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Welsh Anaesthetic Trainees Journal Club

Journal Club: 14th November 2017

Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

Anaesthesia 2013;68:1107-1113 doi:10.1111/anae.12344

Presented by: Dr. A. Gańska

Background

  • The serratus plane block is an alternative block to paravertebral block and thoracic epidural (which are more challenging and have higher potential side-effect profile
  • It can provide a long lasting analgesia for breast, axilla surgery and prevention of acute pain progressing to chronic pain
  • It has fewer side-effects, is safe and easy to perform

Design and Settings

  • Descriptive study on 4 volunteers and 3D reconstruction of local anaesthetic spread using fat-suppression MRI imaging

Subjects

  • 4 female volunteers

Intervention

  • USS guided injections, two per volunteer of solution of 0.4ml/kg 0.125% levobupivacaine mixed with 0.1mmol/kg gadolinium.
    • First superficial to serratus anterior
    • Second underneath the muscle at level of 5th rib in midaxillary line.
  • Thoracodorsal artery was used as an extra reference point

Outcomes

  • Test of sensory loss after 30min with hypodermic needle
  • MRI scan after 1h to show distribution of gadolinium
  • Two observers compared images with MRI atlases

Results

  • T2 – T9 dermatomal paresthesia
  • Weak crossed-arm adduction movement

Conclusions

  • injection I: 752min duration of paresthesia for sensory nerves and 43min for motor nerves
  • Injection II: 386min duration of paresthesia for sensory nerves and 150min for motor nerves
  • MRI showed good spread with both injections

Study limitations

  • Descriptive study on volunteers
  • Small number of participants
  • Needs randomised controlled trial
  • MRI distribution of gadolinium may mimic fat tissue, image analysis software had to be used
  • Possibility of false impression of extent of LA spread – there was greater extension of the clinical effect then MRI suggested

Potential for impact

  • The serratus plane lock appears to give predictable and long lasting regional anaesthesia
  • Alternative to surgical LA infiltration, paravertebral blocks, thoracic epidural and intercostal nerves blocks
  • Compared with above this technique could be better for day case surgery
  • Superficial block was more effective

November 2017

Written by Dr C. Williams

Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. British Medical Journal 2017;359:j4366 doi:10.1136/bmj.j4366

This is a very interesting article published during a time when the argument about males vs females rages on. One only has to do a quick google search to see some of these arguments relating to the medical profession – from female medics have better outcomes to how the high number of female doctors are destroying the NHS.

This population based, retrospective, matched cohort study looked at patients who had surgery between 2007 and 2015. It looked at death rates, readmissions and complications based solely on the sex of the surgeon. The results suggest that patients treated by female surgeons were less likely to die within 30 days but there was no significant difference in readmission or complication rates. This difference in mortality was small and whether it makes any difference to long term survival is unclear. Interestingly no differences were found for patients who were operated on in emergency situations.

This study was done in Canada where, unlike the NHS, patients can freely choose their operating surgeon. The differences seen for elective surgery would suggest confounding factors play a role. The lack of difference in patients having emergency surgery would back this up. So, although an interesting study it would not suggest that one should pick a surgeon based on their sex alone.

Effect of various duration of smoking cessation on postoperative outcomes: A retrospective cohort analysis. Turn A, Koyuncu O, Egan C et al. European Journal of Anaesthesiology 2017 doi: 10.1097/EJA.0000000000000701 

There is now a solid evidence base that smoking is an independent risk factor for perioperative complications. Smokers are 1.4 times more likely to die after surgery than patients who have never smoked. Active smokers also have higher risks of respiratory, cardiovascular and neurological adverse events and are more likely to have problems with infections.

Preoperative smoking cessation would be expected to reduce postoperative smoking and it would be reasonable to expect that longer period of abstinence would correlate with stronger benefits. But the optimal period of preoperative smoking cessation remains controversial. Several randomised trials conclude that 3 to 8 weeks of preoperative cessation reduce wound complications but briefer periods do not seem to reduce respiratory complications. However, a meta-analysis published in 2011 suggested that each additional week of smoking cessation has a significant impact in the reduction in post-operative complications.

Prospective evaluation of the effects of smoking cessation on postoperative outcomes is not easy – a substantial number of patients do not want to stop smoking and even among those that attempt to stop the success rate is thought to be about 50% which makes it difficult to recruit patients in the context of a defined protocol. This paper was a retrospective cohort analysis of adult patients undergoing non-cardiac surgery with the main outcome easier being the relationship between smoking cessation and in-hospital morbidity/mortality.

The summary of the results is that smoking cessation is associated with reduced in-hospital morbidity and mortality – importantly this was shown to be independent of the cessation interval. From a clinical perspective, patients should be encouraged to stop smoking regardless of the time period before surgery.

Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study. Moms MI, Vendler TA, Haidari JE et al for the Copenhagen cOmplete Mesocolic Excision Study group (COMES). Colorectal disease 2017 doi:10.1111/codi.13910

Abdominal surgery in patients with cancer is associated with an increased risk of venous thromboembolism (VTE). Both the Danish and NICE guidelines recommend prolonged thromboprophylaxis with low-molecular weight heparin for 28 days after executive surgery for colon cancer. The evidence behind these guidelines relies on randomised controlled trials that included both benign and malignant colorectal disorders or colorectal abdominal cancers pooled with other gastrointestinal tract, urinary tract and gynaecological malignancies including palliative surgery. None of these trials included enhanced recovery after surgery (ERAS) programmes.  This study aimed to investigate the risk of symptomatic VTE in patients undergoing elective resection of colon cancer following an ERAS without prolonged VTE prophylaxis.

This was a retrospective analysis of patient who underwent surgery between 2008 and 2013. The median length of stay was 4 days. Of the 1893 patients included, 4 (0.2%) had a non-fatal symptomatic VTE. All 4 of these patients had other postoperative complications prior to the VTE. The rate of VTE found in this study is much lower that the overall 14% risk quoted after major abdominal or pelvic surgery.

It would appear that the risk of symptomatic VTEs is negligible in patients having colon cancer resection following an ERAS programme with an uncomplicated post-operative recovery. It may be that the early mobilisation in an ERAS programme may contribute to the lower risk. The findings of this study suggest that there is a possibility that prolonged VTE prophylaxis may not be cost-effective in these patients.

However, before any changes are made or guidelines rewritten – this is a retrospective study. It does raise questions but further randomised trials are needed to investigate this further.

