Evaluation of Frailty Assessment Compliance in Acute Care Surgery: Changing Trends, Lessons Learned.

BACKGROUND: Routine frailty assessment has emerged recently in the surgical literature and is an important prognostication and risk stratification tool. The aim of our study was to review our 7-y experience with two frailty assessment tools and changing trends in their use. METHODS: We performed a 7-y (2011-2017) analysis of our prospectively maintained frailty database. Frail patients were identified using the emergency general surgery and trauma specific frailty indices. Outcome measures were rates of compliance with frailty assessment, overall complications, discharge to skilled nursing facility (SNF)/rehab, and mortality over the study period. Multivariate logistic regression and Cochran-Armitage trend analyses were performed. RESULTS: We evaluated a total of 1045 geriatric patients (Trauma: 587, EGS: 458). Mean age was 74.5 ± 7.9 y, 74% were males, and 81% were white. Overall, 34% of the patients were frail. Compared to non-frail patients, frail patients had higher adjusted rates of complications (OR 2.4 [1.9-2.9]), mortality (OR 1.8 [1.4-2.3]), and rehab/SNF disposition (OR 3.7 [3.1-4.3]). The compliance rate of measuring frailty increased from 12% in 2011 to 78% in 2017, P < 0.001 (Figure). The complication rate decreased (33% versus 21%, P < 0.001), while the rate of discharge disposition to SNF/Rehab increased (41% versus 58%, P < 0.001). There was no difference in mortality (11% versus 9.8%, P = 0.48) over the study period. CONCLUSIONS: Adherence to frailty measurement increased over the study period. This was accompanied by a significant decline in overall in-hospital complications. Frailty indices can be utilized to identify high-risk patients and develop post-operative strategies to improve outcomes in acute care surgery.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

BACKGROUND: Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients. METHODS: We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed. RESULTS: In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality. CONCLUSION: Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

Atrial fibrillation, electroconvulsive therapy, stroke risk, and anticoagulation.

BACKGROUND: Electroconvulsive therapy (ECT) is a therapy used to treat refractory mental health conditions, ranging from depression to catatonia, and it has gained renewed prominence in practice and the literature of late. Given that ECT involves the application of direct current to the body, there exists a risk of a change in cardiac rhythm during therapy. When atrial fibrillation is induced, ECT carries a potential risk of stroke. These risks have not been previously analyzed or summarized in the literature to allow physicians to make educated decisions about periprocedural risk and anticoagulation needs. METHODS: To better describe this risk, the authors reviewed PubMed for articles that described the post-ECT cardioversion of AF to sinus rhythm, new development of AF post-ECT, and new stroke after either rhythm change. RESULTS: Included were 14 studies describing 19 unique patients. Most patients had no rhythm change during at least one of many ECT sessions. Five patients converted from AF to sinus rhythm during at least one session, while AF followed ECT in seventeen patients during at least one ECT session. Four patients experienced both ECT-related cardioversion from AF to sinus rhythm as well as conversion from sinus rhythm to AF. Although no patients with a rhythm change experienced a stroke, one unanticoagulated patient who remained in AF developed a stroke post-ECT. CONCLUSIONS: Electroconvulsive therapy is demonstrated to be associated with rhythm changes-from atrial fibrillation to sinus rhythm as well as from sinus rhythm to atrial fibrillation. Thus, stroke risk during and after ECT remains a possibility. The anticoagulation of patients with AF who undergo ECT should be based on individual stroke risk factors, using validated stroke risk models, rather than prescribed routinely.

Cognition, Frailty, and Functional Outcomes of Transcatheter Aortic Valve Replacement.

BACKGROUND: Cognitive impairment and frailty are highly prevalent in older adults undergoing transcatheter aortic valve replacement. This study aimed to investigate the relationship of cognitive impairment and frailty with functional recovery after transcatheter aortic valve replacement. METHODS: This was a single-center prospective cohort study of 142 patients who were ≥70 years old and underwent transcatheter aortic valve replacement for aortic stenosis. Prior to transcatheter aortic valve replacement, cognitive impairment was defined as Mini-Mental State Examination score <24 points (range: 0-30), and moderate-to-severe frailty was defined as a deficit-accumulation frailty index ≥0.35 (range: 0-1). The functional status composite score, the number of 22 daily and physical tasks that a patient could perform independently, measured at baseline and 1, 3, 6, 9, and 12 months postoperatively were analyzed using linear mixed-effects model. RESULTS: The mean age was 84.2 years; 74 subjects were women (51.8%). Patients with moderate-to-severe frailty and cognitive impairment (n = 27, 19.0%) had the lowest functional status at baseline and throughout 12 months, while patients with mild or no frailty and no cognitive impairment (n = 48, 33.8%) had the best functional status. Patients with cognitive impairment alone (n = 19, 13.4%) had better functional status at baseline than those with moderate-to-severe frailty alone (n = 48, 33.8%), but their functional status scores merged and remained similar during the follow-up. CONCLUSIONS: Preoperative cognitive function plays a vital role in functional recovery after transcatheter aortic valve replacement, regardless of baseline frailty status. Impaired cognition may increase functional decline in the absence of frailty, whereas intact cognition may mitigate the detrimental effects of frailty. Cognitive assessment should be routinely performed prior to transcatheter aortic valve replacement.