1. AGS/ACS Guidelines 2. Evidence of geriatric surgical collaborative care 3. Surgery and anesthesia that geriatricians should know

1. Canadian Geriatrics Society – Resident Day 05.25.2021
Dr. Camilla Wong, MD FRCPC MHSc
Twitter: @camilla_wong Email: camilla.wong@unityhealth.to

2. A painting showing the shore of Lake Ontario and part of Toronto, - then known as
York. This piece was completed in 1804, a year prior to the Toronto Purchase.
Indigenous Peoples have higher rates of death and adverse events after surgery,
while also encountering barriers accessing surgical procedures.
Library and Archives Canada
CMAJ 2021;193(20):E713-E722.

3. I have received research grant funding from the Ministry of Health (Ontario) and the
Canadian Orthopedic Foundation for work related to the development, implementation
and evaluation of cross-specialty collaborative care models. I have received a speaker’s
honoraria from the Hong Kong Health Authority. I am finally supported by the Li Ka Shing
Knowledge Institute through a research stipend.

4. 1. Apply the pre-operative and perioperative ACS NSQIP/AGS guidelines and
quality standards.
2. Appraise the evidence for perioperative geriatric models of care.
3. Incorporate common surgical and anesthesiology considerations every
geriatrician should know into the comprehensive geriatric assessment.

5. J Am Coll Surg. 2012;215(4):453-66.

6. J Am Coll Surg. 2016;222(5):930-47.

7. J Am Geriatr Soc. 2015;63(1):142-50.

8. J Am Geriatr Soc 67:1074–1078, 2019

9. chronic limb ischemia
hypertension, smoking,
dyslipidemia, diabetes
falls
pain
gabapentin,
narcotics
constipation
urine
retention
colace
foley HYPOACTIVE
DELIRIUM
immobility
pressure
ulcers not going home POD#3
Surgical revascularization
and toe amputation
(intra-op: fentanyl, midazolam)
nausea
gravol
caregiver stress
restraints
NG tube
malnutrition
npo
mild vascular
cognitive
impairment
poor oral
intake
hospital
environment
ativan

10. “Why is it acceptable care if the physical therapist doesn’t come every day but
not acceptable care if antibiotics are not given daily? Or acceptable to miss
meals all day waiting for procedures that are often cancelled? Why do the
alarms go off in the patient’s room if it is the nurse who should be notified? For
debilitated patients, why can’t testing and procedures be done in the afternoon,
so the mornings and evenings can be used for physical therapy, optimizing
nutrition, self-care, rest, and time with family?
Why does medical treatment trump recovery?”
JAMA. 2019;321(13):1253-1254.

11. A comprehensive geriatric assessment (CGA) is a
multidimensional, interdisciplinary diagnostic
process to determine the medical, psychological,
and functional capabilities of a frail elderly person in
order to develop a coordinated and integrated plan
for treatment and long-term follow-up

12. “older people who received CGA probably have lower risk of dying, and
that after discharge, were more likely to return to the same location they
lived in before hospital admission (RR 0.71, 95% CI 0.55 to 0.92)”
“CGA also lowers delirium rates (RR 0.75, 95% CI 0.60 to 0.94)”
Cochrane Database of Systematic Reviews 2018,
Issue 1. Art. No.: CD012485
Pro Tip:
evidence

13. CGS Journal CME 2017;7(1):30-38.

14. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia
Perioperative
Analgesia
Perioperative
Nausea
Delirium, pain, falls,
nutrition, function,
catheter, pressure ulcer,
pulmonary care bundles
Care Transitions

15. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment

16. Determine goals and expectations.
Assess cognitive ability and capacity to understand anticipated
surgery.
Screen for depression.
Identify and manage risk factors for delirium.
Screen for substance dependence.
Document functional status, mobility and falls.
Determine frailty.
Assess nutritional status and offer interventions.
Determine support system.
Order appropriate diagnostic tests.
Perform a preoperative cardiac evaluation.
Perform a preoperative pulmonary evaluation and implement
optimization strategies.
Take a medication history and make any appropriate perioperative
adjustments.
1
2
3
4
5
6
7
8
9
10
11
12
13
J Am Coll Surg. 2012;215(4):453-66.
PRE-OP

