Department of Surgery, Virginia Commonwealth University Health Systems, Richmond, Va; Department of Surgery, Central Virginia VA Health System, Richmond, Va.
Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Va.
J Vasc Surg. 2021 Sep;74(3):963-971. doi: 10.1016/j.jvs.2021.02.039. Epub 2021 Mar 5.
Surgical frailty and its assessment have become essential considerations in perioperative management for the modern aging surgical population. The risk analysis index is a validated frailty score that has been proven to predict short-term outcomes and long-term mortality in several surgical subspecialties and high-risk procedures. We examined the association of risk analysis index scores with postoperative outcomes in a retrospective nationwide database of patients who underwent lower extremity amputation in the Veterans Health Administration Health Care System.
The Veteran Affairs Surgical Quality Improvement Program data was queried across the Veteran Affairs Health Care System with institutional review board approval for lower extremity amputations. Records of above and below knee amputation, Current Procedural Terminology codes 27590, 27591, 27592, 27594, 27596 and 27880, 27881, 27882, 27884, and 27886, respectively, from 1999 to 2018 were obtained. Incomplete and traumatic entries were removed. Risk Analysis Index score was calculated from preoperative variables and patients were separated into five score cohorts (≤15, 16-25, 26-35, 36-45, ≥46). The χ test and analysis of variance were used to compare the cohorts. Forward binary logistic regression modeling was used to determine covariate-adjusted odds ratios for outcomes in each cohort (SPSS software; version 25, IBM Corp).
A total of 47,197 patients (98.9% male) with an average age of 66.4 ± 10.6 years underwent nontraumatic lower extremity amputation, including 27,098 below knee and 20,099 above knee amputations, during the study period. Frailty was associated with increased rates of deep vein thrombosis, sepsis, cardiac arrest, myocardial infarction, pneumonia, intubation for more than 48 hours, pulmonary embolism, reintubation, acute kidney injury, renal failure, increased length of stay, overall complications, and death. Increases in the frailty score were associated with up to three times the likelihood for the occurrence of a postoperative complication and up to 32 times likelihood to perish within 30 days than those with low frailty scores.
Risk analysis index assessment of frailty was found to be associated with several postoperative outcomes in a dose-dependent manner in patients undergoing lower extremity amputation in the Veterans Health Care System, with higher scores associated with higher rates of death and major cardiac (myocardial infarction, cardiac arrest), pulmonary (pneumonia, failure to wean vent, reintubation), and renal (renal insufficiency, renal failure) complications. We recommend the use of risk analysis index score as a frailty screening tool for patients undergoing lower extremity amputation to enable providers to adequately inform and counsel patients regarding potential significant risks.
手术脆弱性及其评估已成为现代老龄化手术人群围手术期管理的重要考虑因素。风险分析指数是一种经过验证的脆弱性评分，已被证明可预测多个外科专业和高危手术的短期结果和长期死亡率。我们检查了风险分析指数评分与退伍军人健康管理系统中下肢截肢患者的术后结果之间的关联。
退伍军人事务部手术质量改进计划数据通过机构审查委员会批准，在退伍军人事务部医疗保健系统中对下肢截肢进行了查询。记录了膝关节以上和以下的截肢、当前程序术语代码 27590、27591、27592、27594、27596 和 27880、27881、27882、27884 和 27886，分别从 1999 年到 2018 年获得。排除不完整和创伤性条目。从术前变量计算风险分析指数评分，患者分为五个评分组（≤15、16-25、26-35、36-45、≥46）。使用 χ 检验和方差分析比较队列。使用向前二元逻辑回归模型确定每个队列中结局的协变量调整比值比（SPSS 软件；版本 25，IBM 公司）。
在研究期间，共有 47197 名（98.9%为男性）平均年龄为 66.4±10.6 岁的非创伤性下肢截肢患者接受了手术，其中包括 27098 例膝关节以下截肢和 20099 例膝关节以上截肢。脆弱性与深静脉血栓形成、败血症、心脏骤停、心肌梗死、肺炎、插管超过 48 小时、肺栓塞、重新插管、急性肾损伤、肾衰竭、住院时间延长、总并发症和死亡的发生率增加有关。脆弱性评分的增加与术后并发症发生的可能性增加了两倍，与低脆弱性评分相比，30 天内死亡的可能性增加了 32 倍。
在退伍军人医疗保健系统中接受下肢截肢的患者中，风险分析指数评估的脆弱性与多种术后结局呈剂量依赖性相关，评分较高与较高的死亡率和主要心脏（心肌梗死、心脏骤停）、肺部（肺炎、无法脱机、重新插管）和肾脏（肾功能不全、肾衰竭）并发症发生率相关。我们建议使用风险分析指数评分作为接受下肢截肢患者的脆弱性筛查工具，以便提供者能够充分告知和咨询患者潜在的重大风险。
