M. I. Rochera

Mortality and surgical risk assessment among the extreme old undergoing emergency surgery

BACKGROUND Although longevity is becoming frequent, there are no scores to assess nonagenarians undergoing emergency surgery. The aim of this prospective observational study was to determine 30-day mortality and the individual performance of the Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity (POSSUM) and other scores in predicting their risk for death. METHODS A total of 126 patients were included (2006-2011) and followed for 30 days. Patients risk for death was calculated using different scores. The accuracy of each score was assessed with exponential and linear methods and using the area under the receiver operating characteristic curve. RESULTS Overall mortality was 34.9%. The POSSUM, with a modification in the age category, had an area under the curve of .71 and ratios of observed to predicted deaths of 1.07 and 1.22, respectively, in the linear and exponential analysis. CONCLUSIONS In a population with as high a risk as nonagenarians, the age-modified POSSUM proved accurate to audit surgery and assess mortality risk.

Mortality, Geriatric, and Nongeriatric Surgical Risk Factors Among the Eldest Old: A Prospective Observational Study

BACKGROUND: Preoperative risk and postoperative outcomes among the elderly are the subject of extensive debate. However, the eldest old, that is, the fastest-growing and most vulnerable group, are insufficiently studied; even their mortality rate is unclear. This prospective observational study was performed with the aim of determining the mortality rate of this population and establishing which preoperative conditions were predictors of which postoperative outcomes. The study was undertaken between 2011 and 2015 in a major tertiary care university hospital. METHODS: All patients aged ≥85 years undergoing any elective procedure during the study period were included. Patients were followed up for 30 days postoperatively. The preoperative conditions studied were demographic data, grade of surgical complexity (1–3), preoperative comorbidities, and some characteristically geriatric conditions (functional reserve, nutrition, cognitive status, polypharmacy, dependency, and frailty). The outcome measures were 30-day all-cause mortality (primary end point), morbidity, prolonged length of stay, and escalation of care in living conditions. RESULTS: Of 139 eligible patients, 127 completed follow-up. The 30-day mortality was 7.9%; 95% confidence interval (CI), 3.2–12.6. It had 3 predictors: malnutrition (odds ratio [OR], 15; 95% CI, 3–89), complexity 3 (OR, 9.1; CI, 2–52), and osteoporosis/osteoporotic fractures (OR, 14.7; CI, 2–126). Significant predictors for morbidity (40%) were ischemic heart disease (OR, 3.9; CI, 1–11) and complexity 3 (OR, 3.6; CI, 2–9), while a nonfrail phenotype (OR, 0.3; CI, 0.1–0.8) was found to be protective. Only 2 factors were found to be predictive of longer admissions, namely complexity 3 (OR, 4.4; CI, 2–10) and frailty (OR, 2.7; CI, 2–7). Finally, risk factors for escalation of care in living conditions were slow gait (a surrogate for frailty, OR, 2.5; CI, 1–6), complexity 3 (OR, 3.2; CI, 1–7), and hypertension (OR, 2.9; CI, 1–9). CONCLUSIONS: The eldest old is a distinct group with a considerable mortality rate and their own particular risk factors. Surgical complexity and certain geriatric variables (malnutrition and frailty), which are overlooked in American Society of Anesthesiologists and most other usual scores, are particularly relevant in this population. Inclusion of these factors along with appropriate comorbidities for risk stratification should guide better decision making for families and doctors alike and encourage preoperative optimization of patients.

Anaemia and transfusion in nonagenarians undergoing emergency, non-traumatic surgery: a prospective observational study.

To characterise transfusion and determine its main predictors in nonagenarians undergoing non‐elective, non‐traumatic surgery. Simultaneously, we compared nonagenarians to a similar, but younger sample, as far as the transfusional policy is concerned.

