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Cornia presentation.ppt Cornia presentation.ppt Presentation Transcript

  • The preoperative medical evaluation: Risk stratification and prevention of complications June 3, 2009 HuBio600, Capstone II Paul B. Cornia, MD VA Puget Sound HCS and University of Washington
  • Purpose of the preoperative medical evaluation
    • “ The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of (cardiac) problems over the entire perioperative period; and provide a clinical risk profile that the patient, primary physician, and nonphysician caregivers, anesthesiologist, and surgeon can use in making treatment decisions that may influence short- and long-term cardiac outcomes. No test should be performed unless it is likely to influence patient treatment.”
    Fleisher, L. A. et al. Circulation 2007;116:e418-e499
  • Purpose of the preoperative medical evaluation
    • “ A critical role of the consultant is to determine the stability of the patient’s (cardiovascular) status and whether the patient is in optimal medical condition, within the context of the surgical illness.”
    • “ The consultant must also bear in mind that the perioperative evaluation may be the ideal opportunity to effect the long-term treatment of a patient with significant cardiac disease or risk of such disease.”
    Fleisher, L. A. et al. Circulation 2007;116:e418-e499
  • Goals of the preoperative medical evaluation
    • Identify medical conditions that may increase the risk of perioperative complications
    • Optimize these conditions, as possible
    • Recommend preoperative testing only if it aids in risk stratification patients or influences management
    • Recommend postoperative measures that may reduce the risk of complications
  • The Art of Consultation (for non-specialists)
    • “ Although medical house staff and practicing internists spend much of their time performing consultations, few training programs offer formal instruction in the subtleties of this art. Most physicians learn how to perform consultation through trial and error, resulting in considerable variability in consultative skills. Thus, some consultants are much sought after by their colleagues, while others have trouble translating their expertise into effective consultation.”
    Goldman L, Lee T, Rudd P. Arch Intern Med 1983; 143: 1753-5.
  • Ten Commandments for Effective Consultation
    • Determine the question
    • Establish urgency
    • Look for yourself
    • Be as brief as appropriate
    • Be specific
    • Provide contingency plans
    • Honor thy turf (or thou shalt not covet thy neighbor’s patient)
    • Teach…with tact
    • Talk is cheap…and effective
    • Follow-up
    Goldman L, Lee T, Rudd P. Arch Intern Med 1983; 143: 1753-5.
  • Perioperative cardiac care
    • Preoperative cardiac evaluation
      • Revised cardiac risk index (RCRI)
      • Preoperative cardiac testing
    • Strategies to reduce postoperative cardiac complications
      • Beta blockers
      • Statins
      • Revascularization (CARP trial)
      • Anti-platelet agents (especially in patients with drug-eluting coronary stents)
      • Other
  • Perioperative cardiac care: Background
    • Worldwide, ~100 million adults undergo noncardiac surgery annually; ~30 million annually in the US.
    • Up to 1/2 have coronary artery disease (CAD) or risk factors for it.
    • Therapies for CAD allow persons to live longer…and develop conditions for which surgery may be considered to treat/cure disease (e.g., cancer resection) or improve quality of life (e.g., joint replacement)
  • Perioperative cardiac care: Background
    • 50,000 perioperative myocardial infarctions and 1 million cardiac complications occur annually in the US.
    • More than half of postoperative deaths are caused by cardiac events.
    • Perioperative cardiac complications prolong hospital course by a mean of 11 days.
          • Fleischmann KE. Am J Med. 2003;115:515-20.
    • Estimated cost perioperative cardiac complications (US) = $20 billion/year
          • Mangano DT. Anesthesiology. 1990;72:153-84.
  • Case 1
    • A 72 year old male is admitted to the hospital with a left hip fracture. A preoperative medical evaluation is requested by the orthopedic surgeon. The injury was suffered after he tripped on a rug in his home. He is fairly active and walks approximately one mile daily with rare angina and can climb 2 flights of stairs in his home without difficulty.
    • His past medical history is notable for CAD with prior MI and subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus.
    • Current medications: aspirin 325 mg qd, simvastatin 20 mg qd, glyburide 5 mg bid, atenolol 25 mg qd, and lisinopril 10 mg qd.
    • Vital signs on admission are pulse 84 and blood pressure 162/90. Cardiopulmonary examination is unremarkable. ECG is notable for pathologic q waves in leads 1 and avL.
  • Preoperative medical evaluation
    • When should I consider cancelling/delaying surgery?
