Anästhesiologie & Intensivmedizin

Anästhesiologie & Intensivmedizin
St. Gallen, Urologische Eingriffe beim Hochbetagten: Präoperative Abklärung und Optimierung Anästhesiologie & Intensivmedizin Miodrag Filipovic

Fallbeispiel A 89-jähriger Patient in ordentlichem AZ und EZ
Harnverhalt: Blasenhalsinzision und Cystofixeinlage Hypertensive und V. a. Koronare Herzkrankheit Anstrengungsdyspnoe 2 bis 3; gelegentlich AP Echo: Schwere diastolische Dysfunktion, EF 30% (DD Restriktive Kardiomyopthie: Amyloidose) BNP 3500 ng/ml Kardiologen: “Das OP-Risiko ist deutlich erhöht. … Kleine Volumenschwankungen können im Lungenödem resultieren. … “

Fallbeispiel A

Fallbeispiel A Albert Anker, 1893

Optimieren! Alternativen?
Operieren! Optimieren! Alternativen?

Operative Machbarkeit OP-Risiko
Schwere Begleiter- krankungen Optimierungs- möglichkeit Dringlichkeit Benefit Operieren! Optimieren! Alternativen?

Schwere Begleiter- krankungen Optimierungs- möglichkeit Dringlichkeit Benefit 11825 Operieren! Optimieren! Alternativen?

Verbesserte Mobilität
Heilung Lebensverlängerung Symptommilderung Verbesserte Mobilität Operative Machbarkeit OP-Risiko Schwere Begleiter- krankungen Benefit Optimierungs- möglichkeit Dringlichkeit Operieren! Optimieren! Alternativen? Oresanya LB, et al. JAMA. 2014;311:

Kognitive Dysfunktion
Vorzeitiger Tod Delir Kognitive Dysfunktion Verlust an Funktion Pflegebedürftigkeit OP-Risiko Operative Machbarkeit Dring- lichkeit Schwere Begleiter- krankungen Benefit Optimierungs- möglichkeit Operieren! Optimieren! Alternativen? Oresanya LB, et al. JAMA. 2014;311:

Operative Machbarkeit
Kardial Pulmonal Infekt Endokrinologisch Thromboembolie Hämatologisch OP-Risiko Operative Machbarkeit Dring- lichkeit Schwere Begleiter- krankungen Benefit Optimierungs- möglichkeit Operieren! Optimieren! Alternativen?

Optimierungs- möglichkeit
Operative Machbarkeit OP-Risiko Dringlichkeit Benefit Optimierungs- möglichkeit Schwere Begleiter- krankungen Endo: HbA1c > 9: Elektiveingriff verschieben! Hyperthyreose Operieren! Optimieren! Alternativen?

Mortalität: Einfluss von Begleiterkrankungen
11388 elektive chir. Sanierungen abdomineller Aortenaneurysmen (BAA) Weibliches Geschlecht (14.4%) Hypertonie (25.2%) Diabetes mellitus (4.0%) COPD (7.6%) Chronische koronare Herzkrankheit (10.5%) Herzinsuffizienz (3.8%) Chronische Niereninsuffizienz (3.6%) Odds Ratio (OR) 1.0 Filipovic M, et al. J Epidemiol Community Health 2007; 61:

Albert Anker

Benefit Dringlichkeit
Operative Machbarkeit OP-Risiko Schwere Begleiter- krankungen Benefit Dringlichkeit Optimierungs- möglichkeit Operieren! Optimieren! Alternativen?

Präoperative Abklärungen - umfassend
9619 CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 16

http://guidance.nice.org.uk/CG3/NICEGuidance/pdf/English 2003
CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 17

Präoperative Abklärungen - zusammenfassend
Untersuchung Indikation EKG Kardiale Risikopatienten/-eingriffe Höheres Alter CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 21

Untersuchung Indikation EKG Kardiale Risikopatienten/-eingriffe Höheres Alter Thorax-Rx Kaum je aus „anästhesiologischer“ Indikation CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 22

Untersuchung Indikation EKG Kardiale Risikopatienten/-eingriffe Höheres Alter Thorax-Rx Kaum je aus „anästhesiologischer“ Indikation Labor Gerinnungsparameter 1. Anamnese! Renale Retentionsparameter Bei entsprechender Klinik Leberparameter Bei entsprechender Klink Hämoglobin Vor jeder grösseren OP CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 23

