTS From 928 patients referred to Prehab4Cancer service over 12-months, data on nutritional risk were collected from 526 patients. Pre-operatively, 233 out of 526 (44%) patients were at nutritional risk (score ≥2). During prehabilitation, 31% of patients improved their PG-SGA and 74% of patients maintained or improved their weight. Odds ratios (OR) with confidence intervals (CI) showed that patients with better QoL using EuroQol-5 Dimensions (OR 0.05, 95% CI 0.01, 0.45, P=0.01), EuroQol Visual Analogue Scale (OR 0.96, 95% CI 0.93, 1.00, p=0.04) or sit-to-stand (OR 0.96, 95% 0.93, 1.00, p=0.04) were less likely to be nutritional at risk. CONCLUSION Nearly half of patients in Prehab4Cancer programme assessed using PG-SGA were at risk of malnutrition. However, almost half of the sample did not have their risk assessed. Patients at risk of malnutrition were more likely to have a poorer QoL and sit-to-stand test than those who were not at risk. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Sorrel T Burden
- School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Salford Royal Hospital, Northern Care Alliance Foundation Trust, Scott Lane, Salford, M6 8HD
| | - Neil Bibby
- Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL
| | - Kirsty Donald
- Salford Royal Hospital, Northern Care Alliance Foundation Trust, Scott Lane, Salford, M6 8HD
| | - Kellie Owen
- Salford Royal Hospital, Northern Care Alliance Foundation Trust, Scott Lane, Salford, M6 8HD
| | | | - Chloe French
- School of Health Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Loraine Gillespie
- The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX
| | - Jack Murphy
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| | - Sarah Jayne Hurst
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| | - Robert Mentha
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| | - Karly Baguley
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| | - Ash Rowlands
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| | - Karen McEwan
- Primary Care Lead for GM Cancer Prehab4Cancer, UK
| | - John Moore
- Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL
| | - Zoe Merchant
- Prehab4Cancer GM Cancer Alliance, Christie NHS Foundation trust, Greater Manchester, UK
| |
Collapse
|
18
|
Zhang XM, Wu XJ, Cao J, Guo N, Bo HX, Ma YF, Jiao J, Zhu C. Effect of the Age-Adjusted Charlson Comorbidity Index on All-Cause Mortality and Readmission in Older Surgical Patients: A National Multicenter, Prospective Cohort Study. Front Med (Lausanne) 2022; 9:896451. [PMID: 35836941 PMCID: PMC9274287 DOI: 10.3389/fmed.2022.896451] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIdentifying a high-risk group of older people before surgical procedures is very important. The study aimed to explore the association between the age-adjusted Charlson comorbidity index (ACCI) and all-cause mortality and readmission among older Chinese surgical patients (age ≥65 years).MethodsA large-scale cohort study was performed in 25 general public hospitals from six different geographic regions of China. Trained registered nurses gathered data on clinical and sociodemographic characteristics. All-cause mortality was recorded when patients died during hospitalization or during the 90-day follow-up period. Readmission was also tracked from hospital discharge to the 90-day follow-up. The ACCI, in assessing comorbidities, was categorized into two groups (≥5 vs. <5). A multiple regression model was used to examine the association between the ACCI and all-cause mortality and readmission.ResultsThere were 3,911 older surgical patients (mean = 72.46, SD = 6.22) in our study, with 1,934 (49.45%) males. The average ACCI score was 4.77 (SD = 1.99), and all-cause mortality was 2.51% (high ACCI = 5.06% vs. low ACCI = 0.66%, P < 0.001). After controlling for all potential confounders, the ACCI score was an independent risk factor for 90-day hospital readmission (OR = 1.18, 95% CI: 1.14, 1.23) and 90-day all-cause mortality (OR = 1.26, 95% CI: 1.16–1.36). Furthermore, older surgical patients with a high ACCI (≥5) had an increased risk of all-cause mortality (OR = 6.13, 95% CI: 3.17, 11.85) and readmission (OR = 2.13, 95% CI: 1.78, 2.56) compared to those with a low ACCI (<5). The discrimination performance of the ACCI was moderate for mortality (AUC:0.758, 95% CI: 0.715–0.80; specificity = 0.591, sensitivity = 0.846) but poor for readmission (AUC: 0.627, 95% CI: 0.605–0.648; specificity = 0.620; sensitivity = 0.590).ConclusionsThe ACCI is an independent risk factor for all-cause mortality and hospital readmission among older Chinese surgical patients and could be a potential risk assessment tool to stratify high-risk older patients for surgical procedures.
Collapse
|
19
|
Towards interpretable, medically grounded, EMR-based risk prediction models. Sci Rep 2022; 12:9990. [PMID: 35705550 PMCID: PMC9200841 DOI: 10.1038/s41598-022-13504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/18/2022] [Indexed: 11/08/2022] Open
Abstract
Machine-learning based risk prediction models have the potential to improve patient outcomes by assessing risk more accurately than clinicians. Significant additional value lies in these models providing feedback about the factors that amplify an individual patient's risk. Identification of risk factors enables more informed decisions on interventions to mitigate or ameliorate modifiable factors. For these reasons, risk prediction models must be explainable and grounded on medical knowledge. Current machine learning-based risk prediction models are frequently 'black-box' models whose inner workings cannot be understood easily, making it difficult to define risk drivers. Since machine learning models follow patterns in the data rather than looking for medically relevant relationships, possible risk factors identified by these models do not necessarily translate into actionable insights for clinicians. Here, we use the example of risk assessment for postoperative complications to demonstrate how explainable and medically grounded risk prediction models can be developed. Pre- and postoperative risk prediction models are trained based on clinically relevant inputs extracted from electronic medical record data. We show that these models have similar predictive performance as models that incorporate a wider range of inputs and explain the models' decision-making process by visualizing how different model inputs and their values affect the models' predictions.
Collapse
|
20
|
Kisana H, Hui CH, Deeyor S, Martin JR, Stecher C, Hustedt JW. Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery. Orthopedics 2022; 45:139-144. [PMID: 35201937 DOI: 10.3928/01477447-20220217-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].