17. PRE-OPERATIVE HARMONIZATION
1
VALUES BASED
ASSESSMENT

19. WHAT
MATTERS
TO YOU?
Moving from
“What is the
matter?”

20. JAMA. 2014;311(20):2110-2120.

21. JAMA Surg. 2016; 151(10): 938–945.
Pro Tip

22. PRE-OPERATIVE HARMONIZATION
1 2
VALUES BASED
ASSESSMENT
SURGICAL RISK
ASSESSMENT

23. http://riskcalculator.facs.org/RiskCalculator/

24. http://riskcalculator.facs.org/RiskCalculator/

25. http://riskcalculator.facs.org/RiskCalculator/

26. PRE-OPERATIVE HARMONIZATION
1 3
2
VALUES BASED
ASSESSMENT
SURGICAL RISK
ASSESSMENT
GERIATRIC RISK
ASSESSMENT

27. New York Times 2017

28. Lancet. 2013;381(9868):752-62.

29. J Am Coll Surg. 2015 Dec;221(6):1083-92.

30. BMC Geriatrics (2016) 16:157

33. PRE-OPERATIVE HARMONIZATION
1 3
2
VALUES BASED
ASSESSMENT
SURGICAL RISK
ASSESSMENT
GERIATRIC RISK
ASSESSMENT

34. BMJ Open 2018;8:e019223.
RISK
STRATIFICATION
Informs shared-
decision making
about risks and
benefits.
Focuses evidence-
based prevention
strategies.
1
2

36. “The risk calculators are meant to serve as
decision aids. Numbers, whether taken in
isolation or as an index, are NOT a substitute
for clinical evaluation and clinical judgment.”
JAMA Intern Med. 2019

37. COMMUNICATE THE RISK
patient, family, all team members
Knowing the risk is a pre-requisite for actions to modify risk.
Pro Tip:
Act

38. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment

40. P U L M O N A R Y
Risk assessment for and strategies to reduce
perioperative pulmonary complications for
patients undergoing noncardiothoracic
surgery. Ann Intern Med. 2006;144(8):575-80.
A N T I M I C R O B I A L
Clinical practice guidelines for antimicrobial
prophylaxis in surgery. American Journal of
Health-System Pharmacy 2013;70:195-283.
N U T R I T I O N
The European Society for Clinical Nutrition
and Metabolism guidelines.
http://www.espen.org/education/espen-
guidelines
C A R D I O V A S C U L A R
2017 Canadian Cardiovascular Society
Guidelines on Perioperative Cardic Risk
Assessment and Management. Can J Cardiol.
2017;33(1):17-32.
T H R O M B O E M B O L I S M
American College of Surgeons' Guidelines for
the Perioperative Management of
Antithrombotic Medication. J Am Coll Surg.
2018 Nov;227(5):521-536.
D I A B E T E S
2018 Clinical Practice Guidelines for the
Prevention and Management of Diabetes in
Canada. Can J Diabetes. 2018;42:S1-S325.

41. Administer the CAGE Questionnaire.
If motivated, delay surgery for abstinence or
detoxification.
If at risk, give perioperative prophylaxis for
withdrawal syndromes.
In alcohol use disorder, give perioperative
daily multivitamin and high-dose thiamine.
J Am Coll Surg. 2012;215(4):453-66.

42. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization

43. J Am Geriatr Soc. 2015;63(1):142-50.
Pro-tip:
caregivers
IDENTIFY POST-OP
DELIRIUM RISK
Age > 65, cognitive impairment, severe illness, hearing or
vision impairment, presence of infection, inadequately
controlled pain, depression, alcohol use, sleep deprivation
or disturbance, renal insufficiency, anemia, hypoxia or
hypercarbia, poor nutrition, dehydration, electrolyte
abnormalities, poor functional status, limited mobility, use
of psychotropic medications, risk of urinary retention of
constipation, presence of urinary catheter, aortic
procedures.
Caregiver support is associated with lower odds of
postoperative delirium (OR 0.69, 95% CI 0.52–0.91).

