Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists.

BACKGROUND: The majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients. METHODS: A survey was designed to understand current practice and attitudes of vascular surgeons and vascular anaesthetists in the UK regarding preoperative assessment and optimisation of patients undergoing elective aortic aneurysm repair. The survey was reviewed and validated by an expert panel, then distributed electronically to all vascular surgical and vascular anaesthetic leads in the UK. RESULTS: Overall, the response rate was 68%. The responses were varied between surgeons and anaesthetists, with differences reported in the preoperative assessment and optimisation of patients, the approach to shared decision-making, and the perioperative pathway. CONCLUSIONS: Despite initiatives such as Getting It Right First Time (GIRFT) and National Institute for Health and Care Excellence (NICE) guidelines, variation still exists between centres with some differences in opinion observed between surgeons and anaesthetists. These differences may be leading to duplication of work in the perioperative pathway, inconsistencies in how risk is assessed and communicated with consequent variation in patient care. Addressing these issues requires awareness and implementation of existing guidelines, transdisciplinary working, efficient data-driven pathways, and structured aortic aneurysm multi-disciplinary team to promote meaningful shared decision-making.

A Description of Interventions Prompted by Preoperative Comprehensive Geriatric Assessment and Optimization in Older Elective Noncardiac Surgical Patients.

OBJECTIVES: Comprehensive Geriatric Assessment (CGA), a multicomponent, complex intervention, can be used to improve perioperative outcomes. This study aimed to describe the actions and interventions prompted by preoperative CGA and optimization in elective noncardiac, older, surgical patients. DESIGN: Retrospective observational study. SETTING AND PARTICIPANTS: Five hundred consecutive patients aged over 65 years attending a preoperative CGA and optimization clinic in a single academic center. METHODS: A retrospective review of electronic clinical records was undertaken. CGA prompted actions and interventions were categorized a priori and examined according to the perioperative pathway and frailty status. RESULTS: Patients received a median of nine interventions (IQR 6‒12, range 0‒28). Long-term condition medication changes were made in 375 (75.0%) patients, lifestyle advice provided in 269 (53.8%), therapy interventions delivered in 117 (23.4%), shared decision making documented in 495 (99.0%) with individualized admission plans documented in 410/426 (96.2%). Following CGA, 74/500 (14.8%) patients did not undergo surgery and were more likely to have benign pathology (69% vs 53%, P = .01), higher frailty scores (Edmonton Frail Scale 8 (IQR 5‒10) vs 4 (IQR 2-6), P < .001), lower functional status (Nottingham Extended Activities of Daily Living 33 (IQR 16‒47) vs 57 (IQR 45‒64), P < .001) or cognitive scores (Montreal Cognitive Assessment 19 (IQR 14‒24) vs 24 (IQR 20‒26), P < .001). CONCLUSIONS AND IMPLICATIONS: This study provides a description of actions and interventions prompted by preoperative CGA at one center. Such a detailed exploration of the CGA process and the clinical skills necessary to deliver it, should be used to inform future multicenter studies and the development and implementation of perioperative services for older patients.

Preoperative comprehensive geriatric assessment and optimisation prior to elective arterial vascular surgery: a health economic analysis.

BACKGROUND: increasing numbers of older people are undergoing vascular surgery. Preoperative comprehensive geriatric assessment and optimisation (CGA) reduces postoperative complications and length of hospital stay. Establishing CGA-based perioperative services requires health economic evaluation prior to implementation. Through a modelling-based economic evaluation, using data from a single site clinical trial, this study evaluates whether CGA is a cost-effective alternative to standard preoperative assessment for older patients undergoing elective arterial surgery. METHODS: an economic evaluation, using decision-analytic modelling, comparing preoperative CGA and optimisation with standard preoperative care, was undertaken in older patients undergoing elective arterial surgery. The incremental net health benefit of CGA, expressed in terms of quality-adjusted life-years (QALYs), was used to evaluate cost-effectiveness. RESULTS: CGA is a cost-effective substitute for standard preoperative care in elective arterial surgery across a range of cost-effectiveness threshold values. An incremental net benefit of 0.58 QALYs at a cost-effectiveness threshold of £30k, 0.60 QALYs at a threshold of £20k and 0.63 QALYs at a threshold of £13k was observed. Mean total pre- and postoperative health care utilisation costs were estimated to be £1,165 lower for CGA patients largely accounted for by reduced postoperative bed day utilisation. CONCLUSION: this study demonstrates a likely health economic benefit in addition to the previously described clinical benefit of employing CGA methodology in the preoperative setting in older patients undergoing arterial surgery. Further evaluation should examine whether CGA-based perioperative services can be effectively implemented and achieve the same clinical and health economic outcomes at scale.

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS: Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Distress in delirium: causes, assessment and management.

PURPOSE: Delirium is a common clinical syndrome associated with increased physical and psychological morbidity, mortality, inpatient stay and healthcare costs. There is growing interest in understanding the delirium experience and its psychological impact, including distress, for patients and their relatives, carers and healthcare providers. METHODS: This narrative review focuses on distress in delirium (DID) with an emphasis on its effect on older patients. It draws on qualitative and quantitative research to describe patient and environmental risk factors and variations in DID across a number of clinical settings, including medical and surgical inpatient wards and end of life care. The article provides an overview of the available distress assessment tools, both for clinical and research practice, and outlines their use in the context of delirium. This review also outlines established and emerging management strategies, focusing primarily on prevention and limitation of distress in delirium. RESULTS: Both significant illness and delirium cause distress. Patients who recall the episode of delirium describe common experiential features of delirium and distress. Relatives who witness delirium also experience distress, at levels suggested to be greater than that experienced by patients themselves. DID results in long-term psychological sequelae that can last months and years. Preventative actions, such pre-episode educational information for patients and their families in those at risk may reduce distress and psychological morbidity. CONCLUSIONS: Improving clinicians' understanding of the experience and long term psychological harm of delirium will enable the development of targeted support and information to patients at risk of delirium, and their families or carers.

Frailty in the older surgical patient: a review.

The rate of surgical procedures in the older population is rising. Despite surgical, anaesthetic and medical advances, older surgical patients continue to suffer from adverse postoperative outcomes. Comorbidities and reduction in physiological reserve are consistently identified as major predictors of poor postoperative outcome in this population. Frailty can be defined as a lack of physiological reserve seen across multiple organ systems and is an independent predictor of mortality, morbidity and institutionalisation after surgery. Despite this identification of frailty as a significant predictor of adverse postoperative outcome, there is not yet a consensus on the definition of frailty or how best to assess and diagnose it. This review describes our current definitions of frailty and discusses the available methods of assessing frailty, the impact on the older surgical population and the emerging potential for modification of this important syndrome.