European Journal of Cardiovascular Medicine

Frailty represents a clinical syndrome resulting in progressive loss of mental and physical function with or without the disease coexistence which result in decreased ability for maintaining hemostasis and an increase in the vulnerability to the acute stressors including the surgery.¹

Frailty is being linked with fall and delirium in the postoperative period which results in higher social and person costs. Despite frailty being considered as a risk factor for postoperative mortality and morbidity. The present literature data is uncertain concerning the fact the anesthetic technique could significantly affect the outcomes in surgical patients with frailty.²

Modified frailty index or mFI is a simplified version of the Canadian Study of Health and Ageing Frailty Index, which comprise of 11 health deficits linked with frailty and could be calculated quickly from the data gathered from the physical examination and history of the subjects. Few literature studies have been done to assess the predictive value of mFI score for postoperative mortality and morbidity.^3,4 The present study was aimed to assess the association of frailty with postoperative outcomes in subjects undergoing elective abdominal surgeries for non-malignant lesion under neuraxial or general anesthesia

The present prospective observational study was aimed to assess the association of frailty with postoperative outcomes in subjects undergoing elective abdominal surgeries for non-malignant lesion under neuraxial or general anesthesia. Verbal and written informed consent were taken from all the subjects and school authorities before study participation.

For assessment of mFI preoperatively, standard scores were used and postoperative complications were assessed with CD classification after surgery. The study included 250 subjects aged 18 years or more, from both the genders, from ASA (American Society of Anesthesiologists) physical status I-III, and were undergoing elective non-malignant abdominal surgeries under GA or central neuraxial blockade. The exclusion criteria for the study were subjects with preoperative missing data, GA given after failed spinal or epidural analgesia, prolonged anaesthesia or surgical duration of more than 4 h, and subjects undergoing emergency surgery. 

All subjects underwent routine assessment preoperatively along with assessment of mFI scores.⁷ All subjects were given GA or neuraxial anesthesia following standard protocol based on the preoperative status and the site and duration of the surgery. The study commenced immediate postoperatively and continued till 30 days after surgery, and any complication developed during defined study period were assessed at 15 days interval. Hospital stay duration, mortality, and readmission was also assessed.

Preoperative variables in NSQIP (National Surgical Quality Improvement Programme) were considered to assess mFI including 11 items namely history of angina, prior percutaneous coronary intervention or surgery, history of neurological deficit, impaired sensorium, peripheral vascular disease, hypertension requiring medication, transient ischaemic attack or cerebrovascular accident, history of myocardial infarction (MI), congestive heart failure, chronic obstructive pulmonary disease or pneumonia, functional status; and diabetes. Each item was given one point. mFI was assessed as total points and sum was divided by 11. mFI ≥0.27 was considered as ‘significantly frail’.⁵  

Postoperative complications were assessed following CD classification.⁶ CD grade I complications included mild surgical site infection (SSI), mild anaemia (not requiring blood transfusion), minor bleeding (not requiring blood products or antifibrinolytics), mild hepatic impairment (transaminases <3 times the normal range), mild renal impairment (slightly decreased urine output corrected with fluid bolus), mild cardiac impairment (sinus bradycardia/ tachycardia mild hypotension corrected with fluid bolus and administration of pain medication), mild respiratory impairment (requiring supplemental oxygen by facemask for 4 h), and mild postoperative nausea.

These complications followed standard postoperative course and are managed by administering fluids and oxygen without pharmacological intervention. CD grade II complications were SSI requiring antibiotic escalation, moderate to severe anaemia requiring transfusion, moderate hepatic impairment (>3 times rise in transaminases), moderate renal impairment (requiring diuretics, dose readjustment of nephrotoxic drugs), cardiovascular impairment (arrhythmia, hypotension/ hypertension requiring pharmacological intervention), and moderate respiratory impairment (requiring nebulisation, continuous positive airway pressure, bronchodilators).

Complications needed pharmacological intervention, total parenteral nutrition, and blood transfusion. CD grade III complications included complications that required surgical, radiological, or endoscopic interventions. CD IV complications needed ICU (intensive care unit) admission and management as single or multiorgan dysfunction and central nervous system complications.