Collapse
|
21
|
A Qualitative Exploration of Nutrition Screening, Assessment and Oral Support Used in Patients Undergoing Cancer Surgery in Low- and Middle-Income Countries. Nutrients 2022; 14:nu14040863. [PMID: 35215513 PMCID: PMC8876193 DOI: 10.3390/nu14040863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022] Open
Abstract
Preoperative undernutrition is a prognostic indicator for postoperative mortality and morbidity. Evidence suggests that treating undernutrition can improve surgical outcomes. This study explored the provision of nutritional screening, assessment and support on surgical cancer wards in low- and middle-income countries (LMICs). This was a qualitative study and participants took part in one focus group or one individual interview. Data were analysed thematically. There were 34 participants from Ghana, India, the Philippines and Zambia: 24 healthcare professionals (HCPs) and 10 patients. Results showed that knowledge levels and enthusiasm were high in HCPs. Barriers to adequate nutritional support were a lack of provision of ward and kitchen equipment, food and sustainable nutritional supplements. There was variation across countries towards nutritional screening and assessment which seemed to be driven by resources. Many hospitals where resources were scarce focused on the care of individual patients in favour of an integrated systems approach to identify and manage undernutrition. In conclusion, there is scope to improve the efficiency of nutritional management of surgical cancer patients in LMICs through the integration of nutrition assessment and support into routine hospital policies and procedures, moving from case management undertaken by interested personnel to a system-based approach including the whole multidisciplinary team.
Collapse
|
22
|
Association of Nutritional Status with New-Onset Delirium in Elderly, Acute Care, Orthopaedic Trauma Patients: A Single-Center Observational Study. J Orthop Trauma 2022; 36:67-72. [PMID: 35061654 DOI: 10.1097/bot.0000000000002213] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether nutritional status at hospital admission is independently associated with new-onset delirium (NOD) in elderly, orthopaedic trauma patients. DESIGN Single-center, retrospective, cross-sectional study. SETTING Data from patients at a large teaching hospital in Boston, MA, were analyzed. PATIENTS All patients were ≥65 years and hospitalized for acute surgical management of their major fractures after trauma. INTERVENTION None. MAIN OUTCOME MEASUREMENT Nutritional status was assessed at admission using the Mini Nutritional Assessment-Short Form (MNA-SF). Delirium was assessed using the Confusion Assessment Method within 24 hours of admission and daily throughout hospitalization. RESULTS The incidence of delirium was 20% (94/471). Each unit decrement in MNA-SF was associated with a 14% higher risk of NOD (adjusted OR 1.14; 95% CI 1.05-1.28). Moreover, malnourished patients (MNA-SF score 0-7) were twice as likely to develop NOD (adjusted OR 2.07; 95% CI 1.01-4.35) compared with patients who were not malnourished (MNA-SF score 8-14). CONCLUSIONS In hospitalized, elderly, orthopaedic trauma patients, poor nutritional status may be a modifiable risk factor for NOD. Future studies are needed to determine whether aggressive nutritional interventions can reduce the incidence of NOD and improve outcomes in this cohort of patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
23
|
Analysis of the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) Database to Identify Factors Associated with Postoperative Mortality After Elective Non-cardiac Surgery. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03249-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
24
|
Williams DGA, Wischmeyer PE. Nutrition Status Optimization for Improved Perioperative Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00504-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
25
|
Gillis C, Ljungqvist O, Carli F. Prehabilitation, enhanced recovery after surgery, or both? A narrative review. Br J Anaesth 2022; 128:434-448. [PMID: 35012741 DOI: 10.1016/j.bja.2021.12.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/03/2021] [Accepted: 12/05/2021] [Indexed: 12/12/2022] Open
Abstract
This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.
Collapse
Affiliation(s)
- Chelsia Gillis
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada
| |
Collapse
|
26
|
Kate V, Raghuraman H, Kavyashree M, Balakrishnan G, Elamurugan TP, Shankar G, Nanda N, Thulasingam M. Comparison of Nutrition Risk Screening 2002 and Subjective Global Assessment for predicting postoperative complications among patients undergoing elective abdominal surgery. INTERNATIONAL JOURNAL OF ADVANCED MEDICAL AND HEALTH RESEARCH 2022. [DOI: 10.4103/ijamr.ijamr_239_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
27
|
Williams DG, Aronson S, Murray S, Fuller M, Villalta E, Haines KL, Wischmeyer P. Validation of the Perioperative Nutrition Screen (PONS) for Prediction of Postoperative Outcomes. JPEN J Parenter Enteral Nutr 2021; 46:1307-1315. [PMID: 34850403 DOI: 10.1002/jpen.2310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Preoperative nutrition risk is often underrecognized and undertreated. The Perioperative Nutrition Screen (PONS) was recently introduced as an efficient tool to rapidly screen for preoperative nutritional risk. The relationship between identification of "nutritional risk" via PONS and adverse outcomes postoperatively remains undescribed. METHODS Preoperative nutrition risk was assessed via PONS from 1/1/2019-9/30/2020. Key clinical outcomes were compared with individual and composite PONS components. RESULTS 3,151 patients with PONS evaluations were analyzed. Multivariate regression analysis adjusted for key co-variates demonstrated positive responses for specific PONS component questions was associated with adverse clinical outcomes as follows: 1) Unplanned weight loss (>10% in 6-months preoperatively) associated with a 22.4% increased length of stay (LOS) (95%CI: 13.3%-32.1%, p<0 .0001) and increased 30-day readmission rate (OR 2.44, 95%CI: 1.73-3.44, p<0.001); 2) History of < 50% of previous oral intake in past week associated with a 25% increased LOS (95%CI: 15.7%-35.2%, p<0.001); 3) Preoperative albumin <3.0g/l associated with a 29.9% increased LOS (p< 0.001) and increased 30-day readmission rate (OR 2.66 (95% CI: 1.63-4.35, p<0.001); 4) Low BMI (<18.5 kg/m2 ≤65 years old or <20 kg/m2 in ≥65 years old) was not associated with increased LOS by adjusted analysis although was predictive by univariate analysis. CONCLUSIONS The PONS and its individual components appear to predict risk of adverse postoperative outcomes, even independent of a validated malnutrition diagnosis. Further studies are needed to assess the impact of specific preoperative nutrition interventions on adverse outcomes predicted by PONS when delivered to patients identified via PONS screen. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
| | - Solomon Aronson
- Departments of Anesthesiology, Duke University School of Medicine.,Population Health, Duke University School of Medicine
| | - Sutton Murray
- Departments of Anesthesiology, Duke University School of Medicine
| | - Matt Fuller
- Departments of Anesthesiology, Duke University School of Medicine
| | | | | | - Paul Wischmeyer
- Departments of Anesthesiology, Duke University School of Medicine
| |
Collapse
|
28
|
The Relationship Between Preoperative Physical Activity With American Society of Anesthesiologists Score and Postoperative Length of Stay in Patients Undergoing Radical Prostatectomy. J Phys Act Health 2021; 19:29-36. [PMID: 34740993 DOI: 10.1123/jpah.2021-0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/15/2021] [Accepted: 09/08/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The relationship between preoperative physical activity (PA) and hospital length of stay (LOS) following radical prostatectomy (RP) is poorly understood. In addition, the relationship between PA and the American Society of Anesthesiologists Physical Status score (ASA PS), an established prognosticator of surgical risk, has not been studied. The authors assessed the relationship between leisure-time PA (LTPA), ASA PS, and LOS in individuals undergoing RP. METHODS This retrospective cohort study was conducted using data from an institutional database. Ordinal logistic regression was used to assess the relationship between preoperative LTPA and physical status as indicated by the ASA PS. Binary logistic regression was used to assess the relationship between preoperative LTPA and LOS. RESULTS A sample of 1064 participants were included in the analyses. The participants in the highest preoperative LTPA quartile had 45% reduced odds (P = .015) of a worse ASA PS classification compared with participants in the lowest quartile. The participants engaging in vigorous LTPA preoperatively had 35% lower odds (P = .014) of a >2-day LOS following RP compared with participants who were not engaging in preoperative vigorous LTPA. CONCLUSIONS Our findings suggest that total and vigorous preoperative LTPA is associated with improved preoperative American Society of Anesthesiologists scores and LOS following RP, respectively.