Randomised feasibility trial of high-intensity training before elective abdominal aortic aneurysm repair. New GA, Batterham K, Colling J et al. British Journal of Surgery 2017 doi:10.1002/bjs.10669

Abdominal aortic aneurysms (AAAs) are usually asymptomatic until they rupture which then carries an overall mortality rate in excess of 80%. Elective surgery, either open or endovascular, is the most effective treatment for preventing AAA-related rupture and death. Open aneurysm repair in particular is associated with neuroendocrine, metabolic and inflammatory changes that lead to an increase in global tissue oxygen uptake of up to 50%. Patients who have a low cardiorespiratory fitness levels are less able to meet these extra demands which can lead to tissue hypoxia and life-threatening complications. A study published in 2010 found that up to half of the patients presenting for intra-abdominal surgery did not have the fitness levels to be deemed at low risk of perioperative complications as quantified by cardiopulmonary exercise testing.

It seems intuitive that improving cardiorespiratory fitness would lead to reduced complications rates after surgery. The clinical effectiveness and cost effectiveness of preoperative exercise testing has not yet been established. It is unclear whether meaningful improvements in cardiorespiratory fitness can be achieved for patients with a large AAA in the limited window available before surgery (usually 4-6 weeks). This study aimed to look at the feasibility and acceptability of high-intensity training (HIT) for preoperative optimisation of patients with a large AAA. Patients were either randomised to usual care or preoperative HIT consisting of three exercise sessions a week for four weeks.

The preoperative HIT seemed to be feasible and acceptable to patients although twenty of the twenty-seven exercise participants had to have their exercise aims adjusted due to triggering safety criteria (such as a systolic blood pressure over 180mmHg). This may have contributed to the fact that measured cardiorespiratory fitness did not change substantially at group level. However, the results seem to point to a beneficial effect of the exercise programme on health status and physical function for up to 12 weeks after hospital discharge.

This feasibility study points to the fact that preoperative exercise and improving cardiorespiratory fitness could be beneficial. Large, multicentre trials that explore clinical and cost effectiveness are needed before recommendations can be safely made about preoperative exercise programmes.

Echocardiography and passive leg raising in the postoperative period: A prospective observational study. El Hadouti Y, Valencia L, Becerra A et al. European Journal of Anaesthesiology 2017;34(11):748-754 doi:10.1097/EJA.0000000000000679 

Perioperative fluid management is a controversial and challenging issue. Both over hydration and conservative fluid therapy can lead to postoperative complications. The difficulty is that many patients have signs that could suggest hypovolaemia (such as oliguria, tachycardia and hypotension) but not all these patients will respond to fluid administration.

Passive leg raising has been demonstrated to simulate preload increase and distinguish fluid responders from non-responders. Studies validating passive leg raising have been carried out most frequently on non-surgical patients. In this study patients in whom low cardiac output was suspected in the immediate postoperative period were included. A baseline echocardiogram was done then repeated 90 seconds after the patients legs had been elevated by 45 degrees. The measurements were repeated after legs had been lowered and finally repeated again after 500mls of fluid administered as a bolus. An increase in cardiac output of greater than 11% after passive leg raising predicted a volume response following fluid with 68% sensitivity and 100% specificity.

This study had a very low sample size and a note is made of difficulty in carrying out the echocardiogram as left lateral decubitus position is best for the echocardiogram but passive leg raising in this position is not really possible. Despite the positive results the potential benefits or clinical uses of using echocardiography and passive leg raising to determine fluid responsiveness remain to be seen.

Acute kidney injury in trauma patients. Harris A, Libert N, Duranteau J. Current Opinion in Critical Care. 2017 doi:10.1097/MCC.0000000000000463 

Multiple organ failure is a later complication of severe trauma that substantially increases morbidity and mortality. Acute kidney injury (AKI) after trauma is associated with an independent association with prolonged hospital stay and mortality. Severe trauma is a time when several renal aggressions occur at the same time making it challenging to establish a strategy to prevent AKI. Factors such as haemorrhage, rhabdomyolysis, traumatic inflammation and renal hits due to emergency surgery or infections may cause acute renal disorders.

The incidence of severe AKI ranges from 9 to 23% and a total of 2 to 8% of trauma patient will require renal replacement therapy. The main risk factors for the development of AKI in trauma patients include haemorrhage, rhabdomyolysis, trauma inflammation, excessive fluid resuscitation and abdominal compartment syndrome.

Trauma care aims at stopping haemorrhage as soon as possible. The earlier this is achieved the better for tissue perfusion. Post traumatic vasoplegic shock can occur and in this situation attention should be paid to arterial pressure to try to optimise renal perfusion. Fluid resuscitation with balanced solute solutions seem to be the most beneficial for trauma patients with regards to AKI although there are no randomised controlled trials looking at this. What this paper makes clear is that AKI is a very real risk for trauma patients and once the initial trauma resuscitation has been carried out special attention should be paid to maintaining renal perfusion. Given the diverse nature of why patients develop AKI after trauma it is difficult to have one protocol to try to reduce the risk.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK. Sidloff D, Saratzis M, Sweeting J et al.  British Journal of Surgery 2017;104(12):1656-1664 doi:10.1002/bjs.10600

Abdominal aortic aneurysm (AAA) screening has been shown to be effective in men both at reducing AAA-related mortality and in cost-effectiveness. Consequently there is now an established AAA screening programme for men over the age of 65 in England and Wales. The benefit of screening for women has not been established. However, one in seven elective AAA repairs are on women and women account for approximately one-third of all deaths from ruptured AAA. Furthermore women have a fourfold higher rupture rate than men at equivalent aortic diameters which suggests there is a strong case for intimating AAA screening in women. Perioperative risk is critical in determining the effectiveness of a screening programme and risk estimates are lacking for women having AAA repairs.

Data from the UK National Vascular Registry was analysed for a 4 year period from 2010 to 2014 with the primary outcome being in-hospital mortality. 13% of the patients included were women. Mortality rates were higher in women for both elective AAA repair (open or endovascular) and emergency repair. The excess mortality rate was found to be largely independent of age, aneurysm diameter and smoking status. It is not clear why this difference in mortality exists although the Canadian Society for Vascular Surgery Aneurysm Study Group identified that women are more likely to be older, have a positive family history of AAA and have significant aortoiliac occlusive disease.

A well designed trial of matched women and men undergoing elective AAA repair would be needed to explain the differences seen. The higher mortality rate in women may have an impact on the benefit offered by any AAA screening programme.