Conflicts between anaesthetists and surgeons: 15AP1-1

preanesthesia (the only -2 agonist locally available at the moment) was compared to placebo. Materials and Methods: Two equivalent groups of 40 patients (ASA I–III) were randomised to receive Diazepam in the evening before and oral Clonidine 150 g or placebo in the morning of the surgery. They have received equivalent ballanced general anesthesia for medium amplitude abdominal procedures. Intraand postoperative haemodynamic was assesed, as well as opiod consumption during surgery, opioid antagonisation at emergence. Anxiety, sedation, postoperatory respiratory depression and analgesia were quantified at 5 min postoperatory, at 1 h, then each 3 h until 24 h. Patients’ satisfaction (pain control, side effects) was assesed by a self-administred questionnaire in day 4. The statistic significance of the differences observed in the evolution of these parameters was tested by T Student test. Results and Discussions: Haemodynamic was better in the Clonidine group (variation greater than 20% for arterial pressure and heart rate at induction and during surgery for placebo group, p 0.05). This was even stronger for hypertensive patients. Opioid consumption reported to the duration of the intervention was comparable in the two groups Sedation and respiratory depression was slightly higher in the Clonidine group during the first 12 hours (p 0.05), Analgetic consumption was not statistically different in the two groups, as well as the pain control, Postoperative satisfaction (pain control, sedation, other side effects) was equivalent in the two groups. Conclusion(s): Clonidine premedication for moderate amplitude abdominal surgery ensures a better haemodynamic both intraand postoperatively, with minor side effects concearning sedation and respiratory depression. References: Bonnet F, Houhou A, Aveline C, ESA Refresher Courses 2000. Foëx P, Sear JW Continuing Education in Anaesthesia, Critical Care & Pain 2004 4(5): 139–143. 182 Education, research and presentation

Cerebral oxymetry monitoring after carotid endarterectomy or stenting: A-105

A-105 Cerebral oxymetry monitoring after carotid endarterectomy or stenting M.I. Rochera1, C. Vazquez1, M. de Miguel1, A. Gonzalez1, M. Roca1, B. Alvarez2, M. de Nadal1 1Department of Anesthesiology, Vall d Hebron Universitary Hospital; 2Department of Angiology and Vascular Surgery, Vall d Hebron Universitary Hospital, Barcelona, Spain Background and Goal of Study: Hyperperfusion syndrome (HP) is a rare but potentially grave complication after carotid endarterectomy (CEA) or stenting (CS) (1). Intraoperative regional cerebral oxygen saturation (rSO2) monitoring can identify patients at risk for HP after CEA (2). The goal of this study was to determine whether intra or postoperative changes in rSO2 could help to identify patients at risk for HP after CEA or CS. Methods: 42 patients scheduled for elective severe carotid stenosis repair were studied; 24 underwent CEA and 18 CS. Bilateral rSO2, mean arterial blood pressure (MAP) and periferal oxygen saturation (SpO2) were continuously monitored intraoperatively, at arrival to postanesthesia care unit (PACU) and 12 hours postoperatively. All patients underwent strict control of postoperative blood pressure. Changes in rSO2 ( rSO2) were calculated between T1 (basal awake), T2 (after declamping), T3 (PACU arrival), 1, 6 and 12 hours postoperatively (T4 T6) and PACU discharge (T7). Changes in MAP and SpO2 were also recorded, as well as the postoperative incidence of cephalea, seizures or neurological events. Repeated measures ANOVA with post-hoc test and Pearson’s correlation coefficient were used for statistical analysis. Results: One patient had to be excluded because of intraoperative angina. From the remaining 41 patients (30 M, 11 W, mean age 73 10 years, 55–92), 11 (27%) had contralateral severe ICA stenosis. None of the patients had adverse neurological outcome. No significant changes in rSO2 were observed; however, patients with severe contralateral stenosis showed significant changes in rSO2 between T2–T3, T2–T4 and T2-T5. A positive correlation betweeen rSO2 and MAP for ipsilateral ICA (r2 0.244, p 0.001) was found. Conclusions: This study did not show significant changes in rSO2 immediately after repairing the carotid circulation or in the immediate postoperative period relative to preoperative values. Nevertheless none of the patients had symptoms of HP to be identified by cerebral oxymetry. References: 1 van Mook, Rennenberg RJ, Schuring GW. Lancet Neurol. 2005; 4:877–88. 2 Ogasawara K et al. Neurosurgery. 2003; 53:309–315.