Preoperative Assessment of Older Adults.ppt


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Preoperative Assessment of Older Adults.ppt

  1. 1. Preoperative Assessment of Older Adults Seki Balogun, MD Core Curriculum in Geriatric Medicine February 16, 2004
  2. 2. <ul><li>“The role of the medical consultant is to identify the problems, correct the correctable, and then point out the uncorrectable to the unsuspecting” </li></ul><ul><li>- G.E. McElwain, Jr. </li></ul>
  3. 3. Introduction <ul><li>Preoperative assessment in older patients is important as: </li></ul><ul><li>Surgical procedures are more frequent in the elderly </li></ul><ul><li>Surgical rates are 55% higher in persons over the age of 65 </li></ul><ul><li>40% of admissions of older patients to general hospitals are admissions to surgical services </li></ul>
  4. 4. Introduction <ul><li>Studies evaluating surgical mortality show that older patients have a higher mortality rate than younger patients </li></ul><ul><li>Older patients account for 75% of all postoperative deaths, increasing nearly linearly with each decade of age </li></ul>
  5. 5. Introduction <ul><li>Preop assessment in the elderly is very complex and sometimes difficult, due to factors like: </li></ul><ul><li>Frequent coexistence of multisystem diseases </li></ul><ul><li>Heterogeneity of the geriatric population, requiring individualized approach for older patient undergoing surgery </li></ul><ul><li>As such , there is no simple algorithmic guideline </li></ul>
  6. 6. Epidemiology of surgical risk <ul><li>In the past, higher surgical risk created a reluctance to operate on most older patients </li></ul><ul><li>As late as 1980, continued reluctance to recommend surgery in geriatric patients was common </li></ul><ul><li>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 </li></ul>
  7. 7. Epidemiology <ul><li>Changes in attitude toward the estimation of surgical risk have occurred over the years </li></ul><ul><li>Decline in overall surgical mortality in the elderly </li></ul><ul><li>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 </li></ul><ul><li>More recently, mortality in patients with cardiac disease is about 0.9 – 2.4% </li></ul><ul><li>This change in mortality is attributable primarily to improvements in anesthesia and surgical expertise </li></ul>
  8. 8. Epidemiology <ul><li>Hence, from the standpoint of risk, surgery can longer be denied solely on the basis of age </li></ul><ul><li>Increase in life expectancy over the years also has had a profound impact on evaluating the benefit of surgery </li></ul><ul><li>Prognosis of older patients who survive surgery is often better than age –matched controls </li></ul>
  9. 9. Individual risk factors <ul><li>Patient-specific risk factors </li></ul><ul><li>Age and life expectancy </li></ul><ul><li>Functional Status – Activities of Daily Living (ADL) scales predict surgical complications </li></ul><ul><ul><li>Complications have been found to be more frequent in ‘inactive’ patients </li></ul></ul><ul><li>Medication Use (include Herbal and OTC) </li></ul><ul><li>Obesity </li></ul><ul><ul><ul><li>Not found to be risk factor for adverse postop outcomes </li></ul></ul></ul><ul><ul><ul><li>Relationship to postop pulmonary complications- controversial </li></ul></ul></ul>
  10. 10. Individual risk factors <ul><li>Neuropsychological Status </li></ul><ul><li>Psychological factors predict surgical outcome </li></ul><ul><li>Social support systems and the “will to live,” though difficult to quantify are important predictors of surgical outcome </li></ul><ul><li>Assessment of preoperative mental status is critical to understanding the etiology of postoperative cognitive status </li></ul><ul><li>Dementia is a predictor of poor outcome, with increased mortality compared to nondemented patients </li></ul><ul><li>Postoperative complications also occur more frequently in these patients i.e. delirium </li></ul>
