surgical risk in elderly patients surgical risk factors, morbidity … · 2019. 6. 7. · 1...
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Surgical Risk Factors, Morbidity Surgical Risk Factors, Morbidity and Mortality in Elderly Patients and Mortality in Elderly Patients
Hongkun Wang PhD, Virginia Simpson RNNP,
R. Scott Jones MD
Florence E. Turrentine PhD, RN Florence E. Turrentine PhD, RN University of Virginia, Department of SurgeryUniversity of Virginia, Department of Surgery
Charlottesville, VirginiaCharlottesville, Virginia
The International Society of Geriatric Oncology
October 16-18, 2008
Surgical Risk in Elderly PatientsSurgical Risk in Elderly Patients
What is the influence of age and risk factors on What is the influence of age and risk factors on surgical morbidity and mortality?surgical morbidity and mortality?
University of Virginia IRB approvalUniversity of Virginia IRB approval
Surgical Clinical Nurse ReviewersSurgical Clinical Nurse Reviewers
General and Vascular Surgery General and Vascular Surgery (02/24/2002(02/24/2002--06/30/2005)06/30/2005)
–– Systematic SamplingSystematic Sampling–– All general surgery and esophageal cases included All general surgery and esophageal cases included
1/01/031/01/03-- 6/30/056/30/05
THE ACSTHE ACS--NSQIP DATABASENSQIP DATABASE
Preoperative DataPreoperative Data–– 10 demographic variables10 demographic variables–– 43 clinical variables43 clinical variables–– 13 laboratory variables13 laboratory variables
Intraoperative DataIntraoperative Data–– 41 variables41 variables
Postoperative DataPostoperative Data–– 3030--day postoperative mortalityday postoperative mortality–– 22 categories of 3022 categories of 30--day postoperative morbidity day postoperative morbidity –– Length of hospital stayLength of hospital stay
AnalysisAnalysis
Descriptive statisticsDescriptive statistics
BivariateBivariate analysis with Xanalysis with X2 2 for categorical for categorical variablesvariablesvariablesvariables
Logistic regression for significant variablesLogistic regression for significant variables
SAS version 9.1SAS version 9.1
ResultsResults7696 procedures on 6953 patients7696 procedures on 6953 patients
16% emergency procedures16% emergency procedures
24% of patients had no risk factors24% of patients had no risk factors
Females underwent 58% of proceduresFemales underwent 58% of procedures
Mean age 56Mean age 56
ResultsResults
Mean operation duration 139 minutesMean operation duration 139 minutes
Mean length of stay 5 daysMean length of stay 5 days
Return to OR in 30 days 6%Return to OR in 30 days 6%
Morbidity 28.3%Morbidity 28.3%
Mortality 2.3%Mortality 2.3%
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Distribution of Surgical VolumeDistribution of Surgical Volume
1000
12001400
16001800
Procedures
0200
400600
8001000
18-2930-39
40-4950-59
60-6970-79
80-8990-103
Age in Years
Mean Number of Risk Factors by Mean Number of Risk Factors by DecadeDecade
1 5
2
2.5
3Mean Number
0
0.5
1
1.5
17-1920-29
30-3940-49
50-5960-69
70-7980-89
90-99+
Age in Years
4
5
6
Hypertension
Dyspnea
Top Five Risk Factors by FrequencyTop Five Risk Factors by FrequencyAges 60-90+
Risk Factor
0
1
2
3
60-69 70-79 80-89 90-99+
Smoking
Diabetes
Cardiac Surgery
Impaired
ADL’s
CVA
Gangrene
Age in years
Surgical Morbidity by DecadeSurgical Morbidity by Decade
30%40%50%60%70%
Percent
0%10%20%30%
17-1920-29
