老年麻醉评估以指导心脏手术术前多学科团队护理的患者选择。

Anaesthesia geriatric evaluation to guide patient selection for preoperative multidisciplinary team care in cardiac surgery.

作者信息

Verwijmeren Lisa, Peelen Linda M, van Klei Wilton A, Daeter Edgar J, van Dongen Eric P A, Noordzij Peter G

机构信息

Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, the Netherlands.

Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.

出版信息

Br J Anaesth. 2020 Apr;124(4):377-385. doi: 10.1016/j.bja.2019.12.042. Epub 2020 Feb 14.

DOI:10.1016/j.bja.2019.12.042

PMID:32063340

Abstract

BACKGROUND

A multidisciplinary approach to improve postoperative outcomes in frail elderly patients is gaining interest. Multidisciplinary team care should be targeted at complex patients at high risk for adverse postoperative outcome to limit the strain on available resources and to prevent an unnecessary increase in patient burden. This study aimed to improve patient selection for multidisciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients.

METHODS

This was a two-centre prospective cohort study of 537 patients aged ≥70 yr undergoing elective cardiac surgery. Before surgery, 11 frailty characteristics were investigated. Outcome was disability at 3 months defined as World Health Organization Disability Assessment Schedule 2.0 ≥25%. Multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index was used to identify factors contributing to patient selection.

RESULTS

Disability occurred in 91 (17%) patients. Ten out of 11 frailty characteristics were associated with disability. A multivariable model, including the European System for Cardiac Operative Risk Evaluation II and preoperative haemoglobin, yielded a c-statistic of 0.71 (95% confidence interval [CI]: 0.66-0.77). After adding pre-specified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health-related quality of life, and living alone) to this model, the c-statistic improved to 0.78 (95% CI: 0.73-0.83). The net reclassification index was 0.32 (P<0.001), showing improved discrimination for patients at risk for disability at 3 months.

CONCLUSIONS

The addition of preoperative frailty characteristics to a multivariable model improved discrimination between elderly patients with and without disability at 3 months after cardiac surgery, and can be used to guide patient selection for preoperative multidisciplinary team care.

CLINICAL TRIAL REGISTRATION

NCT02535728.

摘要

背景

一种多学科方法来改善体弱老年患者的术后结局正受到关注。多学科团队护理应针对术后不良结局高风险的复杂患者，以限制可用资源的压力并防止患者负担不必要的增加。本研究旨在通过识别老年患者心脏手术后残疾的风险因素来改善多学科护理的患者选择。

方法

这是一项对537例年龄≥70岁接受择期心脏手术患者的双中心前瞻性队列研究。手术前，调查了11项衰弱特征。结局为3个月时的残疾，定义为世界卫生组织残疾评估量表2.0≥25%。使用逻辑回归、一致性统计量（c统计量）和净重新分类指数进行多变量建模，以识别有助于患者选择的因素。

结果

91例（17%）患者出现残疾。11项衰弱特征中有10项与残疾相关。一个多变量模型，包括欧洲心脏手术风险评估系统II和术前血红蛋白，c统计量为0.71（95%置信区间[CI]：0.66 - 0.77）。在该模型中加入预先指定的衰弱特征（多重用药、步速、身体残疾、术前健康相关生活质量和独居）后，c统计量提高到0.78（95%CI：0.73 - 0.83）。净重新分类指数为0.32（P<0.001），表明对3个月时残疾风险患者的辨别能力有所提高。