Journal Club: 24th October

Emergency Department use of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A Randomized Controlled Trial (The ENDAO Trial)

Academic Emergency Medicine 2017. Doi:10.1111/acem.13274 (epub ahead of print)

Presented by: Dr S. Young             

Background

  • Desaturation leading to hypoxaemia may occur during rapid sequence intubation (RSI)
  • Preoxygenation is an important part of RSI n order to increase the amount of oxygen present in the functional residual capacity of the patients lungs to prolong the maintenance of acceptable oxygen saturation during the apnoeic period of endotracheal intubation
  • Apnoeic oxygenation was developed with the aim to prevent the occurrence of oxygen desaturation during the apnoea period.
  • It involves leaving the nasal cannulae in place with oxygen flowing during laryngoscopy and intubation.
  • It is being used more and more commonly in emergency and critical care departments.

Design & Setting

A randomised controlled trial based in the emergency department looking at whether apnoeic oxygenation during RSI reduces patient desaturations versus usual care.

Subjects

  • 206 Emergency department patients presenting requiring emergency rapid sequence intubation with preoxygenation for any reason apart from cardiac or traumatic arrest.
  • Based in a level 1 trauma centre in New York.

Intervention

  • Use of high flow oxygen via nasal cannula during the apnoeic period vs no nasal cannula.

Outcomes

  1. Primary: Oxygen saturations were measured by pulse oximetry during and for 2 minutes after the apnoeic period during the RSI. The lowest recorded saturations were taken and the means were compared between the two groups.
  2. Secondary: Desaturations below 90%, 80% and 1st pass success.

Results

  • There was no difference in means of lowest recorded saturations detected between the study groups both 92%.
  • There was also no difference in secondary outcomes.

Conclusions

  • The application of apnoeic oxygenation did not change desaturation in the study population.
  • Its use compared with usual care did not prevent desaturation or reduce the chances of it.

Strengths

  • Well designed study
  • Randomised Controlled Trial
  • Good patient selection and randomisation
  • Relevant study population
  • Good recording of data (trained uninvolved assessors)
  • 100% follow up
  • Real life setting

Weaknesses

  • The trial was not powered highly enough to detect clinically important differences in patient outcome.
  • The primary outcome measured, mean lowest saturations, did not give a patient orientated outcome such as mortality or morbidity.
  • There were very short apnoea times and high first pass success; as such there was very little time for the patients to desaturate.

Implications

The implication is that although this is a negative study it may not have been large enough to detect the patients where apnoeic oxygenation is beneficial.

Even if there had been a statistically significant difference in lowest mean saturations it would have been difficult to read this as a clinically important patient orientated outcome. The trial looked into mortality as a secondary outcome and there was no difference but it was not highly powered enough for this.

Potential for impact

This trial adds to the evidence that there is very little to be gained in most patients with apnoeic oxygenation. It does not however prove that the technique is not useful in some patients.

The paper reviewed earlier this year (see: Journal Club 1st August) suggested that apnoeic oxygenation is a relatively simple and safe intervention with few complications which seemed to be of benefit.

What the ENDAO trial does do is offer evidence that apnoeic oxygenation is not the magic solution to maintaining saturations during RSIs in Emergency department patients. The evidence surrounding apnoeic oxygenation is still not certain and large randomised controlled trials are needed to study this further.

At present we can therefore remain justified in not using this method in our patients.

Journal Club: 17th October

A systematic review of information format and timing before scheduled adult surgery for peri-operative anxiety

Anaesthesia 2017;72:1265-1272

Presented by: Dr J. Niebla-Rodriguez

Background

  • About 25% of patients are anxious and this is associated with pain, poor compliance and harm.
  • Advantages of preoperative information: reduce anxiety
  • Information can be conveyed in different formats: verbal, text, multimedia and in various combinations.
  • Patients retain information that is clear, concise and easy to understand.
  • Different formats of information are more effective to particular people: it depends on age, sex, education, personality and other cultural background.
  • Also when and how the information is conveyed accounts for variation in effect across trials and review.
  • Aim to assess the effects of different formats and timing of pre-operative information on perioperative  anxiety reported by adults.

Design & Setting

  • Standard, quasi and cluster RCT that reported format and timing before scheduled surgery on peri-operative outcomes in any language
  • Information formats : passive / interactive text, audio+ and video  via Person, PC, mobile phone
  • 3 months prior surgery
  • Excluded : studies comparing different information content

TABLE OF PAPERS INCLUDED 

Jesus pic 2

  • 1º outcome = Peri-operative anxiety
  • 2º outcome = patient knowledge and satisfaction with surgery, anaesthesia or information

 

  • 2 reviewers: independently assessed article titles, abstract and full texts
  • Articles were included and rated by 3 reviewers by consensus

The 2 reviewers looked at:

  • Risk of bias, randomisation method, allocation concealment, blinding, completeness of outcome data, selective outcome report and other
  • Risk of bias rated as low or risk unclear in 4 domains: randomisation generation, allocation concealment, incomplete outcome data and selective reporting.
  • They also categorised trial risk of bias as high if risk was gih in any of the 4 domains.
  • No meta-analysis was performed because of disparate  interventions and outcome measure

Network plot: node proportionate to number of trials making the comparison

Jesus presentation

Green, yellow and red : comparisons of low, unclear and high risk bias.

Subjects

3742 Patients undergoing a scheduled operation who were able to understand the language in which the info was presented

Intervention

  • They looked at the various methods and combinations of preoperative information text, verbal, person, multimedia in comparison with the same information in a different format (as listed above) at different time durations before surgery.
  • The information content related to behavioural, procedural and sensory aspects of the patient journey.

Outcomes

  • A: pre-operative anxiety
  • B: postoperative anxiety
  • C: postoperative pain
  • D: length of hospital stay
  • E: participant satisfaction with surgery or anaesthesia
  • F: patient satisfaction with information; g, patient knowledge.

Results

  • 34 trials with 3742 participants : 29 randomised controlled, 4 quasi-randomised and 1 was cluster randomised:
  • The effects of different info formats was assessed by 30 trials.
  • The effects of timing by 5 trials
  • Anxiety was measured using different scoring systems
  • Patient knowledge and satisfaction was analysed by a questionnaire individual to each study so prevented a meta-analysis.
  • The explored the bias in the papers they reviewed
  • Low risk of bias = 6, high risk of bias = 10, 17 stated blinding of participants, personnel and outcome assessors wasn’t possible

Verbal vs text in 4 studies

  • 2 trials no difference in anxiety
  • Verbal inc knowledge and satisfaction in 1 trial, dec knowledge in 2 other studies and no affect in another.

Verbal vs multimedia in 4 studies

  • Multimedia format improved anxiety in 1 study and contradicted in another studies
  • Multimedia formats were superior vs verbal in 3 studies
  • Inc knowledge and satisfaction in 2 studies
  • But inc in mod to severe pain in one study

Text vs multimedia 4 studies

  • 1 study showed no difference in anxiety
  • 2 reported multimedia significantly inc satisfaction with info
  • 1 study reported higher knowledge scores in the same group.

