Studies on Perioperative Care for Frail Patients:focused on Gynecology

The population undergoing surgery is getting older. Surgery poses a higher risk in older people compared to younger people. Older patients may have specific health threats, but being old does not necessarily mean one has a decreased health status. A substantial part of the older population is still living active and healthy. Biological age seems to be a more important risk factor for negative health outcomes than chronological age. It is therefore essential to identify older people who are at risk of adverse health outcomes after surgery, to correct modifiable risk factors and to adapt their care if necessary.The aim of this thesis was to study how, through better perioperative care, we can improve postoperative outcomes for older patients. The focus lay on patients undergoing gynecological surgery. We concentrated on three areas: ‘identifying the high-risk group for worse postoperative outcomes’, ‘preoperative care optimization through prehabilitation’, and ‘postoperative delirium prevention’.In order to improve postoperative outcomes for older patients we should target on education and awareness of clinicians on frailty and preoperative risk assessment. Identified frail patients can be offered a comprehensive geriatric assessment and a personalized care program, including prehabilitation, led by a multidisciplinary team. Developing specific prehabilitation programs per specialty does not seem to be necessary, because gynecological patients have much in common with other older patients undergoing abdominal surgery. This thesis suggests that adequate anemia management should be part of the personalized care program for the frail patient, as part of a delirium prevention strategy

PREsurgery thoughts - thoughts on prehabilitation in oncologic gynecologic surgery, a qualitative template analysis in older adults and their healthcare professionals

Purpose This study aimed to reveal information that can be used for composing a prehabilitation program tailored to elderly gynecological oncological patients and is applicable to healthcare professionals. We investigated possible content and indications for prehabilitation, and what potential barriers might exist. Materials and methods Because of the primary exploratory study aim, inductive thematic template analysis on semi-structured interviews with gynecologic oncological patients aged >= 60 years and healthcare professionals were used. Results 16 patients and 20 healthcare professionals were interviewed. Three themes important for prehabilitation were found: (1) "Motivation," (2) "Practical issues and facilitators," and (3) "Patient-related factors." A short time interval between diagnosis and surgery was reported as a potential barrier for prehabilitation. Given components for a tailor-made prehabilitation program are: (1) The first contact with a nurse who screens the patients, gives tailor-made advice on prehabilitation and keeps patients motivated and supports them mentally; (2) If patients are referred to a more extensive/supervised program, this should preferably be arranged close to a patients' home. Conclusion Based on our findings, an outline of a patient-tailored prehabilitation program was developed. The main important themes for prehabilitation were "Motivation," "Practical issues and facilitators," and "Patient-related factors.

Risk assessment for postoperative outcomes in a mixed hospitalized gynecological population by the Dutch safety management system (Veiligheidsmanagementsysteem, VMS) screening tool 'frail elderly'

PURPOSE: Frailty is associated with a higher risk for negative postoperative outcomes. This study aimed to determine the association between the screening tool of the Dutch safety management system, Veiligheidsmanagementsysteem (VMS) ‘frail elderly’ and postoperative complications in a gynecological population. METHODS: This cohort study included women aged 70 years or older, who were scheduled for any kind of gynecological surgery. VMS screening data (including risk for delirium, falling, malnutrition, and functional impairment) were extracted from the electronic patient records. VMS score could range between 0 and 4 patients with a VMS score of one or more were considered frail. Data on possible confounding factors and complications within 30 days after surgery, classified with the Clavien–Dindo classification, were collected. Regression analysis was performed. RESULTS: 157 women were included with a median age of 74 years (inter quartile range 71–79). Most patients underwent prolapse surgery (52%) or hysterectomy (31%). Forty-one patients (26%) experienced any postoperative complication. Sixty-two patients (39%) were considered frail preoperatively by the VMS screening tool. Frailty measured with the VMS screening tool was not independently associated with postoperative complications in multivariable analysis (Odds ratio 1.18; 95% CI 0.49–2.82). However, a recent fall in the last 6 months (n = 208) was associated with postoperative complications (Odds ratio 3.90; 95% CI 1.57–9.66). CONCLUSION: An independent association between frailty, determined by the VMS screening tool ‘Frail elderly’, and postoperative complications in gynecological surgery patients could not be confirmed. A recent fall in the last 6 months seems associated with postoperative complications

Loss of skeletal muscle density during neoadjuvant chemotherapy in older women with advanced stage ovarian cancer is associated with postoperative complications

