Departments of Anesthesiology and Pain Medicine, University of Ottawa and Ottawa Hospita, Ottawa, ON, Canada.
Departments of Anesthesiology and Pain Medicine, University of Ottawa and Ottawa Hospital, School of Epidemiology and Public Health, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Anaesthesia. 2022 Dec;77(12):1430-1438. doi: 10.1111/anae.15860. Epub 2022 Sep 12.
Frailty is a multidimensional state related to accumulation of age- and disease-related deficits across multiple domains. Older people represent the fastest growing segment of the peri-operative population, and 25-50% of older surgical patients live with frailty. When frailty is present before surgery, adjusted rates of morbidity and mortality increase at least two-fold; the odds of delirium and loss of independence are increased more than four- and five-fold, respectively. Care of the older person with frailty presenting for emergency surgery requires individualised and evidence-based care given the high-risk and complex nature of their presentations. Before surgery, frailty should be assessed using a multidimensional frailty instrument (most likely the Clinical Frailty Scale), and all members of the peri-operative team should be aware of each patient's frailty status. When frailty is present, pre-operative care should focus on documenting and communicating individualised risk, considering advanced care directives and engaging shared decision-making when feasible. Shared multidisciplinary care should be initiated. Peri-operatively, analgesia that avoids polypharmacy should be provided, along with delirium prevention strategies and consideration of postoperative care in a monitored environment. After the acute surgical episode, transition out of hospital requires that adequate support be in place, along with clear discharge instructions, and review of new and existing prescription medications. Advanced care directives should be reviewed or initiated in case of readmission. Overall, substantial knowledge gaps about the optimal peri-operative care of older people with frailty must be addressed through robust, patient-oriented research.
虚弱是一种与年龄和疾病相关的多种缺陷在多个领域积累有关的多维状态。老年人是围手术期人群中增长最快的部分，25-50%的老年手术患者存在虚弱。当手术前存在虚弱时，调整后的发病率和死亡率至少增加两倍；谵妄和丧失独立性的几率分别增加了四倍和五倍以上。由于其呈现出的高风险和复杂性，需要为有虚弱症状的老年急诊手术患者提供个体化和基于证据的护理。在手术前，应使用多维虚弱工具（最有可能是临床虚弱量表）评估虚弱，围手术期团队的所有成员都应了解每个患者的虚弱状况。当存在虚弱时，术前护理应侧重于记录和沟通个体化风险，考虑高级护理指令，并在可行的情况下进行共同决策。应启动多学科共同护理。在围手术期，应提供避免多种药物治疗的镇痛，同时预防谵妄，并考虑在监测环境中进行术后护理。急性手术发作后，从医院过渡出来需要有足够的支持，同时要有明确的出院说明，并审查新的和现有的处方药物。在再次入院的情况下，应审查或启动高级护理指令。总的来说，必须通过强有力的、以患者为中心的研究来解决关于虚弱的老年人最佳围手术期护理的大量知识空白。