Addition of multimedia to verbal info 6 studies

  • 3 showed no affect on pre-op anxiety
  • 3 showed it improved knowledge
  • 2 showed no difference
  • 1 showed satisfaction with anaesthetics care was unaffected and 1 showed it increase satisfaction
  • 4 trials looked at patient satisfaction with info : 2 showed no effect of multimedia,
  • 3 studies looked the addition of multimedia to verbal and text info : 1 study showed no effect, 1 study showed inc and 1 study showed knowledge respectively. Post op pain and hospital stay was unaffected in two of the 3 studies
  • Knowledge, anxiety and length of hospital stay were unaffected by the addition of multimedia to text in 1 study but showed a dec in anxiety in another.

Addition of text to verbal info in 6 studies

  • 1 showed a dec in anxiety , 2 showed no affect,
  • 4 showed no affect on knowledge and one showed an increase
  • Satisfaction and hospital stay was unaffected

Verbal combined with text or with a multimedia format in 3 studies

  • 2 showed no difference in outcomes of : anxiety, satisfaction with info given, postoperative recall of complications and readability or usefulness of the info.
  • The 3 trial showed that multimedia format increased knowledge and satisfaction.
  • DVDs don’t increase knowledge but don’t affect length of stay.

Effect of timing in 5 studies

  • Timing doesn’t affect pre-op anxiety, post op pain, or hospital stay
  • Post op anxiety was unaffected by timing of direct teaching, or via audiotapes
  • Early text or video info reduced post-op anxiey
  • Knowledge and satisfaction after an interview and video were unaffected by the order in which they were given.

Conclusions

  • They were able to show effects of pre-op info on peri-op anxiety and other outcomes were affected little by format or timing.
  • Similar findings in systematic reviews that included trials of different info content
  • Other systematic reviews didn’t do meta-analyses for the same reasons
  • They want to look at tailoring formats based on personalities
  • Trials should include of poor literacy or computer unfamiliarity

Strengths

  • Robust inclusion and exclusions criteria
  • Bias analysis was ok
  • Explained why they couldn’t do a meta-analysis = too much variation of study designs

Weaknesses

  • No meta-analysis due to heterogenous studies
  • They didn’t know the methodologies of all studies so their assessment of bias was inaccurate
    One of the paper’s editors is the editor of the journal of Anaesthesia but they underwent extended external procedures.

Implications

Some health authorities spend vast resources on multimedia information formats at great cost, but keeping it simple by verbal and written formats could be just as good. Useful in a resource poor environment.

Potential for impact

  • Multimedia formats increase knowledge more than text > verbal.
  • One can incorporate this into our own pre-op assessments:
  • Provide pts with a multimedia reference after they have been to their pre-assessment appointment, or when on the ward, point them towards and app or whilst they wait for their operation if so wish so that we can empower patients in their knowledge of their procedure.

Journal Club: 3rd October 2017

An evaluation of the validity of the preoperative oxygen uptake efficiency slope as an indicator of cardiorespiratory fitness in elderly patients scheduled for major colorectal surgery

Anaesthesia 2017;72:1206-1216

Presented by: Dr S. Churchill

Background

CPEX testing is widely available in preassessment and guiding decision making. Those who have higher cardiorespiratory fitness may have more resilience to metabolic demands of surgical stress. Cardiorespiratory fitness is indicated by peak oxygen uptake and oxygen uptake at anaerobic threshold.

Using CPEX measures peak oxygen uptake and ventilatory anaerobic threshold, however assessing only these measures leads to loss of data. This paper investigates whether we could use submaximal data and extract relevant clinical outcomes. In particular, the paper looks to see if oxygen uptake efficiency slope can be used. The OUES is based on a curvilinear relationship between minute ventilation and oxygen uptake throughout an incremental CPEX test. OUES is thought to be a predictive marker for major cardiac events.

 Methods

This study was conducted in patients over 60 years of age who qualified and who were due to undergo colorectal surgery. Patients had completed a veteran specific activity questionnaire and those who scored <7 METS were recruited.

Those patients who required emergency surgery or who could not complete a CPEX test were excluded. Those patients who consented to the study underwent CPEX testing on an upright bike. The test was considered maximal when patient showed signs of fatigue or when they either reached a HR of>95% predicted or a RER of >1.10.

Data was analysed independently from clinicians performing test. Values at peak exercise were calculated as an average over the last 30s before termination of the test and peak heart rate was that achieved highest during the whole test. A steeper slope represents a higher oxygen uptake efficiency slope and therefore more efficient oxygen uptake (smaller ventilation is required for a given oxygen uptake).

All data collected was used not just 80-90% of the duration of the test which is what occurred in previous studies. Data was adjusted for sex, age, body surface area and body mass and all data was analysed using SPSS.

 Results

  • The study was conducted between Feb 2013 and July 2016.
  • 72 subjects were recruited and they had their CPEX test 26.8 (mean) before their surgery. One further patient was excluded.
  • There was a subgroup analysis between the Anaerobic threshold of >11ml/kg/min and < 11ml/kg/min.
  • OUES showed a statistical difference between OUES100 and OUES80 and OUES90.
  • The data appears more accurate with more data included in analysis.
  • There was a statistically significant correlation between OUES and AT and peak oxygen uptake.

 Limitations of Study

  • This was a single centre study with a small sample size. The data was analysed retrospectively which could lead to bias. There was no sample size pre determined.
  • The study already highlights those who have low METS. Why not a cross spectrum to see if any false positives/negatives?I wonder whether there may be some user error with VSAQ. This questionnaire is  dependent on patients having accurate perception of their own fitness.
  • On CPEX the assessment of maximal testing usses subjective signs of maximal effort, only 76.1% showed the objective signs of maximal effort.
  • Further corrections needed to make some variables statistically significant (Bonferroni)
  • Given that you need all the data to get accurate readings, then maybe the extrapolations wont be so accurate if test you get is submaximal.
  • The results are dependent on the patient having no significant lung disease. This is no relatable to everyday clinical practice.
  • OUES was adapted for body mass….oxygen uptake was not mentioned as being adapted for body mass.
  • At which point do we stop looking at oxygen uptake – up to the plateau or up to point of constant levelling off.
  • Levels associated with risk pre determined in previous studies.
  • No ackowledgement of actual clinical complication in the population deemed to be high risk.

