Perioperative frailty: lessons learned and future directions.

PURPOSE OF REVIEW: As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions. RECENT FINDINGS: A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients. SUMMARY: Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.

Pulse pressure and perioperative stroke.

PURPOSE OF REVIEW: Central pulse pressure (PP), a marker of vascular stiffness, is a novel indicator of risk for perioperative morbidity including ischemic stroke. Appreciation for the mechanism by which vascular stiffness leads to organ dysfunction along with understanding its clinical detection may lead to improved patient management. RECENT FINDINGS: Vascular stiffness is associated with increased mortality and neurologic, cardiac, and renal injury in nonsurgical and surgical patients. Left ventricular hypertrophy and diastolic dysfunction along with microcirculatory changes in the low vascular resistance, high blood flow, cerebral and renal vasculature are seen in patients with vascular stiffness. Pulse wave velocity and the augmentation index have higher sensitivity for detecting of vascular stiffness than peripheral PP as the hemodynamic consequences of vascular stiffness are secondary to alterations in the central vasculature. Vascular stiffness alters cerebral autoregulation, resulting in a high likelihood of having a lower limit of autoregulation more than 65 mmHg during surgery. Vascular stiffness may predispose to cerebral hypoperfusion, increasing vulnerability to ischemic stroke, postoperative delirium, and acute kidney injury. SUMMARY: Vascular stiffness leads to alterations in cerebral, cardiac, and renal hemodynamics increasing the risk of perioperative ischemic stroke and neurologic, cardiac, and renal dysfunction.