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Preoperative Assessment of Older Adults

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Preoperative assessment in older patients is important as: ... Best strategy for assessment of preoperative cardiac risk remains controversial ... – PowerPoint PPT presentation

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Title: Preoperative Assessment of Older Adults


1
Preoperative Assessment of Older Adults
  • Seki Balogun, MD
  • Core Curriculum in Geriatric Medicine
  • February 16, 2004

2
  • The role of the medical consultant is to
    identify the problems, correct the correctable,
    and then point out the uncorrectable to the
    unsuspecting
  • - G.E. McElwain, Jr.

3
Introduction
  • Preoperative assessment in older patients is
    important as
  • Surgical procedures are more frequent in the
    elderly
  • Surgical rates are 55 higher in persons over the
    age of 65
  • 40 of admissions of older patients to general
    hospitals are admissions to surgical services

4
Introduction
  • Studies evaluating surgical mortality show that
    older patients have a higher mortality rate than
    younger patients
  • Older patients account for 75 of all
    postoperative deaths, increasing nearly linearly
    with each decade of age

5
Introduction
  • Preop assessment in the elderly is very complex
    and sometimes difficult, due to factors like
  • Frequent coexistence of multisystem diseases
  • Heterogeneity of the geriatric population,
    requiring individualized approach for older
    patient undergoing surgery
  • As such , there is no simple algorithmic
    guideline

6
Epidemiology of surgical risk
  • In the past, higher surgical risk created a
    reluctance to operate on most older patients
  • As late as 1980, continued reluctance to
    recommend surgery in geriatric patients was
    common
  • Surgery was often delayed until it was the only
    option available, as such it was often performed
    urgently or emergently, leading to even poorer
    outcome

7
Epidemiology
  • Changes in attitude toward the estimation of
    surgical risk have occurred over the years
  • Decline in overall surgical mortality in the
    elderly
  • In the 1950s, surgical mortality ranged from 9.2
    in patients younger than 55 years with cardiac
    disease to 18 in patients older than 75 years
  • More recently, mortality in patients with cardiac
    disease is about 0.9 2.4
  • This change in mortality is attributable
    primarily to improvements in anesthesia and
    surgical expertise

8
Epidemiology
  • Hence, from the standpoint of risk, surgery can
    longer be denied solely on the basis of age
  • Increase in life expectancy over the years also
    has had a profound impact on evaluating the
    benefit of surgery
  • Prognosis of older patients who survive surgery
    is often better than age matched controls

9
Individual risk factors
  • Patient-specific risk factors
  • Age and life expectancy
  • Functional Status Activities of Daily Living
    (ADL) scales predict surgical complications
  • Complications have been found to be more frequent
    in inactive patients
  • Medication Use (include Herbal and OTC)
  • Obesity
  • Not found to be risk factor for adverse postop
    outcomes
  • Relationship to postop pulmonary complications-
    controversial

10
Individual risk factors
  • Neuropsychological Status
  • Psychological factors predict surgical outcome
  • Social support systems and the will to live,
    though difficult to quantify are important
    predictors of surgical outcome
  • Assessment of preoperative mental status is
    critical to understanding the etiology of
    postoperative cognitive status
  • Dementia is a predictor of poor outcome, with
    increased mortality compared to nondemented
    patients
  • Postoperative complications also occur more
    frequently in these patients i.e. delirium

11
Specific organ system disease factors
  • Most post operative mortality occur as a result
    of
  • Cardiac complications
  • Pulmonary complications
  • Infectious complications

12
Cardiac Disease
  • Cardiovascular Disease
  • the single best predictor of postoperative
    cardiac complications is the presence of ischemic
    heart disease
  • Myocardial infarction (MI) within 3 months of
    surgery carries a risk of recurrent infarction or
    death of 8 30 perioperatively, the risk
    decreases to 3.5 5 after about 6 months
  • Clinical evidence of heart failure and
    arrhythmia powerful predictor of adverse cardiac
    event
  • Best strategy for assessment of preoperative
    cardiac risk remains controversial
  • Prevention of bacterial endocarditis should be
    addressed for susceptible patients using standard
    protocol

13
Cardiac testing in PAD prior to noncardiac surgery
  • Resting Echocardiogram
  • Quantify valvular dysfunction in pts with
    significant murmur
  • Evaluate ventricular dysfunction in poorly
    controlled CHF or CHF of unknown cause
  • EKG
  • Useful in detecting silent ischemia in pts with
    CAD
  • Arrhythmias complex ventricular arrhythmias
    predict future cardiac events

