Neurovascular Research Laboratory, School of Health, Sport and Professional Practice, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.
Department of Anaesthesia, Wrexham Maelor Hospital, Wrexham, UK.
J Card Surg. 2022 Aug;37(8):2258-2265. doi: 10.1111/jocs.16574. Epub 2022 Apr 29.
Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies.
As part of routine preoperative patient contact, patients scheduled for major surgery were prospectively "eyeballed" (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either "frail" or "not frail" by ICE and "fit" or "unfit" from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET "cut-off" metrics incorporating peak pulmonary oxygen uptake, V̇O at the anaerobic threshold (V̇O -AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-center prospective National Health Service database. Data were analyzed using the Chi-square automatic interaction detection decision tree method.
A total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m . Patients were poorly conditioned with a V̇O almost 20% lower than predicted for age, sex-matched healthy controls with 35% exhibiting a V̇O -AT < 11 ml/kg/min. Disagreement existed between the subjective assessments of risk with ∼34% of patients classified as not frail on ICE were considered unfit by notes review (p < .0001). Furthermore, ∼35% of patients considered not frail on ICE and ∼31% of patients considered fit by notes review exhibited a V̇O -AT < 11 ml/kg/min, and of these, ∼28% and ∼19% were classified as intermediate to high risk.
These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help us to improve perioperative risk assessment and better direct critical care provision in patients scheduled for "high-stakes" surgery including open thoracoabdominal aortic aneurysm repair.
传统上，初步临床评估（ICE）被认为是一种有用的筛查工具，可以在术前评估期间识别虚弱患者。然而，新出现的证据支持通过心肺运动测试（CPET）更客观地评估心肺功能（CRF），以改善手术风险分层。在此，我们比较了主观和客观评估方法，以突出解释上的差异。
作为常规术前患者接触的一部分，计划接受大手术的患者由两名经验丰富的临床医生进行前瞻性“目测”（ICE），然后进行更详细的病史采集，其中还包括美国麻醉师协会评分分类。每位患者都通过 ICE 主观判断为“虚弱”或“不虚弱”，并通过仔细审查病历判断为“健康”或“不健康”。主观数据与更客观的术后结局验证评估进行比较，使用包含峰值肺氧摄取、无氧阈时的 V̇O（V̇O -AT）和二氧化碳通气当量的 CPET“截止”指标进行评估，这些指标共同提供风险分层信息。这些数据是从一个单中心前瞻性国家卫生服务数据库中提取的。使用卡方自动交互检测决策树方法分析数据。
共检查了 127 名患者，其中 58%为男性，42%为女性，年龄 69±10 岁，体重指数 29±7kg/m2。患者的身体状况较差，V̇O 比年龄、性别匹配的健康对照组低近 20%，其中 35%的患者 V̇O -AT<11ml/kg/min。主观风险评估存在差异，约 34%的患者在 ICE 上被归类为不虚弱，但根据病历审查被认为不健康（p<0.0001）。此外，约 35%的患者在 ICE 上被归类为不虚弱，约 31%的患者根据病历审查被归类为健康，但 V̇O -AT<11ml/kg/min，其中约 28%和约 19%被归类为中高危。
这些发现突出了与手术风险分类相关的患者虚弱的主观评估的解释局限性，与 CRF 的验证评估相比，多达三分之一的患者的风险分类被低估。它们强调了 CPET 提供的更客观和综合方法的益处，这可能有助于我们改善围手术期风险评估，并更好地指导计划接受“高风险”手术（包括开放性胸腹主动脉瘤修复）的患者的重症监护。
