A multicentre observational study on management of general anaesthesia in elderly patients at high-risk of postoperative adverse outcomes

Molliex, Serge; Passot, Sylvie; Morel, J.; Futier, Emmanuel; Lefrant, Jean Yves; Constantin, Jean Michel; Manach, Yannick Le; Pereira, Bruno; Bruder, Nicolas; Vaisse, Camille; Bechis, Carole; Bernard, Lise; Léone, Marc; Poirier, Mathieu J. P.; Vincent, Ariel; Abdelkrim, N.; Paugam, Catherine; Lion, François; Montravers, Philippe; Langeron, Olivier; Raux, Mathieu; Baussier, M.; Xu, Ke; Bart, François; Dagois, Sophie; Plaud, Benoît; Rabuel, Christophe; Roland, Edmond; Biais, Matthieu; Nouette‐Gaulain, Karine; Cabart, A.; Hanouz, Jean‐Luc; Lambert, Claude; Godet, Thomas; Thibault, Sandrine; Bouhemad, Bélaïd; Chambade, E.; Bouzat, Pierre; Garot, Matthias; Lebuffe, Gilles; Lallemant, Florence; Lemery, C.; Tavernier, B.; Jong, Audrey De; Jaber, Samir; Verzilli, Daniel; Delannoy, M.; Meistelman, Claude; Carlès, Michel; Tran, Lena K; Bertran, Sébastien; Cuvillon, Philippe; Ripart, Jacques; Simon-Pene, S.; Boisson, Matthieu; Debaene, B.; Beloeil, Hélène; Godet, G.; Collange, Olivier; Mertès, Paul-Michel; Diemunsch, Pierre; Joganah, D.; Oehlkern, L.; Baulieu, M.; Beauchesne, B.; Beraud, A.M.; Berthier-Berrada, S.; Bien, Jeffrey; Dupont, Grégory; Gavory, J.; Lambert, Pamela J.; Lanoiselée, Julien; Zufferey, P.; Ferré, Fabrice; Martin, Carolyn; Minville, Vincent; Planté, B.; Baffeleuf, B.; Abdelkarim, Mostafa; David, Jean-Stéphane; Incagnoli, Pascal; Khaled, Maram; Laplace, M.; Lefevre, Michael; Piriou, Vincent; Aubrun, Frédéric; Cero, V.; Delsuc, C.; Faulcon, C.; Meuret, Pascal; Rimmelé, Thomas; Truc, C.

doi:10.1016/j.accpm.2018.05.012

Cited by 21 publications

(8 citation statements)

References 28 publications

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“…Furthermore, this variability is linked to clinical outcomes . Similar patterns of variation in care pertain in peri‐operative blood transfusion , oxygen therapy and peri‐operative ventilation . These observations support the notion that intra‐operative care should be both standardised and individualised; standardised to drive consistent patterns of care between different patients, and individualised to ensure that such care is based on individual patients’ clinical risk.…”

Section: Peri‐operative Care Pathwayssupporting

confidence: 57%

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

et al. 2019

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Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. Re-engineered pre-operative pathways open up opportunities for intervention before surgery including shared decision-making, comorbidity management and collaborative behavioural change. Individualised, risk-adapted, intra-operative interventions will drive more reliable and consistent care. Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.

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Section: Peri‐operative Care Pathwayssupporting

confidence: 57%

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

et al. 2019

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“…• Recommendations for anesthetic care are often difficult to implement in the intraoperative setting because of the requirement for continuous attention utilizing them can largely be improved, especially regarding compliance to treatment protocols. [10][11][12] Part of the difficulty in maintaining compliance with such optimization strategies is that they require sustained continuous attention and frequent adjustments to maintain specific physiologic variables within predefined target ranges. In clinical environments, tightly controlled manual feedback is often not possible because of other important tasks, distractions, and the natural limitations of human attention.…”

Section: Editor's Perspectivementioning

confidence: 99%

“…15,16 Additionally, and perhaps more importantly, the results of the current study emphasized the concept that closedloop systems might represent an interesting approach to ensure standardization and consistent application of physiologic-based recommendations, particular if these recommendations are strict. 11 It is unfortunate that closed-loop systems are still predominantly considered to be simply a research tool, although their increasing acceptance into clinical environment in upcoming years is expected.…”

Section: Impact Of Closed-loop Anesthesia On Cognitive Functionmentioning

confidence: 99%

Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery

et al. 2020

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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Cognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia. Methods In this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes. Results Forty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (–1 [–2 to 0] vs. 0 [–1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group. Conclusions Automated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.

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“…A multicenter RCT involving 807 patients ≥ 75 years old and using a stepped wedge cluster design to assess the effectiveness of an optimization strategy involving GDHT, lung-protective ventilation, and depth of anesthesia monitoring for GA on postoperative morbidity and mortality in high-risk elderly patients undergoing high-risk surgeries (the OPTI-AGED study) identified a considerable gap between clinical practice and the relevant guidelines for anesthetic optimization [108]. Implementation of such multimodal optimization strategies varied independently of factors related to the population or type of surgery, and thus, potential benefit should be further addressed in elderly patients [109].…”

Section: Fluid Management and Blood Transfusionmentioning

confidence: 99%

Anesthetic management of geriatric patients

Lim

2020

Korean J Anesthesiol

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The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.

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A multicentre observational study on management of general anaesthesia in elderly patients at high-risk of postoperative adverse outcomes

Abstract: In patients'≥75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.

Cited by 21 publications

References 28 publications

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

Anesthetic Management Using Multiple Closed-loop Systems and Delayed Neurocognitive Recovery

Anesthetic management of geriatric patients

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