Objective: To assess the association between loss of lumbar skeletal muscle mass and density during neoadjuvant chemotherapy (NACT) and postoperative complications after interval cytoreductive surgery (CRS) in older patients with ovarian cancer. Materials and methods: This multicenter, retrospective cohort study included patients aged 70 years and older with primary advanced stage ovarian cancer (International Federation of Gynecology and Obstetrics stage III-IV), treated with NACT and interval CRS. Skeletal muscle mass and density were retrospectively assessed using Skeletal Muscle Index (SMI) and Muscle Attenuation (MA) on routinely made Computed Tomography scans before and after NACT. Loss of skeletal muscle mass or density was defined as >2% decrease per 100 days in SMI or MA during NACT. Results: In total, 111 patients were included. Loss of skeletal muscle density during NACT was associated with developing any postoperative complication ≤30 days after interval CRS both in univariable (Odds Ratio (OR) 3.69; 95% Confidence Interval (CI) 1.57–8.68) and in multivariable analysis adjusted for functional impairment and WHO performance status (OR 3.62; 95%CI 1.27–10.25). Loss of skeletal muscle density was also associated with infectious complications (OR 3.67; 95%CI 1.42–9.52) and unintended discontinuation of adjuvant chemotherapy (OR 5.07; 95%CI 1.41–18.19). Unlike loss of skeletal muscle density, loss of skeletal muscle mass showed no association with postoperative outcomes. Conclusion: In older patients with ovarian cancer, loss of skeletal muscle density during NACT is associated with worse postoperative outcomes. These results could add to perioperative risk assessment, guiding the decision to undergo surgery or the need for perioperative interventions

Low preoperative skeletal muscle density is predictive for negative postoperative outcomes in older women with ovarian cancer

Objective. To determine the predictive value of lumbar skeletal muscle mass and density for postoperative outcomes in older women with advanced stage ovarian cancer.Methods. A multicenter, retrospective cohort study was performed in women >= 70 years old receiving surgery for primary, advanced stage ovarian cancer. Skeletal muscle mass and density were assessed in axial CT slices on level L3. Low skeletal muscle mass was defined as skeletal muscle index = 2).Conclusion. Low skeletal muscle density, as a proxy of muscle quality, is associated with poor postoperative outcomes in older patients with advanced stage ovarian cancer. These findings can contribute to postoperative risk assessment and clinical decision making. (C) 2021 The Author(s). Published by Elsevier Inc.Cervix cance

The Comparative Risk of Delirium with Different Opioids:A Systematic Review

There is substantial evidence that the use of opioids increases the risk of adverse outcomes such as delirium, but whether this risk differs between the various opioids remains controversial. In this systematic review, we evaluate and discuss possible differences in the risk of delirium from the use of various types of opioids in older patients. We performed a search in MEDLINE by combining search terms on delirium and opioids. A specific search filter for use in geriatric medicine was used. Quality was scored according to the quality assessment for cohort studies of the Dutch Cochrane Institute. Six studies were included, all performed in surgical departments and all observational. No study was rated high quality, one was rated moderate quality, and five were rated low quality. Information about dose, route, and timing of administration of the opioid was frequently missing. Pain and other important risk factors of delirium were often not taken into account. Use of tramadol or meperidine was associated with an increased risk of delirium, whereas the use of morphine, fentanyl, oxycodone, and codeine were not, when compared with no opioid. Meperidine was also associated with an increased risk of delirium compared with other opioids, whereas tramadol was not. The risk of delirium appeared to be lower with hydromorphone or fentanyl, compared with other opioids. Numbers used for comparisons were small. Some data suggest that meperidine may lead to a higher perioperative risk for delirium; however, high-quality studies that compare different opioids are lacking. Further comparative research is neede

Prehabilitatie voor kwetsbare ouderen, goed voorbereid voor abdominale chirurgie

Older, frail patients have an increased risk of post-operative complications resulting in loss of function, dependency, reduced quality of life and mortality. Possibly, prehabilitation can improve postoperative outcomes. The aim of this clinical lesson was to present the current evidence for prehabilitation in abdominal surgery with a specific focus on the geriatric population. Prehabilitation seems to be acceptable and feasible for older patients. Especially multidimensional prehabilitation programs seem promising. Moreover, tailor-made exercise programs have been shown to have a positive effect on postoperative complications. However, none of this has yet been conclusively proven. More studies are needed to evaluate the effect of prehabilitation in the frail surgical population

The Comparative Risk of Delirium with Different Opioids: A Systematic Review

Objective There is substantial evidence that the use of opioids increases the risk of adverse outcomes such as delirium, but whether this risk differs between the various opioids remains controversial. In this systematic review, we evaluate and discuss possible differences in the risk of deliriumfromthe use of various types of opioids in older patients. Methods We performed a search in MEDLINE by combining search terms on delirium and opioids. A specific search filter for use in geriatric medicine was used. Quality was scored according to the quality assessment for cohort studies of the Dutch Cochrane Institute. Results Six studies were included, all performed in surgical departments and all observational. No study was rated high quality, one was rated moderate quality, and five were rated low quality. Information about dose, route, and timing of administration of the opioid was frequently missing. Pain and other important risk factors of delirium were often not taken into account. Use of tramadol or meperidine was associated with an increased risk of delirium, whereas the use of morphine, fentanyl, oxycodone, and codeine were not, when compared with no opioid. Meperidine was also associated with an increased risk of delirium compared with other opioids, whereas tramadol was not. The risk of delirium appeared to be lower with hydromorphone or fentanyl, compared with other opioids. Numbers used for comparisons were small. Conclusion Some data suggest that meperidine may lead to a higher perioperative risk for delirium; however, highquality studies that compare different opioids are lacking. Further comparative research is needed