Preop risk stratification & postop management in elderly cancer patients laudia Spies Klinik für Anästhesiologie und Intensivmedizin ampus Virchow-Klinikum und ampus harité Mitte U N I V E R S I T Ä T S M E HARITÉ D I Z I N B E AMPUS R L I N VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Elderly Patients Aged 65 yrs Most rapidly growing ancer: Incidence 2/3 of solid tumors 69% of cancer deaths Perioperatively: pts. receive substandard care before surgery, risk assessment is not adequate prognostic: severity of preop. co-morbidities (1) http://www.destatis.de/basis/d/gesu/drg Statistik.php (2) oebergh. Eur J ancer, 2001 (3) Fentiman IS, Anna Oncol, 1996 (4) Enger J lin Oncol, 2006. HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
PAE- Preoperative Assessment of ancer in the Elderly Surgical risk - American Society for anaesthesiologist scale (ASA) - Physiological & Operative Severity Score for Enumeration of Mortality and Morbidity (Possum) Functional status Activities of daily living ADL Instrumental activities of daily living IADL EOG performance status PS Mental Health Mini-mental state inventory MMS Geriatric depression scale GDS Brief fatigue inventory BFI omorbidity Satariano's index of co-morbidities SI Audisio R et al. Supportive ancer Therapy 1(2003)pp 55-60 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
PAE Results - hospital stay N=460 patients elective surgery for solid tumors under general anaesthesia omponent of PAE Rra 95%I MMS abnormal (<24) 1.18 0.76 1.86 ADL dependent (>0) 2.01* 1.37 2.93 IADL dependent (<8) 1.58* 1.11 2.24 GDS depressed (>4) 1.30 0.91 1.85 BFI mod/severe fatigue (>3) 1.29 0.90 1.84 ASA abnormal ( 2) 0.85 0.60 1.20 PS abnormal (>1) 1.64* 1.06 2.56 Satariano's index (1) 1.23 0.85 1.78 Satariano's index (2+) 1.36 0.70 2.65 * P < 0,05 Audisio RA rit Rev Hematol Oncol 2008 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
PreoperativeRisk Evaluation 15 ASA PS 4 Probability for major complications 12 9 6 3 ASA PS 3 ASA PS 1, 2 Total complication rate 0 20 30 40 50 60 70 80 Age (years) Prough J Am oll Surg 2005 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
PAE Results - 30-day morbidity omponent of PAE Any complication Major complication RRa 95% I RRa 95% I MMS abnormal (< 24) 1.23 0.81 1.88 1.08 0.48 2.44 ADL dependent (> 0) 1.41 0.95 2.10 1.87 0.95-3.69 IADL dependent (< 8) 1.43* 1.03-1.98 1.65 0.88-3.08 GDS depressed (> 4) 1.30 0.93-1.81 1.69 0.93-3.08 BFI mod/severe fatigue (> 3) 1.52* 1.09-2.12 1.24 0.67-2.27 ASA abnormal ( 2) 1.00 0.73-1.38 1.96* 1.09-3.53 PS abnormal (> 1) 1.64* 1.07-2.52 1.97 0.92-4.23 Satariano's index (1) 1.11 0.78 1.59 1.29 0.68-2.44 Satariano's index (2+) 1.58 0.88 2.85 1.95 0.74 5.18 * P < 0,05 Audisio RA rit Rev Hematol Oncol 2008 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Elderly Surgical IU Patients aged 65 y 6-months mortality (n =16) Alive at 6 months (n = 91) p Frailty Age (yr) ognition (Mini- og) Weight loss (10 Ibs) Body mass index Albumin (g/dl) Falls (#) Depression Hematocrit (%) 76.1 ± 4.7 2.3 ± 1.3 3/16 (26 %) 23.8 ± 5.8 2.93 ± 0.57 1.6 ± 1.6 3/16 (18.8 %) 35.0 ± 5.5 73.9 ± 6.2 3.5 ± 1.56 12/88 (13.6 %) 26.7 ± 4.7 3.69 ± 0.62 0.7 ± 1.4 31/90 (34.4 %) 41.0 ± 5.2 0.1285 0.0017 0.4549 0.0314 < 0.0001 0.0033 0.2590 0.0002 Disability Average ADL 3.2 ± 1.7 4.8 ± 2.0 0.0004 omorbidity harlson index ASA score Medications (#) 5.1 ± 2.6 3.2 ± 0.4 6.5 ± 3.2 3.1 ± 2.2 2.9 ± 0.5 5.3 ± 3.2 0.0050 0.0114 0.1457 Robinson et al. Annals of Surgery 2009 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Elderly Surgical IU Patients aged 65 y Frailty Age (yr) ognition (Mini- og) Weight loss(10 Ibs) Body mass index