Collapse
|
29
|
Alser O, Gallastegi AD, Christensen MA, Mashbari H, Saillant N, Parks J, Mendoza A, Fagenholz P, King D, Hwabejire J, Kaafarani HM, Velmahos GC, Fawley JA. Modified Frailty Index-5 Score and Post-Operative Infectious Complications in Patients Undergoing Surgery for Intestinal-Cutaneous Fistula: A Nationwide Retrospective Cohort Analysis. Surg Infect (Larchmt) 2021; 22:903-909. [PMID: 33926272 PMCID: PMC11079609 DOI: 10.1089/sur.2020.441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Post-operative infectious complications after repair of intestinal-cutaneous fistulas (ICF) represent a substantial burden and these outcomes vary widely in the literature. We aimed to evaluate the use of the modified frailty index-5 (mFI-5) to account for physiologic reserve to predict infectious complications in patients with ICF undergoing operative repair. Methods: We used the American College of Surgeon National Surgical Quality Improvement Program (ACS-NSQIP) 2006-2017 dataset to include patients who underwent ICF repair. The main outcome measure was 30-day infectious complications (surgical site infection [SSI], sepsis, pneumonia, and urinary tract infection [UTI]). The risk of 30-day post-operative infectious complications was assessed based on mFI-5 score. We performed multivariable logistic regression analyses to evaluate the association between infectious complications and mFI-5. Results: We identified 4,197 patients who underwent an ICF repair. The median age (interquartile range [IQR]) was 57 (46, 67) years, and the majority of patients were female (2,260; 53.9%); white (3,348; 79.8%); and 1,586 (38.3%) were obese. After adjustment for relevant confounders such as baseline patient characteristics, and operative details, mFI-5 was independently associated with infectious complications (odds ratio [OR], 2.00; 95% confidence interval [CI], 1.25-3.21), particularly SSI (OR, 2.16; 95% CI, 1.28-3.63) and pneumonia (OR, 5.31; 95% CI, 2.29-12.35), but not UTI or sepsis. Conclusions: We showed that the mFI-5 is a strong predictor of infectious complications after ICF repair. It can be utilized to account for physiologic reserve, therefore reducing the variability of outcomes reported for ICF repair.
Collapse
Affiliation(s)
- Osaid Alser
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mathias A. Christensen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Mashbari
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M.A. Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George C. Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A. Fawley
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
30
|
Matthews LS, Wootton SA, Davies SJ, Levett DZH. Screening, assessment and management of perioperative malnutrition: a survey of UK practice. Perioper Med (Lond) 2021; 10:30. [PMID: 34433498 PMCID: PMC8390283 DOI: 10.1186/s13741-021-00196-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/31/2021] [Indexed: 01/04/2023] Open
Abstract
Background Perioperative malnutrition is common and is associated with increased mortality, complications and healthcare costs. Patients having surgery for cancer and gastro-intestinal disease are at particular risk. It is a modifiable pre-operative risk factor and perioperative clinicians are well placed to identify those at risk and instigate interventions shown to improve outcome. Thus, we conducted a survey of Perioperative Medicine Leads with the aim of assessing the current provision of nutritional screening and intervention pathways in the UK. Methods Perioperative Medicine Leads registered with the Royal College of Anaesthetists were asked to complete an online survey exploring current practice in screening, assessment and management of malnutrition in the perioperative period. The survey included a mixture of open and closed questions, graded response questions and options for free text. Where a response was not received, departments were phoned directly and e-mails sent to non-responders. Results We received 121 completed questionnaires from 167 Perioperative Medicine Leads (response rate of 72.5%). Seventy respondents (57.9%) reported using the Malnutrition Universal Screening Tool to screen patients; however, only 61 (50.4%) referred patients at nutritional risk onto a dietitian. Sixty (49.6%) lacked confidence in local ability to identify and manage malnutrition perioperatively, with 28 (23.1%) reporting having a structured pathway for managing malnourished patients. One hundred eleven respondents (91.7%) agreed that malnutrition impacts on quality of life after surgery and 105 (86.8%) felt adopting a standard protocol would improve outcomes for patients. Those reporting a lack of confidence in dealing with malnutrition perioperatively cited a lack of organisational support, patients being seen too close to surgery and lack of clarity around responsibility as key reasons for difficulties in managing this group of patients. Conclusions Malnutrition in the perioperative period is a modifiable risk factor which is common and results in increased morbidity for patients and increased cost to healthcare systems. This survey highlights areas of practice where perioperative clinicians can improve the assessment and management of patients at nutritional risk prior to elective surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00196-2.
Collapse
Affiliation(s)
- L S Matthews
- Department of Perioperative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK. .,University of Southampton, Southampton, UK.