14
Recommendations for Preop Resting EKG
  • Class I
  • Recent chest pain or ischemic equivalent in
    moderate to high risk patients scheduled for
    moderate to high risk surgery
  • Class IIA
  • Asymptomatic with DM
  • Class IIB
  • Prior coronary revascularization
  • Asymptomatic male gt 45 yrs or female gt55 yrs with
    two or atherosclerotic risk factors
  • Prior hospital admission for cardiac disease
  • Class III
  • Routine test in asymptomatic subjects undergoing
    low risk procedures

Eagle KA, Berger PB et al. J Am Coll Cardiology
39542, 2002
15
Cardiac testing in PAD prior to noncardiac surgery
  • Stress testing (Exercise or pharmacologic)
  • Useful in
  • New, unexplained chest pain
  • Status of CAD uncertain
  • Moderate risk for perioperative cardiac
    complication (Eagle Class I or II)
  • C reactive Protein
  • Risk factor for cardiovascular disease
  • Prognostic importance in CAD
  • Data from larger studies needed

16
Estimation of Coronary Risk before noncardiac
surgery
  • Revised Goldman Cardiac Risk Index
  • Six independent predictors
  • High risk surgery
  • Hx of ischemic heart disease
  • Hx of heart failure
  • Hx of cerebrovascular disease
  • DM with insulin therapy
  • Preop serum creatinine gt2mg/dl

17
Revised Goldman Cardiac Risk Index
  • Risk factor
  • 0
  • 1
  • 2
  • 3 or more
  • Major complication Rate
  • 0.4
  • 0.9
  • 7
  • 11

Lee TH, Marcantonio ER et al. Circ 1001043 1999
18
Pulmonary Diseases
  • Increases the risk of postoperative complications
  • Accounts for 40of total complications and 20 of
    deaths
  • Risk factors include
  • Obesity (controversial)
  • cough,
  • smoking,
  • history of lung disease,
  • site of surgery (more complications when surgery
    is in upper abdomen, close to the diaphragm)
  • prolonged duration of anesthesia (gt3 hours)
  • repeat surgery within one year
  • Respiratory Infection
  • Type of anesthesia (general gt epidural or spinal
    )
  • Clinical findings (wheezes, rales, rhonchi,
    decreased breath sounds) predict postop pulmonary
    complications

19
Chest X-ray
  • Add little to clinical evaluation in identifying
    periop risks
  • May be useful in patients with suspected
    pulmonary disease or cardiac disease

20
Pulmonary Function Test
  • Indicated in lung resection surgery
  • In unexplained dyspnea
  • Maybe used in COPD or Asthma if unable to
    determine patients best baseline
  • Arterial blood gas analysis- indicated in
  • Pts undergoing CABG or upper abdominal surgery
    with a history of tobacco use or dyspnea
  • lung resection surgery

21
Strategies To Reduce Postoperative Pulmonary
Complications
  • Complications include
  • Atelectasis
  • Infections
  • Prolonged mechanical ventilation and respiratory
    failure
  • Exacerbation of underlying chronic lung disease
  • Bronchospasm

22
Strategies To Reduce Postoperative Pulmonary
Complications
  • Preoperative strategies
  • Smoking Cessation
  • At least 8 weeks before surgery
  • Adequate treatment of COPD and Asthma (inhaled
    ipratropium, inhaled beta agonists,
    corticosteriods)
  • Delay elective surgery with respiratory
    infections
  • Treat respiratory infections
  • Patient education on lung expansion maneuvers
    (coughing, incentive spirometry)
  • Intraoperative
  • Minimize duration of anesthesia and surgery (when
    possible)
  • Choose laparoscopic rather than open abdominal
    surgery
  • Choose regional, epidural or spinal anesthesia
    (when possible)
  • Postoperative
  • Deep breathing exercises
  • Epidural anesthesia in lieu of parenteral opioids

23
Renal Disease
  • Important impact on morbidity and postop course
  • Adjust CrCl for age and decrease in muscle mass
  • The dosing of medications should be adjusted
    appropriately
  • Preoperative renal status is the best universal
    predictor of postop renal failure
  • Risk of renal deterioration postop higher in
    patients with serum creatinine greater than
    1.2mg/dl ( 2.9 vs. 14.4)

24
Renal Disease
  • Other Risk factors for postoperative renal
    failure
  • rising serum creatinine
  • LV dysfunction
  • advanced age
  • decreased serum albumin
  • Malignancy
  • emergency surgery
  • vascular surgery,
  • Preop diuretic,
  • hypotension
  • Poor prognostic indicators
  • oliguria,
  • urine sediment abnormalities,
  • severity of renal failure
  • Attention should be paid to volume status
  • Avoid use of nephrotoxic medications when possible

