Prehabilitation

As the geriatric population continues to grow, the number of elderly patients undergoing major surgeries has also increased. These patients have a higher incidence of postoperative complications, potentially resulting in long-term disability, prolonged hospitalization and poor quality of life. Recent research has identified several predictive factors for postoperative morbidity and mortality; these include premorbid functional dependence, malnutrition, anaemia, cognitive impairment and an increased number of comorbidities. A rising body of evidence shows that optimization of patients' physiological, physical, nutritional and mental status in the preoperative setting may improve the overall surgical outcome. This is known as prehabilitation. This article focuses on the multi-modal approach for prehabilitation – which comprises of medical optimization, exercise therapy, nutritional supplementation, and psychological support.     

Prehabilitation

As the geriatric population continues to grow, the number of elderly patients undergoing major surgeries has also increased. These patients have a higher incidence of postoperative complications, potentially resulting in long-term disability, prolonged hospitalization and poor quality of life. Recent research has identified several predictive factors for postoperative morbidity and mortality; these include premorbid functional dependence, malnutrition, anaemia, cognitive impairment and an increased number of comorbidities. A rising body of evidence shows that optimization of patients’ physiological, physical, nutritional and mental status in the preoperative setting may improve the overall surgical outcome. This is known as prehabilitation. This article focuses on the multi-modal approach for prehabilitation – which comprises of medical optimization, exercise therapy, nutritional supplementation, and psychological support.     

区域阻滞麻醉与老年患者术后神经系统功能、病死率关系的研究进展

背景 区域阻滞麻醉应用于老年患者手术日益增多,其对老年患者术后神经系统功能、病死率的影响有待总结. 目的 通过文献综述,分析区域阻滞麻醉对老年患者术后神经系统、病死率的影响. 内容 讨论区域阻滞麻醉与老年患者术后神经系统功能,包括术后谵妄、认知功能障碍、脑卒中以及与病死率之间的关系. 趋向 区域阻滞麻醉可以减少老年患者术后肺部并发症,减少术后早期认知功能障碍,与全身麻醉相比,具有一定优势.区域阻滞麻醉是否能降低老年患者术后病死率、心血管并发症发生率、谵妄发生率、围手术期脑卒中发生率尚有待于进一步研究.     

Peri-operative optimisation of elderly and frail patients: a narrative review

With increasing life expectancy and technological advancement, provision of anaesthesia for elderly patients has become a significant part of the overall case-load. These patients are unique, not only because they are older with more propensity for comorbidity but a decline in physiological reserve and cognitive function invariably accompanies ageing; this can substantially impact peri-operative outcome and quality of recovery. Furthermore, it is not only morbidity and mortality that matters; quality of life is also especially relevant in this vulnerable population. Comprehensive geriatric assessment is a patient-centred and multidisciplinary approach to peri-operative care. The assessment of frailty has a central role in the pre-operative evaluation of the elderly. Other essential domains include optimisation of nutritional status, assessment of baseline cognitive function and proper approach to patient counselling and the decision-making process. Anaesthetists should be proactive in multidisciplinary care to achieve better outcomes; they are integral to the process.     

衰弱对老年患者手术后认知功能影响的研究进展

衰弱是身体机能、认知、心理衰退的一种多维综合征。衰弱可增加机体对应激的易损性,并导致患者术后并发症增加、住院时间延长、甚至死亡率上升。随着人口老龄化进程不断加快,越来越多的老年患者需接受手术治疗,而该类患者手术后容易发生认知功能障碍。衰弱是老年患者常见的合并状态,但衰弱对老年患者手术后认知功能的影响尚未完全明确。本文就衰弱与老年患者术后谵妄、术后认知功能障碍及术后认知功能改善相关研究做出综述,为临床开展衰弱与术后认知研究提供参考。     

老年人改良衰弱指数与新辅助治疗后行腹腔镜直肠癌患者围手术期并发症的相关性分析

［摘要］ 目的 评估改良衰弱指数（mFI）在预测新辅助治疗后行腹腔镜直肠癌手术老年患者短期疗效及肿瘤学结果中的应用。方法 收集广州市第一人民医院2012年1月至2018年6月行新辅助治疗后再行腹腔镜直肠癌手术的老年患者147例,依据患者术前mFI评分分为无衰弱组（mFI≤0.29,106例） 、衰弱组（mFI> 0.29,41例）,并对两组患者在人口统计学、手术相关数据、短期临床疗效、术后并发症等指标进行统计分析。结果 27.9%的患者被评估为衰弱。衰弱组患者在住院天数、术后并发症均高于非衰弱组患者（13.7±8.6 vs 10.5±3.8 d,P=0.025;20/106 vs 16/14例,P=0.011）。结论 mFI过高是预测新辅助治疗后行直肠癌患者术后并发症发生的重要指标,术前对老年结直肠癌患者患者进行mFI评分有助于为临床诊疗提供合理依据,降低术后并发症发生率。     