Albumin (g/dl) Falls (#) Depression Hematocrit (%) Discharged to an institution (n =27) 75.9 ± 5.7 2.8 ± 1.4 7/27 (20 %) 26.8 ± 5.8 3.03 ± 0.76 1.5 ± 1.7 10/27 (37.0 %) 36.5 ± 5.3 Discharged to home (n = 78) 73.5 ± 6.1 3.5 ± 1.6 8/76 (10.5 %) 26.3 ± 4.7 3.77 ± 0.48 0.5 ± 1.2 27/77 (31.2 %) 41.6 ± 5.1 p 0.0669 0.0143 0.0884 0.6559 < 0.0001 0.0005 0.9934 < 0.0001 Disability Average ADL 3.8 ± 1.9 4.8 ± 2.0 0.0023 omorbidity harlson index ASA score Medications (#) 4.7 ± 2.5 3.0 ± 0.3 5.7 ± 2.8 3.0 ± 2.2 2.9 ± 0.5 5.3 ± 3.2 0.0018 0.1885 0.5686 Robinson et al. Annals of Surgery 2009 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Predictor Predictors of One Year Mortality Univariate analysis Relative risk (odds ratio) (95 % I) P value harlson omorbidity Score (3+ versus 0 2) 13.091 (7.722 25.027) < 0.0001 ASA physical status lass 3, 4 versus lass 1 8.300 (2.009 34.289) 0.0035 Age (65+ versus 18 39 yr) 4.459 (2.032 9.784) 0.0002 Predictor Multivariate analysis Relative risk (odds ratio) (bootstrapped 95 % I) P value harlson omorbidity Score (3+ versus 0 2) 16.116 (10.110 33.717) < 0.0001 umulative deep hypnotic time (per h) 1.244 (1.062 1.441) 0.0121 Systolic blood pressure < 80 mm Hg (per min) 1.036 (1.006 1.066) 0.0125 Monk TG, et al.; Anesthesiology 2008 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
7.0 Volume Management Liter 6.0 5.0 4.0 3.0 difference: ~2,5 l oral fluid iv-saline 0.9% iv-glucose 0.5% iv-haes 6 % iv-other or unspecified 2.0 1.0 0 R S R S R S R S R S R S R S Brandstrup, B. et al., Ann Surg, 2003 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Restrictive Volume Management Number of patients with complications (per-protocol analysis) Blinded assessment Restricted Standard p group group value Overall complications 21 40 0.003 Major complications 8 18 0.040 Minor complications 15 36 0.000 Tissue-healing complications 11 22 0.040 ardiopulmonary complications 5 17 0.007 Brandstrup, B. et al., Ann Surg, 2003 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Knowledge Management Hemicolectomy - Occult Hypovolemia Initial values after establishing EDM: ABP: 110/60 mmhg I: 2.1 l/min/m² HF: 67 /min HF: BIS: 29 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Early postoperative recovery of elderly patients Patients not oriented (%) 100 75 50 25 0 P< 0.001 BIS titrated Standard practice 0 5 10 15 20 Time after discontinuation of anaesthetics (min) Standard practice (n=31) BIS titrated (n=29) Awakening (min) 4.9 ± 3.4 4.0 ± 2.1 Orientation (min) 13.1 ± 3.8 9.5 ± 3.1* Aldrete score of 10 (min) 19.1 ± 2.1 16.9 ± 2.2* PAU discharge (min) 123 ± 48 111 ± 30 *P <0.05. Wong et al., AN J ANESTH 2002 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Postoperative Delirium (PD) Emergence Delirium Delirium POD Dementia Emergence Delirium Postoperative Delirium Mild neurocognitive disorder POD Dementia (first 30 min. after surgery) (hours days after surgery) (weeks to month after surgery) (years) HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
recovery room Delirium: 45% postoperative Delirium: 36% RR-Delirium is predictive for postoperative delirium with a sensitivity of 100% und specificity of 85% Sharma PT et al.; Anesth Analg 2005 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Postoperative Delirium (PD) Preoperative risk factors: dementia, further chronic impaired cognitive function, and physical debilitation physical restraints age malnutrition addition of more than three medications bladder catheter Inouye et al Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationsship with baseline vulnerability JAMA, 1996. p. 852-957 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Risk