The Importance of the First Complication: Understanding Failure to Rescue after Emergent Surgery in the Elderly. Sheetz KH, Krell RW, Englesbe MJ, et al. J Am Coll Surg. 2014 September; 219(3): 365-370.
As populations age, successful management of elderly patients after emergency surgery is an increasingly important aspect of Acute Care Surgery. Sheetz and colleagues performed a retrospective review of perioperative mortality in the elderly following emergency surgery in the state of Michigan. Utilizing the Michigan Surgical Quality Collaborative database, the authors identified 23,217 patients who underwent emergent general or vascular procedures at 41 Michigan hospitals between 2007 and 2012. They then compared rates of failure to rescue overall and for specific complications for patients less than 75 versus those 75 years of age or greater. Participating hospitals were subsequently divided into “high”, “middle” and “low” mortality hospitals by risk-adjusted 30-day mortality.
Survival for patients 75 years of age or older was significantly different after infectious (p<0.01) and pulmonary (p<0.01) complications for “high” and “low” mortality centers, while survival after cardiovascular complications showed no significant difference in the context of patient age or institution. Successful management and prevention of infectious and pulmonary complications was concluded to be a major area of opportunity at Michigan hospitals for improving emergency surgical care of the elderly. The study’s findings further reinforce the importance of a systematic, evidence-based approach to the practice of Acute Care Surgery as the foundation of successful patient outcomes.
Emergency general surgery in the geriatric patient. Desserud KF, Veen T, Soreide K. Br J Surg. 2016 Jan;103(2):e52-61.
This review examined papers related to emergency surgery in elderly patients. Most papers specific to the surgical subspecialties were excluded. The need for emergency surgical services increases with age. Unfortunately the rate of complications, as well as mortality also increases with age. This is especially prominent for each decade above 50 years. Mortality takes a significant jump above age 75. Chronologic age alone, however, is an insufficient predictor of mortality. Organ failure, specifically new onset organ failure as well as the presence of more than one comorbidity are strong factors influencing outcome. Frailty also contributes to mortality. It is defined as a state of vulnerability to poor resolution of homeostasis after a stressor event and is a consequence of cumulative decline in many physiological systems during a lifetime. The five indicators of frailty are: weight loss, self-reported exhaustion, low energy expenditure, slow gait speed and weak grip strength. None of these are reliable or easily assessable in the acutely ill patient. Numerous studies have attempted to evaluate or develop a frailty score for this population. Through their review, the authors found that the Vulnerable Elderly Survey Score as well as the Charleston Age Co-morbidity Index and a modified version of the Canadian Study of Health and Aging Frailty Index were predictive of postoperative mortality and/or complications in acute surgical patients, however they had not been validated specifically for the elderly. The authors state that like minorities and children, geriatric patients are less often included in research studies. If we are to gain knowledge about these populations, we must tailor our research to include them. Of note, the Apache II system was excellent in estimating postoperative mortality however it is a labor-intensive tool and not feasible for application in the clinical setting.
Given the lack of definitive predictors of morbidity, mortality and futility and the fact that age alone is not predictive of poor outcome, we are challenged as clinicians to develop tailored care plans for our elderly patients. Postoperative functional capacity and quality of life are paramount when considering surgical intervention. Realistic goals and expectation setting may guide therapeutic approach.
Perioperative clinical optimization may be complicated by occult disease states, as well as medications which can affect organ function. Elderly patients do not tolerate hypovolemia well and should be wisely resuscitated. In trauma patients, a systolic blood pressure of 110, rather than 90 has been suggested as a new threshold for concern for shock in the elderly. This consideration may extend into the emergency general surgery forum. Elderly patients are also prone to reduced pulmonary function and reduced function of the immune system. Other considerations which initially emerged in the trauma setting may be pertinent in the emergency general surgery population. This includes the concept of damage control surgery. When possible, minimally invasive surgeries, smaller incisions and shorter operations or less strenuous anesthetic options, such as local anesthesia may facilitate recovery in patients with comorbidities. The development of complications after emergency laparotomy always carries with it an increased rate of mortality, however this is threefold in the elderly population.
Delirium occurs in up to 18% of patient after emergency surgery with age being a risk factor. The American Geriatric Society has developed guidelines for the prevention and treatment of delirium. Their recommendations include the use of interdisciplinary teams, early mobility, avoiding restraints, sleep hygiene, adequate nutrition, fluids and oxygen and postoperative pain control with the avoidance or minimization of opioid use.
Postoperative morbidity survey, mortality and length of stay following emergency laparotomy. Howes TE, Cook TM, Corrigan LJ, Dalton SJ, Richards SK, Peden CJ. Anaesthesia. 2015 Sep;70(9):1020-7.
This is a prospective observational cohort study of adults (age ≥18) at a single center undergoing emergency laparotomy via midline incision for non-traumatic gastrointestinal pathology. The authors' primary aim was to elucidate the type and incidence of postoperative complications encountered in this cohort in order to better inform future targets for improvement. The group's secondary aim was to further clarify the nature of outcomes by age group (<80 vs ≥80).
The study population included a total of 144 patients, 30 of whom were aged ≥80. Data regarding mortality, length of stay, and inpatient morbidity were collected by chart review on postoperative days 3, 5, 10, and 28. Inpatient morbidity was defined using a previously validated postoperative morbidity survey (POMS), which identifies complications by physiologic category (pulmonary, infectious, renal, gastrointestinal, cardiovascular, neurological, hematological, wound, and pain). Any patient discharged home by the data collection point was presumed to be alive with no ongoing POMS-defined morbidity.
Overall 30-day mortality was 14.6% (9.6% in the age <80 subgroup vs 33.3% in the age ≥80 subgroup, p=0.003) with median length of stay 12 days (11 days in the age <80 subgroup vs 17 days in the age ≥80 subgroup, p=0.008). POMS-defined morbidity was common among all patients (particularly infectious, pulmonary, and gastrointestinal morbidity), with no significant difference in incidence or type between the younger and older subgroups. Linear regression analysis revealed a predictive relationship between POMS cardiovascular, hematological, renal, and wound categories and length of stay. Logistic regression analysis demonstrated that only cardiovascular complications were associated with increased mortality.
The authors concluded that despite similar incidences of postoperative complications, elderly patients undergoing emergency laparotomy for non-traumatic gastrointestinal pathology experience longer length of stay and higher mortality compared to younger patients of the same cohort, suggesting that this subgroup may benefit from more intensive postoperative monitoring to optimize prevention and earlier detection of complications. The group also concluded that cardiovascular, hematological, renal, or wound complications may have a greater impact on recovery than the more commonly encountered infectious, pulmonary, and gastrointestinal complications.