  11. 11. Specific organ system disease factors <ul><li>Most post operative mortality occur as a result of: </li></ul><ul><li>Cardiac complications </li></ul><ul><li>Pulmonary complications </li></ul><ul><li>Infectious complications </li></ul>
  12. 12. Cardiac Disease <ul><li>Cardiovascular Disease </li></ul><ul><li>the single best predictor of postoperative cardiac complications is the presence of ischemic heart disease </li></ul><ul><li>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 </li></ul><ul><li>Clinical evidence of heart failure and arrhythmia: powerful predictor of adverse cardiac event </li></ul><ul><li>Best strategy for assessment of preoperative cardiac risk remains controversial </li></ul><ul><li>Prevention of bacterial endocarditis should be addressed for susceptible patients using standard protocol </li></ul>
  13. 13. Cardiac testing in PAD prior to noncardiac surgery <ul><li>Resting Echocardiogram </li></ul><ul><ul><li>Quantify valvular dysfunction in pts with significant murmur </li></ul></ul><ul><ul><li>Evaluate ventricular dysfunction in poorly controlled CHF or CHF of unknown cause </li></ul></ul><ul><li>EKG </li></ul><ul><ul><li>Useful in detecting silent ischemia in pts with CAD </li></ul></ul><ul><ul><li>Arrhythmias : complex ventricular arrhythmias predict future cardiac events </li></ul></ul>
  14. 14. Recommendations for Preop Resting EKG <ul><li>Class I </li></ul><ul><li>Recent chest pain or ischemic equivalent in moderate to high risk patients scheduled for moderate to high risk surgery </li></ul><ul><li>Class IIA </li></ul><ul><li>Asymptomatic with DM </li></ul><ul><li>Class IIB </li></ul><ul><li>Prior coronary revascularization </li></ul><ul><li>Asymptomatic male > 45 yrs or female >55 yrs with two or atherosclerotic risk factors </li></ul><ul><li>Prior hospital admission for cardiac disease </li></ul><ul><li>Class III </li></ul><ul><li>Routine test in asymptomatic subjects undergoing low risk procedures </li></ul>Eagle KA, Berger PB et al. J Am Coll Cardiology 39:542, 2002
  15. 15. Cardiac testing in PAD prior to noncardiac surgery <ul><li>Stress testing (Exercise or pharmacologic) </li></ul><ul><li>Useful in: </li></ul><ul><ul><li>New, unexplained chest pain </li></ul></ul><ul><ul><li>Status of CAD uncertain </li></ul></ul><ul><ul><li>Moderate risk for perioperative cardiac complication (Eagle Class I or II) </li></ul></ul><ul><li>C reactive Protein </li></ul><ul><li>Risk factor for cardiovascular disease </li></ul><ul><li>Prognostic importance in CAD </li></ul><ul><li>Data from larger studies needed </li></ul>
  16. 16. Estimation of Coronary Risk before noncardiac surgery <ul><li>Revised Goldman Cardiac Risk Index </li></ul><ul><li>Six independent predictors </li></ul><ul><ul><li>High risk surgery </li></ul></ul><ul><ul><li>Hx of ischemic heart disease </li></ul></ul><ul><ul><li>Hx of heart failure </li></ul></ul><ul><ul><li>Hx of cerebrovascular disease </li></ul></ul><ul><ul><li>DM with insulin therapy </li></ul></ul><ul><ul><li>Preop serum creatinine >2mg/dl </li></ul></ul>
  17. 17. Revised Goldman Cardiac Risk Index <ul><li>Risk factor </li></ul><ul><li>0 </li></ul><ul><li>1 </li></ul><ul><li>2 </li></ul><ul><li>3 or more </li></ul><ul><li>Major complication Rate </li></ul><ul><li>0.4% </li></ul><ul><li>0.9% </li></ul><ul><li>7% </li></ul><ul><li>11% </li></ul>Lee TH, Marcantonio ER et al. Circ 100:1043; 1999