Präoperative Abklärungen – Anämie
Analyse von 227‘425 nicht-herzchirurgischen Patienten Anämie: 69‘229 (30.4%) 9691 BACKGROUND: Preoperative anaemia is associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. We aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery. METHODS: We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) effect of anaemia, which was defined as mild (haematocrit concentration >29-<39% in men and >29-<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes. FINDINGS: We obtained data for 227 425 patients, of whom 69 229 (30·44%) had preoperative anaemia. After adjustment, postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1·42, 95% CI 1·31-1·54); this difference was consistent in mild anaemia (1·41, 1·30-1·53) and moderate-to-severe anaemia (1·44, 1·29-1·60). Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia (adjusted OR 1·35, 1·30-1·40), again consistent in patients with mild anaemia (1·31, 1·26-1·36) and moderate-to-severe anaemia (1·56, 1·47-1·66). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone. INTERPRETATION: Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery. FUNDING: Vifor Pharma. PMID: Musallam KM, et al. Lancet 2011; 378: 24

Präoperative Abklärungen – Anämie
Analyse von 227‘425 nicht-herzchirurgischen Patienten Anämie: 69‘229 (30.4%): Mortalität 4.6% vs. 0.8% 9691 BACKGROUND: Preoperative anaemia is associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. We aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery. METHODS: We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) effect of anaemia, which was defined as mild (haematocrit concentration >29-<39% in men and >29-<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes. FINDINGS: We obtained data for 227 425 patients, of whom 69 229 (30·44%) had preoperative anaemia. After adjustment, postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1·42, 95% CI 1·31-1·54); this difference was consistent in mild anaemia (1·41, 1·30-1·53) and moderate-to-severe anaemia (1·44, 1·29-1·60). Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia (adjusted OR 1·35, 1·30-1·40), again consistent in patients with mild anaemia (1·31, 1·26-1·36) and moderate-to-severe anaemia (1·56, 1·47-1·66). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone. INTERPRETATION: Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery. FUNDING: Vifor Pharma. PMID: Musallam KM, et al. Lancet 2011; 378: 25

Untersuchung Indikation EKG Kardiale Risikopatienten/-eingriffe Höheres Alter Thorax-Rx Kaum je aus „anästhesiologischer“ Indikation Labor Gerinnungsparameter 1. Anamnese! Renale Retentionsparameter Bei entsprechender Klinik Leberparameter Bei entsprechender Klinik Hämoglobin Vor jeder grösseren OP Anamnese: Körperliche Leistungsfähigkeit CG3 Preoperative Tests: The use of routine preoperative tests for elective surgery. NICE guideline 26

ACC/AHA Guidelines; Circulation 2007;116:1971-96
Modifiziert: Filipovic M, Zellweger M, Lurati Buse G, Scheidegger D, Seeberger MD. Schweiz Med Forum 2008; 8:

Ziel der präoperativen Evaluation
Erfassung bisher unbekannter oder unterschätzter kardiovaskulärer Erkrankungen mit grosser prognostischer Bedeutung und hoher therapeutischer Priorität

ACC/AHA Guidelines; Circulation 2007;116:1971-96
Modifiziert: Filipovic M, Zellweger M, Lurati Buse G, Scheidegger D, Seeberger MD. Schweiz Med Forum 2008; 8:

