術前跌倒可預測術後問題


  【24drs.com】根據線上發表於10月9日JAMA Surgery期刊的一篇前瞻研究,術前6個月內發生過1次以上跌倒事件者,術後併發症風險可能比一般外科病患增加。
  
  科羅拉多大學醫學院外科Teresa S. Jones醫師招募了在一個轉診中心進行選擇性大腸直腸手術和心臟手術的65歲以上病患,納入的235名病患中,33%指出在術前6個月內跌倒過。
  
  研究者發現,相較於不曾跌倒者,術前曾跌倒者的術後併發症比率顯著較高(大腸直腸手術後為59% vs 25% [P = .004],心臟手術後為39% vs 15% [P = .001])。
  
  研究者也發現,相較於沒有跌倒史者,術前發生過跌倒的病患比較可能需要轉到照護機構,大腸直腸手術組(52% vs 6%;P < .001)和心臟手術組(62% vs 32%;P = .001)皆是,這些病患的30天再住院率也比較高。
  
  作者們寫道,在年長者生理衰退因素之外增加特定變項進行風險評估,將比使用慢性病(如高血壓)和單一種末端器官失能(如末期腎臟病)更能量化年長者的手術風險,更適當的量化年長者的生理脆弱性。
  
  大腸直腸和心臟手術者中,術前曾經跌倒的病患傾向比較年長、且Charlson共病症指標分數較高。在雙變項分析中,年紀被評估為連續的分類變項,年齡增加與術後併發症之間的關聯,在大腸直腸手術和心臟手術組都未達統計上的顯著程度(P = .32),而跌倒史仍與結果有關(勝算比10.214;95%信心區間,2.401 - 43.455; P = .002)。兩種手術類型中,手術特徵(手術時間、失血量、輸血需求)在有跌倒史和無跌倒史的病患差不多。
  
  作者們表示,研究限制如:研究團隊蒐集的回溯跌倒資料是否和標準臨床紀錄摘錄的資料一樣;此外,這篇研究中的大多數病患是男性,導致發現的跌倒與術後併發症之關聯可能會有性別偏差。
  
  約翰霍普金斯醫學院的Michael E. Zenilman醫師在受邀評論時表示,雖然樂見評估手術風險的更簡單方法,作者們首先應對所有造成骨骼脆弱的預測因子進行多變項分析,並確認哪個是最強力的因素。
  
  Zenilman醫師也指出,作者們的敗筆是沒有在多變項分析中評估心血管疾病這個強力預測因子。此外,不同的手術類型會有不同的術後併發症風險,因此,造成骨骼脆弱的指標必須因不同器官或不同手術而有所差別。
  
  資料來源: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.

    
相關報導
研究:一般手術對孕婦是安全的
2015/5/25 上午 09:49:34
精神科藥物與骨折、跌倒有關的證據越來越多
2015/1/21 上午 10:37:38
關節炎可能會使跌倒相關受傷風險加倍
2014/5/13 上午 10:04:30

上一頁
   1   2   3   4  




回上一頁