Frailty, Sarcopenia and Outcomes after Emergency Surgery Admissions Across Wessex Wessex Surgical Trainee Research Collaborative Malcolm A West MD MRCS PhD NIHR Clinical Lecturer in Surgery ST6 Colorectal Surgical Trainee Academic Surgery Unit, Cancer Sciences, Faculty of Medicine, University of Southampton, UK
Wessex Led Projects Pan Wessex DISCLOSE BLiSS ibra 1+2 Acute Pancreatitis Audit Comparison of Wessex practice to national guidelines Colorectal cancer follow up Regional follow up protocols and compliance Breast Liver Metastases Regional management of liver alone metastasis Breast Implant Reconstruction National prospective audit of implant based reconstruction practice
Emergency Surgery Emergency surgical patients account for 50% of NHS work load and 80% of surgical deaths 2015-2016 NHSE Hospital statistics report 565,983 patients admitted as a surgical emergency NELA 2017 report appx 24,000 laparotomies with a 10% 30-day and 14% 90-day mortality
Lack of distinction between normal healthy ageing and physiological frailty Frailty phenotype (Fried et al) unintentional weight loss, grip strength, selfreported exhaustion, slow gait speed, low physical activity level Leading to falls, disability, hospitalisation and death Frailty: Multimodal decline of physiological reserve across several body systems leaving patients vulnerable to minor stressors Frailty Cumulative Deficit model of frailty A number of deficits accrued over time across a number of different domains including current illnesses, ability to manage activities of daily living (ADL) and physical signs.
What does it actually mean in a surgical context? There is strong evidence that frailty in older surgical patients (>75 years) predicts post operative mortality, complications and prolonged length of stay Frailty is also present in pre-hospital critically ill patients (<55 years), which is associated with higher 1-year mortality and rehospitalisation
What does it actually mean in a surgical context? Prevalence of frailty in subjects aged between 65-74 years is 4.1% of men and 8.5% of women Surgical patients up to 50%! Unknown in Emergency Surgery! NELA Report 2017
How to measure frailty? Frailty can be measured using a variety of tools: Population screening Self assessment Geriatrician assessment Utilising these tools can depend on intention: Assessing, screening, case finding, prognostic Single surrogate markers ( i.e. grip strength, sarcopenia) Clinically based tools i.e. Reported Edmonton Frail Scale or Edmonton Frail Scale None of which are currently used in Emergency Surgery!
Reported Edmonton Frail Scale Frailty Domain Item 0 Point 1 Point 2 Points Cognition General Health Status Please imagine this pre-drawn circle is a clock. I would like you to place the numbers in the correct positions, then place the hands to indicate a time of ten after eleven. In the past year, how many times have you been admitted to a hospital? In general, how would you describe your health? No errors 0 Excellent/Ver y Good/Good Minor spacing errors 1-2 Fair Other errors >2 Poor Functional Independence Social Support With how many of the following activities do you require help? meal preparation / shopping / transportation / telephone / housekeeping / laundry / managing money / taking medications When you need help, can you count on someone who is willing and able to meet your needs? 0-1 2-4 5-8 Always Sometim es Never Do you use five or more different prescription medications on a regular basis? Medication Use At times, do you forget to take your prescription medications? No No Yes Yes Nutrition Have you recently lost weight such that your clothing has become looser? No Yes Mood Do you often feel sad or depressed? No Yes Continence Do you have a problem with losing control of urine when you don t want to? No Yes Self Reported Performance Two weeks ago, were you able to: (1) Do heavy work around the house like washing windows, walls, or floors without help? (2) Walk up and down stairs to the second floor without help? (3) Walk 1 km without help? Scoring for the Reported Edmonton Frail Scale ( /18): Not Frail: 0-5 Apparently Vulnerable: 6-7 Mildly Frail: 8-9 Moderate Frailty: 10-11 Severe Frailty: 12-18 Yes Yes Yes No No No
Sarcopenia Significant interplay between conditions (Partridge et al 2011): Frailty Co-morbidity and Polypharmacy Disability Sarcopenia Cancer Cachexia Sarcopenia is an age related syndrome characterized by the progressive loss of muscle mass and muscle strength associated with adverse outcome
Frailty and Sarcopenia Outcomes in Emergency General Surgery - FrOGS AIM: To prospectively investigate markers of frailty and CT-measured sarcopenia in relation to 30-day mortality in acutely unwell surgical patients to improve risk stratification and shared decision making HYPOTHESIS: Patients with high frailty scores and lower muscle attenuation will have poor outcomes (30-day mortality, longer in-hospital stay, in-hospital compilations and institutionalisation) DESIGN: follow-up Pragmatic, Prospective, Trainee-led, Wessex wide (9 centers), 30-day snap shot, with 30-day INCLUSION CRITERIA: Emergency surgical laparotomy group (as per NELA inclusion) and a non-emergency laparotomy group (fulfilling NELA inclusion but no procedure performed) All patients will undergoing a diagnostic CT and a Reported Edmonton Frailty Questionnaire. Patients will be aged 18 years and above.
SAMPLE SIZE: NELA-derived figures demonstrate a 30-day mortality of 26.9% for high risk (>10% P- POSSUM predicted mortality) laparotomy patients, versus 1.7% for low risk patients (<5%). Using these figures to calculate sample size at 90% power and significance (alpha) level 0.05, 74 patients. We inflated the sample to 93 patients with a 25% drop out/ or non-complete data STUDY FLOW: CT Abdomen: Acute abdominal pain Inpatient referred to acute surgical team Study set up/ ethics/ HRA process ASU Admission ASU/acute take team handover NELA database Inclusion criteria met CT banking / Sarcopenia indexing/p-possum/ NELA risk score Reported Edmonton Frailty Questionnaire Emergency Laparotomy No Laparotomy 30-day Outcome Follow Up In-hospital Morbidity and Mortality Study Closure/ Analyses/ Reporting
Conclusion Frailty and sarcopenia are related to post-operative outcomes especially in the elderly, however these are not exclusively found in the elderly A balance between function, frailty, fatality and futility needs to be defined in emergency surgical patients FrOGS will interrogate the whole emergency surgical patient cohort with a unique emphasis on the non-operative surgical patient Frailty and sarcopenia variables might improve prognostic models improving tailored risk stratification, resource utilization and shared decision making
Questions? m.west@soton.ac.uk @drmalcolmwest