25
Type of surgery
  • Important in determining risk
  • Elective or emergent
  • Inside or outside body cavity

26
Emergency versus Elective Surgery
  • Older adults undergo 50 of all emergency
    procedures
  • Surgical risk increases tremendously, especially
    in the elderly
  • Mortality rate 20 in older adults undergoing
    emergency surgery, compared to 1.9 in patients
    who had elective surgery
  • Post-op complications and morbidity were also
    higher

27
Emergency versus Elective Surgery
  • Possible reasons
  • Surgical disease may have a more sudden onset in
    the elderly or may be more difficult to diagnose
    because of atypical presentation
  • Surgeons are reluctant to operate electively in
    older patients
  • Older patients are sometimes reluctant to undergo
    any invasive procedure, and wait until option of
    last resort

28
Body Cavity versus Non-Body Cavity Surgery
  • Surgical mortality increases dramatically in
    thoracic and abdominal procedures

29
Common surgical procedures in older adults
  • Most common surgical procedures are
    prostatectomy, coronary artery bypass grafting,
    pacemaker implantation
  • Others are angioplasty, cholecystectomy, eye
    surgeries, orthopedic, operations on the nervous
    system and abdominal

30
Relatively Safe Procedures
  • TURP - mortality about 0.2
  • Mortality can increase up to 6.3 in patients
    older than 80 years or otherwise at high risk
  • Eye Surgeries Cataract very safe, likelihood
    of life threatening postop complication is about
    1.2

31
Relatively risky Procedures
  • Biliary surgery In patients older than 70, 30
    50 of cholecystectomies are performed emergently
    resulting in up to a 5-fold increase in mortality
    compared to elective surgery
  • Other abdominal surgery older patients have an
    incidence of perforation

32
Relatively risky Procedures
  • Cardiovascular Surgery
  • PTCA mortality 2 6 in patients 60 and above
    (higher mortality with age)
  • CABG increased mortality can be predicted from
    the following emergency surgery, renal
    insufficency, severe LV dysfunction, preop hct
    less than 34, COPD, advanced age, MVR, DM, Body
    weight less 65kg, Aortic stenosis, Stroke

33
Relatively risky Procedures
  • Orthopedic surgery
  • Hip surgery, especially after falls one of the
    most common in older adults
  • In-hospital mortality in about 4, 1-year
    mortality of about 14 17
  • Frequent complications DVT (40 60 of
    patients), Pulmonary embolism (20), pressure
    ulcer (20 70), Urinary retention (28 52)
  • Total knee replacement relatively safe,
    mortality rates of about 1.5

34
Perioperative Medication Management
  • Consultants often must decide if chronic
    medications should be continued in perioperative
    period

35
Perioperative Medication Management
  • In general
  • Medications associated with known adverse effects
    if withdrawn abruptly should be continued
    (consider alternative route when appropriate)
  • Medications that can increase surgical
    complications or not essential for short term
    improvement in QOL should be held
  • Medications not meeting either criterion will
    depend on individual physician judgment

36
Perioperative Medication Management
  • Cardiovascular Medications
  • Beta-blockers
  • Beneficial effects
  • Recommended in patients at high risk for
    cardiovascular disease
  • Reduce ischemia by decreasing myocardial oxygen
    demand due to increased stress and catecholamine
    release
  • Reduce risk of perioperative myocardial
    infarction and death
  • Should be continued in perioperative period

37
Centrally acting antihypertensives Alpha 2
agonists
  • Clonidine
  • May improve outcomes
  • Data less conclusive
  • Decrease in stress response to surgery
  • Has sedative, anxiolytic and analgesic properties
  • Reduce anesthetic requirement
  • Abrupt withdrawal can precipitate rebound
    hypertension
  • Should be continued in perioperative period
  • Transdermal clonidine for patients who may not be
    able to resume oral medications by 12hrs after
    surgery

38
Calcium Channel Blockers
  • Limited data regarding benefits and risks of CCB
  • Acute withdrawal symptoms not typical, though
    reported severe vasospasm in patients undergoing
    revascularization
  • No serious interactions with anesthetic agents
  • Possible association with increased bleeding risk
    (Conflicting data)
  • Can be safely administered in perioperative period

39
ACE Inhibitors and ARBs
  • Controversial
  • Can blunt the compensatory activation of the
    renin-angoiotensin system during surgery, leading
    to prolonged hypotension
  • Possibly, reduces incidence of postoperative
    hypertension
  • Recommendations continue ACEI/ARB in patients
    with HTN
  • Can withhold in pts with CHF, who also have low
    BP