      • Decompensated/uncontrolled disease (e.g., decompensated heart failure, asthma/COPD exacerbation, uncontrolled arrhythmia)
      • Uninvestigated symptoms or signs that may increase the risk of perioperative complications (e.g., uninvestigated angina)
  • Preoperative cardiovascular questions for the medical consultant
    • Does the patient require additional cardiac testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to surgery?
    • What is the estimated cardiac risk?
    • What can be done to decrease cardiac risk for those at high (or intermediate) risk?
  • Cardiac Risk * Stratification for Noncardiac Surgical Procedures *Combined incidence of cardiac death and nonfatal myocardial infarction. Eagle, K. A. et al. Circulation 2002;105:1257-1267 Endoscopic procedures Superficial procedure Cataract surgery Breast surgery Ambulatory surgery Low (reported cardiac risk generally less than 1%) Intraperitoneal and intrathoracic surgery Carotid endarterectomy Head and neck surgery Orthopedic surgery Prostate surgery Intermediate (reported cardiac risk generally 1% to 5%) Aortic and other major vascular surgery Peripheral vascular surgery Vascular (reported cardiac risk often more than 5%) Procedure Examples Risk Stratification
  • Copyright ©2007 American Heart Association Fleisher, L. A. et al. Circulation 2007;116:e418-e499 Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients 50 years of age or greater
  • Case 1
    • Does the patient require additional cardiac testing (e.g., myocardial perfusion study, coronary angiography) before proceeding to surgery?
        • No – proceed to surgery without additional cardiac testing.
        • When to consider:
          • Angina that has not been investigated
          • High risk patients undergoing moderate or high risk surgery with poor functional status, if it will alter management
  • Revised Cardiac Risk Index
    • High risk surgery (major vascular, intra-abdominal, or intrathoracic)
    • Ischemic heart disease (h/o MI, Q waves, angina, use of nitrates, or positive stress test)
    • Congestive heart failure
    • Cerebrovascular disease (prior stroke or TIA)
    • Insulin-treated diabetes mellitus
    • Renal insufficiency (serum creatinine >2.0 mg/dL)
    Lee TH et al. Circulation. 1999; 100: 1043-1049.
  • Preoperative cardiac risk stratification: Revised Cardiac Risk Index
    • *Major cardiac events = cardiac arrest, MI (fatal or non-fatal)
    • **All cardiac events = cardiac arrest, MI (fatal or non-fatal), pulmonary edema, or complete heart block.
    Lee TH. Circulation. 1999;100:1043-9. IV III II I Class 11.0 (5.8-18.4) 5.4 (2.8-7.9) ≥ 3 6.6 (3.9-10.3) 2.4 (1.3-3.5) 2 0.9 (0.3-2.1) 1.0 (0.5-1.4) 1 0.5 (0.05-1.5) 0.4 (0.1-0.8) 0 All cardiac events, % ** Major cardiac events, % * Number of predictors
  • Case 1
    • What is the estimated cardiac risk?
    • “ His past medical history is notable for CAD with prior M and subsequent CABG x3; hypertension; prior TIA; and recently diagnosed type 2 diabetes mellitus.”
      • RCRI score = 2
      • ~5-10% risk of perioperative cardiac complications
  • Perioperative cardiac events: Pathophysiology
    • Cardiac death
      • Myocardial infarction (MI), fatal arrhythmia, or heart failure
    • MI
      • Majority of non-operative MIs are due to atherosclerotic plaque rupture  thrombosis
      • Perioperative MI
        • Limited available data is conflicting
          • Datwood MM. Int J Cardiol. 1996;57-37-44.
          • Cohen MC. Cardiovasc Pathol. 1999;8:133-9.
          • Landesberg G. J Cardiothorac Vasc Anesth. 2003;17:90-100.
        • Plaque rupture or prolonged myocardial oxygen supply-demand mismatch (in setting of CAD)
  • Perioperative cardiac care: Pathophysiology
    • Postoperative period is a hyperadrenergic state – an extreme stress test.
    • Also, inflammation and hypercoagulability
    • Several studies have linked postoperative myocardial ischemia (assessed by continuous ECG monitoring) to postoperative cardiac events, as well as long-term cardiac morbidity and mortality.
