Which preoperative screening tool should be applied to older patients undergoing elective surgery to predict short-term
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IM - COMMENTARY
Which preoperative screening tool should be applied to older patients undergoing elective surgery to predict short‑term postoperative outcomes? Lessons from systematic reviews, meta‑analyses and guidelines: heart and non‑cardiac surgery need a different approach? Carlo Rostagno1 Received: 31 August 2020 / Accepted: 4 September 2020 © Società Italiana di Medicina Interna (SIMI) 2020
The paper by Aikten et al. [1] excellently reviews predictive screening tools applied in elderly patients undergoing elective surgery. American Society of Anesthesiologists Physical Status (ASA-PS), frailty tools and domain-specific tools administered as part of comprehensive geriatric assessment (CGA) are the most frequently employed and frailty, cognitive and/or functional status showed a relation with early post-operative outcome. In their review, however, they evaluate different tools without any distinction between cardiac and major non-cardiac surgery (oncologic, vascular, mixed surgery). Moreover, mean age of patients included in the considered studies was in most > 60 years, in 3 > 65 years. Therefore, they consider a relatively young population, being actually elderly population undergoing surgery largely above 70 years. In present commentary some aspects differentiating the approach in elderly patients referred to cardiac and non-cardiac surgery are reported.
Heart surgery and structural interventional cardiology Euroscore II and STS score [2, 3] have been extensively used since a long time to evaluate surgical risk in patients who need heart surgery, nevertheless these scores tend to overestimate and respectively underestimate the risk of surgery. In patients undergoing heart surgery we must not forget that postoperative outcome depends on heart function, pulmonary artery pressure other, and not less relevant, by factors * Carlo Rostagno [email protected] 1
Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134 Firenze, Italy
related to the technical difficulties of surgical intervention per se and finally on the severity of any disabilities and comorbidities. At variance with STS, Euroscore II includes an item, “poor mobility”, defined as severe impairment of mobility secondary to musculoskeletal or neurological dysfunction which encompasses also functional limitation characteristic of “frail” patient. However, the term “poor mobility” may be referred to several different conditions, from musculoskeletal to neurocognitive impairment. Therefore although inclusion of this item adds an information on general functional condition and increases the predictability of Euroscore II in elderly patients [4], it fails to distinguish the true “frail” patient from other conditions which have a lower prognostic impact. Adding the Edmonton Frail Scale [5] to Euroscore II in patients aged 75 years or older undergoing cardiac surgery resulted in a significant improvement in the prediction of 30-day mortality (the addition of frailty determined by the EFS to the EuroSCORE I
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