| | - S A Wootton
- University of Southampton, Southampton, UK.,National Institute for Health Research Cancer and Nutrition Collaboration, Southampton, UK
| | - S J Davies
- Department of Dietetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - D Z H Levett
- Department of Perioperative Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK.,University of Southampton, Southampton, UK
| |
Collapse
|
31
|
Sweeny L, Curry JM, Crawley MB, DiLeo M, Bonaventure CA, Luginbuhl AJ, Guice KM, Taghizadeh F, McCreary E, Buncke M, Petrisor D, Wax MK. Age and Comorbidities Impact Medical Complications and Mortality Following Free Flap Reconstruction. Laryngoscope 2021; 132:772-780. [PMID: 34415067 DOI: 10.1002/lary.29828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/09/2021] [Accepted: 08/08/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction. STUDY DESIGN Retrospective review of prospectively collected databases. METHODS Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary). RESULTS Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3). CONCLUSION Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
Collapse
Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, U.S.A
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Meghan B Crawley
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Michael DiLeo
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, U.S.A
| | - Caroline A Bonaventure
- School of Medicine, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, U.S.A
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Kelsie M Guice
- School of Medicine, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, U.S.A
| | - Farshid Taghizadeh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Eleanor McCreary
- Oregon Health and Science University School of Medicine, Portland, Oregon, U.S.A
| | - Michelle Buncke
- Oregon Health and Science University School of Medicine, Portland, Oregon, U.S.A
| | - Daniel Petrisor
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| |
Collapse
|
32
|
Damasceno AM, Kesley R, Paolino BS, Dos Santos do Amaral MR, Pitombo MB. Perioperative score for octogenarian patients eligible for rectal cancer surgery. J Surg Oncol 2021; 124:1409-1416. [PMID: 34363616 DOI: 10.1002/jso.26634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/08/2021] [Accepted: 07/29/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Colorectal cancer incidence increases with age; therefore, rectal cancer treatment in elderly patients is increasingly common. Surgery is a common rectal cancer treatment, and the risks involve complicated surgical decisions. There are currently few surgical outcome data for rectal cancer in elderly patients. The aim of this study is to identify new perioperative risk factors that could be associated with higher 30- and 180-day mortality in elderly patients in good clinical condition considering traditional perioperative risk scores and to develop a risk score. METHODS A single-centre, retrospective cohort study was performed by reviewing the medical records of patients from the National Cancer Institute of Brazil aged 80 years or older who electively underwent rectal cancer surgery; several independent variables correlated with death from all causes at 30 and 180 days were studied. RESULTS Multivariate analysis found new variables (CEA, albumin and reoperation) that had independent correlations with increased 30- and 180-day mortality. A clinical risk score was developed with survival profiles ranging from 29.3% to 97.2% within 30 days and 2.45% to 91.8% within 180 days. CONCLUSIONS This score can aid in deciding whether a patient should undergo rectal cancer surgery.
Collapse
Affiliation(s)
- Arthur Mota Damasceno
- Post-Graduate Program in Medical Sciences (PGCM), Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rubens Kesley
- Department of Abdominal Surgery, National Cancer Institute of Brazil (INCA), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruno Souza Paolino
- Post-Graduate Program in Medical Sciences (PGCM), Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Rubens Dos Santos do Amaral
- Post-Graduate Program in Medical Sciences (PGCM), Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos Bettini Pitombo
- Post-Graduate Program in Medical Sciences (PGCM), Medical Sciences College (FCM), Rio de Janeiro State University (UERJ), Rio de Janeiro, Rio de Janeiro, Brazil
| |
Collapse
|
33
|
Postoperative Pulmonary Complications' Association with Sugammadex versus Neostigmine: A Retrospective Registry Analysis. Anesthesiology 2021; 134:862-873. [PMID: 33730169 DOI: 10.1097/aln.0000000000003735] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative residual neuromuscular blockade related to nondepolarizing neuromuscular blocking agents may be associated with pulmonary complications. In this study, the authors sought to determine whether sugammadex was associated with a lower risk of postoperative pulmonary complications in comparison with neostigmine. METHODS Adult patients from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who underwent general anesthesia procedures between January 2010 and July 2019 were included in an observational cohort study. In early 2017, a wholesale switch from neostigmine to sugammadex occurred at Vanderbilt University Medical Center. The authors therefore identified all patients receiving nondepolarizing neuromuscular blockades and reversal with neostigmine or sugammadex. An inverse probability of treatment weighting propensity score analysis approach was applied to control for measured confounding. The primary outcome was postoperative pulmonary complications, determined by retrospective chart review and defined as the composite of the three postoperative respiratory occurrences: pneumonia, prolonged mechanical ventilation, and unplanned intubation. RESULTS Of 10,491 eligible cases, 7,800 patients received neostigmine, and 2,691 received sugammadex. A total of 575 (5.5%) patients experienced postoperative pulmonary complications (5.9% neostigmine vs. 4.2% sugammadex). Specifically, 306 (2.9%) patients had pneumonia (3.2% vs. 2.1%), 113 (1.1%) prolonged mechanical ventilation (1.1% vs. 1.1%), and 156 (1.5%) unplanned intubation (1.6% vs. 1.0%). After propensity score adjustment, the authors found a lower absolute incidence rate of postoperative pulmonary complications over time (adjusted odds ratio, 0.91 [per year]; 95% CI, 0.87 to 0.96; P < .001). No difference was observed on the odds of postoperative pulmonary complications in patients receiving sugammadex in comparison with neostigmine (adjusted odds ratio, 0.89; 95% CI, 0.65 to 1.22; P = 0.468). CONCLUSIONS Among 10,491 patients at a single academic tertiary care center, the authors found that switching neuromuscular blockade reversal agents was not associated with the occurrence of postoperative pulmonary complications. EDITOR’S PERSPECTIVE
Collapse
|
34
|
Gonçalves DM, Henriques R, Costa RS. Predicting Postoperative Complications in Cancer Patients: A Survey Bridging Classical and Machine Learning Contributions to Postsurgical Risk Analysis. Cancers (Basel) 2021; 13:cancers13133217. [PMID: 34203189 PMCID: PMC8269422 DOI: 10.3390/cancers13133217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/04/2021] [Accepted: 06/22/2021] [Indexed: 02/05/2023] Open
Abstract
Simple Summary Structured survey on the predictive analysis of postoperative complications in oncology, bridging classic risk scores with machine learning advances, and further establishing principles to guide the design of cohort studies and the predictive modeling of postsurgical risks. Abstract Postoperative complications can impose a significant burden, increasing morbidity, mortality, and the in-hospital length of stay. Today, the number of studies available on the prognostication of postsurgical complications in cancer patients is growing and has already created a considerable set of dispersed contributions. This work provides a comprehensive survey on postoperative risk analysis, integrating principles from classic risk scores and machine-learning approaches within a coherent frame. A qualitative comparison is offered, taking into consideration the available cohort data and the targeted postsurgical outcomes of morbidity (such as the occurrence, nature or severity of postsurgical complications and hospitalization needs) and mortality. This work further establishes a taxonomy to assess the adequacy of cohort studies and guide the development and assessment of new learning approaches for the study and prediction of postoperative complications.
Collapse
Affiliation(s)
- Daniel M. Gonçalves
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal; (D.M.G.); (R.S.C.)