Complications of radical cystectomy and correlation with nutritional assessment

Single stage radical cystectomy and ileal conduit remains the procedure of choice for invasive bladder cancer and is a formidable operation performed on an elderly population. A retrospective review of 69 radical cystectomies was done to evaluate not only operative mortality and complication rate, but also the nutritional status of the patients and its relationship to the frequency of complications. Preoperative nutritional status was assessed by total lymphocyte count and serum albumin. There was an operative mortality rate of 2.9 per cent and early complication rate of 41 per cent. The findings suggest that patients with severe nutritional depletion should receive hyperalimentation prior to cystectomy to reduce serious postoperative complications.     

Nutritional status as a risk factor in esophageal surgery

BACKGROUND: Nutritional condition is one of the factors determining postoperative outcome in esophageal surgery. This study explored the relation between preoperative nutritional status and postoperative infectious complications. METHODS: From a prospective database, 400 patients who underwent esophageal resection for malignancy were selected. Preoperative nutritional status was assessed by body mass index, prognostic nutritional index (PNI), nutritional risk index (NRI) and weight loss. The association between nutritional parameters and postoperative complications and mortality, gender, age and hospitalization was assessed. RESULTS: PNI and NRI differed between the patients with and without postoperative infectious complications (p = 0.031 and p = 0.009, respectively). However, receiver operating characteristic curves showed that PNI and NRI have a low predictive value for such complications. Also, no associations were found between nutritional parameters and in-hospital mortality. Although mean nutritional parameters were significantly lower, i.e. worse, in patients with neoadjuvant treatment as compared to no such treatment, the incidence of complications did not significantly differ between these treatment groups. Although PNI and NRI correlated negatively with age, no association was found between age and infectious complications. Multivariate analysis of various factors showed the male gender to be the only significant risk factor for development of infectious complications. DISCUSSION: Preoperative nutritional status established by PNI, NRI, body mass index and weight loss has limited value in predicting complications following esophageal resection.     

Analyzing Chinese Patients with Post-Operative Acute Kidney Injury

Abstract

Background: To investigate clinical characteristics and risk factors of Chinese patients with post-operative acute kidney injury (PO-AKI). Methods: Patients with PO-AKI in Ruijin Hospital from December 1997 to December 2005 were retrospectively studied. Results: Patients’ mean age was 62.2 ± 18.1 years. There were 111 males and 57 females. The mean serum creatinine at diagnosis was 370.41 ± 320.92 μmol/L and the mean estimated glomerular filtration rate was 33.56 ± 24.24 mL/min. For the outcome of the patients, 38 died and the mortality rate was 22.6%. There were 17 patients (10.1%) with Acute Dialysis Quality Initiative-RIFLE (risk-injury-failure-loss-end classification) phase R, 21 (12.5%) with phase I, and 130 (77.4%) with phase F. There was no significant difference in mortality regarding patients who underwent different types of surgeries. For the risk factors related to PO-AKI, acute tubular necrosis (ATN) increased relative risk of mortality PO-AKI (odds ratio = 7.089, 95% confidence interval = 2.069–24.288, p < 0.001). Multivariate regression models showed that ATN had a positive correlation with mortality of PO-AKI. Conclusions: PO-AKI is one of the most common causes of AKI in patients who underwent operations. Special attention should be paid to risk factors related to PO-AKI in order to improve prognosis.     

衰弱及营养风险对初次髋关节置换术并发症的影响因素分析

目的：分析衰弱及营养风险与初次髋关节置换术并发症的关系,影响初次髋关节置换术并发症的危险因素。方法：回顾性分析2019年1月至2021年1月接受髋关节置换术100例患者的临床资料,男36例,女64例;年龄18～85(73.82±4.04)岁。采用改良衰弱指数评估术后患者的衰弱状况,临床生化指标及NRS2002营养风险评估量表评估术后患者的营养状况,根据改良衰弱指数将100例患者分为衰弱组和非衰弱组,根据营养状况将100例患者分为营养正常组和营养风险组,并分析衰弱、营养风险与初次髋关节置换术后并发症的关系。结果：衰弱组和非衰弱组的年龄、体质量指数（body mass index,BMI）、合并症、美国麻醉医师协会（Amercican Scociety of Anesthesiologists,ASA）分级比较,差异有统计学意义（P<0.05）。营养正常组和营养风险组的年龄、BMI、合并症、ASA分级比较,差异有统计学意义（P<0.05）。有35例患者发生至少1个术后并发症,其中肺部感染发生率最高,占34.29%(12/35);其次为泌尿感染,占22.86%(8/35)。单因素...     