Discussion

  • There are good correlations between OUES and peak oxygen uptake and AT mean it could give us an objective way of assessing cardiorespiratory fitness even in a submaximal exercise test. Data could be extrapolated and AT and peak oxygen uptake could be predicted and could facilitate decision making in high risk patients.
  • Some studies find no difference between maximal and submaximal studies. This one shows that your figures are lower in those in which all data is collected
  • Two patients who had big differences in their OUES100,90 and 80 were excluded and then the data showed no statistical difference between submaximal and maximal tests.
  • There was a strong correlation with peak oxygen uptake and anaerobic threshold is in keeping with other studies.
  • The risk of post-operative morbidity was still correlated to data surrounding AT (<11.1 being high risk). Peak oxygen uptake is still dependent on fatigue and patient effort and therefore results may be submaximal indicator of fitness.

October 2017

Written by Dr C. Williams

Caffeine accelerates recovery from general anesthesia via multiple pathways. Fong R, Khokhar S, Chowdhury A et al. Journal of Neurophysiology 2017;118:1591-1597 doi:10.1152/jn.00393.2017

Currently there is no method to accelerate emergence from general anaesthsia. Patient’s wake when they clear the anaesthetic from their systems. Drugs that had the ability to reverse the coma-like state induced by general anaesthetic agents would likely have considerable utility in clinical settings. In 1975 it was shown that direct intraventricular application of a membrane permeant cAMP analog could accelerate recovery from a variety of anaesthetic and sedative agents.

In 2014 the authors of this study demonstrated that drugs that increase intracellular cAMP dramatically accelerated emergence from anaesthesia. Three intravenous agents that increase cAMP levels were tested – forskolin, theophylline and caffeine – caffeine was shown to accelerate emergence time when anaesthesia was maintained with isoflurane 2%. This study aimed to determine whether caffeine had the same effect at higher anaesthetic concentrations. In this study, rats were anaesthetised for 60 minutes with end-tidal isoflurane levels of 3%. Ten minutes before anaesthesia was terminated the rats were injected with either saline (as a control) or a solution containing caffeine. Recovery time was taken as the time the rat was removed from the anaesthesia chamber, placed on its back on a table to the time it could stand with 4 paws on the table. This study appeared to show that caffeine accelerates emergence from anaesthesia even at high levels of isoflurane. The dose of caffeine was increased by 25mg/kg – starting at 25mg/kg and increasing to 75mg/kg. Caffeine at 75mg/kg produced a 55% reduction in emergence time

Caffeine inhibits phosphodiesterase which prevents the breakdown of cAMP. It also acts as an antagonist at all adenosine receptors. Blockade of the A adenosine receptor mediates caffeine’s arousal effects. Caffeine is already the most psychoactively used drug – in the USA more than 90% of adults use it daily. It is already used clinically either to treat neonatal apnoeas or for certain types of headache and is readily available.

However, this is a small study – no more than 9 rats were studied. There are also questions as to whether this study could be transferred to humans. Also the question as to whether a drug to accelerate emergence is necessary must be raised. It is tempting to speculate about other possible benefits of caffeine. Caffeine is known to have cognitive benefits – hence the reason it is one of the most widely used ‘drugs’. Anaesthetics can impair the cognitive abilities of patients, particularly the elderly, for significant periods of time. If caffeine was shown to accelerate cognitive recovery then it may play a significant role in postoperative recovery. To explore this theory would require extensive research.

Preoperative fluid retention increases blood loss during major open abdominal surgery. Hahn RG, Bahaman H, Nilsson L. Perioperative Medicine 2017;6:12 doi:10.1186/s13741-017-0068-1

Fluid management is an essential component in the management of major abdominal surgery. There is a marked variation in how the kidneys excrete or conserve fluid both in everyday life and preoperatively. Urine analysis can give a measure of the kidney’s state of fluid retention. It is known that a high concentration of urinary waste products is associated with a longer half-life of crystalloid fluid, a greater need for fluid optimisation, more complications after hip fracture surgery and a higher 30-day mortality in acute geriatric care. Little is known about how preoperative fluid retention affects intraoperative fluid balance. The aim of this study was to explore the relationship between preoperative dehydration and fluid requirements during major abdominal surgery with the hypothesis that fluid retention, indicating dehydration would mean more fluid is needed intra-operatively.

Patients undergoing elective open major abdominal surgery had their urine analysed for colour, specific weight, osmolality and creatinine concentration to calculate a fluid retention index. The fluid balance was obtained as the sum of infused fluid (crystalloid, colloid or blood products), minus the blood loss and excreted urine. Fluid retention was found in 37% of patients. It was associated with a significantly higher blood loss, a higher haemorrhage rate and a greater need for intravenous fluids. Despite the larger blood loss, the total fluid balance remained positive after surgery in dehydrated patients.

Preoperative dehydration is associated with higher fluid requirements intra-operatively but also a greater blood loss and a more positive fluid balance. These effects were most apparent in gynaecological and urological surgery. The results from this study would suggest that more fluid should be given to patients found to have concentrated urine preoperatively. More studies are needed to determine if this would improve patient outcome.

Paravertebral block does not reduce cancer recurrence, but is related to higher overall survival in lung cancer surgery: a retrospective cohort study. Lee EK, Ahn HJ, Zo J, Kim K, Jung DM, Park JH. Anaesthesia and Analgesia. 2017 doi:10.1213/ANE.0000000000002342 

Evidence is continuing to emerge about how postoperative analgesic methods have an impact on long-term prognosis after cancer surgery. Opioids trigger immune suppression by impairing innate immunity, altering antigen presentation and predominately favouring pro tumour cytokines. If a patient’s innate immunity is suppressed during the postoperative period there is the potential that remnant malignant cells or micro metastases may grow, establish and spread early after surgery.

Regional anaesthesia can reduce the need for opioids. Using this simple well known fact, it stands to reason that one would expect a lower cancer recurrence and higher survival if regional analgesic techniques were used instead of opioids. This was a large retrospective cohort study aiming to look at precisely this. They hypothesised that thoracic epidural or paravertebral catheters rather than intravenous opioids (via a PCA) as the postoperative analgesic method would be associated with better outcomes in patients undergoing lung cancer surgery.

The notes of 1729 patients undergoing open thoracotomy for primary non-small-cell lung cancer were reviewed. Patients either had a fentanyl PCA, a thoracic epidural with ropivacaine/hydromorphone solution or paravertebral catheter with ropivacaine infusion. Patients had what was then described as a ‘balanced’ anaesthetic  including opioids – either fentanyl boluses or remifentanil infusion. All patients had the same post-operative analgesic protocol for the next 2-3 weeks which was oral analgesics and/or fentanyl patch.

Recurrence rates were similar in all three groups and cancer recurrence was the cause of death in over 80% of the patients in each of the three groups. There was a statistically significant higher overall survival rate in the patients who received paravertebral catheters as the method of post-operative analgesia. Other variables were also related to overall survival including age, male sex, cancer stage, transfusion and duration and extent of surgery.