Herzinsuffizienz: Perioperative Bedeutung
Prozent 9571 Figure 3. Unadjusted 30-day perioperative mortality (blue), rehospitalization (red), and cardiac rehospitalization (green). HF indicates heart failure. 9571 Background- The postoperative risks for patients with coronary artery disease (CAD) undergoing noncardiac surgery are well described. However, the risks of noncardiac surgery in patients with heart failure (HF) and atrial fibrillation (AF) are less well known. The purpose of this study is to compare the postoperative mortality of patients with HF, AF, or CAD undergoing major and minor noncardiac surgery. Methods and Results- Population-based data were used to create 4 cohorts of consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta, Canada. The main outcome was 30-day postoperative mortality. The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P<0.0001). Among patients undergoing minor surgical procedures, the 30-day postoperative mortality was 8.5% in NIHF, 8.1% in IHF, 2.3% in CAD, and 5.7% in AF (P<0.0001). After multivariable adjustment, postoperative mortality remained higher in NIHF, IHF, and AF patients than in those with CAD (NIHF versus CAD: odds ratio 2.92; 95% confidence interval 2.44 to 3.48; IHF versus CAD: odds ratio 1.98; 95% confidence interval 1.70 to 2.31; AF versus CAD: odds ratio 1.69; 95% confidence interval 1.34 to 2.14). Conclusions- Although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD, and even minor procedures carry a risk higher than previously appreciated PMID: Circulation Jul 19;124(3):289-96 Herzinsuffizienz (nicht-KHK) Herzinsuffizienz (KHK) 30-Tage Mortalität Rehospitalisation Kardiale Rehospitalisation van Diepen S, et al. Circulation 2011; 124:

KHK ohne Herzinsuffizienz
Herzinsuffizienz: Perioperative Bedeutung Prozent 9571 Figure 3. Unadjusted 30-day perioperative mortality (blue), rehospitalization (red), and cardiac rehospitalization (green). HF indicates heart failure. 9571 Background- The postoperative risks for patients with coronary artery disease (CAD) undergoing noncardiac surgery are well described. However, the risks of noncardiac surgery in patients with heart failure (HF) and atrial fibrillation (AF) are less well known. The purpose of this study is to compare the postoperative mortality of patients with HF, AF, or CAD undergoing major and minor noncardiac surgery. Methods and Results- Population-based data were used to create 4 cohorts of consecutive patients with either nonischemic HF (NIHF; n=7700), ischemic HF (IHF; n=12 249), CAD (n=13 786), or AF (n=4312) who underwent noncardiac surgery between April 1, 1999, and September 31, 2006, in Alberta, Canada. The main outcome was 30-day postoperative mortality. The unadjusted 30-day postoperative mortality was 9.3% in NIHF, 9.2% in IHF, 2.9% in CAD, and 6.4% in AF (each versus CAD, P<0.0001). Among patients undergoing minor surgical procedures, the 30-day postoperative mortality was 8.5% in NIHF, 8.1% in IHF, 2.3% in CAD, and 5.7% in AF (P<0.0001). After multivariable adjustment, postoperative mortality remained higher in NIHF, IHF, and AF patients than in those with CAD (NIHF versus CAD: odds ratio 2.92; 95% confidence interval 2.44 to 3.48; IHF versus CAD: odds ratio 1.98; 95% confidence interval 1.70 to 2.31; AF versus CAD: odds ratio 1.69; 95% confidence interval 1.34 to 2.14). Conclusions- Although current perioperative risk prediction models place greater emphasis on CAD than HF or AF, patients with HF or AF have a significantly higher risk of postoperative mortality than patients with CAD, and even minor procedures carry a risk higher than previously appreciated PMID: Circulation Jul 19;124(3):289-96 Herzinsuffizienz (nicht-KHK) Herzinsuffizienz (KHK) KHK ohne Herzinsuffizienz Vorhoff- flimmern 30-Tage Mortalität Rehospitalisation Kardiale Rehospitalisation van Diepen S, et al. Circulation 2011; 124:

Herzinsuffizienz: Abklärung
10188 PMID: Eur Heart J (2012) 33(14): McMurray JJ, et al. Eur Heart J 2012;33:

Herzinsuffizienz: Abklärung
Klinik & Symptome EKG Thorax-Rx BNP Echo 10188 PMID: Eur Heart J (2012) 33(14): McMurray JJ, et al. Eur Heart J 2012;33:

Natriuretische Peptide: BNP
proBNP NT-proBNP BNP 7467 FIGURE 2. B-type natriuretic peptide (BNP) is produced as pre–prohormone BNP (proBNP), processed to proBNP, and then cleaved by corin to mature, biologically active 32–amino acid (aa) BNP and non–biologically active N-terminal (NT)-proBNP. 7468 McKie PM, Burnett JC. Mayo Clin Proc 2005; 80: Wilkins MR, et al. Lancet 1997; 349:

BNP: Präoperative Wertigkeit
Gepoolte Odds ratio (Mortalität < 6 Monte postop): 4.97 ( ) Positiver prädiktiver Wert 0.24 ( ) Negativer prädiktiver Wert: 0.94 ( ) 9287 Objective: to summarize the evidence and assess the prognostic accuracy of natriuretic peptides (NP) to predict mortality in adults undergoing cardiac and non-cardiac surgery. Methods: Systematic review of studies reporting on the prognostic association of preoperative NP concentrations and mortality in adult patients undergoing cardiac and non-cardiac surgery. Studies were identified by electronic search of MEDLINE and EMBASE. Study selection and data extraction was independently performed by 2 readers. We primarily considered mid-term (≥6 months) all-cause mortality. We used bivariate random effects regression to study between-study variation and derive measures of prognostic accuracy.Results: Of the 1558 retrieved references, 11 cardiac and 12 non-cardiac surgery studies fulfilled the inclusion criteria. The cardiac and non-cardiac surgery studies addressed mid-term mortality in 1696 and 930 patients, respectively. In patients undergoing cardiac surgery, the diagnostic odds ratio (dOR) of NP was on 4.11 (95% confidence interval ) for mid-term all-cause mortality, the positive predictive value (PPV) 0.17 (95% credibility interval ) and the negative predictive value (NPV) 0.96 ( ). In patients undergoing non-cardiac surgery, the dOR of NP was 4.97 ( ) for mid-term all-cause mortality, the PPV 0.24 ( ) and the NPV 0.94 ( ). Conclusion: Preoperative NP concentrations were associated with mid-term mortality after both cardiac and non-cardiac surgery. In both settings, NP had high negative predictive values, i.e. NP may be helpful in preoperative risk stratification as rule out test for mid- and short-term mortality after surgery. Lurati Buse G, et al. Anesth Analg 2010: 112:

11654 Neuauflage ab verfügbar: Sekretariat Kardiologie: Frau Claudia Hofmann

Lebensqualität Morbidität
Perfekt Lebensqualität Morbidität Tot Albert Anker

Perfekt Lebensqualität Morbidität Tot Zeit

Lebensqualität, Krankheit und Tod: Frailty
Figure 1. Cycle of frailty hypothesized as consistent with demonstrated pairwise associations and clinical signs and symptoms of frailty. Reproduced with permission from (14). 10487 BACKGROUND: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. METHODS: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in and 582 from an African American cohort recruited in ). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. RESULTS: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and , adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). CONCLUSIONS: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty. PMID: J Gerontol A Biol Sci Med Sci Mar;56(3):M Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56

Lebensqualität, Krankheit und Tod: Frailty
Gebrechlichkeit Lebensqualität, Krankheit und Tod: Frailty Figure 1. Cycle of frailty hypothesized as consistent with demonstrated pairwise associations and clinical signs and symptoms of frailty. Reproduced with permission from (14). 10487BACKGROUND: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. METHODS: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in and 582 from an African American cohort recruited in ). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. RESULTS: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and , adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). CONCLUSIONS: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty. PMID: J Gerontol A Biol Sci Med Sci Mar;56(3):M Fried LP, et al. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56

Schwere Begleiter- krankungen Optimierungs- möglichkeit Dringlichkeit Benefit 11825 Operieren! Optimieren! Alternativen?

Frailty Operative Machbarkeit OP-Risiko Schwere Begleiter- krankungen Optimierungs- möglichkeit Dringlichkeit Benefit 11825 Operieren! Optimieren! Alternativen?

Frailty Operative Machbarkeit OP-Risiko Dringlichkeit Schwere Begleiter- krankungen Benefit Optimierungs- möglichkeit 11825 Operieren! Optimieren! Alternativen?

Lebensqualität, Krankheit und Tod Perfekt Lebensqualität Morbidität Tot Zeit

Lebensqualität, Krankheit und Tod Perfekt „Best Outcome“ Lebensqualität Morbidität Tot Zeit

Lebensqualität, Krankheit und Tod Perfekt Lebensqualität Morbidität Tot Zeit

Lebensqualität, Krankheit und Tod Perfekt „Best Outcome“ Lebensqualität Morbidität Tot Zeit

