Ronnie A. Rosenthal

Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practices Guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society

The population of the United States (US) is growing and aging.The US Census Bureau projects that the number of Americans age 65 years and older will more than double between 2010 and 2050. The percentage of Americans 65 and older will grow from 13% to more than 20% of the total population by 2030, and the fastest growing segment of this group (individuals 85 years and older) is expected to triple in number over the next 4 decades.These changes in the age demographics of the US population are largely due to people living longer and the “baby boomer” generation

The duration of postoperative acute kidney injury is an additional parameter predicting long-term survival in diabetic veterans

Acute kidney injury (AKI) is primarily defined and staged according to the magnitude of the rise in serum creatinine. Here we sought to determine if the duration of AKI adds additional prognostic information above that from the magnitude of injury alone. We prospectively studied 35,302 diabetic patients from 123 Veterans Affairs Medical Centers undergoing their first noncardiac surgery. The main outcome was long-term mortality in those who survived the index hospitalization. AKI was stratified by magnitude according to AKI Network stages and by the duration (short (less than 2 days), medium (3-6 days) or long (7 days or more)). Overall, 17.8% of patients experienced at least stage 1 AKI or greater following surgery. Both the magnitude and duration of AKI were significantly associated with long-term survival in a dose-dependent manner. Within each stage, longer duration of AKI was significantly associated with a graded higher rate of mortality. However, within each of the duration categories, the stage was not associated with mortality. When considered separately in multivariate analyses, both a higher stage and duration were independently associated with increased risk of long-term mortality. Hence, the duration of AKI adds additional information to predict long-term mortality.

Glycemic control and infections in patients with diabetes undergoing noncardiac surgery.

Objective:Examine the relationship between perioperative glucose control and postoperative infections in a nationwide sample of diabetic patients undergoing a wide variety of surgical procedures. Summary of Background Data:Perioperative glucose control has been linked to postoperative infections after selected surgical procedures. Methods:Retrospective analysis of surgical outcomes data from 1999 to 2004 on 55,408 patients with diabetes undergoing a variety of noncardiac operations contained in the Veterans Heath Administration National Surgical Quality Improvement Program database, supplemented with the Veterans Heath Administration Decision Support Services hemoglobin A1c (HbA1c) and serum glucose data. Multivariate Poisson regression model of postoperative infection including demographics, comorbidities, functional status, preoperative laboratories, surgical data, and glucose control (diabetes medications, serum glucose, HbA1c, mean serum glucose within 24 hours after surgery). Results:The most common procedures were herniorrhaphy (10%), carotid endarterectomy (6.6%), and open colectomy (5.6%). Mean (SD) preoperative HbA1c concentration was 7.9% (2.3); 51% of patients had preoperative serum glucose concentrations more than 150 mg/dL; and 72% of patients had a mean 24 hour postoperative glucose concentration at least 150 mg/dL. The overall postoperative infection rate was 8.0%. Higher rates of postoperative infection were associated with mean 24 hour postoperative serum glucose concentrations of 150 to 250 mg/dL (incidence rate ratio 1.22, 95% confidence interval, 1.04–1.43; P = 0.01) and more than 250 mg/dL (incidence rate ratio: 1.43; 95% confidence interval, 1.19–1.71; P < 0.001). Preoperative HbA1c and glucose concentrations were not associated with increased infection rates. Conclusions:In a large nationwide sample of diabetic patients undergoing a variety of noncardiac surgical procedures, glucose control in the first 24 hours after surgery was poor, and mean serum glucose concentrations of 150 mg/dL and higher during this time period were associated with increased rates of postoperative infectious complications.