  18. 18. Pulmonary Diseases <ul><li>Increases the risk of postoperative complications </li></ul><ul><li>Accounts for 40%of total complications and 20% of deaths </li></ul><ul><li>Risk factors include: </li></ul><ul><ul><li>Obesity (controversial) </li></ul></ul><ul><ul><li>cough, </li></ul></ul><ul><ul><li>smoking, </li></ul></ul><ul><ul><li>history of lung disease, </li></ul></ul><ul><ul><li>site of surgery (more complications when surgery is in upper abdomen, close to the diaphragm) </li></ul></ul><ul><ul><li>prolonged duration of anesthesia (>3 hours) </li></ul></ul><ul><ul><li>repeat surgery within one year </li></ul></ul><ul><ul><li>Respiratory Infection </li></ul></ul><ul><ul><li>Type of anesthesia (general > epidural or spinal ) </li></ul></ul><ul><li>Clinical findings (wheezes, rales, rhonchi, decreased breath sounds) predict postop pulmonary complications </li></ul>
  19. 19. Chest X-ray <ul><li>Add little to clinical evaluation in identifying periop risks </li></ul><ul><li>May be useful in patients with suspected pulmonary disease or cardiac disease </li></ul>
  20. 20. Pulmonary Function Test <ul><li>Indicated in lung resection surgery </li></ul><ul><li>In unexplained dyspnea </li></ul><ul><li>Maybe used in COPD or Asthma if unable to determine patient’s best baseline </li></ul><ul><li>Arterial blood gas analysis- indicated in: </li></ul><ul><li>Pts undergoing CABG or upper abdominal surgery with a history of tobacco use or dyspnea </li></ul><ul><li>lung resection surgery </li></ul>
  21. 21. Strategies To Reduce Postoperative Pulmonary Complications <ul><li>Complications include: </li></ul><ul><li>Atelectasis </li></ul><ul><li>Infections </li></ul><ul><li>Prolonged mechanical ventilation and respiratory failure </li></ul><ul><li>Exacerbation of underlying chronic lung disease </li></ul><ul><li>Bronchospasm </li></ul>
  22. 22. Strategies To Reduce Postoperative Pulmonary Complications <ul><li>Preoperative strategies </li></ul><ul><li>Smoking Cessation </li></ul><ul><li>At least 8 weeks before surgery </li></ul><ul><li>Adequate treatment of COPD and Asthma (inhaled ipratropium, inhaled beta agonists, corticosteriods) </li></ul><ul><li>Delay elective surgery with respiratory infections </li></ul><ul><li>Treat respiratory infections </li></ul><ul><li>Patient education on lung expansion maneuvers (coughing, incentive spirometry) </li></ul><ul><li>Intraoperative </li></ul><ul><li>Minimize duration of anesthesia and surgery (when possible) </li></ul><ul><li>Choose laparoscopic rather than open abdominal surgery </li></ul><ul><li>Choose regional, epidural or spinal anesthesia (when possible) </li></ul><ul><li>Postoperative </li></ul><ul><li>Deep breathing exercises </li></ul><ul><li>Epidural anesthesia in lieu of parenteral opioids </li></ul>
  23. 23. Renal Disease <ul><li>Important impact on morbidity and postop course </li></ul><ul><li>Adjust CrCl for age and decrease in muscle mass </li></ul><ul><li>The dosing of medications should be adjusted appropriately </li></ul><ul><li>Preoperative renal status is the best universal predictor of postop renal failure </li></ul><ul><li>Risk of renal deterioration postop higher in patients with serum creatinine greater than 1.2mg/dl ( 2.9% vs. 14.4%) </li></ul>
