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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Friday, September 06, 2013
September, 2013 Journal Club
Moderator: Dr. Mark Katlic
 
Article: Cardiorespiratory Fitness Predicts Mortality and Hospital Length of Stay After Major Elective Surgery in Older People. Snowden, Chris P.; Prentis, James; Jacques, Byron; Anderson, Helen; Manas, Derek; Jones, Dave; Trenell, Michael. Annals of Surgery. 257(6):999-1004, June 2013.
 
Summary: We have known for decades that cardiopulmonary fitness declines with age, even in elite athletes.  The authors have shown that this phenomenon, admittedly associated with age, is more important than chronologic age itself in predicting risk.  Thereby, they also have struck an indirect blow against “ageism,” prejudice based on chronologic age alone.
 
In nearly 400 patients who underwent major open hepatobiliary and sarcoma operations, anaerobic threshold, at a level of 10 ml/kg/min, proved to be the best predictor, better than chronologic age.  Age became important when fitness was poor but was unimportant when fitness was good.  The study also shows that CPET is safe and even elderly patients with malignancy can complete the test (96% achieved anaerobic threshold).
 
Questions:

      1.       Is it practical, in your hospital or most hospitals, to administer Cardiopulmonary Exercise Test (CPET; maximal oxygen consumption; VO2max) to all elderly patients scheduled for major elective surgery? What would be the barriers to doing this?

2.       Even if we discover reduced cardiopulmonary fitness preoperatively, can we improve this prior to surgery? How?

3.       Some centers achieve results in the elderly equivalent to the general population, even for complex operations, while across the country and around the world age remains a risk factor. What do you think that these centers do better?

4.       What practical alternatives exist to CPET for evaluating our elderly surgery patients?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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