Worldwide, over 25% (15 million) of deaths are due to the two leading causes of mortality – heart disease and stroke (Lancet 2019;393:401). The third-leading cause of death in the United States and the world is 30-day postoperative mortality, with 7.7% of all global deaths (4.2 million people) (Lancet 2019;393:401). Postoperative mortality and morbidity are significant risks associated with major surgery, and these risks increase with age (Clin Ther 2019;41:387-99). Elderly patients frequently present with multiple chronic conditions, including cardiac and vascular disease, hypertension, and cognitive impairment, contributing to increased risk for postoperative mortality, major adverse cardiac and cerebrovascular events (MACCE), and negative postoperative cognitive outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are the most common postoperative complications in elderly patients (Br J Anaesth 2019;123:917; Br J Anaesth 2019;123:464-78). Reducing costly postoperative mortality and major morbidity that includes POD and POCD is a critical unmet public health need due to limited proactive preoperative prediction and prevention strategies.
It is a public health priority to improve physical, brain, and emotional health outcomes after surgery, and to reduce the associated health care costs. Effective real-world perioperative risk predictions and interventions are needed to reduce postoperative mortality and morbidity, including depression, delirium, and cognitive decline, in millions of patients undergoing surgeries.
Proactive perioperative risk prediction
Comprehensive preoperative risk-prediction algorithms accurately identify high-risk surgical patients: Validated, fully automated, highly accurate machine learning risk-prediction algorithms integrated in the electronic health record outperform other predictive approaches in predicting 30-day postoperative mortality and MACCE prior to surgery (JAMA Netw Open 2023;6:e2322285). Flagging high-risk patients at the time of surgical scheduling allows for proactive prehabilitation and personalized perioperative interventions.
Age and frailty: Age – one of the strongest predictors of high risk for surgical complications – is associated with frailty, postoperative mortality, and morbidity, including POD and POCD (Am J Surg 2019;218:393-400; Circ Cardiovasc Qual Outcomes 2012;5:222-8; JAMA Surg 2017;152:233-40). Frailty is a multidimensional syndrome related to the accumulation of age- and disease-related deficits. Multiple guidelines recommend preoperative frailty assessments using well-studied clinical tools (i.e., the Clinical Frailty Scale) (Anesthesiology 2022;136:255-57).
Intraoperative triple low events (TLEs) are associated with mortality, stroke, and POD: Intraoperative hypotension is associated with postoperative mortality, stroke, and acute kidney injury in cardiac surgical patients. TLEs (low blood pressure: MAP <75 mmHg, low bispectral index [<45], and low minimum alveolar concentration [<0.8]) are associated with prolonged length of stay and increased rates of 30-day mortality (Anesthesiology 2019;130:72-82; Anesthesiology 2012;116:1195-203). Vigilant monitoring for TLEs is needed to avoid adverse outcomes.
Intraoperative neuromonitoring (IONM) to predict mortality, stroke, and POD: IONM of somatosensory evoked potential (SSEP) and EEG can reliably identify stroke and mortality after cardiac surgery (Ann Thorac Surg 2023;116:623-29; J Clin Neurophysiol 2023;40:180-86). IONM can also help predict and prevent POD, cognitive decline, and MACCE.
“Patients for high-risk elective surgery can undergo preoperative evaluation to optimize health with personalized prehabilitation using established disease-specific algorithms.”
Perioperative interventions to reduce postoperative mortality and improve outcomes
- Personalized prehabilitation: Patients for high-risk elective surgery can undergo preoperative evaluation to optimize health with personalized prehabilitation using established disease-specific algorithms. For example, patients with BMI ≥30 or over 45 years of age could proceed through the endocrinology pathway with assessment of HbA1c levels. If A1c is normal, no prehabilitation for diabetes may be required. If A1c is between 6.5%-8%, a primary care referral may be helpful, and if A1c is >8%, an endocrinologist referral could facilitate optimization.
- Cognitive and behavioral interventions and cognitive training: The Neurobics trial showed that Lumosity cognitive exercise games reduced the incidence of POD when patients played preoperatively, with greater reductions observed for more hours (10.2% for 5-10 hours and 18.4% for <5 hours, and compared to the nonintervention control rate of 28%) (JAMA Surg 2021;156:148-56). Patients can complete a cognitive exercise before and after surgery to decrease their POD and cognitive decline risks.
- Exercise: Physical exercise (aerobic and strength training) can lead to better physical and mental reserves to optimize and support postoperative recovery.
- Enhanced social support: This reduces perioperative depression and associated cognitive decline.
- Proactive depression treatment: Depression can be preoperatively assessed using easy-to-use scales (e.g., PHQ-9). Preoperative management of depression can significantly reduce severe postoperative depression and worsening of brain and mental health.
- Sleep: Improving sleep quality and hygiene preoperatively will also reduce risks for POD and optimize postoperative brain and mental health.
Postoperative mortality, MACCE, depression, delirium, and cognitive decline are major public health problems, and their preoperative risk prediction can help proactive mitigation and prevention with prehabilitation, preoperative cognitive/behavioral training, and personalized perioperative interventions.
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