Pre‐operative co‐morbidity and postoperative survival in the elderly: beyond one lunar orbit

Abstract

SummaryMortality is a good measure of killing, but it is a poor measure of cure, palliation or the maintenance of function. Nevertheless, it has remained the primary metric of hospital care for 200 years. This article discusses the factors that contribute to mortality risk and survival trajectories, as well as the increasing recognition that surgery kills for months after the last suture is tied. This article discusses how disparate factors can usefully combine to generate an 'elderly' group with a monthly mortality in excess of 1% and a median life expectancy less than 3.5 years. A downloadable spreadsheet is provided that combines risk factors to generate mortality risks and their associated survival curves, emphasising the importance of looking beyond one postoperative month. If the function of a hospital were to kill the sick, statistical comparisons of this nature would be admissible.-Florence Nightingale, 1859 [1] Mortality is an insensitive measure of care: most patients survive the postoperative period, whilst (perhaps) many observed deaths are not associated with poor care. We should concentrate on the living, not the dead. Unfortunately, information on the effect surgery has on people's lives is scarce, in comparison with how often it kills them. This paper discusses how to estimate the chance that someone will die and how much this might change following surgery, but in so doing, we might reflect on Florence Nightingale's observation that mortality is an excellent measure of performance only for those trying to kill. Chance (at least in part) determines survival and death, which can be estimated using certain characteristics throughout adulthood: age; sex; historical morbidity; and physiological function [2][3][4][5][6][7][8][9][10][11][12]. The latter two characteristics are meant in their broadest sense, so that together they might accommodate variables that are, or might be, independently associated with survival. For instance, socioeconomic status is an historical characteristic that confers morbidity and mortality risks, whereas brain natriuretic peptide (BNP) is a marker of physiological function that might be shown to have an independent prognostic value. Crucially, variables used in the calculation should have a known independent effect on long-term survival in the general, non-surgical population, so that all the purposes of pre-operative mortality estimation are served (see below). Variables, such as BNP, have yet to declare their value in promoting the precision of perioperative prognostication, because their relationship with general survival has been inadequately described.It is one's risk of death, rather than one's proximity to birth, that determines the trajectory of one's remain-

Paciente Adulto Mayor Y Cirugía No Cardíaca: ¿qué Debemos Saber?

“…no existe evidencia só-lida de que un tipo específico de anestesia sea la mejor opción para este subgrupo de pacientes 5,35 , por lo que la decisión debe ser caso a caso. Sin embargo, se ha visto que la anestesia regional tiene algunas ventajas como mejor manejo del dolor postoperatorio y menor incidencia de trombosis venosa profunda 36 .…”

Peri‐operative care of the elderly 2014

“…• Risk related to the patient [24]: Age-related physiological decline, multi-morbidity and frailty are independently associated with increased perioperative risk. Pre-operative assessment of the higher-risk elderly patient, involving a structured multifactorial approach [25], therefore, should be undertaken by both a senior geriatrician and a senior anaesthetist with specific subspecialty training in geriatrics (depending on resources and time available).…”

“…In practice, this may include information about the nature, purpose, (short-term and long-term) risks and benefits of a specific procedure, an alternative procedure, or no procedure at all (conservative therapy). For older patients, the Working Party recommends that information should be provided specifically about how an intervention might affect the quantity or quality of a patient's remaining life; a pre-operative risk calculator is available for this purpose [24].…”

Anaesthetists' contribution to mortality after cardiac surgery

“…Of course, mortality may not be the correct outcome by which to measure the effect of anaesthesia or anaesthetist [5,6]. The authors' call for the non-publication of anaesthetic data sets a precedent, however, for future data suppression when more common and 'anaesthesia-sensitive' peri-operative outcomes become routinely measured (for example, pain, hypotension, pulmonary complications, delirium [7]).…”