Operative risk factors of colon resection in the elderly.

Between January 1, 1974, and December 31, 1978, patients over 50 years of age underwent colon resections in three West Virginia Hospitals. The patients were studied by decades of age to compare the operative risks in younger and elderly patients. Preoperative assessments of cardiovascular, pulmonary, renal, hepatic, metabolic and nutritional states were compared with the postoperative morbidity and mortality rates. Complications occurred in 33% of all the patients who had resections, with 17 (4.8%) deaths. Mortality rates compared by decades of age correlated with the number of pre-existing conditions, and not with age as an isolated factor. There were no deaths in patients with no pre-existing conditions. The rate of infectious complications increased because the number of emergency procedures increased. This was also true for the mortality rate. Preoperative pulmonary and nutritional problems were significant contributing factors in the patients who died from sepsis. Careful preoperative assessment, correction of pre-existing pulmonary and nutritional deficiencies, and avoidance of emergency procedures may improve the morbidity and mortality rates associated with colon resections in elderly patients.     

A Review of the Effects of Growth Hormone Changes on Symptoms of Frailty in the Elderly with Chronic Kidney Disease

The incidence and prevalence of chronic kidney disease (CKD) is increasing worldwide, especially in the elderly. Recently, functional impairment and frailty have been recognized as factors affecting the quality of life, and outcomes in elderly patients with CKD and therapeutic interventions to improve function and reduce frailty are therefore being considered. Growth hormone (GH) levels decrease with age and GH actions are impaired in CKD patients. GH stimulates protein synthesis, bone, and glucose metabolism, and affects body composition by reducing body fat and increasing lean body mass. An increase in lean body mass may reduce frailty and thus avoid functional impairment. Thus, providing GH to elderly CKD patients could potentially improve outcomes and quality of life by lowering the risk of frailty and associated functional impairment. There are few studies assessing the long-term effects of GH administration on symptoms of frailty in elderly patients with CKD. In this review we will try to shed some light on the trials assessing the administration of GH to elderly subjects and to patients with CKD and focus on the possible role GH administration may play to improve frailty and quality of life in those patients.     

Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist

The comprehensive management of proximal hip fractures in elderly patients requires dedicated and responsive teamwork. Elderly patients often present with several comorbidities and the immediate treatment of a fracture has to optimize both medical therapy and analgesic control in order to reduce surgical and anesthetic complications and to preserve as much cognitive functioning as possible. The elderly are uniquely exposed to complications related to bed rest, delirium and postoperative cognitive dysfunction (POCD), which appear to be independent factors of morbidity. Anesthetic management that includes good perioperative pain management can influence the patient's inflammatory response and possibly decrease the incidence of POCD. The best choice of surgical treatment depends on the type of fracture as well as the patient's age and medical condition. However, the type of anesthesia management, which includes neuraxial blocks, peripheral nerve blocks and/or general anesthesia, has to be tailored towards generated the best outcome. We present a review from a surgical and anesthetic perspective on the most common perioperative issues in proximal fracture repair.     

Peri-operative care considerations for primary total knee arthroplasty in the obese patient

In the United States an increasing obesity epidemic compounded with growth in total knee arthroplasty (TKA) utilization is increasing the incidence of TKA in the obese population. Arthroplasty surgeons are directly affected by the obesity epidemic and need to understand how to safely offer a range of peri-operative care for these patients in order to ensure good clinical outcomes. Preoperative care for the obese patient involves nutritional counseling, weight loss methods, consideration for bariatric surgery, physical therapy, metabolic workup with diagnosis, and management of frequent comorbid conditions. Obese patients must also be counseled on their increased risk of complications following TKA. A successful surgical result is dependent on early risk mitigation techniques including weight loss, co-morbidity management, and nutritional optimization. In the operating room several steps can be taken to improve successful outcomes when performing TKA on obese patients. Peri-operative techniques including adequate surgical exposure, component positioning, and implant selection play an important role in the longevity of the implant in the obese TKA population who are at risk for post-operative tibial loosening and increased re-operation rates. Appropriate weight-adjusted antibiotic dosing, sterile surgical techniques, wound closure and coverage are essential in reducing infection in this susceptible population. Post-operative care of the obese patient following TKA involves several unique considerations. Chronic pain and obesity are frequent comorbid conditions and post-operative pain control regimens need to be tailored to these patients to improve function and surgical outcome. Obese patients can have a higher rate of all complications compared to healthy weight. All infection and deep infection increased in obese patients and patients must be counseled on their risks pre-operatively to encourage an active role in risk mitigation in the peri-operative period.     

