Anthony Falvo

Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly.

BACKGROUND America’s aging population has led to an increase in the number of elderly patients necessitating emergency general surgery. Previous studies have demonstrated that increased frailty is a predictor of outcomes in medicine and surgical patients. We hypothesized that use of a modification of the Canadian Study of Health and Aging Frailty Index would be a predictor of morbidity and mortality in patients older than 60 years undergoing emergency general surgery. METHODS Data were obtained from the National Surgical Quality Improvement Program Participant Use Files database in compliance with the National Surgical Quality Improvement Program Data Use Agreement. We selected all emergency cases in patients older than 60 years performed by general surgeons from 2005 to 2009. The effect of increasing frailty on multiple outcomes including wound infection, wound occurrence, any infection, any occurrence, and mortality was then evaluated. RESULTS Total sample size was 35,334 patients. As the modified frailty index increased, associated increases occurred in wound infection, wound occurrence, any infection, any occurrence, and mortality. Logistic regression of multiple variables demonstrated that the frailty index was associated with increased mortality with an odds ratio of 11.70 (p < 0.001). CONCLUSION Frailty index is an important predictive variable in emergency general surgery patients older than 60 years. The modified frailty index can be used to evaluate risk of both morbidity and mortality in these patients. Frailty index will be a valuable preoperative risk assessment tool for the acute care surgeon. (J Trauma Acute Care Surg. 2012;72: 1526–1531. Copyright

Acute renal failure in cardiothoracic surgery patients: what is the best definition of this common and potent predictor of increased morbidity and mortality

BACKGROUND Universal agreement on criteria for acute renal failure (ARF) is lacking. The purpose of the current study was to determine which of 6 definitions for ARF best predicted clinical outcomes in postoperative cardiothoracic surgery (CTS) patients. METHODS Criteria for ARF were retrospectively applied to 1,085 CTS patients. General linear models analyzed length of stay (LOS) and ventilator days with logistic regression for mortality. RESULTS Thirty-seven percent of patients met at least 1 of 6 definitions of ARF. For each 1-mg/dL increase from the initial creatinine, LOS increased by 6.96 days, ventilator days increased by 3.58 days, and mortality increased by 2.23 times (P < .0001). CONCLUSIONS One definition that best predicted ARF was not found. ARF was a significant independent predictor of increased mortality, LOS, and ventilator days. Even small increases in creatinine correlate with clinically significant worsening of expected outcomes.

What ring tone should be used for patient safety? Early results with a Blackberry-based telementoring safety solution

OBJECTIVE Technology currently exists for the application of remote guidance in the laparoscopic operating suite. However, these solutions are costly and require extensive preparation and reconfiguration of current hardware. We propose a solution from existing technology, to send video of laparoscopic cholecystectomy to the Blackberry Pearl device (RIM Waterloo, ON, Canada) for remote guidance purposes. This technology is time- and cost-efficient, as well as reliable. METHODS After identification of the critical maneuver during a laparoscopic cholecystectomy as the division of the cystic duct, we captured a segment of video before its transection. Video was captured using the laparoscopic camera input sent via DVI2USB Solo Frame Grabber (Epiphan Ottawa, Canada) to a video recording application on a laptop. Seven- to 40-second video clips were recorded. The video clip was then converted to an .mp4 file and was uploaded to our server and a link was then sent to the consultant via e-mail. The consultant accessed the file via Blackberry for viewing. After reviewing the video, the consultant was able to confidently comment on the operation. RESULTS Approximately 7 to 40 seconds of 10 laparoscopic cholecystectomies were recorded and transferred to the consultant using our method. All 10 video clips were reviewed and deemed adequate for decision making. CONCLUSION Remote guidance for laparoscopic cholecystectomy with existing technology can be accomplished with relatively low cost and minimal setup. Additional evaluation of our methods will aim to identify reliability, validity, and accuracy. Using our method, other forms of remote guidance may be feasible, such as other laparoscopic procedures, diagnostic ultrasonography, and remote intensive care unit monitoring. In addition, this method of remote guidance may be extended to centers with smaller budgets, allowing ubiquitous use of neighboring consultants and improved safety for our patients.

Developing an experimental model for surgical drainage investigations: An initial report

BACKGROUND We sought to pilot and initiate validation of a surgical drainage model. METHODS We designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling. RESULTS Under serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice. CONCLUSIONS The Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program Analysis.

BACKGROUND Unplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. OBJECTIVE To elucidate factors associated with increased mortality risk in patients with unplanned postoperative reintubation. DESIGN Retrospective study. Patients older than 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Multiple regression models were used to examine the impact on mortality of factors that included the modified frailty index (mFI) we developed, American Society of Anesthesiologists (ASA) score, age decile, and days to reintubation. MAIN OUTCOME MEASURE Mortality. RESULTS A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). On postoperative day 1, 4434 patients were reintubated and 878 (19.8%) died. On postoperative day 7 and beyond, 6329 patients were reintubated and 2215 (35.0%) died. Increasing mFI resulted in increasing incidence of mortality (mFl of 0 = 20.5% mortality vs mFl of 0.37-0.45 = 41.7% mortality). As ASA score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality (40-49 years, 17.9% vs 80-89 years, 42.1%). After adjustment for confounding factors, mFI, ASA score, age decile, and increasing number of days to reintubation were independently and significantly associated with increased mortality in the study population. CONCLUSION Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.