Unfortunately this study still does not help to answer the questions surrounding the role of anaesthetic techniques on cancer recurrence.

Regional anaesthesia and analgesia in cancer care: is it time to break the bad news? Sekandarzad MW, van Zundert A, Doornebal CW, Hollmann MW. Current opinion in anaesthesiology 2017;30(5):606-612 doi:10.1097/ACO.0000000000000492

The perioperative period is increasingly being recognised as a narrow but crucial window in cancer treatment. As the above paper hypothesises, regional anaesthesia has been proposed to reduce the incidence of cancer recurrence after surgery. There is a separate body of evidence suggesting that perioperative regional anaesthesia may be associated with a survival benefit in cancer patients.

The truth is that existing literature presents conflicting and inconclusive results about the impact of regional anaesthesia on cancer recurrence in patients undergoing surgery. Data is predominantly based on retrospective studies. with as many studies suggesting regional techniques have a positive outcome on cancer recurrence as those that suggest the opposite. The results from meta-analyses and systematic reviews are equally as conflicting. Conflicting results may be due to confounding factors including tumour-specific factors (such as type, grade and lymph invasion) which many studies do not take into account.

It seems unlikely that regional anaesthesia techniques either alone or in combination with modification of other perioperative factors can give clinically meaningful immune-protective effects when powerful chemotherapeutic agents appear to play a small role in cancer survival (contributing to 2% of the 5-year survival in adults). Additionally there is little convincing evidence that opioids promote cancer recurrence or facilitate the development of metastatic disease.

This review article critically refutes the concept that regional anaesthesia as a single modality in the complex oncological setting if cancer surgery can give positive cancer outcomes. The results of ongoing RCTs designed to investigate the link between regional anaesthesia and its ability to reduce cancer recurrence are eagerly awaited although it is unclear as to whether any clear results will be produced. Proving the efficacy of a single intervention (regional anaesthesia) in the multifactorial perioperative oncological setting will be challenging. What is clear is that a reducing postoperative pain and if possible preventing the progression to persistent post surgical pain, even at the expense of no difference in relation to reduced cancer recurrence, is still a goal to aim for.

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly. Kozek-Langenecker S, Fenger-Eriksen C, Thienpont E, Barauskas G, for the ESA VTE Guidelines Task Force. European Journal of Anaesthesiology 2017;34:1-7 doi: 10.1097/EJA.0000000000000705

The risk of venous thromboembolism (VTE) is higher in elderly patients particularly those aged over 70 years and elderly patients with co-morbidities. Large population-based epidemiological studies globally show that VTE predominantly occurs in the elderly and rarely occurs prior to late adolescence. But with an increased VTE risk comes an increased risk of bleeding. Therefore it is important to address this issue and ensure that there is appropriate risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis.

Limited physiological reserves of older patients make them more vulnerable to postoperative stress and illness including VTE. Factors that have been associated in various studies with deep vein thrombosis and pulmonary emboli in there elderly include: congestive cardiac failure, pulmonary circulation disorders, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy, anaemia and coagulopathies.

Recommendations for VTE prophylaxis in the elderly are typically extrapolated from non-age specific VTE prophylaxis trials therefore timing and dosing of pharmacoprophylaxis are adopted from the non-aged population.

The general recommendations include:

  • Age over 70 is a risk factor for postoperative VTE
  • In elderly patients identify risk factors and correct if possible
  • Avoid bilateral knee replacements in elderly or frail patients
  • Timing and dosing of pharmacological VTE prophylaxis as in the non-aged population
  • In elderly patients with rena failure, low-dose un-fractionated heparin may be used or weight-adjusted dosing of LMWH
  • Careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation
  • Multi-faceted interventions for VTE prophylaxis in elderly and frail patients including pneumatic compression devices, LMWH (and/or direct oral anti-coagulants after knee or hip replacement)

Risk factors for postoperative ileus after colorectal cancer surgery. Rybakov EG, Shelygin YA, Khomyakov EA, Zarodniuk IV. Colorectal Disease 2017 doi:10.1111/codi.13888

Postoperative ileus is a temporary dysfunction of the gastrointestinal tract in response to surgical intervention. It is a common complication of abdominal surgery and most frequently developed after extensive colorectal operations. It causes significant financial and resource burden on healthcare institutions. The reduction in the incidence of ileus has therefore been placed as one of the top five priorities by the association of coloproctology of Great Britain and Ireland. Treatment is mainly symptomatic as there are no effective pharmacologic agents to treat it, therefore ileus prophylaxis based on the knowledge of potential risk factors is important.

300 patients having elective surgery for colorectal cancer were included. All patients had routine multimodal anaesthesia, a thoracic epidural (with a ropivacaine infusion) and the principles of enhanced recovery were followed: minimal preoperative starvation, no mechanical bowel preparation, no routine use of nasogastric tubes, maintenance of normothermia and minimisation of intraoperative infusions.

Ileus developed in 13% of the patients studied. After multivariate analysis four independent risk factors were identified: a BMI or 26 or over, previous abdominal surgery, the presence of extensive organ adhesions and the administration of opioids in the postoperative period. Importantly due to the fact that every patient in the study had an epidural with a plain ropivacaine infusion only a small proportion (10.7%) required opioids postoperatively. Yet a negative impact of opioids was demonstrated even at this small proportion.

It will never be possible to omit opioids in all patients but actively trying to use techniques that are opioid sparing may be a potential method in which anaesthetists can contribute to reducing the rates of postoperative ileus. This is however a retrospective and relatively small sized study therefore results should be interpreted with some caution.

The impact of fatigue on the non-technical skills performance of critical care air ambulance clinicians. Myers JA, Powell DMC, Adlington S, Sim D, Psirides A, Hathway K, Haney MF. Acts Anaesthesiologica Scandinavia 2017. doi:10.1111/aas.12994

Fatigue and how it affects performance is highly topical at the moment, particularly in anaesthetics following on from the publication of a national survey of the effects of fatigue on trainees in anaesthesia in the UK (Anaesthsia 2017;72:1069-1077) which was reviewed in July’s journal watch.*

This study looked at critical care doctors who are involved in air transfer of patients. The critical care air transport setting is dynamic and challenging and even a small performance decrement has the potential to affect clinical care and patient safety. Fatigue is presumed to negatively influence patient and clinician safety although the precise relationship is not entirely clear. It is also possible that sleep deprived clinicians may not recognise the extent to which their performance is impaired.

Nineteen physicians undertook two different simulated air ambulance missions, once while rested and once when fatigued. Performance was assessed by blinded observers based on expected behaviour in four non-technical skills domains: teamwork, situational awareness, task management and decision making. Participants also rated their own performances. They also completed a psychomotor vigilance task and a cognitive function test.