Factors for Early Postoperative Delirium (at D/ from RR) Duration of Surgery 1.00; 95 % I: (1.00-1.01); p = 0.252 Site 2.09; 95 % I: (0.99 4.42); p = 0.055 Intraop. Opioids 2.27; 95 % I: (1.01 5.06); p = 0.046 Anaesthetic 1.37; 95 % I: (0.67 2.81); p = 0.394 Preop. Fasting (solids) 1.27; 95 % I: (0.60 2.71); p = 0.537 Preop. Fasting (fluids) 10.57; 95 % I: (1.42 78.62); p = 0.021 Gender 1.36; 95 % I: (0.68 2.71); p = 0.388 Age 1.02; 95 % I: (1.00 1.04); p = 0.106 0.1 1 10 100 (multiple logistic regression: odds ratios with 95%-I) Radtke, Spies et al, EJA 2009, in press HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Early Postoperative Delirium and LOS Delirium on day 1 after surgery 5.524; 95 % I: (3.602 7.446); p < 0.001 Age 0.062; 95 % I: (0.038 0.086); p < 0.001 Gender 0.089; 95 % I: (-0.707 0.885); p = 0.826 Preop. Fasting (fluids) 0.28; 95 % I: (-0.661 1.222); p = 0.550 Preop. Fasting (solids) 0.798; 95 % I: (-0.04 1.636); p = 0.062 Anaesthetic 307; 95 % I: (-0.496 1.111); p = 0.453 Intraop. Opioids 0.628; 95 % I: (-1.445 0.190); p = 0.132 Site -0.841; 95 % I: (-1.975 0.294); p = 0.146 Duration of Surgery 0.022; 95 % I: (0.010 0.029); p < 0.001-2 -1 0 1 2 3 4 6 5 7 (multiple linear regression: regression coefficients with 95% I) Radtke, Spies al, EJA 2009 in press HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Postoperative Delirium (PD) Perioperative factors Intraoperative blood loss, postoperative hematocrit < 30% physical restraints electrolyte abnormalities sepsis Marcantonio et al The association of intraoperative factors with the development of postoperative delirium Am J Med, 1998. p. 380-384 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Rudolph et al., Anaesthesia, 2008 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Postoperative ognitive Dysfunction (POD) 80 Percentage (%) of patients with POD 70 60 50 40 30 20 10 * * * control young middle-aged elderly 0 Early Late Postoperative cognitive testing session Monk TG, et al.; Anesthesiology; 2008 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Postoperative Delirium 100 no dementia dementia (40% more delirum) 86.1 umulative delirium rate (%) 80 60 40 20 26.8 41.7 59.8 66.7 63.4 0 at admission d/c IU post-iu McNicoll et al. J Am Geriatr Soc 2003 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Intervention Delirium 50% vs. 32% Adequate NS O 2 -transport Pain Management Avoid unnecessary drugs Regulate bladder-/bowel function Nutrition Early mobilisation Monitoring postoperative complications Adequate Stimuli (z.b. glasses, hearing aids, clock, calendar) Therapy of delirium Inouye SK et al. New Engl J Med 1999 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Antipsychotics for delirium Haloperidol (<3.5mg/d), Risperidone, and Olanzapine were equally effective in treating delirium, with few adverse effects. Parkinsonian adverse effects were common with higher dose haloperidol (>4.5mg/d) compared with olanzapine Pre-operative haloperidol decreased severity and duration of post-surgery delirium All studies were small and should be repeated. Level of evidence: Antipsychotics for delirium (Review), Lonergan et al., 2007 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Haloperidol Prophylaxis in Elderly Patients after Hip Surgery with Increased Risk DRS-R-98 20 18 16 14 Placebo (n=36) Haloperidol 3 times 0,5 mg (n=32) 12 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Postop days Kalisvaart KJ et al. JAGS 2005 HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E
Pablo Picasso: Musical Instruments HARITÉ AMPUS VIRHOW-KLINIKUM und AMPUS HARITÉ MITTE K L I N I K F Ü R A N Ä S T H E S I O L O G I E