Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer.

Importance: Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer. Objective: To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. Design, Setting, and Participants: This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019. Exposures: Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group). Main Outcomes and Measures: 90-day mortality, adverse surgical events, and use of supportive care services. Results: Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P < .001), had longer operative time (mean [SD], 203 [146] minutes vs 138 [112] minutes; P < .001), and longer length of stay (median [interquartile range], 5 [3-8] days vs 4 [2-7] days; P < .001). There were no differences in the proportions of men (488 [47.8%] men vs 450 [51.6%] men; P = .11). Adverse surgical events were not significantly different between groups (odds ratio, 0.93 [95% CI, 0.73-1.18]; P = .54). However, the adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric comanagement group vs 8.9% for the surgical service group (difference, 4.6% [95% CI, 2.3%-6.9%]; P < .001). Additionally, compared with patients who received postoperative care management from the surgery service only, a higher proportion of patients in the geriatric comanagement group received inpatient supportive care services, including physical therapy (555 patients [63.6%] vs 820 patients [80.4%]; P < .001), occupational therapy (220 patients [25.2%] vs 385 patients [37.7%]; P < .001), speech and swallow rehabilitation (42 patients [4.8%] vs 86 patients [8.4%]; P = .002), and nutrition services (637 patients [73.1%] vs 803 patients [78.7%]; P = .004). Conclusions and Relevance: This cohort study found that geriatric comanagement was associated with significantly lower 90-day postoperative mortality among older patients with cancer. These findings suggest that such patients may benefit from geriatric comanagement, which could improve their ability to survive adverse postoperative events.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial.

BACKGROUND: Delirium is a common and serious postoperative complication. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia, and some evidence suggests that ketamine prevents delirium. The primary purpose of this trial was to assess the effectiveness of ketamine for prevention of postoperative delirium in older adults. METHODS: The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] study is a multicentre, international randomised trial that enrolled adults older than 60 years undergoing major cardiac and non-cardiac surgery under general anaesthesia. Using a computer-generated randomisation sequence we randomly assigned patients to one of three groups in blocks of 15 to receive placebo (normal saline), low-dose ketamine (0·5 mg/kg), or high dose ketamine (1·0 mg/kg) after induction of anaesthesia, before surgical incision. Participants, clinicians, and investigators were blinded to group assignment. Delirium was assessed twice daily in the first 3 postoperative days using the Confusion Assessment Method. We did analyses by intention-to-treat and assessed adverse events. This trial is registered with clinicaltrials.gov, number NCT01690988. FINDINGS: Between Feb 6, 2014, and June 26, 2016, 1360 patients were assessed, and 672 were randomly assigned, with 222 in the placebo group, 227 in the 0·5 mg/kg ketamine group, and 223 in the 1·0 mg/kg ketamine group. There was no difference in delirium incidence between patients in the combined ketamine groups and the placebo group (19·45% vs 19·82%, respectively; absolute difference 0·36%, 95% CI -6·07 to 7·38, p=0·92). There were more postoperative hallucinations (p=0·01) and nightmares (p=0·03) with increasing ketamine doses compared with placebo. Adverse events (cardiovascular, renal, infectious, gastrointestinal, and bleeding), whether viewed individually (p value for each >0·40) or collectively (36·9% in placebo, 39·6% in 0·5 mg/kg ketamine, and 40·8% in 1·0 mg/kg ketamine groups, p=0·69), did not differ significantly across groups. INTERPRETATION: A single subanaesthetic dose of ketamine did not decrease delirium in older adults after major surgery, and might cause harm by inducing negative experiences. FUNDING: National Institutes of Health and Cancer Center Support.