Complexity and Frailty in Cardiothoracic and Vascular Anesthesia (CAfCA). Prospective Multicentric Observational Study

The Western population is going through a rapid process of aging, which is of major relevance for perioperative medicine because it is associated with an increase of approximately 2,5 times in postoperative morbidity and mortality. Despite the clear association between advanced age and adverse outcomes, there is a significant variability of outcomes in older patients which is not explainable solely based on the differences in age and comorbidities. In this regard, frailty seems to play a key role to explain such variability. Frailty is a multidimensional syndrome characterized by a decline in physiological homeostatic reserve, which translates into an increased susceptibility to adverse events and unfavorable outcomes following even small exposures to physical, physiological or psychosocial stress. However, frailty has not to be considered exclusively in a geriatric context. Several studies conducted in intensive care and perioperative settings have observed a not negligible prevalence of frailty also in age groups below 65 years.

In the European population up to 69 years, the prevalence is generally 6,5%, beyond 85 years of age it exceeds 50% and reaches 65% in the over-ninety population. The prevalence of frailty in the surgical population varies, depending on the studies, from 10 to 40%. Such variability is determined by several factors: the tools and thresholds used to define frailty, the type of surgery, the type of procedure within the same surgical specialty and the setting of surgery. In cardiac surgery, prevalences oscillating between 10 and 50% have been reported. In vascular surgery, the prevalence of frailty is on average high oscillating between 20 and 60%, while in the field of thoracic surgery data of prevalence stands around 12 and 50%.

Frailty and its severity grade represent themselves noticeably as strong predictors of adverse postoperative outcomes. The strongest evidence of association is recorded between frailty and mortality at 30 days (Odds Ration variable between 1.4 and 8.33).

In the physio-pathological processes that link frailty to adverse postoperative outcomes, there are certainly modifiable factors. Several data in the literature demonstrate this correlation, including the evidence that patients diagnosed with frailty, if subjected to major elective surgery in centers with low volumes of fragile patients, have lower rates of survival at 30 days and a higher incidence of mortality correlated to postoperative complications, other conditions being equal.

From what has been outlined, it is easy to understand how a better knowledge of frailty and its prevalence can be useful for health systems that have to be more and more structured with the availability of clinical and organizational resources appropriate for the increasing complexity and frailty of patients.