Frailty as a growing challenge for anesthesiologists - results of a Dutch national survey.

BACKGROUND: Frailty is a multidimensional condition characterized by loss of functional reserve, which results in increased vulnerability to adverse outcomes following surgery. Anesthesiologists can reduce adverse outcomes when risk factors are recognized early and dedicated care pathways are operational. As the frail elderly population is growing, we investigated the perspective on the aging population, familiarity with the frailty syndrome and current organization of perioperative care for elderly patients among Dutch anesthesiologists. METHODS: A fifteen-item survey was distributed among anesthesiologists and residents during the annual meeting of the Dutch Society of Anesthesiology. The first section included questions on self-reported competence on identification of frailty, acquaintance with local protocols and attitude towards the increasing amounts of elderly patients presenting for surgery. The second part included questions on demographic features of the participant such as job position, experience and type of hospital. Answers are presented as percentages, using the total number of replies for the question per group as a denominator. RESULTS: A sample of 132 surveys was obtained. The increasing number of elderly patients was primarily perceived as challenging by 76% of respondents. Ninety-nine percent agreed that frailty should influence anesthetic management, while 85% of respondents claimed to feel competent to recognize frailty. Thirty-four percent of respondents reported the use of a dedicated pathway in the preoperative approach of frail elderly patients. However, only 30% of respondents reported to know where to find the frailty screening in the patient file and appointed that frailty is not consistently documented. Interestingly, only 43% of respondents reported adequate collaboration with geriatricians. This could include for example a standardized preoperative multidisciplinary approach or dedicated pathway for the elderly patient. CONCLUSIONS: This survey demonstrated that the increasing number of frail elderly patients is perceived as important and relevant for anesthetic management. Opportunities lie in improving the organization and effectuation of perioperative care by more consistent involvement of anesthesiologists.

The impact of autonomic dysfunction on peri-operative cardiovascular complications.

Cardiovascular autonomic neuropathy is frequently observed in patients with diabetes mellitus. As anaesthesia has a marked effect on peri-operative autonomic function, the interplay between diabetic neuropathy and anaesthesia may result in unexpected haemodynamic instability during surgery. The objective of this literature review was to examine the association of cardiovascular autonomic neuropathy with peri-operative cardiovascular complications. We searched PubMed for articles with search elements of autonomic dysfunction [MeSH] AND anaesthesia [MeSH] AND complications [MeSH]. Depending on the type of anaesthesia, the presence of cardiovascular autonomic neuropathy in surgical patients can markedly affect peri-operative haemodynamics and postoperative recovery. Pre-operative testing of the extent of autonomic dysfunction in particular populations, like diabetics, may contribute to a reduction in haemodynamic instability and cardiovascular complications. Non-invasive diagnostic methods assessing autonomic function may be an important tool during pre-operative risk assessment.

Cardiovascular autonomic function testing under non-standardised and standardised conditions in cardiovascular patients with type-2 diabetes mellitus.

Autonomic function tests require standardised test conditions. We compared testing under non-standardised and standardised conditions and investigated the agreement between heart and pulse rate variability in 30 subjects with diabetes mellitus. Deep breathing, Valsalva manoeuvre and quick standing tests showed non-standardised reproducibility intraclass correlations (95% CI) of 0.96 (0.82-0.99), 0.96 (0.81-0.99) and 0.75 (-0.98 to 0.94), respectively. Intraclass correlations for sustained handgrip and quick standing were poor. Heart and pulse rate variability showed high-frequency band intraclass correlations (95% CI) of 0.65 (-0.07 to 0.89) and 0.47 (-0.88 to 0.85) for the very low-frequency band, respectively, 0.68 (0.00-0.90) and 0.70 (-0.09 to 0.91) for the low-frequency band, and 0.86 (0.57-0.95) and 0.82 (0.39-0.95) for the high-frequency band. Reproducibility under standardised conditions was comparable. The mean difference (95% limits of agreement) between heart and pulse rate variability was 0.99 (0.80-1.22) for very low frequency, 1.03 (0.88-1.21) for low frequency and 1.35 (0.84-2.16) for high frequency, with a Spearman's correlation coefficient of 1.00, 0.99 and 0.98, respectively. We demonstrated a high agreement between heart and pulse rate variability and acceptable reproducibility with most autonomic function tests, heart and pulse rate variability.

Reproducibility of non-standardised autonomic function testing in the pre-operative assessment screening clinic*.

By convention, autonomic function tests are undertaken under standard test conditions that limit their implementation during routine pre-operative assessment. We therefore evaluated the comparability of autonomic function tests under both non-standardised and standardised test conditions in 20 healthy male subjects. Autonomic function was assessed using an ECG monitor and a continuous non-invasive blood pressure measurement device. Under non-standardised conditions, intraclass correlation for heart rate variability analysis was good for the low and high frequency bands (0.87; 95% CI 0.58-0.96 and 0.83; 95% CI 0.56-0.94, respectively), but moderate (0.65; 95% CI 0.14-0.86) for the very low frequency band; reproducibility was high for the expiration/inspiration ratio (0.89; 95% CI 0.71-0.96), Valsalva ratio (0.76; 95% CI 0.37-0.91) and handgrip test (0.76; 95% CI 0.35-0.91) (all p<0.05) but was low for the response to quick standing. Reproducibility under standardised conditions was comparable to the above values. We demonstrated that reproducibility for most autonomic tests under non-standardised conditions is acceptable and suggest that implementation of these tests during pre-operative assessment may be feasible.

Axillary recurrence rate after tumour negative and micrometastatic positive sentinel node procedures in breast cancer patients, a population based multicenter study.

BACKGROUND: The sentinel lymph node procedure is a widely accepted method for staging of patients with early breast cancer. This study evaluates the incidence of axillary relapse after negative sentinel node biopsy in the seven hospitals in the central part of the Netherlands. METHODS: This study concerns all patients with a T1-2 breast carcinoma who were staged with a sentinel lymph node biopsy in one of the hospitals in the region. Patients with a tumour-free sentinel node without additional axillary lymph node dissection and patients with a sentinel node containing micrometastases were prospectively included and data concerning tumour and primary treatment were recorded. After a median follow-up period of 46 months supplementary data were collected of all patients. RESULTS: Between January 2002 and December 2003, 541 patients underwent a sentinel node biopsy of which the sentinel node was negative for metastatic disease. During the follow-up period three patients were diagnosed with an axillary recurrence. The incidence of axillary relapse after tumour negative sentinel node biopsy in this study is 0.6% (3/541). In 23 patients a distant metastasis developed. An event occurred in 11% of the patients with a micrometastasis in the sentinel node. This was not significantly different from the patients with a tumour-free sentinel node. CONCLUSION: The results suggest that the sentinel lymph node procedure as performed in the region Middle Netherlands is a reliable and accurate instrument for staging of patients with early breast cancer. In our study we observed a non-significant different risk of distant disease in case of micrometastases compared to a tumour negative sentinel node.