Pre-operative

Clinical Frailty Score and Outcome

Frailty assessment should now be as much a standard as cardiorespiratory evaluation pre-op. No gold standard exists and one qualitative tool is the Clinical Frailty Scale – CFS link

This study on unscheduled surgeries in those over 65 years of age used the CFS as well as other outcome prediction tools.

It found that duration of hospital stay was independently associated with: pre‐operative ASA physical status; surgical severity; peri‐operative E‐POSSUM score; and SORT. Duration of stay was also associated with the CFS, but not independent of these variables.

Future refining of frailty assessment tools may lead to better prediction scales.

study link

 

Appendectomy Delay

This meta-analysis might provide some considerations for discussion with surgeons on appendectomy timing.  The authors conclude “delaying appendicectomy for presumed uncomplicated appendicitis for up to 24 h after admission does not appear to be a risk factor for complicated appendicitis, postoperative surgical‐site infection or morbidity. Delaying appendicectomy for up to 24 h may be an acceptable alternative for patients with no preoperative signs of complicated appendicitis“.  The feared perforation may actually be an early occurrence. Of course patient symptoms and comfort should enter into the equation, as well as discussion of antibiotic conservative approach.

link

 

Preoperative carbohydrate loading

In addition to more liberal guidelines for clear fluids in recent years, preoperative carbohydrate drinks have become popular and perhaps ahead of the evidence but seem to improve well being, speed of recovery and insulin sensitivity. A Cochrane review ( link ) found positive benefits.

This Pediatric study showed reduced nausea and gastric content (but not vomiting) after gastroscopy under GA with preoperative carbohydrate drinks.

link

Pre-operative Assessment for Non-Cardiac Surgery

Cardiac assessment is well covered in the AHA guideline, but this European  Society of Anaesthesiology guideline is more comprehensive in looking at areas such as cardiac, respiratory, renal, diabetes, coagulation, medications, anemia, frailty and geriatric, airway, neuromuscular, alcohol and drug misuse. It’s worth comparing your practice…

link

(click on PDF article top right for a clear display).

Clinic vs Ambulatory Blood Pressure

An important study from general medicine that impacts us in our pre-admission service. Always seeing patients who say their hypertension is only when they come to hospital – white coat hypertension. This, and it’s opposite – masked hypertension (even more) is shown to be associated with mortality and cardiovascular assessment and advice should be so tailored.

“Ambulatory blood-pressure measurements were a stronger predictor of all-cause and cardiovascular mortality than clinic blood-pressure measurements. White-coat hypertension was not benign, and masked hypertension was associated with a greater risk of death than sustained hypertension“.

nejm link