Patient safety, cost-effectiveness, and quality of life: reduction of delirium risk and postoperative cognitive dysfunction after elective procedures in older adults—study protocol for a stepped-wedge cluster randomized trial (PAWEL Study) Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass. Prediction of Postoperative Complications Following Elective Surgery in Elderly Patients with Colorectal Cancer Using the Comprehensive Geriatric Assessment Risk factors for pulmonary complications after emergency abdominal surgery. Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. High preoperative plasma neopterin predicts delirium after cardiac surgery in older adults. Predictors of Short-Term Postoperative Survival After Elective Colectomy in Colon Cancer Patients ≥80 Years of Age Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial. Xenon for the prevention of postoperative delirium in cardiac surgery: study protocol for a randomized controlled clinical trial Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. Brain atrophy and white-matter hyperintensities are not significantly associated with incidence and severity of postoperative delirium in older persons without dementia Frailty is an independent predictor of survival in older patients with colorectal cancer. The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery. Randomized trial of hypotensive epidural anesthesia in older adults. A clinical prediction rule for delirium after elective noncardiac surgery. Postoperative Nausea and Vomiting: A Retrospective Analysis in Patients Undergoing Elective Craniotomy Thirty-Day Mortality After Primary Cytoreductive Surgery for Advanced Ovarian Cancer in the Elderly Pressure ulcer risk factors in patients undergoing surgery. Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. The Clinical Significance of an Elevated Postoperative Glucose Value in Nondiabetic Patients after Colorectal Surgery: Evidence for the Need for Tight Glucose Control? Donepezil in the prevention and treatment of post-surgical delirium. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison
Background Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality , prolonged cognitive impairment , development of dementia , higher institutionalization rates , and rising healthcare costs . The probability of delirium after surgery increases with patients ’ age , with pre-existing cognitive impairment , and with comorbidities , and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria , risk factors , and treatment options of the medical staff . In this study , we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline ( POCD ) in patients older than 70 years undergoing elective surgery . Additionally , we will analyze whether the intervention is cost-effective . Methods The study will be conducted at five medical centers ( with two or three surgical departments each ) in the southwest of Germany . The study employs a stepped-wedge design with cluster r and omization of the medical centers . Measurements are performed at six consecutive points : preadmission , preoperative , and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2 , 6 , and 12 months after surgery . Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures ( cardiac , thoracic , vascular , proximal big joints and spine , genitourinary , gastrointestinal , and general elective surgery procedures ) . Discussion Results of the trial should form the basis of future st and ards for preventing delirium and POCD in surgical wards . Key aims are the improvement of patient safety and quality of life , as well as the reduction of the long-term risk of conversion to dementia . Furthermore , from an economic perspective , we expect benefits and decreased costs for hospitals , patients , and healthcare insurances . Trial registration German Clinical Trials Register , DRKS00013311 . Registered on 10 November 2017 OBJECTIVES Postoperative delirium after cardiac surgery is associated with increased morbidity and mortality as well as prolonged stay in both the intensive care unit and the hospital . The authors sought to identify modifiable risk factors associated with the development of postoperative delirium in elderly patients after elective cardiac surgery in order to be able to design follow-up studies aim ed at the prevention of delirium by optimizing perioperative management . DESIGN A post hoc analysis of data from patients enrolled in a r and omized controlled trial was performed . SETTING A single university hospital . PARTICIPANTS One hundred thirteen patients aged 65 or older undergoing elective cardiac surgery with cardiopulmonary bypass .  INTERVENTIONS None . MEASUREMENTS AND MAINS RESULTS : Screening for delirium was performed using the  Confusion Assessment Method ( CAM ) on the first 6 postoperative days . A multivariable logistic regression model was developed to identify significant risk factors and to control for confounders . Delirium developed in 35 of 113 patients ( 30 % ) . The multivariable model showed the maximum value of C-reactive protein measured postoperatively , the dose of fentanyl per kilogram of body weight administered intraoperatively , and the duration of mechanical ventilation to be independently associated with delirium . CONCLUSIONS In this post hoc analysis , larger doses of fentanyl administered intraoperatively and longer duration of mechanical ventilation were associated with postoperative delirium in the elderly after cardiac surgery . Prospect i ve r and omized trials should be performed to test the