Surgical Risk in Elderly Patients Surgical Risk Factors, Morbidity … · 2019. 6. 7. · 1 Surgical Risk Factors, Morbidity and Mortality in Elderly Patients Hongkun Wang PhD, Virginia

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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



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



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



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



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


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



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

Documents

Surgical Risk in Elderly Patients Surgical Risk Factors, Morbidity … · 2019. 6. 7. · 1 Surgical Risk Factors, Morbidity and Mortality in Elderly Patients Hongkun Wang PhD, Virginia