Audit of transfusion among the oldest old: treading the fine line between undertransfusion and optimum trigger.

BACKGROUND: Recent research has questioned restrictive transfusion policies in vulnerable elderly populations. Our audit assesses the prevalence and postoperative outcomes of extremely elderly patients undergoing the stress of surgery with perioperative hemoglobin (Hb) less than 9 g/dL. STUDY DESIGN AND METHODS: This retrospective analysis of prospectively collected data addressed patients aged 85+ undergoing elective surgery. Demographic data and baseline characteristics were recorded, as well as Hb and transfused red blood cell (RBC) units. The main endpoint was the prevalence of perioperative Hb less than 9 g/dL, that is, patients with baseline Hb <9 g/dL without preoperative transfusions (defined as Group A). Patients with perioperative Hb of 9 g/dL or greater (with or without transfusion) were designated as Group B. Secondary outcomes included morbidity, length of hospital stay, and mortality 30 days and 6 months after surgery. A bivariate analysis was performed followed by logistic regression to determine whether undergoing the stress of surgery with perioperative Hb less than 9 g/dL was an independent risk factor for postoperative outcomes. RESULTS: A total of 148 patients were included. The prevalence of perioperative Hb less than 9 g/dL was 25%. It was associated with increased morbidity and mortality -both 30 days and 6 months after surgery- and a prolonged length of hospital stay. Anemia-associated complications were higher among patients from Group A, whereas transfusion-associated ones were evenly distributed. In all the regression models, perioperative Hb less than 9 g/dL was an independent risk factor for worse postoperative outcomes. CONCLUSION: Perioperative Hb less than 9 g/dL was common among patients aged 85+, and it was associated with increased risk of adverse postoperative outcomes. The tolerance to anemia might decrease perioperatively when Hb is less than 9 g/dL. Thus, less restrictive thresholds deserve further evaluation.

Mortality, Geriatric, and Nongeriatric Surgical Risk Factors Among the Eldest Old: A Prospective Observational Study.

BACKGROUND: Preoperative risk and postoperative outcomes among the elderly are the subject of extensive debate. However, the eldest old, that is, the fastest-growing and most vulnerable group, are insufficiently studied; even their mortality rate is unclear. This prospective observational study was performed with the aim of determining the mortality rate of this population and establishing which preoperative conditions were predictors of which postoperative outcomes. The study was undertaken between 2011 and 2015 in a major tertiary care university hospital. METHODS: All patients aged ≥85 years undergoing any elective procedure during the study period were included. Patients were followed up for 30 days postoperatively.The preoperative conditions studied were demographic data, grade of surgical complexity (1-3), preoperative comorbidities, and some characteristically geriatric conditions (functional reserve, nutrition, cognitive status, polypharmacy, dependency, and frailty). The outcome measures were 30-day all-cause mortality (primary end point), morbidity, prolonged length of stay, and escalation of care in living conditions. RESULTS: Of 139 eligible patients, 127 completed follow-up. The 30-day mortality was 7.9%; 95% confidence interval (CI), 3.2-12.6. It had 3 predictors: malnutrition (odds ratio [OR], 15; 95% CI, 3-89), complexity 3 (OR, 9.1; CI, 2-52), and osteoporosis/osteoporotic fractures (OR, 14.7; CI, 2-126). Significant predictors for morbidity (40%) were ischemic heart disease (OR, 3.9; CI, 1-11) and complexity 3 (OR, 3.6; CI, 2-9), while a nonfrail phenotype (OR, 0.3; CI, 0.1-0.8) was found to be protective. Only 2 factors were found to be predictive of longer admissions, namely complexity 3 (OR, 4.4; CI, 2-10) and frailty (OR, 2.7; CI, 2-7). Finally, risk factors for escalation of care in living conditions were slow gait (a surrogate for frailty, OR, 2.5; CI, 1-6), complexity 3 (OR, 3.2; CI, 1-7), and hypertension (OR, 2.9; CI, 1-9). CONCLUSIONS: The eldest old is a distinct group with a considerable mortality rate and their own particular risk factors. Surgical complexity and certain geriatric variables (malnutrition and frailty), which are overlooked in American Society of Anesthesiologists and most other usual scores, are particularly relevant in this population. Inclusion of these factors along with appropriate comorbidities for risk stratification should guide better decision making for families and doctors alike and encourage preoperative optimization of patients.

Influence of right ventricular function on the development of primary graft dysfunction after lung transplantation.

BACKGROUND: Primary graft dysfunction (PGD) remains a significant cause of lung transplant postoperative morbidity and mortality. The underlying mechanisms of PGD development are not completely understood. This study analyzed the effect of right ventricular function (RVF) on PGD development. METHODS: A retrospective analysis of a prospectively assessed cohort was performed at a single institution between July 2010 and June 2013. The primary outcome was development of PGD grade 3 (PGD3). Conventional echocardiographic parameters and speckle-tracking echocardiography, performed during the pre-transplant evaluation phase up to 1 year before surgery, were used to assess preoperative RVF. RESULTS: Included were 120 lung transplant recipients (LTr). Systolic pulmonary arterial pressure (48 ± 20 vs 41 ± 18 mm Hg; p = 0.048) and ischemia time (349 ± 73 vs 306 ± 92 minutes; p < 0.01) were higher in LTr who developed PGD3. Patients who developed PGD3 had better RVF estimated by basal free wall longitudinal strain (BLS; -24% ± 9% vs -20% ± 6%; p = 0.039) but had a longer intensive care unit length of stay and mechanical ventilation and higher 6-month mortality. BLS ≥ -21.5% was the cutoff that best identified patients developing PGD3 (area under the receiver operating characteristic curve, 0.70; 95% confidence interval, 0.54-0.85; p = 0.020). In the multivariate analysis, a BLS ≥ -21.5% was an independent risk factor for PGD3 development (odds ratio, 4.56; 95% confidence interval, 1.20-17.38; p = 0.026), even after adjusting for potential confounding. CONCLUSIONS: A better RVF, as measured by BLS, is a risk factor for severe PGD. Careful preoperative RVF assessment using speckle-tracking echocardiography may identify LTrs with the highest risk of developing PGD.

Mortality and surgical risk assessment among the extreme old undergoing emergency surgery.

BACKGROUND: Although longevity is becoming frequent, there are no scores to assess nonagenarians undergoing emergency surgery. The aim of this prospective observational study was to determine 30-day mortality and the individual performance of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and other scores in predicting their risk for death. METHODS: A total of 126 patients were included (2006-2011) and followed for 30 days. Patients risk for death was calculated using different scores. The accuracy of each score was assessed with exponential and linear methods and using the area under the receiver operating characteristic curve. RESULTS: Overall mortality was 34.9%. The POSSUM, with a modification in the age category, had an area under the curve of .71 and ratios of observed to predicted deaths of 1.07 and 1.22, respectively, in the linear and exponential analysis. CONCLUSIONS: In a population with as high a risk as nonagenarians, the age-modified POSSUM proved accurate to audit surgery and assess mortality risk.