Frailty ups ICU stay, mortality in older patients undergoing emergency laparotomy

Several older adults who undergo emergency laparotomy (EL) in Singapore are frail, and these patients have a longer length of stay in the intensive care unit (ICU) and a higher rate of 90-day mortality than nonfrail counterparts, a study has found.

A total of 233 participants were included in this study, of whom a quarter (26 percent) were frail, indicating a higher susceptibility among older patients. Frailty was associated with increased preoperative risk, prolonged ICU stays, and a threefold greater mortality at 90 days (21.3 percent vs 6.4 percent). [Ann Acad Med Singap 2024;53:352-360]

An earlier study showed that aggressive treatments commonly administered in the ICU (eg, mechanical ventilation and vasopressor support) are associated with a higher risk of complications and mortality in frail patients. [CMAJ 2014;186:E95-102]

The “nuanced connection” between frailty and adverse outcomes underscores the need for reliable predictive tools in this context, according to the investigators.

“The integration of frailty assessment, particularly when combined with established metrics like P-POSSUM, showcased enhanced predictive accuracy,” the investigators said. “This finding offers valuable insights for shared decision-making and acute surgical unit practices, emphasizing the imperative of considering frailty in the management of older patients undergoing EL.”

Symptom burden

Older patients with frailty normally have a greater burden of symptoms such as fatigue, medical complexity, and reduced tolerance for medical and surgical interventions including EL. [Surgeon 2020;18:e55-e66]

Frailty was also found to contribute to increased postoperative mortality and morbidity, irrespective of age, in the EL and frailty trial in the UK. [Ann Surg 2021;273:709-718]

“Genetic heterogeneity, socioeconomic dynamics, cultural paradigms, healthcare accessibility, and lifestyle choices collectively contribute to the distinctive portrayal and implications of frailty in Asian societies,” the investigators said.

“These factors may exert influence over the prevalence, phenotypic expression, and consequent outcomes associated with frailty,” they added.

Care model

In a previous study, researchers found that using comprehensive geriatric care models with preoperative geriatric assessment, nutritional assessment, and interventions, as well as postoperative follow-up could lower the risk of mortality and morbidity in older patients undergoing elective colorectal surgery. [World J Surg 2011;35:1608-1614]

“The American College of Surgeons and the American Geriatrics Society highlighted that older patients are at higher risk of postoperative delirium, functional decline, pulmonary complications, and urinary tract infections, and recommended for the implementation of geriatric care models for multidisciplinary and holistic management of older patients,” the investigators said. [J Am Coll Surg 2016;222:930-947; Age Ageing 2012;41:142-147]

“Further studies should evaluate the incidence of specific complications as mentioned above to truly identify the clinical utility of postoperative geriatric assessment,” they added.

This retrospective cohort study was conducted at two tertiary centres in Singapore from January to December 2019. The investigators examined EL outcomes in patients aged ≥65 years. They also integrated frailty assessment into demographic, diagnostic, and procedural analyses using the Clinical Frailty Scale (CFS).

Patient data were obtained from Tan Tock Seng Hospital and Khoo Teck Puat Hospital. These data provided a comprehensive view of the role of frailty in EL.