hypotheses that a reduced dose of fentanyl administered intraoperatively , the use of a different opioid , or weaning protocol s aim ed at early extubation prevent delirium in these patients Aims : The study aims to determine whether the Comprehensive Geriatric Assessment ( CGA ) could predict complications of colorectal cancer ( CRC ) surgery and identify the problems . So we compared the prognostic value of the CGA with patient characteristics and determined predictive scores . Methods : A total of 156 patients aged 75 years and older , who underwent surgery for CRC at Osaka University Hospital , were enrolled . Each patient was examined by the CGA prospect ively , and all postoperative complications were obtained from the medical records . The CGA included the  Barthel Index ( BI ) , Vitality Index , instrumental activities of daily living ( iADL ) , Mini-Mental State Examination ( MMSE ) and Geriatric Depression Score ( GDS ) .  All elements were retrospectively compared in patients with or without postoperative complications , including delirium , surgical site infection and ileus . Results : Overall , postoperative complications developed in 76 patients ( 48.7 % ) . The BI and MMSE were associated with the incidence of complications , and BI , iADL , MMSE and GDS were significantly related with delirium . Multivariate logistic analysis identified the MMSE as a significant determinant of postoperative complications after adjusting for other determined predictive scores including the prognostic nutritional index and performance status . Conclusion : The CGA was a useful predictor of postoperative complications in elderly patients when administered before surgery for CRC OBJECTIVE Pulmonary complications are common after abdominal surgery .  Although a variety of risk factors have been described for these complications , studies so far have focused on elective interventions . The aim of this study was to determine the incidence and predictors of pulmonary complications following  emergency abdominal surgery .  METHODS This was a prospect i ve cohort study . Pre and intra-operative data were collected through interview and chart review and their association with the occurrence of postoperative pulmonary complications ( PPC ) were analyzed . RESULTS Two hundred and sixty-six consecutive adult patients were included and seventy-five ( 28.2 % ) developed PPC . Age > 50 years ( adjusted OR=3.86 ; P<0.001 ) , body mass index ( BMI ) < 21 kg/m(2 ) or 30 kg/m(2 ) ( adjusted OR=2.43 ; P=0.007 ) and upper or upper/lower abdominal incision ( adjusted OR=2.57 ; P=0.027 ) were independently associated with PPC . Patients su bmi tted to multiple procedures tended to be at a higher risk for PPC ( adjusted OR=1.73 ; P=0.079 ) . The development of PPC was associated with prolonged hospital stay ( P<0.001 ) and increased death rate ( P<0.001 ) . CONCLUSIONS Pulmonary complications are frequent among patients undergoing abdominal emergency surgery  and lead to increased length of hospital stay and death rate . Older age , abnormal BMI , upper or upper/lower abdominal incision and multiple procedures are predictors of PPC in this setting BACKGROUND older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation . OBJECTIVE to design , embed , and evaluate an evidence -based comprehensive geriatric assessment ( CGA ) service for at-risk older patients undergoing elective surgery . SETTING urban teaching hospital . SUBJECTS elective surgical patients aged 65 + . INTERVENTION multidisciplinary preoperative CGA service with post-operative follow-through ( proactive care of older people undergoing surgery [ ' POPS ' ] ) . METHODS observational cohort study and multilevel surveys ( development and modelling phase ) . Prospect i ve ' before and after ' comparison ( exploratory evaluation ) . RESULTS findings from the development phase showed high levels of preoperative co-morbidity , no multidisciplinary preoperative input , and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients . Comparison of 2 cohorts of elective orthopaedic patients ( pre-POPS vs POPS , N = 54 ) showed the POPS group had fewer post-operative medical complications including pneumonia ( 20 % vs 4 % [ p = 0.008 ] ) and delirium ( 19 % vs 6 % [ p = 0.036 ] ) , and significant improvements in areas reflecting multidisciplinary practice including pressure sores ( 19 % vs 4 % [ p = 0.028 ] ) , poor pain control ( 30 % vs 2 % [ p<0.001 ] ) , delayed mobilisation ( 28 % vs 9 % [ p = 0.012 ] ) and inappropriate catheter use ( 20 % vs 7 % [ p = 0.046 ] ) . Length of stay was reduced by 4.5 days . There were fewer delayed discharges relating to medical complications ( 37 % vs 13 % ) or waits for OT assessment or equipment ( 20 % vs 4 % ) . CONCLUSION a proactive evidence -based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions . Pre/post comparison in elective orthopaedic patients showed improved ( within method ological limitations ) post-operative outcomes indicative of better clinical effectiveness and efficiency , and contributed to the service obtaining mainstream funding . Informed by the present study , a r and omised controlled trial is ongoing OBJECTIVES To examine the association between plasma levels of pterins and amino acids and postoperative delirium . DESIGN Prospect i ve cohort study . SETTING Cardiothoracic service in an university hospital in Rotterdam , the Netherl and s. PARTICIPANTS One hundred twenty-five individuals aged 70 and older undergoing elective cardiac surgery .  