    • Hypothesis:
      • (Relative) tachycardia  myocardial O2 supply/demand mismatch  shear stress across atherosclerotic plaque  plaque rupture  thrombus  MI
    • Postoperative myocardial ischemia is:
      • common
      • almost always clinically silent
      • associated with relative tachycardia
  • Copyright ©2005 Canadian Medical Association or its licensors Devereaux, P.J. et al. CMAJ 2005;173:779-788
  • Case 2
    • A 72 year-old male is referred for preoperative medical evaluation prior to partial colectomy for colon cancer.
    • PMHx: DM2; hypertension; stage 3 CKD (SCr 2.2); h/o CVA (mild residual right arm weakness); hyperlipidemia; mild COPD; GERD
    • Medications: Insulin (basal NPH, prandial regular), HCTZ 25 mg qd, lisinopril 20 mg qd, simvastatin 20 mg qd, omeprazole 20 mg qd, albuterol MDI prn
    • Functional status is excellent. He has no angina or heart failure sx’s. Cardiopulmonary examination and ECG are normal.
  • Case 2
    • For this patient, strong evidence exists to support the use of a prophylactic perioperative beta-blocker in this patient to reduce the risk of cardiac complications (i.e., class I recommendation, level A evidence).
    • 1. True
    • 2. False
  • Perioperative cardiac care: Beta-blockade – landmark trials
    • 200 patients scheduled for noncardiac surgery who had or were at risk for CAD were randomized to receive either perioperative atenolol or placebo.
    • Atenolol was started on the day of surgery and continued for the length of the hospitalization to a maximum of 7 days.
    • No difference in in-hospital cardiac morbidity/mortality (as expected).
    • Prospective follow-up (for 2 years) showed a decrease in both overall mortality and event free survival with perioperative beta-blockade.
    Mangano DT et al. N Engl J Med 1996; 335: 1713-20.
  • Perioperative cardiac care: Beta-blockade – landmark trials Mangano DT et al. N Engl J Med 1996; 335: 1713-20. 2- year survival = 90% 2- year survival = 79%
  • Perioperative cardiac care: Beta-blockade – landmark trials Mangano DT et al. N Engl J Med 1996; 335: 1713-20. 2- year event free survival = 68% 2- year event free survival = 83%
  • Perioperative cardiac care: Beta-blockade – landmark trials
    • 112 patients scheduled for elective major vascular surgery (AAA repair or lower extremity revascularization) with a positive dobutamine echocardiogram randomized to bisoprolol or placebo.
    • Bisoprolol was started at least 1 week preoperatively, uptitrated if heart rate >60 bpm, and continued for 30 days postoperatively.
    • Dramatic reduction in 30-day postoperative cardiac death and non-fatal MI.
    Poldermans D et al. N Engl J Med 1999; 341: 1789-94.
  • Perioperative cardiac care: Beta-blockade – landmark trials Poldermans D et al. N Engl J Med 1999; 341: 1789-94. Cardiac death or non-fatal MI
  • Perioperative beta-blockade…what’s new
    • Recent trials showing no benefit
      • POBBLE trial ( J Vasc Surg 2005; 41: 602-9.)
        • 103 patients without known CAD undergoing elective vascular surgery.
        • Randomized to metoprolol ( fixed dose ) or placebo ( started on admission , continued for up to 7 days).
      • MaVS study (Am Heart J. 2006;152:983-90.)
        • 496 patients undergoing elective vascular surgery.
        • Randomized to metoprolol ( fixed dose ) or placebo ( started on admission , continued for up to 5 days).
      • DIPOM trial (BMJ. 2006;332:1482-8.)
        • 921 patients with diabetes undergoing major, non-cardiac surgery.
        • Randomized to metoprolol ( fixed dose ) or placebo ( started 1 day before surgery , continued for up to 8 days).
      • Large (>300 hospitals, >700k patients), retrospective database study confirmed reduced mortality in high and (probably) intermediate risk, but trend towards harm in low risk. ( Lindenauer PK et al. N Engl J Med 2005; 353: 348-61.)
  • Perioperative beta-blockade: PeriOperative ISchemic Evaluation (POISE) trial
    • 190 hospitals, 23 countries, 8351 patients enrolled
    • Inclusion:
      • >45 yrs old, expected hospitalization >24 hours, and: CAD; PVD; prior stroke; hospitalization for CHF within 3 years; major vascular surgery; or any 3 of the following: intrathoracic or intraperitoneal surgery, h/o CHF, h/o TIA, DM, Cr >2.0, >70 yrs old, or emergent/urgent surgery)
    • Exclusion:
      • HR <50 bpm, 2 nd or 3 rd degree AVB, asthma, on beta-blocker or planned periop beta-blockade, prior ADR with beta-blocker, CABG within 5 yrs and no recurrent angina; low risk surgery; on verapamil.