- INESC-ID, Lisboa Portugal and Instituto Superior Técnico, Universidade de Lisboa, R. Alves Redol 9, 1000-029 Lisboa, Portugal
| | - Rui Henriques
- INESC-ID, Lisboa Portugal and Instituto Superior Técnico, Universidade de Lisboa, R. Alves Redol 9, 1000-029 Lisboa, Portugal
- Correspondence: ; Tel.: +351-21-310-0300
| | - Rafael S. Costa
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais 1, 1049-001 Lisboa, Portugal; (D.M.G.); (R.S.C.)
- LAQV-REQUIMTE, NOVA School of Science and Technology, Campus Caparica, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal
| |
Collapse
|
35
|
Oliver JB, Merchant AM, Koneru B. The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization. J INVEST SURG 2021; 34:617-626. [PMID: 31661332 DOI: 10.1080/08941939.2019.1676846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes. METHODS Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression. RESULTS There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation. CONCLUSION Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.
Collapse
Affiliation(s)
- Joseph B Oliver
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA.,Department of Surgery, East Orange Veterans Affairs Hospital, East Orange, NJ, USA
| | - Aziz M Merchant
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| | - Baburao Koneru
- Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA
| |
Collapse
|
36
|
Systematic review and meta-analysis: risks of postoperative complications with preoperative use of anti-tumor necrosis factor-alpha biologics in inflammatory bowel disease patients. Eur J Gastroenterol Hepatol 2021; 33:799-816. [PMID: 33079779 DOI: 10.1097/meg.0000000000001944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The preoperative use of anti-tumor necrosis factor-alpha (anti-TNF) in inflammatory bowel disease (IBD) patients undergoing surgery has been controversial due to concern for increased risks of postoperative complications. We aimed to determine the effect of preoperative anti-TNF therapy on postoperative complications in IBD patients undergoing abdominal surgery. METHODS A literature search of Google Scholar, PubMed, The Cochrane Library, EMBASE, and CINAHL was performed through October 2019. Studies reporting postoperative complication rates of Crohn's disease (CD), ulcerative colitis (UC), and IBD-unspecified patients with preoperative anti-TNF treatment undergoing abdominal surgery compared to controls without preoperative anti-TNF treatment were included. The main outcomes measured were overall, infectious, and noninfectious postoperative complications. RESULTS Forty-one studies totaling 20 274 patients were included. There was a significant increase in overall complications in all patients treated with anti-TNF vs. controls [odds ratio (OR) = 1.13, 95% confidence interval (CI), 1.01-1.25, P = 0.03, I2 = 6%] with an absolute risk increase (ARI) of 5.5% and a number needed to harm (NNH) of 18. There was also a significant increase in infectious complications in CD patients (OR = 1.44; 95% CI 1.02-2.03, P = 0.04, I2 = 49%, ARI = 5.5%, NNH = 20) only. Contrastingly, there was a significant increase in noninfectious complications in all patients (OR = 1.44, 95% CI 1.13-1.85, P = 0.003, I2 = 8%, ARI = 6.4%, NNH = 16) and UC patients (OR = 1.57, 95% CI 1.15-2.14, P = 0.005, I2 = 25%, ARI = 8.5%, NNH = 12) only. CONCLUSION Preoperative use of anti-TNF agents in IBD patients undergoing abdominal surgery is associated with increases in overall postoperative complications in all patients, infectious postoperative complications in CD patients, and noninfectious postoperative complications in UC patients.
Collapse
|
37
|
Kenny E, Samavat H, Touger-Decker R, Parrott JS, Byham-Gray L, August DA. Adverse perioperative outcomes among patients undergoing gastrointestinal cancer surgery: Quantifying attributable risk from malnutrition. JPEN J Parenter Enteral Nutr 2021; 46:517-525. [PMID: 34057749 DOI: 10.1002/jpen.2200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Preoperative malnutrition adversely impacts perioperative outcomes among patients with gastrointestinal (GI) cancer. The attributable risk (AR) that nutrition status contributes towards negative outcomes is poorly understood. METHODS Adults undergoing GI cancer surgeries were identified within the American College of Surgeons National Surgical Quality Improvement Program database (2005-2017). Emergency surgeries, outpatients, and cases with an American Society of Anesthesiologists status above III were excluded. Adjusted multivariable models were constructed to determine the associations between markers of nutrition status (body mass index, >10% weight loss in last 6 months, functional status, and serum albumin level) and adverse perioperative outcomes (presence and number of complications, death, 30-day readmission, and length of stay). Predictive accuracy statistics and population AR (PAR) were determined. RESULTS The final sample included 78,662 cases. Patients with >10% weight loss 6 months preceding surgery (compared with those who did not), had a significantly increased risk of complications (Relative Risk = 1.28; 95% CI, 1.20-1.37) and odds of death (odds ratio [OR] = 1.37; 95% CI, 1.18-1.59). A totally dependent functional status (compared with independent status) was associated with a 3.3-times higher odds of death (OR = 3.30; 95% CI, 1.53-7.15). Multivariable models were not predictive of adverse outcomes; PAR from the markers ranged 1%-2%. CONCLUSION Ten percent weight loss in preceding 6 months was associated with increased risk of adverse perioperative outcomes among adults undergoing GI cancer surgery. The contribution of nutrition status markers to surgical outcomes as assessed by PAR was small (1%-2%), a finding not previously reported. Future intervention studies should include validated nutrition risk markers, control for effects of perioperative variables, and evaluate PAR within the immediate/long-term postoperative periods.