MEASUREMENTS Plasma pterins and amino acids were measured pre- and postoperatively . Using multiple logistic regression analyses , the associations between pterins and amino acid levels and postoperative delirium were examined in relation to age , sex , comorbidity , cognitive functioning ( Mini-Mental State Examination ( MMSE ) score ) , and cardiac risk factors . RESULTS Delirium incidence in the main study group was 31.3 % . The preoperative measures associated with delirium were neopterin ( odds ratio ( OR ) = 1.05 , P = .009 ) ; MMSE score less than 28 ( OR = 4.39 , P = .001 ) ; European System for Cardiac Operative Risk Evaluation score greater than 6 ( OR = 2.84 , P = .03 ) ; and combined coronary artery bypass graft ( CABG ) and aortic , mitral , or tricuspid valve surgery ( OR = 4.32 , P = .01 ) . Postoperative measures associated with delirium were neopterin ( OR = 3.84 , P = .02 ) , homovanillic acid ( HVA , OR = 1.01 , P = .04 ) , and preoperative MMSE score less than 28 ( OR = 3.32 , P = .008 ) . CONCLUSION Preoperatively high neopterin levels predicted delirium after cardiac surgery in older adults , in addition to the well-known risk factors of poor cognitive function , high cardio-surgical risk , and combined CABG and valve surgery . Postoperative neopterin and HVA levels were also found to be associated with delirium , together with preoperative cognitive functioning . Plasma neopterin may be a c and i date biomarker for delirium after cardiac surgery in these older adults Background Individuals ≥80 years of age represent an increasing proportion of colon cancer diagnoses . Selecting these patients for elective surgery is challenging because of diminished overall health , functional decline , and limited data to guide decisions . The objective was to identify overall health measures that are predictive of poor survival after elective surgery in these oldest-old colon cancer patients . Methods Medicare beneficiaries ≥80 years who underwent elective colectomy for stage I – III colon cancer from 1992–2005 were identified from the Surveillance , Epidemiology and End Results (SEER)-Medicare data base . Kaplan – Meier survival analysis determined 90-day and 1-year overall survival . Multivariable logistic regression assessed factors associated with short-term postoperative survival . Results Overall survival for the 12,979 oldest-old patients undergoing elective colectomy for colon cancer was 93.4 and 85.7 % , at 90 days and 1 year . Older age , male gender , frailty , increased hospitalizations in prior year , and dementia were most strongly associated with decreased survival . In addition , AJCC stage III ( vs stage I ) disease and widowed ( vs married ) were highly associated with decreased survival at 1 year . Although only 4.4 % of patients were considered frail , this had the strongest association with mortality , with an odds ratio of 8.4 ( 95 % confidence interval , 6.4–11.1 ) . Conclusions Although most oldest-old colon cancer patients do well after elective colectomy , a significant proportion ( 6.6 % ) die by postoperative day 90 and frailty is the strongest predictor . The ability to identify frailty through billing cl aims is intriguing and suggests the potential to prospect ively identify , through the electronic medical record , patients at highest risk of decreased survival OBJECTIVE To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults . DESIGN R and omized controlled clinical trial . SETTING Orthopedic specialty academic hospital . PATIENTS A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years ; 70 % women . INTERVENTION R and om assignment to either epidural or general anesthesia . MAIN OUTCOME MEASURES A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively . Cognitive outcome was assessed by within-patient change on 10 tests of memory , psychomotor , and language skills . Prospect i ve st and ardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes . RESULTS The two groups were similar at baseline in terms of age , sex , comorbidity , and cognitive function . There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months . Overall , 5 % of patients showed a long-term clinical ly significant deterioration in cognitive function . There was no difference between the anesthesia groups in the incidence of major cardiovascular complications ( 3 % overall ) . CONCLUSIONS The type of anesthesia , general or epidural , does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement . This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date , with more than 99 % power to detect a clinical ly significant difference on any of the neuropsychological tests Background Postoperative delirium ( POD ) is a manifestation of acute postoperative brain dysfunction that is frequently observed after cardiac surgery . POD is associated with short-term complications such as an increase in mortality , morbidity , costs and length of stay , but can also have long-term sequelae , including persistent cognitive deficits , loss of independence , and increased mortality for up to 2 years . The noble gas xenon has been demonstrated in various models of neuronal injury to exhibit remarkable neuroprotective properties . We therefore hypothesize that xenon anesthesia reduces the incidence of POD in elderly patients undergoing cardiac surgery with the use of cardiopulmonary bypass . Methods / Design One hundred and ninety patients , older than 65 years , and scheduled for elective cardiac surgery , will be enrolled in this prospect i ve , r and omized , controlled trial . Patients will be r and omized to receive  general anesthesia with either xenon or sevoflurane . Primary outcome parameter will be the incidence of POD in the first 5 postoperative days . The occurrence of POD will be assessed by trained research personnel , blinded to study group , with the vali date d 3-minute Diagnostic Confusion Assessment Method ( 3D-CAM ) ( on the intensive care unit in its version specifically adapted for the ICU ) , in addition to chart review and the results of delirium screening tools that will be performed by the bedside nurses ) . Secondary outcome parameters include duration and severity of POD , and postoperative cognitive function as assessed with the Mini-Mental State Examination . Discussion Older patients undergoing cardiac surgery are at particular risk to develop POD .  