  24. 24. Renal Disease <ul><li>Other Risk factors for postoperative renal failure: </li></ul><ul><li>rising serum creatinine </li></ul><ul><li>LV dysfunction </li></ul><ul><li>advanced age </li></ul><ul><li>decreased serum albumin </li></ul><ul><li>Malignancy </li></ul><ul><li>emergency surgery </li></ul><ul><li>vascular surgery, </li></ul><ul><li>Preop diuretic, </li></ul><ul><li>hypotension </li></ul><ul><li>Poor prognostic indicators: </li></ul><ul><li>oliguria, </li></ul><ul><li>urine sediment abnormalities, </li></ul><ul><li>severity of renal failure </li></ul><ul><li>Attention should be paid to volume status </li></ul><ul><li>Avoid use of nephrotoxic medications when possible </li></ul>
  25. 25. Type of surgery <ul><li>Important in determining risk </li></ul><ul><li>Elective or emergent </li></ul><ul><li>Inside or outside body cavity </li></ul>
  26. 26. Emergency versus Elective Surgery <ul><li>Older adults undergo 50% of all emergency procedures </li></ul><ul><li>Surgical risk increases tremendously, especially in the elderly </li></ul><ul><li>Mortality rate 20% in older adults undergoing emergency surgery, compared to 1.9% in patients who had elective surgery </li></ul><ul><li>Post-op complications and morbidity were also higher </li></ul>
  27. 27. Emergency versus Elective Surgery <ul><li>Possible reasons: </li></ul><ul><li>Surgical disease may have a more sudden onset in the elderly or may be more difficult to diagnose because of atypical presentation </li></ul><ul><li>Surgeons are reluctant to operate electively in older patients </li></ul><ul><li>Older patients are sometimes reluctant to undergo any invasive procedure, and wait until option of last resort </li></ul>
  28. 28. Body Cavity versus Non-Body Cavity Surgery <ul><li>Surgical mortality increases dramatically in thoracic and abdominal procedures </li></ul>
  29. 29. Common surgical procedures in older adults <ul><li>Most common surgical procedures are prostatectomy, coronary artery bypass grafting, pacemaker implantation </li></ul><ul><li>Others are: angioplasty, cholecystectomy, eye surgeries, orthopedic, operations on the nervous system and abdominal </li></ul>
  30. 30. Relatively Safe Procedures <ul><li>TURP - mortality about 0.2% </li></ul><ul><li>Mortality can increase up to 6.3% in patients older than 80 years or otherwise at high risk </li></ul><ul><li>Eye Surgeries: Cataract – very safe, likelihood of life threatening postop complication is about 1.2% </li></ul>
  31. 31. Relatively risky Procedures <ul><li>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 </li></ul><ul><li>Other abdominal surgery: older patients have an incidence of perforation </li></ul>
  32. 32. Relatively risky Procedures <ul><li>Cardiovascular Surgery: </li></ul><ul><li>PTCA – mortality 2 – 6% in patients 60 and above (higher mortality with age) </li></ul><ul><li>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 </li></ul>
  33. 33. Relatively risky Procedures <ul><li>Orthopedic surgery </li></ul><ul><li>Hip surgery, especially after falls – one of the most common in older adults </li></ul><ul><li>In-hospital mortality in about 4%, 1-year mortality of about 14 – 17% </li></ul><ul><li>Frequent complications – DVT (40 – 60% of patients), Pulmonary embolism (20%), pressure ulcer (20 – 70%), Urinary retention (28 – 52%) </li></ul><ul><li>Total knee replacement: relatively safe, mortality rates of about 1.5% </li></ul>
  34. 34. Perioperative Medication Management <ul><li>Consultants often must decide if chronic medications should be continued in perioperative period </li></ul>
  35. 35. Perioperative Medication Management <ul><li>In general: </li></ul><ul><ul><li>Medications associated with known adverse effects if withdrawn abruptly should be continued (consider alternative route when appropriate) </li></ul></ul><ul><ul><li>Medications that can increase surgical complications or not essential for short term improvement in QOL should be held </li></ul></ul><ul><ul><li>Medications not meeting either criterion will depend on individual physician judgment </li></ul></ul>