40
Diuretics
  • Possible adverse effects
  • Hypokalemia
  • Can theoretically increase perioperative
    arrhythmia (not found in observational studies)
  • Hypovolemia
  • Anesthetic agents can induce vasodilatation,
    leading to hypotension in pts who are volume
    depleted
  • Most recommend withholding diuretics on the
    morning of surgery in some pts

41
Gastrointestinal Agents
  • H2 blockers/PPI
  • Decrease stress related mucosal damage
  • Decrease gastric volume and increase gastric pH
  • Reduces risk of chemical pneumonitis
  • Should be continued in the perioperative period

42
Pulmonary agents
  • Inhaled beta agonists and anticholinergics
  • Reduces postoperative pulmonary complications in
    patients with COPD and asthma
  • Should be continued in perioperative period
  • Theophylline
  • Potential for serious toxicity
  • No data on benefits
  • Recommendation discontinue the evening before
    surgery

43
Pulmonary agents
  • Corticosteriod
  • Chronic use in COPD should continued in periop
  • Maintains optimal lung function
  • Minimizes risk of adrenal insufficiency
  • Leukotriene Inhibitors
  • Effect on asthma symptoms and pulmonary function
    lasts up to 3 weeks
  • No adverse interactions with anesthetic agents
  • Rec continue in periop

44
Endocrine Agents
  • Insulin and oral hypoglycemics
  • Generally can continue with subcutaneous insulin
    perioperatively (rather than an insulin infusion)
    for procedures that are not long and complex
  • Can switch patients taking long-acting insulin
    (Ultralente or glargine) to an intermediate-acting
    insulin one to two days prior to surgery because
    of a potential increased risk for hypoglycemia
  • May also reduce the night time (supper or HS)
    intermediate-acting insulin on the night prior to
    surgery to prevent hypoglycemia if the patient
    has borderline hypoglycemia or tight control of
    the fasting blood glucose.
  • Sliding scale may be used in place of oral
    hypoglycemics on morning of surgery

45
Endocrine Agents
  • HRT/SERM
  • Recommendation Stop 4 -6 weeks before surgery at
    moderate to high risk for thromboembolism
  • Can be continued in surgeries at low risk for
    thromboembolism
  • If on SERM for Breast Cancer recommend
    consultation with oncologist

46
Endocrine Agents
  • Lipid Lowering agents
  • May cause myopathy and rhabdomyolysis
  • Statins may prevent vascular events and reduce
    perioperative mortality
  • Recommendation continue statins, discontinue
    niacin, fibric acid derivative and cholestyramine
    at least one day before surgery

47
Endocrine Agents
  • Thyroid agents
  • Should be continued
  • IV or IM administration if oral intake cannot be
    resumed in 5 7 days after surgery

48
Medications that affect hemostasis
  • Aspirin
  • Optimal periop management uncertain
  • Inhibits platelet cyclooxygenase
  • Increases intraop blood loss and hemorhagic
    complications
  • May prevent vascular complications in cardiac
    surgeries (CABG, PVD surgery)
  • Recommendations depends on pt risk factors and
    surgical procedure
  • 2004 ACC/AHA Continue CABG after ST elevation MI
  • Should be withheld in procedures with high
    hemorrhagic risk (CNS surgery)
  • 5- 10 days before procedure (for new platelets to
    be formed)
  • Plavix, dipyridamole
  • Stop 7 10 days before surgery
  • NSAIDS
  • Stop 3 days before surgery

49
Warfarin
  • Patients at low risk for perioperative bleeding,
    anticoagulation can be maintained at or below the
    low end of the therapeutic range (INR 2.0).
  • Patients with a high risk of bleeding, INR should
    be 1.5. or less
  • Stop warfarin two to five days preop in those at
    low risk for thrombosis
  • Stop warfarin in pts at high risk for thrombosis,
    but treat with intravenous or subcutaneous
    heparin when the INR is subtherapeutic.
  • Can be restarted postop when there is no
    contraindication to anticoagulation.

50
Psychotropic Agents
  • TCA
  • Withdrawal symptoms insomnia, headache,
    increased salivation
  • Recommend Continue
  • SSRIs
  • May increase need for blood transfusions
  • Inhibits platelet aggregation
  • Recommend Weigh benefits vs. risks

51
Chronic Opioid Therapy
  • Abrupt discontinuation may result in withdrawal
    symptoms
  • Continue in periop period
  • If oral intake not possible, consider alternative
    routes
  • Higher doses may be required
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