30-3940-49
50-5960-69
70-7980-89
90-99+
Age in Years
Age Statistically Associated with Age Statistically Associated with MorbidityMorbidity
WoundWound 1.01 (1.0021.01 (1.002--1.020)1.020) 0.0210.021OR 95% CI pOR 95% CI p--value value MorbidityMorbidity
RenalRenal 1.019 (1.0081.019 (1.008--1.03)1.03) 0.0010.001
CardiovascularCardiovascular 1.034 (1.0151.034 (1.015-- 1.054)1.054) 0.00040.0004
RespiratoryRespiratory 1.028 (1.0151.028 (1.015-- 1.041)1.041) <0.0001<0.0001
Surgical Mortality by DecadeSurgical Mortality by Decade
6%
8%
10%
12%
Percent
0%
2%
4%
17-1920-29
30-3940-49
50-5960-69
70-7980-89
90-99+Age in Years
OR 95% CI pOR 95% CI p--value value MortalityMortality 1.040 (1.0251.040 (1.025--1.055)1.055) <0.001<0.001
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Predictors of Wound OccurrencePredictors of Wound Occurrence
Do Not Resuscitate3.9 (1.4 - 11.3) 0.0111 ASA classification: 1,20.7 (0.5 - 0.96) 0.0249Wound classification: clean0.6 (0.4 - 0.9) 0.0116
DNR3.9 (1.5 - 10.5) 0.0068
6060--79 Years79 Years 8080--103 Years103 YearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
0.6 (0.4 0.9) 0.0116Operative duration1. 15 (1.11 - 1.18) <0.0001Emergency surgery1.5 (1.1 - 2.2) 0.0184Open wound2.1 (1.4 - 3.1) 0.0004Steroids2.0 (1.3 - 3.2) 0.0021Smoker1.3 (1.01 - 1.8) 0.0419
Predictors of Renal OccurrencePredictors of Renal Occurrence
Operative duration1.104 (1.062 - 1.147) <0.0001Emergency surgery1.7 (1.1 - 2.7) 0.0219Open Wound1.7 (1.0 - 2.8) 0.0469 ASA classification 1,2
Operative duration1.09 (1.02 - 1.18) 0.0100Emergency surgery2.6 (1.4 - 4.9) 0.0035Weight loss3 7 (1 6 8 6) 0 0026
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--value value
0.5 (0.3 - 0.8) 0.0038DNR4.3 (1.5 - 12.9) 0.0085Transfer: direct admission 0.4 (0.3 - 0.7) 0.0018 Diabetes1.5 (1.04 - 2.2) 0.0291Smoker1.5 (1.02 - 2.1) 0.0390RVU1.05 (1.031 - 1.064) <0.0001Sepsis1.8 (1.0 – 3.3) 0.0387
3.7 (1.6 - 8.6) 0.0026Preoperative transfusion 8.2 (1.5 - 44.6) 0.0146
Predictors of Cardiovascular OccurrencePredictors of Cardiovascular Occurrence
Emergency surgery6.3 (3.5 - 11.4) <0.0001Hypertension2.7 (1.4 - 5.3) 0.0043 Gangrene4.0 (2.0 - 8.0) <0.0001ASA classification: 1,2
Emergency surgery5.6 (2.4 - 12.7) <0.0001PVD3.7 (1.4 - 10.0) 0.0098RVU1 09 (1 05 1 1) <0 0001
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
0.3 (0.1 - 0.7) 0.0073Ventilator 3.3 (1.2 - 8.7) 0.0170Weight loss2.3 (1.0 - 5.1) 0.0421Steroids2.3 (1.1 - 4.9) 0.0240Smoker1.8 ( 1.1 - 3.1) 0.0261Operative duration1.17 (1.10 - 1.24) <0.0001Impaired Sensorium2.4 (1.1- 8.0) 0.0352
1.09 (1.05 - 1.1) <0.0001Preoperative transfusion8.8 (1.2 - 63.6) 0.0313
Predictors of Respiratory OccurrencePredictors of Respiratory Occurrence
Emergency surgery4.9 (3.3 - 7.3) <0.0001
COPD1.9 (1.1 - 3.1) 0.0124
RVU1.03 (1.0 - 1.05) 0.0151
Operative duration
Emergency surgery3.9 (1.9 - 8.1) 0.0002COPD6.3 (2.8 - 14.4) <0.0001RVU1.068 (1.03 - 1.105) 0.0001
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
1.07 (1.01 - 1.13) 0.0134ASA classification: 1,2
0.6 (0.4 - 0.9) 0.0254Intraoperative transfusion
1.1 (1.0 - 1.2) 0.0110Dyspnea 1.8 (1.2 - 2.6) 0.0021Transfer: direct admission
0.3 (0.2 - 0.5) <0.0001Male Gender 1.5 (1.1 - 2.2) 0.0162Open Wound 1.8 (1.1 - 3.0) 0.0175Impaired Sensorium
2.4 (1.1 - 5.1) 0.0300Smoker 1.5 (1.0 - 2.1) 0.0417