Xenon provides remarkable hemodynamic stability and has been suggested in pre clinical studies to exhibit neuroprotective properties . The present trial will assess whether the promising profile of xenon can be translated into a better outcome in the geriatric population .Trial registration EudraCT Identifier : 2014 - 005370 - 11 ( 13 May 2015 ) BACKGROUND Preoperative risk stratification is commonly performed by assessing end-organ function ( such as cardiac and pulmonary ) to define postoperative risk . Little is known about impaired preoperative cognition and outcomes . The purpose of this study was to evaluate the impact of baseline impaired cognition on postoperative outcomes in geriatric surgery patients . STUDY DESIGN Subjects 65 years and older undergoing a planned elective operation requiring postoperative ICU admission were recruited prospect ively .  Preoperative baseline cognition was assessed using the vali date d Mini-Cog test . Impaired cognition was defined as a Mini-Cog score of ≤ 3 . Delirium was assessed using the Confusion Assessment Method -ICU by a trained research team . Adverse outcomes were defined using the Veterans Affairs Surgical Quality Improvement Program definitions . RESULTS One hundred and eighty-six subjects were included , with a mean age of 73 ± 6 years . Eighty-two subjects ( 44 % ) had baseline impaired cognition . The impaired cognition group had the following unadjusted outcomes : increased incidence of 1 or more postoperative complications ( 41 % vs 24 % ; p = 0.011 ) , higher incidence of delirium ( 78 % vs 37 % ; p < 0.001 ) , longer hospital stays ( 15 ± 14 vs 9 ± 9 days ; p = 0.001 ) , higher rate of discharge institutionalization ( 42 % vs 18 % ; p = 0.001 ) , and higher 6-month mortality ( 13 % vs 5 % ; p = 0.040 ) . Adjusting for potential confounders determined by univariate analysis , logistic regression found impaired cognition was still associated with the occurrence of 1 or more postoperative complications ( odds ratio = 2.401 ; 95 % CI , 1.185 - 4.865 ; p = 0.015 ) . Kaplan-Meier survival analysis revealed higher mortality in the impaired cognition group ( log-rank p = 0.008 ) . CONCLUSIONS Baseline cognitive impairment in older adults undergoing major elective operations is related to adverse postoperative outcomes including increased complications , length of stay , and long-term mortality . Improved underst and ing of baseline cognition and surgical outcomes can aid surgical decision making in older adults Postoperative delirium is a common complication in older people and is associated with increased mortality , morbidity , institutionalization , and caregiver burden . Although delirium is an acute confusional state characterized by global impairments in attention and cognition , it has been implicated in permanent cognitive impairment and dementia . The pathogenesis of delirium and the mechanisms leading to these disabling consequences remain unclear . The present study is the first to address the potential predisposing role of brain morphologic changes toward postoperative delirium in a large prospect i ve cohort of patients undergoing elective surgery using state-of-the-art magnetic resonance imaging ( MRI ) techniques conducted before admission . We investigated the association of MRI-derived quantitative measures of white-matter damage , global brain , and hippocampal volume with the incidence and severity of delirium . Presurgical white-matter hyperintensities ( WMHs ) , whole brain , and hippocampal volume were measured in 146 consecutively enrolled subjects , ≥70 years old , without dementia who were undergoing elective surgery . These 3 presurgical MRI indices were tested as predictors of incidence and severity of subsequent delirium . Out of 146 subjects , 32 ( 22 % ) developed delirium . We found no statistically significant differences in WMH , whole brain , or hippocampal volume between subjects with and without delirium . Both unadjusted and adjusted ( age , gender , vascular comorbidity , and general cognitive performance ) regression analyses demonstrated no statistically significant association between any of the MRI measures with respect to delirium incidence or severity . In persons without dementia , preexisting cerebral WMHs , general and hippocampal atrophy may not predispose to postoperative delirium or worsen its severity BACKGROUND Colorectal cancer ( CRC ) is prevalent in the older population .  