Collapse
Affiliation(s)
- Erin Kenny
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| | - Hamed Samavat
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| | - Riva Touger-Decker
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA.,Program/Devision: Clinical Nutrition, The Rutgers School of Dental Medicine, Newark, New Jersey, USA
| | - J Scott Parrott
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA.,Department of Interdisciplinary Studies, Rutgers School of Health Professions, Newark, New Jersey, USA
| | - Laura Byham-Gray
- Department of Clinical and Preventive Nutrition Sciences, Rutgers School of Health Professions, Newark, New Jersey, USA
| | - David Allen August
- The Rutgers Cancer Institute of New Jersey, Newark, New Jersey, USA.,The Department of Surgery, Rutgers Robert Wood Johnson Medical School, Newark, New Jersey, USA
| |
Collapse
|
38
|
Emergency General Surgery (EGS) Risk Stratification Scores. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00281-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
39
|
Current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
40
|
Minnella EM, Baldini G, Quang ATL, Bessissow A, Spicer J, Carli F. Prehabilitation in Thoracic Cancer Surgery: From Research to Standard of Care. J Cardiothorac Vasc Anesth 2021; 35:3255-3264. [PMID: 33752968 DOI: 10.1053/j.jvca.2021.02.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether personalized, stepped prehabilitation care is a feasible, safe, and effective implementation strategy. DESIGN Quality improvement project. Data collected prospectively from August 2018 to December 2019 were analyzed retrospectively to describe the clinical implementation of a prehabilitation care program for elective lung cancer surgery. SETTING Single center, tertiary university hospital. PARTICIPANTS Eighty-one consecutive adult patients living in the metropolitan area of Montreal were included if an elective resection of suspected or confirmed lung cancer was planned. INTERVENTIONS At the earliest contemplation of surgery, the whole cohort was screened for impaired physical, nutritional, and/or psychological status. Patients screened at higher risk received dedicated assessment and personalized prehabilitation care upon specific needs. MEASUREMENTS AND MAIN RESULTS Patients' specific needs and their access and flow through the different services were described. Prehabilitation effectiveness was evaluated using walking and exercise tests, and adverse events were monitored. Eighty-one patients were screened for functional impairments. Forty patients showed reduction of physical function, seven of them refused the specific assessment, one refused in-hospital exercise; 48 patients showed nutritional risk, eight of them refused or did not comply with nutritional therapy. Overall, 45 high-risk patients received a one-month personalized prehabilitation program: 16 partook in a trimodal program (exercise, nutrition, and psychological), and 22 received a program with both nutrition and exercise. No adverse events occurred during the study period. After prehabilitation, six-minute waking distance improved by 29.9 meters (standard deviation 47.3 m) (n = 35; p = 0.001) and the oxygen uptake at the anaerobic threshold improved by 1.6 (1.7) mL/kg/min (n = 13; p = 0.004). Length of hospital stay was two (interquartile range one-four) days in prehabilitated patients versus three (two-seven) days in the usual care group (p = 0.101). CONCLUSIONS A personalized, stepped prehabilitation program targeting high-risk patients undergoing elective lung cancer surgery was feasible, safe, and effective.
Collapse
Affiliation(s)
- Enrico Maria Minnella
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada; Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Anh Thy Le Quang
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amal Bessissow
- Department of Medicine, Division of Internal Medicine, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Surgery, Division of Thoracic Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
41
|
Alser O, Naar L, Christensen MA, Saillant N, Parks J, Mendoza A, Fagenholz P, King D, Kaafarani HMA, Velmahos GC, Fawley J. Preoperative frailty predicts postoperative outcomes in intestinal-cutaneous fistula repair. Surgery 2021; 169:1199-1205. [PMID: 33408040 DOI: 10.1016/j.surg.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/19/2020] [Accepted: 11/12/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The outcomes of operative repair of intestinal-cutaneous fistulas vary widely throughout the literature. We aimed to investigate whether the modified frailty index-5 is a reliable tool to account for physiologic reserve and whether it serves as a predictor of Clavien-Dindo grade IV complications in those with intestinal-cutaneous fistulas undergoing operative repair. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2017 database to include patients who underwent intestinal-cutaneous fistulas repair. The outcome of interest was 30-day Clavien-Dindo grade IV complications. The incidence of 30-day post-operative Clavien-Dindo grade IV complications were evaluated based on calculated modified frailty index-5 score. Multivariable logistic regression analyses were performed to assess the association of Clavien-Dindo grade IV complications and modified frailty index-5. RESULTS A total of 3,995 patients were identified who underwent an intestinal-cutaneous fistulas repair. The median age (interquartile range) was 57 years (46, 67), and most patients were female (2,143 [53.7%]), White (3,206 [80.3%]), and 1,512 (38.2%) were obese. After adjusting for relevant covariates such as demographics, comorbidities, and operative details, modified frailty index-5 was independently associated with Clavien-Dindo grade IV complications (odds ratio = 2.81, 95% confidence interval 1.64-4.82; P < .001). CONCLUSION Modified frailty index-5 is an independent predictor of Clavien-Dindo grade IV complications following intestinal-cutaneous fistulas repair. It can be used to account for physiologic reserve, thus reducing the variability of outcomes reported for intestinal-cutaneous fistulas repair.
Collapse
Affiliation(s)
- Osaid Alser
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mathias A Christensen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Denmark
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - April Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
42
|
Impact of Artificial Nutrition on Postoperative Complications. Healthcare (Basel) 2020; 8:healthcare8040559. [PMID: 33327483 PMCID: PMC7764968 DOI: 10.3390/healthcare8040559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/26/2022] Open
Abstract
Malnutrition is common in surgical cancer patients and it is widely accepted that it can adversely affect their postoperative outcome. Assessing the nutritional status of every patient, in particular care of elderly and cancer patients, is a crucial feature of the therapeutic pathway in order to optimize every strategy. Evidence exists that the advantages of perioperative nutrition are more significant in malnourished patients submitted to major surgery. For patients recognized as malnourished, preoperative nutrition therapies are indicated; the choice between parenteral and enteral nutrition is still controversial in perioperative malnourished surgical cancer patients, although enteral nutrition seems to have the best risk–benefit ratio. Early oral nutrition after surgery is advisable, when feasible, and should be administered in all the patients undergoing elective major surgery, if compliant. In patients with high risk for postoperative infections, perioperative immunonutrition has been proved in some ways to be effective, even if operations including those for cancer have to be delayed.
Collapse
|
43
|
DiSilvestro KJ, Veeramani A, McDonald CL, Zhang AS, Kuris EO, Durand WM, Cohen EM, Daniels AH. Predicting Postoperative Mortality After Metastatic Intraspinal Neoplasm Excision: Development of a Machine-Learning Approach. World Neurosurg 2020; 146:e917-e924. [PMID: 33212282 DOI: 10.1016/j.wneu.2020.11.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Mortality following surgical resection of spinal tumors is a devastating outcome. Naïve Bayes machine learning algorithms may be leveraged in surgical planning to predict mortality. In this investigation, we use a Naïve Bayes classification algorithm to predict mortality following spinal tumor excision within 30 days of surgery. METHODS Patients who underwent laminectomies between 2006 and 2018 for excisions of intraspinal neoplasms were selected from the National Surgical Quality Initiative Program. Naïve Bayes classifier analysis was conducted in Python. The area under the receiver operating curve (AUC) was calculated to evaluate the classifier's ability to predict mortality within 30 days of surgery. Multivariable logistic regression analysis was performed in R to identify risk factors for 30-day postoperative mortality. RESULTS In total, 2094 spine tumor surgery patients were included in the study. The 30-day mortality rate was 5.16%. The classifier yielded an AUC of 0.898, which exceeds the predictive capacity of the National Surgical Quality Initiative Program mortality probability calculator's AUC of 0.722 (P < 0.0001). The multivariable regression indicated that smoking history, chronic obstructive pulmonary disease, disseminated cancer, bleeding disorder history, dyspnea, and low albumin levels were strongly associated with 30-day mortality. CONCLUSIONS The Naïve Bayes classifier may be used to predict 30-day mortality for patients undergoing spine tumor excisions, with an increasing degree of accuracy as the model better performs by learning continuously from the input patient data. Patient outcomes can be improved by identifying high-risk populations early using the algorithm and applying that data to inform preoperative decision making, as well as patient selection and education.
