术前跌倒可预测术后问题


  【24drs.com】根据在线发表于10月9日JAMA Surgery期刊的一篇前瞻研究,术前6个月内发生过1次以上跌倒事件者,术后并发症风险可能比一般外科病患增加。
  
  科罗拉多大学医学院外科Teresa S. Jones医师招募了在一个转诊中心进行选择性大肠直肠手术和心脏手术的65岁以上病患,纳入的235名病患中,33%指出在术前6个月内跌倒过。
  
  研究者发现,相较于不曾跌倒者,术前曾跌倒者的术后并发症比率显著较高(大肠直肠手术后为59% vs 25% [P = .004],心脏手术后为39% vs 15% [P = .001])。
  
  研究者也发现,相较于没有跌倒史者,术前发生过跌倒的病患比较可能需要转到照护机构,大肠直肠手术组(52% vs 6%;P < .001)和心脏手术组(62% vs 32%;P = .001)皆是,这些病患的30天再住院率也比较高。
  
  作者们写道,在年长者生理衰退因素之外增加特定变项进行风险评估,将比使用慢性病(如高血压)和单一种末端器官失能(如末期肾脏病)更能量化年长者的手术风险,更适当的量化年长者的生理脆弱性。
  
  大肠直肠和心脏手术者中,术前曾经跌倒的病患倾向比较年长、且Charlson共病症指标分数较高。在双变项分析中,年纪被评估为连续的分类变项,年龄增加与术后并发症之间的关联,在大肠直肠手术和心脏手术组都未达统计上的显著程度(P = .32),而跌倒史仍与结果有关(胜算比10.214;95%信心区间,2.401 - 43.455; P = .002)。两种手术类型中,手术特征(手术时间、失血量、输血需求)在有跌倒史和无跌倒史的病患差不多。
  
  作者们表示,研究限制如:研究团队搜集的回溯跌倒资料是否和标准临床纪录摘录的资料一样;此外,这篇研究中的大多数病患是男性,导致发现的跌倒与术后并发症之关联可能会有性别偏差。
  
  约翰霍普金斯医学院的Michael E. Zenilman医师在受邀评论时表示,虽然乐见评估手术风险的更简单方法,作者们首先应对所有造成骨骼脆弱的预测因子进行多变项分析,并确认哪里个是最强力的因素。
  
  Zenilman医师也指出,作者们的败笔是没有在多变项分析中评估心血管疾病这个强力预测因子。此外,不同的手术类型会有不同的术后并发症风险,因此,造成骨骼脆弱的指标必须因不同器官或不同手术而有所差别。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7018&x_classno=0&x_chkdelpoint=Y
  

Falls Before Surgery May Predict Postoperative Problems

By Jennifer Garcia
Medscape Medical News

A history of 1 or more falls in the 6 months before surgery may predict an increased risk for postoperative complications in geriatric patients, according to a prospective study published online October 9 in JAMA Surgery.

Teresa S. Jones, MD, from the Department of Surgery, University of Colorado School of Medicine, Aurora, enrolled patients aged 65 years or older undergoing elective colorectal and cardiac surgery at a referral center. Of the 235 patients enrolled, 33% reported falling in the 6 months before surgery.

The researchers found that postoperative complications were significantly more likely in the patients with a history of falls compared with nonfallers (59% vs 25% [P = .004] after colorectal surgery and 39% vs 15% [P = .001] after cardiac surgery).

The researchers also found that patients with a history of preoperative falls were more likely to require discharge to an institutional care facility compared with patients who had no fall history in both the colorectal (52% vs 6%; P < .001) and cardiac (62% vs 32%; P = .001) groups. These patients also had a higher 30-day readmission rate.

"The addition of variables specific to geriatric physiologic vulnerability would allow...risk calculators to move beyond quantifying surgical risk in older adults using chronic diseases (eg, hypertension) and single end-organ dysfunction (eg, end-stage renal disease) to using frailty characteristics, which more appropriately quantify physiologic vulnerability of the older adult," the authors write.

In both the colorectal and cardiac surgery groups, patients with a history of preoperative falls tended to be older and have a higher Charlson Comorbidity Index score. In the bivariable analysis, where age was evaluated as both a continuous and categorical variable, the association between advancing age and postoperative complications was not statistically significant for either the colorectal surgery group or the cardiac surgery group (P = .32), whereas a history of falls remained associated with the outcome (odds ratio, 10.214; 95% confidence interval, 2.401 - 43.455; P = .002). Surgical characteristics (operative time, blood loss, transfusion requirements) were similar between patients with a history of falls and those who did not have a fall history for both surgery types.

The authors acknowledge study limitations such as whether retrospective fall data collected by a research team would be similar to data extracted from standard clinical notes.. In addition, the fact that the majority of patients in this study were men may have introduced a sex bias in the association of falls with postoperative complications.

Although a simpler way of assessing surgical risk would be welcome, "the authors should have first performed a multivariate analysis of all the predictors of frailty and identified which one was the most powerful," Michael E. Zenilman, MD, from the Johns Hopkins School of Medicine, Bethesda, Maryland, writes in an invited commentary.

Dr. Zenilman also notes "[t]he article suffers in that the authors did not measure cardiovascular disease in the multivariate analysis — it is a powerful predictor." In addition, different surgery types will have different risks for postoperative complications so "the frailty indicators must be individualized for different organ systems or operations," he concludes.

The authors and editorialist have disclosed no relevant financial relationships.

JAMA Surg. Published online October 9, 2013.

    
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