Ventilator 11.5 (2.1 - 63.9) 0.0053Weight loss4.4 (1.7 - 11.3) 0.0023Radiotherapy 8.1 (1.8 - 36.7) 0.0070ADL impairment2.9 (1.2 - 6.9) 0.0139
Predictors of Central Nervous System Predictors of Central Nervous System OccurrenceOccurrence
Emergency surgery8.7 (3.6 - 21.4) <0.0001Alcohol
Preoperative transfusion 48.3 (7.4 - 316.2) <0.0001
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
4.1 (1.1 - 14.8) 0.0306Hemiplegia8.6 (1.8 - 40.7) 0.0067Impaired Sensorium5.0 (1.3 - 18.8) 0.0180RVU1.06 (1.02 - 1.09) 0.0055
Predictors of Other OccurrencesPredictors of Other Occurrences
Operative Duration1.18 (1.14 - 1.23) <0.0001COPD2.1 (1.3 - 3.4) 0.0035
Operative duration 1.17 (1.08 - 1.25) <0.0001COPD4.1 (1.7 - 9.6) 0.0012
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
2.1 (1.3 3.4) 0.0035Male Gender 1.5 (1.1 - 2.2) 0.0227Caucasian Race0.5 (0.3 - 0.7) 0.0002ASA classification: 1,20.5 (0.3 - 0.8) 0.0064Steroids3.1 (1.8 - 5.2) <0.0001Hypertension 2.2 (1.5 - 3.4) 0.0002
4.1 (1.7 9.6) 0.0012Weight loss3.1 (1.1 - 8.4) 0.0279Preoperative transfusion14.2 (2.5 - 80.9) 0.0028 Renal failure13.9 (1.5 - 129.0) 0.0207Gangrene5.0 (2.0 - 12.2) 0.0005
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Predictors of Other OccurrencesPredictors of Other OccurrencesContinuedContinued
Bleeding disorder2.5 (1.3- 4.6) 0.0056Ascites 3 3 (1 2 9 0) 0 0177
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CIOR 95% CI
3.3 (1.2 - 9.0) 0.0177Transfer: direct admission 0.5 (0.3 - 0.8) 0.0045Wound classification: clean0.5 (0.3 - 0.8) 0.0024Open wound2.0 (1.2 - 3.2) 0.0108Renal Impairment3.8 (1.1 - 13.4) 0.0360
Predictors for MortalityPredictors for Mortality
Emergency surgery5.2 (2.9 - 9.4) <0.0001ASA Classification: 1,20.3 (0.1 - 0.8) 0.0114ADL impairment3.4 (1.7 - 6.7) 0.0005 RVU1 07 (1 05 1 1) <0 0001
Emergency surgery11.4 (4.7 - 27.5) <0.0001ASA classification: 1,20.1 (0.03 - 0.7) 0.0134ADL impairment3.2 (1.3 - 8.1) 0.0116RVU
6060--79 years79 years 8080--103 years103 yearsRisk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
Risk factorRisk factorOR 95% CI pOR 95% CI p--valuevalue
1.07 (1.05 - 1.1) <0.0001Bleeding disorder2.9 (1.4 - 6.3) 0.0053Ascites11.5 (4.0 - 33.1) <0.0001Steroids 3.8 (2.0 - 7.4) <0.0001 Sepsis3.5 (1.8 - 6.8) 0.0002Dialysis 3.2 (1.3 - 7.5) 0.0086COPD 2.2 (1.1 - 4.2) 0.0171
RVU1.06 (1.0 - 1.1) 0.0176Operative duration1.17 (1.05 - 1.3) 0.0039 Hypertension0.3 (0.1 - 0.6) 0.0019
60 - 79 Hepatobiliary
GastricVascular
Colorectal
Mortality: Surgical Category Mortality: Surgical Category
Musculoskeletal
Age
0 10 20 30 40
80 -103
Esophageal
Percent
DiscussionDiscussion
Preoperative screeningPreoperative screening
Expedient scheduling of elective Expedient scheduling of elective proceduresproceduresproceduresprocedures
Clinical pathways Clinical pathways
Care coordinationCare coordination
ConclusionsConclusions
Increasing surgical morbidity and mortality Increasing surgical morbidity and mortality without increased cowithout increased co--morbidity suggests morbidity suggests that morbidity and mortality depends on that morbidity and mortality depends on age as well as coage as well as co--morbiditiesmorbiditiesage as well as coage as well as co morbiditiesmorbidities
Aging was statistically significantly Aging was statistically significantly associated with morbidity and mortality associated with morbidity and mortality when adjusted for other risk factorswhen adjusted for other risk factors