    • Primary outcome = cardiac death, non-fatal cardiac arrest or non-fatal MI
    POISE study group. Lancet 2008;371:1839-47.
  • Perioperative beta-blockade: POISE trial
    • Randomized to metoprolol XL vs. placebo
      • 1 st dose metoprolol XL = 100mg, given 2-4 hours preop
      • If HR > 80 bpm or SBP >100 mmHg at any time 1 st 6 hours after surgery, another dose of metoprolol 100mg administered.
      • Daily dosage metoprolol 200mg thereafter x30 days
      • If HR < 45 bpm or SBP <100 mmHg consistently, decrease metoprolol to 100mg qd
    POISE study group. Lancet 2008;371:1839-47.
  • Perioperative beta-blockade: POISE trial POISE study group. Lancet 2008;371:1839-47. 0.0053 2.17 (1.26-3.74) 19 (0.5%) 41 (1.0%) Stroke 0.0317 1.33 (1.03-1.74) 97 (2.3%) 129 (3.1%) Total mortality 0.0008 0.70 (0.57-0.86) 215 (5.1%) 152 (3.6%) Non-fatal MI 0.0399 0.84 (0.70-0.99) 290 (6.9%) 244 (5.8%) Primary outcome p value HR Placebo Metoprolol
  • Perioperative beta-blockade: POISE trial POISE study group. Lancet 2008;371:1839-47.                                                                                                      Meta-analysis of β-blocker trials in patients undergoing non-cardiac surgery 
  • Perioperative cardiac care: Beta-blockade…bottom line
    • For patients chronically receiving beta-blockers  continue perioperatively
    • Which patients may benefit from prophylactic beta-blockade, if any, is uncertain.
      • My opinion:
        • High risk patients (RCRI ≥3) are likely to benefit
        • Must be started days to weeks before surgery with dose titration to achieve resting heart rate < ~70 bpm
  • Perioperative cardiac care: What about the other cardiac meds?
    • In general:
      • Continue uninterrupted including the morning of surgery:
        • Beta-blockers
        • Calcium channel blockers
        • Centrally acting alpha agonists (e.g., clonidine)
        • Nitrates
        • Digoxin
      • Hold morning of surgery, resume postop:
        • ACE-I, ARB (if using for CHF or baseline BP is low – risk of intraop hypotension)
        • Diuretics
    • Pathophysiology of perioperative MI is believed to be similar to non-perioperative MI (i.e., plaque rupture in many cases)
    • Pleiotropic effects of statins are well known
      • Anti-inflammatory, stabilize vulnerable atherosclerotic plaques, reduce platelet aggregation, improve endothelial vasodilation
    Perioperative cardiac care: Statins
  • Perioperative cardiac care: Statins
    • Retrospective studies
      • Case control study of patients undergoing major vascular surgery
        • 4 fold reduction in perioperative morality in patients that received perioperative statins.
          • Poldermans D et al. Circulation 2003; 107: 1848-51.
      • Large cohort study of patients undergoing major noncardiac surgery
        • Reduced crude mortality rates in patients that received perioperative statins.
        • Benefit was greatest in patients at highest risk (RCRI ≥ 4).
          • Lindenauer PK. JAMA 2004; 291: 2092-99.
    • Single, small, RCT comparing 45 days of perioperative atorvastatin (irrespective of serum cholesterol) to placebo.
      • 69% relative risk reduction in composite endpoint (death, nonfatal MI, stroke, unstable angina) with atorvastatin.
        • Durazzo AE et al. J Vasc Surg 2004; 39: 967-75.
    • Available data is encouraging and suggests benefit, risk is largely unknown – larger, prospective trials are ongoing
      • DECREASE IV  large RCT of beta-blocker (titrated), statin, beta-blocker + statin, or placebo.
    • Bottom line:
      • Insufficient data to recommend routine perioperative statin use.
      • Consider continuing statin therapy perioperatively, particularly in high-risk patients.
    Perioperative cardiac risk reduction: Statin therapy
  • Perioperative cardiac care: Prophylactic revascularization - background
    • Expert groups and practice guidelines recommend preoperative revascularization only if indicated for reasons independent of the non-cardiac surgery, but substantial variability in practice patterns exists.