衰弱对老年患者外科手术结局影响的研究进展

随着人口的老龄化,老年手术患者越来越多.常用的术前评估工具如ASA分级、纽约心脏协会分级、Charlson共病指数和代谢当量,并没有得到令人满意的预测外科手术结局的效果.最近的研究表明,衰弱会增加老年患者的术后并发症和死亡率,延长住院时间,增加医疗费用.衰弱是一种多维综合征,其特征是与年龄或疾病相关的缺陷累积、储备减少...     

老年患者术后认知功能障碍病理生理机制的研究进展

背景 以往研究显示老年患者更易受到术后认知功能障碍(postoperative cognitive dysfunction,POCD)的困扰,近年来随着接受手术治疗的老年患者的增加,POCD的发生率随之增加,POCD是指在多种因素影响下发生于术后的精神紊乱综合征,包括术后人格、社交能力及认知能力的改变,可导致术后并发症...     

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??Perioperative supplementary parenteral nutrition support therapy ZHU Ming-wei.Department of General Surgery, Beijing Hospital, National Center for Geriatrics, Beijing 100730??China
Abstract The incidence of malnutrition is high in surgical patients. Inadequate intake and gastrointestinal dysfunction are the main causes, which can lead to increased postoperative complications and prolonged hospitalization. Standardized nutritional support can improve the clinical outcome. Enteral nutrition is preferred as perioperative support to protect the intestinal barrier and immune function. Intolerance is the main reason of enteral nutrition which is difficult to implement. The insufficient supply of energy and protein for longer periods of time can lead to increased mortality and complications. The combined with PN on the basis of EN is the core of parenteral nutrition which is to maintain intestinal barrier function, quickly reach the target amount to meet the metabolic needs and improve the clinical outcome. The target patient of perioperative parenteral nutrition is that enteral nutrition can not provide more than 60% energy needs. The start of enteral nutrition in patients with low nutrition risk (NRS2002 ≤??or Nutric score ≤ 5 ) will start after 7 days; and start at 48-72 hours after operation for high preoperative nutritional risk (NRS2002 ≥5 or Nutric score≥6). Supplement of parenteral nutrition with glutamine and ω-3 fatty acids can optimize the clinical outcomes of surgical patients. The application of multichamber bags can reduce bloodstream infections and is suitable for short-term supplementary parenteral nutrition after surgery.     

Reconsideration of frailty in relation to surgical indication

Given that an increasing number of elderly patients are undergoing surgical procedures for a diversity of indications, the concept of frailty is currently being examined in more depth in clinical medicine. Established surgical risk scores designed to predict mortality are mainly focused on general demographic information and clinical factors; however, these do not account for the frailty condition. With vulnerability and low resiliency in the frail elderly, these conventional scores are unable to accurately predict postoperative outcomes including adverse complications, disability, the need for additional rehabilitation, and prolonged length of hospitalization. Over the last decade, it has been demonstrated that frailty is an independent risk factor of surgery and strongly associated with adverse postoperative outcomes and mortality. It is essential today that surgeons assimilate the concept of frailty and the relationship between frailty and surgical outcomes. A preoperative frailty assessment can assist in determining surgical indication and optimal perioperative management, ultimately impacting the postoperative functional state and quality of life. Here we review the validity of preoperative frailty assessments for surgical intervention, possible treatments for frailty, and indicate future directions in this field.     

Preoperative statins improve recovery of renal function but not by an anti-inflammatory effect: observational study in 69 elderly patients undergoing cardiac surgery

Background  

Older subjects, including those with normal renal function, have an increased risk of acute kidney injury. Preoperative statin therapy has been reported to improve renal outcome after cardiac surgery and to reduce inflammatory response to cardiopulmonary bypass. No study has hitherto evaluated whether the positive effect of pretreatment with statins on postoperative renal outcome is due to their positive effect on inflammatory burst in elderly patients undergoing myocardial revascularization using cardiopulmonary bypass.     

预防术后肺部并发症对改善食管切除术临床结果的重要性

食管切除术后食管癌患者预后可能与包括患者年龄、肿瘤分期、手术方式、术后并发症在内的许多因素有关。肺部并发症是食管切除术后的主要并发症和死亡原因。许多研究显示,导致食管切除术后肺部并发症发生的术前因素包括高龄、营养不良及心肺储备低下（术前放化疗是否会增加术后肺部并发症发生率尚不明确）：手术因素包括术中大量失血、手术时间过长、进展期食管癌、近端食管癌、手术范围过大如McKeown切除加三野淋巴结清扫：术后因素包括心房颤动、喉返神经损伤、吞咽异常。可能的预防措施有：术前戒烟、积极的术后排痰、恢复进食前要确保吞咽机制的完整性。