Routine frailty assessment predicts postoperative complications in elderly patients across surgical disciplines - a retrospective observational study.

BACKGROUND: Frailty is a frequent and underdiagnosed functional syndrome involving reduced physiological reserves and an increased vulnerability against stressors, with severe individual and socioeconomic consequences. A routine frailty assessment was implemented at our preoperative anaesthesia clinic to identify patients at risk. OBJECTIVE: This study examines the relationship between frailty status and the incidence of in-hospital postoperative complications in elderly surgical patients across several surgical disciplines. DESIGN: Retrospective observational analysis. SETTING: Single center, major tertiary care university hospital. Data collection took place between June 2016 and March 2017. PATIENTS: Patients 65 years old or older were evaluated for frailty using Fried's 5-point frailty assessment prior to elective non-cardiac surgery. Patients were classified into non-frail (0 criteria, reference group), pre-frail (1-2 positive criteria) and frail (3-5 positive criteria) groups. MAIN OUTCOME MEASURES: The incidence of postoperative complications was assessed until discharge from the hospital, using the roster from the National VA Surgical Quality Improvement Program. Propensity score matching and logistic regression analysis were performed. RESULTS: From 1186 elderly patients, 46.9% were classified as pre-frail (n = 556), and 11.4% as frail (n = 135). The rate of complications were significantly higher in the pre-frail (34.7%) and frail groups (47.4%), as compared to the non-frail group (27.5%). Similarly, length of stay (non-frail: 5.0 [3.0;7.0], pre-frail: 7.0 [3.0;9.0], frail 8.0 [4.5;12.0]; p < 0.001) and discharges to care facilities (non-frail:1.6%, pre-frail: 7.4%, frail: 17.8%); p < 0.001) were significantly associated with frailty status. After propensity score matching and logistic regression analysis, the risk for developing postoperative complications was approximately two-fold for pre-frail (OR 1.78; 95% CI 1.04-3.05) and frail (OR 2.08; 95% CI 1.21-3.60) patients. CONCLUSIONS: The preoperative frailty assessment of elderly patients identified pre-frail and frail subgroups to have the highest rate of postoperative complications, regardless of age, surgical discipline, and surgical risk. Significantly increased length of hospitalisation and discharges to care facilities were also observed. Implementation of routine frailty assessments appear to be an effective tool in identifying patients with increased risk. Now future studies are needed to investigate whether patients benefit from optimization of patient counselling, process planning, and risk reduction protocols based on the application of risk stratification.

[Why and How Should I Assess Frailty? A Guide for the Preoperative Anesthesia Clinic]. / Warum und wie sollte ich Frailty erfassen? ­ ein Ansatz für die Anästhesieambulanz.

Introduction: Frailty is a condition of decreased physiological reserves seen in approx. one third of elderly anesthesiological patients, and affecting many aspects of treatment as well as outcome. Although there are over 60 measurement instruments, frailty assessment is still poorly implemented. Understanding why and how to assess frailty is key to its implementation in preoperative anesthesia clinics. Method: After presenting the impact of perioperative frailty and the benefits of an early diagnosis on health related quality of life, we present an overview of the most important tools that can be used in the preoperative frailty assessment. Results: Early diagnosis offer several optimization opportunities for the perioperative period. The most efficient frailty assessment tools are presented and discussed, including physical, cognitive, and psychosocial aspects. Conclusion: Frailty assessments vary immensely in terms of required time, equipment, and expertise. We recommend at least one test for each domain of frailty, so as to obtain a more holistic view of the patient's physiological reserve. The implementation of an adequate and consistent preoperative frailty assessment has the potential to improve patient safety as well as short and long term outcomes.

Balloon dilatational tracheostomy: initial experience with the Ciaglia Blue Dolphin method.

BACKGROUND: Percutaneous dilational tracheostomy has become an established technique for ensuring safe and uncomplicated access to the respiratory systems of patients undergoing prolonged intubation. We studied a new balloon dilation percutaneous dilational tracheostomy technique which primarily uses radial force to widen the tracheostoma, the Ciaglia Blue Dolphin system. METHODS: We report our initial clinical experience with this method in 20 patients from a cardiosurgical intensive care unit. We analyzed the results with regard to the practical feasibility of balloon dilation as well as possible complications. RESULTS: Tracheostomy surgery time averaged 3.3 +/- 1.9 min. The new technique caused neither bleeding requiring treatment nor injuries of the posterior tracheal wall. Routine bronchoscopic checks revealed one fracture of a single tracheal cartilage ring (5%). One patient developed subcutaneous emphysema during the balloon dilation, but this regressed spontaneously without treatment. No wound infections or prolonged wound healing of the tracheostoma were observed in any patient. There were no differences in terms of practical feasibility or bleeding complications when skin incisions of different lengths were analyzed. CONCLUSIONS: The balloon dilational tracheostomy proved to be a feasible, easy, and successful technique. Its use of mainly radial force may reduce typical complications such as fractures of tracheal cartilage rings or injuries of the posterior tracheal wall.