  36. 36. Perioperative Medication Management <ul><li>Cardiovascular Medications </li></ul><ul><li>Beta-blockers </li></ul><ul><ul><li>Beneficial effects </li></ul></ul><ul><ul><li>Recommended in patients at high risk for cardiovascular disease </li></ul></ul><ul><ul><li>Reduce ischemia by decreasing myocardial oxygen demand due to increased stress and catecholamine release </li></ul></ul><ul><ul><li>Reduce risk of perioperative myocardial infarction and death </li></ul></ul><ul><ul><li>Should be continued in perioperative period </li></ul></ul>
  37. 37. Centrally acting antihypertensives Alpha 2 agonists <ul><li>Clonidine </li></ul><ul><ul><li>May improve outcomes </li></ul></ul><ul><ul><li>Data less conclusive </li></ul></ul><ul><ul><li>Decrease in stress response to surgery </li></ul></ul><ul><ul><li>Has sedative, anxiolytic and analgesic properties </li></ul></ul><ul><ul><li>Reduce anesthetic requirement </li></ul></ul><ul><ul><li>Abrupt withdrawal can precipitate rebound hypertension </li></ul></ul><ul><ul><li>Should be continued in perioperative period </li></ul></ul><ul><ul><li>Transdermal clonidine for patients who may not be able to resume oral medications by 12hrs after surgery </li></ul></ul>
  38. 38. Calcium Channel Blockers <ul><li>Limited data regarding benefits and risks of CCB </li></ul><ul><li>Acute withdrawal symptoms not typical, though reported severe vasospasm in patients undergoing revascularization </li></ul><ul><li>No serious interactions with anesthetic agents </li></ul><ul><li>Possible association with increased bleeding risk (Conflicting data) </li></ul><ul><li>Can be safely administered in perioperative period </li></ul>
  39. 39. ACE Inhibitors and ARBs <ul><li>Controversial </li></ul><ul><li>Can blunt the compensatory activation of the renin-angoiotensin system during surgery, leading to prolonged hypotension </li></ul><ul><li>Possibly, reduces incidence of postoperative hypertension </li></ul><ul><li>Recommendations: continue ACEI/ARB in patients with HTN </li></ul><ul><li>Can withhold in pts with CHF, who also have low BP </li></ul>
  40. 40. Diuretics <ul><li>Possible adverse effects </li></ul><ul><li>Hypokalemia </li></ul><ul><ul><li>Can theoretically increase perioperative arrhythmia (not found in observational studies) </li></ul></ul><ul><li>Hypovolemia </li></ul><ul><ul><li>Anesthetic agents can induce vasodilatation, leading to hypotension in pts who are volume depleted </li></ul></ul><ul><li>Most recommend withholding diuretics on the morning of surgery in some pts </li></ul>
  41. 41. Gastrointestinal Agents <ul><li>H2 blockers/PPI </li></ul><ul><li>Decrease stress related mucosal damage </li></ul><ul><li>Decrease gastric volume and increase gastric pH </li></ul><ul><li>Reduces risk of chemical pneumonitis </li></ul><ul><li>Should be continued in the perioperative period </li></ul>
  42. 42. Pulmonary agents <ul><li>Inhaled beta agonists and anticholinergics </li></ul><ul><li>Reduces postoperative pulmonary complications in patients with COPD and asthma </li></ul><ul><li>Should be continued in perioperative period </li></ul><ul><li>Theophylline </li></ul><ul><li>Potential for serious toxicity </li></ul><ul><li>No data on benefits </li></ul><ul><li>Recommendation: discontinue the evening before surgery </li></ul>