Frailty Clegg A, et al. Lancet 2013;381:752-62
10792 Figure 1: Vulnerability of frail elderly people to a sudden change in health status after a minor illness The green line represents a fi t elderly individual who, after a minor stressor event such as an infection, has a small deterioration in function and then returns to homoeostasis. The red line represents a frail elderly individual who, after a similar stressor event, undergoes a larger deterioration, which may manifest as functional dependency, and who does not return to baseline homoeostasis. The horizontal dashed line represents the cutoff between dependent and independent. Clegg A, et al. Lancet 2013;381:752-62

Entscheidungsablauf „Best Outcome“ Filipovic M, persönliches Vorgehen
. Filipovic M, persönliches Vorgehen

Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“
Entscheidungsablauf „Best Outcome“ Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“ . Filipovic M, persönliches Vorgehen

Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“
Entscheidungsablauf „Best Outcome“ Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“ Patientenwille . Filipovic M, 2012; persönliches Vorgehen

Entscheidungsablauf „Best Outcome“
Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“ Patientenwille Therapieentscheidung . Filipovic M, 2012; persönliches Vorgehen

Entscheidungsablauf – JAMA
11825 Importance Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. Objective To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. Evidence Acquisition A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline). Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. Results This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n = 1 422 433 patients) and 26 that examined factors associated with surgical complications (n = 136 083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, ] to 5.77 [95% CI, ]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, ] to 59.2 [95% CI, ]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, ] to 3.27 [95% CI, ]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, ) to an adjusted OR of 18.7 (95% CI, ) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, ) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, ) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, ; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, ] to [95% CI, ]). Conclusions and Relevance Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making. JAMA. 2014;311(20): Oresanya LB, et al. JAMA. 2014;311:

Entscheidungsablauf – Optimierung

Ethische Aspekte – Entscheidungsablauf
„Best Outcome“ Wahrscheinlichkeit und notwendige Mittel für „Best Outcome“ Patientenwille Therapieentscheidung . Reevaluation Verlauf / Komplikationen Filipovic M, 2012; persönliches Vorgehen

Outcome (TURP) 30-Tage-Mortalität (%) Alter < 80 J.
11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. TURP n=38674 Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

Komplikationen – outcome
Alter < 80 J. 30-Tage-Mortalität (%) Alter > 80 J. 11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. Keine Komplikation n=463‘974 Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

Alter < 80 J. Häufigkeit (%) Alter > 80 J. 11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. ≥ 1Komplikation Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

Alter < 80 J. 30-Tage-Mortalität (%) Alter > 80 J. 11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. Keine Komplikation n=463‘974 ≥ 1Komplikation n=130‘937 Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

Häufigkeit (%) 11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. Reintubation Myokard- infarkt CVI Sepsis Nieren- versagen Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

30-Tage-Mortalität (%) 11616 OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older. PMID: J Am Geriatr Soc Mar;53(3):424-9. Reintubation Myokard- infarkt CVI Sepsis Nieren- versagen Hamel MB, et al. J Am Geriatr Soc. 2005; 53:

Nephrektomie – Komplikationen
Häufigkeit (%) 11822 PURPOSE: Previous reports of the morbidity of renal surgery have been primarily from academic tertiary referral centers and, thus, they may not reflect general clinical practice. We determined the effect of age and comorbidity on in-hospital surgical morbidity for radical and partial nephrectomy on a population level. MATERIALS AND METHODS: Data were obtained from a Canadian national discharge abstract database. From April 1998 to March 2008 information was available on 20,286 radical and 4,292 partial nephrectomies. Complications were identified using specific ICD-9 and 10 diagnosis and procedure codes. Complication rates were estimated by procedure type and by various explanatory variables, including patient age and Charlson comorbidity score. Multivariate logistic regressions were constructed for radical and partial nephrectomy to determine associations between explanatory variables and complications. RESULTS: Overall complications developed in 34.1% of radical and 34.3% of partial nephrectomy cases. Patients were more likely to have cardiac, respiratory, vascular and surgical complications after radical nephrectomy while they were more likely to experience genitourinary and nephrectomy specific complications after partial nephrectomy. On multivariate logistic regression after radical and partial nephrectomy complications increased with age and Charlson score. After adjusting for other covariates patients with a Charlson score of greater than 2 were approximately 6 times more likely to experience a complication than patients with a Charlson score of 0 for radical and partial nephrectomy (OR 6.22, 95% CI and OR 5.68, 95% CI , respectively). CONCLUSIONS: In our population based study radical nephrectomy and partial nephrectomy were associated with higher morbidity than previously reported, particularly in the elderly population and in patients with comorbidity. PMID: J Urol Sep;186(3): doi: /j.juro Epub 2011 Jul 23. Altersgruppe Abouassaly R, et al. J Urol. 2011; 186:

Nephrektomie – Komplikationen
Lokale Komplikationen Kardiale Komplikationen Häufigkeit (%) 11822 PURPOSE: Previous reports of the morbidity of renal surgery have been primarily from academic tertiary referral centers and, thus, they may not reflect general clinical practice. We determined the effect of age and comorbidity on in-hospital surgical morbidity for radical and partial nephrectomy on a population level. MATERIALS AND METHODS: Data were obtained from a Canadian national discharge abstract database. From April 1998 to March 2008 information was available on 20,286 radical and 4,292 partial nephrectomies. Complications were identified using specific ICD-9 and 10 diagnosis and procedure codes. Complication rates were estimated by procedure type and by various explanatory variables, including patient age and Charlson comorbidity score. Multivariate logistic regressions were constructed for radical and partial nephrectomy to determine associations between explanatory variables and complications. RESULTS: Overall complications developed in 34.1% of radical and 34.3% of partial nephrectomy cases. Patients were more likely to have cardiac, respiratory, vascular and surgical complications after radical nephrectomy while they were more likely to experience genitourinary and nephrectomy specific complications after partial nephrectomy. On multivariate logistic regression after radical and partial nephrectomy complications increased with age and Charlson score. After adjusting for other covariates patients with a Charlson score of greater than 2 were approximately 6 times more likely to experience a complication than patients with a Charlson score of 0 for radical and partial nephrectomy (OR 6.22, 95% CI and OR 5.68, 95% CI , respectively). CONCLUSIONS: In our population based study radical nephrectomy and partial nephrectomy were associated with higher morbidity than previously reported, particularly in the elderly population and in patients with comorbidity. PMID: J Urol Sep;186(3): doi: /j.juro Epub 2011 Jul 23. Altersgruppe Abouassaly R, et al. J Urol. 2011; 186:

Fallbeispiel A 89-jähriger Patient in ordentlichem AZ und EZ
Harnverhalt: Blasenhalsinzision und Cystofixeinlage Hypertensive und V. a. Koronare Herzkrankheit Anstrengungsdyspnoe 2 bis 3; gelegentlich AP Echo: Schwere diastolische Dysfunktion, EF 30% (DD Restriktive Kardiomyopthie: Amyloidose) BNP 3500 ng/ml Kardiologen: “Das OP-Risiko ist deutlich erhöht. … Kleine Volumenschwankungen können im Lungenödem resultieren. … “

Benefit Dringlichkeit Operative Machbarkeit OP-Risiko Schwere
Begleiter- krankungen Benefit Optimierungs- möglichkeit Dringlichkeit Operieren! Optimieren! Alternativen?

Entscheidungsablauf – WER?

Entscheidungsablauf – Risiko-Benefit I

Entscheidungsablauf – Assessment

Begleiter- krankungen
Elemente des perioperativen Risikos Begleiter- krankungen Chirurgie OUTCOME Anästhesie RISIKO Fleisher LA, Anderson GF. Anesthesiology 2002; 96:

Elemente des perioperativen Risikos - Lokalbefund/Krankheitsstadium Wahl des chirurgischen Vorgehens Durchführung des Eingriffs Begleiter- krankungen Chirurgie OUTCOME Anästhesie RISIKO Fleisher LA, Anderson GF. Anesthesiology 2002; 96:

Elemente des perioperativen Risikos Begleiter- krankungen Chirurgie OUTCOME Anästhesie RISIKO - Präoperative Vorbereitung und Anästhesieplan Durchführung der Anästhesie Perioperative Behandlung Fleisher LA, Anderson GF. Anesthesiology 2002; 96:

Elemente des perioperativen Risikos Koronare Herzkrankheit Herzinsuffizienz Hypertonie Diabetes mellitus Niereninsuffizienz Lungenkrankheiten Übergewicht Alter, Geschlecht Begleiter- krankungen Chirurgie OUTCOME Anästhesie RISIKO Fleisher LA, Anderson GF. Anesthesiology 2002; 96:

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