44. RR = 0.53
95% CI: 0.41–0.69
J Am Geriatr Soc. 2020;68(8):1864-1871.

45. Ann Intern Med. 2019;171:474-484.
“There is limited evidence that second-generation antipsychotics may lower the
incidence of delirium in postoperative patients, but more research is needed.”

46. • cholinesterase inhibitors
• gabapentin
• tryptophan
fail
verb
be unsuccessful in achieving one's goal
in·trigue (n=1)
verb
arouse the curiosity or interest of
• parecoxib (joint replacement)
• methylprednisolone (hip fracture)
• IV acetaminophen (cardiac surgery)
• aripiprazole (neurosurgery)
• thiamine (GI surgery)
Melatonin / Ramelteon

47. IF SCREEN IS POSITIVE, THEN FURTHER
EVALUATION IS RECOMMENDED.
In the past 12 months, have you
ever had a time when you felt
sad, blue, depressed, or down
for most of the time for at least
2 weeks?
In the past 12 months, have you
ever had a time, lasting at least
2 weeks, when you didn’t care
about the things that you
usually cared about or when
you didn’t enjoy the things that
you usually enjoyed?
J Am Coll Surg. 2012;215(4):453-66.

48. Management of
ADLs and IADLS
History of
falls
Vision,
hearing,
swallowing
Gait and
balance
assessment
P E R F O R M A N C E S TAT U S
DEFICITS SHOULD PROMPT PROACTIVE DISCHARGE PLANNING
AND REFERRALS TO ALLIED HEALTH
J Am Coll Surg. 2012;215(4):453-66.

49. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization

50. increase functional capacity in anticipation of an upcoming stress

51. BJA Education 2017;17(12):401–405.

52. JAMA Surg. 2021;156(2):148-156.
cognitive exercise-based interventions
may decrease postoperative delirium RR 0.58 (95% CI 0.33-0.99)

53. decreases pneumonia
RR 0.45, 95% CI 0.24-0.83
decreases length of stay
3.21 days, p=0.01
Cochrane Database of Systematic Reviews 2012 (11): CD010118.

54. PREOPERATIVE
inspiratory muscle training
Reduces atelectasis and pneumonia
RR 0.53, 95% CI 0.34 to 0.82
Cochrane Database Syst Rev. 2015 Oct 5;(10):CD010356.

55. Surg Endosc. 2013;27(4):1072-82.
P R E H A B I L I TAT I O N
A 1-month trimodal program improves post-op functional recovery.

56. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation

57. J Am Coll Surg. 2016;222(5):930-47.
“Definitive evidence does
not exist establishing the
superiority of regional
anesthesia compared with
general anesthesia when
used as a primary modality
for surgical anesthesia in
older adults.”

58. using processed EEG to help deliver
the optimal depth of anaesthesia
MAY reduce delirium incidence:
RR 0.71, 95% CI 0.59-0.85
3 RCTs, 2138 cases, low-quality evidence
PLoS One. 2020;15(2):e0229018.

59. PLoS One. 2019 Aug 16;14(8):e0218088.
D E X M E D E TO M I D I N E
reduces postoperative delirium
RR = 0.61, 95% CI 0.34–0.76, P = 0.001

60. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia

61. Anesthesiology 2011;114:495-511.
Clear liquids may be ingested for up to 2
h before procedures requiring general
anesthesia, regional anesthesia, or
procedural sedation and analgesia..
A light meal may be ingested for up to 6
h before elective procedures requiring
general anesthesia, regional anesthesia,
or procedural sedation and analgesia.
Anesthesiology. 2017;126(3):376-393.
Pro-tip: first
morning case

62. J Am Coll Surg. 2016;222(5):930-47.

63. J Am Coll Surg. 2016;222(5):930-47.

64. J Am Coll Surg. 2016;222(5):930-47.

65. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia
Perioperative
Analgesia
Perioperative
Nausea

66. Delirium prevention strategies
Multimodal, individualized acute pain control
Minimize pulmonary complications
Fall risk reduction
Maintain adequate nutrition
Urinary tract infection prevention
Prevent functional decline
Reduce pressure ulcers
1
2
3
4
5
6
7
J Am Coll Surg. 2012;215(4):453-66.
POST-OP
8

