Design and setting: Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004.
Results: 1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04–1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65–3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09–4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63–9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17–6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06–5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44–9.10; P = 0.008) in the multivariate analysis.
Conclusion: Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.
- 1. Bellomo R, Goldsmith D, Uchino S, et al. Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med 2004; 32: 916-921.
- 2. Semmens JB, Aitken RJ, Sanfilippo FM, et al. The Western Australian Audit of Surgical Mortality: advancing surgical accountability. Med J Aust 2005; 183: 504-508. <MJA full text>
- 3. Bufalari A, Ferri M, Cao P, et al. Surgical care in octogenarians. Br J Surg 1996; 83: 1783-1787.
- 4. Hamel MB, Henderson WG, Khuri SF, Daley J. Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery. J Am Geriatr Soc 2005; 53: 424-429.
- 5. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001; 49: 1080-1085.
- 6. Liu LL, Leung JM. Predicting adverse postoperative outcomes in patients aged 80 years or older. J Am Geriatr Soc 2000; 48: 405-412.
- 7. Polanczyk CA, Marcantonio E, Goldman L, et al. Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery. Ann Intern Med 2001; 134: 637-643.
- 8. Aust JB, Henderson W, Khuri S, Page CP. The impact of operative complexity on patient risk factors. Ann Surg 2005; 241: 1024-1027.
- 9. Bellomo R, Goldsmith D, Russell S, Uchino S. Postoperative serious adverse events in a teaching hospital: a prospective study. Med J Aust 2002; 176: 216-218. <MJA full text>
- 10. Higlett T, Bishop N, Hart GK, Hicks P. Review of intensive care resources and activity 2002–2003. Melbourne: Australian and New Zealand Intensive Care Society, 2005.
- 11. Rigg JR, Jamrozik K, Myles PS, et al. Design of the multicenter Australian study of epidural anesthesia and analgesia in major surgery: the MASTER trial. Control Clin Trials 2000; 21: 244-256.
- 12. Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 2002; 359: 1276-1282.
- 13. Story DA, Shelton AC, Poustie SJ, et al. The effect of critical care outreach on postoperative serious adverse events. Anaesthesia 2004; 59: 762-766.
- 14. Fleisher LA. Risk of anesthesia. In: Miller RD, editor. Miller’s anesthesia. 6th ed. Philadelphia: Elsevier, 2005: 893-925.
- 15. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg 1999; 134: 36-42.
- 16. Roizen MF. Preoperative evaluation. In: Miller RD, editor. Miller’s anesthesia. 6th ed. Philadelphia: Elsevier, 2005: 1599-1615.
- 17. Story DA, Shelton AC, Poustie SJ, et al. Effect of an anaesthesia department led critical care outreach and acute pain service on postoperative serious adverse events. Anaesthesia 2006; 61: 24-28.
- 18. Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthesiology 2005; 103: 1121-1129.
- 19. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003; 31: 1250-1256.
- 20. Mehta RL, Chertow GM. Acute renal failure definitions and classification: time for change? J Am Soc Nephrol 2003; 14: 2178-2187.
- 21. Haga Y, Beppu T, Doi K, et al. Systemic inflammatory response syndrome and organ dysfunction following gastrointestinal surgery. Crit Care Med 1997; 25: 1994-2000.
- 22. Helmy SA, Wahby MA, El-Nawaway M. The effect of anaesthesia and surgery on plasma cytokine production. Anaesthesia 1999; 54: 733-738.
- 23. Kertai MD, Boersma E, Westerhout CM, et al. A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2004; 28: 343-352.
- 24. Sear JW. Kidney dysfunction in the postoperative period. Br J Anaesth 2005; 95: 20-32.
- 25. Goldhill D, Waldmann C. Excellent anaesthesia needs patient preparation and postoperative support to influence outcome. Curr Opin Anaesthesiol 2006; 19: 192-197.
- 26. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006; 34: 2463-2478.
- 27. Kingston M. Determining the professional attributes of a hospitalist: experience in one Australian metropolitan hospital. Intern Med J 2005; 35: 305-308.
- 28. Fisher AA, Davis MW, Rubenach SE, et al. Outcomes for older patients with hip fractures: the impact of orthopedic and geriatric medicine cocare. J Orthop Trauma 2006; 20: 172-180.
- 29. Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004; 141: 28-38.
- 30. UK Department of Health. Expert Group. Comprehensive critical care: a review of adult critical care services. London: Department of Health, 2000: 1-31.
- 31. Wong K, Levy RD. Do surgeons need to look after unwell patients? The role of medical emergency teams. ANZ J Surg 2005; 75: 848-851.
- 32. Walsh SR, Tang T, Gaunt ME, Schneider HJ. New arrhythmias after non-cardiothoracic surgery. BMJ 2006; 333: 715.
- 33. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005; 242: 326-343.
- 34. Merli GJ. The hospitalist joins the surgical team. Ann Intern Med 2004; 141: 67-69.
- 35. Watters DA, Green AJ, van Rij A. Guidelines for surgical audit in Australia and New Zealand. ANZ J Surg 2006; 76: 78-83.
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