    • Observational studies (CASS and BARI) have suggested that recent (<5 years) coronary revascularization reduces the risk of cardiac complications for subsequent non-cardiac operations
      • Eagle KA. Circulation 1997; 96: 1882-7.
      • Hassan SA. Am J Med 2001; 110: 260-6.
    • Increased rates of in-stent thrombosis  perioperative MI and cardiac death when non-cardiac surgery performed in the immediate period following PCI
      • Kaluza GL. J Am Coll Cardiol 2000; 35: 1288-94.
      • Wilson SH. J Am Coll Cardiol 2003; 42: 234-40.
  • Perioperative cardiac care: Prophylactic revascularization – CARP trial
    • Randomized controlled trial conducted at 18 VA medical centers.
    • 510 patients with stable CAD ( ≥70% stenosis in at least one major coronary artery) scheduled for vascular surgery (AAA repair [1/3] or lower extremity bypass surgery [2/3]) randomized to prophylactic revascularization (CABG [~40%] or PCI [~60%]) or none.
    • Medical therapy (including beta-blockade and statins) was equivalent in the 2 groups
    McFalls EO et al. N Engl J Med 2004; 351: 2795-804.
  • Perioperative cardiac care: Prophylactic revascularization – CARP trial
    • No difference in 30-day rates of MI, stroke, limb loss, or dialysis
    • No difference in long-term mortality
    McFalls EO et al. N Engl J Med 2004; 351: 2795-804.
  • Case 3
    • 70 year-old male referred for preoperative medical evaluation prior to planned RRP for recently dx’ed prostate cancer (PSA 21, Gleason 8, confined to prostate).
    • PMHx: CAD (h/o MI, s/p CABG 10 years ago, and PCI
    • 2 months ago for class 3 angina), HTN, hyperlipidemia, tobacco
    • Medications: ASA 325 mg qd, clopidogrel 75 mg qd, metoprolol 50 mg bid, lisinopril 10 mg qd, simvastatin 40 mg qd
    • Functional status is good and he has had no angina since the recent PCI.
  • Regarding perioperative anti-platelet management, you recommend:
    • Hold aspirin and clopidogrel for 7 days preop and resume as soon as possible postop
    • Hold clopidogrel for 7 days preop and resume as soon as possible postop; continue aspirin (uninterrupted) perioperatively
    • Hold aspirin for 7 days preop and resume as soon as possible postop; continue clopidogrel (uninterrupted) perioperatively
    • Cancel surgery, interruption of anti-platelet agents is not safe
    • More information is needed
  • PCI: general
    • PTCA alone
      • Relatively high rates of acute (during or immediately after procedure) and subacute (within 30 days) thrombosis or restenosis
      • Uncommonly used because of these limitations
    • PTCA vs. Coronary stents (Bare metal and drug-eluting [DES])
        • Acute (hours) thrombosis: up to 10%  <1%
        • Subacute (days) thrombosis: 5%  0.5-1%
        • Restenosis: 30-40% (PTCA) vs. 20-30% (bare-metal) vs. <10% (DES)
        • Late thrombosis: DES
  • Drug-eluting coronary stents Schuchman M. N Engl J Med 2007; 356: 325-8
  • Drug-eluting coronary stents
    • Dual anti-platelet therapy reduces the risk cardiac events following DES
    • Premature discontinuation may lead to in-stent thrombosis  MI, cardiac death.
    • Increasing reports of late (>1 month thrombosis) led to recent ACC/AHA recommendation of 12 months dual antiplatelet therapy following DES
      • Casey DE. Circulation. 2007; 115: 1-6.
    • Elective procedures should be deferred at least until 12-month course of dual antiplatelet therapy complete (or procedure may performed without interruption of antiplatelet therapy).
  • Case 4
    • An 62-year old clinic patient of your with severe COPD presents for preoperative evaluation prior to elective cholecystectomy. He smokes 1 pack of cigarettes daily. He is functionally limited by dyspnea, but this is stable.
    • His medications include inhaled albuterol/ipratroprium qid, inhaled albuterol prn, and prednisone 10 mg qd.
    • What are your recommendations?
  • Preoperative pulmonary risk stratification: Background
    • Decreased lung volumes and atelectasis are the principal cause of postoperative pulmonary complications
    • Postoperative pulmonary complications: atelectasis, pneumonia, prolonged mechanical ventilation, respiratory failure, and exacerbation of chronic lung disease
    • Postoperative pulmonary complications are as common as cardiac complications
    • Postoperative pulmonary complications may predict long-term mortality
      • Manku K, Bacchetti P, Leung JM. Anesth Analg 2003; 96: 583-9.