Collapse
Affiliation(s)
- Kevin J DiSilvestro
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ashwin Veeramani
- Division of Applied Mathematics, Brown University, Providence, Rhode Island, USA
| | - Christopher L McDonald
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Andrew S Zhang
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Eren O Kuris
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Wesley M Durand
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Eric M Cohen
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.
| |
Collapse
|
44
|
Neuzillet C, Anota A, Foucaut AM, Védie AL, Antoun S, Barnoud D, Bouleuc C, Chorin F, Cottet V, Fontaine E, Garabige V, Hébuterne X, Huguet F, Lièvre A, Marchal T, Mouillot T, Peschaud F, Quilliot D, Raynard B, Schneider S, Scotté F, Vansteene D, Mariani P, Bouché O, Joly F. Nutrition and physical activity: French intergroup clinical practice guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, AFC, SFP-APA, SFNCM, AFSOS). BMJ Support Palliat Care 2020; 11:381-395. [PMID: 33177113 DOI: 10.1136/bmjspcare-2020-002751] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 12/22/2022]
Abstract
This document is a summary of the French intergroup guidelines regarding the nutrition and physical activity (PA) management in digestive oncology. This collaborative work was produced under the auspices of all French medical and surgical societies involved in digestive oncology, nutrition and supportive care. It is based on published guidelines, recent literature review and expert opinions. Recommendations are graded according to the level of evidence. Malnutrition affects more than half of patients with digestive cancers and is often underdiagnosed. It has multiple negative consequences on survival, quality of life and risk of treatment complications. Consequently, in addition to anticancer treatments, supportive care including nutritional support and PA plays a central role in the management of digestive cancers. It is crucial to detect malnutrition (diagnostic criteria updated in 2019) early, to prevent it and to act against it at all stages of the cancer and at all times of the care pathway. In this context, we proposed recommendations for the evaluation and management in nutrition and PA in digestive oncology for each stage of the disease (perioperative setting, during radiation therapy, during systemic treatments, at the palliative phase, after cancer). Guidelines for nutrition and PA management aim at increasing awareness about malnutrition in oncology. They are continuously evolving and need to be regularly updated.
Collapse
Affiliation(s)
- Cindy Neuzillet
- Department of Medical Oncology, Curie Institute, Versailles Saint-Quentin University (UVSQ) - Paris Saclay University, Saint-Cloud, France
| | - Amélie Anota
- Methodology and Quality of Life Unit in Oncology, UMR 1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, University Hospital of Besançon, University Bourgogne Franche-Comté, Inserm, EFS BFC, Besançon, France.,Biostatistics Unit, DRCI, Centre Léon Bérard, Lyon, France
| | - Aude-Marie Foucaut
- Laboratoire Educations et Pratiques de Santé UR 3412, Université Sorbonne Paris Nord, Bobigny, France
| | - Anne-Laure Védie
- Department of Gastroenterology and Pancreatology, Beaujon University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris 7 Diderot University, Clichy La Garenne, France
| | - Sami Antoun
- Nutrition and Readaptation Unit, Gustave Roussy Institute - Cancer Campus, Villejuif and Chevilly-Larue, France
| | - Didier Barnoud
- Department of Intensive Clinical Nutrition, Hospices Civils de Lyon (CHU Lyon), Lyon, France
| | - Carole Bouleuc
- Department of Supportive Care, Curie Institute, Paris, France
| | - Frédéric Chorin
- Plateforme Fragilité, Université Côte d'Azur, CHU Nice, LAMHESS, Nice, France
| | - Vanessa Cottet
- INSERM UMR1231 CIC 1432, CHU Dijon, NACRe National Network, University of Burgundy Franche-Comté, Dijon, France
| | - Eric Fontaine
- University of Grenoble Alpes, INSERM, LBFA, Grenoble, France
| | | | - Xavier Hébuterne
- Gastroenterology and Clinical Nutrition, CHU of Nice and University Côte d'Azur, Nice, France
| | - Florence Huguet
- Service d'Oncologie Radiothérapie, CHU Tenon, IUC, AP-HP, Sorbonne Université, Paris, France
| | - Astrid Lièvre
- Department of Gastroenterology, INSERM U1242 "Chemistry Oncogenesis Stress Signaling", University Hospital Pontchaillou, Rennes 1 University, Rennes, France
| | | | - Thomas Mouillot
- Service d'Hépato-gastro-entérologie, CHU F. Mitterrand, Dijon, France
| | - Frédérique Peschaud
- Department of Surgical Oncology, CHU Ambroise Paré, APHP, UVSQ - Paris Saclay University, Boulogne-Billancourt, France
| | - Didier Quilliot
- Nutritional Assistance Department and Transversal Nutrition Unit, University Hospital of Nancy, University of Lorraine, Nancy, France
| | - Bruno Raynard
- Nutrition and Readaptation Unit, Gustave Roussy Institute - Cancer Campus, Villejuif and Chevilly-Larue, France
| | - Stéphane Schneider
- Plateforme Fragilité, Université Côte d'Azur, CHU Nice, LAMHESS, Nice, France
| | - Florian Scotté
- Department of Supportive Care (Département Interdisciplinaire d'Organisation des Parcours Patients - DIOPP), Gustave Roussy Institute - Cancer Campus, Villejuif, France
| | - Damien Vansteene
- Department of Medical Oncology, Institut de Cancérologie de l'Ouest, Nantes, France
| | - Pascale Mariani
- Department of Digestive Surgery, Curie Institute, Paris, France
| | - Olivier Bouché
- Department of Digestive Oncology, CHU Reims, Reims, France
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, CHU Beaujon, AP-HP, Paris 7 Diderot University, Clichy La Garenne, France
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Kao AM, Maloney SR, Prasad T, Reinke CE, May AK, Heniford BT, Ross SW. The CELIOtomy Risk Score: An effort to minimize futile surgery with analysis of early postoperative mortality after emergency laparotomy. Surgery 2020; 168:676-683. [DOI: 10.1016/j.surg.2020.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
|
46
|