The physician’s non-technical skills were significantly better across all categories of skills and cognitive tests when rested. Clinicians completed relatively routine air transfer scenarios at levels of fatigue they routinely experience during usual clinical practice (e.g. towards the end of a night shift). Clinician’s also demonstrated limited awareness of their one degraded performance when fatigued. Self-ratings of performance showed no difference between fatigued and non-fatigued performance, in direct contrast to the rating provided by blinded observers.

This study highlights the importance of fatigue and how it can adversely affect performance. There is currently no good policy on recognising and managing the impact of fatigue in the NHS. Hopefully as awareness increases this will be addressed for all healthcare professionals, not only for the impact it has on patient safety but also the long term health impacts of chronic fatigue.

*A national survey of the effects of fatigue on trainees in anaesthesia in the UK. McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. Anaesthesia 2017 doi:10.1111/anae.13965

Complications and unplanned admissions in non-operating room procedures. Leslie K, Kave B. Current opinion in Anaesthesiology 2017 doi:10.1097/ACO.0000000000000519 (13)

Increasing numbers of increasingly complex diagnostic and therapeutic procedures are being performed in areas remote from the operating theatre suite. This review aims to look at complications and unplanned admissions in patients requiring anaesthetic care for endoscopy, bronchoscopy and radiology procedures.

For endoscopy large analyses of databases show a low incidence of complications and unplanned admissions. In outpatients the incidence of cardiopulmonary complications was 0.9% – significant predictors included age over 60 years, higher ASA status and inpatient versus outpatient treatment.  Reviews of bronchoscopy seem to show that moderate sedation is tolerated well in these patients. Studies looking at procedures in radiology found that unplanned admissions were more likely to be due to pain, haemorrhage or infection as opposed to a sedation related problem.

Obstructive sleep apnoea has been associated with worse outcomes after procedures in the operating theatre. Studies have shown that OSA in patients having endoscopy or colonoscopy was not associated with any significant increase in cardiovascular or respiratory complications – the authors do make a note that caution should be applied in interpreting this due to poor methodological quality of the studies.

Overall, sedation seems to be associated with a low rate of complications – although some studies suggest more complications during deep propofol-based sedation rather than lighter benzodiazepine sedations. As anaesthetists we would like to think that if we provide the sedation as opposed to it being provided by a non-anaesthetist then it would be safer and have fewer complications. However, studies appear to suggest that sedation provided by anaesthetists is associated with more complications than if given by non-anaesthetists. The reasons for this are not explored but could be related to the fact that anaesthetists may provide sedation for higher risk patients and may provide a deeper level of sedation than non-anaesthetists. Clearly further randomised trials are required to define the optimum sedation drugs, sedation depth and the sedation provider.

Journal Club: 17th July 2017

The SLUScore: A Novel Method for Detecting Hazardous Hypotension in Adult Patients Undergoing Noncardiac Surgical Procedures. 

Anesthesia and Analgesia 2017;124(4):1135–1152. 

Presented by: Dr T. Newton

Background

  • Adequate blood pressure control is one of the major concerns in an intra-operative setting.
  • Increasing evidence that extended periods of severe hypotension may effect long-term outcomes.
  • Patients currently categorised in binary fashion- intervention either unnecessary or already too late.
  • Hypothesis: adverse outcomes affected by severity of hypotension and duration accumulated below thresholds commonly encountered during anaesthesia.

Design and Setting

  • 3 centre retrospective cohort study
  • Approval from institutional ethics bodies
  • Databases searched for adult patients undergoing non-cardiac procedures. Data collected on demographics, Charlson comorbidity score, type of anaesthetic, case duration, blood loss, minute to minute MAP values, all-cause 30 day mortality.
  • Development of score:
    • N=33904
    • Multivariable logistic regression to identify risks associated with increased 30 day mortality including time spent below 31 commonly encountered MAP thresholds
    • % increase in odds of 30d mortality calculated for each minute spent below each of the MAP thresholds
    • Number of minutes calculated for each threshold required to produce identical increases in 30d mortality from 5-30%
    • 20% set used to determine SLUScore- each increment of score corresponds to +5%compounding progression of odds of 30d mortality
  • Validation of score with 3 centre study, n=116,541

Results

  • Independent factors affecting 30 day mortality: age, Charlson comorbidity score, cumulative blood loss. All adjusted for.
  • Dropping below progressively lower MAP thresholds à greater increase in 30d mortality per unit time below that threshld.
  • Preoperative diagnosis of hypertension means time needed below each threshold for same increase in risk.
  • Increase in mortality depended on number of exposure limits exceeded.
  • 30 day mortality approximately doubled in patients with SLUScore >0.
  • Less time may be spent at lower MAP to accrue same risks (analogous to diving charts).

Strengths

  • Large sample size for creation of score, larger size across multiple sites for valifation.
  • 5 year duration at one site.
  • Accounts for some confounding factors, separate scores for pre-existing hypertension.

Weaknesses

  • Does not account for severity/risk of procedure- increased risk of procedure vs MAP, or does procedure cause drop in MAP?
  • Minute to minute measurements taken from extrapolation of 5 minute NIBPs.

Impact

  • Too complex to calculate in real time intra-op.
  • Relies on assumptions with 5 minute NIBPs in most cases.
  • May be useful in future generations of monitors/anaesthetic machines as in-built function.
  • Potential for litigation- if any patient has morbidity from renal function/sepsis etc and has had a GA, anaesthetist may be targeted using SLUScore.

Journal Club: 20th September 2017

Postoperative delirium in elderly patients is associated with subsequent cognitive impairment. Sprung J, Roberts R, Weingarten T et al.

British Journal of Anaesthesia 2017;119(2):316-323

Presented by: Dr I. Roberts

Background  

Paper examined the risk for postoperative delirium (POD) in patients with mild cognitive impairment (MCI) or dementia, and the association between POD and subsequent development of MCI or dementia in cognitively normal elderly patients.

Design & Setting

  • Ran by Mayo clinic.
  • Made use of a cohort that already available on a database to ascertain if patients with cognitive dysfunction experienced post operative delirium.
  • Patients 65 yr of age enrolled in the Mayo Clinic Study of Aging who were exposed to any type of anaesthesia from 2004 to 2014 were included.
  • Cognitive status was evaluated before and after surgery by neuropsychological testing and clinical assessment, and was defined as normal or MCI/dementia.
  • Postoperative delirium was detected with the Confusion Assessment Method for the intensive care unit.