  43. 43. Pulmonary agents <ul><li>Corticosteriod </li></ul><ul><li>Chronic use in COPD should continued in periop </li></ul><ul><li>Maintains optimal lung function </li></ul><ul><li>Minimizes risk of adrenal insufficiency </li></ul><ul><li>Leukotriene Inhibitors </li></ul><ul><li>Effect on asthma symptoms and pulmonary function lasts up to 3 weeks </li></ul><ul><li>No adverse interactions with anesthetic agents </li></ul><ul><li>Rec: continue in periop </li></ul>
  44. 44. Endocrine Agents <ul><li>Insulin and oral hypoglycemics </li></ul><ul><li>Generally can continue with subcutaneous insulin perioperatively (rather than an insulin infusion) for procedures that are not long and complex </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>Sliding scale may be used in place of oral hypoglycemics on morning of surgery </li></ul>
  45. 45. Endocrine Agents <ul><li>HRT/SERM </li></ul><ul><li>Recommendation: Stop 4 -6 weeks before surgery at moderate to high risk for thromboembolism </li></ul><ul><li>Can be continued in surgeries at low risk for thromboembolism </li></ul><ul><li>If on SERM for Breast Cancer – recommend consultation with oncologist </li></ul>
  46. 46. Endocrine Agents <ul><li>Lipid Lowering agents </li></ul><ul><li>May cause myopathy and rhabdomyolysis </li></ul><ul><li>Statins may prevent vascular events and reduce perioperative mortality </li></ul><ul><li>Recommendation: continue statins, discontinue niacin, fibric acid derivative and cholestyramine at least one day before surgery </li></ul>
  47. 47. Endocrine Agents <ul><li>Thyroid agents </li></ul><ul><li>Should be continued </li></ul><ul><li>IV or IM administration if oral intake cannot be resumed in 5 – 7 days after surgery </li></ul>
  48. 48. Medications that affect hemostasis <ul><li>Aspirin </li></ul><ul><li>Optimal periop management uncertain </li></ul><ul><li>Inhibits platelet cyclooxygenase </li></ul><ul><li>Increases intraop blood loss and hemorhagic complications </li></ul><ul><li>May prevent vascular complications in cardiac surgeries (CABG, PVD surgery) </li></ul><ul><li>Recommendations: depends on pt risk factors and surgical procedure </li></ul><ul><li>2004 ACC/AHA: Continue CABG after ST elevation MI </li></ul><ul><li>Should be withheld in procedures with high hemorrhagic risk (CNS surgery) </li></ul><ul><li>5- 10 days before procedure (for new platelets to be formed) </li></ul><ul><li>Plavix, dipyridamole </li></ul><ul><li>Stop 7 – 10 days before surgery </li></ul><ul><li>NSAIDS </li></ul><ul><li>Stop 3 days before surgery </li></ul>
  49. 49. Warfarin <ul><li>Patients at low risk for perioperative bleeding, anticoagulation can be maintained at or below the low end of the therapeutic range (INR 2.0). </li></ul><ul><li>Patients with a high risk of bleeding, INR should be 1.5. or less </li></ul><ul><ul><li>Stop warfarin two to five days preop in those at low risk for thrombosis </li></ul></ul><ul><ul><li>Stop warfarin in pts at high risk for thrombosis, but treat with intravenous or subcutaneous heparin when the INR is subtherapeutic. </li></ul></ul><ul><li>Can be restarted postop when there is no contraindication to anticoagulation. </li></ul>
  50. 50. Psychotropic Agents <ul><li>TCA </li></ul><ul><li>Withdrawal symptoms: insomnia, headache, increased salivation </li></ul><ul><li>Recommend: Continue </li></ul><ul><li>SSRIs </li></ul><ul><li>May increase need for blood transfusions </li></ul><ul><li>Inhibits platelet aggregation </li></ul><ul><li>Recommend: Weigh benefits vs. risks </li></ul>
  51. 51. Chronic Opioid Therapy <ul><li>Abrupt discontinuation may result in withdrawal symptoms </li></ul><ul><li>Continue in periop period </li></ul><ul><li>If oral intake not possible, consider alternative routes </li></ul><ul><li>Higher doses may be required </li></ul>
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