Frailty

Frailty reflects a state of increased vulnerability coupled with diminished capacity to respond to stressors, resulting in increased adverse health outcomes for individuals of the same chronological age.

Prehabilitation

Sarcopenia

Sarcopenia is a complex multifactorial age-related loss of skeletal muscle mass, quality, and function
an independent predictor of adverse perioperative outcomes following vascular surgery

physical disability,
poor quality of life,
↑ in all-cause mortality
major lower limb amputation
Sarcopenia is highly prevalent in vascular surgical patients, with a particularly high prevalence of 25% in patients with peripheral arterial disease (PAD)

Sarcopenia may be identified:

clinical history,
by examination,
via screening tools
- (e.g. the SARC-F questionnaire for ‘strength, assistance with walking, rising from a chair, climbing stairs, and falls')
imaging
- not routinely performed

modification strategies include

physical exercises,
resistance and endurance training to increase muscle mass,
optimization of nutrition

Malnutrition

Malnutrition is a state of deficiency or energy imbalance leading to measurable adverse effects on function and/or clinical outcomes

Malnutrition can be identified as a body mass index (BMI) of less than 18.5 kg/m2

Malnutrition can be screened using the Malnutrition Universal Screening Tool (MUST) which gives points for

low BMI
- (<18.5 kg/m2., 18.5–20 kg/m2., >20 kg/m2.),
unplanned weight loss in the last 3 months
- (<5%, 5–10%, >10%)
if there is an acute illness or 5 days with no nutritional intake

Once identified targeted nutritional conditioning can be achieved through protein or carbohydrate loading

Cognition

Attempts should be made to reduce the chance of developing POD or POCD.
Close attention should be paid to intraoperative

control of blood pressure,
depth of anaesthesia,
temperature

Physical activity

The physical frailty phenotype: low physical activity, slowness, exhaustion, and weakness are associated with an increased risk of adverse perioperative outcomes

a systematic review of exercise before abdominal aortic aneurysm surgery demonstrated a high compliance rate and significant improvement in the anaerobic threshold

Some have concerns about the safety of exercise with significant vascular pathology. However, in the HIT-AAA study, where patients underwent preoperative high-intensity interval training involving short bursts of vigorous exercise interspersed with periods of low-intensity recovery, there was a very low adverse event rate for exercise

Anaesthetic care

should be consideration of relative or carer presence in the anaesthetic room and recovery areas in patients with cognitive impairment

A urinary catheter should be avoided unless needed due to the risk of hospital-acquired catheter-related infections

There needs to be careful attention to positioning to relieve pressure on vulnerable areas

Physiology should be meticulously attended to intraoperatively and the calculation of a pre-defined blood pressure target, invasive arterial monitoring, vasopressor infusions and advanced cardiac output monitoring may aid this

'Anticholinergic load' should be minimized, as this can lead to delirium.
These drugs include

benzodiazepines,
cyclizine,
tramadol,
atropine
Glycopyrronium, a quaternary amine, should be used in preference to atropine, a tertiary amine, as it does not cross the blood–brain barrier as easily

SNAP-3 project: ongoing

GA vs RA

no clear evidence

Pharmacokinetic considerations

Due to sarcopenia and possibly a higher percent of adipose tissue, lipophilic drugs will have a larger volume of distribution with a potentially longer duration of action, while hydrophilic drugs will have a higher peak plasma concentration

↓ hepatic blood flow and activity of the cytochrome P450 system may reduce clearance by phase 1 and phase 2 reactions

Frail patients often have

↓ renal mass,
↓ speed of renal excretion of drugs,
↑ sensitivity to nephrotoxic drugs.
A normal eGFR may reflect sarcopenia with ↓ creatinine production and should be interpreted with caution

Due to a smaller initial volume of distribution in the Schnider model of target-controlled infusion, a lower bolus dose is given at induction versus the Marsh model and is often preferred in the elderly and frail where total intravenous anaesthesia is being used

References

The Perioperative Management of Frailty in Patients Presenting for Vascular Surgery - A&ICM