Abdominal surgeries were divided as minor, intermediate, and major surgeries.⁷ Minor surgeries were inguinal lymph node biopsy and superficial abscess drainage, intermediate surgeries were superficial abdominal like umbilical hernia and laparoscopic surgeries and open inguinal hernia, and major surgeries were intra- and extraperitoneal abdominal surgeries. Readmission was considered as hospital admission from any surgery-related complications in 30 days of surgery. Mortality was considered for death within 30 days of surgery or from surgery complications.

The data collected from the study subjected was assessed with statistical evaluation using the chi-square test, Fisher’s exact test, Mann Whitney U test, and SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) using ANOVA, chi-square test, and student's t-test. The significance level was considered at a p-value of <0.05.

The present prospective observational study was aimed to assess the association of frailty with postoperative outcomes in subjects undergoing elective abdominal surgeries for non-malignant lesion under neuraxial or general anesthesia. The present study assessed 250 subjects aged 18 years or above, from both the genders, and were undergoing surgery under neuraxial or general anesthesia. In all the subjevts, mFI scores were assessed preoperatively. Significant frailty was considered for mFI of >0.27. The subjects were followed from immediate postoperative period to 1 months after surgery. Postoperative complications were assessed using CD (Clavien–Dindo) classification during hospital stay. After discharge, subjects were followed every 15 days for a month to assess mortality or readmission.

Table 1: Age-wise distribution of demographic data in study subjects

Table 2: Correlation of CD grade and mFI in various age groups of study subjects

Table 3: Association of length of hospital stay and 30-days readmission to mFI in study subjects

It was seen that for age-wise distribution of demographic data in study subjects, there were 42.9% (n=18), 42.1% (n=32), 50% (n=40), and 53.85 (n=28) males and 57.1% (n=24), 57.9% (n=44), 50% (n=40), and 46.2% (n=240 females from 18-35, 36-50, 51-65, and >65 years respectively which was statistically non-significant with p=0.74. Similar non-significant results were seen for anesthesia technique as general anesthesia and neuraxial anesthesia considering age with p=0.07. Statistically significant results were seen for surgery type as major, intermediate, and minor with p=0.001. Similar significant results were seen for postoperative complications with p<0.01 with increased complications with age (Table 1).

The study results showed that for correlation of CD grade and mFI in various age groups of study subjects, for age of 18-35 years, mFI was 0.04 (0.05), CD grade was 0.64 (0.95), correlation coefficient was 0.76 depicting statistically significant correlation with p<0.001. Similar significant correlation was seen for the age ranges of 36-50 years, 51-65 years, and >65 years with p<0.001 (Table 2). 

Concerning the association of length of hospital stay and 30-days readmission to mFI in study subjects, length of hospital stay in study subjects was 3.63±1.44 days in subjects with mFI=0, 5.51±1.44 days for mFI=0.09, 6.04±0.77 days for mFI=0.18, and was 8.2±2.57 days for mFI ≥0.27 which was significantly higher with increased mFI scores with p<0.001. For 30-days readmission rate, it was 0, 5.3% (n=2), 2.1% (n=2), and 41.5% (n=34) for mFI scores of 0, 0.09, 0.18, and ≥0.27 respectively depicting statistically non-significant difference with p<0.001 (Table 3).

The present study assessed 250 subjects aged 18 years or above, from both the genders, and were undergoing surgery under neuraxial or general anesthesia. In all the subjevts, mFI scores were assessed preoperatively. Significant frailty was considered for mFI of >0.27. The subjects were followed from immediate postoperative period to 1 months after surgery. Postoperative complications were assessed using CD (Clavien–Dindo) classification during hospital stay. After discharge, subjects were followed every 15 days for a month to assess mortality or readmission. The study design of the present study was similar to the previous studies of Louwers L et al⁸ in 2016 and Pitts KD et al⁹ in 2019 where study design similar to the present study was also reported by the authors in their respective studies.

The study results showed that for age-wise distribution of demographic data in study subjects, there were 42.9% (n=18), 42.1% (n=32), 50% (n=40), and 53.85 (n=28) males and 57.1% (n=24), 57.9% (n=44), 50% (n=40), and 46.2% (n=240 females from 18-35, 36-50, 51-65, and >65 years respectively which was statistically non-significant with p=0.74. Similar non-significant results were seen for anesthesia technique as general anesthesia and neuraxial anesthesia considering age with p=0.07. Statistically significant results were seen for surgery type as major, intermediate, and minor with p=0.001. Similar significant results were seen for postoperative complications with p<0.01 with increased complications with age. These results were consistent with the findings of Wahl¹⁰ in 2017 and Eslami MH et al¹¹ in 2019 where reported by the authors in their studies was comparable to the results of the present study. 