Geriatric assessment ( GA ) has previously been found to predict treatment tolerance and postoperative complications in older cancer patients . The aim of this study was to explore whether GA also predicts 1-year and 5-year survival after  CRC surgery in older patients and to compare the predictive power of GA with that of established prognostic factors such as TNM classification of malignant tumors ( TNM ) stage and age . MATERIAL S AND METHODS A cohort of 178 CRC patients aged 70 and older were followed prospect ively . All patients went through elective surgery , and GA was performed presurgery . The GA result ed in patients being divided into two groups : frail or nonfrail . All patients were followed for 5 years or until death . Data were analyzed by Kaplan-Meier plots and the Cox proportional hazards model . RESULTS Seventy-six patients ( 43 % ) were frail , and one hundred and two ( 57 % ) were nonfrail . Twenty-three patients ( 13 % ) died during the first year after surgery . One-year survival was 80 % in the frail group and 92 % in the nonfrail group . Five-year survival was significantly lower in frail ( 24 % ) than nonfrail patients ( 66 % ) , and this difference was apparent both within the stratums of TNM stages 0-II and TNM stage III . In multivariable analysis adjusting for TNM stage , age , and sex , frailty was an independent prognostic factor for survival . CONCLUSION A GA-based frailty assessment predicts 1-year and 5-year survival in older patients after surgery for CRC . In localized and regional disease , the impact of frailty upon 5-year survival is comparable with that of TNM stage BACKGROUND Malnutrition in gastrointestinal ( GI ) surgery is associated with increased morbidity . Therefore , careful screening remains crucial to identify patients at risk for malnutrition and consequently postoperative complications . The aim of this study was to evaluate the ability of 3 established score systems to identify patients at risk of developing postoperative complications in GI surgery and to assess the correlation among the score systems . METHODS We evaluated prospect ively 200 patients admitted for elective GI surgery using ( 1 ) nutrition risk index , ( 2 ) nutrition risk score , and ( 3 ) bioelectrical impedance analysis .  Complications were assessed using a st and ardized complication classification . The findings of the score systems were correlated with the incidence and severity of complications . Parametric and nonparametric correlation analysis was performed among the different score systems . RESULTS All 3 score systems correlated significantly with the incidence and severity of postoperative complications and the duration of hospital stay . Using multiple regression analysis , only nutrition risk score and malignancy remained prognostic factors for the development of complications with odds ratios of 4.2 ( P = .024 ) and 5.6 ( P < .001 ) , respectively . The correlation between nutrition risk score and nutrition risk index was only moderate ( Pearson coefficient = 0.54 ) . Bioelectrical impedance analysis displayed only weak to trivial correlation to the nutrition risk index ( 0.32 ) and nutrition risk score ( 0.19 ) , respectively . CONCLUSION The nutrition risk score , nutrition risk index , and bioimpedance analysis correlate with the incidence and severity of perioperative complications in GI surgery . The nutrition risk score was the best score in predicting patients who will develop complications in this study population . The correlation between the individual scores was only moderate , and therefore , they do not necessarily identify the same patients BACKGROUND Data are sparse on the incidence of postoperative cognitive , cardiac , and renal complications after deliberate hypotensive anesthesia in elderly patients . METHODS This r and omized , controlled clinical trial included 235 older adults with comorbid medical illnesses undergoing elective primary total hip replacement with epidural anesthesia .  The patients were r and omly assigned to one of two levels of intraoperative mean arterial blood pressure management : either to a markedly hypotensive mean arterial blood pressure range of 45 - 55 mmHg or to a less hypotensive range of 55 - 70 mmHg . Cognitive outcome was assessed by within-patient change on 10 neuropsychologic tests assessing memory , psychomotor , and language skills from before surgery to 1 week and 4 months after surgery . Prospect i ve st and ardized surveillance was performed for cardiovascular and renal outcomes , delirium , thromboembolism , and blood loss and replacement . RESULTS The two groups were similar at baseline in terms of age ( mean , 72 yr ) , sex ( 50 % women ) , comorbid conditions , and cognitive function . After operation , no significant differences in the incidence of early or long-term cognitive dysfunction were observed between the two blood pressure management groups . There were no significant differences in the rates of other adverse consequences , including cardiac , renal , and thromboembolic complications . In addition , no differences occurred in the duration of surgery , intraoperative estimated blood loss , or transfusion rates . CONCLUSIONS Elderly patients can safely receive controlled hypotensive epidural anesthesia with this protocol . There was no evidence of greater risks , or early benefits , with the use of the more markedly hypotensive range OBJECTIVE To develop and vali date a clinical prediction rule for postoperative delirium using data available to clinicians preoperatively . DESIGN Prospect i ve cohort study . SETTING General surgery , orthopedic surgery , and gynecology services at Brigham and Women 's Hospital , Boston , Mass. PATIENTS Consenting patients older than 50 years admitted for major elective noncardiac surgery between November 1 , 1990 , and March 15 , 1992 ( N = 1341 ) . MEASUREMENTS All patients underwent preoperative evaluations , including a medical history , physical examination , laboratory tests , and assessment s of physical and cognitive function using the Specific Activity Scale and the Telephone Interview for Cognitive Status . Postoperative delirium was diagnosed using the Confusion Assessment Method or using data from the medical record and the hospital 's nursing intensity index . Patients were followed up for the duration of hospitalization to determine major complication rates , length of stay , and discharge disposition . RESULTS Postoperative delirium occurred in 117 ( 9 % ) of the 1341 patients studied . Independent correlates included age 70 years or older ; self-reported alcohol abuse ; poor cognitive status ; poor functional status ; markedly abnormal preoperative serum sodium , potassium , or glucose level ; noncardiac thoracic surgery ; and aortic aneurysm surgery . Using these seven preoperative factors , a simple predictive rule was developed . In an independent population , the rule stratified patients into groups with low ( 2 % ) , medium ( 8 % , 13 % ) , and high ( 50 % ) rates of postoperative delirium . Patients who developed delirium had higher rates of major complications , longer lengths of stay , and higher rates of discharge to long-term care or rehabilitative facilities . CONCLUSIONS Using data available preoperatively , clinicians can stratify patients into risk groups for the development of delirium . Since delirium is associated with a variety of adverse outcomes , patients with substantial risk for this complication could be c and i date s for interventions to reduce the incidence of postoperative delirium and potentially improve overall surgical outcomes Nausea and vomiting are important complications after craniotomy , for which there are little published epidemiologic data . We retrospectively examined the incidence of postcraniotomy nausea and vomiting to define risk factors . Medical records from 199 adults undergoing elective craniotomy were identified . Data extracted from surgery and the initial 48 hours postoperatively included gender , age , supratentorial versus infratentorial craniotomy , type of anesthesia ( general versus monitored anesthesia care ) , intraoperative fentanyl dose , duration of anesthesia , antiemetic administration intraoperatively and postoperatively , and incidence of postoperative nausea , emesis , and opioid use . Postoperative nausea was recorded in 99 patients ( 50 % ) and emesis in 78 patients ( 39 % ) . Postoperative opioids were administered to 170 patients ( 85 % ) . Antiemetics were given intraoperatively to 13 patients ( 7 % ) and postoperatively to 121 patients ( 61 % ) . More women ( 61 % ) than men ( 37 % ) had nausea ( P = 0.001 ) ; emesis ( women = 46 % ; men = 31 % , P = 0.03 ) ; and postoperative antiemetic use ( women = 69 % ; men = 51 % , P = 0.013 ) . The incidence of postoperative nausea ( P = 0.04 ) and vomiting ( P = 0.06 ) was greater in patients having infratentorial surgery . Emesis was more frequent in younger patients ( P = 0.03 ) . Postoperative nausea and vomiting were independent of anesthetic duration , fentanyl dose , or postoperative opioid use and occurred with similar frequency after general anesthesia or monitored anesthesia care . We conclude that postoperative nausea and vomiting occur frequently after craniotomy . Infratentorial surgery , female gender , and younger age are significant risk factors for this complication OBJECTIVE : To identify factors associated with increased 30-day mortality after advanced ovarian cancer debulking among elderly women . METHODS : A data base linking Medicare records with the Surveillance , Epidemiology , and End Results ( SEER ) data was used to identify a cohort of 5,475 women aged 65 and older who had primary debulking surgery for stage III or IV epithelial ovarian cancer ( diagnosed 1995–2005 ) . Women were stratified by acuity of hospital admission . Multivariable analysis was performed to identify patient-related and treatment-related variables associated with 30-day mortality . RESULTS : Five thous and four hundred seventy-five women had surgery for advanced ovarian cancer , and the overall 30-day mortality was 8.2 % . Women admitted electively had a 30-day mortality of 5.6 % ( 251 of 4,517 ) , and those admitted emergently had a 30-day mortality of 20.1 % ( 168 of 835 ) . Advancing age , increasing stage , and increasing comorbidity score were all associated with an increase in 30-day mortality ( all P<.05 ) among elective admissions . A group of women at high risk admitted electively included those aged 75 or older with stage IV disease and women aged 75 or older with stage III disease and a comorbidity score of 1 or more . This group had an observed 30-day mortality of 12.7 % ( 95 % confidence interval 10.7%–14.9 % ) . CONCLUSION : Age , cancer stage , and comorbidity scores may be helpful to stratify electively admitted patients based on predicted postoperative mortality . If vali date d in a prospect i ve cohort , then these factors may help identify women who may benefit from alternative treatment strategies . LEVEL OF EVIDENCE : AIM This paper reports a study to identify risk factors associated with pressure ulcer development among a mixed group of adult patients undergoing surgery . BACKGROUND Few studies have been carried out with patients undergoing surgery to assess the risk of pressure ulcer development , and so there is a little knowledge of the risk factors for this group . However , studies among non-surgical patients have shown that nutritional predictors such as low serum albumin level and low body mass index ( BMI ) are of great importance . An additional predictive factor may be low blood pressure . It is important to study these predictors further among patients undergoing surgery , using techniques such as multiple regression techniques , design ed to identify the most important predictors for pressure ulcer development . METHODS A prospect i ve comparative study was carried out in 1996 - 1998 with 286 adult patients undergoing surgical treatment .  