67. orientation strategies vision and hearing aids sleep environment
family participation uncluttered hallways multimodal pain control
remove urinary catheters
and other tethers
WHAT IS GOOD
FOR DELIRIUM,
IS GOOD FOR
FALLS, IS GOOD
FOR FUNCTIONAL
DECLINE.
wound care: minimize
pressure, friction,
humidity, shear force
avoid potentially
inappropriate medications
resume diet early and
provide dentures, if needed
chest physiotherapy and
incentive spirometry
early, multidisciplinary
involvement
nutritional supplement,
if needed
early mobilization, using
walking aids if needed
scheduled toileting
aspiration precautions

68. A. Start Lorazepam 0.5-1.0 mg po q4h prn
A. Start Haloperidol 0.25 mg po/im/iv q4h prn
B. Apply soft restraints so he will not pull out the catheter or
touch his sternal wound.
C. Request a sitter.
D. Remove the catheter.
Antipsychotics do NOT shorten the duration or reduce the severity.
Cochrane Database Syst Rev. 2018 Jun 18;6:CD005594.

69. A. Start Lorazepam 0.5-1.0 mg po q4h prn
A. Start Haloperidol 0.25 mg po/im/iv q4h prn
B. Apply soft restraints so he will not pull out the catheter or
touch his sternal wound.
C. Request a sitter.
D. Remove the catheter.
Insufficient evidence for benzodiazepines to treat delirium.
Cochrane Database Syst Rev. 2020;2(2):CD012670.

70. A. Start Lorazepam 0.5-1.0 mg po q4h prn
A. Start Haloperidol 0.25 mg po/im/iv q4h prn
B. Apply soft restraints so he will not pull out the catheter or
touch his sternal wound.
C. Request a sitter.
D. Remove the catheter.
Cholinesterase inhibitors do NOT shorten the duration.
Cochrane Database Syst Rev. 2018;6(6):CD012494.

71. NeuroVISION
Study
COVERT STROKE
• not uncommon (7%)
• increased perioperative delirium HR 2.24 (95% CI 1.06-4.73)
• cognitive decline at one year aOR 1.98 (95% CI 1.22-3.20)
• stroke/TIA at one year HR 4.13 (95% CI 1·14–14·99)
Lancet 2019;21;394:1022-1029

72. BJA Education 2021; 21(2):75e82.
Anesthesiology. 2018;129(5):872-879.
Postoperative Cognitive Dysfunction (POCD)
is a research construct defined as “new cognitive impairment after a
surgical procedure”.
Time Period
Perioperative Cognitive Disorders
Mild NCD Major NCD
Emergency from
anesthesia
emergence delirium
Immediate post-op
until expected
recovery (to 30 days)
postoperative
delirium
delayed
neurocognitive
recovery
delayed
neurocognitive
recovery
From expected
recovery (to 30 days)
until 12 months
minor NCD (POCD) major NCD (POCD)
Beyond 12 months mild NCD major NCD

73. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia
Perioperative
Analgesia
Perioperative
Nausea
Delirium, pain, falls,
nutrition, function,
catheter, pressure ulcer,
pulmonary care bundles

74. COMMON COMPONENTS OF
TRANSITION CARE MODELS
• Coordinated care with primary care physician
• Engagement of caregiver (RR 0.75, 95% CI 0.62-0.91)
reduces re-hospitalization
• Patient-centered medical record
• Post-discharge follow up plan
• Medication management
• Knowledge of important signs and symptoms
J Am Coll Surg. 2016;222(5):930-47.
J Am Geriatr Soc. 2017;65(8):1748–1755.

75. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia
Perioperative
Analgesia
Perioperative
Nausea
Delirium, pain, falls,
nutrition, function,
catheter, pressure ulcer,
pulmonary care bundles
Care Transitions

76. Pre-operative Intra-operative Post-operative Discharge
PROACTIVE Comprehensive Geriatric Assessment
Values-based
assessment
Surgical risk
assessment
Geriatric risk
assessment
Medical
optimization
Geriatric
optimization
Pre-habilitation
Anesthesia
Perioperative
Analgesia
Perioperative
Nausea
Delirium, pain, falls,
nutrition, function,
catheter, pressure ulcer,
pulmonary care bundles
Care Transitions
Palliative
Care
Family
Doctor
Geriatrics
Surgery
Internist
Pain
Service
Anesthesia
PT
RD
Pharmacy
Nursing
SW
OT
SLP