It was seen that for correlation of CD grade and mFI in various age groups of study subjects, for age of 18-35 years, mFI was 0.04 (0.05), CD grade was 0.64 (0.95), correlation coefficient was 0.76 depicting statistically significant correlation with p<0.001. Similar significant correlation was seen for the age ranges of 36-50 years, 51-65 years, and >65 years with p<0.001. These findings were in agreement with the results of Ali et al¹² in 2016 and Farhat JS et al¹³ in 2012 where correlation of CD grade and mFI in various age groups reported by the authors was comparable to the results of the present study. 

On assessing the association of length of hospital stay and 30-days readmission to mFI in study subjects, length of hospital stay in study subjects was 3.63±1.44 days in subjects with mFI=0, 5.51±1.44 days for mFI=0.09, 6.04±0.77 days for mFI=0.18, and was 8.2±2.57 days for mFI ≥0.27 which was significantly higher with increased mFI scores with p<0.001. For 30-days readmission rate, it was 0, 5.3% (n=2), 2.1% (n=2), and 41.5% (n=34) for mFI scores of 0, 0.09, 0.18, and ≥0.27 respectively depicting statistically non-significant difference with p<0.001. These results correlated with the findings of Adams P et al¹⁴ in 2013 and Karam J et al¹⁵ in 2013 where association of length of hospital stay and 30-days readmission to mFI reported by the authors was comparable to the results of the present study.

The present study, within its imitations, concludes that higher mFI scores were consistent in prediction of more severe postoperative complications, especially in Clavien–Dindo grades of II and IV and intensive care unit. The technique of anesthesia depicted no significant association with postoperative complications except in subjects with higher mFI.

1. Velanovich V, Antoine H, Swartz A, Peters D, Rubinfeld I. Accumulating deficits model of frailty and postoperative mortality and morbidity: Its application to a national database. J Surg Res 2013;183:104-10.
2. Oliver D, Griffiths R, Roche J, Sahota O. Hip fracture. BMJ Clin Evid 2010;2010:1110.
3. Murthy S, Hepner DL, Cooper Z, Bader AM, Neuman MD. Controversies in anaesthesia for noncardiac surgery in older adults. Br J Anaesth 2015;115:ii15-25.
4. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg 2010;210:901-8.
5. Cesari M, Gambassi G, van Kan GA, Vellas B. The frailty phenotype and the frailty index: Different instruments for different purposes. Age Ageing 2014;43:10-2.
6. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-95.
7. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people [published correction appears in Lancet 2013;382:1328]. Lancet 2013;381:752-62.
8. Louwers L, Schnickel G, Rubinfeld I. Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: Analysis of the national surgical quality improvement project database. Am J Surg 2016;211:1071-6.
9. Pitts KD, Arteaga AA, Stevens BP, White WC, Su D, Spankovich C, et al. Frailty as a predictor of postoperative outcomes among patients with head and neck cancer. Otolaryngol Head Neck Surg 2019;160:664-71.
10. Wahl TS, Graham LA, Hawn MT, Richman J, Hollis RH, Jones CE, et al. Association of the modified frailty index with 30-day surgical readmission. JAMA Surg 2017;152:749-57.
11. Eslami MH, Saadeddin Z, Rybin DV, Doros G, Siracuse JJ, Farber A. Association of frailty index with perioperative mortality and in-hospital morbidity after elective lower extremity bypass. J Vasc Surg 2019;69:863-74.
12. Ali R, Schwalb JM, Nerenz DR, Antoine HJ, Rubinfeld I. Use of the modified frailty index to predict 30-day morbidity and mortality from spine surgery. J Neurosurg Spine 2016;25:537-41.
13. Farhat JS, Velanovich V, Falvo AJ, Horst HM, Swartz A, Patton JH Jr, et al. Are the frail destined to fail? Frailty index as predictor of surgical morbidity and mortality in the elderly. J Trauma Acute Care Surg 2012;72:1526-31.
14. Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubinfeld I. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg 2013;139:783-9.
15. Karam J, Tsiouris A, Shepard A, Velanovich V, Rubinfeld I. Simplified frailty index to predict adverse outcomes and mortality in vascular surgery patients. Ann Vasc Surg 2013;27:904-8.