Evaluation of malnutrition via modified GLIM criteria for in patients undergoing emergent gastrointestinal surgery. Clin Nutr 2020; 40:1367-1375. [PMID: 32938549 DOI: 10.1016/j.clnu.2020.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 08/19/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Malnutrition remains a critical public health issue in the US, particularly in surgery where perioperative malnutrition is commonly underdiagnosed and undertreated. In 2016, the Global Leadership Initiative on Malnutrition (GLIM) proposed a set of consensus criteria for the diagnosis of malnutrition. Our project aims to assess the post-operative outcomes of patients meeting a modified GLIM-defined (mGLIM) malnutrition criteria undergoing emergent gastrointestinal surgery (EGS) in the NSQIP database. Current GLIM-criteria were modified with addition of admission albumin (a NSQIP-defined malnutrition variable). METHODS Adapting NSQIP data, mGLIM criteria are (1) BMI of ≤20 for age ≤ 70 and BMI ≤22 for age ≥ 71, (2) weight loss > 10% within the past 6 months, (3) admission albumin ≤ 3.5, and (4) emergent bowel surgery as etiologic criteria of acute disease/injury. All patients undergoing emergent small bowel, colon, and rectal procedures were extracted from the NSQIP database and included in the study. Multivariate linear and logistic regression models controlling for relevant covariates were developed to evaluate mGLIM criteria on length of stay (LOS), mortality, and overall complication rates. RESULTS We included 31,029 patients who underwent emergent bowel surgeries from years 2011-2016. Demographically, 53.6% (n = 16,622) were female, 13.0% (n = 4023) were African American, and 78.3% (n = 24,292) were Caucasian. Case composition included 71.5% colon operations, 28.0% small bowel, and 0.5% rectal cases. Overall, 1.7% (n = 517) had data necessary to qualify as malnourished as per mGLIM. Controlling for covariates, multivariate linear and logistic regression analyses show that these patients have significantly higher mortality for both colon (p < 0.001, CI 1.55 | 2.61) and small bowel (p = 0.022, CI 1.08 | 2.67) procedures, longer LOS for colon (p < 0.001, CI 1.93 | 4.33) operations, and higher post-operative complications for both colon (p < 0.001, CI 1.61 | 2.62) and small bowel (p < 0.001, CI 1.57 | 3.37) cases. CONCLUSION This analysis shows that mGLIM criteria malnutrition is associated with poor clinical outcomes following EGS affecting LOS and mortality. Our data indicates the new mGLIM criteria can be a powerful and simple predictive score for malnutrition that can be used to predict malnutrition-related risk of poor outcomes after EGS.
Collapse
|
47
|
Cao Y, Bass GA, Ahl R, Pourlotfi A, Geijer H, Montgomery S, Mohseni S. The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients. BMC Med Inform Decis Mak 2020; 20:86. [PMID: 32380980 PMCID: PMC7206787 DOI: 10.1186/s12911-020-1100-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 04/23/2020] [Indexed: 12/14/2022] Open
Abstract
Background Geriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care. Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects. Methods One hundred and fifty-seven geriatric patients aged ≥65 years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance. Results The mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0–36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy > 0.8 and a specificity ≥0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction. Conclusion P-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of > 0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables’ importance and the models’ robustness is needed by use of larger dataset.
Collapse
Affiliation(s)
- Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden.
| | - Gary A Bass
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - Rebecka Ahl
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arvid Pourlotfi
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Örebro University Hospital, Örebro, Sweden
| | - Håkan Geijer
- Department of Radiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182, Örebro, Sweden.,Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, 17177, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Shahin Mohseni
- Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.,Department of General Surgery, Örebro University Hospital, Örebro, Sweden
| |
Collapse
|
48
|
Williams DGA, Villalta E, Aronson S, Murray S, Blitz J, Kosmos V, Wischmeyer PE. Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic. JPEN J Parenter Enteral Nutr 2020; 44:1185-1196. [PMID: 32232882 PMCID: PMC7540666 DOI: 10.1002/jpen.1824] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/25/2020] [Indexed: 12/29/2022]
Abstract
Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated—a true “silent epidemic” in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian–driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.
Collapse
Affiliation(s)
- David G A Williams
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Solomon Aronson
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sutton Murray
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | |
Collapse
|
49
|
Shatveryan GA, Chardarov NK, Nikoda VV, Bagmet NN, Tadzhibova IM, Lishova EA, Ratnikova NP, Karagyozyan GA. [Short-term results of pancreatoduodenectomy in patients over 70 years old]. Khirurgiia (Mosk) 2020:25-32. [PMID: 31994496 DOI: 10.17116/hirurgia202001125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To analyze the immediate results of PDE in patients younger and older 70 years. MATERIAL AND METHODS The study included patients who underwent PDE for various indications from March 2010 to February 2019. All patients are divided into 2 groups: <70 years old and ≥70 years old. Primary endpoints were postoperative mortality and complication rate. RESULTS There were 110 procedures within 9 years. There were 93 patients aged <70 years (group 1) and 17 patients aged ≥70 years (group 2). ASA (American Society of Anesthesiologists) and PMP scores (Preoperative Mortality Predictor) were higher in group 2: 3 (2-3) vs 2 (1-3) (p=0,002) and 12 (6-15) vs 6.5 (5-15) (p<0.001), respectively. Mortality rate was higher in group 2 (11.7% vs. 3.2%) without statistical significance (p=0.16). Overall morbidity (72% vs 76%; p=1.0), incidence of major complications grade ≥IIIa (29% vs 29%), delayed gastric emptying B/C (17.2% vs 17.6%), pancreatic fistula grade B/C (23.6% vs 35.3%, p=0.3), biliary fistula grade B/C (7.5% vs 11.8%; p=0.62), postoperative hospital-stay [22 (8-165) days vs 23 (9-71) days; p=0.92] were comparable in both groups. CONCLUSION Short-term results of PDE in patients aged <70 and ≥70 years are comparable despite higher ASA and PMP scores in the group 2. General status and concomitant diseases should be considered during selection of patients with resectable tumors for PDE. Age per se is not a contraindication for surgery.
Collapse
Affiliation(s)
- G A Shatveryan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N K Chardarov
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - V V Nikoda
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N N Bagmet
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - I M Tadzhibova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - E A Lishova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - N P Ratnikova
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| | - G A Karagyozyan
- Petrovsky National Research Centre of Surgery, Moscow, Russia
| |
Collapse
|
50
|
Ehresman J, Ahmed AK, Schilling A, Pennington Z, Lubelski D, Cottrill E, Goodwin ML, Liddy A, Abu-Bonsrah N, Goodwin CR, Sciubba DM. Preoperative Nutrition Consults Associated with Decreased Postoperative Complication Rate and Decreased Length of Hospital Stay After Spine Metastasis Surgery. World Neurosurg 2020; 133:e173-e179. [DOI: 10.1016/j.wneu.2019.08.197] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 12/11/2022]
|