Principles and practice of geriatric surgery

PART I- GENERAL PRINCIPLES.- Section 1- Physiology of Aging.- Invited Commentary.- Cellular and Molecular Aging.- Cancer, Carcinogenesis and Aging.- Effects of Aging on Immune Function.- Hematological Changes, Anemia and Bleeding.- Invited Commentary.- Nutrition and Metabolism.- Wound Healing and Aging.- Frailty and Surgery in the Elderly.- Section 2 - Social/Societal Issues.- Invited Commentary.- Demography of Aging and Disability.- Economics of Providing Surgical Care to an Aging Population: Implications for the Surgical Workforce.- Defining Quality of Care in Geriatric Surgery.- Ethics in Clinical Practice.- Teaching Geriatrics to Surgeons.- Palliative Care and Decision Making at the End of Life.- Surgery in Centenarians.- The Effects of Advanced Age on Physician Performance.- Section 3- Perioperative Issues.- Invited Commentary.- Principles of Geriatric Surgery.- Geriatric Models of Care.- Preoperative Evaluation of the Older Surgical Patient.- Invited Commentary.- Physiologic Response to Anesthesia in the Elderly.- Choosing the Best Anesthetic Regimen.- Acute Perioperative Pain Management in Elderly Patients.- Drug Usage in Surgical Patients: Preventing Medication-Related Problems.- Invited Commentary.- Common Perioperative Complications in Older Patients.- Management and Outcomes of Intensive Care in the Geriatric Surgical Patient.- Care of the Injured Elderly.- Maximizing Postoperative Functional Recovery.- PART II SPECIFIC ISSUES.- Section 1- Endocrine System/Breast.- Invited Commentary.- Surgcial Disorders of the Thyroid in the Elderly.- Parathyroid Disorders in the Elderly.- Adrenal Tumors in Older Persons.- Benign Breast Disease in Elderly Women and Men.- Breast Cancer in Elderly Women.- Diabetes in the Elderly.- Section 2- Oral Cavity, Eyes, Ears, Nose and Throat.- Invited Commentary.- Changes in the Oral Cavity with Age.- Geriatric Ophthalmology.- Anatomic and Physiologic Changes of the Ears, Nose, and Throat.- Geriatric Dysphagia.- Head and Neck Cancer in the Elderly.- Section 3 - Respiratory System.- Invited Commentary.- Physiologic Changes in Respiratory Function.- Pulmonary Surgery for Malignant Disease in the Elderly.- Section 4 - Cardiovascular System.- Invited Commentaries.- Physiologic Changes in Cardiac Function with Age.- Risk Factor for Atherosclerotic Disease in the Elderly.- Cardiac Surgery.- Surgical Treatment of Vascular Occlusive Disease.- Natural History and Treatment of Extracranial Cerebrovascular Disease.- Natural History and Treatment of Aneurysms .- Section 5 - Gastrointestinal System.- Invited Commentary.- Physiologic Changes of the Gastrointestinal Track.- Benign Esophageal Disease.- Esophageal Cancer in the Elderly.- Benign Diseases of the Stomach and Duodenum.- Gastric Cancer in the Elderly.- Small Bowel Obstruction in Geriatric Patients.- Lower Gastrointestinal Bleeding in the Elderly.- Ishcemic Disorders of the Large and Small Bowel.- Inflammatory Bowel Disease.- Diverticulitis and Appendicitis in the Elderly.- Benign Colorectal Disease.- Neoplastic Diseases of the Colon and Rectum.- Abdominal Wall Hernia in the Elderly.- Section 6 - Hepatobiliary System.- Invited Commentary.- Hepatobiliary and Pancreatic Function: Physiologic Changes.- Benign Disease of the Gallbladder and Pancreas.- Malignant Diseases of the Gallbladder and Bile Ducts.- Benign and Malignant Neoplasms of the Exocrine Pancreas.- Benign and Malignant Tumors of the Liver.- Section 7- Urogenital System.- Invited Commentaries.- Change in Renal Function, Fluids and Electrolytes.- Urinary Incontinence.- Neoplasms of the Kidney, Ureters and Bladder.- Benign and Malignant Diseases of the Prostate.- Benign Gynecological Disorders in Older Women.- Gynecological Malignancies in the Elderly.- Section 8 - Nervous System.- Invited Commentary.- Effects of Aging on the Nervous System.- Geriatric Neurosurgical Emergencies.- Benign and Malignant Tumors of the Brain.- Spinal Disorders and Nerve Compression Syndromes.- Section 9- Musculoskeletal System and Soft Tissue.- Invited Commentary.- Physiologic Changes of the Bones and Soft Tissue with Age.- Benign and Malignant Lesions of the Skin in Old Age.- Surgical Management of Soft Tissue Sarcoma in the Geriatric Population.- Pressure Sores in the Elderly.- Orthopedic Trauma in the Elderly.- Treatment of Degenerative Joint Diseases.- Section 10- Transplantation.- Invited Commentary.- Elderly Donors in Transplantation.- Elderly Transplant Recipients

Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP

OBJECTIVES To describe the incidence, characteristics, and outcomes of surgical patients who experience cardiac arrest requiring cardiopulmonary resuscitation (CPR). DESIGN Retrospective cohort study. SETTING American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2010. MAIN OUTCOME MEASURES Incidence of CPR, complications, mortality, and survival to hospital discharge at 30 days or less after surgery. RESULTS A total of 6382 nontrauma patients (mean age, 68 years) underwent CPR; 85.9% of events occurred postoperatively, of which 49.8% occurred within 5 days after surgery. Overall incidence of CPR was 1 in 203 surgical cases but varied by specialty (1 in 33 for cardiac surgery vs 1 in 258 for general surgery). The mortality rates varied by specialty (45.0%-74.5%) and were associated with comorbidity burden (58.7% for no comorbidity, 63.1% for 1 comorbidity, and 72.8% for ≥2 comorbidities; P < .001). A total of 77.6% of CPR patients experienced a complication; approximately 75.0% occurred before or on the day of CPR, and septicemia (26.7%), ventilator dependence (22.1%), significant bleeding (13.9%), and renal impairment (11.9%) were the most common. The overall 30-day mortality was 71.6%. Survival to discharge in 30 postoperative days or less was 19.2%; 9.2% of CPR patients were alive but hospitalized at postoperative day 30. Older age, a preexisting do-not-resuscitate order, renal impairment, disseminated cancer, preoperative sepsis, and postoperative arrest were among the factors independently associated with worse survival. CONCLUSIONS One in 203 surgical patients undergoes CPR, and more than 70.0% of patients die in 30 postoperative days or less. Complications commonly precede arrest; prevention or aggressive treatment of these complications may potentially prevent CPR and improve outcomes. These data could aid discussions regarding advance directives among surgical patients.

Age matters: a study of clinical and economic outcomes following cholecystectomy in elderly Americans.

BACKGROUND Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes. METHODS This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (1999-2006), of elderly patients (aged 65-79 and ≥80 years) and a comparison group (aged 50-64 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost. RESULTS A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged ≥ 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged ≥80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients. CONCLUSIONS Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome.

Association of Loss of Independence With Readmission and Death After Discharge in Older Patients After Surgical Procedures

IMPORTANCE Older adults are at increased risk for adverse events after surgical procedures. Loss of independence (LOI), defined as a decline in function or mobility, increased care needs at home, or discharge to a nonhome destination, is an important patient-centered outcome measure. OBJECTIVE To evaluate LOI among older adult patients after surgical procedures and examine the association of LOI with readmission and death after discharge in this population. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined 9972 patients 65 years and older with known baseline function, mobility, and living situation undergoing inpatient operations from January 2014 to December 2014 at 26 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot Project. A total of 4895 patients were excluded because they were totally dependent, classified as class 5 by the American Society of Anesthesiologists, undergoing orthopedic or spinal procedures, or died prior to discharge. EXPOSURES Loss of independence at time of discharge. MAIN OUTCOMES AND MEASURES Readmission and death after discharge. RESULTS Of the 5077 patients included in this study, 2736 (53.9%) were female and 3876 (76.3%) were white, with a mean (SD) age of 75 (7) years. For this cohort, LOI increased with age; LOI occurred in 1386 of 2780 patients (49.9%) aged 65 to 74 years, 1162 of 1726 (67.3%) aged 75 to 84 years, and 479 of 571 (83.9%) 85 years and older (P < .001). Readmission occurred in 517 patients (10.2%). In a risk-adjusted model, LOI was strongly associated with readmission (odds ratio, 1.7; 95% CI, 1.4-2.2) and postoperative complication (odds ratio, 6.7; 95% CI, 4.9-9.0). Death after discharge occurred in 69 patients (1.4%). After risk adjustment, LOI was the strongest factor associated with death after discharge (odds ratio, 6.7; 95% CI, 2.4-19.3). Postoperative complication was not significantly associated with death after discharge. CONCLUSIONS AND RELEVANCE Loss of independence, a patient-centered outcome, was associated with postoperative readmissions and death after discharge. Loss of independence can feasibly be collected across multiple hospitals in a national registry. Clinical initiatives to minimize LOI will be important for improving surgical care for older adults.

Proposed Competencies in Geriatric Patient Care for Use in Assessment for Initial and Continued Board Certification of Surgical Specialists

treatedpatientsareolderthan65yearsofageand41%of gastrointestinal operations are performed on patients in this age group. In orthopaedics, older patients account for 52% of all total hip replacements and 58% of total knee replacements. In the year 2007, approximately 16,000,000 inpatient operations and invasive procedures, 36% of the total number, were performed in patients older than 65 years of age. 2

Application of Assessing Care of Vulnerable Elders-3 Quality Indicators to Patients with Advanced Dementia and Poor Prognosis

OBJECTIVES: To use a formal decision‐making strategy to reach clinically appropriate, internally consistent decisions on the application of quality indicators (QIs) to vulnerable elders (VEs) with advanced dementia (AD) or poor prognosis (PP).

Predictors of Mortality Up to 1 Year After Emergency Major Abdominal Surgery in Older Adults

To identify factors associated with mortality in older adults 30, 180, and 365 days after emergency major abdominal surgery.