Abstract:
BACKGROUND:Frailty, a state of decreased physiological reserve, is strongly associated with perioperative mortality in older adults. However, the mechanism by which frailty is associated with mortality is not yet understood. Autonomic dysfunction in the form of decreased intraoperative hemodynamic variability has been shown to be associated with increased mortality. We aimed to see whether frail patients have less hemodynamic variability under anesthesia and whether variability mediates the relationship between frailty and 30-day mortality. METHODS:We performed a single-center retrospective study of 1223 patients ≥65 years of age undergoing surgery between July 2008 and December 2012. We used markers of frailty: age >70, preoperative body mass index <18.5, hematocrit <35%, albumin <3.4 g/dL, and creatinine >2.0 mg/dL. We modeled the outcome of 30-day mortality with number of frailty conditions adjusting for gender, length of surgery, American Society of Anesthesiologists class, and need for transfusion. Intraoperative hemodynamic variability was defined as the count of episodes of absolute change >15% in fractional mean arterial pressure (MAP) between consecutive 5-minute intervals. We evaluated the role of intraoperative hemodynamic variability as a mediator (modifier) of the relationship between frailty and mortality, checking for 3 conditions: (1) frailty must affect episodes of absolute change >15% in fractional MAP; (2) episodes of absolute change >15% in fractional MAP must affect 30-day mortality; and (3) mediation effect is significant. We used the product method, in which the mediation effect was estimated as the product of the first 2 relationships. Then we applied the percentile bootstrap method to obtain the 95% CI for the estimate of mediation effect. RESULTS:Number of frailty conditions and episodes of absolute change >15% in fractional MAP were inversely proportional. Presence of ≥4 frailty conditions was associated with >40% reduction of the number of episodes of absolute change >15% in fractional MAP. Regarding mortality, episodes of absolute change >15% in fractional MAP were protective. The addition of absolute change >15% in fractional MAP in the mortality model resulted in a decrease in the frailty odds ratio from 10.6 to 9.1 (4+ conditions), suggesting that episodes of absolute change >15% in fractional MAP are indeed a mediator. The mediation effect was modest; 5 episodes of absolute change >15% in fractional MAP was 5.2%, 6.4%, 6.9%, and 9.0% for frailty conditions from 1 to 4+, respectively. CONCLUSIONS:Frailty is associated with less intraoperative blood pressure variation, and the relationship of frailty with 30-day mortality is partially mediated by episodes of absolute change >15% in fractional MAP. This suggests that autonomic dysregulation may be a modest part of the mechanism behind the association between frailty and perioperative mortality. Our finding is consistent with recent literature, suggesting that an intact autonomic nervous system confers lower perioperative mortality.
journal_name
Anesth Analgjournal_title
Anesthesia and analgesiaauthors
James LA,Levin MA,Lin HM,Deiner SGdoi
10.1213/ANE.0000000000004085subject
Has Abstractpub_date
2019-06-01 00:00:00pages
1279-1285issue
6eissn
0003-2999issn
1526-7598pii
00000539-201906000-00038journal_volume
128pub_type
杂志文章abstract::Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental ...
journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/01.ane.0000239224.48719.28
更新日期:2006-11-01 00:00:00
abstract::Education is the fundamental process used to develop and maintain the professional skills of physicians. Medical students, residents, and fellows are expected to learn considerable amounts of information as they progress toward board certification. Established practitioners must continue to learn in an effort to remai...
journal_title:Anesthesia and analgesia
pub_type: 杂志文章,评审
doi:10.1213/ANE.0000000000000890
更新日期:2015-12-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/ANE.0b013e31827ab89c
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1097/00000539-200204000-00050
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/01.ANE.0000160531.65953.77
更新日期:2005-09-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章,评审
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更新日期:2004-04-01 00:00:00
abstract::Prior studies have suggested that the antifibrinolytic drug aprotinin increases the infarct size after ischemia and reperfusion (I/R) and attenuates the effect of ischemic preconditioning (IPC). Aprotinin was replaced by tranexamic acid (TXA) in clinical practice. Here, we investigated whether TXA influences I/R injur...
journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/ANE.0000000000002230
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journal_title:Anesthesia and analgesia
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更新日期:2015-03-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章,评审
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journal_title:Anesthesia and analgesia
pub_type: 临床试验,杂志文章,随机对照试验
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/ane.0b013e3181a9d75a
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章,收录出版
doi:10.1097/00000539-199905000-00038
更新日期:1999-05-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 临床试验,杂志文章
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abstract:BACKGROUND:Computerized reviews of patient data promise to improve patient care through early and accurate identification of at-risk and well patients. The significance of sampling strategy for patient vital signs data is not known. In the instance of the surgical Apgar score (SAS), we hypothesized that larger sampling...
journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/ANE.0b013e3182a46d6d
更新日期:2013-12-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/00000539-197609000-00022
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1097/00000539-200212000-00040
更新日期:2002-12-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:10.1213/ANE.0000000000000423
更新日期:2014-12-01 00:00:00
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journal_title:Anesthesia and analgesia
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journal_title:Anesthesia and analgesia
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pub_type: 杂志文章,随机对照试验
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journal_title:Anesthesia and analgesia
pub_type: 临床试验,杂志文章
doi:
更新日期:1987-12-01 00:00:00
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journal_title:Anesthesia and analgesia
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pub_type: 杂志文章
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
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journal_title:Anesthesia and analgesia
pub_type: 临床试验,杂志文章,随机对照试验
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journal_title:Anesthesia and analgesia
pub_type: 杂志文章
doi:
更新日期:1980-03-01 00:00:00
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journal_title:Anesthesia and analgesia
pub_type: 临床试验,杂志文章,随机对照试验
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更新日期:2003-07-01 00:00:00