77. chronic limb ischemia
hypertension, smoking,
dyslipidemia, diabetes
falls
pain
gabapentin,
narcotics
constipation
urine
retention
colace
foley HYPOACTIVE
DELIRIUM
immobility
pressure
ulcers not going home POD#3
Surgical revascularization
and toe amputation
(intra-op: fentanyl, midazolam)
nausea
gravol
caregiver stress
restraints
NG tube
malnutrition
npo
mild vascular
cognitive
impairment
poor oral
intake
hospital
environment
ativan

78. chronic limb ischemia
hypertension, smoking,
dyslipidemia, diabetes
falls
pain
gabapentin,
narcotics
constipation
urine
retention
colace
foley HYPOACTIVE
DELIRIUM
immobility
pressure
ulcers not going home POD#3
Surgical revascularization
and toe amputation
(intra-op: fentanyl, midazolam)
nausea
gravol
caregiver stress
restraints
NG tube
malnutrition
npo
mild vascular
cognitive
impairment
poor oral
intake
hospital
environment
ativan
identification of
frailty
advanced care
planning
timed first
morning surgery
use better
medications
use multimodal
analgesia including
popliteal nerve
cathether
intermittent
catheterization
use better
medications
early
mobilization
counsel and
empower
caregivers
bispectral
index to guide
sedation
avoid bad
medications
use better
surfaces
protein
supplementation
cognitive
prehab
exercises
incentive
spirometry

79. O n e - s t o p s h o p .
CROSS SPECIALTY COLLABORATION

80. Patient Family
Surgeon
Anesthesia
Geriatrics
Palliative
Care
PT, OT, RD
SW, SLP, RN
Internal Medicine
Pharmacy
Primary
Care

81. ENHANCED
RECOVERY
PROGRAMS
“ T H E I M M E D I AT E C H A L L E N G E TO
I M P R OV I N G T H E Q UA L I T Y O F
S U R G I C A L C A R E I S N OT
D I S C OV E R I N G N E W K N OW L E D G E ,
B U T R AT H E R H OW TO I N T E G R AT E
W H AT W E A L R E A DY K N OW I N TO
P R A C T I C E .”
17 systematic reviews and 12 additional
showed Enhanced Recovery After
Surgery (ERAS) programs may reduce
hospital stays by 0.5–3.5 days compared
with conventional care.
BMJ. 2005; 330(7505): 1401–1402.
BMJ Open 2014;4:e005015.
CMAJ. 2019;191(17):E469-E475

82. Age Ageing. 2007;36(2):190-6.
‘POPS’ IN
ORTHOPEDICS
• elective orthopedic
surgery
• 65 years +
• before-and-after
study (N=54)
 LOS (4.9 vs 4.0 days,
P=0.01)
 delirium (19% vs 6%,
P=0.036)
 pneumonia (20% vs
4%, P=0.008)
 urinary catheter use
(20% vs 7%, P=0.046)

83. Br J Surg. 2017;104(6):679-687
PREOPERATIVE
GERIATRIC
ASSESSMENT IN
VASCULAR SURGERY
• elective aortic aneurysm repair
or lower-limb arterial surgery
• 65 years +
• RCT, N=176
 LOS (5.5 vs 3.3 d, P<.001)
 delirium (11% vs 24%, P=.018)
 cardiac complications (8% vs
27%, P=.001)
 bowel/bladder complications
(33% vs 55%, P=.003)

84. ‘POPS’
UROLOGY-
GERIATRICS
LIAISON
• elective and
emergency urology
patients
• 65 years +
• before-and-after
study (N=242)
 LOS (4.9 vs 4.0 days,
P=0.01)
 postoperative
complications (RR
0.24, P=.001)
BJU Int. 2017 Jul;120(1):123-129.