 Subjects

  • In 2004, 70–89 yr olds were identified from a Mayo Clinic Database, randomly selected, and invited to participate in the study.
  • In 2008, ongoing recruitment was initiated using the same protocols as baseline
  • In 2012, the lower limit of the age criterion was reduced to 50 years of age.
  • The study includes all participants enrolled and examined in person in the MCSA study from November 2004 to February 2014 who underwent surgeries and procedures under anaesthesia at Mayo Clinic in Rochester, MN, USA
  • Only participants who were 65 yr of age at enrolment were included.

 Intervention

  • Nil specific intervention.
  • The use of the CAM ICU scoring system was used to identify post op delirium.
  • A pre and post op cognitive impairment screen was used to ascertain both baseline and post op cognition levels.

Outcomes

Claimed to have confirmed previous findings that in a general surgical population elderly patients with cognitive dysfunction at the time of surgery are at higher risk for clinically evident post op delirium compared with patients without mild cognitive impairment.

Main finding is that elderly patients who are cognitively normal at a detailed assessment performed before surgery and who experience clinically evident post op delirium are more likely to develop cognitive impairment or dementia subsequently compared with those who do not experience post op delirium.

Results

  • The frequency of POD was higher in patients with pre-existing cognitive impairment compared with no cognitive impairment/dementia.
  • The frequency of MCI/dementia at the first postoperative evaluation was higher in patients who experienced POD compared with those who did not.

Conclusions

Mild cognitive impairment or dementia is a risk for post op delirium. Elderly patients who have not been diagnosed with cognitive impairment but experience post op delirium are more likely to be diagnosed subsequently with cognitive impairment or dementia.

Strengths

  • Ambitious project.
  • Made us of a large source of data that was readily available.
  • Appeared to confirm a notion that is already in existing literature.
  • Made use of validated means for detecting both cognitive dysfunction and post op delirium.

Weaknesses

  • Observational study only.
  • Mixed methodology with observation both retrospective and prospective.
  • Data observational in nature with no firm validated intervention being studied.
  • Lots of the conclusions seem to be inferred.
  • Did not drill into the data to ascertain if there was one particular factor causing post op delirium.
  • Did not offer any insights into how this phenomenon may be tackled in the future.
  • The journal club group felt it was a weak paper with no rigorous methodology that could be used to garner meaningful results.
  • Appears that this group had a large data set and used it to contrived this paper, which doesn’t appear to clinically add anything to this known phenomenon that already exists in the literature.

Implications

The reader will be aware of the notion that the long term effect of anaesthesia can result in cognitive impairment. The reader will also be appreciative of the fact that post op delirium can contribute to cognitive decline in at risk patients over time.

Potential for impact

  • Raises awareness amongst trainees about this phenomenon.
  • Impact level is poor due to weaknesses within the paper.

 

Journal Club: 12th September 2017

Patterns and Predictors of Frailty Transitions in Older Men: The Osteoporotic Fractures in Men Study

Journal of the American Geriatrics Society, September 2017. doi:10.1111/jgs.15003

 Presented by: Dr R. Christie

Background

  • Frailty is a geriatric syndrome leading to reduced physiological reserve. Frail patients are therefore more vulnerable to adverse outcomes i.e. anaesthesia and surgery.
  • 2 small scale studies have suggested that frailty is a dynamic process and prevention and reversal may be possible.

Primary Objectives:

  • To determine patterns and probability of frailty progression and improvement.

Secondary Objectives:

  • To Identify predictors of transitions in frailty status

Design and Setting

  • Prospective observational cohort study across 6 US clinical centres
  • Recruited patients from osteoporotic fractures in men study (MrOS) which used mailings, newspaper advertisements and presentations aimed at older populations to recruit individuals
  • 5,086 men received a second visit at 4.6 +/- 0.4 years after recruitment to MrOS. 908 of the 5,994 originally recruited were not included in the study.

Subjects

  • Men, over 65.
  • 10% from minority groups (African-American, Asian).
  • All lived in the community and were able to walk independently at time of recruitment.

Intervention

  • At recruitment the cohort completed:
    • A self-administered questionnaire which included factors based on socioeconomic status and ADLs.
    • A mini mental state examination to assess cognitive function.
  • A fifth of the men also had physiological parameters measured.
  • Men were classified as robust, pre-frail or frail based on defined criteria at the start and end of the study period and the transition between groups was compared with data from the questionnaires, MMSE and physiological parameters.

Outcomes

Primary Outcomes:

  • Probability of transition between frailty states between visit 1 and visit 2.

Secondary Outcomes:

  • The odds of progression in frailty status from visit 1 to visit 2 based on baseline characteristics.
  • The odds of improvement in frailty status from visit 1 to visit 2 based on baseline characteristics.

Results

Probability of transition:

  • Robust patients:
    • Robust to Robust – 0.6
    • Robust to Prefrail – 0.32
    • Robust to Frail – 0.03
    • Robust to Death – 0.05
  • Pre frail patients:
    • Prefrail to Robust – 0.15
    • Prefrail to Prefrail – 0.55
    • Prefrail to Frail – 0.17
    • Prefrail to Death – 0.12
  • Frail Patients:
    • Frail to Robust – 0.005
    • Frail to Prefrail – 0.16
    • Frail to Frail – 0.45
    • Frail to Death – 0.28

Characteristics that correlate with progression of frailty:

  • DM
  • Instrumental activity of daily living limitations
  • Smoking
  • CCF
  • Low albumin
  • High interleukin 6

Characteristics that correlate with improvement in frailty:

  • Leg power
  • Marriage

Conclusions

  • Improvement in frailty status is possible and is associated with social, functional and clinical factors.
  • Future studies need to target interventions in frail and pre-frail states such as improving strength and lower limb power, improvement management of co-morbidities and social and nutritional support.

Strengths

  • Large study
  • Prospective
  • Well written and presented

Weaknesses

  • Single sex (male) and predominantly white cohort.
  • Residential/Nursing home residents and those living in assisted living not included. May not be representative of the over 65 population.
  • Only two visits over 4.6 +/- 0.4 year period.
    • Did not identify transitions in between visits nor identify ongoing factors that may have influenced transitions e.g. men who stopped smoking
  • Acute illnesses at time of visits may affect results classification of frailty.
  • Did not state cause of death in the 568 patients that died, and was this related to their frailty status.
  • Did not state why over 700 patients were left out of study.

Implications

  • Identified possible targets for intervention that could be further investigated to determine if they improve patient’s frailty scores. These include improving social support networks, smoking and increased physical activity.

Potential for impact

  • Nothing new identified
  • Confirmed what they had hypothesised from data already available
  • This paper is unlikely to drastically change what is already done in in pre-assessment clinics.

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