The data were collected from patient records by Registered Nurses preoperatively , for seven days postoperatively and thereafter once a week for up to 12 weeks . Perioperative data were also collected . The  Risk Assessment Pressure Sore Scale  was used , and data were collected on general physical condition , activity , mobility , moisture , food intake , fluid intake , sensory perception , friction and shear , body temperature and serum albumin . RESULTS Forty-one ( 14.3 % ) patients developed pressure ulcers during the observation period . The most common type was non-blanchable erythema . Those who developed pressure ulcers were significantly older , weighed less , and had a lower BMI and serum albumin . More women than men developed pressure ulcers . Risk factors identified in multiple stepwise regression analyses were female gender , American Society of Anaesthesiologists ( ASA ) status or New York Heart Association ( NYHA ) status and food-intake . CONCLUSION Special attention , with regard to risk of pressure ulcer development , should be paid to patients undergoing surgery who have low ASA or NYHA scores , low food intake and /or are women Background Frailty is a phenotype characterized by complex and challenging medical problems and higher susceptibility to adverse health outcomes . It can be derived at by a multidimensional process known as comprehensive geriatric assessment ( CGA ) , which assesses the functional reserves of the elderly . In this study we report for the first time on a prospect i ve evaluation of the association between CGA and postoperative complications after elective laparoscopic cholecystectomy for biliary disease . Methods Fifty-seven patients older than 65 years who were to undergo elective laparoscopic cholecystectomy for uncomplicated biliary disease were prospect ively examined .  Preoperative CGA was performed and the patients were categorized as fit or frail . The main outcome of the study was the rate of any postoperative complication within 30 days of surgery . Results There were 29 women ( 50.9 % ) and the median ( interquartile range ) age of the cohort was 73 ( 8.8 ) years . Thirty-two patients ( 56.1 % ) were categorized as frail and 25 ( 43.9 % ) as fit . The overall incidence of postoperative complications was 23.7 % , most of which were grade I and II ( 18.8 % ) . Frail patients , according to the CGA assessment , experienced a significantly higher incidence of postoperative complications compared to their fit counterparts ( 84.6 vs. 15.4 % , p = 0.023 ) . Frail patients experienced a significantly higher frequency of prolonged ( more than 2 days ) postoperative hospital stay compared with their fit counterparts ( p = 0.023 ) . Conclusions Preoperative CGA may predict postoperative complications and prolonged postoperative hospital stay of elderly patients who undergo elective laparoscopic cholecystectomy . Larger-scale studies independently assessing this association are warranted IMPORTANCE Major postoperative complications and delirium contribute independently to adverse outcomes and high re source use in patients who undergo major surgery ; however , their interrelationship is not well examined . OBJECTIVE To evaluate the association of major postoperative complications and delirium , alone and combined , with adverse outcomes after surgery . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic , vascular , or abdominal surgical procedures with a minimum 3-day hospitalization between June 18 , 2010 , and August 8 , 2013 . Data analysis took place from December 13 , 2013 , through May 1 , 2015 . MAIN OUTCOMES AND MEASURES Major postoperative complications , defined as life-altering or life-threatening events ( Accordion Severity grade 2 or higher ) , were identified by expert-panel adjudication . Delirium was measured daily with the Confusion Assessment Method and a vali date d medical record review method . The following 4 subgroups were analyzed : ( 1 ) no complications or delirium ; ( 2 ) complications only ; ( 3 ) delirium only ; and ( 4 ) complications and delirium . Adverse outcomes included a length of stay ( LOS ) of more than 5 days , institutional discharge , and rehospitalization within 30 days of discharge . RESULTS In the 566 participants , the mean ( SD ) age was 76.7 ( 5.2 ) years , 236 ( 41.7 % ) were male , and 523 ( 92.4 % ) were white . Forty-seven patients ( 8.3 % ) developed major complications and 135 ( 23.9 % ) developed delirium . Compared with no complications or delirium as the reference group , major complications only contributed to prolonged LOS only ( relative risk [ RR ] , 2.8 ; 95 % CI , 1.9 - 4.0 ) ; by contrast , delirium only significantly increased all adverse outcomes , including prolonged LOS ( RR , 1.9 ; 95 % CI , 1.4 - 2.7 ) , institutional discharge ( RR , 1.5 ; 95 % CI , 1.3 - 1.7 ) , and 30-day readmission ( RR , 2.3 ; 95 % CI , 1.4 - 3.7 ) . The subgroup with complications and delirium had the highest rates of all adverse outcomes , including prolonged LOS ( RR , 3.4 ; 95 % CI , 2.3 - 4.8 ) , institutional discharge ( RR , 1.8 ; 95 % CI , 1.4 - 2.5 ) , and 30-day readmission ( RR , 3.0 ; 95 % CI , 1.3 - 6.8 ) . Delirium exerted the highest attributable risk at the population level ( 5.8 % ; 95 % CI , 4.7 - 6.8 ) compared with all other adverse events ( prolonged LOS , institutional discharge , or readmission ) . CONCLUSIONS AND RELEVANCE Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect . Delirium occurs more frequently and has a greater effect at the population level than other major complications Objectives : To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery . Methods : Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center . Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and /or based on HbA1C levels . The association between any elevated postoperative r and om glucose value ( hyperglycemia : > 125 mg/dL ) and level of elevation ( > 125 mg/dL or > 200 mg/dL ) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed . Results : Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7 % patients experienced hyperglycemia . Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity ( blood loss ) . Hyperglycemia was associated with infectious and noninfectious complications and mortality , the rates of these complications increasing parallel to the degree of hyperglycemia . Hyperglycemia was independently associated with septic complications ( P = 0.024 ) . Conclusions : Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients . Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality ; this risk is related to the degree of glucose elevation . These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients OBJECTIVE Delirium is a frequent complication of major surgery in older persons . The authors evaluated the possible benefit of donepezil versus placebo in the prevention and treatment of postoperative delirium in an older population without dementia undergoing elective total joint-replacement surgery . METHODS A sample of 80 patients participated in this r and omized , double-blind , placebo-controlled trial of donepezil . Each participant was evaluated before surgery and then received donepezil or placebo for 14 days before surgery and 14 days afterward . Postoperative delirium was assessed with the Delirium Symptom Interview , Confusion Assessment Method , daily medical record , nurse-observation review s , and DSM-IV diagnostic criteria for delirium . Subsyndromal delirium was also assessed for each participant . RESULTS Delirium , diagnosed by DSM-IV criteria , was found on at least 1 postoperative day in 18.8 % of subjects , but there were no significant differences between the donepezil and placebo groups . When delirium was present , it lasted only 1 day , and there was no difference between the groups . Subsyndromal delirium was found on at least 1 postoperative day for 68.8 % of subjects , and , when this occurred , lasted 2 days or less , on average . There was no difference between the groups in the occurrence or duration of subsyndromal delirium . There was no difference between the groups in disposition to home or to another facility . CONCLUSIONS This pilot study was unable to demonstrate a benefit for donepezil in preventing or treating delirium in a relatively young and cognitively-intact group of elderly patients undergoing elective orthopedic surgery . Furthermore , postoperative delirium was not a major problem in this population BACKGROUND Despite use of thromboprophylaxis , elective hip-replacement surgery carries a high risk of venous thromboembolic complications . We aim ed to assess the ability of the pentasaccharide fondaparinux , the first of a new class of synthetic antithrombotic agents , to further reduce this risk . METHODS In a double-blind study , we r and omly assigned 2309 consecutive patients aged 18 years or older who were undergoing elective hip-replacement surgery to once daily , subcutaneous injections of either 2.5 mg fondaparinux , starting postoperatively , or 40 mg enoxaparin , starting preoperatively . The primary efficacy outcome was venous thromboembolism up to day 11 , defined as deep-vein thrombosis detected by m and atory bilateral venography , documented symptomatic deep-vein thrombosis , or documented symptomatic pulmonary embolism . The main safety outcomes were bleeding and death . The duration of follow-up was 6 weeks . Analysis was per protocol . FINDINGS We assessed the primary efficacy outcome in 1827 ( 79 % ) of 2309 patients . By day 11 , venous thromboembolisms were recorded in 37 ( 4 % ) of 908 patients assigned to fondaparinux and in 85 ( 9 % ) of 919 assigned to enoxaparin ( difference -5.2 % [ 95 % CI -8.1 to -2.7 ] , p<0.0001 ) . The relative reduction in risk was 55.9 % ( 95 % CI 33.1 - 72.8 ) . The two groups did not differ in frequency of death or clinical ly relevant bleeding . INTERPRETATION Drugs that act through specific inhibition of factor Xa , such as fondaparinux , could be more effective than low molecular weight heparins in prevention of venous thromboembolism in patients undergoing hip-replacement surgery
Conclusion Geriatric syndromes are important prognostic factors for postoperative complications .
Background Elective surgeries can be associated with significant harm to older adults .
The present study aim ed to identify the prognostic factors associated with the development of postoperative complications among older adults undergoing elective surgery .