  • Preoperative pulmonary risk stratification
    • Patient-related factors
      • Age (70-79 y OR 3.9, >80 y OR 5.63)
      • ASA II or higher (OR 4.87)
      • Congestive heart failure (OR 2.93)
      • Total functional dependence (OR 2.51)
      • COPD (OR 2.36)
      • Cigarette use (OR 1.40)
      • NO: obesity, diabetes, asthma
      • POSSIBLY: sleep apnea
    Smetana G, Lawrence VA, Cornell JE. Ann Intern Med 2006; 144: 581-95.
  • Preoperative pulmonary risk stratification
    • Procedure-related factors
      • Surgical site
        • Especially aortic, thoracic and upper abdominal
      • Duration of surgery (OR 2.26)
      • Anesthetic technique (OR 1.83)
    Smetana G, Lawrence VA, Cornell JE. Ann Intern Med 2006; 144: 581-95.
  • Preoperative pulmonary risk stratification: Laboratory testing
    • Spirometry
      • May not be superior to clinical evaluation
      • Uncertain if it is useful to identify patients at higher risk of pulmonary complications
      • No “threshold” below which risk is prohibitive
    • Chest radiograph
      • Commonly performed, but rarely changes management
    Smetana G, Lawrence VA, Cornell JE. Ann Intern Med 2006; 144: 581-95.
  • Arozullah, A. M. et. al. Ann Intern Med 2001;135:847-857 Postoperative Pneumonia Risk Index
  • Postoperative Respiratory Failure Risk Index Arozullah, A. M. et. al. Ann Surg 2000;232:242-53.
  • Strategies to reduce postoperative pulmonary complications
    • Lung expansion maneuvers
      • e.g., incentive spirometry, deep breathing exercises, CPAP
    • Preoperative smoking cessation
      • Health benefits of cessation are well recognized; must quit >2 months before surgery.
      • Reduces wound complications (esp. infection) and UTI, but has not been shown to reduce postoperative pulmonary complications (may increase risk if <2 months before surgery)
        • Moller AM, Villebro N, Pederson T, Tonneson H. Lancet 2002; 359: 114-7.
    • Selective nasogastric decompression
      • i.e., for postoperative nausea/vomiting, symptomatic abdominal distension
  • Case 5
    • A 92 year-old male presents for consideration of total hip arthroplasty. Prior to the development of hip pain due to OA, he was quite active – played Pickleball regularly. Currently, he remains active by performing yoga exercises and doing push-ups. His medical history is notable for CAD (s/p PCI), prior stroke (minimal residua), HTN, dyslipidemia, hearing loss and macular degeneration (legally blind).
  • Surgery in the elderly
    • Persons age 65 years and older are the fastest growing segment of the US population.
    • Advances in medicine, particularly therapies for cardiovascular disease, allow persons to live longer…and develop conditions for which surgery may be considered to treat/cure disease (e.g., cancer resection) or improve quality of life (e.g., joint replacement).
    • Surgeons and anesthesiologists rely on medical consultants to assist with perioperative care
    • In general, perioperative data on elderly populations is limited
  • Age and overall perioperative complications, length of stay and nursing home placement
    • Largest, prospective cohort study of non-emergent, non-cardiac major surgery:
      • Increased risk of overall postop complications with increased age (RRI 2.3 for 70-79yrs and 3.1 for >80 yrs, compared to 50-59 yrs)
      • Mean length of stay ~2 days longer for
      • >80 yrs compared to 50-59 yrs
      • >80yrs more likely to be discharged to nursing facility (39% vs. 16%)
    Polanczyk CA. Ann Intern Med 2001;134:637-43.
  • Polanczyk, C. A. et. al. Ann Intern Med 2001;134:637-643 Major postoperative complications and in-hospital mortality in patients undergoing noncardiac surgery
  • Surgery in the elderly – Take home points
    • Advanced age is associated with increased postoperative complications, longer recovery times, and some age-specific morbitidities (most notably, delirium).
    • In general, chronic medical comorbidities, rather than chronologic age, are more important determinants of perioperative morbidity and mortality.
    • Reported perioperative morbidity and mortality rates in elderly persons undergoing a variety of surgical procedures (eg, abdominal, cardiac, vascular, orthopedic, etc) are favorable.
  • Thank you