85. J Orthop Trauma 2014;28:e49–e55.
JAGS 2017;65(7):1559-1565.
HIP FRACTURE–
ORTHOGERIATRICS
• Meta-analysis (N=242)
 LOS (SMD -0.25)
 in-hospital mortality (RR
0.60, 95% CI 0.42-0.84)
 long term mortality (RR 0.83,
95% CI 0.74–0.94).
• Systematic review (4
studies)
 delirium RR 0.81, 95%CI
0.69-0.94

86. ‘POSH’ IN
ABDOMINAL
SURGERY
• Elective abdominal
surgery
• 65 years +
• control cohort (N=326)
 post-op complications
(.9 vs 1.4; P< .001)
 LOS (4 vs 6 days, P<.001)
 discharge home and
independent (62% vs
51%, p=.04)
JAMA Surg. 2018;153{5);454-462.

87. ‘POSH’ IN SPINE
SURGERY
• elective spine surgery
• 65 years +
• historical match (n=324)
 LOS (4.7 vs 5.4 days; P =
.016)
J Am Geriatr Soc 00:1-9, 2021.

88. GERIATRIC CO-
MANAGEMENT
IN CANCER
SURGERY
• cancer surgery
• 75 years +
• Retrospective cohort
study (N = 1892)
 LOS 4 vs 5 days; P < .001
 90-day mortality [OR
0.5, 95% CI 0.37-0.92]
JAMA Netw Open. 2020;3(8):e209265.

89. PROACTIVE
GERIATRIC
TRAUMA
CONSULTATION
• trauma activation
• 65 years +
• before-and-after study
(N=486)
 delirium (51% vs 41%,
P=0.05)
 discharge to LTC (6.5%
vs1.7%, P=0.03)
Ann Surg 2012;256: 1098–1101

90. JAMA Surg. 2020 Feb 12:e196021.

91. some u sefu l th in g s geriatric ian s sh ou ld kn ow ab ou t
su rger y an d an esth esiolog y

92. Epidural
Important Peripheral Nerve Blocks
fascia iliaca
serratus
anterior
plane
popliteal
interscalene
femoral
Regional
Anesthesia
Neuraxial Block
Peripheral Nerve Block
(single shot vs continous)
General
Anesthesia
Spinal
Epidural transverse
abdominus
plane
hip fracture
laparotomy
rib fractures
proximal
humerus
fracture
acute limb
ischemia
hip/knee
arthroplasty
Pro-tip:
PNBs

93. Epidurals are NOT a contraindication to urinary catheter removal!

94. Pro-tip:
pre-admit
Bowel
Prep
May be needed before
some GI surgeries.

95. Colostomy vs Ileostomy

96. ILEOSTOMY COLOSTOMY
• empty six times a day
• change appliance twice a week
• troubleshooting: 'burping', blockage
• avoid time-release and enteric coated medications
• dietary: volume and electrolyte intake
• monitor for high outputs
• expensive!
• empty twice a day
• change appliance twice a week
• troubleshooting: 'burping'
• dietary: avoid constipation
• expensive!
Pro-tip:
pre-op
functional
assessment

97. Vitamin
B12
Deficiency
post-gastrectomy
post-ileostomy
Pro-tip:
start B12 IM

98. TOTA L H I P A R T H R O P L A S T Y
Postoperative precautions:
• avoid hip flexion > 90°
• do not cross legs
• avoid internal rotation

99. C A R D I A C S U R G E RY
Sternal precautions:
• no pushing
• no lifting
• no pulling

100. Parkinson’s Medications
In the immediate postoperative
period and due for medication
but too drowsy:
• levodopa (IR) disperses in
water for use in enteral
tubes, but degrades and
absorption is altered by
feeds
• ropinirole and pramipexole
disperses in water for use in
enteral tubes
• selegiline, rasagiline,
entacapone, amantadine are
not essential
Pro-tip:
NG intraop

101. http://www.parkinsonscalculator.com
OPTIMAL Calculator

102. 1. Apply the pre-operative and perioperative ACS NSQIP/AGS guidelines and
quality standards.
2. Appraise the evidence for perioperative geriatric models of care.
3. Incorporate common surgical and anesthesiology considerations every
geriatrician should know into the comprehensive geriatric assessment.

103. “If you want to go fast, go alone;
if you want to go far go
TOGETHER”
-- African Proverb

104. D r. C a m i l l a Wo n g
c a m i l l a .w o n g @ u n i t y h e a l t h .t o